Early start of adjuvant chemotherapy may improve treatment outcome for premenopausal breast cancer patients with tumors not expressing estrogen receptors. The International Breast Cancer Study Group

Landscape of neoadjuvant therapy for breast cancer

Neoadjuvant chemotherapy provides clinical outcomes equivalent to those achieved when the same regimen is provided in the adjuvant setting. The therapeutic response to neoadjuvant treatment may include a reduction in tumor burden that alleviates the morbidity associated with locoregional therapy. Important prognostic information can be gained based on the response to treatment and knowing the quantity and biology of the residual disease. The evaluation of investigational agents in the neoadjuvant setting is of particular value for accelerating drug development. This review highlights landmark trials and contemporary perspectives on neoadjuvant chemotherapy and hormonal therapy, treatment response as a prognostic biomarker, use of the neoadjuvant paradigm for new drug development, and clinical advances in neoadjuvant therapy by molecular subtype of breast cancer.

Ethnic differences in timely adjuvant chemotherapy and radiation therapy for breast cancer in New Zealand: a cohort study

Background

Indigenous and/or minority ethnic women are known to experience longer delays for treatment of breast cancer, which has been shown to contribute to ethnic inequities in breast cancer mortality. We examined factors associated with delay in adjuvant chemotherapy and radiotherapy for breast cancer, and its impact on the mortality inequity between Indigenous Māori and European women in New Zealand.

Methods

All women with newly diagnosed invasive non-metastatic breast cancer diagnosed during 1999–2012, who underwent adjuvant chemotherapy (n = 922) or radiation therapy (n = 996) as first adjuvant therapy after surgery were identified from the Waikato breast cancer register. Factors associated with delay in adjuvant chemotherapy (60-day threshold) and radiation therapy (90-day threshold) were analysed in univariate and multivariate models. Association between delay in adjuvant therapy and breast cancer mortality were explored in Cox regression models.

Results

Overall, 32.4% and 32.3% women experienced delays longer than thresholds for chemotherapy and radiotherapy, respectively. Higher proportions of Māori compared with NZ European women experienced delays longer than thresholds for adjuvant radiation therapy (39.8% vs. 30.6%, p = 0.045) and chemotherapy (37.3% vs. 30.5%, p = 0.103). Rural compared with urban residency, requiring a surgical re-excision and treatment in public compared with private hospitals were associated with significantly longer delays (p < 0.05) for adjuvant therapy in the multivariate model. Breast cancer mortality was significantly higher for women with a delay in initiating first adjuvant therapy (hazard ratio [HR] =1.45, 95% confidence interval [CI] 1.05-2.01). Mortality risks were higher for women with delays in chemotherapy (HR = 1.34, 95% CI 0.89-2.01) or radiation therapy (HR = 1.28, 95% CI 0.68-2.40), although these were statistically non-significant.

Conclusions

Indigenous Māori women appeared to experience longer delays for adjuvant breast cancer treatment, which may be contributing towards higher breast cancer mortality in Māori compared with NZ European women. Measures to reduce delay in adjuvant therapy may reduce ethnic inequities and improve breast cancer outcomes for all women with breast cancer in New Zealand.

Fertility preservation in women with cancer

Enhanced long-term survival rates of young women with cancer and advances in reproductive medicine and cryobiology have culminated in an increased interest in fertility preservation methods in girls and young women with cancer. Present data suggest that young patients with cancer should be referred for fertility preservation counselling quickly to help with their coping process. Although the clinical application of novel developments, including oocyte vitrification and oocyte maturation in vitro, has resulted in reasonable success rates in assisted reproduction programmes, experience with these techniques in the setting of fertility preservation is in its infancy. It is hoped that these and other approaches, some of which are still regarded as experimental (eg, ovarian tissue cryopreservation, pharmacological protection against gonadotoxic agents, in-vitro follicle growth, and follicle transplantation) will be optimised and become established within the next decade. Unravelling the complex mechanisms of activation and suppression of follicle growth will not only expand the care of thousands of women diagnosed with cancer, but also inform the care of millions of women confronted with reduced reproductive fitness because of ageing.

Wait times for breast surgical operations, 2003-2011: a report from the National Cancer Data Base

BACKGROUND

Few large-scale multicenter studies have examined wait times for breast surgery and no benchmarks exist.

METHODS

Using the National Cancer Data Base, we analyzed time from diagnosis to first surgery for 819,175 non-neoadjuvant AJCC stage 0-III breast cancer patients treated from 2003 to 2011. Chi-square tests and logistic regression models were used to examine factors associated with delays to surgery and adjuvant chemotherapy.

