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Babu G, Goel A, Agarwal S, Gupta S, Kumar P, Smruti BK, Goel V, Sarangi R, Gairola M, Aggarwal S, Parikh PM. Practical consensus recommendations regarding the management of hormone receptor positive early breast cancer in elderly women. South Asian J Cancer 2020; 7:123-126. [PMID: 29721478 PMCID: PMC5909289 DOI: 10.4103/sajc.sajc_117_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Breast cancer is a leading cause of death among women, and its incidence increases with age. Currently the treatment of breast cancer in older patients is almost identical to their younger counterparts. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists regarding the management of early breast cancer specifically in elderly women.
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Affiliation(s)
- Govind Babu
- Department of Medical Oncology, KMIO, Bengaluru, Karnataka, India
| | - A Goel
- Department of Surgical Oncology, Max Hospital, New Delhi, India
| | - S Agarwal
- Department of Radiation Oncology, Max Hospital, New Delhi, India
| | - S Gupta
- Department of Medical Oncology, Sarvodaya Hospital, Faridabad, Haryana, India
| | - P Kumar
- Department of Radiation Oncology, Ram Murti Medical College, Bareilly, Uttar Pradesh, India
| | - B K Smruti
- Department of Medical Oncology, Bombay Hospital, Mumbai, Maharashtra, India
| | - V Goel
- Department of Radiation Oncology, Max Hospital, New Delhi, India
| | - R Sarangi
- Department of Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - M Gairola
- Department of Radiation Oncology, RGCI, New Delhi, India
| | - S Aggarwal
- Department of Medical Oncology, Sir Ganga Ram Hospital, New Delhi, India
| | - Purvish M Parikh
- Department of Oncology, Shalby Cancer and Research Institute, Mumbai, Maharashtra, India
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Omitting radiotherapy is safe in breast cancer patients ≥ 70 years old after breast-conserving surgery without axillary lymph node operation. Sci Rep 2020; 10:19481. [PMID: 33173112 PMCID: PMC7655830 DOI: 10.1038/s41598-020-76663-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/29/2020] [Indexed: 12/20/2022] Open
Abstract
To verify whether omitting radiotherapy from breast cancer treatment for patients ≥ 70 years old following breast-conserving surgery (BCS) without axillary lymph node dissection is safe. Previous studies have shown that omitting breast radiotherapy after BCS and axillary lymph node dissection is safe for elderly breast cancer patients. We aimed to evaluate the safety of BCS without axillary surgery or breast radiotherapy (BCSNR) in elderly patients with breast cancer and clinically negative axillary lymph nodes. We performed a retrospective analysis of 481 patients with breast cancer, aged ≥ 70 years, between 2010 and 2016. Of these, 302 patients underwent BCSNR and 179 underwent other, larger scope operations. Local recurrence rate, ipsilateral breast tumor recurrence (IBTR) rate, distant metastasis rate, breast-related death, disease-free survival (DFS), and overall survival (OS) were compared between the two groups. After a median follow-up of 60 months, no significant differences in local recurrence, distant metastasis rate, breast-related death, and DFS were noted. The OS was similar (P = 0.56) between the BCSNR group (91.7%) and other operations group (93.0%). The IBTR rate was considered low in both groups, however resulted greater (P = 0.005) in the BCSNR group (5.3%) than in other operations group (1.6%). BCSNR did not affect the survival of elderly patients with breast cancer with clinically negative axillary lymph nodes. IBTR was infrequent in both groups; however, there was a significant difference between the two groups. BCSNR is a feasible treatment modality for patients with breast cancer ≥ 70 years old with clinically negative axillary lymph nodes.
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Ruiz J, Maldonado G, Ablah E, Okut H, Reyes J, Quinn K, Tenofsky PL. Could lymph node evaluation be eliminated in nearly 50% of women with early stage ER/PR positive breast cancer? Am J Surg 2020; 220:1417-1421. [PMID: 33097191 DOI: 10.1016/j.amjsurg.2020.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/16/2020] [Accepted: 10/04/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Society of Surgical Oncology introduced guidance discouraging routine axillary staging in women 70 years or older with invasive, clinically node negative, hormone-receptor positive breast cancer. Due to concerns this could result in patients missing necessary treatment, researchers from the Mayo Clinic developed a rule to distinguish between those at low/high-risk of having positive nodes. The purpose of this study was to validate the Mayo Clinic rule in women of all ages. METHODS A retrospective review was conducted on patients seen in one breast surgeon's practice from January 1, 2006 through March 1, 2018. The Mayo Clinic rule was applied, and accuracy was evaluated. RESULTS Utilizing the Mayo Clinic rule, 46.8% (n = 289) of women met low-risk criteria. Unexpected positive lymph nodes in low-risk women was 10.0% (n = 29), which was similar to the Mayo Clinic study finding (7.8%, P = 0.167). CONCLUSIONS These data suggest the Mayo Clinic rule is reproducible. Nearly 50% of women with hormone receptor positive breast cancer could avoid axillary staging, but about 10% will have unexpected positive lymph nodes.
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Affiliation(s)
- Juan Ruiz
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Gerson Maldonado
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Elizabeth Ablah
- Department of Preventive Medicine and Public Health, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Hayrettin Okut
- Office of Research, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Jared Reyes
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Karson Quinn
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Patty L Tenofsky
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA; Department of Surgery, Ascension Via Christi Clinic, Wichita, KS, USA.
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Xu L, Wen N, Qiu J, He T, Tan Q, Yang J, Du Z, Lv Q. Predicting Survival Benefit of Sparing Sentinel Lymph Node Biopsy in Low-Risk Elderly Patients With Early Breast Cancer: A Population-Based Analysis. Front Oncol 2020; 10:1718. [PMID: 33042815 PMCID: PMC7517716 DOI: 10.3389/fonc.2020.01718] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/31/2020] [Indexed: 02/06/2023] Open
Abstract
Objective: The application of sentinel lymph node biopsy (SLNB) in elderly patients with early breast cancer remains somewhat controversial. This study aimed to establish individualized nomograms to predict survival outcomes of elderly patients with and without SLNB and find out which patients could avoid SLNB. Methods: A total of 39,962 ≥70-year-old patients diagnosed with T1–T2 breast cancer in 2010–2015 were included from the Surveillance, Epidemiology, and End Results (SEER) program and were divided into the training set (n = 29,971) and the validation set (n = 9,991). Axillary surgery was not specified in the SEER database, and we defined removing one to five lymph nodes as SLNB. Survival analysis was performed using the Kaplan–Meier plot and log-rank test. Multivariate Cox analysis was utilized to identify risk factors for overall survival (OS) and breast-cancer-specific survival (BCSS). Nomograms and a risk stratification model were constructed. Results: In the training set, patients with SLNB had better OS (adjusted HR 0.57, P < 0.001) and BCSS (adjusted HR 0.55, P < 0.001) than patients without SLNB. Multivariate COX analysis identified age, marital status, grade, subtype, T stage, and radiation as independent risk factors for OS and BCSS in both SLNB and non-SLNB groups (all P < 0.05). They were subsequently incorporated to establish nomograms to predict 3- and 5-year OS and BCSS for patients with or without SLNB. The concordance index ranged from 0.687 to 0.820, and calibration curves in the internal set and external set all demonstrated sufficient accuracies and good predictive capabilities. Further, we generated a risk stratification model which indicated that SLNB improved OS and BCSS in high-risk group (OS: HR 0.49, P < 0.001; BCSS: HR 0.54, P < 0.001), but not in the low-risk group (all P > 0.05). Conclusion: Well-validated nomograms and a risk stratification model were constructed to evaluate survival benefit from SLNB in elderly patients with early-stage breast cancer. SLNB was important for patients in the high-risk group but could be omitted in the low-risk group without sacrificing survival. This study could assist clinicians and elderly patients to weigh the risk–benefit of SLNB and make individualized decisions. We look forward to more powerful evidence from prospective trials.
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Affiliation(s)
- Li Xu
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Nan Wen
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Juanjuan Qiu
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Tao He
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Qiuwen Tan
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jiqiao Yang
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenggui Du
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Lv
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
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Wang T, Mott N, Miller J, Berlin NL, Hawley S, Jagsi R, Dossett LA. Patient Perspectives on Treatment Options for Older Women With Hormone Receptor-Positive Breast Cancer: A Qualitative Study. JAMA Netw Open 2020; 3:e2017129. [PMID: 32960279 PMCID: PMC7509630 DOI: 10.1001/jamanetworkopen.2020.17129] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/07/2020] [Indexed: 12/27/2022] Open
Abstract
Importance Women aged 70 years or older with hormone receptor-positive breast cancer have an excellent prognosis, but because of their age and comorbidities, they are at higher risk for treatment-related adverse events. Despite studies demonstrating the safety of omitting previously routine therapies, including sentinel lymph node biopsy (SLNB) and postlumpectomy radiotherapy, these treatments continue to be used at high rates. Physicians cite patient preference as one factor associated with overuse. However, little is known about how women view potential de-escalation of therapies. Objective To evaluate older women's preferences for SLNB and radiotherapy in the setting of guidelines recommending them or allowing for their omission. Design, Setting, and Participants This qualitative study was performed from October 2019 to January 2020. Midwestern women aged 70 years and older who had never received a diagnosis of breast cancer were recruited online and interviewed. Guided by an interpretive description approach, interviews were analyzed to produce a thematic description. Data analysis was performed from January to March 2020. Exposures Participants were presented with hypothetical scenarios in which they received a diagnosis of low-risk, hormone receptor-positive breast cancer and were given treatment options in accordance with current guidelines. Main Outcomes and Measures The interviews elicited perspectives on breast cancer treatment, including surgery, SLNB, chemotherapy, and postlumpectomy radiotherapy. Results The median (interquartile range) age of the 30 participants was 72.0 (71.0-76.5) years. Most of the women were White (26 participants [87%]), lived in metropolitan areas (29 participants [97%]), and were college educated (20 participants [67%] had a 4-year degree or higher). Overall, women expressed the belief that age-based guidelines were appropriate on the basis of decreased recurrence risk and increased frailty in older patients. However, many participants stated that these guidelines should not apply to healthy older women with a long life expectancy. Some participants struggled to understand that the basis for treatment de-escalation in older patients is a favorable, not poor, prognosis. Women who said they would undergo SLNB (12 participants [40%]) perceived the procedure as low risk and providing peace of mind. Most participants (22 participants [73%]) expressed a preference for omitting postlumpectomy radiotherapy because of the perceived risks, lack of benefit, and inconvenience. Conclusions and Relevance Positive reframing of the excellent prognosis driving national recommendations for de-escalation may reduce breast cancer overtreatment in older women. Strategies for reducing SLNB use will likely require education on the risks vs benefits and addressing patient preferences for peace of mind. In contrast, efforts to reduce radiotherapy use may need to address clinician or organizational factors.
