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Matar R, Barrio AV, Sevilimedu V, Le T, Heerdt A, Morrow M, Tadros A. Can We Successfully De-Escalate Axillary Surgery in Women Aged ≥ 70 Years with Ductal Carcinoma in Situ or Early-Stage Breast Cancer Undergoing Mastectomy? Ann Surg Oncol 2022; 29:2263-2272. [PMID: 34994896 PMCID: PMC11404126 DOI: 10.1245/s10434-021-11140-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/08/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Omission of sentinel lymph node biopsy (SLNB) in older women with clinically node-negative, hormone receptor-positive (HR+) early-stage breast cancer undergoing lumpectomy is accepted, given established low rates of regional recurrence. The safety of omitting SLNB in women undergoing mastectomy is unknown and may differ depending on extent of breast disease and variation in radiotherapy use. PATIENTS AND METHODS From 2006 to 2018, 123 cTis and 328 cT1-2 HR+/HER2- tumors from 410 women aged ≥ 70 years who underwent mastectomy and SLNB were included (41 bilateral cases). The rate of nodal positivity and effect of nodal positivity on adjuvant therapy use were examined. RESULTS Median age was 74 years; 21% of patients had positive sentinel lymph nodes, 7% had micrometastases, and 14% had macrometastases. Of cases of cTis tumors, 31% were upstaged to invasive carcinoma; 1% had macrometastases. Fewer cases of cT1 than cT2 tumors had macrometastases [13% (26/200) versus 29% (37/128); p < 0.001]. Eight percent of patients with pT1 tumors (18/228) and 27% of patients with pT2 tumors (30/113) received chemotherapy. Most patients with pT1, pN1 disease (78%; 25/32) did not receive chemotherapy. Rates of locoregional recurrence were similar between patients with cT1 or cT2 tumors with and without nodal metastases (median follow-up, 4.5 years). CONCLUSIONS Women aged ≥ 70 years with cTis and cT1N0 HR+/HER2- tumors who underwent mastectomy had low rates of nodal positivity, similar to rates reported for lumpectomy. Given this and the RxPONDER results, omission of SLNB may be considered, as findings are unlikely to alter adjuvant therapy recommendations.
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MESH Headings
- Aged
- Axilla/pathology
- Axilla/surgery
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/metabolism
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/metabolism
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Humans
- Mastectomy/methods
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/surgery
- Receptor, ErbB-2/biosynthesis
- Receptors, Estrogen/biosynthesis
- Receptors, Progesterone/biosynthesis
- Sentinel Lymph Node Biopsy
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Affiliation(s)
- Regina Matar
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tiana Le
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexandra Heerdt
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Audree Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Chagpar AB, Horowitz N, Sanft T, Wilson LD, Silber A, Killelea B, Moran MS, DiGiovanna MP, Hofstatter E, Chung G, Pusztai L, Lannin DR. Does lymph node status influence adjuvant therapy decision-making in women 70 years of age or older with clinically node negative hormone receptor positive breast cancer? Am J Surg 2017; 214:1082-1088. [PMID: 28939252 DOI: 10.1016/j.amjsurg.2017.07.036] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/03/2017] [Accepted: 07/07/2017] [Indexed: 02/09/2023]
Abstract
BACKGROUND Women ≥70 years old with clinically (c) lymph node (LN) negative (-), hormone receptor (HR) positive (+) breast cancer are recommended not to be routinely staged with a sentinel LN biopsy. We sought to determine how this affects adjuvant decision-making. METHODS Statistical analyses were performed to determine the association of LN evaluation with adjuvant chemotherapy and radiation therapy in cLN-, HR + breast cancer patients in the National Cancer Database. RESULTS Between 2004 and 2013, there were 193,728 patients aged 70-90 with cLN-, HR + breast cancer; 15.0% were LN+. LN + patients were more likely to receive chemotherapy (28.3% vs. 5.5%, p < 0.001), hormonal therapy (83.6% vs. 71.4%, p < 0.001), post-lumpectomy radiation therapy (81.4% vs. 73.6%, p < 0.001) and post-mastectomy radiation therapy (30.3% vs. 5.1%, p < 0.001). CONCLUSION 15% of patients aged 70-90 will be LN+. These patients more frequently receive systemic and radiation therapy. LN status may affect treatment in these patients.
