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Miller K, Kreis IA, Gannon MR, Medina J, Clements K, Horgan K, Dodwell D, Park MH, Cromwell DA. The association between guideline adherence, age and overall survival among women with non-metastatic breast cancer: A systematic review. Cancer Treat Rev 2022; 104:102353. [PMID: 35152157 DOI: 10.1016/j.ctrv.2022.102353] [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: 11/30/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Conformity with treatment guidelines should benefit patients. Studies have reported variation in adherence to breast cancer (BC) guidelines, particularly among older women. This study investigated (i) whether adherence to treatment guideline recommendations for women with non-metastatic BC improves overall survival (OS), (ii) whether that relationship varies by age. METHODOLOGY MEDLINE and EMBASE were systematically searched for studies on guideline adherence and OS in women with non-metastatic BC, published after January 2000, which examined recommendations on breast surgery, chemotherapy, radiotherapy or endocrine therapy. Study results were summarised using narrative synthesis. RESULTS Sixteen studies met the inclusion criteria. The recommendations for each treatment covered were similar, but studies differed in their definitions of adherence. 5-year OS rates among patients having compliant treatment ranged from 91.3% to 93.2%, while rates among patients having non-compliant treatment ranged from 75.9% to 83.4%. Six studies reported an adjusted hazard ratio (aHR) for non-compliant treatment compared with compliant treatment; all concluded OS was worse among patients whose overall treatment was non-compliant (aHR range: 1.52 [1.30-1.82] to 2.57 [1.96-3.37]), but adjustment for potential confounders was limited. Worse adherence among older women was reported in 12/16 studies, but they did not provide consistent evidence on whether OS was associated with treatment adherence and age. CONCLUSIONS Individual studies reported that better adherence to guidelines improved OS among women with non-metastatic BC, but the evidence base has weaknesses including inconsistent definitions of adherence. More precise and consistent research designs, including the evaluation of barriers to adherence across the spectrum of healthcare practice, are required to fully understand guideline compliance, as well as the relationship between compliance and OS following a BC diagnosis.
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Affiliation(s)
- Katie Miller
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.
| | - Irene A Kreis
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Melissa R Gannon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jibby Medina
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Karen Clements
- National Cancer Registration and Analysis Service, NHS Digital, 2(nd) Floor, 23 Stephenson Street, Birmingham, UK
| | - Kieran Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, UK
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Min Hae Park
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
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Bierbaum M, Rapport F, Arnolda G, Tran Y, Nic Giolla Easpaig B, Ludlow K, Braithwaite J. Adherence to clinical practice guidelines (CPGs) for the treatment of cancers in Australia and the factors associated with adherence: a systematic review protocol. BMJ Open 2021; 11:e050912. [PMID: 34548359 PMCID: PMC8458325 DOI: 10.1136/bmjopen-2021-050912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Clinical practice guidelines (CPGs) synthesise the latest evidence to support clinical and patient decision-making. CPG adherent care is associated with improved patient survival outcomes; however, adherence rates are low across some cancer streams in Australia. Greater understanding of specific barriers to cancer treatment CPG adherence is warranted to inform future implementation strategies.This paper presents the protocol for a systematic review that aims to determine cancer treatment CPG adherence rates in Australia across a variety of common cancers, and to identify any factors associated with adherence to those CPGs, as well as any associations between CPG adherence and patient outcomes. METHODS AND ANALYSIS Five databases will be searched, Ovid Medline, PsychInfo, Embase, Scopus and Web of Science, for eligible studies evaluating adherence rates to cancer treatment CPGs in Australia. A team of reviewers will screen the abstracts in pairs according to predetermined inclusion criteria and then review the full text of eligible studies. All included studies will be assessed for quality and risk of bias. Data will be extracted using a predefined data extraction template. The frequency or rate of adherence to CPGs, factors associated with adherence to those CPGs and any reported patient outcome rates (eg, relative risk ratios or 5-year survival rates) associated with adherence to CPGs will be described. If applicable, a pooled estimate of the rate of adherence will be calculated by conducting a random-effects meta-analysis. The systematic review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. ETHICS AND DISSEMINATION Ethics approval will not be required, as this review will present anonymised data from other published studies. Results from this study will form part of a doctoral dissertation (MB), will be published in a journal, presented at conferences, and other academic presentations. PROSPERO REGISTRATION NUMBER CRD42020222962.