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Affiliation(s)
- Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Nicole Mott
- University of Michigan Medical School, Ann Arbor
| | - Jacquelyn Miller
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Nicholas L. Berlin
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Sarah Hawley
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Reshma Jagsi
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Lesly A. Dossett
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Sun J, Loftus LS, Lee MC. ASO Author Reflections: The De-Escalation of Sentinel Node Biopsy for Breast Cancer. Ann Surg Oncol 2020; 27:838-839. [PMID: 32666299 DOI: 10.1245/s10434-020-08854-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/02/2020] [Indexed: 11/18/2022]
Affiliation(s)
- James Sun
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Department of General Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Loretta S Loftus
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Marie Catherine Lee
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
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Cortina CS, Woodfin AA, Tangalakis LL, Wang X, Son JD, Poirier J, Rao R, Kopkash K, Madrigrano A. Treating Positive Axillary Disease in Elderly Breast Cancer Patients: The Impact of Age on Radiation Therapy. Breast Care (Basel) 2020; 16:276-282. [PMID: 34248469 DOI: 10.1159/000508243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/28/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Breast cancer is the second most common cause of cancer death in females, and 30% of these patients are over the age of 70 years. Studies have shown deviation from the standard treatment paradigms in the elderly, especially in regard to radiation treatment. Methods We performed a retrospective chart review on 118 patients over the age of 70 years diagnosed with breast cancer and pathologically proven axillary disease over an 8-year period at an urban academic hospital to examine which patient factors influenced radiotherapy. Results Increasing patient age was associated with a decrease in the probability of receiving radiotherapy, while HER2-negative patients were more likely to receive radiation. Neither race, number of coexisting medical conditions, or insurance status showed any influence on radiation treatment. Conclusion Patient age has a significant influence if elderly patients with axillary disease receive radiotherapy. Further investigation and validation are needed to understand why chronological age rather than biological age influences treatment modalities.
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Affiliation(s)
| | - Ashley A Woodfin
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Laurel L Tangalakis
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Xuanji Wang
- Rush Medical College, Chicago, Illinois, USA
| | - Jennifer D Son
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jennifer Poirier
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Ruta Rao
- Division of Oncology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Katherine Kopkash
- Division of Surgical Oncology, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Andrea Madrigrano
- Division of Surgical Oncology, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
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58
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Sun J, Mathias BJ, Sun W, Fulp WJ, Zhou JM, Laronga C, Loftus LS, Lee MC. Is it Wise to Omit Sentinel Node Biopsy in Elderly Patients with Breast Cancer? Ann Surg Oncol 2020; 28:320-329. [PMID: 32613363 DOI: 10.1245/s10434-020-08759-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Society of Surgical Oncology's Choosing Wisely® guidelines recommend against routine sentinel lymph node biopsy (SLNB) in clinically node-negative (cN0), hormone receptor (HR)-positive breast cancer patients aged ≥ 70 years. We examined the effect of SLNB on treatment and outcomes in this population. MATERIALS AND METHODS A single-institution retrospective review of consecutive cN0 women ≥ 70 years of age who received SLNB was performed. We collected clinicopathologic characteristics and treatment data. Patients were compared according to SLN status with subset analysis of HR-positive patients. Outcomes were analyzed using the Kaplan-Meier method and univariable analysis, and were compared using log-rank tests. RESULTS Of 500 patients, 345 (69%) were SLN-negative. Median age was 74 years (range 70-96). Most tumors were T1 (72%), N0 (69%), invasive ductal (77%), without lymphovascular invasion (88%), estrogen receptor-positive (88%) and progesterone receptor-positive (75%), and human epidermal growth factor receptor 2 (HER2)-negative (88%) treated with lumpectomy (71%). Median number of SLNs obtained was 2 (range 0-12) and median number of positive SLNs was 0 (range 0-8). Characteristics of the HR-positive subset were similar. In both the overall cohort and the HR-positive subset, SLN status significantly affected the use of adjuvant chemotherapy, although no significant effect on recurrence was observed. SLN-negative patients had better overall survival and less distant recurrence (both p < 0.0001). Adjuvant hormone therapy significantly improved overall survival. CONCLUSIONS SLNB can be safely omitted in elderly patients with T1, HR-positive, invasive ductal carcinoma tumors, but may still provide important information affecting treatment. Patients who are candidates for adjuvant systemic chemotherapy should still be considered for SLNB.
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Affiliation(s)
- James Sun
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Brittany J Mathias
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Mercy Clinic Breast Surgery - Coletta, Oklahoma City, OK, USA
| | - Weihong Sun
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - William J Fulp
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.,Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Jun-Min Zhou
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Christine Laronga
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Loretta S Loftus
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - M Catherine Lee
- Department of Breast Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
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Breast-conserving surgery without axillary lymph node surgery or radiotherapy is safe for HER2-positive and triple negative breast cancer patients over 70 years of age. Breast Cancer Res Treat 2020; 182:117-126. [PMID: 32430680 DOI: 10.1007/s10549-020-05686-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/11/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The prognosis of elderly patients with hormone receptor-positive breast cancer is very good, and their survival is unaffected by performing breast-conserving surgery (BCS) without radiotherapy. Therefore, we aimed to verify that BCS without axillary lymph node dissection, sentinel lymph node biopsy, or radiotherapy (BCSNR) is safe for patients over 70 years of age with luminal-type breast cancer, as well as for those with HER2-positive and triple negative breast cancer (TNBC). METHODS This study retrospectively included 450 patients > 70-year-old with breast cancer from 2010 to 2016. The patients were divided into two groups, one treated with BCSNR and the other treated with mastectomy and axillary lymph node dissection (MALND), with a median follow-up period of 5 years. Disease-free survival (DFS), overall survival, local recurrence, distant metastasis, and ipsilateral breast tumor recurrence (IBTR) were compared between the two groups. RESULTS The 5-year DFS for patients who underwent BCSNR and MALND was 90.1 and 91.3% (p = 0.903), respectively. In the BCSNR and MALND groups, respectively, the 5-year DFS for patients with luminal A type breast cancer was 99.2 and 100% (p = 0.167), that for patients with luminal B type breast cancer was 89.2 and 95.5% (p = 0.138), that for patients with HER2-positive breast cancer was 86.7 and 75.9% (p = 0.455), and that for TNBC patients was 71.7 and 89.7% (p = 0.195). IBTR significantly differed between the BCSNR and MALND groups for patients with TNBC (18.9% vs 0.0%, p = 0.040) and luminal B type patients (5.6% vs 0.0%, p = 0.043). CONCLUSION BCSNR is not only suitable for elderly patients with luminal-type breast cancer but also for those with HER2-positive breast cancer and TNBC.
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Smith ME, Vitous CA, Hughes TM, Shubeck SP, Jagsi R, Dossett LA. Barriers and Facilitators to De-Implementation of the Choosing Wisely ® Guidelines for Low-Value Breast Cancer Surgery. Ann Surg Oncol 2020; 27:2653-2663. [PMID: 32124126 DOI: 10.1245/s10434-020-08285-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND To address overuse of unnecessary practices, several surgical organizations have participated in the Choosing Wisely® campaign and identified four breast cancer surgical procedures as unnecessary. Despite evidence demonstrating no survival benefit for all four, evidence suggests only two have been substantially de-implemented. Our objective was to understand why surgeons stop performing certain unnecessary cancer operations but not others and how best to de-implement entrenched and emerging unnecessary procedures. METHODS We sampled surgeons who treat breast cancer in a variety of practice types and geographic regions in the United States. Using a semi-structured guide, we conducted telephone interviews (n = 18) to elicit attitudes and understand practices relating to the four identified breast cancer procedures in the Choosing Wisely® campaign. Interviews were recorded, transcribed, and anonymized. Transcripts were analyzed using inductive and deductive thematic analysis. RESULTS For the two procedures successfully de-implemented, surgeons described a high level of confidence in the data supporting the recommendations. In contrast, surgeons frequently described a lack of familiarity or skepticism toward the recommendation to avoid sentinel-node biopsy in women ≥ 70 years of age and the influence of other collaborating oncology providers as justification for continued use. Regarding contralateral prophylactic mastectomy, surgeons consistently agreed with the recommendation that this was unnecessary, yet reported continued utilization due to the value placed on patient autonomy and preference. CONCLUSIONS With a growing focus on the elimination of ineffective, unproven or low value practices, it is imperative that the behavioral determinants are understood and targeted with specific interventions to decrease utilization rapidly.
