Neoadjuvant Systemic Therapy Use for Younger Patients with Breast Cancer Treated in Different Types of Cancer Centers Across the United States

Axillary Management Following Neoadjuvant Chemotherapy in Clinically Node-Positive Breast Cancer

INTRODUCTION

Clinical trial data indicate that omitting axillary lymph node dissection (ALND) is feasible and may reduce morbidity for carefully selected patients with clinically node-positive breast cancer who achieve a pathological complete response (pCR) after neoadjuvant chemotherapy (NCT). However, there remains a need to understand how these findings translate to broader clinical practice and to identify which patients benefit most. This study utilizes a national dataset to assess outcomes in axillary management, aiming to inform best practice in axillary de-escalation.

METHODS

The National Cancer Data Base was used to identify women diagnosed with clinically node-positive invasive breast cancer between 2012 to 2020 who received NCT and subsequent ALND. Associations between clinicopathologic factors and axillary pCR were analyzed statistically.

RESULTS

Of the 59,791 patients included, 8,827 (14.76%) achieved nodal pCR. Patients with HR-negative and HER2-positive receptor status more frequently underwent ALND instead of sentinel lymph node biopsy. Conversely, patients over the age of 70, those with private or public insurance, and cases classified as ypT1 or ypT2 were less likely to undergo ALND.

CONCLUSION

A subset of patients with clinically node-positive breast cancer received ALND despite achieving axillary pCR following NCT. This highlights an opportunity to enhance precision in identifying candidates for axillary de-escalation, potentially reducing morbidity and tailoring treatment more closely to individual patient needs.

The Comparison of Newly Diagnosed Invasive Breast Patient Cohorts in Genomics Evidence Neoplasia Information Exchange Biopharma Collaborative (GENIE-BPC) and Other Real-World Databases

BACKGROUND

Oncology databases that integrate genomic and clinical data have become valuable resources for precision medicine. However, the generalizability of these databases has not been comprehensively assessed.

OBJECTIVES

To describe the demographics, clinical characteristics, treatments, and overall survival of breast cancer cohorts in GENIE-BPC and three other databases.

METHODS

This study utilized GENIE-BPC, SEER, SEER-Medicare, and Merative MarketScan Research Databases. Women with invasive breast cancer were identified through EHR, cancer registries or ICD-9/10-CM codes. The ages were 18+ years or per database requirement. Treatments were based on EHR or HCPCS/NDC codes in claims. Overall survival was estimated as time from diagnosis to death.

RESULTS

Of female breast cancer patients in GENIE-BPC (n = 775), SEER (n = 548 336), SEER-Medicare (n = 68 914), and Marketscan (n = 109 499) databases, the median ages at initial diagnosis were 44, 62, 74, and 57 years, respectively. A greater proportion of patients in GENIE-BPC, compared to SEER/SEER-Medicare, had higher nuclear grades (%III-%IV: 57% vs. 26%/24%), advanced disease stage (%IV: 25.3% vs. 5%/3.6%), percent of triple negative breast cancer (19.7% vs. 10.2%/8.5%), and receipt of chemotherapy (85.0% vs. NA/22.3%). The 1-, 3-, and 5-year overall survival rates were lower in GENIE-BPC (78.5%, 60.5%, 55.5%) than in SEER (95.8%, 89.5%, 85.5%) and SEER-Medicare (91.6%, 81.4%, 75.0%).

CONCLUSION

Breast cancer patients in GENIE-BPC were younger, had more advanced disease, had a higher proportion of triple negative breast cancer and recipients of chemotherapy, and had poorer overall survival. Researchers must use statistical adjustment when extrapolating results (e.g., biomarker prevalence) from GENIE-BPC to the larger breast cancer population.

Neoadjuvant chemotherapy for triple-negative and Her2 +ve breast cancer: striving for the standard of care

PURPOSE

Neoadjuvant chemotherapy (NAC) for triple-negative (TN) and Her2-positive (HER2) breast cancers is supported by international guidelines as it can decrease extent of surgery, provide prognostic information, and allow response-driven adjuvant therapies. Our goal was to describe practice patterns for patients with TN and HER2-positive breast cancer and identify the factors associated with the receipt of NAC versus surgery as initial treatment.

