Postmastectomy Radiotherapy Reduces Locoregional Recurrence in Elderly Women with High-risk Breast Cancer

Efficacy and safety of adjuvant therapies in older patients with breast cancer: a systematic review and meta-analysis of real-world data

BACKGROUND

Insufficient data available for older patients with breast cancer complicates decision-making regarding optimal treatment. A systematic review that uses real-world data is required for assessing the effectiveness and potential adverse effects of various therapies for this age group of patients.

METHODS

Databases of PubMed, Embase, and Cochrane Library were searched. We included clinical studies that evaluated various treatments for geriatric breast cancer, including adjuvant radiation therapy, hypofractionated radiation therapy (hypo-RT) and accelerated and partial breast irradiation (APBI), endocrine therapy, chemotherapy, and targeted therapy.

RESULTS

A total of 71 studies were retrieved. Adjuvant radiation therapy significantly improved overall survival (OS) compared with no radiation [hazard ratio (HR) = 0.60, 95% confidence interval (CI) 0.54-0.67]. The pooled estimates of OS for hypo-RT and APBI demonstrated no inferiority compared with conventional radiation. Both endocrine treatment (HR = 0.63, 95% CI 0.43-0.92) and chemotherapy (HR = 0.76, 95% CI 0.65-0.88) significantly increased OS compared with no treatment. Trastuzumab monotherapy significantly enhanced OS compared with no trastuzumab use (HR = 0.23, 95% CI 0.07-0.73).

CONCLUSION

Despite concerns about potential complications during treatment in older patients, proactive therapies significantly increase their survival rates. For patients who are frailer, hypo-RT and APBI offer survival rates comparable to traditional modalities. Additionally, targeted therapy as a monotherapy holds promise as a viable option for patients with HER2-positive breast cancer who cannot undergo chemotherapy. Therefore, by conducting thorough general assessments and clinical evaluations, the side effects of postoperative treatments can be effectively managed.

A dynamic approach for outpatient scheduling

AIMS

Patient no-show is a recurrent problem in medical centers and, in conjunction with cancellation of appointments, often results in loss of productivity and excessive patient time to appointment. The purpose of this study was to develop a dynamic procedure for scheduling patients within an outpatient clinic where patients are expected to have multiple appointments, such as physical therapy, occupational therapy, primary care, and dentistry.

METHODS

This retrospective study involved the year 2014 de-identified patient records from an outpatient clinic affiliated with a large university hospital. A number of patient characteristics, appointment data, and historical attendance records were examined to determine whether they significantly impacted patients who missed scheduled appointments (no-shows). Patient attendance behaviors over multiple appointments were examined to determine whether their no-show and cancellation patterns differed from one appointment to the next. Decision tree analysis was applied to those predictors that significantly correlated with patient attendance behavior to assess the likelihood of a patient no-show. A sample dynamic appointment scheduling procedure that utilized different overbooking strategies for different appointment numbers was then developed. Computer simulation was used to assess the effectiveness of the dynamic procedure versus two other methods consisting of randomly assigned and uniformly assigned appointments.

RESULTS

The dynamic scheduling procedure resulted in increased scheduling efficiency through overbooking but with less than 5% risk of appointment conflicts (i.e. two patients showing at the same time), equating to approximately 0.16 conflicts per clinician per day. It also increased clinic utilization by about 6.7%. It consistently outperformed the other two methods with respect to the percentage of appointment conflicts.

LIMITATIONS

The study is limited with respect to potential clinician cost increase resulting from possible appointment conflicts. A second limitation is that patients experiencing appointment conflicts might not wait for treatment, resulting in potential loss of revenue. A third limitation is that the model does not take into account patient satisfaction, nor the ethics of overbooking patients.

CONCLUSIONS

A dynamic appointment scheduling procedure was developed using actual patient characteristics. The procedure resulted in creation of more efficient appointment schedules thereby increasing the clinic utilization.

Treatment options for older woman with early breast cancer

Breast cancer is the most common cancer in women and its incidence increases with age. Older women are not often offered optimal treatment compared with younger women for any particular stage. This is due to various reasons, including the lack of evidence for older women from well-conducted clinical trials. In this paper, the currently available evidences from clinical trials are reviewed and the various treatment options for older women with early breast cancer are discussed.

Treatment of breast cancer in the elderly: a prospective, population-based Swiss study

OBJECTIVES

The primary objective of this population-based study is to describe the patterns of care of elderly patients with breast cancer (BC), and evaluate potential causative factors for the decrease in BC-specific survival (BCSS) in the elderly.