RESULTS

Seventy percent of patients underwent an initial lumpectomy (LP), 22% a mastectomy (MA), and 8% a mastectomy with reconstruction (MR). The median time from diagnosis to first surgery significantly increased by approximately 1 week for all three procedures over the study period. In a multivariate analysis, the following variables were independent predictors of a longer wait time to first surgery: increasing age, black or Hispanic race, Medicaid or no insurance, low-education communities and metropolitan areas, increasing comorbidities, stage 0 and grade 1 disease, academic/research facilities, high-volume facilities, and facilities located in the New England, Mid-Atlantic, and Pacific regions. In 2010-2011, patients who waited >30 days for surgery were 1.36 times more likely (OR = 1.36, 95% CI 1.30-1.43) to experience a delay to adjuvant chemotherapy >60 days compared with patients who were surgically treated within 30 days of diagnosis.

CONCLUSIONS

Facility and socioeconomic factors are most strongly associated with longer wait times for breast operations, and delays to surgery are associated with delays to adjuvant chemotherapy initiation.

The impact of postoperative complications on the administration of adjuvant therapy following pancreaticoduodenectomy for adenocarcinoma

BACKGROUND

The impact of postoperative complications on the administration of adjuvant therapy following pancreaticoduodenectomy (PD) for adenocarcinoma is still unclear.

METHODS

A retrospective review of all patients undergoing PD at our institution between 1995 and 2011 was performed. Clinicopathological data, including Clavien-Dindo complication grade, time to adjuvant therapy (TTA), and survival, were analyzed.

RESULTS

A total of 1,144 patients underwent PD for adenocarcinoma between 1995 and 2011. The overall complication rate was 49.1 % and clinically severe complications (≥IIIb) occurred in 4.2 %. Overall, 621 patients (54.3 %) were known to have received adjuvant therapy. The median TTA was 60 days. Although the presence of a complication was associated with a delay in TTA (p = 0.002), the grade of complication was not (p = 0.112). On multivariate analysis, only age > 68 years (p < 0.001) and length of stay >9 days (p = 0.002) correlated with no adjuvant therapy. Patients with postoperative complications were more likely to receive single adjuvant chemotherapy or radiation therapy (31.4 %) than were patients without complications (17.1 %; p < 0.001). Patients without a complication had a longer median survival compared with patients who experienced complications (19.5 vs. 16.1 months; p = 0.001). Patients without complications who received adjuvant therapy had longer median survival than patients with complications who received no adjuvant therapy (22.5 vs. 10.7 months; p < 0.001). Multivariate analysis demonstrated that complications [hazard ratio (HR) 1.16; p = 0.023] and adjuvant therapy (HR 0.67; p < 0.001) were related to survival.

CONCLUSION

Complications and no adjuvant therapy are common following PD for adenocarcinoma. Postoperative complications delay TTA and reduce the likelihood of multimodality adjuvant therapy. Identifying patients at increased risk for complications and those unlikely to receive adjuvant therapy warrants further investigation as they may benefit from a neoadjuvant approach.

Proper timing of adjuvant chemotherapy affects survival in patients with stage 2 and 3 gastric cancer

BACKGROUND

Adjuvant chemotherapy improves survival in patients with gastric cancer. However, the relationship between the timing of adjuvant chemotherapy and survival has not been investigated.

METHODS

Patients with D2-resected stage 2 and 3 gastric cancer that received adjuvant chemotherapy from 2005 to 2011 at Yonsei University Health System were included. The patients were grouped according to intervals between surgery and adjuvant chemotherapy.

RESULTS

Among 840 patients, the interval from surgery to the start of adjuvant therapy was less than 4 weeks in 337 (40.1 %) patients (early group), 4-8 weeks in 467 (55.6 %) patients (intermediate group), and more than 8 weeks in 36 (4.3 %) patients (late group). The 5-year RFS was 55.7 % in the early group, 54.4 % in the intermediate group, and 43.6 % in the late group (p = 0.076). The corresponding 5-year OS rates were 63.4, 62.8, and 51.7 % (p = 0.037).

CONCLUSIONS

There is insufficient evidence to suggest starting adjuvant chemotherapy within 4 weeks after surgery for patients with D2 resected stage 2 and 3 gastric cancer. However, delayed treatment of adjuvant chemotherapy after 8 weeks showed worse survival outcomes than early and intermediate treatment initiation, suggesting that adjuvant chemotherapy should be considered start within 8 weeks after radical resection.

Organizing medical oncology care at a regional level and its subsequent impact on the quality of early breast cancer management: a before-after study

BACKGROUND

One of the main measures of the French national cancer plan is to encourage physicians to work collectively, and to minimize territorial inequities in access to care by rethinking the geographical distribution of oncologists. For this reason, cancer care services are currently being reorganized at national level. A new infrastructure for multidisciplinary cancer care delivery has been put in place in our region. Patients can receive multidisciplinary health care services nearer their homes, thanks to a mobile team of oncologists. The objective of our study was to assess, using a quality approach, the impact on medical management and on the costs of treating early breast cancer, of the new regional structure for cancer care delivery.

METHODS

Before-and-after study performed from 2007 to 2010, including patients treated for early breast cancer in three hospitals in the region of Franche-Comté in Eastern France. The main outcome measures were quality criteria, namely delayed treatment (>12 weeks), dose-intensity and assessment of adjuvant chemotherapy. Other outcomes were 24-month progression-free survival (PFS) and economic evaluation.