METHODS

A retrospective population-based cohort study of adult women diagnosed with stage I-III TN or HER2-positive breast cancer (2012-2020) in Ontario was completed using linked administrative datasets. The primary outcome was NAC as first treatment. The association between NAC and patient, tumor, and practice-related factors was examined using multivariable logistic regression models.

RESULTS

Of 14,653 patients included, 23.9% (n = 3500) underwent NAC as first treatment. Patients who underwent NAC were more likely to be younger and have larger tumors, node-positive disease, and stage 3 disease. Of patients who underwent surgery first, 8.8% were seen by a medical oncologist prior to surgery. On multivariable analysis, increasing tumor size (T2 vs T1/T0: 2.75 (2.31-3.28)) and node-positive (N1 vs N0: OR 3.54 (2.92-4.30)) disease were both associated increased odds of receiving NAC.

CONCLUSION

A considerable proportion of patients with TN and HER2-positive breast cancer do not receive NAC as first treatment. Of those, most were not assessed by both a surgeon and medical oncologist prior to initiating therapy. This points toward potential gaps in multidisciplinary assessment and disparities in receipt of guideline-concordant care.

Relapse-free survival in Sudanese women with non-metastatic breast cancer

Background

Breast cancer (BC) is the most frequently diagnosed cancer and a major cause of cancer mortality in Sudan. However, there is lack of data related to BC relapse. Therefore, this study was undertaken to estimate the 5-year relapse free survival (RFS) rate and factors related to BC relapse in Sudanese women with non-metastatic BC.

Methods

Data of BC women with BC diagnosed and treated at the National Cancer Institute-University of Gezira during 2012 were retrieved from medical records. The cases were followed-up through hospital records and telephone contact. Survival functions were calculated using Kaplan-Meier method and compared by log-rank test. The prognostic factors were tested using univariate and multivariable Cox regression analyses.

Results

We included 168 women with median age of 45 years (range, 22-83 years). 53.5%of women had stage III at time of diagnosis, whereas 4.2% and 42.3% of women presented with stage I and stage II, respectively. At the end of 5 years follow-up, with median follow-up period of 64 months, 94 (56.0%) women were alive in remission, 11 (6.5%) were alive with BC relapse, 49 (29.2%) were dead, and survival status was unknown in 14 (8.3%) women. Most of the occurred relapses were distant relapses. The 5-year RFS was 59%. The independent predictors of relapse were: larger primary tumor size (HR:1.84, 95% CI: 1.54-5.48, p=0.018); involved axillary lymph nodes with tumour (HR:  2.91, 95% CI:  1.53-7.91, p=0.001); not receiving adjuvant radiotherapy (HR: 2.2, 95% CI: 1.22-3.95, p=0.009); and not receiving hormone therapy (HR: 1.67, 95% CI: 1.01-2.76, p= 0.046).

Conclusion

We found a high risk of BC relapse in our resource-constrained settings. Advanced stages, not receiving adjuvant radiotherapy, and not receiving adjuvant hormone therapy were independent predictors associated with worse 5-year RFS. Therefore, enhancing the early diagnosis of BC and improving timely access to appropriate treatments represent key approaches to achieving better treatment outcomes.

Neoadjuvant chemotherapy use trends among older women with breast cancer: 2010-2017

PURPOSE

This study assessed chemotherapy use trends before (neoadjuvant chemotherapy [NAC]) or after surgery (adjuvant chemotherapy [AdC]) among older women with breast cancer and examined factors related to NAC receipt.

METHODS

Women (> 65 years) diagnosed with stage I-III breast cancer during 2010-2017 who received NAC or AdC were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. All patients were stratified into six strata based on subtype (hormone receptor-positive/human epidermal growth factor receptor 2-negative [HR + /HER2-], HER2 + , and triple-negative breast cancer [TNBC]) and stage (I-II and III). Cochran-Armitage tests were performed to test temporal trends of NAC use in each stratum. Multivariable logistic regression analyses were performed to identify factors (sociodemographic and clinical) related to NAC use.

