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Jaraj D, Höijer J, Widman L, Ahlgren J, Arnesson LG, Einbeigi Z, Klintman M, Vikhe Patil E, Sund M, Fredriksson I, Bergh J, Andreas P. Long-Term Prognostication for 20 114 Women With Small and Node-Negative Breast Cancer (T1abN0). JNCI Cancer Spectr 2020; 5:pkaa084. [PMID: 33442658 PMCID: PMC7791632 DOI: 10.1093/jncics/pkaa084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/22/2020] [Indexed: 11/14/2022] Open
Abstract
Background Although small, node-negative breast cancer (ie, T1abN0) constitutes 20% of all newly diagnosed breast cancers, data on prognosis and prognostic factors are limited. Methods We conducted a population-based cohort study including 20 114 Swedish women treated for T1abN0 breast cancer from 1977 onward. Patient and tumor data were collected from Swedish breast cancer registries. Cohort subjects were followed through linkage to the Cause of Death Register. We calculated the cumulative incidence of breast cancer–specific and overall death and used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Results During a median follow-up of 9.1 years (range = 0-38), 915 women died of breast cancer and 5416 of any cause. The 10-, 20-, and 30-year cumulative incidences of breast cancer death were 3.4% (95% CI = 3.1% to 3.7%), 7.6% (95% CI = 7.1% to 8.2%), and 10.5% (95% CI = 9.6% to 11.4%), respectively. The multivariable hazard ratios and 95% confidence intervals of breast cancer death were 0.92 (95% CI = 0.88 to 0.97) for each additional calendar year of diagnosis, 4.38 (95% CI = 2.79 to 6.87) for grade 3 vs grade 1 tumors, 0.43 (95% CI = 0.31 to 0.62) for progesterone receptor–positive vs progesterone receptor–negative disease, and 2.01 (95% CI = 0.99 to 4.07) for HER2-positive vs HER2-negative disease. Women with grade 3 vs grade 1 tumors had a 56% increased risk of death from any cause (HR = 1.56, 95% CI = 1.30 to 1.88). Conclusions The risk of breast cancer death in T1abN0 disease continues to increase steadily beyond 10 years after diagnosis, has improved over time, and varies substantially by tumor characteristics.
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Affiliation(s)
- David Jaraj
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Capio St Görans Hospital, Stockholm, Sweden
| | - Jonas Höijer
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Linnea Widman
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Ahlgren
- Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Regional Cancer Centre, Uppsala Örebro Health Care Region, Uppsala, Sweden
| | | | - Zakaria Einbeigi
- Department of Medicine, Southern Älvsborg Hospital, Borås, Sweden.,Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marie Klintman
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Eva Vikhe Patil
- Department of Surgery, University Hospital, Linköping, Sweden
| | - Malin Sund
- Department of Surgical and Perioperative Sciences/Surgery, Umeå University, Umeå, Sweden
| | - Irma Fredriksson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Breast, Endocrine and Sarcoma Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Bergh
- Department of Breast, Endocrine and Sarcoma Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Pettersson Andreas
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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Ingvar C, Ahlgren J, Emdin S, Lofgren L, Nordander M, Niméus E, Arnesson LG. Long-term outcome of pT1a-b, cN0 breast cancer without axillary dissection or staging: a prospective observational study of 1543 women. Br J Surg 2020; 107:1299-1306. [PMID: 32335901 DOI: 10.1002/bjs.11610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/18/2019] [Accepted: 03/09/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The implementation of screening programmes in Sweden during the mid-1990s increased the number of small node-negative breast cancers. In this era before staging by sentinel node biopsy, routine axillary dissection for staging of early breast cancer was questioned owing to the increased morbidity and lack of perceived benefit. The long-term risk of axillary recurrence when axillary staging is omitted remains unclear. METHODS This prospective observational multicentre cohort study included Swedish women diagnosed with breast cancer between 1997 and 2002. The patients had clinically node-negative, pT1a-b, grade I-II tumours. No axillary staging or dissection was performed. The primary outcome was ipsilateral axillary recurrence and survival. RESULTS A total of 1543 patients were included. Breast-conserving surgery (BCS) was performed in 94·0 per cent and the rest underwent mastectomy. After surgery, 58·1 per cent of the women received adjuvant radiotherapy, 11·9 per cent adjuvant endocrine therapy and 31·5 per cent did not receive any adjuvant treatment. After a median follow-up of 15·5 years, 6·4 per cent developed contralateral breast cancer and 16·5 per cent experienced a recurrence. The first recurrence was local in 116, regional in 47 and distant in 59 patients. The breast cancer-specific survival rate was 93·7 per cent after 15 years. There were no differences in overall or breast cancer-specific survival between patients who received adjuvant radiotherapy and those who did not. Only 3·0 per cent of patients had an axillary recurrence, which was isolated in only 1·0 per cent. CONCLUSION Axillary surgery can safely be omitted in patients with low-grade, T1a-b, cN0 breast cancers. This large prospective cohort with 15-year follow-up had a very low incidence of axillary recurrences and high breast cancer-specific survival rate.