RESULTS

This study included 667 patients. The rate of chemotherapy tended to decrease, but not significantly (49.3% before versus 42.2% after, p=0.07), while the use of taxanes increased by 38% across all centres (59.6% before versus 98.0% after, p < 0.0001). There was a non-significant reduction in the time between surgery and adjuvant chemotherapy (6.0 ± 3.0 weeks before versus 5.6 ± 3.6 weeks after, p=0.11). Dose-dense chemotherapy improved slightly, albeit non significantly (86.3% versus 91.1% p=0.22) and time to treatment tended to decrease. The new regional infrastructure did not change 24-month PFS, which remained at about 96%. The average cost of treatment was estimated at € 7000, with no difference between the two periods.

CONCLUSIONS

Despite a shortage of oncologists, the new organization put in place in our region for the provision of care for early breast cancer makes it possible to maintain local community-based treatment, without negative economic consequences. This new structure for cancer care delivery offers cancer services of similar quality with no modification of 24-month PFS in early breast cancer.

Current practices and challenges of adjuvant chemotherapy in patients with colorectal cancer

Colorectal cancer is one of the most commonly diagnosed cancers in men and women in the developed world. Although surgery is the foundation of curative treatment, adjuvant chemotherapy also improves overall and disease-free survival in high-risk stage II and all stage III patients. Research strongly suggests that the timing from surgery to adjuvant chemotherapy is critical, because delays to the start of treatment significantly affect patient outcomes. Both clinical and systemic barriers, such as postoperative complications and institutional wait times, challenge the timely administration of adjuvant chemotherapy. Further research investigating solutions to overcome these barriers is needed.

Impact of bilateral versus unilateral mastectomy on short term outcomes and adjuvant therapy, 2003-2010: a report from the National Cancer Data Base

BACKGROUND

Rates of bilateral mastectomy (BM) have increased, but the impact on length of stay (LOS), readmission rate, 30-day mortality, and time to adjuvant therapy is unknown.

METHODS

Using the National Cancer Data Base, we selected 390,712 non-neoadjuvant AJCC stage 0-III breast cancer patients who underwent either unilateral mastectomy (UM) or BM from 2003 to 2010 with and without reconstruction. We used chi-square and logistic regression models for the analysis.

RESULTS

A total of 315,278 patients (81 %) had UM, and 75,437 (19 %) had BM; 97,031 (25 %) underwent reconstruction. The number of median days from diagnosis to UM increased from 19 days in 2003 to 28 days in 2010, and for BM, increased from 21 to 31 days (p < 0.001). BM was independently associated with a longer time to surgery when adjusting for patient, facility, and tumor factors and reconstruction (OR 1.11; 95 % CI 1.07-1.15; p < 0.001). Reconstructed patients were twice as likely to have a longer time to surgery (OR 2.07; 95 % CI 2.01-2.14; p < 0.001). The median LOS was 1 day (range 0-184 days) for UM versus 2 (range 0-182) for BM (p < 0.001); 30-day mortality and readmission rates were not different between BM and UM. The median number of days from diagnosis to definitive chemotherapy, hormonal therapy, and radiation therapy was significantly greater in the BM group.

CONCLUSIONS

Delays to surgical and adjuvant treatment are significantly longer for BM irrespective of reconstruction, and these delays have increased over the study period. These findings can be used by clinicians to counsel patients on BM.

Association of molecular subtypes with Ki-67 changes in untreated breast cancer patients undergoing pre-surgical trials

BACKGROUND

Ki-67 is increasingly being used as a response biomarker in window of opportunity, pre-surgical trials for breast cancer patients. Since Ki-67 is often higher at surgery than at baseline core biopsy in subjects allocated to placebo, we investigated which factors affected this change.

PATIENTS AND METHODS

We retrieved data from 274 patients who received no active treatment in three consecutive pre-surgical trials from a single institution. We assessed the association between changes in Ki-67 from diagnostic biopsy to surgical specimen and the following factors: age, body mass index, tumor prognostic and predictive factors, including immunohistochemical molecular subtype, number and size of biopsy specimens, time from biopsy to surgery, circulating insulin-like growth factor-I, sex hormone-binding globulin and hsCRP.

RESULTS

A total of 269 patients with paired measures of Ki-67 at biopsy and surgery were analyzed. Overall, the mean (±SD) change was 2.2 ± 9.2% after a median interval of 41 days (inter-quartile range 33-48). Molecular subtype was the only factor associated with a significant change of Ki-67 (P = 0.004), with a mean absolute increase of 5.3% [95% confidence interval (CI): 2.3-8.3, P = 0.0005] in estrogen receptor-negative HER2-positive tumors (n = 36) and 5.4% (95% CI: 2.9-7.9, P < 0.0001) in triple-negative tumors (n = 78). No significant change in luminal-A (n = 46), luminal-B (n = 85) and luminal-B HER2-positive (n = 24) tumors was observed.