RESULTS

Among included older (mean ± standard deviation: 72.3 ± 5.2 years) women (N = 8,495) with stage I-III breast cancer, NAC use increased from 11.7% (2010) to 32.6% (2017). Significant increases in NAC were found in all strata (p < .0001) with more substantial increases in HER2 + disease and TNBC compared to HR + /HER2- disease. Multivariable logistic regressions identified the youngest age category (66-69 years) and later stage as significant (p < 0.05) predictors of NAC receipt in most strata, in addition to diagnosis year.

CONCLUSION

Similar to the overall breast cancer population, NAC use increased among a population of older women. NAC was received by most patients with stage III HER2 + disease or TNBC in more recent years and was more common among younger elderly women and those in stage III.

Receipt of guideline-concordant care among young adult women with breast cancer

BACKGROUND

Little is known about the real-world care of young adult (YA) females (aged 20-39 years) with breast cancer. This study describes factors associated with the receipt of guideline-concordant care (GCC) among YAs.

METHODS

The authors identified 1259 YA women with invasive breast cancer diagnosed in 2013 in the National Cancer Institute's Patterns of Care study. Hospital records were re-abstracted, and treatment was verified. Using the National Comprehensive Cancer Network's 2013 breast cancer guidelines, the authors assessed the receipt of GCC by cancer subtype among a subset of YAs (n = 952). Associations between sociodemographic and clinical factors and GCC receipt were examined.

RESULTS

Most YAs were 35 to 39 years old (51.2%) and partnered (56.4%); half had hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) tumors. GCC was found for 81.7% of YAs. Relationships between sociodemographic and clinical factors and GCC receipt differed by subtype. Stage was the only significant predictor of GCC receipt for all subtypes (stage II vs III: odds ratio [OR] for HR+/HER2+, 0.20; 95% confidence interval [CI], 0.08-0.50; OR for HR-/HER2+, 0.13; 95% CI, 0.07-0.25; OR for HR-/HER2-, 3.86; 95% CI, 1.55-9.62; OR for HR+/HER2-, 2.81; 95% CI, 1.63-5.80).

CONCLUSIONS

GCC is high among YAs with breast cancer. The effects of sociodemographic factors and treatment facility size on GCC differ by subtype. Consistent with recommendations, tumor biology, not age, is associated with GCC for all subtypes. Future studies should assess the effect of GCC on survival among YAs.

Expression of therapy-induced senescence markers in breast cancer samples upon incomplete response to neoadjuvant chemotherapy

Senescence is a cell stress response induced by replicative, oxidative, oncogenic, and genotoxic stresses. Tumor cells undergo senescence in response to several cancer therapeutics in vitro (Therapy-Induced Senescence, TIS), including agents utilized as neoadjuvant chemotherapy (NAC) in the treatment of invasive breast cancer. TIS has been proposed to contribute to adverse therapy outcomes including relapse. However, there is limited evidence on the induction of senescence in response to NAC in clinical cancer and its contribution to disease outcomes. In this work, the expression of three senescence-associated markers (p21CIP1, H3K9Me3 (histone H3 lysine 9 trimethylation), and Lamin B1) was investigated in breast cancer samples that developed partial or incomplete pathological response to NAC (n=37). Accordingly, 40.54% of all samples showed marker expression consistent with a senescence-like phenotype, while the remainders were either negative or inconclusive for senescence (2.70 and 56.8%, respectively). Moreover, analysis of core-needle biopsies revealed minimal changes in p21CIP1 and H3K9Me3, but significant changes in Lamin B1 expression levels following NAC, highlighting a more predictive role of Lamin B1 in senescence detection. However, our analysis did not establish an association between TIS and cancer relapse as only three patients (8.1%) with a senescence-like profile developed short-term recurrent disease. Our analysis indicates that identification of TIS in tumor samples requires large-scale transcriptomic and protein marker analyses and extended clinical follow-up. Better understanding of in vivo senescence should elucidate its contribution to therapy outcomes and pave the way for the utilization of senolytic approaches as potential adjuvant cancer therapy.

Neoadjuvant Chemotherapy, Endocrine Therapy, and Targeted Therapy for Breast Cancer: ASCO Guideline

PURPOSE

To develop guideline recommendations concerning optimal neoadjuvant therapy for breast cancer.

METHODS

ASCO convened an Expert Panel to conduct a systematic review of the literature on neoadjuvant therapy for breast cancer and provide recommended care options.