PATIENTS AND METHODS

We included all or representative samples of patients with newly diagnosed BC from seven Swiss cancer registries between 2003 and 2005 (n=4820). Surgical and non-surgical BC treatment was analyzed over 5 age groups (<65, 65 to <70, 70 to <75, 75 to <80 and ≥80years), and the predictive impact of patient age on specific treatments was calculated using multivariate logistic regression analysis.

RESULTS

The proportion of locally advanced, metastatic and incompletely staged BC increased with age. The odds ratio for performing breast-conserving surgery (BCS) in stages I-II BC (0.37), sentinel lymph node dissection (SLND) in patients with no palpable adenopathy (0.58), post-BCS radiotherapy (0.04) and adjuvant endocrine treatment (0.23) were all in disfavor of patients ≥80years of age compared to their younger peers. Only 36% of patients ≥80years of age with no palpable adenopathy underwent SLND. In the adjusted model, higher age was a significant risk factor for omitting post-BCS radiotherapy, SLND and adjuvant endocrine treatment.

CONCLUSIONS

This study found an increase in incomplete diagnostic assessment, and a substantial underuse of BCS, post-BCS radiotherapy, SLND and adjuvant endocrine treatment in elderly patients with BC. There is a need for improved management of early BC in the elderly even in a system with universal access to health care services.

Breast cancer treatment practices in elderly women in a community hospital

Background. Elderly women with breast cancer are considered underdiagnosed and undertreated, and this adversely affects their overall survival. Methods. A total of 393 female breast cancer patients aged 70 years and older, diagnosed within the years 1989-1999, were identified from the tumor registry of The Brooklyn Hospital Center. Comparisons between the 3 different subgroups 70-74, 75-79, and 80 years and older were made using the Pearson Chi Square test. Results. Lumpectomy was performed in 42% of all patients, while mastectomy was done in 46% of patients. Adjuvant therapy such as chemotherapy, radiation therapy, and hormonal therapy were done in 12%, 25%, and 38%, respectively. Forty-seven percent of patients with positive lymph nodes received chemotherapy. Eighty-six percent of patients who were estrogen receptor-positive received adjuvant hormonal therapy. Overall five-year survival was only 14% for the ≥80 age group, compared to that of 32% and 35% for the 70-74 and the 75-79 age groups, respectively. Conclusions. Surgery was performed in majority of these patients, about half received lumpectomy, the other half mastectomy. Adjuvant therapies were frequently excluded, with only hormonal therapy being the most commonly used. Overall five-year survival is significantly worse in patients ≥80 years with breast cancer.

Quality-of-life considerations in the treatment of early-stage breast cancer in the elderly

Breast cancer is a common tumour in the elderly population and management of early disease in particular is a major challenge for oncologists and geriatricians alike. An important aspect is a differentiated knowledge about the short-term effects and long-term perspectives regarding levels of functioning and subjective well-being associated with different treatment strategies. The article focuses on available quality-of-life (QOL) measurement instruments in elderly patients with early breast cancer and the impact of various local or systemic treatments on QOL scores. A selective literature search was carried out in the PubMed database from January 2000 to May 2010 using the terms 'early breast cancer', 'elderly' and 'quality of life'. Contributions to international congresses on breast cancer in 2009 were also included. Of the 80 articles retrieved, 46 publications were excluded from further consideration due to failure to fulfil inclusion criteria (e.g. not restricted to the elderly, inclusion of patients with metastatic disease, no adjuvant treatment). Sixteen papers focusing on complementary treatment were also rejected. The remaining 18 articles were extensively reviewed. The selection of described QOL measurements was very heterogeneous in these 18 studies. Commonly used QOL instruments were the European Organization for Research and Treatment of Cancer QOL questionnaires (EORTC QLQ-C30, EORTC QLQ-BR23) and the Functional Assessment of Cancer Therapy questionnaires (FACT-G, FACT-B) and its subscales. Additionally, the Medical Outcomes Study 36-Item Short-Form Health Survey (MOS-SF-36), the Hospital Anxiety and Depression Scale (HADS) and the International Breast Cancer Study Group (IBCSG) approach were used by various study groups. The general limitations of QOL assessment in the elderly population are discussed in the review. Surgery, when considered from a technical point of view, does not differ significantly with patient age. Furthermore, age in itself should not be a contraindication to breast-conserving surgery (BCS) because QOL appears somewhat better after conservative surgical treatment. Avoiding axillary surgery and undergoing sentinel lymph node dissection in elderly patients are both associated with better short-term QOL. However, conventional axillary surgery has little effect on long-term QOL in older women. The advent of innovative radiotherapy techniques has resulted in marked improvements in short-term tolerability together with reductions in the incidence and severity of late normal tissue damage. A potential alternative to conventional postoperative radiotherapy after BCS in the future is the intraoperative radiotherapy technique. Chemotherapy has considerable effects on QOL in breast cancer patients. Most studies found that overall QOL was maintained or improved in patients receiving either aromatase inhibitors or tamoxifen but patients reported different adverse effects. For the majority of older breast cancer survivors, cancer-specific well-being and general emotional health do not change substantially after a breast cancer diagnosis. In summary, issues related to baseline co-morbidities in frail elderly, the adverse effects of novel chemotherapeutic agents (e.g. nanoparticle albumin-bound paclitaxel) or target drugs (biologicals) and compliance in the elderly population should receive more attention in evaluations of QOL in elderly breast cancer patients. Future studies that include QOL measurements should also provide details on the data collection and quality control methodologies used.