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Affiliation(s)
- Margaret E Smith
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - C Ann Vitous
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Tasha M Hughes
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Sarah P Shubeck
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
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61
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Tran HT, Pack D, Mylander C, Martino L, Rosman M, Tafra L, Jackson RS. Ultrasound-Based Nomogram Identifies Breast Cancer Patients Unlikely to Harbor Axillary Metastasis: Towards Selective Omission of Sentinel Lymph Node Biopsy. Ann Surg Oncol 2020; 27:2679-2686. [PMID: 32026063 DOI: 10.1245/s10434-019-08164-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND As tumor biology takes precedence over anatomic staging to determine breast cancer (BC) prognosis, there is growing interest in limiting axillary surgery. There is a need for tools to identify patients at the lowest risk of harboring axillary lymph node (ALN) disease, to determine when omission of sentinel lymph node biopsy (SLNB) may be appropriate. We examined whether a nomogram using preoperative axillary ultrasound (axUS) findings, clinical tumor size, receptor status, and grade to calculate the probability of nodal metastasis (PNM) has value in surgical decision making. METHODS This was a retrospective analysis of female patients (February 2011-October 2014) with invasive BC who underwent preoperative axUS and axillary surgery. Cases with locally advanced BC, neoadjuvant treatment, or bilateral BC were excluded. PNM was calculated for each case. Using various PNM thresholds, the proportion of cases with ALN metastasis on pathology was examined to determine an optimal PNM cut-point to predict ALN negativity. RESULTS Of 357 included patients, 72% were node-negative on surgical staging, and 69 (19.6%) had a PNM < 9.3%. Of these 69 patients, 6 had ALN metastasis on surgical pathology, yielding a false negative rate (FNR) of 8.7% for predicting negative ALN when a PNM threshold of < 9.3% was used. CONCLUSION A nomogram incorporating axUS findings and tumor characteristics identified a sizeable subgroup (19.6%) in whom ALN was predicted to be negative, with an 8.7% FNR. Surgeons can use this nomogram to quantify the probability of ALN metastasis and select patients who may benefit from omitting SLNB.
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Affiliation(s)
- Hanh-Tam Tran
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Daina Pack
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Charles Mylander
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Laura Martino
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Martin Rosman
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Lorraine Tafra
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA
| | - Rubie Sue Jackson
- The Rebecca Fortney Breast Center, Anne Arundel Medical Center, Annapolis, MD, USA.
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Gunn J, Lemini R, Partain K, Yeager T, Almerey T, Attwood K, McLaughlin S, Bagaria SP, Gabriel E. Trends in utilization of sentinel node biopsy and adjuvant radiation in women ≥ 70. Breast J 2020; 26:1321-1329. [PMID: 31908095 DOI: 10.1111/tbj.13750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/19/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Omission of routine axillary staging and adjuvant radiation (XRT) in women ≥ 70 years old with early stage, hormone receptor-positive, clinically node-negative breast cancer has been endorsed based on several landmark studies. We sought to determine how much omission of axillary staging/XRT has been adopted. METHODS Using the National Cancer Data Base, we selected malignant breast cancer cases in women ≥ 70 with ER + tumors, ≤2 cm with clinically negative lymph nodes who underwent breast conservation and had known XRT status in 2005-2015. The use of sentinel lymph node biopsy (SNB) and XRT status was summarized by year to determine trends over time. RESULTS In total, 57 230/69 982 patients underwent SNB. Of the 12 752 patients in whom SNB was omitted, 6296 were treated at comprehensive community cancer programs. Regarding XRT, 33 891/70 114 received adjuvant XRT. There were no significant trends with regards to patients receiving SNB or those receiving XRT. CONCLUSION Since 2005, there has been no change in SNB or XRT for early stage ER + breast tumors. However, there was a difference in omission of SNB based on facility type and setting. Future monitoring is needed to determine if these trends persist following the recently released Choosing Wisely® recommendations.
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Affiliation(s)
- Jinny Gunn
- Department of Surgery, Mayo Clinic, Jacksonville, Florida
| | | | | | - Tamanie Yeager
- Department of Surgery, Mayo Clinic, Jacksonville, Florida
| | - Tariq Almerey
- Department of Surgery, Mayo Clinic, Jacksonville, Florida
| | - Kristopher Attwood
- Department of Biostatistics & Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, New York
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Downs-Canner SM, Gaber CE, Louie RJ, Strassle PD, Gallagher KK, Muss HB, Ollila DW. Nodal positivity decreases with age in women with early-stage, hormone receptor-positive breast cancer. Cancer 2019; 126:1193-1201. [PMID: 31860136 DOI: 10.1002/cncr.32668] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/01/2019] [Accepted: 11/20/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Despite data demonstrating the safety of omitting axillary surgery in older women with early-stage breast cancer, the incidence of axillary surgery remains high. It was hypothesized that the prevalence of nodal positivity would decrease with advancing age. METHODS The National Cancer Data Base was used to construct a cohort of adult women with early-stage, clinically node-negative, estrogen receptor-positive (ER+), human epidermal growth factor receptor 2-negative breast cancer treated between 2013 and 2015. Multivariable logistic regression was used to assess the relationship between age and nodal positivity, and this was stratified by the axillary surgery category. Modified Poisson regression was used to estimate the proportion of women receiving adjuvant therapy according to age and nodal status. RESULTS The incidence of axillary surgery among women aged 70 and older (n = 51,917) remained high nationwide (86%). There was a significant decrease in nodal positivity with advancing age in women with early-stage, ER+, clinically node-negative breast cancer from the youngest cohort up to patients aged 70 to 89 years, and this was independent of histologic subtype (ductal vs lobular), race, comorbidities, and socioeconomic factors. Overall, less than 10% of women aged 70 or older who underwent surgery had node-positive disease, regardless of axillary surgery type, and almost 95% of node-positive patients aged 70 or older were at pathological stage N1mi or N1. CONCLUSIONS Axillary surgery may be safely omitted for many older women with ER+, clinically node-negative, early-stage breast cancer. Nodal positivity declines with advancing age, and this suggests varied biology in older patients versus younger patients.
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Affiliation(s)
- Stephanie M Downs-Canner
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Charles E Gaber
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Raphael J Louie
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Paula D Strassle
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kristalyn K Gallagher
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Hyman B Muss
- Department of Medical Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David W Ollila
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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64
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Calderon E, Webb C, Kosiorek HE, Richard J Gray M, Cronin P, Anderson K, Northfelt D, McCullough A, Ocal IT, Pockaj B. Are we choosing wisely in elderly females with breast cancer? Am J Surg 2019; 218:1229-1233. [DOI: 10.1016/j.amjsurg.2019.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/16/2019] [Accepted: 08/06/2019] [Indexed: 12/11/2022]
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65
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Blackhall V, Bugelli M, Abbott N, Mullen R. The role of sentinel lymph node biopsy in planning adjuvant therapy for elderly women with low‐risk breast cancer. Breast J 2019; 26:716-720. [DOI: 10.1111/tbj.13577] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Nick Abbott
- Highland Breast Centre Raigmore Hospital Inverness UK
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66
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Kocik J, Pajączek M, Kryczka T. Worse survival in breast cancer in elderly may not be due to underutilization of medical procedures as observed upon changing healthcare system in Poland. BMC Cancer 2019; 19:749. [PMID: 31362702 PMCID: PMC6668291 DOI: 10.1186/s12885-019-5930-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 07/12/2019] [Indexed: 11/24/2022] Open
Abstract
Background Evidence is emerging that older women may tolerate breast cancer therapies equally well as the young ones, providing that they receive good supportive care. It has also been reported that these patients remain outside the current therapeutic standards. The aim of this observational study was to assess the access of breast cancer patients to medical procedures. Methods We retrospectively reviewed a database of breast cancer patients registered in the National Cancer Registry in Poland, searching for the numbers of new cases and deaths in the years 2010–2015. We obtained the numbers and costs of key medical procedures provided for these patients from the National Health Fund in Poland. Breast cancer survival in the years 2010–2015 was estimated based on the mortality/incidence ratio. The t-Student test and Spearman correlation coefficient were used for the analysis of data obtained from both databases. Results There was no increase in survival throughout the years 2010–2015 in both analysed subpopulations of all breast cancer patients below and over 65 years of age, despite an unprecedented rise in healthcare funding in Poland. We noted 37% lower probability of 5-year survival in patients older than 65 years. The average number of outpatient visits and surgical procedures per person per year were slightly, yet significantly (p < 0.01), higher in younger vs. older patients (3.9 vs. 3.4 and 1.18 vs. 1.02, respectively). Outpatient chemotherapy was more common in older patients (6.0 vs. 5.25 cycles a year per person on average, p < 0.01). There were no significant differences in the average numbers of hospitalisations for chemotherapy, frequencies of radiotherapy and in the use of targeted therapy programmes (calculated per person per year), between younger and older patients. Conclusions Older women with breast cancer are treated similarly to younger patients, but have significantly worse chances to survive breast cancer in Poland. A simple increase in healthcare financing will not improve the survival in the elderly with breast cancer without developing funded individualised care and survivorship programmes. Electronic supplementary material The online version of this article (10.1186/s12885-019-5930-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janusz Kocik
- Gerontooncology Department, School of Public Health, Centre of Postgraduate Medical Education, Warsaw, Poland.
| | | | - Tomasz Kryczka
- Department of Development of Nursing & Medical Sciences, Medical University of Warsaw, Warsaw, Poland.,Department of Experimental Pharmacology, Mosakowski Medical Research Center of Polish Academy of Science, Warsaw, Poland
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Abstract
PURPOSE OF REVIEW Breast cancer incidence and mortality increase with age. Older patients (≥ 70) are often excluded from studies. Due to multiple factors, it is unclear whether this population is best-treated using standard guidelines. Here, we review surgical management in older women with breast cancer. RECENT FINDINGS Geriatric assessments can guide treatment recommendations and aid in predicting survival and quality of life. Surgery remains a principal component of breast cancer treatment in older patients, though differences exist compared with younger women, including higher mastectomy rates and evidence-based support of omission of post-lumpectomy radiation or axillary dissection in subsets of patients. In those forgoing surgical management, there is increased use of endocrine therapy. Hospice is also a valuable element of end-of-life care. Physicians should utilize geriatric assessment to make treatment recommendations for older breast cancer patients, including omission of radiation therapy, alterations to standard surgeries, or enrollment in hospice care.