RESULTS

A total of 41 articles met eligibility criteria and form the evidentiary basis for the guideline recommendations.

RECOMMENDATIONS

Patients undergoing neoadjuvant therapy should be managed by a multidisciplinary care team. Appropriate candidates for neoadjuvant therapy include patients with inflammatory breast cancer and those in whom residual disease may prompt a change in therapy. Neoadjuvant therapy can also be used to reduce the extent of local therapy or reduce delays in initiating therapy. Although tumor histology, grade, stage, and estrogen, progesterone, and human epidermal growth factor receptor 2 (HER2) expression should routinely be used to guide clinical decisions, there is insufficient evidence to support the use of other markers or genomic profiles. Patients with triple-negative breast cancer (TNBC) who have clinically node-positive and/or at least T1c disease should be offered an anthracycline- and taxane-containing regimen; those with cT1a or cT1bN0 TNBC should not routinely be offered neoadjuvant therapy. Carboplatin may be offered to patients with TNBC to increase pathologic complete response. There is currently insufficient evidence to support adding immune checkpoint inhibitors to standard chemotherapy. In patients with hormone receptor (HR)-positive (HR-positive), HER2-negative tumors, neoadjuvant chemotherapy can be used when a treatment decision can be made without surgical information. Among postmenopausal patients with HR-positive, HER2-negative disease, hormone therapy can be used to downstage disease. Patients with node-positive or high-risk node-negative, HER2-positive disease should be offered neoadjuvant therapy in combination with anti-HER2-positive therapy. Patients with T1aN0 and T1bN0, HER2-positive disease should not be routinely offered neoadjuvant therapy.Additional information is available at www.asco.org/breast-cancer-guidelines.

Disparities in Laryngeal Cancer Treatment and Outcomes: An Analysis by Hospital Safety-Net Burden

OBJECTIVES/HYPOTHESIS

To analyze the impact of hospital safety-net burden on survival outcomes for laryngeal squamous cell carcinoma (LSCC) patients.

STUDY DESIGN

Retrospective cohort study.

METHODS

From 2004 to 2015, 59,733 LSCC patients treated with curative intent were identified using the National Cancer Database. Low (LBH) <25th, medium (MBH) 25th-75th, and high (HBH) >75th safety-net burden hospitals were defined by the percentage quartiles (%) of uninsured/Medicaid-insured patients treated. Social and clinicopathologic characteristics and overall survival (using Kaplan-Meier survival analysis) were evaluated. Crude and adjusted hazard ratios (HR) with 95% confidence intervals (CI) were computed using Cox regression modeling.

RESULTS

There were 324, 647, and 323 hospitals that met the criteria as LBH, MBH, and HBH, respectively. The median follow-up was 38.6 months. A total of 27,629 deaths were reported, with a median survival of 75.8 months (a 5-year survival rate of 56.6%). Median survival was 83.2, 77.8, and 69.3 months for patients from LBH, MBH, and HBH, respectively (P < .0001). The median % of uninsured/Medicaid-insured patients treated among LBH, MBH, and HBH were 3.6%, 14.0%, and 27.0%, respectively. Patients treated at HBH were significantly more likely to be young, Black, Hispanic, of low income, and present with more advanced disease compared to LBH and MBH. Survival was comparable for LBH and MBH (HR = 1.02; 95% CI = 0.97-1.07, P = .408) on multivariate analysis. HBH, compared to LBH patients, had inferior survival (HR = 1.07; 95% CI = 1.01-1.13, P = .023).

CONCLUSIONS

High burden safety-net hospitals receive disproportionately more patients with advanced-stage and low socioeconomic status, yielding inferior survival compared to low burden hospitals.

LEVEL OF EVIDENCE

3 (individual cohort study) Laryngoscope, 131:E1987-E1997, 2021.

A comparison of complete pathologic response rates following neoadjuvant chemotherapy among South African breast cancer patients with and without concurrent HIV infection

PURPOSE

Among patients diagnosed with breast cancer (BC), women also living with HIV (WLWH) have worse survival than women without HIV. Chronic HIV infection may interfere with the effectiveness of BC treatment, contributing to this disparity. We attempted to determine the impact of HIV infection on response to neoadjuvant chemotherapy (NACT) among South African women with BC.