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Affiliation(s)
- C Ingvar
- Department of Surgery, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - J Ahlgren
- Regional Cancer Centre, Uppsala University Hospital, Uppsala, Sweden.,Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - S Emdin
- Department of Surgery, Clinical Sciences, Umeå University, Umeå, Sweden
| | - L Lofgren
- Department of Surgery, St Göran's Hospital, Stockholm, Sweden
| | - M Nordander
- Department of Surgery, Clinical Sciences, Lund University, Lund, Sweden
| | - E Niméus
- Department of Surgery, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - L-G Arnesson
- Department of Surgery, Clinical Sciences, Linköping University, Linköping, Sweden
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Kald BA, Boiesen P, Ronnow K, Jonsson PE, Bisgaard T. Preoperative Assessment of Small Tumours in Women with Breast Cancer. Scand J Surg 2016; 94:15-20. [PMID: 15865110 DOI: 10.1177/145749690509400105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Objectives: In patients with breast cancer, planning of the surgical strategy may rely on preoperative tumour size. The optimal method for assessment of small tumours has not been established. We compared findings from preoperative mammography and ultrasonography with histopathological tumour size in patients treated with breast-conserving surgery. Material and Methods: The study was retrospective and the setting a single institution clinic with free referral of patients. The patients were examined before the operation with mammography, ultrasonography, and findings were compared with postoperative histopathological tumour size. Results: The study included 131 patients (median age was 59) years with grade I, II, and III cancers in 47, 71 and in 13 patients, respectively. The medium histological tumour size was 14 mm, range 4–45 mm. A wide 95 % confidence interval between histopathological tumour size and preoperative mammography (standard deviation 4.8 mm) and ultrasonography (standard deviation 4.8 mm) was found. The combination of mammography and ultrasonography did not improve the results (standard deviation 4.3 mm). Preoperative mammography tended to over estimate the tumour size compared with histological tumour size whereas preoperative ultrasonography tended to underestimate the tumour size. Conclusion: In this retrospective study with preoperative evaluation of small breast cancers by mammography and ultrasonography, wide 95 % confidence intervals for the methods were found and they should therefore be used with caution in the planning of the surgical strategy.
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Affiliation(s)
- B A Kald
- Departments of Surgery, Helsingborg Hospital, Helsingborg, Sweden.
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Kaufman CS, Jacobson-Kaufman L, Thorndike-Christ T, Kaufman L, Tabár L. A treatment scale for axillary management in breast cancer. Am J Surg 2001; 182:377-83. [PMID: 11720675 DOI: 10.1016/s0002-9610(01)00741-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We have investigated a method, the Kaufman axillary treatment scale (KATS), to help assign patients with a clinically negative axilla to one of three current options of axillary management: standard axillary dissection, sentinel node sampling followed by axillary dissection if the sentinel node is positive, or no axillary surgery at all. The KATS score uses preoperative data to guide the choice of axillary treatment. METHODS The KATS score is calculated by adding the preoperative values of tumor size, patient age, and pathologic grade. Values range from 1 to 4 for size (1 to 9 mm, 10 to 14 mm, 15 to 19 mm, and 20 to 30 mm), 1 to 3 for age (70 years and over, 50 to 69 years, less than 50 years), and 1 to 2 for grade (low or not low) to calculate the score. The KATS score ranges from 3 to 9. We have applied this score against the SEER (Surveillance, Epidemiology, and End Results) tumor registry of 529 patients with invasive breast cancer with known pathologic data. We then validated it by applying it to our own set of 190 patients using preoperative data. The chi-square test and logistic regression analysis were used for P values (all two sided), univariate and multivariate analysis, odds ratio and confidence intervals utilizing SPSS statistics software. RESULTS In the SEER database using American Joint Committee on Cancer pathologic size alone, no sizable group was identified with a positive node rate neither below 8% (T1a) nor above 48% (T2). KATS scores of 3 and 4 (68 patients, group 1) identify patients with an average node positive rate of 4.4% (P <0.02, group 1 versus 2). Those patients with KATS scores of 5, 6, and 7 (341 patients, group 2) carry an average node positive rate of 22% (P <0.001, group 2 versus 3). KATS scores of 8 and 9 (120 patients, group 3) identify patients with an average node positive rate of 50% (P <0.001, group 3 versus 1). Similar results were found on our own group of 190 patients using preoperative available data. KATS scores of 3 or 4 (11 patients, group 1) had no positive nodes. Group 2 (100 patients, KATS score 5, 6, and 7) had an average 30% node positive rate. Group 3 (79 patients, KATS score 8 and 9) had 61% node positive rate. The KATS score allows the clinician to separate patients into three axillary management groups. Group 1 are those patients who may need no axillary surgery at all. Group 2 are patients who would benefit from sentinel node mapping. Group 3 has a node positive rate (61%) similar to that of clinically palpable nodes (since not all clinically palpable nodes are positive). Group 3 patients may be considered for standard axillary dissection, similar to the palpable node patient. If group 3 patients have sentinel node mapping, more than half of these patients require axillary dissection and the impact of false negative sentinel node procedures may become clinically significant. CONCLUSIONS An axillary treatment score has been developed to aid in the triage of patients toward reasonable axillary treatment choices for the benefit of the patient. The KATS score is a guideline and not a mandate. The KATS score attempts to use breakpoints that are both clinically practical and validated by scientific data. Like many other attempts to categorize patients, there is a continuum of data points along any variable. The treating physician utilizing the full array of available data on each patient makes the final clinical decision of axillary management.
