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Wang Y, Sun Y, Lu F, Zhao X, Nie Z, Zhu F, He B. Efficacy and safety of a combination treatment of immune checkpoint inhibitors in metastatic breast cancer: a systematic review and meta-analysis. Clin Transl Oncol 2024; 26:1725-1737. [PMID: 38587602 DOI: 10.1007/s12094-024-03396-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/22/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE Immune checkpoint inhibitors (ICIs) in combination with chemotherapy have showed its benefits in clinical studies, and here we conducted a further evaluation on the safety and efficacy of this treatment strategy. METHODS A systematic literature review was conducted in PubMed, Embase and Cochrane Library to identify clinical studies on ICIs and chemotherapy for metastatic breast cancer. The primary efficacy endpoints were progression-free survival (PFS) and overall survival (OS), and adverse events (AEs) were analyzed. Random or fixed effects models were used to estimate pooled Hazard ratio (HR), odds ratio (OR) and the data of 95% confidence interval (CI) depend on the Heterogeneity. Cochrane risk assessment tool was used to assess risk of bias. We also drew forest plots and funnel plots, respectively. RESULTS Seven studies with intend-to-treat (ITT) population for 3255 patients were analyzed. ICIs pooled therapy showed clinical benefits compared with chemotherapy alone, improving PFS (HR = 0.81, 95% CI: 0.74-0.90) of patients with metastatic triple negative breast cancer (mTNBC), especially in patients with PD-L1-positive tumors. However, it had no effect on OS (HR = 0.92, 95% CI 0.85-1.01). Besides, mTNBC patients received pooled therapy were less frequently to have AEs (OR = 1.30, 95% CI: 1.09-1.54). In patients with metastatic Human Epidermal Growth Factor Receptor 2 (HER2) negative breast cancer, pooled therapy showed no benefit for PFS (HR = 0.80, 95% CI: 0.50-1.28) and OS (HR = 0.87, 95% CI: 0.48-1.58). CONCLUSION Pooled therapy had improved PFS in mTNBC patients, especially in patients with PD-L1-positive tumors, and it was less likely to cause grade ≥ 3 AEs.
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Affiliation(s)
- Ying Wang
- School of Basic-Medicine & Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Deparment of Laboratory Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Yalan Sun
- School of Basic-Medicine & Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Deparment of Laboratory Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Fang Lu
- School of Basic-Medicine & Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Deparment of Laboratory Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Xianghong Zhao
- School of Basic-Medicine & Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Deparment of Laboratory Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Zhenlin Nie
- Deparment of Laboratory Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Feng Zhu
- Department of Laboratory Medicine, Nanjing Jiangning People's Hospital, 68 Gushan Road, Jiangning District, Nanjing, Jiangsu, 211100, China.
| | - Bangshun He
- School of Basic-Medicine & Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.
- Deparment of Laboratory Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China.
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Hatzipanagiotou ME, Pigerl M, Gerken M, Räpple S, Zeltner V, Hetterich M, Ugocsai P, Inwald EC, Klinkhammer-Schalke M, Ortmann O, Seitz S. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with early triple negative breast cancer. Breast Cancer Res Treat 2024; 204:607-615. [PMID: 38238552 PMCID: PMC10959785 DOI: 10.1007/s10549-023-07207-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/29/2023] [Indexed: 03/24/2024]
Abstract
PURPOSE The optimal time to initiation of adjuvant chemotherapy (TTAC) for triple negative breast cancer (TNBC) patients is unclear. This study evaluates the association between TTAC and survival in TNBC patients. METHODS We conducted a retrospective study using data from a cohort of TNBC patients diagnosed between January 1, 2010 to December 31, 2018, registered in the Tumor Centre Regensburg was conducted. Data included demographics, pathology, treatment, recurrence and survival. TTAC was defined as days from primary surgery to first dose of adjuvant chemotherapy. The Kaplan-Meier method was used to evaluate impact of TTAC on overall survival (OS) and 5-year OS. RESULTS A total of 245 TNBC patients treated with adjuvant chemotherapy and valid TTAC data were included. Median TTAC was 29 days. The group receiving systemic therapy within 22 to 28 days after surgery had the most favorable outcome, with median OS of 10.2 years. Groups receiving systemic therapy between 29-35 days, 36-42 days, and more than 6 weeks after surgery had significantly decreased median survival, with median OS of 8.3 years, 7.8 years, and 6.9 years, respectively. Patients receiving therapy between 22-28 days had significantly better survival compared to those receiving therapy between 29-35 days (p = 0.043), and patients receiving therapy after 22-28 days also demonstrated significantly better survival compared to those receiving therapy after more than 43 days (p = 0.033). CONCLUSION Timing of adjuvant systemic therapy can influence OS in TNBC patients. Efforts should be made to avoid unnecessary delays in administering chemotherapy to ensure timely initiation of systemic therapy and optimize patient outcomes.