METHODS

We evaluated women from the South African Breast Cancer and HIV Outcomes cohort study who had stage I-III disease, initiated NACT, underwent definitive breast surgery, and had available surgical pathology reports. We compared pathologic complete response (pCR) rates among women with and without HIV infection, using multivariable logistic regression to control for differences in tumor characteristics. We also evaluated the impact of HIV infection on pCR within subgroups based on patient and tumor factors.

RESULTS

Of 715 women, the 173 (24.2%) WLWH were less likely to achieve pCR than women without HIV (8.7% vs 16.4%, [odds ratio (OR) 0.48, 95% confidence interval (95% CI) 0.27-0.86]). WLWH continued to have lower likelihood of achieving pCR on multivariable analysis (OR 0.52, 95% CI 0.28-0.98). A similar pattern was seen within subgroups, although HIV infection appeared to affect pCR more in ER/PR-positive BC (OR 0.24, 95% CI 0.08-0.71) than in ER/PR-negative BC (OR 0.94, 95% CI 0.39-2.29).

CONCLUSION

WLWH were less like to achieve pCR following NACT for BC than women without HIV. This reduced response to systemic therapy may contribute to the poorer BC outcomes seen in WLWH.

Impact of Neoadjuvant Versus Adjuvant Chemotherapy on the Extent of Axillary Surgery for Clinically Node-Negative Breast Cancers of Triple-Negative and HER2-Overexpressing Phenotypes

BACKGROUND

Breast cancer patients with triple-negative or human epidermal growth factor receptor 2 (HER2)-overexpressing phenotypes are recommended to receive chemotherapy for primary tumors greater than 1 cm regardless of nodal status. Neoadjuvant chemotherapy may eradicate subclinical nodal metastases and reduce the extent of axillary surgery performed.

PATIENTS AND METHODS

A query of the National Cancer Database Participant User File was performed for new cases of female breast cancer from 2012 to 2015. Inclusion criteria were clinical N0 status, receipt of chemotherapy, and receipt of axillary surgery. Exclusions included hormone-positive/HER2-negative tumors and/or distant metastatic disease. Subjects were divided into groups by receipt of neoadjuvant or adjuvant chemotherapy. The primary end point was the extent of axillary surgery, defined as sentinel lymph node biopsy alone or axillary lymph node dissection (ALND). Subgroup analyses were performed on the basis of tumor phenotype and surgery of the primary site.

RESULTS

A total of 66,771 female patients were included, 15,967 of whom underwent neoadjuvant chemotherapy. ALND rates were higher in patients who received adjuvant chemotherapy (30.6% vs. 28.8%, P < .001). Among tumor phenotypes, the extent of axillary surgery was reduced most significantly for hormone-negative, HER2-positive disease (30.0% vs. 25.8%, P < .001). ALND rates were more substantially reduced for patients who underwent mastectomy (41.3% vs. 36.1%, P < .001) compared to partial mastectomy (21.8% vs. 20.1%, P = .002). Adjuvant chemotherapy was an independent predictor of ALND (odds ratio, 1.26; 95% confidence interval, 1.19-1.33).

CONCLUSION

Neoadjuvant chemotherapy reduces the extent of axillary surgery in clinically node-negative, nonluminal breast cancers.

Neoadjuvant therapy for breast cancer

Objective:

To evaluate the frequency of neoadjuvant therapy (NT) in women with stage I–III breast cancer in Italy and whether it is influenced by biological characteristics, screening history, and geographic area.

Methods:

Data from the High Resolution Study conducted in 7 Italian cancer registries were used; they are a representative sample of incident cancers in the study period (2009–2013). Included were 3546 women aged <85 years (groups <50, 50–69, 70–64, and 75+) with stage I–III breast cancer at diagnosis who underwent surgery. Women were classified as receiving NT if they received chemotherapy, target therapy, and/or hormone therapy before the first surgical treatment. Logistic models were built to test the association with biological and contextual variables.