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Affiliation(s)
- Anees B Chagpar
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
| | - Nina Horowitz
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Tara Sanft
- Department of Medicine (Medical Oncology), Yale University School of Medicine, New Haven, CT, USA
| | - Lynn D Wilson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Andrea Silber
- Department of Medicine (Medical Oncology), Yale University School of Medicine, New Haven, CT, USA
| | - Brigid Killelea
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Meena S Moran
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Michael P DiGiovanna
- Department of Medicine (Medical Oncology), Yale University School of Medicine, New Haven, CT, USA
| | - Erin Hofstatter
- Department of Medicine (Medical Oncology), Yale University School of Medicine, New Haven, CT, USA
| | - Gina Chung
- Department of Medicine (Medical Oncology), Yale University School of Medicine, New Haven, CT, USA
| | - Lajos Pusztai
- Department of Medicine (Medical Oncology), Yale University School of Medicine, New Haven, CT, USA
| | - Donald R Lannin
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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Chagpar AB, Hatzis C, Pusztai L, DiGiovanna MP, Moran M, Mougalian S, Sanft T, Evans S, Hofstatter E, Wilson LD, Lannin DR. Association of LN Evaluation with Survival in Women Aged 70 Years or Older With Clinically Node-Negative Hormone Receptor Positive Breast Cancer. Ann Surg Oncol 2017; 24:3073-3081. [PMID: 28766195 DOI: 10.1245/s10434-017-5936-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Some suggest that lymph node (LN) evaluation not be performed routinely in women aged ≥70 years with clinically (c) LN-negative (-), hormone receptor (HR)-positive (+) breast cancer. We sought to determine the association of omission of LN evaluation on survival. METHODS Patients who met the above criteria and were diagnosed from 2004 to 2012 were identified in the NCDB and SEER databases. Overall survival (OS) and breast cancer-specific survival (BCSS) were determined. RESULTS Using the NCDB, we identified 157,584 cLN- HR+ patients aged ≥70 years in whom survival and LN evaluation data were available. A total of 126,638 patients (80.2%) had regional LN surgery. With a median follow-up of 41.6 months, there was a significant difference in OS between those who had LN evaluation and those who did not (median OS: 100.5 vs. 70.9 months, respectively, p < 0.001). After adjusting for patient age, race, insurance, income, comorbidities, tumor characteristics and treatment, patients who had undergone LN evaluation still had a lower hazard rate for death than those who had not (hazard ratio = 0.633; 95% confidence interval [CI] 0.613-0.654, p < 0.001). We then did a parallel analysis using SEER data that showed LN evaluation was associated with a lower hazard rate for both BCSS (hazard ratio = 0.452; 95% CI 0.427-0.479, p < 0.001) and non-BCSS (hazard ratio = 0.465; 95% CI 0.447-0.482, p < 0.001). CONCLUSIONS Roughly 20% of patients older than aged 70 years with cLN-, HR+ breast cancer did not have LN evaluation. Those who did had better OS controlling for sociodemographic, pathologic, and treatment variables; however, this may be due to patient selection.