ACR appropriateness criteria on postmastectomy radiotherapy expert panel on radiation oncology-breast

This summary focuses on the role of postoperative radiation therapy in patients treated with modified radical mastectomy for invasive breast cancer, particularly in patients receiving systemic therapy.

Breast radiotherapy: considerations in older patients

With an ageing population, the number of older women with breast cancer eligible for adjuvant irradiation after breast conserving surgery and mastectomy is rising. There is a dearth of level 1 data on the effect of adjuvant irradiation on local control, quality of life and survival. In large part this reflects the exclusion of patients over the age of 70 years from randomised trials. The prevention of local recurrence may reduce the risks of dissemination. However, older women with early breast cancer and a life expectancy of less than 5 years are unlikely to derive a survival benefit from adjuvant radiotherapy. Rates of access of older patients to adjuvant irradiation are lower than for younger patients. Physician and patient bias and co-morbidities are contributory factors. There are also competing risks of mortality from co-morbidities, particularly in women over the age of 80 years. Postoperative radiotherapy after breast conserving surgery does not seem to compromise overall quality of life of older patients. Although the absolute reduction in local recurrence from adjuvant radiotherapy is modest in lower risk older patients after breast conserving surgery and adjuvant systemic therapy, there has to date been no group of fitter old patients defined from whom radiotherapy can be reasonably omitted. Guidelines for postmastectomy radiotherapy should not differ from younger patients. Adequately powered randomised trials are needed to assess the effect of adjuvant irradiation in older patients on outcomes after breast conserving surgery and mastectomy to provide a more robust basis for evidence-based radiotherapy practice.

Non-compliance with a postmastectomy radiotherapy guideline: decision tree and cause analysis

BACKGROUND

The guideline for postmastectomy radiotherapy (PMRT), which is prescribed to reduce recurrence of breast cancer in the chest wall and improve overall survival, is not always followed. Identifying and extracting important patterns of non-compliance are crucial in maintaining the quality of care in Oncology.

METHODS

Analysis of 759 patients with malignant breast cancer using decision tree induction (DTI) found patterns of non-compliance with the guideline. The PMRT guideline was used to separate cases according to the recommendation to receive or not receive PMRT. The two groups of patients were analyzed separately. Resulting patterns were transformed into rules that were then compared with the reasons that were extracted by manual inspection of records for the non-compliant cases.

RESULTS

Analyzing patients in the group who should receive PMRT according to the guideline did not result in a robust decision tree. However, classification of the other group, patients who should not receive PMRT treatment according to the guideline, resulted in a tree with nine leaves and three of them were representing non-compliance with the guideline. In a comparison between rules resulting from these three non-compliant patterns and manual inspection of patient records, the following was found: In the decision tree, presence of perigland growth is the most important variable followed by number of malignantly invaded lymph nodes and level of Progesterone receptor. DNA index, age, size of the tumor and level of Estrogen receptor are also involved but with less importance. From manual inspection of the cases, the most frequent pattern for non-compliance is age above the threshold followed by near cut-off values for risk factors and unknown reasons.

CONCLUSION

Comparison of patterns of non-compliance acquired from data mining and manual inspection of patient records demonstrates that not all of the non-compliances are repetitive or important. There are some overlaps between important variables acquired from manual inspection of patient records and data mining but they are not identical. Data mining can highlight non-compliance patterns valuable for guideline authors and for medical audit. Improving guidelines by using feedback from data mining can improve the quality of care in oncology.