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Affiliation(s)
- Maria Eleni Hatzipanagiotou
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuterstraße 65, 93053, Regensburg, Germany.
| | - Miriam Pigerl
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuterstraße 65, 93053, Regensburg, Germany
| | - Michael Gerken
- Bavarian Cancer Registry, Regional Centre Regensburg, Bavarian Health and Food Safety Authority, Regensburg, Germany
| | - Sophie Räpple
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuterstraße 65, 93053, Regensburg, Germany
| | - Verena Zeltner
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuterstraße 65, 93053, Regensburg, Germany
| | - Madeleine Hetterich
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuterstraße 65, 93053, Regensburg, Germany
| | - Peter Ugocsai
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuterstraße 65, 93053, Regensburg, Germany
| | - Elisabeth Christine Inwald
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuterstraße 65, 93053, Regensburg, Germany
| | - Monika Klinkhammer-Schalke
- Tumor Center Regensburg - Centre for Quality Management and Health Services Research, University of Regensburg, Regensburg, Germany
| | - Olaf Ortmann
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuterstraße 65, 93053, Regensburg, Germany
| | - Stephan Seitz
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuterstraße 65, 93053, Regensburg, Germany
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3
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Hatzipanagiotou ME, Pigerl M, Gerken M, Räpple S, Zeltner V, Hetterich M, Ugocsai P, Fernandez-Pacheco M, Inwald EC, Klinkhammer-Schalke M, Ortmann O, Seitz S. Does timing of neoadjuvant chemotherapy influence the prognosis in patients with early triple negative breast cancer? J Cancer Res Clin Oncol 2023; 149:11941-11950. [PMID: 37418056 PMCID: PMC10465651 DOI: 10.1007/s00432-023-05060-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/28/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE For patients with triple negative breast cancer (TNBC), the optimal time to initiate neoadjuvant chemotherapy (TTNC) is unknown. This study evaluates the association between TTNC and survival in patients with early TNBC. METHODS A retrospective study using data from of a cohort of TNBC patients diagnosed between January 1, 2010 to December 31, 2018 registered in the Tumor Centre Regensburg was performed. Data included demographics, pathology, treatment, recurrence, and survival. Interval to treatment was defined as days from pathology diagnosis of TNBC to first dose of neoadjuvant chemotherapy (NACT). The Kaplan-Meier and Cox regression methods were used to evaluate the impact of TTNC on overall survival (OS) and 5 year OS. RESULTS A total of 270 patients were included. Median follow up was 3.5 years. The 5-year OS estimates according to TTNC were 77.4%, 66.9%, 82.3%, 80.6%, 88.3%, 58.3%, 71.1% and 66.7% in patients who received NACT within 0-14, 15-21, 22-28, 29-35, 36-42, 43-49, 50-56 and > 56 days after diagnosis. Patients who received systemic therapy early had the highest estimated mean OS of 8.4 years, while patients who received systemic therapy after more than 56 days survived an estimated 3.3 years. CONCLUSION The optimal time interval between diagnosis and NACT remains to be determined. However, starting NACT more than 42 days after diagnosis of TNBC seems to reduce survival. Therefore, it is strongly recommended to carry out the treatment in a certified breast center with appropriate structures, in order to enable an adequate and timely care.
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Affiliation(s)
- Maria Eleni Hatzipanagiotou
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany.
- Department of Gynecology and Obstetrics, Maria Eleni Hatzipanagiotou, University Medical Centre Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany.
| | - Miriam Pigerl
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - Michael Gerken
- Bavarian Cancer Registry, Regional Centre Regensburg, Bavarian Health and Food Safety Authority, Regensburg, Germany
| | - Sophie Räpple
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - Verena Zeltner
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - Madeleine Hetterich
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - Peter Ugocsai
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - Miriam Fernandez-Pacheco
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - Elisabeth Christine Inwald
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - Monika Klinkhammer-Schalke
- Tumor Center Regensburg - Centre for Quality Management and Health Services Research, University of Regensburg, Regensburg, Germany
| | - Olaf Ortmann
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
| | - Stephan Seitz
- Department of Gynecology and Obstetrics, University Medical Centre Regensburg, Landshuter Straße 65, 93053, Regensburg, Germany
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Abdel-Razeq H, Mansour A, Edaily S, Dayyat A. Delays in Initiating Anti-Cancer Therapy for Early-Stage Breast Cancer-How Slow Can We Go? J Clin Med 2023; 12:4502. [PMID: 37445537 DOI: 10.3390/jcm12134502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023] Open
Abstract
Breast cancer is the most commonly diagnosed cancer among women worldwide, and is a leading cause of cancer-related deaths. When diagnosed at an early stage, appropriate and timely treatment results in a high cure rate and better quality of life. Delays in initiating anti-cancer therapy, including surgical resection, adjuvant/neoadjuvant chemotherapy and radiation therapy are commonly encountered, even in developed health care systems. Existing comorbidities that mandate referral to other services, genetic counseling and testing that may dictate the extent and type of anti-cancer therapy and insurance coverage, are among the most commonly cited factors. However, delays can be unavoidable; for over three years, health care systems across the globe were busy dealing with the unprecedented COVID-19 pandemic. War across hot zones around the globe resulted in millions of refugees; most of them have no access to cancer care, and when/where available, there may be significant delays. Thus, cancer patients across the globe will probably continue to suffer from significant delays in diagnosis and appropriate treatment. Many retrospective reports showed significant negative impacts on different aspects of treatment outcomes and on patients' psychosocial wellbeing and productivity. In this paper, we review the available data on the impact of delays in initiating appropriate treatment on the outcomes of patients with early-stage breast cancer.