CONCLUSIONS

A significant increase in Ki-67 from baseline biopsy to end point surgery in untreated subjects was ascertained in HER2-positive and triple-negative tumors. This biological association suggests a real increase in cancer proliferation, possibly as a result of a biopsy-driven wound healing effect, and should be considered in the design and interpretation of pre-surgical studies.

REGISTERED CLINICAL TRIAL NUMBERS

ISRCTN86894592; ISRCTN16493703.

Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer

PURPOSE

For patients with breast cancer (BC), the optimal time to initiation of adjuvant chemotherapy (TTC) after definitive surgery is unknown. We evaluated the association between TTC and survival according to breast cancer subtype and stage at diagnosis.

PATIENTS AND METHODS

Women diagnosed with BC stages I to III between 1997 and 2011 who received adjuvant chemotherapy at our institution were included. Patients were categorized into three groups according to TTC: ≤ 30, 31 to 60, and ≥ 61 days. Survival outcomes were estimated and compared according to TTC and by BC subtype.

RESULTS

Among the 6,827 patients included, the 5-year overall survival (OS), relapse-free survival (RFS), and distant RFS (DRFS) estimates were similar for the different TTC categories. Initiation of chemotherapy ≥ 61 days after surgery was associated with adverse outcomes among patients with stage II (DRFS: hazard ratio [HR], 1.20; 95% CI, 1.02 to 1.43) and stage III (OS: HR, 1.76; 95% CI, 1.26 to 2.46; RFS: HR, 1.34; 95% CI, 1.01 to 1.76; and DRFS: HR, 1.36; 95% CI, 1.02 to 1.80) BC. Patients with triple-negative BC (TNBC) tumors and those with human epidermal growth factor receptor 2 (HER2) -positive tumors treated with trastuzumab who started chemotherapy ≥ 61 days after surgery had worse survival (HR, 1.54; 95% CI, 1.09 to 2.18 and HR, 3.09; 95% CI, 1.49 to 6.39, respectively) compared with those who initiated treatment in the first 30 days after surgery.

CONCLUSION

TTC influenced survival outcomes in the overall study cohort. This finding was particularly meaningful for patients with stage III BC, TNBC, and trastuzumab-treated HER2-positive tumors who experienced worse outcomes when chemotherapy was delayed. Our findings suggest that early initiation of chemotherapy should be granted for patients in these high-risk groups.

Breast Cancer during Pregnancy: An Interdisciplinary Approach in Our Institution

BACKGROUND

Breast cancer is the most common cancer diagnosed during pregnancy.

CASE REPORT

We report on a case of a 26-year-old woman who was diagnosed with right-sided breast cancer in her 15th week of gestation. We discussed possible treatment scenarios and the patient opted for neoadjuvant therapy with taxanes and anthracyclines during pregnancy, followed by delivery and then followed by surgery, antibody therapy, and radiotherapy. The patient received neoadjuvant chemotherapy with paclitaxel 80 mg/m(2) weekly for 12 cycles, followed by 4 cycles of epirubicin and cyclophosphamide (90/600 mg/m(2)) every 3 weeks. Complete clinical response was seen after preoperative chemotherapy. After delivery of a healthy child at 40 weeks of gestation, she received breast-conserving surgery and axillary dissection. Anti-HER2 antibody treatment with trastuzumab was started concomitantly with adjuvant radiotherapy. Endocrine treatment with a gonadotropin-releasing hormone (GnRH) analog and tamoxifen for 5 years was planned to be started after radiotherapy.

CONCLUSION

Treatment of breast cancer during pregnancy requires an interdisciplinary approach and careful consideration of the patient's stage of disease, the gestational age, and the preferences of the patient and her family.

Biomarkers for the clinical management of breast cancer: international perspective

The higher incidence of breast cancer in developed countries has been tempered by reductions in mortality, largely attributable to mammographic screening programmes and advances in adjuvant therapy. Optimal systemic management requires consideration of clinical, pathological and biological parameters. Oestrogen receptor alpha (ERα), progesterone receptor (PgR) and human epidermal growth factor receptor 2 (HER2) are established biomarkers evaluated at diagnosis, which identify cardinal subtypes of breast cancer. Their prognostic and predictive utility effectively guides systemic treatment with endocrine, anti-HER2 and chemotherapy. Hence, accurate and reliable determination remains of paramount importance. However, the goals of personalized medicine and targeted therapies demand further information regarding residual risk and potential benefit of additional treatments in specific circumstances. The need for biomarkers which are fit for purpose, and the demands placed upon them, is therefore expected to increase. Technological advances, in particular high-throughput global gene expression profiling, have generated multi-gene signatures providing further prognostic and predictive information. The rational integration of routinely evaluated clinico-pathological parameters with key indicators of biological activity, such as proliferation markers, also provides a ready opportunity to improve the information available to guide systemic therapy decisions. The additional value of such information and its proper place in patient management is currently under evaluation in prospective clinical trials. Expanding the utility of biomarkers to lower resource settings requires an emphasis on cost effectiveness, quality assurance and possible international variations in tumor biology; the potential for improved clinical outcomes should be justified against logistical and economic considerations.