Treatment of breast cancer in older women

BACKGROUND

Breast carcinoma management in the elderly often differs from the management in younger women and there is considerable controversy about what constitutes appropriate cancer care for older women. This controversy is reflected in the persistence of age-dependent variations in care over time, with older women being less likely to receive definitive care for breast cancer. There has been a significant increase in the last years in the number of studies conducted in older patients with breast cancer. Although available age-specific clinical trials data demonstrate that treatment efficacy is not modified by age, this evidence is limited by the lack of inclusion of substantial numbers of older women, particularly those of advanced age and those with comorbidities.

METHOD

The literature-based evidence of the last 10 years was extensively reviewed on the main issues concerning the treatment of breast cancer in older women.

RESULTS

Surgical treatment in older patients has evolved from avoidance to mastectomy to breast-conserving surgery, similarly to younger patients. Given its negative effect on the quality of life, in the last few years the role of adjuvant radiotherapy has been questioned in elderly patients with breast cancer. Adjuvant chemotherapy benefit in older patients applies mainly to Estrogen-receptor-negative patients, while in Estrogen-receptor-positive patients a major role is played by endocrine treatment. New "elderly-friendly" drugs, that can help clinicians to reduce toxicity, are now available for breast cancer.

Management of breast cancer in elderly individuals: recommendations of the International Society of Geriatric Oncology

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer mortality in women worldwide. Elderly individuals make up a large part of the breast cancer population, and there are important specific considerations for this population. The International Society of Geriatric Oncology created a task force to assess the available evidence on breast cancer in elderly individuals, and to provide evidence-based recommendations for the diagnosis and treatment of breast cancer in such individuals. A review of the published work was done with the results of a search on Medline for English-language articles published between 1990 and 2007 and of abstracts from key international conferences. Recommendations are given on the topics of screening, surgery, radiotherapy, (neo)adjuvant hormone treatment and chemotherapy, and metastatic disease. Since large randomised trials in elderly patients with breast cancer are scarce, there is little level I evidence for the treatment of such patients. The available evidence was reviewed and synthesised to provide consensus recommendations regarding the care of breast cancer in older adults.

Multidisciplinary approach to the geriatric oncology patient

Given the dramatic demographic shift observed in developed countries, the medical community, especially oncologists, geriatricians, and primary care providers, are confronted with the expanding challenge of the management of elderly people with cancer. Ageing is associated with the accumulation of multiple and various medical and social problems. With a prevalence comparable to that of other chronic conditions in this age group, such as diabetes or dementia, cancer holds a prominent place among diseases of the elderly. The care of elderly cancer patients is fundamentally interdisciplinary. Communication and collaboration between geriatricians/primary care providers and oncologists represent key features of effective care in geriatric oncology. The combination of the disease-oriented approach of oncologists and the patient-oriented approach of geriatricians is the most powerful way to better serve this specific population. The medical approach of elderly cancer patients should ideally be under the lead of geriatricians or primary care providers sensitive to geriatric issues. Oncologists should manage the biologic consequences of the interplay between cancer and ageing. Close collaboration between clinicians will help promote active dedicated clinical research and the development of guidelines on the management of elderly people with cancer.

Management of early breast cancer in the elderly

Breast cancer is the most common malignancy in women with an age related increase in incidence ranging from 1 in 50 at age 50 to 1 in 10 at age 80. This is particularly significant in view of the changing demographics in the western population, characterised by an aging population and increased life expectancy. However in spite of favourable prognostic factors and less aggressive biological behaviour, elderly breast cancer patients receive less aggressive treatment when compared with their younger counterparts. Appropriate treatment should be offered depending on physiological reserve and comorbidities. Primary endocrine treatment has been shown to be associated with significant morbidity in terms of disease progression. Prompt surgery and adjuvant treatment can decrease relapse and improve survival. Radiation therapy is shown to decrease local relapse and chemotherapy may have a role in a select group of patients with adverse prognostic factors. With incidence of breast cancer bound to increase in the elderly population, it is essential to establish optimum therapy in this cohort of patients as studies reveal good outcome from standard treatment.

Impact of Radiotherapy on Breast Reconstruction

Breast reconstruction in the face of radiotherapy poses a unique set of challenges to the plastic surgeon and thus alters the algorithm of the reconstruction. The impact of radiation changes on alloplastic and autologous breast reconstruction is unpredictable. This article reviews the pathophysiology of radiation changes and the alterations to the reconstructive process.