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Affiliation(s)
- Anees B Chagpar
- Department of Surgery, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA.
| | - Christos Hatzis
- Department of Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Lajos Pusztai
- Department of Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Michael P DiGiovanna
- Department of Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Meena Moran
- Department of Therapeutic Oncology, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Sarah Mougalian
- Department of Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Tara Sanft
- Department of Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Suzanne Evans
- Department of Therapeutic Oncology, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Erin Hofstatter
- Department of Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Lynn D Wilson
- Department of Therapeutic Oncology, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Donald R Lannin
- Department of Surgery, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
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Merrill A, Brown DR, Klepin HD, Levine EA, Howard-Mcnatt M. Outcomes after Mastectomy and Lumpectomy in Octogenarians and Nonagenarians with Early-Stage Breast Cancer. Am Surg 2017. [DOI: 10.1177/000313481708300842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prospective studies have shown equal outcomes after mastectomy or breast conservation in patients with invasive breast cancer; however, many of these studies excluded elderly patients. We identified patients in their eighties and nineties with clinical stage 0 to II breast cancer undergoing mastectomy or lumpectomy with or without radiation from the prospective sentinel lymph node database at Wake Forest Baptist Health and analyzed their treatment and survival. Of 92 patients, 24 (26.1%) underwent mastectomy, 22 (23.9%) lumpectomy with radiation, and 46 (50.0%) lumpectomy alone. Significant differences were noted in tumor size (P = 0.018), nodal status (P = 0.013), and stage (P = 0.011) between the groups. Only 7.6 per cent of patients had chemotherapy, whereas 51.1 per cent took antiestrogen therapy. Recurrence occurred in 11 patients. In univariate analysis, overall survival did not differ by surgery. Age was the only factor that increased risk of death (HR = 1.19, P = 0.028). In this age group, neither tumor factors nor the type of local treatment significantly influenced overall survival. Octogenarians and nonagenarians with early-stage breast cancer undergoing breast-conserving surgery with or without radiation have equivalent survival to patients having a mastectomy.
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Mamtani A, Gonzalez JJ, Neo D, Slanetz PJ, Houlihan MJ, Herold CI, Recht A, Hacker MR, Sharma R. Early-Stage Breast Cancer in the Octogenarian: Tumor Characteristics, Treatment Choices, and Clinical Outcomes. Ann Surg Oncol 2016; 23:3371-8. [PMID: 27364507 DOI: 10.1245/s10434-016-5368-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Nodal staging with sentinel node biopsy (SLNB), post-lumpectomy radiotherapy (RT), and endocrine therapy (ET) for estrogen receptor-positive (ER+) tumors is valuable in the treatment of early-stage (stages 1 or 2) breast cancer but used less often for elderly women. METHODS This retrospective study investigated women referred for surgical evaluation of biopsy-proven primary early-stage invasive breast cancer from January 2001 to December 2010. Clinicopathologic features, treatment course, and outcomes for women ages 80-89 years and 50-59 years were compared. RESULTS The study identified 178 eligible women ages 80-89 years and 169 women ages 50-59 years. The elderly women more often had grade 1 or 2 disease (p = 0.003) and ER+ tumors (p = 0.007) and less frequently had undergone adjuvant therapies (all p ≤ 0.001). Lumpectomy was performed more commonly for the elderly (92 vs. 83 %, p = 0.02), and axillary surgery was less commonly performed (46 vs. 96 %; p < 0.001). Fewer elderly women had undergone post-lumpectomy RT (42 vs. 89 %; p < 0.001) and ET for ER+ tumors (72 vs. 95 %; p < 0.001). During the median follow-up period of 56 months for the 80- to 89-year old group and 98 months for the 50- to 59-year-old group, death from breast cancer was similar (4 vs. 5 %; p = 0.5). The two groups respectively experienced 7 versus 6 locoregional recurrences and 11 versus 13 distant recurrences. CONCLUSIONS The octogenarians had disease survivorship similar to that of the younger women despite less frequent use of adjuvant therapies, likely reflecting lower-risk disease features. Whether increased use of axillary surgery, post-lumpectomy RT, and/or ET for ER+ tumors would further improve outcomes is an important area for further study, but treatment should not be deferred solely on the basis of age.
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Affiliation(s)
- Anita Mamtani
- Breast Service, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Julie J Gonzalez
- Breast Service, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Dayna Neo
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Priscilla J Slanetz
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mary Jane Houlihan
- Breast Service, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Christina I Herold
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Abram Recht
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michele R Hacker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ranjna Sharma
- Breast Service, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
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