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Affiliation(s)
- Mia Bierbaum
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Frances Rapport
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Yvonne Tran
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Macquarie University Hearing, Sydney, New South Wales, Australia
| | - Bróna Nic Giolla Easpaig
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Kristiana Ludlow
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- The University of Queensland, School of Psychology, Saint Lucia, Queensland, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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3
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Adherence to breast cancer guidelines is associated with better survival outcomes: a systematic review and meta-analysis of observational studies in EU countries. BMC Health Serv Res 2020; 20:920. [PMID: 33028324 PMCID: PMC7542898 DOI: 10.1186/s12913-020-05753-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/22/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Breast cancer (BC) clinical guidelines offer evidence-based recommendations to improve quality of healthcare for patients with or at risk of BC. Suboptimal adherence to recommendations has the potential to negatively affect population health. However, no study has systematically reviewed the impact of BC guideline adherence -as prognosis factor- on BC healthcare processes and health outcomes. The objectives are to analyse the impact of guideline adherence on health outcomes and on healthcare costs. METHODS We searched systematic reviews and primary studies in MEDLINE and Embase, conducted in European Union (EU) countries (inception to May 2019). Eligibility assessment, data extraction, and risk of bias assessment were conducted by one author and crosschecked by a second. We used random-effects meta-analyses to examine the impact of guideline adherence on overall survival and disease-free survival, and assessed certainty of evidence using GRADE. RESULTS We included 21 primary studies. Most were published during the last decade (90%), followed a retrospective cohort design (86%), focused on treatment guideline adherence (95%), and were at low (80%) or moderate (20%) risk of bias. Nineteen studies (95%) examined the impact of guideline adherence on health outcomes, while two (10%) on healthcare cost. Adherence to guidelines was associated with increased overall survival (HR = 0.67, 95%CI 0.59-0.76) and disease-free survival (HR = 0.35, 95%CI 0.15-0.82), representing 138 more survivors (96 more to 178 more) and 336 patients free of recurrence (73 more to 491 more) for every 1000 women receiving adherent CG treatment compared to those receiving non-adherent treatment at 5 years follow-up (moderate certainty). Adherence to treatment guidelines was associated with higher costs, but adherence to follow-up guidelines was associated with lower costs (low certainty). CONCLUSIONS Our review of EU studies suggests that there is moderate certainty that adherence to BC guidelines is associated with an improved survival. BC guidelines should be rigorously implemented in the clinical setting. TRIAL REGISTRATION PROSPERO ( CRD42018092884 ).
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Bierbaum M, Rapport F, Arnolda G, Nic Giolla Easpaig B, Lamprell K, Hutchinson K, Delaney GP, Liauw W, Kefford R, Olver I, Braithwaite J. Clinicians' attitudes and perceived barriers and facilitators to cancer treatment clinical practice guideline adherence: a systematic review of qualitative and quantitative literature. Implement Sci 2020; 15:39. [PMID: 32460797 PMCID: PMC7251711 DOI: 10.1186/s13012-020-00991-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/14/2020] [Indexed: 01/08/2023] Open
Abstract
Background Clinical Practice Guidelines (CPGs) synthesize the best available evidence to guide clinician and patient decision making. There are a multitude of barriers and facilitators to clinicians adhering to CPGs; however, little is known about active cancer treatment CPG adherence specifically. This systematic review sought to identify clinician attitudes, and perceived barriers and facilitators to active cancer treatment CPG adherence. Methods A systematic search was undertaken of five databases; Ovid Medline, PsychInfo, Embase, Scopus, CINAHL, and PROQUEST. The retrieved abstracts were screened for eligibility against inclusion criteria, and a full text review was conducted of all eligible studies. Data were extracted, and a quality assessment was conducted of all included studies. The qualitative papers were thematically analyzed. Attitudes, barriers, and facilitating factors extracted from the quantitative papers were categorized within the qualitative thematic framework. Results The search resulted in the identification of 9676 titles. After duplicates were removed, abstracts screened, and full texts reviewed, 15 studies were included. Four themes were identified which related to negative clinician attitudes and barriers to active cancer treatment CPG adherence: (1) concern over CPG content and currency of CPGs; (2) concern about the evidence underpinning CPGs; (3) clinician uncertainty and negative perceptions of CPGs; and (4) organizational and patient factors. The review also identified four themes related to positive attitudes and facilitators to active cancer treatment CPG adherence: (5) CPG accessibility and ease of use; (6) endorsement and dissemination of CPGs and adequate access to treatment facilities and resources; (7) awareness of CPGs and belief in their relevance; and (8) belief that CPGs support decision making, improve patient care, reduce clinical variation, and reduce costs. Conclusion These results highlight that adherence to active cancer treatment CPG recommendations by oncology clinicians is influenced by multiple factors such as attitudes, practices, and access to resources. The review has also revealed many similarities and differences in the factors associated with general CPG, and active cancer treatment CPG, adherence. These findings will inform tailored implementation strategies to increase adherence to cancer treatment CPGs. Trial registration PROSPERO (2019) CRD42019125748.