Association between delayed initiation of adjuvant CMF or anthracycline-based chemotherapy and survival in breast cancer: a systematic review and meta-analysis

Background

Adjuvant chemotherapy (AC) improves survival among patients with operable breast cancer. However, the effect of delay in AC initiation on survival is unclear. We performed a systematic review and meta-analysis to determine the relationship between time to AC and survival outcomes.

Methods

PubMed, EMBASE, Cochrane Database of Systematic Reviews, and Web-of-Science databases (between January-1 1978 and January-29, 2013) were searched for eligible studies. Hazard ratios (HRs) for overall survival (OS) and disease-free survival (DFS) from each study were converted to a regression coefficient (β) corresponding to a continuous representation per 4-week delay of AC. Most used regimens of chemotherapy in included studies were CMF (cyclophosphamide, methotrexate, and fluorouracil) or anthracycline-based. Individual adjusted β were combined using a fixed-effects or random-effects model depending on heterogeneity.

Results

We included 7 eligible studies with 9 independent analytical groups involving 34,097 patients, 1 prospective observational study, 2 secondary analyses in randomized trials (4 analytical groups), and 4 hospital-/population-based retrospective study. The overall meta-analysis demonstrated that a 4-week increase in time to AC was associated with a significant decrease in both OS (HR = 1.15; 95% confidence interval [CI], 1.03-1.28; random-effects model) and DFS (HR = 1.16; 95% CI, 1.01-1.33; fixed-effects model). One study caused a significant between-study heterogeneity for OS (P < 0.001; I² = 75.4%); after excluding that single study, there was no heterogeneity (P = 0.257; I² = 23.6%) and the HR was more significant (HR = 1.17; 95% CI, 1.12-1.22; fixed-effects model). Each single study did not fundamentally influence the positive outcome and no evidence of publication bias was observed in OS.

Conclusions

Longer time to AC is probably associated with worse survival in breast cancer patients.

Obstetrical, fetal and postnatal effects of gestational antiblastic chemotherapy: how to counsel cancer patients

At least one in a thousand pregnancies is complicated by cancer and, as the maternal age at pregnancy increases, numbers are growing. If chemotherapy cannot be postponed, both doctors and patients face complex medical and ethical issues. There is a conflict between optimal maternal therapy and fetal wellbeing. Treatment during the first trimester increases the risk of congenital malformations, spontaneous abortions and fetal death. Second and third trimester exposure is less risky, but it can cause intrauterine growth retardation and low birth weight. Other effects on pregnancy after the first trimester include premature birth, stillbirth, impaired functional development, myocardial toxicity and myelosuppression. Counseling and management of these cases are difficult, because literature is mostly represented by case reports or retrospective series while randomized prospective studies or guidelines are lacking. Moreover, personal experience is often scanty due to the rarity of the condition. This article reviews the available data regarding the different aspects of systemic treatment of cancer during pregnancy to help oncologist and obstetricians in counseling their patients and treat them accordingly.

Early initiation of adjuvant chemotherapy improves survival of patients with pancreatic carcinoma after surgical resection

PURPOSE

Adjuvant chemotherapy is accepted as a standard treatment after surgical resection of pancreatic carcinoma; however, the optimal timing between surgery and initiation of adjuvant chemotherapy has not been reported. The aim of this study was to determine the optimal timing of adjuvant chemotherapy after surgical resection of pancreatic carcinoma.

METHODS

Records of 104 patients who received adjuvant chemotherapy after curative surgical resection of pancreatic carcinoma were reviewed retrospectively. Patients were grouped according to whether they received initial adjuvant chemotherapy within 20 days after surgery (20 days, n = 47). Relationships between time to initiation of adjuvant chemotherapy, other clinicopathological factors, and survival were analyzed.

RESULTS

The rate of postoperative complication was significantly lower than in the 20 days group (P = 0.003); no significant difference in other clinicopathological factors was found. Multivariate analysis revealed that time to initiation of adjuvant chemotherapy was an independent prognostic factor of disease-free survival (P = 0.009) and overall survival (P = 0.037). The 20 days group (52 vs. 26 %, P = 0.013) as well as longer 5-year disease-free survival rates (53 vs. 22 %, P = 0.007).

CONCLUSIONS

Adjuvant chemotherapy for patients with resected pancreatic carcinoma should be initiated as soon as possible after surgical resection. Prevention of postoperative complication is needed to enable early initiation.

Disparities in timeliness of care for U.S. Medicare patients diagnosed with cancer

BACKGROUND

Timeliness of care (rapid initiation of treatment after definitive diagnosis) is a key component of high-quality cancer treatment. The present study evaluated factors influencing timeliness of care for U.S. Medicare enrollees.