Results:

Only 8.2% of women (290 cases) underwent NT; the treatment decreases with increasing age (14.5% in age <50 and 2.2% in age 75+), is more frequent in women with negative receptors (14.8%), HER2-positive (15.7%), and triple-negative (15.6%). The multivariable analysis showed the probability of receiving NT is higher in stage III (odds ratio [OR] 3.83; 95% confidence interval [CI] 2.83–5.18), luminal B (OR 1.87; 95% CI 1.27–2.76), triple-negatives (OR 1.88; 95% CI 1.15–3.08), and in symptomatic cancers (OR 1.98; 95% CI 1.13–3.48). Use of NT varied among geographic areas: Reggio Emilia had the highest rates (OR 2.29; 95% CI 1.37–3.82) while Palermo had the lowest (OR 0.41; 95% CI 0.24–0.68).

Conclusions:

The use of NT in Italy is limited and variable. There are no signs of greater use in hospitals with more advanced care.

Trends and Outcomes of Proton Radiation Therapy Use for Non-Small Cell Lung Cancer

Purpose:

To examine national care patterns in proton radiation therapy (PBT) use for non–small cell lung cancer (NSCLC) and the effect of facility type on survival.

Patients and Methods:

Using the National Cancer Database, we identified 506 patients with a diagnosis of NSCLC from 2004-2014 who underwent PBT. Patients were categorized as having received treatment at an academic/research facility (ARF) or a form of community cancer program (CCP). Descriptive analysis was performed, and overall survival was analyzed by Kaplan-Meier methods and Cox proportional hazard models.

Results:

Treatments at ARFs and CCPs were equally distributed with 253 patients at each facility type. A positive trend in PBT use over time was observed with 2.8% of cases being treated in 2008 compared to 21.5% in 2014 (P = .001). Definitive doses (≥60 Gy) were more commonly given at ARFs than CCPs (72% versus 45%, respectively; P < .001). Five-year overall survival was 31% at ARFs and 18% at CCPs (P < .001). On multivariate analysis, outcomes were worse with treatments at CCPs (hazard ratio [HR] 1.61; 95% Confidence Interval, 1.14-2.27; P = .007). On subanalysis of nonsurgical patients treated with ≥60 Gy, facility type became insignificant and dose escalation was associated with improved outcomes (≥70 Gy HR 0.45; 95% CI, 0.25-0.81; P = .008).

Conclusion:

Use of PBT for management of NSCLC is on the rise. Community cancer programs were associated with higher rates of nondefinitive PBT doses and correspondingly worse outcomes. Differences in survival by facility became insignificant when definitive doses were used, warranting further investigation of practice patterns in CCPs at a national level.

Present and changing trends in surgical modalities and neoadjuvant chemotherapy administration for female breast cancer in Beijing, China: A 10-year (2006-2015) retrospective hospitalization summary report-based study

BACKGROUND

This study was conducted to describe present and changing trends in surgical modalities and neoadjuvant chemotherapy (NACT) in female breast cancer patients in China from 2006 to 2015.

METHODS

Data of 44 299 female breast cancer patients from 15 tertiary hospitals in Beijing were extracted from hospitalization summary reports. Surgeries were categorized into five modalities: breast-conserving surgery (BCS), simple mastectomy (SM), modified radical mastectomy (MRM), radical mastectomy (RM), and extensive radical mastectomy (ERM).

RESULTS

In total, 38 471 (86.84%) breast cancer patients underwent surgery: 22.64% BCS, 8.22% SM, 63.97% MRM, 4.24% RM, and 0.93% ERM. Older patients (> 60) underwent surgery more frequently than younger patients (< 60). The proportion of patients who underwent BCS was highest in the age ≥ 80 (39.24%) and < 40 (28.69%) subgroups and in patients with papillary carcinoma (35.48%), and lowest in the age 60- subgroup (18.17%) and in patients with Paget's disease (19.05%). SM was most frequently performed in patients with Paget's disease (29.00%), and MRM for ductal (64.99%), and lobular (63.78%) carcinomas. During the study period, the proportion of patients who underwent MRM dropped by 29.04%, SM and BCS increased from 15.78% and 30.83%, respectively, and NACT increased in all subgroups, particularly in patients with lymph node involvement (26.72%).

CONCLUSIONS

Surgical modalities varied significantly by age and histologic group. The use of BCS and SM increased dramatically, while MRM declined significantly. The proportion of patients treated with NACT has increased significantly, especially in patients with lymph node involvement.

