Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials

Background: After breast-conserving surgery, radiotherapy reduces recurrence and breast cancer death, but it may do so more for some groups of women than for others. We describe the absolute magnitude of these reductions according to various prognostic and other patient characteristics, and relate the absolute reduction in 15-year risk of breast cancer death to the absolute reduction in 10-year recurrence risk.
Methods: We undertook a meta-analysis of individual patient data for 10?801 women in 17 randomised trials of radiotherapy versus no radiotherapy after breast-conserving surgery, 8337 of whom had pathologically confirmed node-negative (pN0) or node-positive (pN+) disease.
Findings: Overall, radiotherapy reduced the 10-year risk of any (ie, locoregional or distant) first recurrence from 35·0% to 19·3% (absolute reduction 15·7%, 95% CI 13·7–17·7, 2p<0·00001) and reduced the 15-year risk of breast cancer death from 25·2% to 21·4% (absolute reduction 3·8%, 1·6–6·0, 2p=0·00005). In women with pN0 disease (n=7287), radiotherapy reduced these risks from 31·0% to 15·6% (absolute recurrence reduction 15·4%, 13·2–17·6, 2p<0·00001) and from 20·5% to 17·2% (absolute mortality reduction 3·3%, 0·8–5·8, 2p=0·005), respectively. In these women with pN0 disease, the absolute recurrence reduction varied according to age, grade, oestrogen-receptor status, tamoxifen use, and extent of surgery, and these characteristics were used to predict large (=20%), intermediate (10–19%), or lower (<10%) absolute reductions in the 10-year recurrence risk. Absolute reductions in 15-year risk of breast cancer death in these three prediction categories were 7·8% (95% CI 3·1–12·5), 1·1% (–2·0 to 4·2), and 0·1% (–7·5 to 7·7) respectively (trend in absolute mortality reduction 2p=0·03). In the few women with pN+ disease (n=1050), radiotherapy reduced the 10-year recurrence risk from 63·7% to 42·5% (absolute reduction 21·2%, 95% CI 14·5–27·9, 2p<0·00001) and the 15-year risk of breast cancer death from 51·3% to 42·8% (absolute reduction 8·5%, 1·8–15·2, 2p=0·01). Overall, about one breast cancer death was avoided by year 15 for every four recurrences avoided by year 10, and the mortality reduction did not differ significantly from this overall relationship in any of the three prediction categories for pN0 disease or for pN+ disease.
Interpretation: After breast-conserving surgery, radiotherapy to the conserved breast halves the rate at which the disease recurs and reduces the breast cancer death rate by about a sixth. These proportional benefits vary little between different groups of women. By contrast, the absolute benefits from radiotherapy vary substantially according to the characteristics of the patient and they can be predicted at the time when treatment decisions need to be made.
Funding: Cancer Research UK, British Heart Foundation, and UK Medical Research Council.

'False, fleeting, perjured Clarence': pseudonymity and criminality in the writings of James Clarence Mangan

This article explores the significance of the adopted partial pseudonym “Clarence” to James Clarence Mangan (1803-1849), who is increasingly regarded as the most important Irish poet before W. B. Yeats. Tracing the literary history of “Clarence” from Shakespeare to Maria Edgeworth, this essay argues that the intriguing adoption exposes a preoccupation with themes of unlawful textual copying that is at the centre of Mangan’s imagination. These tropes assume singular significance when appreciated alongside Mangan’s profession as a scrivener. While literary criticism has separated Mangan the poet from Mangan the legal scribe, his hitherto under-explored assumption of “Clarence” provides a clue to their close and crucial connection. These themes of pseudonymity, copying, and criminality combine with particular resonance in his quasi-translation “The Man in the Cloak” (1838) to open up new perspectives on Mangan’s writing and its participation in wider European cultural contexts and concerns. The essay will conclude with a salient comparison of Mangan’s story with Nikolay Gogol’s seminal story “The Overcoat”, or, “The Cloak” (1842).

Kingship by Descent or Kingship by Election? The Contested Title of James VI and I

Throughout the reign of Elizabeth I, a steady stream of tracts appeared in English print to vindicate the succession of the most prominent contenders, Mary and James Stuart of Scotland. This article offers a comprehensive account of the polemical battle between the supporters and opponents of the Stuarts, and further identifies various theories of English kingship, most notably the theory of corporate kingship, developed by the Stuart polemicists to defend the Scottish succession. James's accession to the English throne in March 1603 marked the protracted end of the debate over the succession. The article concludes by suggesting that, while powerfully renouncing the opposition to his succession, over the course of his attempt to unify his two kingdoms, James and his supporters ultimately departed from the polemic of corporate kingship, for a more assertive language of kingship by natural and divine law.

The 1863 Melbourne Shakespeare War: Barry Sullivan, Charles and Ellen Kean, and the Play of Cultural Usurpation on the Australian Stage

This essay investigates an intricate drama of cultural identity in performances of Shakespeare on the nineteenth-century Melbourne stage. It considers the rivalry between Charles and Ellen Kean and their competitor, Barry Sullivan, for the two-month period in 1863 during which their Australian tours overlapped. This Melbourne Shakespeare war was anticipated,augmented, and richly documented in Melbourne’s papers: The Age, The Argus and Melbourne Punch. This essay pursues two seams of inquiry. The first is an investigation of the discourses of cultural and aesthetic value laced through the language of reviews of their Shakespearean roles.The essay identifies how reviewers register affective engagement with the performers in these roles, and suggests how the roles themselves reflected, by accident or design, the terms of the dispute. The second is concerned with the national identity of the actors. Kean, although born in Waterford, Ireland, had held the post of Queen Victoria’s Master of the Revels and identified himself as English. Sullivan, although born in Birmingham, was of Cork parentage and was identified as Irish by both his supporters and his detractors. This essay tracks the development of the actors’ national and artistic identities established prior to Melbourne and ask how they played out on in the context of the particularities of Australian reception. It shows that, in this instance, these actors were implicated in complex debates over national authority and cultural ownership.

Seven new loci associated with age-related macular degeneration

Age-related macular degeneration (AMD) is a common cause of blindness in older individuals. To accelerate the understanding of AMD biology and help design new therapies, we executed a collaborative genome-wide association study, including >17,100 advanced AMD cases and >60,000 controls of European and Asian ancestry. We identified 19 loci associated at P <5 × 10(-8). These loci show enrichment for genes involved in the regulation of complement activity, lipid metabolism, extracellular matrix remodeling and angiogenesis. Our results include seven loci with associations reaching P <5 × 10(-8) for the first time, near the genes COL8A1-FILIP1L, IER3-DDR1, SLC16A8, TGFBR1, RAD51B, ADAMTS9 and B3GALTL. A genetic risk score combining SNP genotypes from all loci showed similar ability to distinguish cases and controls in all samples examined. Our findings provide new directions for biological, genetic and therapeutic studies of AMD.