METHODS

Data for Medicare enrollees diagnosed with breast, colorectal, lung, or prostate cancer while living in U.S. seer (Surveillance, Epidemiology and End Results) regions in 2000-2002 were analyzed. Patients were classified as experiencing delayed treatment if the interval between diagnosis and treatment was greater than the 95th percentile for each cancer site. The impacts of patient sociodemographic, clinical, and area-based factors on the likelihood of delayed treatment were analyzed using multivariate logistic regression.

RESULTS

Black patients (compared with white patients) and patients initially treated with radiation therapy or chemotherapy (rather than surgery) had a greater likelihood of treatment delays across all four cancer sites. Hispanic status, dual Medicare-Medicaid status, location of initial treatment (inpatient vs. outpatient), and stage at diagnosis also affected timeliness of care for some cancer sites. Surprisingly, area-based factors reflecting availability of cancer care services were not significantly associated with timeliness of care or were associated with greater delays in areas with greater numbers of service providers.

CONCLUSIONS

Multiple factors affected receipt of timely cancer care for members of the study population, all of whom had coverage of medical care services through Medicare. Because delays in treatment initiation can increase morbidity, decrease quality of life, shorten survival, and result in greater costs, prospective studies and tailored interventions are needed to address those factors among at-risk patient groups.

Time to adjuvant chemotherapy for breast cancer in National Comprehensive Cancer Network institutions

BACKGROUND

High-quality care must be not only appropriate but also timely. We assessed time to initiation of adjuvant chemotherapy for breast cancer as well as factors associated with delay to help identify targets for future efforts to reduce unnecessary delays.

METHODS

Using data from the National Comprehensive Cancer Network (NCCN) Outcomes Database, we assessed the time from pathological diagnosis to initiation of chemotherapy (TTC) among 6622 women with stage I to stage III breast cancer diagnosed from 2003 through 2009 and treated with adjuvant chemotherapy in nine NCCN centers. Multivariable models were constructed to examine factors associated with TTC. All statistical tests were two-sided.

RESULTS

Mean TTC was 12.0 weeks overall and increased over the study period. A number of factors were associated with a longer TTC. The largest effects were associated with therapeutic factors, including immediate postmastectomy reconstruction (2.7 weeks; P < .001), re-excision (2.1 weeks; P < .001), and use of the 21-gene reverse-transcription polymerase chain reaction assay (2.2 weeks; P < .001). In comparison with white women, a longer TTC was observed among black (1.5 weeks; P < .001) and Hispanic (0.8 weeks; P < .001) women. For black women, the observed disparity was greater among women who transferred their care to the NCCN center after diagnosis (P (interaction) = .008) and among women with Medicare vs commercial insurance (P (interaction) < .001).

CONCLUSIONS

Most observed variation in TTC was related to use of appropriate therapeutic interventions. This suggests the importance of targeted efforts to minimize potentially preventable causes of delay, including inefficient transfers in care or prolonged appointment wait times.

[Influence of clinical and biographical factors on the delay in starting adjuvant chemotherapy treatment among breast cancer patients]

BACKGROUND AND OBJECTIVE

Previous studies have related the delay in starting chemotherapy (>3 months from date of surgery) with worse survival. The study objective is to analyse the delay in the start of chemotherapy and associated biomedical, sociodemographic and cultural factors.

PATIENTS AND METHODS

A cohort of women operated on for breast cancer, candidates for receiving adjuvant chemotherapy and participants in a clinical trial of non-pharmacological intervention, were surveyed regarding the delay in starting their chemotherapy, measured by the number of days from date of surgery. Differences in function of the clinical and biographical variables were studied.

RESULTS

In 197 women, mean delay was 42.32 (15.29) days; this was associated with tumour stage (i, 40.06 days; ii, 44.76 days; iii, 38.7 days; P=.049), age (≤ 35, 37.36 days; 36-64, 41.49 days; ≥ 65, 52.61 days; P=.007) and occupational situation (active, 36.91 days; unemployed, 45.5 days; pensioner, 40.07 days; housewife, 43.17 days; P=.038). For patients older than 65 years, the delay in starting adjuvant chemotherapy was longer than for those in the 2 lower age groups -less than 35 years, and between 35 and 65 years- (P=.023 and P=.009 respectively). In the multivariate analysis, the variables associated independently with the delay in starting chemotherapy were again age (P=.019), tumour stage (P=.037) and occupational situation (P=.022).

CONCLUSION

Patients began receiving adjuvant chemotherapy within the time period (3 months from surgery) defined as appropriate, and during which no evidence exists of worse survival results. Length of delay varied according to age, tumour stage and occupational situation.

Delays in Adjuvant Chemotherapy Treatment Among Patients With Breast Cancer Are More Likely in African American and Hispanic Populations: A National Cohort Study 2004-2006

Purpose

Previous studies have indicated poorer survival among women receiving adjuvant chemotherapy > 90 days after surgery compared with women receiving adjuvant chemotherapy within 90 days of surgery.