Neoadjuvant chemotherapy among patients treated for nonmetastatic breast cancer in a population with a high HIV prevalence in Johannesburg, South Africa

Background

Neoadjuvant (primary) chemotherapy (NACT) is the standard of care for locally advanced breast cancer. It also allows for the short-term assessment of chemotherapy response; a pathological complete responses correspond to improved long-term breast cancer outcomes. In sub-Saharan Africa, many patients are diagnosed with large nonresectable tumors. We examined NACT use in breast cancer patients who visited public hospitals in Johannesburg, South Africa.

Methods

We assessed demographic characteristics, tumor stage and grade, hormone receptor status, and human immunodeficiency virus (HIV) status of female patients diagnosed with nonmetastatic invasive carcinoma of the breast at Chris Hani Baragwanath Academic Hospital between January 1, 2009, and December 31, 2011. The patients received neoadjuvant, adjuvant, or no chemotherapy. Trastuzumab was unavailable. We developed logistic regression models to analyze the factors associated with NACT receipt in these patients.

Results

Of 554 women with nonmetastatic breast cancer, the median age at diagnosis was 52 years (range: 28–88 years). Only 5.8% of patients were diagnosed with stage I disease; 49.3% and 44.9% were diagnosed with stages II and III, respectively. Most patients had hormone-responsive tumors: luminal A, 38.1%; luminal B₁ (human epidermal growth factor receptor 2 [HER2]-negative and high grade), 12.5%, and luminal B₂ (HER2-positive any grade), 11.6%; 11.6% had a HER2-enriched tumor and 20.6% a triple-negative tumor. Eighty (14.4%) patients were HIV-positive. In total, 195 patients (35.2%) received NACT, 264 (47.7%) patients received adjuvant chemotherapy, and 95 patients (17.1%) received no chemotherapy, including 62 (11.2%) patients who received only hormonal therapy. Of patients receiving NACT, 125 (64.1%) were evaluable for clinical response. Eighty (64.0%) patients had a clinically significant response; 19 (15.2%) patients had a stable disease, and 26 (20.8%) patients had a progressive disease. Multivariate analysis showed age <40 years and disease stage to be independently associated with the receipt of NACT.

Conclusion

Most women receiving NACT with available response data showed a clinical benefit. Stage III disease at diagnosis and age <40 years were predictors of neoadjuvant versus adjuvant chemotherapy treatment.

Patient Age and Tumor Subtype Predict the Extent of Axillary Surgery Among Breast Cancer Patients Eligible for the American College of Surgeons Oncology Group Trial Z0011

BACKGROUND

The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial established the safety of omitting axillary lymph node dissection (ALND) for early-stage breast cancer patients with limited nodal disease undergoing lumpectomy. We examined the extent of axillary surgery among women eligible for Z0011 based on patient age and tumor subtype.

METHODS

Patients with cT1-2, cN0 breast cancers and one or two positive nodes diagnosed from 2009 to 2014 and treated with lumpectomy were identified in the National Cancer Data Base. Sentinel lymph node biopsy (SLNB) was defined as the removal of 1-5 nodes and ALND as the removal of 10 nodes or more. Tumor subtype was categorized as luminal, human epidermal growth factor 2-positive (HER2+), or triple-negative. Logistic regression was used to estimate the odds of receiving SLNB alone versus ALND.

RESULTS

The inclusion criteria were met by 28,631 patients (21,029 SLNB-alone and 7602 ALND patients). Patients 70 years of age or older were more likely to undergo SLNB alone than ALND (27.0% vs 20.1%; p < 0.001). The radiation therapy use rate was 89.4% after SLNB alone and 89.7% after ALND. In the multivariate analysis, the uptake of Z0011 recommendations increased over time (2014 vs 2009: odds ratio [OR] 13.02; p < 0.001). Younger patients were less likely to undergo SLNB alone than older patients (age <40 vs ≥70: OR 0.59; p < 0.001). Patients with HER2+ (OR 0.89) or triple-negative disease (OR 0.79) (p < 0.001) were less likely to undergo SLNB alone than those with luminal subtypes.

CONCLUSIONS

Among women potentially eligible for ACOSOG Z0011, the use of SLNB alone increased over time in all groups, but the extent of axillary surgery differed by patient age and tumor subtype.