Completion of adjuvant radiation therapy among women with breast cancer

Socioeconomic disparities in breast cancer survival: relation to stage at diagnosis, treatment and race

BACKGROUND

Previous studies have documented lower breast cancer survival among women with lower socioeconomic status (SES) in the United States. In this study, I examined the extent to which socioeconomic disparity in breast cancer survival was explained by stage at diagnosis, treatment, race and rural/urban residence using the Surveillance, Epidemiology, and End Results (SEER) data.

METHODS

Women diagnosed with breast cancer during 1998-2002 in the 13 SEER cancer registry areas were followed-up to the end of 2005. The association between an area-based measure of SES and cause-specific five-year survival was estimated using Cox regression models. Six models were used to assess the extent to which SES differences in survival were explained by clinical and demographical factors. The base model estimated the hazard ratio (HR) by SES only and then additional adjustments were made sequentially for: 1) age and year of diagnosis; 2) stage at diagnosis; 3) first course treatment; 4) race; and 5) rural/urban residence.

RESULTS

An inverse association was found between SES and risk of dying from breast cancer (p < 0.0001). As area-level SES falls, HR rises (1.00 --> 1.05 --> 1.23 --> 1.31) with the two lowest SES groups having statistically higher HRs. This SES differential completely disappeared after full adjustment for clinical and demographical factors (p = 0.20).

CONCLUSION

Stage at diagnosis, first course treatment and race explained most of the socioeconomic disparity in breast cancer survival. Targeted interventions to increase breast cancer screening and treatment coverage in patients with lower SES could reduce much of socioeconomic disparity.

Cancer treatment adherence among low-income women with breast or gynecologic cancer: a randomized controlled trial of patient navigation

BACKGROUND

The authors implemented a controlled, randomized trial that compared 2 interventions: the provision of written resource navigation information (enhanced usual care [EUC]) versus written information plus patient navigation (TPN) aimed at improving adjuvant treatment adherence and follow-up among 487 low-income, predominantly Hispanic women with breast cancer or gynecologic cancer.

METHODS

Women were randomized to receive either TPN or EUC; and chemotherapy, radiation therapy, hormone therapy, and follow-up were assessed over 12 months. Patients with breast cancer were analyzed separately from patients with gynecologic cancer.

RESULTS

Overall adherence rates ranged from 87% to 94%, and there were no significant differences between the TPN group and the EUC group. Among women with breast cancer, 90% of the EUC group and 88% of the TPN group completed chemotherapy (14% of the EUC group and 26% of the TPN group delayed the completion of chemotherapy), 2% of the EUC group and 4% of the TPN group failed to complete chemotherapy, and 8% of the EUC group and 7% of the TPN group refused chemotherapy. Radiation treatment adherence was similar between the groups: Ninety percent of patients completed radiation (40% of the EUC group and 42% of the TPN group delayed the completion of radiation); in both groups, 2% failed to complete radiation, and 8% refused radiation. Among gynecologic patients, 87% of the EUC group and 94% of the TPN group completed chemotherapy (41% of the EUC group and 31% of the TPN group completed it with delays), 7% of the EUC group and 6% of the TPN group failed to complete chemotherapy, 6% of the EUC refused chemotherapy, 87% of the EUC group and 84% of the TPN group completed radiation (51% of the EUC group and 42% of the TPN with delays), 5% of the EUC group and 8% of the TPN group failed to complete radiation, and 8% of the EUC group and 5% of the TPN group refused radiation.

CONCLUSIONS

Treatment adherence across randomized groups was notably higher than reported in previous studies, suggesting that active telephone patient navigation or written resource informational materials may facilitate adherence among low-income, predominantly Hispanic women. Adherence also may have be facilitated by federal-state breast and cervical cancer treatment funding.

Breast-conserving surgery in older patients with invasive breast cancer: current patterns of treatment across the United States

BACKGROUND

Breast-conserving surgery (BCS) followed by radiotherapy is as effective as mastectomy for treatment of early invasive breast cancer. But earlier studies report low BCS use rates of 12% to 43% nationally, especially in older patients. We sought to determine current patterns and predictors of BCS use.

STUDY DESIGN

In a national Medicare database of all beneficiaries (age greater than 65 years) with incident invasive breast cancer treated with operation in 2003, claims codes identified BCS versus mastectomy and demographic, treatment, and geographic region covariates. The 2003 Area Resource File provided socioeconomic covariates. Logistic regression modeled predictors of BCS.

RESULTS

In 56,725 women, 59% were treated with BCS versus 41% with mastectomy. BCS was more likely in women who were younger than 70 years (odds ratio [OR], 1.37; 95% CI, 1.31 to 1.44; p < 0.001) and had lymph node-negative disease (OR, 1.60; 95% CI, 1.52 to 1.68; p < 0.001). Socioeconomic factors influenced use, with BCS more likely in areas with low poverty (OR, 1.05; 95% CI, 1.00 to 1.09; p = 0.03), high education (OR, 1.13; 95% CI, 1.08 to 1.19), high density of radiation oncologists (OR, 1.30; 95% CI, 1.06 to 1.59), and in metropolitan areas (OR, 1.20; 95% CI, 1.14 to 1.26). Significant geographic variation existed: 70% of women were treated with BCS in northeastern New England compared with only 48% to 50% in the South (p < 0.001).