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Developing a patient decision aid for women aged 70 and older with early stage, estrogen receptor positive, HER2 negative, breast cancer. J Geriatr Oncol 2019; 10:980-986. [PMID: 31130442 DOI: 10.1016/j.jgo.2019.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/16/2019] [Accepted: 05/03/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Since women ≥70 years with early stage, estrogen receptor positive (ER+), HER2 negative breast cancer face several preference-sensitive treatment decisions, the investigative team aimed to develop a pamphlet decision aid (DA) for such women. MATERIALS AND METHODS The content of the DA was informed by literature review, international criteria, and expert feedback, and includes information on benefits and risks of lumpectomy versus mastectomy, lymph node surgery, radiotherapy after lumpectomy, and endocrine therapy. It considers women's overall health and was written using low literacy principles. Women from two Boston-based hospitals who were diagnosed in the past 6-24 months were recruited to provide feedback on the DA and its acceptability. The DA was iteratively revised based on their qualitative input. RESULTS Of 48 eligible women contacted, 35 (73%) agreed to participate. Their mean age was 74.3 years; 33 (94%) were non-Hispanic white; and 24 (67%) were college graduates. Overall, 26 (74%) thought the length of the DA was just right, 29 (83%) thought all or most of the information was clear, 32 (91%) found the DA helpful, and 33 (94%) would recommend it. In open ended comments, participants noted that the DA was clear, well-organized, and would help women prepare for and participate in treatment decision-making. CONCLUSIONS The investigative team developed a novel breast cancer treatment DA that is acceptable to women ≥70 years with a history of ER+, HER2-, early stage breast cancer. Next, the DA's efficacy needs to be tested with diverse older women newly diagnosed with breast cancer.
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69
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Wasif N, Neville M, Gray R, Cronin P, Pockaj BA. Competing Risk of Death in Elderly Patients with Newly Diagnosed Stage I Breast Cancer. J Am Coll Surg 2019; 229:30-36.e1. [PMID: 30930100 DOI: 10.1016/j.jamcollsurg.2019.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The majority of newly diagnosed breast cancers in the US are in women aged older than 65 years who can have additional comorbidities. Balancing the risks and benefits of treatment should take into account these competing risks of death. STUDY DESIGN The Surveillance, Epidemiology, and End Results Program-Medicare database was used to identify women with stage I breast cancer undergoing operations from 2004-2012. Using neural network analysis, comorbidities associated with mortality were grouped into clinically relevant categories. Cumulative incidence graphs and Fine and Gray competing risk regression analyses were used to study the association of age, race, comorbidity groupings, and tumor variables with 3 competing mortality outcomes: dead of disease (DOD), dead of other cancers (DOC), and non-cancer death (NCD). RESULTS The overall cumulative incidence of mortality was 4.9% for DOD, 3.7% for DOC, and 21.3% for NCD for the 47,220 patients studied. For all patients, the 5- and 8-year probability of DOD was 3% and 4.7%, for DOC 1.9% and 3.5%, and for NCD 9.8% and 18.9%, respectively. The presence of any major comorbidity (eg cardiovascular or neurologic disorders) significantly increased the probability of NCD, and estrogen receptor status was the strongest predictor of DOD. Given patient age, comorbidity, and estrogen receptor status, an estimate of competing risks of death from DOD, DOC, and NCD can be calculated. CONCLUSIONS To aid clinical decision making, we quantify competing risks of death in patients with stage I breast cancer by taking into account patient age, comorbidity, and estrogen receptor status.
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Affiliation(s)
- Nabil Wasif
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ; Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic Arizona, Phoenix, AZ.
| | - Matthew Neville
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic Arizona, Phoenix, AZ; Department of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ
| | - Richard Gray
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ
| | - Patricia Cronin
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ
| | - Barbara A Pockaj
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ
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Whitworth P, Schonholz S, Phillips R, Robertson Y, Ruiz A, Winchester S, Graham C, Simpson J, Wernecke C. Minimally Invasive Intact Excision of High-Risk Breast Lesions and Small Breast Cancers: The Intact Percutaneous Excision (IPEX) Registry. Ann Surg Oncol 2019; 26:954-960. [PMID: 30756327 DOI: 10.1245/s10434-019-07212-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Aiming to minimize overtreatment of high-risk breast lesions (HRLs), including atypical ductal hyperplasia, and small breast cancers, including ductal carcinoma in situ (DCIS), we investigated a minimally invasive (MI) approach to definitive diagnosis and management of these conditions. METHODS In the prospective Intact Percutaneous Excision registry study, women aged 31-86 years had removal of small invasive cancers, DCIS, or HRLs using image-guided 12-20 mm radiofrequency basket capture (MI excision). Second-pass 20 mm basket capture obtained shaved margins in cancer patients. Standard imaging (specimen, breast) and histologic criteria were applied. Patient data were registered in an Institutional Review Board approved, Health Insurance Portability and Accountability Act-compliant registry. RESULTS Of 282 registered patients, 124 had DCIS (n = 52) or invasive cancer (n = 72) and 160 had HRLs. Among cancer patients, 101 (81%) had clear histologic margins [average lesion size was 11 mm for both invasive cancers (4-20 mm) and DCIS (1.5-20 mm)]; 29 patients had re-excision (six despite clear margins). Among 160 HRLs, two were upgraded to DCIS and had MI excision. Two other HRL patients had subsequent standard surgical excision (no cancer found). CONCLUSION For diminutive HRLs, DCIS, and invasive cancers, MI excision can achieve the same procedure goals as standard surgical excision. Because MI excision removes less tissue with small incisions, it may reduce the discomfort and expense associated with standard treatment.
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Affiliation(s)
| | | | | | | | - Antonio Ruiz
- Chesapeake Regional Medical Center, Chesapeake, VA, USA
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71
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Houvenaeghel G, Lambaudie E, Classe JM, Mazouni C, Giard S, Cohen M, Faure C, Charitansky H, Rouzier R, Daraï E, Hudry D, Azuar P, Villet R, Gimbergues P, Tunon de Lara C, Martino M, Fraisse J, Dravet F, Chauvet MP, Boher JM. Lymph node positivity in different early breast carcinoma phenotypes: a predictive model. BMC Cancer 2019; 19:45. [PMID: 30630443 PMCID: PMC6327612 DOI: 10.1186/s12885-018-5227-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 12/16/2018] [Indexed: 11/11/2022] Open
Abstract
Background A strong correlation between breast cancer (BC) molecular subtypes and axillary status has been shown. It would be useful to predict the probability of lymph node (LN) positivity. Objective: To develop the performance of multivariable models to predict LN metastases, including nomograms derived from logistic regression with clinical, pathologic variables provided by tumor surgical results or only by biopsy. Methods A retrospective cohort was randomly divided into two separate patient sets: a training set and a validation set. In the training set, we used multivariable logistic regression techniques to build different predictive nomograms for the risk of developing LN metastases. The discrimination ability and calibration accuracy of the resulting nomograms were evaluated on the training and validation set. Results Consecutive sample of 12,572 early BC patients with sentinel node biopsies and no neoadjuvant therapy. In our predictive macro metastases LN model, the areas under curve (AUC) values were 0.780 and 0.717 respectively for pathologic and pre-operative model, with a good calibration, and results with validation data set were similar: AUC respectively of 0.796 and 0.725. Among the list of candidate’s regression variables, on the training set we identified age, tumor size, LVI, and molecular subtype as statistically significant factors for predicting the risk of LN metastases. Conclusions Several nomograms were reported to predict risk of SLN involvement and NSN involvement. We propose a new calculation model to assess this risk of positive LN with similar performance which could be useful to choose management strategies, to avoid axillary LN staging or to propose ALND for patients with high level probability of major axillary LN involvement but also to propose immediate breast reconstruction when post mastectomy radiotherapy is not required for patients without LN macro metastasis. Electronic supplementary material The online version of this article (10.1186/s12885-018-5227-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gilles Houvenaeghel
- Institut Paoli Calmettes et CRCM, 232 boulevard de Sainte Marguerite, 13009, Marseille, France. .,Aix-Marseille University, Unité Mixte de Recherche S912, Institut de Recherche pour le Développement, 13385, Marseille, France.
| | - Eric Lambaudie
- Institut Paoli Calmettes et CRCM, 232 boulevard de Sainte Marguerite, 13009, Marseille, France.,Aix-Marseille University, Unité Mixte de Recherche S912, Institut de Recherche pour le Développement, 13385, Marseille, France
| | - Jean-Marc Classe
- Institut René Gauducheau, Site Hospitalier Nord, St Herblain, France
| | - Chafika Mazouni
- Institut Gustave Roussy, 114 rue Edouard Vaillant, Villejuif, France
| | - Sylvia Giard
- Centre Oscar Lambret, 3 rue Frédéric Combenal, Lille, France
| | - Monique Cohen
- Institut Paoli Calmettes et CRCM, 232 boulevard de Sainte Marguerite, 13009, Marseille, France
| | | | | | - Roman Rouzier
- Centre René Huguenin, 35 rue Dailly, Saint Cloud, France
| | - Emile Daraï
- Hôpital Tenon, 4 rue de la Chine, Paris, France
| | - Delphine Hudry
- Centre Georges François Leclerc, 1 rue du Professeur Marion, Dijon, France
| | - Pierre Azuar
- Hôpital de Grasse, Chemin de Clavary, Grasse, France
| | - Richard Villet
- Hôpital des Diaconnesses, 18 rue du Sergent Bauchat, Paris, France
| | | | | | - Marc Martino
- Institut Paoli Calmettes et CRCM, 232 boulevard de Sainte Marguerite, 13009, Marseille, France
| | - Jean Fraisse
- Centre Georges François Leclerc, 1 rue du Professeur Marion, Dijon, France
| | - François Dravet
- Institut René Gauducheau, Site Hospitalier Nord, St Herblain, France
| | | | - Jean Marie Boher
- Institut Paoli Calmettes et CRCM, 232 boulevard de Sainte Marguerite, 13009, Marseille, France
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Loza CM, Mandó P, Ponce C, Coló F, Fabiano V, Loza J, Costanzo MV, Nervo A, Nadal J, Nuñez de Pierro A, Chacon R, Contributors RCMD. Predictive Factors for Non-Sentinel Lymph Node Metastasis in Patients with ACOSOG Z0011 Criteria. Breast Care (Basel) 2018; 13:434-438. [PMID: 30800038 PMCID: PMC6381814 DOI: 10.1159/000488277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nodal staging constitutes an element of great importance in the treatment planning for early breast cancer. The ACOSOG Z0011 trial demonstrated that sentinel lymph node (SLN) biopsy alone results in rates of local control, disease-free survival, and overall survival equivalent to those seen after axillary lymph node dissection. The purpose of this study was to determine the rate of patients that fulfill the ACOSOG Z0011 inclusion criteria and to define predictive factors for non-SLN positivity. METHODS A retrospective analysis of the breast surgery database of the Argentinian Society of Mastology was carried out. Patients were selected if they fulfilled the ACOSOG Z0011 inclusion criteria. The association of clinical and pathological factors with non-SLN positivity was evaluated in univariate and multivariate analysis. RESULTS Among 8,262 patients, 973 had positive SLN, and 348 satisfied the inclusion criteria. Histological grade (G3 vs. G1-2, odds ratio (OR) 1.81; p = 0.024), tumor size (T2 vs. T1, OR 2.39; p = 0.001), and age (>50 vs. <50 years, OR 1.95; p = 0.007) were associated with non-SLN positivity in multivariate analysis. CONCLUSION Although the clinical relevance of our data is not established, older women with tumors bigger than 2 cm and/or high histological grade are at greater risk of having metastatic disease in the lymph nodes if axillary lymph node dissection is avoided. This subgroup of patients represents only 30% of the trial population.