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Affiliation(s)
- Mia Bierbaum
- Australian Institute of Health Innovation (AIHI), Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2019, Australia.
| | - Frances Rapport
- Australian Institute of Health Innovation (AIHI), Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2019, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation (AIHI), Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2019, Australia.,Centre for Research Excellence in Implementation Science in Oncology, AIHI, Macquarie University, Sydney, Australia
| | - Brona Nic Giolla Easpaig
- Australian Institute of Health Innovation (AIHI), Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2019, Australia.,Centre for Research Excellence in Implementation Science in Oncology, AIHI, Macquarie University, Sydney, Australia
| | - Klay Lamprell
- Australian Institute of Health Innovation (AIHI), Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2019, Australia.,Centre for Research Excellence in Implementation Science in Oncology, AIHI, Macquarie University, Sydney, Australia
| | - Karen Hutchinson
- Australian Institute of Health Innovation (AIHI), Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2019, Australia
| | - Geoff P Delaney
- Centre for Research Excellence in Implementation Science in Oncology, AIHI, Macquarie University, Sydney, Australia.,Cancer Services, South Western Sydney Local Health District Cancer Services, Sydney, Australia.,University of NSW, Sydney, Australia.,Ingham Institute of Applied Medical Research, Liverpool, Australia
| | - Winston Liauw
- Centre for Research Excellence in Implementation Science in Oncology, AIHI, Macquarie University, Sydney, Australia.,University of NSW, Sydney, Australia.,South Eastern Sydney Local Health District Cancer Services, Kogarah, Australia
| | - Richard Kefford
- Centre for Research Excellence in Implementation Science in Oncology, AIHI, Macquarie University, Sydney, Australia.,Department of Clinical Medicine, Macquarie University, Sydney, Australia
| | - Ian Olver
- Centre for Research Excellence in Implementation Science in Oncology, AIHI, Macquarie University, Sydney, Australia.,University of Adelaide, Adelaide, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation (AIHI), Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2019, Australia.,Centre for Research Excellence in Implementation Science in Oncology, AIHI, Macquarie University, Sydney, Australia
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Niño de Guzmán E, Song Y, Alonso-Coello P, Canelo-Aybar C, Neamtiu L, Parmelli E, Pérez-Bracchiglione J, Rabassa M, Rigau D, Parkinson ZS, Solà I, Vásquez-Mejía A, Ricci-Cabello I. Healthcare providers' adherence to breast cancer guidelines in Europe: a systematic literature review. Breast Cancer Res Treat 2020; 181:499-518. [PMID: 32378052 PMCID: PMC7220981 DOI: 10.1007/s10549-020-05657-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
Abstract
Purpose Clinical guidelines’ (CGs) adherence supports high-quality care. However, healthcare providers do not always comply with CGs recommendations. This systematic literature review aims to assess the extent of healthcare providers’ adherence to breast cancer CGs in Europe and to identify the factors that impact on healthcare providers’ adherence. Methods We searched for systematic reviews and quantitative or qualitative primary studies in MEDLINE and Embase up to May 2019. The eligibility assessment, data extraction, and risk of bias assessment were conducted by one author and cross-checked by a second author. We conducted a narrative synthesis attending to the modality of the healthcare process, methods to measure adherence, the scope of the CGs, and population characteristics. Results Out of 8137 references, we included 41 primary studies conducted in eight European countries. Most followed a retrospective cohort design (19/41; 46%) and were at low or moderate risk of bias. Adherence for overall breast cancer care process (from diagnosis to follow-up) ranged from 54 to 69%; for overall treatment process [including surgery, chemotherapy (CT), endocrine therapy (ET), and radiotherapy (RT)] the median adherence was 57.5% (interquartile range (IQR) 38.8–67.3%), while for systemic therapy (CT and ET) it was 76% (IQR 68–77%). The median adherence for the processes assessed individually was higher, ranging from 74% (IQR 10–80%), for the follow-up, to 90% (IQR 87–92.5%) for ET. Internal factors that potentially impact on healthcare providers’ adherence were their perceptions, preferences, lack of knowledge, or intentional decisions. Conclusions A substantial proportion of breast cancer patients are not receiving CGs-recommended care. Healthcare providers’ adherence to breast cancer CGs in Europe has room for improvement in almost all care processes. CGs development and implementation processes should address the main factors that influence healthcare providers' adherence, especially patient-related ones. Registration: PROSPERO (CRD42018092884). Electronic supplementary material The online version of this article (10.1007/s10549-020-05657-8) contains supplementary material, which is available to authorised users.