CONCLUSIONS

Currently, more than half of older women across the US diagnosed with nonmetastatic invasive breast cancer treated surgically receive BCS, representing a substantial increased use compared with historical data. Lack of BCS use appears in part associated with socioeconomic disadvantage, suggesting that persistent barriers to breast conservation exist.

Prognosis after ipsilateral breast tumor recurrence and locoregional recurrences in patients treated by breast-conserving therapy in five National Surgical Adjuvant Breast and Bowel Project protocols of node-negative breast cancer

PURPOSE

Locoregional failure (LRF) after breast-conserving therapy (BCT) is associated with increased risk of distant disease and death. The magnitude of this risk has not been adequately characterized in patients with lymph node-negative disease.

PATIENTS AND METHODS

Our study population included 3,799 women randomly assigned to five National Surgical Adjuvant Breast and Bowel Project protocols of node-negative disease (ie, B-13, B-14, B-19, B-20, and B-23) who underwent lumpectomy and whole breast irradiation with or without adjuvant systemic therapy. Cumulative incidences of ipsilateral breast tumor recurrence (IBTR) and other locoregional recurrence (oLRR) were calculated, along with distant-disease-free interval (DDFI) and overall survival (OS) after these events. Cox models were employed to model mortality by using clinical and pathologic factors jointly with these events.

RESULTS

Four hundred nineteen patients (11.0%) experienced LRF: 342 (9.0%) experienced IBTR, and 77 (2.0%) experienced oLRR. The 12-year cumulative incidences of IBTR and oLRR in patients treated with adjuvant systemic therapy were 6.6% and 1.8%, respectively. Overall, 37.1% of IBTRs and 72.7% of oLRRs occurred within 5 years of diagnosis. Older age, black race, higher body mass index (BMI), larger tumors, and occurrence of IBTR or oLRR were significantly associated with increased mortality. The 5-year OS after IBTR and oLRR were 76.6% and 34.9%, respectively. Adjusted hazard ratios for mortality associated with IBTR and oLRR were significantly higher in estrogen receptor (ER)-negative patients than in ER-positive patients (P = .002 and P < .0001, respectively). Patients with early LRF had worse OS and DDFI than those with later-occurring LRF.

CONCLUSION

Although LRF is uncommon in patients with node-negative breast cancer who are treated with lumpectomy, radiation, and adjuvant systemic therapy, those who do develop LRF have substantially worse OS and DDFI.

Correlates and effect of suboptimal radiotherapy in women with ductal carcinoma in situ or early invasive breast cancer

BACKGROUND

The study aimed to identify factors associated with less-than-optimal radiotherapy (RT) and its impact on disease-free survival in women aged 66+ years diagnosed with stage I breast cancer or ductal carcinoma in situ (DCIS).

METHODS

The subjects were women diagnosed from 1991 to 1999 in the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database who underwent breast-conserving surgery and RT within 12 months postdiagnosis. The authors conducted descriptive and multivariate survival analyses, and considered age, race, poverty, marital status, comorbidity indices, rural/urban, radiation oncologist density, comedo necrosis histology (DCIS only), chemotherapy receipt (stage I only), and RT completion (3+ weeks of treatment) and delay (8+ weeks postsurgery without chemotherapy; 4+ weeks postchemotherapy).

RESULTS

Of 7791 subjects, 16% experienced RT delay, and 3% had incomplete RT. Subjects with stage I disease who were more likely to delay RT were of black race (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.17-2.08), whereas women in areas of high radiation oncologist density were less likely to delay (OR, 0.73; 95% CI, 0.66-0.81). Those living in high poverty areas were less likely to complete RT (P < .03), as were those undergoing chemotherapy (OR, 1.82; 95% CI, 1.15-2.88). Stage I breast cancer patients with delayed RT were more likely to experience a subsequent breast event (OR, 1.14; 95% CI, 1.00-1.30), and those with incomplete RT had a higher rate of overall mortality (OR, 1.32; 95% CI, 1.06-1.63). Factors associated with lower subsequent breast events included older age, lower poverty, and being married. RT delays of 12+ weeks (or 8+ weeks postchemotherapy) had a strongly negative impact on subsequent events (OR, 3.94; 95% CI, 2.51-6.17 for DCIS; OR, 2.77; 95% CI, 1.84-2.59 for stage I).

CONCLUSIONS

RT should be facilitated to ensure completion and timeliness, especially for early invasive breast cancer patients.

[Is geriatric assessment adapted to radiotherapy?]

Cancer in the elderly represents a major public health topic and its importance will increase in the future because of increased life expectancy and ageing. Cancer prognosis is worse due to late diagnosis, frequent comorbidities and treatment often considered as suboptimal. Reference treatments were primarily validated for younger or selected elderly patients and experimental data collected on most vulnerable are rare. Oncogeriatrics development for 15 years made it possible to consider two fundamental aspects, which are the geriatric evaluation, from the most simple to the complete one, and the development of specific trials. In addition, a strong institutional policy allowed promotion, on the French national territory, of regional experiments thanks to Pilot Units of Oncogeriatrics Coordination (UPCOG). The question of the interest of a geriatric evaluation in radiotherapy is related mainly to the difficulties of tolerance and observance of this treatment, but also with its effectiveness and this review explores the main curative, adjuvant and palliative indications as well as research perspectives.