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Affiliation(s)
| | - Pablo Mandó
- Fundación Cancer-FUCA, Buenos Aires, Argentina
- CEMIC, Buenos Aires, Argentina
| | | | - Federico Coló
- Instituto Alexander Fleming, Buenos Aires, Argentina
| | | | - Jose Loza
- Instituto Alexander Fleming, Buenos Aires, Argentina
| | | | - Adrian Nervo
- Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Jorge Nadal
- Instituto Alexander Fleming, Buenos Aires, Argentina
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73
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Tamirisa N, Thomas SM, Fayanju OM, Greenup RA, Rosenberger LH, Hyslop T, Hwang ES, Plichta JK. Axillary Nodal Evaluation in Elderly Breast Cancer Patients: Potential Effects on Treatment Decisions and Survival. Ann Surg Oncol 2018; 25:2890-2898. [PMID: 29968029 PMCID: PMC6404232 DOI: 10.1245/s10434-018-6595-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recent studies suggest that surgical lymph node (LN) evaluation may be omitted in select elderly breast cancer patients as it may not influence adjuvant therapy decisions. To evaluate differences in adjuvant therapy receipt and overall survival (OS), we compared clinically node-negative (cN0) elderly patients who did and did not undergo axillary surgery. METHODS Patients aged ≥70 years in the National Cancer Database (2004-2014) with cT1-3, cN0 breast cancer were divided into two cohorts-those with surgical LN evaluation (one or more nodes removed) and those without (no nodes removed). Propensity scores were used to match patients based on age, year of diagnosis, tumor grade, cT stage, estrogen receptor status, and Charlson-Deyo comorbidity score. A Cox proportional hazards model was used to estimate the effect of LN surgery on OS. RESULTS Overall, 133,778 patients were matched, of whom 102,247 patients (76.4%) underwent nodal surgery. Patients undergoing nodal surgery were more likely to receive chemotherapy (pN1-3: 22.2%; pN0: 5.8%; cN0-no nodal surgery: 2.8%; p < 0.001), radiation (pN1-3: 49.7%; pN0: 47.5%; cN0-no nodal surgery: 26%; p < 0.001), and endocrine therapy (pN1-3: 72%; pN0: 58.5%; cN0-no nodal surgery: 46.5%; p < 0.001). After adjustment for known covariates, patients who did not undergo nodal surgery had a worse OS (hazard ratio 1.66, 95% confidence interval 1.61-1.70). CONCLUSIONS For elderly cN0 breast cancer patients, axillary surgery was associated with higher rates of adjuvant therapy and improved OS. A selective approach to omitting nodal surgery should be considered in elderly patients with cN0 breast cancer as axillary staging may influence subsequent treatment decisions and long-term outcomes.
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Affiliation(s)
- Nina Tamirisa
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samantha M Thomas
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Oluwadamilola M Fayanju
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Rachel A Greenup
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Laura H Rosenberger
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Terry Hyslop
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Jennifer K Plichta
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA.
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75
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Change of paradigm in treating elderly with breast cancer: are we undertreating elderly patients? Ir J Med Sci 2018; 188:379-388. [DOI: 10.1007/s11845-018-1851-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 06/13/2018] [Indexed: 12/16/2022]
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76
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Individualizing Local-Regional Therapy of Breast Cancer in the Elderly. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0272-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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77
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Choosing Wisely: Optimizing Routine Workup for the Newly Diagnosed Breast Cancer Patient. CURRENT BREAST CANCER REPORTS 2018. [DOI: 10.1007/s12609-018-0268-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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78
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Welsh JL, Hoskin TL, Day CN, Habermann EB, Goetz MP, Boughey JC. Predicting Nodal Positivity in Women 70 Years of Age and Older with Hormone Receptor-Positive Breast Cancer to Aid Incorporation of a Society of Surgical Oncology Choosing Wisely Guideline into Clinical Practice. Ann Surg Oncol 2017; 24:2881-2888. [PMID: 28766197 DOI: 10.1245/s10434-017-5932-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE One of the Society of Surgical Oncology Choosing Wisely guidelines recommends avoiding routine sentinel lymph node (SLN) surgery in clinically node-negative women ≥70 years of age with hormone receptor-positive (HR+) breast cancer. We sought to assess the impact of tumor stage and grade on nodal positivity, and to develop a model to identify patients at low-risk of nodal positivity to aid adoption of the guideline. METHODS We identified women ≥70 years of age with HR+ cN0 invasive breast cancer in the National Cancer Database (NCDB; 2010-2013) and examined the impact of tumor stage and grade on nodal positivity to identify low-risk combinations. A multivariable logistic regression model was developed to incorporate additional factors. The area under the curve (AUC) and relative risks (RR) were used to assess performance. RESULTS Among 71,834 cases, the pathologic nodal positivity (pN+) rate was 15.3%. We identified low-risk criteria as grade 1, cT1mi-T1c (≤2.0 cm), or grade 2, cT1mi-T1b (≤1.0 cm), with pN+ rates of 7.8% compared with 22.3% in patients not meeting these criteria (RR 2.86, p < 0.001). On multivariable analysis, factors associated with pN+ status included clinical T stage, grade, and histology (each p < 0.001). The resulting model had AUC 0.70 and identified women with low predicted probability (<10%) of positive nodes, of whom 6.3% were pN+, versus 21.2% in those with predicted probability ≥10% (RR 3.34, p < 0.001). CONCLUSION The simple clinical rule (grade 1, cT1mi-T1c, or grade 2, cT1mi-T1b), as well as the predictive model, both identify women at low risk of nodal positivity where SLN surgery can be omitted.
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Affiliation(s)
| | - Tanya L Hoskin
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Courtney N Day
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Matthew P Goetz
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
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Controversial issues in the management of older adults with early breast cancer. J Geriatr Oncol 2017; 8:397-402. [PMID: 28602710 DOI: 10.1016/j.jgo.2017.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/05/2017] [Accepted: 05/24/2017] [Indexed: 12/12/2022]
Abstract
It is well recognized that the incidence of breast cancer increases significantly with age. Despite this, older people remain under-represented in many clinical trials and their management relies on extrapolation of data from younger patients. Providing an aggressive intervention can be challenging, particularly in less fit older patients where a conservative approach is commonly perceived to be more appropriate. The optimal management of this population is unknown and treatment decision should be personalized. This review article will discuss several controversial issues in managing older adults with early breast cancer in a multidisciplinary setting, including the role of surgical treatment of the axilla in clinically node negative disease, radiotherapy after breast conservation surgery in low-risk tumours, personalizing adjuvant systemic therapy, and geriatric assessments in breast cancer treatment decisions.
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Locoregional Recurrence After Sentinel Lymph Node Dissection With or Without Axillary Dissection in Patients With Sentinel Lymph Node Metastases: Long-term Follow-up From the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 Randomized Trial. Ann Surg 2017; 264:413-20. [PMID: 27513155 DOI: 10.1097/sla.0000000000001863] [Citation(s) in RCA: 322] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVE The early results of the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial demonstrated no difference in locoregional recurrence for patients with positive sentinel lymph nodes (SLNs) randomized either to axillary lymph node dissection (ALND) or sentinel lymph node dissection (SLND) alone. We now report long-term locoregional recurrence results. METHODS ACOSOG Z0011 prospectively examined overall survival of patients with SLN metastases undergoing breast-conserving therapy randomized to undergo ALND after SLND or no further axillary specific treatment. Locoregional recurrence was prospectively evaluated and compared between the groups. RESULTS Four hundred forty-six patients were randomized to SLND alone and 445 to SLND and ALND. Both groups were similar with respect to age, Bloom-Richardson score, Estrogen Receptor status, adjuvant systemic therapy, histology, and tumor size. Patients randomized to ALND had a median of 17 axillary nodes removed compared with a median of only 2 SLNs removed with SLND alone (P < 0.001). ALND, as expected, also removed more positive lymph nodes (P < 0.001). At a median follow-up of 9.25 years, there was no statistically significant difference in local recurrence-free survival (P = 0.13). The cumulative incidence of nodal recurrences at 10 years was 0.5% in the ALND arm and 1.5% in the SLND alone arm (P = 0.28). Ten-year cumulative locoregional recurrence was 6.2% with ALND and 5.3% with SLND alone (P = 0.36). CONCLUSION Despite the potential for residual axillary disease after SLND, SLND without ALND offers excellent regional control for selected patients with early metastatic breast cancer treated with breast-conserving therapy and adjuvant systemic therapy.