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Affiliation(s)
- Ena Niño de Guzmán
- Iberoamerican Cochrane Centre - Department of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antonio María Claret 167, 08025, Barcelona, Spain.
| | - Yang Song
- Iberoamerican Cochrane Centre - Department of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antonio María Claret 167, 08025, Barcelona, Spain
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre - Department of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antonio María Claret 167, 08025, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Carlos Canelo-Aybar
- Iberoamerican Cochrane Centre - Department of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antonio María Claret 167, 08025, Barcelona, Spain.,CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Luciana Neamtiu
- European Commission, Joint Research Centre (JRC), Via E. Fermi 2749, 21027, Ispra, VA, Italy.
| | - Elena Parmelli
- European Commission, Joint Research Centre (JRC), Via E. Fermi 2749, 21027, Ispra, VA, Italy
| | | | - Montserrat Rabassa
- Iberoamerican Cochrane Centre - Department of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antonio María Claret 167, 08025, Barcelona, Spain
| | - David Rigau
- Iberoamerican Cochrane Centre - Department of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antonio María Claret 167, 08025, Barcelona, Spain
| | - Zuleika Saz Parkinson
- European Commission, Joint Research Centre (JRC), Via E. Fermi 2749, 21027, Ispra, VA, Italy
| | - Iván Solà
- Iberoamerican Cochrane Centre - Department of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), Sant Antonio María Claret 167, 08025, Barcelona, Spain
| | - Adrián Vásquez-Mejía
- Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Ignacio Ricci-Cabello
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.,Balearic Islands Health Research Institute (IdISBa), Palma, Spain.,Primary Care Research Unit of Mallorca, Balearic Islands Health Service, Palma, Spain
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6
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Bierbaum M, Braithwaite J, Arnolda G, Delaney GP, Liauw W, Kefford R, Tran Y, Nic Giolla Easpaig B, Rapport F. Clinicians' attitudes to oncology clinical practice guidelines and the barriers and facilitators to adherence: a mixed methods study protocol. BMJ Open 2020; 10:e035448. [PMID: 32205377 PMCID: PMC7103843 DOI: 10.1136/bmjopen-2019-035448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/27/2020] [Accepted: 03/03/2020] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Clinical practice guidelines (CPGs) are designed to reduce inappropriate clinical variation and improve the quality of care. Barriers to CPGs include a lack of awareness of CPGs, access to them, time pressures and concerns regarding the evidence underpinning CPG development, implementation and dissemination. The objectives of this study are to assess clinicians' attitudes to CPGs for cancer treatment and the perceived barriers to and facilitators of CPG adherence in order to inform the implementation of cancer treatment CPGs. METHODS AND ANALYSIS A mixed methods study will be conducted using a three-phase, sequential design, with each phase informing the next. In phase 1, a qualitative study using recorded interviews will investigate clinicians' attitudes to CPGs for cancer treatment and perceptions of barriers and facilitators to CPG adherence (n=30); interview transcripts will be analysed thematically. In phase 2, a survey will quantify the frequency of attitudes, barriers and facilitators identified in phase 1, in a broader clinical sample (n=200). In phase 3, a workshop forum will be held to facilitate discussions examining the implications of phase 1 and 2 findings for cancer CPG implementation strategies (n=40) leading to recommendations for improvements to practice. The workshop discussion will be recorded, and the transcript will be analysed thematically. ETHICS AND DISSEMINATION This study has received ethics approval in New South Wales, Australia (2019/ETH11722, #52019568810127). Study findings will be published in peer-reviewed journals and will form part of a doctoral thesis and be presented at national and international conferences.
