To the Editor Steenbruggen et al1 shared a 20-year follow-up of a phase 3 randomized clinical trial of high-dose chemotherapy (HDCT) with hematopoietic stem cell transplant in patients with high-risk breast cancer and 4 or more involved axillary lymph nodes. The authors’ conclusion suggests that selected subgroups may benefit from this treatment, highlighting a 14.6% improvement in 20-year overall survival estimates with HDCT in the predefined subgroup for patients with 10 or more involved axillary lymph nodes. The authors are to be commended for their efforts in reporting the long-term results of this trial. However, the conclusions generate questions in both statistical interpretation and generalized application.