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81
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Boughey JC, Haffty BG, Habermann EB, Hoskin TL, Goetz MP. Has the Time Come to Stop Surgical Staging of the Axilla for All Women Age 70 Years or Older with Hormone Receptor-Positive Breast Cancer? Ann Surg Oncol 2017; 24:614-617. [PMID: 28054190 DOI: 10.1245/s10434-016-5740-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Indexed: 11/18/2022]
Affiliation(s)
| | - Bruce G Haffty
- Department of Surgery, Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN, USA.,Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Tanya L Hoskin
- Health Care Policy and Research and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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82
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O'Connell R, Rusby J, Stamp G, Conway A, Roche N, Barry P, Khabra K, Bonomi R, Rapisarda I, della Rovere G. Long term results of treatment of breast cancer without axillary surgery – Predicting a SOUND approach? Eur J Surg Oncol 2016; 42:942-8. [DOI: 10.1016/j.ejso.2016.03.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/29/2016] [Indexed: 12/01/2022] Open
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Bernier J, Rossier C, Horiot JC. Recent advances in regional treatment of breast carcinoma. Crit Rev Oncol Hematol 2016; 99:107-14. [PMID: 26718148 DOI: 10.1016/j.critrevonc.2015.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 11/11/2015] [Accepted: 12/09/2015] [Indexed: 10/22/2022] Open
Abstract
Regional treatment is driven by surgery and radiotherapy in early breast cancer patients as sole or combined modalities. Lymph node dissection, performed in patients with positive sentinel lymph nodes accurately identifies malignant spread in the nodal areas and ensures high levels of control in the axilla. At the turn of the century, its real impact on survival indices was nevertheless questioned, also in terms of therapeutic index, by cooperative groups and meta-analyses. As regards radiotherapy, both the indication and extension of regional irradiation remained for a long time open questions, since these issues were never addressed by randomized trials. Recent results of controlled trials investigating the exact impact of nodal surgery or irradiation on survival indices provide useful tools to optimize the regional treatment in patients with early breast cancer. Caution on interpreting some of the key messages from these controlled studies is nevertheless mandatory due to methodological limitations and caveats identified in several of these major trials enrolling patients with positive sentinel nodes.
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Affiliation(s)
- Jacques Bernier
- Genolier Swiss Medical Network, Department of Radio-Oncology, Breast Unit, Genolier, Geneva, Switzerland.
| | - Christine Rossier
- Genolier Swiss Medical Network, Department of Radio-Oncology, Breast Unit, Genolier, Geneva, Switzerland
| | - Jean-Claude Horiot
- Genolier Swiss Medical Network, Department of Radio-Oncology, Breast Unit, Genolier, Geneva, Switzerland
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84
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Ahmed M, Rubio IT, Kovacs T, Klimberg VS, Douek M. Systematic review of axillary reverse mapping in breast cancer. Br J Surg 2015; 103:170-8. [DOI: 10.1002/bjs.10041] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/11/2015] [Accepted: 09/29/2015] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Axillary reverse mapping (ARM) assesses the lymphatic drainage of the arm simultaneously with that of the breast, enabling preservation of arm lymphatics during axillary surgery for breast cancer. This article systematically reviews the evidence on the lymphoedema rate and oncological safety of the ARM technique.
Methods
PubMed, Embase and the Cochrane Library were searched systematically for studies that addressed the use of ARM during axillary surgery in breast cancer. Studies were eligible if they performed ARM during sentinel node biopsy (SNB) or axillary node clearance (ANC) for breast cancer in prospective studies of more than 50 patients, with assessment of lymphoedema and oncological outcomes during a minimum follow-up of 6 months.
Results
Eight studies reported data on ARM in 1142 patients undergoing axillary surgery for breast cancer. Lymphoedema rates ranged from 0 to 6 per cent during ARM-assisted SNB, and from 5·9 to 24 per cent during ARM lymphatic preservation at ANC. Crossover nodes between the arm and breast lymphatics were identified in 0–10 per cent of patients, and metastases were present in 0–20 per cent of these patients. ARM nodes were not preserved in between 11 and 18 per cent of patients with ARM nodes identified, and metastases were detected in 0–19 per cent of these patients.
Conclusion
ARM can achieve low rates of lymphoedema, but the risk of metastasis in crossover and clinically suspicious ARM nodes, or those in close proximity to an involved sentinel node, warrants their excision.
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Affiliation(s)
- M Ahmed
- Research Oncology, Division of Cancer Studies, King's College London, London, UK
- Department of Breast Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - I T Rubio
- Breast Surgical Unit, Breast Cancer Centre, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - T Kovacs
- Department of Breast Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - V S Klimberg
- Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - M Douek
- Research Oncology, Division of Cancer Studies, King's College London, London, UK
- Department of Breast Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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85
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Elomrani F, Zine M, Afif M, L’annaz S, Ouziane I, Mrabti H, Errihani H. Management of early breast cancer in older women: from screening to treatment. BREAST CANCER (DOVE MEDICAL PRESS) 2015; 7:165-71. [PMID: 26185468 PMCID: PMC4500607 DOI: 10.2147/bctt.s87125] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Breast cancer is a common condition. It is a leading cause of death among women, and its incidence increases with age. Aging of the population and improvement of the quality of life of elders make it a major public health issue. We reviewed the literature to try to determine the management of breast cancer in older women. METHODS We conducted a narrative review by literature searches using key words "breast cancer", "elderly and older", and "women" in Pubmed, Scopus, and Google Scholar. The aim of this review is to summarize the management of early breast cancer in older women by discussing the controversies of screening in older women. Then, we try to define the optimal strategy for these women, either surgery alone or primary endocrine therapy. We also discuss the indications of lymph node dissection, and we evaluate the benefit of adjuvant radiotherapy, chemotherapy, and the anti HER2 treatment for these women. RESULTS More than 50% of patients with breast cancer are 65 years or older, and around 30% are more than 70 years old. Most randomized trials did not include older women. Hence, the treatment of breast cancer in older patients is based on the management provided to younger women. Regardless of age, the treatment must aim for the best efficiency. Advanced age in itself should not be a limitation to treatment. There are no standard guidelines set for elderly patients. Surgical treatment for older patients evolved to avoid mastectomy, and conservative mammary surgery was proposed, similar to that used in younger patients. The proportion of elderly patients receiving adjuvant radiotherapy is increasing. The role of adjuvant radiotherapy in older patients with breast cancer was analyzed. Adjuvant chemotherapy is beneficial to women with hormone receptor-negative tumors. In those with hormone receptor-positive tumors, adjuvant chemotherapy in association to trastuzumab is beneficial for HER2-positive tumors, and for women with HER2-negative tumors adjuvant hormonal therapy is a very good option. CONCLUSION Breast cancer is common in older women. This population requires particular and adapted management. It is essential for older patients to be included in new clinical trials for individualized treatment recommendation.
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Affiliation(s)
- Fadwa Elomrani
- Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
| | - Maryem Zine
- Department of Onco Hematology, Military Hospital Mohamed V, Rabat, Morocco
| | - Mohamed Afif
- Department of Radiotherapy, National Institute of Oncology, Rabat, Morocco
| | - Saad L’annaz
- Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
| | - Imane Ouziane
- Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
| | - Hind Mrabti
- Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
| | - Hassan Errihani
- Department of Medical Oncology, National Institute of Oncology, Rabat, Morocco
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86
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Variations in compliance to quality indicators by age for 41,871 breast cancer patients across Europe: A European Society of Breast Cancer Specialists database analysis. Eur J Cancer 2015; 51:1221-30. [DOI: 10.1016/j.ejca.2015.03.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 02/26/2015] [Accepted: 03/14/2015] [Indexed: 11/24/2022]
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87
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Treatment patterns of elderly breast cancer patients at two Canadian cancer centres. Eur J Surg Oncol 2015; 41:625-34. [DOI: 10.1016/j.ejso.2015.01.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 12/27/2014] [Accepted: 01/11/2015] [Indexed: 11/20/2022] Open
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Le Saux O, Ripamonti B, Bruyas A, Bonin O, Freyer G, Bonnefoy M, Falandry C. Optimal management of breast cancer in the elderly patient: current perspectives. Clin Interv Aging 2015; 10:157-74. [PMID: 25609933 PMCID: PMC4293298 DOI: 10.2147/cia.s50670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Breast cancer (BC) is the most common female malignancy in the world and almost one third of cases occur after 70 years of age. Optimal management of BC in the elderly is a real challenge and requires a multidisciplinary approach, mainly because the elderly population is heterogeneous. In this review, we describe the various possibilities of treatment for localized or metastatic BC in an aging population. We provide an overview of the comprehensive geriatric assessment, surgery, radiotherapy, and adjuvant therapy for early localized BC and of chemotherapy and targeted therapies for metastatic BC. Finally, we attempt to put into perspective the necessary balance between the expected benefits and risks, especially in the adjuvant setting.
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Affiliation(s)
- Olivia Le Saux
- Medical Oncology Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Bertrand Ripamonti
- Gynaecology-Obstetrics Department, University Hospital, Saint-Etienne, France
| | - Amandine Bruyas
- Croix Rousse University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France ; Lyon University, Lyon, France
| | | | - Gilles Freyer
- Medical Oncology Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France ; Lyon University, Lyon, France
| | - Marc Bonnefoy
- Lyon University, Lyon, France ; Geriatric Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Claire Falandry
- Lyon University, Lyon, France ; Geriatric Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
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89
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Moossdorff M, van Roozendaal LM, Schipper RJ, Strobbe LJA, Voogd AC, Tjan-Heijnen VCG, Smidt ML. Inconsistent selection and definition of local and regional endpoints in breast cancer research. Br J Surg 2014; 101:1657-65. [PMID: 25308345 DOI: 10.1002/bjs.9644] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 04/16/2014] [Accepted: 08/07/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Results in breast cancer research are reported using study endpoints. Most are composite endpoints (such as locoregional recurrence), consisting of several components (for example local recurrence) that are in turn composed of specific events (such as skin recurrence). Inconsistent endpoint selection and definition might lead to unjustified conclusions when comparing study outcomes. This study aimed to determine which locoregional endpoints are used in breast cancer studies, and how these endpoints and their components are defined. METHODS PubMed was searched for breast cancer studies published in nine leading journals in 2011. Articles using endpoints with a local or regional component were included and definitions were compared. RESULTS Twenty-three different endpoints with a local or regional component were extracted from 44 articles. Most frequently used were disease-free survival (25 articles), recurrence-free survival (7), local control (4), locoregional recurrence-free survival (3) and event-free survival (3). Different endpoints were used for similar outcomes. Of 23 endpoints, five were not defined and 18 were defined only partially. Of these, 16 contained a local and 13 a regional component. Included events were not specified in 33 of 57 (local) and 27 of 50 (regional) cases. Definitions of local components inconsistently included carcinoma in situ and skin and chest wall recurrences. Regional components inconsistently included specific nodal sites and skin and chest wall recurrences. CONCLUSION Breast cancer studies use many different endpoints with a locoregional component. Definitions of endpoints and events are either not provided or vary between trials. To improve transparency, facilitate trial comparison and avoid unjustified conclusions, authors should report detailed definitions of all endpoints.