Patients and Methods

Women diagnosed between 2004 and 2006 with invasive breast cancer (stages I to III) and treated with surgery and adjuvant chemotherapy were selected from the National Cancer Database (n = 107,587). We evaluated factors associated with prolonged time to start adjuvant chemotherapy (≥ 60 and ≥ 90 days after surgical resection) using multivariable log binomial models to estimate risk ratios (RRs) and 95% CIs.

Results

The average time to adjuvant chemotherapy was 41.46 days (± 24.46 days). Overall, 85.2% and 95.8% of women received adjuvant chemotherapy within 60 and 90 days of surgery, respectively. African American and Hispanic patients had higher risk of 60-day delay (RR, 1.36; 95% CI, 1.30 to 1.41 and RR, 1.31; 95% CI, 1.23 to 1.39, respectively) and 90-day delay (RR, 1.56; 95% CI, 1.44 to 1.69 and RR, 1.41; 95% CI, 1.26 to 1.59, respectively) compared with white patients. Insurance type, stage, comorbidity, and facility type were also associated with adjuvant chemotherapy delay.

Conclusion

The majority of women in our study received adjuvant chemotherapy within the time frame (90 days) for which there is no evidence of poorer outcome. However, the rate of delay varied by patient and by clinical and facility factors. Future studies on the role of structural, physician, clinical, and patient factors in adjuvant chemotherapy delay in populations of women with higher rates of delay and potential interventions are needed.

Adjuvant FOLFOX-4 in patients with radically resected gastric cancer: Tolerability and prognostic factors

The aim of the present study was to evaluate the toxicity and efficacy of the FOLFOX-4 regimen as adjuvant chemotherapy in patients with gastric cancer after radical surgery. Fifty-four patients (1 stage Ib, 6 stage II, 22 stage IIIa, 14 stage IIIb and 11 stage IV) received 8-12 cycles of FOLFOX-4 (oxaliplatin 85 mg/m(2), Day 1; leucovorin 100 mg/m(2) i.v., Days 1 and 2; 5-fluorouracil 400 mg/m(2) i.v. bolus, Days 1 and 2 and 600 mg/m(2) in 22 h i.v. continuous infusion, Days 1 and 2; every 14 days). Toxicity was recorded at each cycle according to the National Cancer Institute Common Toxicity Criteria. Disease-free (DFS) and overall survival (OS) were calculated according to the Kaplan-Meier method. Thirty-eight patients (70.4%) completed the prescribed number of cycles of chemotherapy. The toxicity was mild. Grade 3-4 neutropenia occurred in 57% of patients, thrombocytopenia and anemia in 2% of cases. Peripheral neuropathy was experienced by 46% of the patients (grade 4 in 2% of cases). Five patients experienced grade 3 gastrointestinal toxicity. After a median follow-up of 33.1 months, 17 patients relapsed and 17 succumbed to the disease. The mean observed DFS and OS were 49.7 months (range 40.7-58.8) and 57.9 months (range 49.6-66.2), respectively. At univariate analysis, females and patients who had received <8 cycles of chemotherapy had a significantly worse probability of DFS and OS. The Cox model showed gender to be independent of the factors affecting DFS. Adjuvant FOLFOX-4 is feasible and well-tolerated in patients radically resected for gastric cancer. Receiving <4 months of adjuvant FOLFOX-4 could be detrimental to prognosis.

Optimal timing of adjuvant treatment in patients with early breast cancer

It is well established that adjuvant treatment reduces mortality after early breast cancer. However, the optimal timing of adjuvant treatment is not well described. To determine the optimal timing of adjuvant treatment, 402 breast cancer patients who received adjuvant treatment at Ankara Oncology Research and Training Hospital between January 1995 and August 2002 were evaluated retrospectively. Three hundred and fifty-seven (88.8%) patients received adjuvant chemotherapy, 204 (50.7%) of these patients received only adjuvant chemotherapy and 153 (38%) patients received tamoxifen following chemotherapy. Remaining 45 (11.2%) patients received only adjuvant tamoxifen. The median time to start adjuvant treatment after surgery was day 21 (range, days 4 to days 258), and the median follow-up was 50 months (range, 6-105 months). The patients were divided into 5 groups according to starting time of chemotherapy (shorter than 14 days, between days 15-29, between days 30-44, between days 45.-59 and more than 59 days). Overall survival (OS) and disease-free survival (DFS) were not shown significantly different between for 5 groups (P>0.05). Secondly, patients were divided into two groups as starting adjuvant treatment equal to or shorter than 44 days and longer than 44 days (n=344, 85.6% and vs. n=58, 14.4%, respectively). OS was significantly better in patients who started to receive adjuvant treatment within 44 days after surgery compared to patients who received adjuvant treatment after 44 days (92 vs. 83.3%, P=0.03) for 5 years, but DFS was not significantly different between two groups (83.4 vs. 82.2%, P>0.05). According to our study, adjuvant treatment of breast cancer should be initiated earlier after surgery.