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Affiliation(s)
- Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan
- Department of Internal Medicine, School of Medicine, The University of Jordan, Amman 11942, Jordan
| | - Asem Mansour
- Department of Radiology, King Hussein Cancer Center, Amman 11941, Jordan
| | - Sarah Edaily
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan
| | - Abdulmajeed Dayyat
- Department of Radiation Oncology, King Hussein Cancer Center, Amman 11941, Jordan
- Department of Radiation Oncology, Dalhousie University, Halifax, NS B3H 4R2, Canada
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Lv Y, Lv D, Lv X, Xing P, Zhang J, Zhang Y. Immune Cell Infiltration-Based Characterization of Triple-Negative Breast Cancer Predicts Prognosis and Chemotherapy Response Markers. Front Genet 2021; 12:616469. [PMID: 33815462 PMCID: PMC8017297 DOI: 10.3389/fgene.2021.616469] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/23/2021] [Indexed: 12/24/2022] Open
Abstract
Breast cancer represents the number one cause of cancer-associated mortality globally. The most aggressive molecular subtype is triple negative breast cancer (TNBC), of which limited therapeutic options are available. It is well known that breast cancer prognosis and tumor sensitivity toward immunotherapy are dictated by the tumor microenvironment. Breast cancer gene expression profiles were extracted from the METABRIC dataset and two TNBC clusters displaying unique immune features were identified. Activated immune cells formed a large proportion of cells in the high infiltration cluster, which correlated to a good prognosis. Differentially expressed genes (DEGs) extracted between two heterogeneous subtypes were used to further explore the underlying immune mechanism and to identify prognostic biomarkers. Functional enrichment analysis revealed that the DEGs were predominately related to some processes involved in activation and regulation of innate immune signaling. Using network analysis, we identified two modules in which genes were selected for further prognostic investigation. Validation by independent datasets revealed that CXCL9 and CXCL13 were good prognostic biomarkers for TNBC. We also performed comparisons between the above two genes and immune markers (CYT, APM, TILs, and TIS), as well as cell checkpoint marker expressions, and found a statistically significant correlation between them in both METABRIC and TCGA datasets. The potential of CXCL9 and CXCL13 to predict chemotherapy sensitivity was also evaluated. We found that the CXCL9 and CXCL13 were good predictors for chemotherapy and their expressions were higher in chemotherapy-responsive patients in contrast to those who were not responsive. In brief, immune infiltrate characterization on TNBC revealed heterogeneous subtypes with unique immune features allowed for the identification of informative and reliable characteristics representative of the local immune tumor microenvironment and were potential candidates to guide the management of TNBC patients.
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Affiliation(s)
- Yufei Lv
- Department of Anatomy, Harbin Medical University, Harbin, China
| | - Dongxu Lv
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, China
| | - Xiaohong Lv
- Department of Anatomy, Harbin Medical University, Harbin, China
| | - Ping Xing
- Department of Ultrasound, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jianguo Zhang
- Department of Breast Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yafang Zhang
- Department of Anatomy, Harbin Medical University, Harbin, China
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Abstract
L’expertise médicale lors de la pandémie à la COVID-19 s’est arrêtée durant le confinement et la reprise des activités juridiques va se faire progressivement. L’épidémie a induit un retard au diagnostic des cancers. Des modifications des procédures de prise en charge ont été validées par des consensus d’experts des sociétés savantes. Il est néanmoins possible que dans les années à venir, les patients estiment avoir été victimes d’une « perte de chance » et en demandent réparation. Les différentes situations qui se présentent aux médecins au cours de cette pandémie et les recommandations pour la tenue des dossiers médicaux sont discutées.