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Affiliation(s)
- M Moossdorff
- Departments of Surgical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
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90
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Reginelli A, Calvanese M, Ravo V, Di Franco R, Silvestro G, Gatta G, Squillaci E, Grassi R, Cappabianca S. Management of breast cancer in elderly patients. Int J Surg 2014; 12 Suppl 2:S187-S192. [DOI: 10.1016/j.ijsu.2014.08.344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/15/2014] [Indexed: 11/29/2022]
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91
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Dambros Gabbi MC, Masiero PR, Uchoa D, Moraes IV, Biazus JV, Edelweiss MIA. Comparison between preoperative and intraoperative injection of (99m)Tc Dextran-500 for sentinel lymph node localization in breast cancer. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2014; 4:602-610. [PMID: 25250208 PMCID: PMC4171845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 07/25/2014] [Indexed: 06/03/2023]
Abstract
A retrospective study was conducted from a review of the medical records of patients with early-stage, invasive breast cancer who underwent surgical treatment and sentinel node biopsy with a radiotracer from January 2008 to August 2012 at a single institution (221 patients included). The patients were grouped according to the time of (99m)Tc Dextran-500 injection, which was preoperatively (with lymphoscintigraphy) (81 patients) or intraoperatively (140 patients). The purpose of the report is to compare the results of sentinel node biopsy of early-stage breast cancer patients who were subjected to intraoperative (99m)Tc Dextran-500 injections with the patients who received preoperative injections. The following parameters were analyzed: clinical tumor staging, histological and pathological results, size and number of tumor foci, peritumoral vascular invasion, number of lymph nodes removed, size of lymph node metastasis and hormone receptor expression.There were no differences in sentinel lymph node localization whether (99m)Tc Dextran-500 was injected preoperatively or intraoperatively.
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Affiliation(s)
- Maria C Dambros Gabbi
- Medical Sciences (PPGCM), Famed-Universidade Federal do Rio Grande do Sul (UFRGS)Brazil
| | - Paulo R Masiero
- The Hospital de Clínicas de Porto Alegre (HCPA) Nuclear Medicine ServiceBrazil
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Heil J, Fuchs V, Golatta M, Schott S, Wallwiener M, Domschke C, Sinn P, Lux MP, Sohn C, Schütz F. Extent of primary breast cancer surgery: standards and individualized concepts. ACTA ACUST UNITED AC 2014; 7:364-9. [PMID: 24647774 DOI: 10.1159/000343976] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Surgery is still a main therapeutic option in breast cancer treatment. Nowadays, methods of resection and reconstruction vary according to different tumors and patients. This review presents and discusses standards of care and arising questions on how radical primary breast cancer surgery should be according to different clinical situations. In most early breast cancer patients, breast conservation is the method of choice. The discussion on resection margins is still controversial as different studies show conflicting results. Modified radical mastectomy is the standard in locally advanced breast cancer patients, although there are different promising approaches to spare skin or even the nipple-areola complex. A sentinel node biopsy is the standard of care in clinically node-negative invasive breast cancer patients, whereas the significance of axillary lymphonodectomy seems to be questioned through a number of different findings. Although there are interesting findings to modify surgical approaches in very young or elderly breast cancer patients, it will always be an individualized approach if we do not adhere to current guidelines. Up to date, there are no special surgical procedures in BRCA mutation carriers or patients of high-risk families.
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Affiliation(s)
- Joerg Heil
- Universitäts-Frauenklinik, Universitätsklinikum Heidelberg, Germany
| | - Valerie Fuchs
- Universitäts-Frauenklinik, Universitätsklinikum Heidelberg, Germany
| | - Michael Golatta
- Universitäts-Frauenklinik, Universitätsklinikum Heidelberg, Germany
| | - Sarah Schott
- Universitäts-Frauenklinik, Universitätsklinikum Heidelberg, Germany
| | | | | | - Peter Sinn
- Institut für Pathologie, Universität Heidelberg, Germany
| | - Michael P Lux
- Universitäts-Brustzentrum Franken, Frauenklinik, Universitätsklinikum Erlangen, Germany
| | - Christof Sohn
- Universitäts-Frauenklinik, Universitätsklinikum Heidelberg, Germany
| | - Florian Schütz
- Universitäts-Frauenklinik, Universitätsklinikum Heidelberg, Germany
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93
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Offersen BV, Nielsen HM, Overgaard M, Overgaard J. Is regional nodes radiotherapy an alternative to surgery? Breast 2014; 22 Suppl 2:S118-28. [PMID: 24074772 DOI: 10.1016/j.breast.2013.07.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Sentinel node biopsy (SN) in breast cancer treatment was introduced in the mid-1990s in order to be able to stage patients before decision of definitive surgery. Since then, both the pathological examinations of the SN and the systemic adjuvant treatment have improved and cause new challenges in the correct decision making regarding whether or not to radically treat the axilla in case of a positive SN. In SN positive patients, current St. Gallen guidelines support no completion ALND (axillary lymph node dissection) in clinically node-negative patients with 1-2 macrometastatic sentinel nodes operated with breast conservation and receiving tangential field adjuvant radiotherapy (RT). ALND is being questioned due to increased morbidity compared with SN biopsy alone, and to limited long term benefit on disease free survival in selected patients. An alternative to ALND is treating the axilla with nodal RT although this treatment is mostly used as adjuvant treatment after ALND in high risk patients. Few studies have investigated the benefit of nodal RT compared to ALND, and no consensus has yet been reached. Clinical decision making regarding treating the axilla should be based on relevant data, and in this review studies aiming at deciding whether or not and how the axilla should be treated in SN positive patients will be discussed. Furthermore treatment choice will be discussed, since besides ALND, both breast irradiation and nodal irradiation might cure residual disease after SN. Also the issue of improved systemic adjuvant treatment will be discussed in relation to eventually no regional axillary treatment.
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94
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Yen TWF, Laud PW, Sparapani RA, Nattinger AB. Surgeon specialization and use of sentinel lymph node biopsy for breast cancer. JAMA Surg 2014; 149:185-92. [PMID: 24369337 DOI: 10.1001/jamasurg.2013.4350] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in patients with clinically node-negative breast cancer. It is not known whether SLNB rates differ by surgeon expertise. If surgeons with less breast cancer expertise are less likely to offer SLNB to these patients, this practice pattern could lead to unnecessary axillary lymph node dissections and lymphedema. OBJECTIVE To explore potential measures of surgical expertise (including a novel objective specialization measure: percentage of a surgeon's operations performed for breast cancer determined from Medicare claims) on the use of SLNB for invasive breast cancer. DESIGN, SETTING, AND POPULATION A population-based prospective cohort study was conducted in California, Florida, and Illinois. Participants included elderly (65-89 years) women identified from Medicare claims as having had incident invasive breast cancer surgery in 2003. Patient, tumor, treatment, and surgeon characteristics were examined. MAIN OUTCOME AND MEASURE Type of axillary surgery performed. RESULTS Of 1703 women who received treatment by 863 surgeons, 56.4% underwent an initial SLNB, 37.2% initial axillary lymph node dissection, and 6.3% no axillary surgery. The median annual surgeon Medicare volume of breast cancer cases was 6.0 (range, 1.5-57.0); the median surgeon percentage of breast cancer cases was 4.5% (range, 0.4%-100.0%). After multivariable adjustment of patient and surgeon factors, women operated on by surgeons with higher volumes and percentages of breast cancer cases had a higher likelihood of undergoing SLNB. Specifically, women were most likely to undergo SLNB if the operation was performed by high-volume surgeons (regardless of percentage) or by lower-volume surgeons with a high percentage of breast cancer cases. In addition, membership in the American Society of Breast Surgeons (odds ratio, 1.98; 95% CI, 1.51-2.60) and Society of Surgical Oncology (1.59; 1.09-2.30) were independent predictors of women undergoing an initial SLNB. CONCLUSIONS AND RELEVANCE Patients who receive treatment from surgeons with more experience with and focus on breast cancer are significantly more likely to undergo SLNB, highlighting the importance of receiving initial treatment by specialized providers. Factors relating to specialization in a particular area, including our novel surgeon percentage measure, require further investigation as potential indicators of quality of care.
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Affiliation(s)
- Tina W F Yen
- Division of Surgical Oncology, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Purushuttom W Laud
- Division of Biostatistics, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Rodney A Sparapani
- Division of Biostatistics, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
| | - Ann B Nattinger
- Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee
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95
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Martelli G, Boracchi P, Orenti A, Lozza L, Maugeri I, Vetrella G, Agresti R. Axillary dissection versus no axillary dissection in older T1N0 breast cancer patients: 15-year results of trial and out-trial patients. Eur J Surg Oncol 2014; 40:805-12. [PMID: 24768443 DOI: 10.1016/j.ejso.2014.03.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 03/29/2014] [Accepted: 03/31/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Our randomized trial found no survival advantage for axillary dissection (AD) compared observation only (no AD) in older patients with early breast cancer and a clinically negative axilla, indicating that AD is unnecessary. We compared characteristics and outcomes in out-trial patients with those in trial patients to provide indications as to whether AD can be safely omitted outside the trial setting. METHODS The trial started in 1996, recruiting 238 patients age 65-80 years with cT1cN0 breast cancer, randomized to conservative surgery with or without AD. Over the recruitment period, 109 eligible patients who refused to participate in the trial, also received conservative breast surgery with or without AD depending on patient preference/surgeon opinion. Trial and out-trial patients received conventionally-fractioned whole breast radiation and tamoxifen for five years. Endpoints were breast cancer mortality, overall survival, and cumulative incidence of axillary disease in patients not receiving AD. RESULTS After 15 years of follow-up, breast cancer mortality and overall survival did not differ between the AD and no AD arms, in either the trial or out-trial cohorts. The 15-year cumulative incidence of axillary relapse was 6% in the no AD arm of the trial group, and zero in the no AD arm of the out-trial group. CONCLUSIONS Outside the trial setting, older patients with T1N0 breast cancer can be safely treated by conservative surgery, postoperative radiotherapy and tamoxifen for five years (if ER-positive). Axillary surgery is appropriate only for the small proportion of patients who develop overt axillary disease during follow-up.