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Affiliation(s)
- Mia Bierbaum
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Centre for Research Excellence in Implementation Science in Oncology, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Centre for Research Excellence in Implementation Science in Oncology, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Geoffrey P Delaney
- Centre for Research Excellence in Implementation Science in Oncology, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Liverpool Cancer Therapy Centre, Liverpool, New South Wales, Australia
- University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Winston Liauw
- Centre for Research Excellence in Implementation Science in Oncology, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Translational Cancer Research Network, Lowy Cancer Research Centre, University of New South Wales, Sydney, New South Wales, Australia
- Cancer Services, South Eastern Sydney Local Health District, Kogarah, New South Wales, Australia
| | - Richard Kefford
- Centre for Research Excellence in Implementation Science in Oncology, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Department of Clinical Medicine, Macquarie University, Sydney, New South Wales, Australia
- Melanoma Institute Australia, North Sydney, New South Wales, Australia
| | - Yvonne Tran
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Centre for Research Excellence in Implementation Science in Oncology, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Bróna Nic Giolla Easpaig
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Centre for Research Excellence in Implementation Science in Oncology, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Frances Rapport
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Ebner F, Wöckel A, Schwentner L, Blettner M, Janni W, Kreienberg R, Wischnewsky M. Does the number of removed axillary lymphnodes in high risk breast cancer patients influence the survival? BMC Cancer 2019; 19:90. [PMID: 30658597 PMCID: PMC6339270 DOI: 10.1186/s12885-019-5292-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
Background The decision making process for axillary dissection has changed in recent years for patients with early breast cancer and positive sentinel lymph nodes (LN). The question now arises, what is the optimal surgical treatment for patients with positive axillary LN (pN+). This article tries to answer the following questions:Is there a survival benefit for breast cancer patients with 3 or more positive LN (pN3+) and with more than 10 removed LN? Is there a survival benefit for high risk breast cancer patients (triple negative or Her2 + breast cancer) and with 3 or more positive LN (pN3+) with more than 10 removed LN? In pN + patients is the prognostic value of the lymph node ratio (LNR) of pN+/pN removed impaired if 10 or less LN are removed?
Methods A retrospective database analysis of the multi center cohort database BRENDA (breast cancer under evidence based guidelines) with data from 9625 patients from 17 breast centers was carried out. Guideline adherence was defined by the 2008 German National consensus guidelines. Results 2992 out of 9625 patients had histological confirmed positive lymph nodes. The most important factors for survival were intrinsic sub types, tumor size and guideline adherent chemo- and hormonal treatment (and age at diagnosis for overall survival (OAS)). Uni-and multivariable analyses for recurrence free survival (RFS) and OAS showed no significant survival benefit when removing more than 10 lymph nodes even for high-risk patients. The mean and median of LNR were significantly higher in the pN+ patients with ≤10 excised LN compared to patients with > 10 excised LN. LNR was in both, uni-and multivariable, analysis a highly significant prognostic factor for RFS and OAS in both subgroups of pN + patients with less respective more than 10 excised LN. Multivariable COX regression analysis was adjusted by age, tumor size, intrinsic sub types and guideline adherent adjuvant systemic therapy. Conclusion The removal of more than 10 LN did not result in a significant survival benefit even in high risk pN + breast cancer patients.
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Affiliation(s)
- Florian Ebner
- University Ulm, Germany, Prittwitzstraße 43, 89075, Ulm, Germany. .,HELIOS-Amper Klinikum, Germany, Krankenhausstr. 15, 85221, Dachau, Germany.
| | - Achim Wöckel
- Department of Gynaecology and Obstetrics, University Würzburg, Germany, Josef-Schneider-Str. 4 · Haus C15, 97080, Würzburg, Germany
| | - Lukas Schwentner
- University Ulm, Germany, Prittwitzstraße 43, 89075, Ulm, Germany
| | - Maria Blettner
- Institut für Medizinische Biometrie, Epidemiologieund Informatik (IMBEI), Universität Mainz, Germany, Obere Zahlbacher Straße 69, 55131, Mainz, Germany
| | - Wolfgang Janni
- University Ulm, Germany, Prittwitzstraße 43, 89075, Ulm, Germany
| | - Rolf Kreienberg
- University Ulm, Germany, Prittwitzstraße 43, 89075, Ulm, Germany
| | - Manfred Wischnewsky
- Department of Mathematics and Computer Science, University Bremen, Germany, Universitätsallee, 28359, Bremen, Germany
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