Neoadjuvant versus adjuvant chemotherapy for triple negative breast cancer

BACKGROUND

The study aim was to investigate factors that predict the use of neoadjuvant versus adjuvant chemotherapy in patients with triple negative breast cancer (TNBC) and the overall survival in each group.

METHODS

We identified 493 patients with Stage I-III TNBC between 1998 and 2008. Patients were divided according to receipt of neoadjuvant, adjuvant, or none/unknown chemotherapy. Data were compared using chi(2) and Fisher's exact test. For more than two group comparisons and analyzing multiple dependent variables, MANOVA was used. Kaplan-Meier curves were generated.

RESULTS

Of 493 patients with TNBC, 154 (31%) received neoadjuvant chemotherapy, 251 (51%) received adjuvant chemotherapy, and 88 (18%) had no or unknown chemotherapy. Patients undergoing neoadjuvant chemotherapy were younger (mean 50, range 20-83) compared with those undergoing adjuvant chemotherapy (mean 53, range 25-83) or none/unknown chemotherapy (mean 62, range 29-86) (P < 0.0001). The three groups did not differ significantly by patient race, tumor histology, or tumor grade. Increased tumor size, nodal positivity, and advanced stage were more likely to be associated with use of neoadjuvant chemotherapy (all comparisons P < 0.0001). After controlling for covariates associated with survival in unadjusted tests, patients undergoing adjuvant therapy were less likely to die compared with patients undergoing neoadjuvant therapy or none/unknown therapy (overall aHR 0.476, 95% CI 0.295-0.770).

CONCLUSIONS

Women with TNBC who underwent adjuvant chemotherapy were 52% less likely to die overall compared with those who received neoadjuvant chemotherapy or none/unknown chemotherapy in this institutional series. Prospective studies are necessary to determine if this finding is durable.

Combinatorial biomarker expression in breast cancer

Current clinical management of breast cancer relies on the availability of robust clinicopathological variables and few well-defined biological markers. Recent microarray-based expression profiling studies have emphasised the importance of the molecular portraits of breast cancer and the possibility of classifying breast cancer into biologically and molecularly distinct groups. Subsequent large scale immunohistochemical studies have demonstrated that the added value of studying the molecular biomarker expression in combination rather than individually. Oestrogen (ER) and progesterone (PR) receptors and HER2 are currently used in routine pathological assessment of breast cancer. Additional biomarkers such as proliferation markers and 'basal' markers are likely to be included in the future. A better understanding of the prognostic and predictive value of combinatorial assessment of biomarker expression could lead to improved breast cancer management in routine clinical practice and would add to our knowledge concerning the variation in behaviour and response to therapy. Here, we review the evidence on the value of assessing biomarker expression in breast cancer individually and in combination and its relation to the recent molecular classification of breast cancer.

What's new in neoadjuvant therapy for breast cancer?

Neoadjuvant treatment of breast cancer is currently being used in patients with advanced disease as well as with increasing application in those that present with initially operable breast cancer. The current clinical benefits of the use of NAC include: NAC increases the possibility of the use of BCS, the safety of NAC is comparable with that of adjuvant chemotherapy, and pCR may be predictive of overall survival. Although there are still unresolved clinical questions regarding the use of neoadjuvant therapy in initially operable breast cancer, there appears to be equivalent survival to the standard of care. Future research should be aimed at tailoring treatment to individual patients using specific tumor characteristics that may predict response to different types of chemotherapy, molecular targeted therapy, and endocrine therapy.

Etiology of delays in the initiation of adjuvant chemotherapy and their impact on outcomes for Stage II and III rectal cancer

PURPOSE

This study was designed to evaluate the role of access to care and postsurgical recovery on delays in adjuvant chemotherapy for rectal cancer.

METHODS

Using data from the linked Surveillance, Epidemiology, and End Results-Medicare database, we analyzed patients with Stage II or III rectal cancer who received adjuvant chemotherapy after curative rectal cancer surgery between 1991 and 2002. Logistic and Cox regressions were performed to assess determinants of adjuvant chemotherapy delays and outcomes in two cohorts: patients with access to medical oncology care because of prior neoadjuvant chemotherapy (Group A) and patients without such access (Group B). Length of postoperative hospital stay served as the main proxy for postsurgical recovery.

RESULTS

A total of 442 and 5,617 patients were included in Groups A and B, respectively. The median interval between surgery and adjuvant chemotherapy was 46 days in Group A and 42 days in Group B. Although 17 percent and 11 percent of patients in Groups A and B, respectively, waited three or more months for adjuvant chemotherapy, median overall survival was worse in this subset than in those who waited less than 3 months (54 vs. 76 months, P < 0.01). Postoperative hospital stay independently predicted for adjuvant chemotherapy delay in both groups. Disparities in delays were seen only in Group B, such that patients who were older or black had greater odds of an adjuvant chemotherapy delay (for both, P < 0.05).

CONCLUSION

Advanced age and black race contribute to adjuvant chemotherapy delays and inferior outcomes, but postoperative recovery is the more important driver.