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Affiliation(s)
- G Martelli
- Breast Unit, National Cancer Institute of Milan, Milan, Italy.
| | - P Boracchi
- Department of Clinical Science and Community Health, University of Milan, Italy
| | - A Orenti
- Department of Clinical Science and Community Health, University of Milan, Italy
| | - L Lozza
- Radiotherapy Unit, National Cancer Institute of Milan, Milan, Italy
| | - I Maugeri
- Breast Unit, National Cancer Institute of Milan, Milan, Italy
| | - G Vetrella
- Unit of Preventive Gynecology, Melegnano Hospital, Melegnano, Italy
| | - R Agresti
- Breast Unit, National Cancer Institute of Milan, Milan, Italy
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96
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Surgical Management of the Axilla. Breast Cancer 2014. [DOI: 10.1007/978-1-4614-8063-1_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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97
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Agresti R, Martelli G, Sandri M, Tagliabue E, Carcangiu ML, Maugeri I, Pellitteri C, Ferraris C, Capri G, Moliterni A, Bianchi G, Mariani G, Trecate G, Lozza L, Langer M, Rampa M, Gennaro M, Greco M, Menard S, Pierotti MA. Axillary lymph node dissection versus no dissection in patients with T1N0 breast cancer: a randomized clinical trial (INT09/98). Cancer 2013; 120:885-93. [PMID: 24323615 DOI: 10.1002/cncr.28499] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 10/19/2013] [Accepted: 11/04/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND Although axillary surgery is still considered to be a fundamental part of the management of early breast cancer, it may no longer be necessary either as treatment or as a guide to adjuvant treatment. The authors conducted a single-center randomized trial (INT09/98) to determine the impact of avoiding axillary surgery in patients with T1N0 breast cancer and planning chemotherapy based on biological factors of the primary tumor on long-term disease control. METHODS From June 1998 to June 2003, 565 patients aged 30 years to 65 years with T1N0 breast cancer were randomized to either quadrantectomy with (QUAD) or without (QU) axillary lymph node dissection; a total of 517 patients finally were evaluated. All patients received radiotherapy to the residual breast only. Chemotherapy for patients in the QUAD treatment arm was determined based on lymph node status, estrogen receptor status, and tumor grade. Chemotherapy for patients in the QU treatment arm was based on estrogen receptor status, tumor grade, and human epidermal growth factor receptor 2 and laminin receptor status. Overall survival (OS) was the primary endpoint. Disease-free survival (DFS) and rate and time of axillary lymph node recurrence in the QU treatment arm were the secondary endpoints. RESULTS After a median follow-up of >10 years, the estimated adjusted hazards ratio of the QUAD versus QU treatment arms for OS was 1.09 (95% confidence interval, 0.59-2.00; P = .783) and was 1.04 (95% confidence interval, 0.56-1.94; P = .898) for DFS. Of the 245 patients in the QU treatment arm, 22 (9.0%) experienced axillary lymph node recurrence. The median time to axillary lymph node recurrence from breast surgery was 30.0 months (interquartile range, 24.2 months-73.4 months). CONCLUSIONS Patients with T1N0 breast cancer did not appear to benefit in terms of DFS and OS from immediate axillary lymph node dissection in the current randomized trial. The biological characteristics of the primary tumor appear adequate for guiding adjuvant treatment.
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Affiliation(s)
- Roberto Agresti
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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98
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Cappellani A, Vita MD, Zanghì A, Cavallaro A, Piccolo G, Majorana M, Barbera G, Berretta M. Prognostic factors in elderly patients with breast cancer. BMC Surg 2013; 13 Suppl 2:S2. [PMID: 24268048 PMCID: PMC3851261 DOI: 10.1186/1471-2482-13-s2-s2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Breast cancer (BC) remains principally a disease of old ages; with 35-50% of cases occurring in women older than 65 years. Even mortality for cancer increases with aging: 19.7% between 65 and 74 years; 22.6% between 75 and 84 years; and 15.1% in 85 years or more. METHODS A search was performed on Medline, Embase, Scopus using the following Key words: Breast cancer, Breast neoplasms, Aged, Elder, Elderly, Eldest, Older, Survival analysis, Prognosis, Prognostic factors, Tumor markers, Biomarkers, Comorbidity, Geriatric assessment, Axilla, Axillary surgery. 3029 studies have been retrieved. Paper in which overall or disease free survival were not end points, or age class was not well defined, or the sample was too small, were excluded. At last 42 papers fulfilled the criteria. RESULTS AND DISCUSSION Lack of screening and delay in diagnosis may be responsible for the minor improvement in survival observed in elderly respect to younger breast cancer patients. Predictive factors are the same and must be assessed with the same attention reserved to younger women. CONCLUSIONS Most of elderly patient are fit to undergo standard treatment and can get the same benefits of younger women. Nevertheless it is possible that some older women with early breast cancer can be spared too aggressive treatments. Geriatric assessment and co-morbidities can affect the prognosis modifying surveillance, life expectancy and compliance to therapies. They can thus be useful to select the better treatment, either surgical or radio or hormone - or chemo-therapy.
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Affiliation(s)
- Alessandro Cappellani
- Department of Surgery, General and Breast Surgery Unit, University of Catania, Catania, Italy
| | - Maria Di Vita
- Department of Surgery, General and Breast Surgery Unit, University of Catania, Catania, Italy
| | - Antonio Zanghì
- Department of Surgery, General and Breast Surgery Unit, University of Catania, Catania, Italy
| | - Andrea Cavallaro
- Department of Surgery, General and Breast Surgery Unit, University of Catania, Catania, Italy
| | - Gaetano Piccolo
- Department of Surgery, General and Breast Surgery Unit, University of Catania, Catania, Italy
| | - Marcello Majorana
- Department of Radiology, Mediterranean Institute of Oncology, Viagrande, (CT), Italy
| | - Giuseppina Barbera
- Department of Surgery, General and Breast Surgery Unit, University of Catania, Catania, Italy
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99
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Luque M, Arranz F, Cueva JF, de Juan A, García-Teijido P, Calvo L, Peláez I, García-Palomo A, García-Mata J, Antolín S, García-Estévez L, Fernández Y. Breast cancer management in the elderly. Clin Transl Oncol 2013; 16:351-61. [PMID: 24085574 DOI: 10.1007/s12094-013-1113-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 09/15/2013] [Indexed: 01/02/2023]
Abstract
The increase in life expectancy in the western world means that we are faced with patients diagnosed with breast cancer in old age with increasing frequency. The management of these cases is a challenge for the oncologist, who must take into account the conditions associated with advanced age and the lack of trials in this population. In this review, we addressed the incorporation of geriatric assessment methods that may be useful in making decisions, the particular biological characteristics of breast cancer in elderly patients and their treatment in both localized and advanced disease. Finally, we collected recommendations based on scientific evidence regarding the monitoring and life-style after finishing treatment.
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Affiliation(s)
- M Luque
- Medical Oncology Department, Hospital Universitario Central de Asturias, C/Julian Clavería s/n, 33006, Oviedo, Spain,
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100
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Dengel LT, Van Zee KJ, King TA, Stempel M, Cody HS, El-Tamer M, Gemignani ML, Sclafani LM, Sacchini VS, Heerdt AS, Plitas G, Junqueira M, Capko D, Patil S, Morrow M. Axillary dissection can be avoided in the majority of clinically node-negative patients undergoing breast-conserving therapy. Ann Surg Oncol 2013; 21:22-7. [PMID: 23975314 DOI: 10.1245/s10434-013-3200-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND The extent to which ACOSOG Z0011 findings are applicable to patients undergoing breast-conserving therapy (BCT) is uncertain. We prospectively assessed how often axillary dissection (ALND) was avoided in an unselected, consecutive patient cohort meeting Z0011 eligibility criteria and whether subgroups requiring ALND could be identified preoperatively. METHODS Patients with cT1,2cN0 breast cancer undergoing BCT were managed without ALND for metastases in <3 sentinel nodes (SNs) and no gross extracapsular extension (ECE). Patients with and without indications for ALND were compared using Fisher's exact and Wilcoxon rank sum tests. RESULTS From August 2010 to November 2012, 2,157 invasive cancer patients had BCT. A total of 380 had histologic nodal metastasis; 93 did not meet Z0011 criteria. Of 287 with ≥1 H&E-positive SN (209 macrometastases), 242 (84 %) had indications for SN only. ALND was indicated in 45 for ≥3 positive SNs (n = 29) or ECE (n = 16). The median number of SNs removed in the SN group was 3 versus 5 in the ALND group (p < 0.0001). Age, hormone receptor and HER2 status, and grade did not differ between groups; tumors were larger in the ALND group (p < 0.0001). Of ALND patients, 72 % had additional positive nodes (median = 1; range 1-19). No axillary recurrences have occurred (median follow-up, 13 months). CONCLUSIONS ALND was avoided in 84 % of a consecutive series of patients having BCT, suggesting that most patients meeting ACOSOG Z0011 eligibility have a low axillary tumor burden. Age, ER, and HER2 status were not predictive of ALND, and the criteria used for ALND (≥3 SNs, ECE) reliably identified patients at high risk for residual axillary disease.
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Affiliation(s)
- Lynn T Dengel
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, USA
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