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Affiliation(s)
- C S Kaufman
- Bellingham Breast Center, 2940 Squalicum Parkway, Bellingham, WA 98225, USA.
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Fisher B, Dignam J, Tan-Chiu E, Anderson S, Fisher ER, Wittliff JL, Wolmark N. Prognosis and treatment of patients with breast tumors of one centimeter or less and negative axillary lymph nodes. J Natl Cancer Inst 2001; 93:112-20. [PMID: 11208880 DOI: 10.1093/jnci/93.2.112] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Uncertainty about prognosis and treatment of axillary lymph node-negative patients with estrogen receptor (ER)-negative or ER-positive invasive breast tumors of 1 cm or less prompted the analysis of data from five National Surgical Adjuvant Breast and Bowel Project randomized clinical trials. METHODS Two hundred thirty-five patients with ER-negative tumors and 1024 patients with ER-positive tumors were identified in these trials. Patients with ER-negative tumors received surgery alone or surgery and chemotherapy. Patients with ER-positive tumors received surgery alone; surgery and tamoxifen; or surgery, tamoxifen, and chemotherapy. End points were relapse-free survival (RFS), event-free survival, and overall survival. A result was considered to be statistically significant with a P value of.05 or less; all statistical tests were two-sided. RESULTS The 8-year RFS of women with ER-negative tumors who received surgery alone or with chemotherapy was 81% and 90%, respectively (P = .06). Survival was similar in both groups (93% and 91%; P = .65). The 8-year RFS of women with ER-positive tumors was 86% after surgery alone, 93% when tamoxifen was added (P = .01), and 95% after the addition of tamoxifen and chemotherapy (P = .07 compared with tamoxifen). Survival in the three groups was 90%, 92% (P = .41), and 97%, respectively. The difference between the latter two groups was significant (P = .01). Regardless of ER status or treatment, overall mortality was 8%; one half of the deaths were related to breast cancer. Several covariates affected the risk of recurrence in ER-negative and ER-positive patients. Risk was greater in women with tumors of 1 cm than in those with tumors of less than 1 cm, in women aged 49 years or younger than in those aged 50 years or older, and in women with infiltrating ductal or lobular carcinoma than in those with other histologic tumor types. CONCLUSIONS Chemotherapy and/or tamoxifen should be considered for the treatment of women with ER-negative or ER-positive tumors of 1 cm or less and negative axillary lymph nodes.
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Affiliation(s)
- B Fisher
- B. Fisher, National Surgical Adjuvant Breast and Bowel Project (NSABP), Pittsburgh, PA, USA.
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Page DL, Jensen RA, Simpson JF. Routinely available indicators of prognosis in breast cancer. Breast Cancer Res Treat 1999; 51:195-208. [PMID: 10068079 DOI: 10.1023/a:1006122716137] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Diagnosis coupled with prognostication is the challenge for and charge of the pathologist. In this time of rapidly developing basic knowledge and increasing sophistication in the evaluation of prognostic information, there has also been an important re-evaluation of the validity, reliability, and relevance of classic histopathology. Also, the precision of and criteria for evaluating tumor size and status of regional lymph nodes is under study. Our emphasis in this review is tissue pathology and further, its practical relevance to patient management. Histopathology remains the basis of diagnosis universally; the addition of other elements will increase precision of prediction, particularly of responsiveness to individual therapies. Histologic grade may be integrated to substratify high and low stage cases into prognostically more useful subsets. Histologic types also interact with size and nodal status to predict patients with excellent prognosis. Further refinement of these parameters may occur by analysis within clinical, pathologic, or therapeutic subsets.
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Affiliation(s)
- D L Page
- Department of Preventive Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
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Ruibal A, Nuñez MI, Arias J, Folgueras V, Garcia Miralles MT, Tejerina A. Clinical and Biological Differences between Diploid and Hyperdiploid Infiltrating Ductal Carcinomas of the Breast. Int J Biol Markers 1998; 13:42-4. [PMID: 9681298 DOI: 10.1177/172460089801300107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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