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Heeg E, Marang-van de Mheen PJ, Van Maaren MC, Schreuder K, Tollenaar RAEM, Siesling S, Bos MEMM, Vrancken Peeters MJTFD. Association between initiation of adjuvant chemotherapy beyond 30 days after surgery and overall survival among patients with triple-negative breast cancer. Int J Cancer 2020; 147:152-159. [PMID: 31721193 PMCID: PMC7317578 DOI: 10.1002/ijc.32788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/28/2019] [Indexed: 12/24/2022]
Abstract
Delayed time to chemotherapy (TTC) is associated with decreased outcomes of breast cancer patients. Recently, studies suggested that the association might be subtype‐dependent and that TTC within 30 days should be warranted in patients with triple‐negative breast cancer (TNBC). The aim of the current study is to determine if TTC beyond 30 days is associated with reduced 10‐year overall survival in TNBC patients. We identified all TNBC patients diagnosed between 2006 and 2014 who received adjuvant chemotherapy in the Netherlands. We distinguished between breast‐conserving surgery (BCS) vs. mastectomy given the difference in preoperative characteristics and outcomes. The association was estimated with hazard ratios (HRs) using propensity‐score matched Cox proportional hazard analyses. In total, 3,016 patients were included. In matched patients who underwent BCS (n = 904), 10‐year overall survival was favorable for patients with TTC within 30 days (84.4% vs. 76.9%, p = 0.001). Patients with TTC beyond 30 days were more likely than those with TTC within 30 days to die within 10 years after surgery (HR 1.69 (95% CI 1.22–2.34), p = 0.002). In matched patients who underwent mastectomy (n = 1,568), there was no difference in 10 years overall survival between those with TTC within or beyond 30 days (74.5% vs. 74.7%, p = 0.716), nor an increased risk of death for those with TTC beyond 30 days (HR 1.04 (95% CI 0.84–1.28), p = 0.716). Initiation of adjuvant chemotherapy beyond 30 days is associated with decreased 10 years overall survival in TNBC patients who underwent BCS. Therefore, timelier initiation of chemotherapy in TNBC patients undergoing BCS seems warranted. What's new? Current breast cancer treatment guidelines recommend that chemotherapy is initiated between 6‐12 weeks after surgery. Delayed treatment can lead to poorer outcome, but there's no precise definition of the optimal window. Recent work suggests that for patients with triple negative breast cancer (TNBC), it's best to initiate chemotherapy within 30 days. Here, the authors evaluated outcomes for TNBC patients correlated with time to chemotherapy. They found that in patients undergoing breast‐conserving surgery, an interval of more than 30 days before chemotherapy was associated with decreased survival. If the patient had undergone a mastectomy, a longer delay before chemotherapy did not impact survival.
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Affiliation(s)
- Erik Heeg
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Marissa C Van Maaren
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Kay Schreuder
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Monique E M M Bos
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Prolonged Time to Adjuvant Chemotherapy Initiation Was Associated with Worse Disease Outcome in Triple Negative Breast Cancer Patients. Sci Rep 2020; 10:7029. [PMID: 32341397 PMCID: PMC7184599 DOI: 10.1038/s41598-020-64005-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/09/2020] [Indexed: 01/01/2023] Open
Abstract
The optimal time to adjuvant chemotherapy (TTC) for breast cancer (BC) patients remains uncertain. Herein, we aim to evaluate the association between TTC and prognosis among different subtypes in modern era of adjuvant chemotherapy. BC patients receiving operation and adjuvant chemotherapy between January 2009 and December 2015 were included. Enrolled patients were categorized into TTC ≤4 weeks and >4 weeks groups. Relapse-free survival (RFS) and overall survival (OS) were compared according to TTC and analyzed among different BC molecular subtypes. A total of 2611 patients were included. Elder age (P = 0.005), more comorbidities (P <0.001), breast-conserving surgery (P = 0.001), non-invasive ductal carcinoma (P = 0.012), and HER2-positivity (P <0.001) were associated with prolonged TTC. Among whole BC population, no significant difference was observed between two TTC groups in terms of RFS (P = 0.225) or OS (P = 0.355). However, for triple negative (TNBC) patients, TTC >4 weeks was independently related with worse RFS (5-year RFS 81.9% vs 89.3%; HR, 1.89; 95% CI, 1.09 to 3.27; P = 0.024) and OS (5-year OS 84.0% vs 94.0%; HR, 2.49; 95% CI, 1.30 to 4.76; P = 0.006) compared with those TTC ≤4 weeks. Prolonged TTC >4 weeks after BC surgery was not associated with worse survival outcomes in the whole BC patients. However, TTC >4 weeks may increase risk of relapse or death in TNBC patients, which deserves further clinical evaluation.
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