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Kosaka Y, Minatani N, Tanaka Y, Shida A, Kikuchi M, Nishimiya H, Waraya M, Katoh H, Sato T, Sengoku N, Tanino H, Yamashita K, Watanabe M. Lymph node metastasis and high serum CEA are important prognostic factors in hormone receptor positive and HER2 negative breast cancer. Mol Clin Oncol 2018; 9:566-574. [PMID: 30402236 PMCID: PMC6201040 DOI: 10.3892/mco.2018.1716] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 09/12/2018] [Indexed: 12/16/2022] Open
Abstract
In recent years, treatment options for breast cancer have increased, and prognosis has improved since the 1990s. The present study examined the prognosis for recurrence of breast cancer between 2006 and 2009, in comparison with the results of past treatments, and sought to guide future treatment strategies by elucidating present prognostic factors. A total of 662 patients with breast cancer stage 0-III who underwent surgery at Kitasato University Hospital between January 2006 and March 2009 were included. Cases were classified into four subtypes, based on the presence or absence of hormone receptors and human epidermal growth factor receptor 2 (HER2). Factors associated with recurrence and prognosis were then examined. The 5-year recurrence-free survival (RFS) was 94.9% and the 5-year disease-specific survival (DSS) was 98.4%. Factors related to RFS were pathological lymph node (pN) positive [hazard ratio (HR)=2.85, P=0.001], clinical lymph node (cN) positive (HR=2.28, P<0.01), and hormone receptor negative (HR=1.83, P<0.05). Factors associated with DSS were cN positive (HR=4.55, P<0.01), pN positive (HR=3.40, P<0.05), higher preoperative serum carcinoembryonic antigen (CEA) (HR=3.04, P<0.05), and hormone receptor negative (HR=2.32, P<0.05). In the hormone receptor positive HER2 negative, cN-positive/pN-positive breast cancer group, RFS and DSS were poorer compared with the other groups. In this group, preoperative high CEA level was a poor prognostic factor. The prognosis for hormone receptor positive HER2-negative breast cancer has improved significantly since the 1990s. On the other hand, the prognosis for cN-positive/pN-positive breast cancer was poor. Pre-treatment serum CEA positive cases exhibited a particularly poor prognosis.
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Affiliation(s)
- Yoshimasa Kosaka
- Department of Breast and Endocrine Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Naoko Minatani
- Department of Breast and Endocrine Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Yoko Tanaka
- Department of Breast and Endocrine Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Akiko Shida
- Department of Breast and Endocrine Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Mariko Kikuchi
- Department of Breast and Endocrine Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Hiroshi Nishimiya
- Department of Breast and Endocrine Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Mina Waraya
- Department of Breast and Endocrine Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Hiroshi Katoh
- Department of Breast and Endocrine Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Takeo Sato
- Department of Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Norihiko Sengoku
- Department of Breast and Endocrine Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Hirokazu Tanino
- Department of Breast and Endocrine Surgery, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Keishi Yamashita
- Department of Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
| | - Masahiko Watanabe
- Department of Surgery, School of Medicine, Kitasato University Hospital, Sagamihara, Kanagawa 252-0374, Japan
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Davies C, Pan H, Godwin J, Gray R, Arriagada R, Raina V, Abraham M, Alencar VHM, Badran A, Bonfill X, Bradbury J, Clarke M, Collins R, Davis SR, Delmestri A, Forbes JF, Haddad P, Hou MF, Inbar M, Khaled H, Kielanowska J, Kwan WH, Mathew BS, Müller B, Nicolucci A, Peralta O, Pernas F, Petruzelka L, Pienkowski T, Rajan B, Rubach MT, Tort S, Urrútia G, Valentini M, Wang Y, Peto R. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. Lancet 2013; 381:805-16. [PMID: 23219286 PMCID: PMC3596060 DOI: 10.1016/s0140-6736(12)61963-1] [Citation(s) in RCA: 1322] [Impact Index Per Article: 120.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND For women with oestrogen receptor (ER)-positive early breast cancer, treatment with tamoxifen for 5 years substantially reduces the breast cancer mortality rate throughout the first 15 years after diagnosis. We aimed to assess the further effects of continuing tamoxifen to 10 years instead of stopping at 5 years. METHODS In the worldwide Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) trial, 12,894 women with early breast cancer who had completed 5 years of treatment with tamoxifen were randomly allocated to continue tamoxifen to 10 years or stop at 5 years (open control). Allocation (1:1) was by central computer, using minimisation. After entry (between 1996 and 2005), yearly follow-up forms recorded any recurrence, second cancer, hospital admission, or death. We report effects on breast cancer outcomes among the 6846 women with ER-positive disease, and side-effects among all women (with positive, negative, or unknown ER status). Long-term follow-up still continues. This study is registered, number ISRCTN19652633. FINDINGS Among women with ER-positive disease, allocation to continue tamoxifen reduced the risk of breast cancer recurrence (617 recurrences in 3428 women allocated to continue vs 711 in 3418 controls, p=0·002), reduced breast cancer mortality (331 deaths vs 397 deaths, p=0·01), and reduced overall mortality (639 deaths vs 722 deaths, p=0·01). The reductions in adverse breast cancer outcomes appeared to be less extreme before than after year 10 (recurrence rate ratio [RR] 0·90 [95% CI 0·79–1·02] during years 5–9 and 0·75 [0·62–0·90] in later years; breast cancer mortality RR 0·97 [0·79–1·18] during years 5–9 and 0·71 [0·58–0·88] in later years). The cumulative risk of recurrence during years 5–14 was 21·4% for women allocated to continue versus 25·1% for controls; breast cancer mortality during years 5–14 was 12·2% for women allocated to continue versus 15·0% for controls (absolute mortality reduction 2·8%). Treatment allocation seemed to have no effect on breast cancer outcome among 1248 women with ER-negative disease, and an intermediate effect among 4800 women with unknown ER status. Among all 12,894 women, mortality without recurrence from causes other than breast cancer was little affected (691 deaths without recurrence in 6454 women allocated to continue versus 679 deaths in 6440 controls; RR 0·99 [0·89–1·10]; p=0·84). For the incidence (hospitalisation or death) rates of specific diseases, RRs were as follows: pulmonary embolus 1·87 (95% CI 1·13–3·07, p=0·01 [including 0·2% mortality in both treatment groups]), stroke 1·06 (0·83–1·36), ischaemic heart disease 0·76 (0·60–0·95, p=0·02), and endometrial cancer 1·74 (1·30–2·34, p=0·0002). The cumulative risk of endometrial cancer during years 5–14 was 3·1% (mortality 0·4%) for women allocated to continue versus 1·6% (mortality 0·2%) for controls (absolute mortality increase 0·2%). INTERPRETATION For women with ER-positive disease, continuing tamoxifen to 10 years rather than stopping at 5 years produces a further reduction in recurrence and mortality, particularly after year 10. These results, taken together with results from previous trials of 5 years of tamoxifen treatment versus none, suggest that 10 years of tamoxifen treatment can approximately halve breast cancer mortality during the second decade after diagnosis. FUNDING Cancer Research UK, UK Medical Research Council, AstraZeneca UK, US Army, EU-Biomed.
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Affiliation(s)
- Christina Davies
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, UKClinical Trial Service Unit and Epidemiological Studies Unit (CTSU)University of OxfordUK
- Correspondence to: Dr Christina Davies, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Hongchao Pan
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, UKClinical Trial Service Unit and Epidemiological Studies Unit (CTSU)University of OxfordUK
| | - Jon Godwin
- Glasgow Caledonian University, Glasgow, UKGlasgow Caledonian UniversityGlasgowUK
| | - Richard Gray
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, UKClinical Trial Service Unit and Epidemiological Studies Unit (CTSU)University of OxfordUK
| | - Rodrigo Arriagada
- Institut Gustave-Roussy, Villejuif, FranceInstitut Gustave-RoussyVillejuifFrance
| | - Vinod Raina
- Institute Rotary Cancer Hospital, All-India Institute of Medical Sciences, New Delhi, IndiaInstitute Rotary Cancer HospitalAll-India Institute of Medical SciencesNew DelhiIndia
| | - Mirta Abraham
- Instituto Cardiovascular Rosario (ICR), Rosario, ArgentinaInstituto Cardiovascular Rosario (ICR)RosarioArgentina
| | | | - Atef Badran
- National Cancer Institute, Cairo University, Cairo, EgyptNational Cancer InstituteCairo UniversityCairoEgypt
| | - Xavier Bonfill
- Sant Pau Biomedical Research Institute (IIB Sant Pau-CIBERESP), Barcelona, SpainSant Pau Biomedical Research Institute (IIB Sant Pau-CIBERESP)BarcelonaSpain
| | - Joan Bradbury
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, AustraliaSchool of Public Health and Preventive MedicineMonash University, MelbourneMelbourneVictoriaAustralia
| | - Michael Clarke
- Queens University, Belfast, UKQueens UniversityBelfastUK
| | - Rory Collins
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, UKClinical Trial Service Unit and Epidemiological Studies Unit (CTSU)University of OxfordUK
| | - Susan R Davis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, AustraliaSchool of Public Health and Preventive MedicineMonash University, MelbourneMelbourneVictoriaAustralia
| | - Antonella Delmestri
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, UKClinical Trial Service Unit and Epidemiological Studies Unit (CTSU)University of OxfordUK
| | - John F Forbes
- Australia and New Zealand Breast Cancer Trials Group, University of Newcastle, Newcastle, NSW, AustraliaAustralia and New Zealand Breast Cancer Trials GroupUniversity of NewcastleNewcastleNSWAustralia
| | - Peiman Haddad
- Cancer Institute, Tehran University of Medical Sciences, Tehran, IranCancer InstituteTehran University of Medical SciencesTehranIran
| | - Ming-Feng Hou
- Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ChinaKaohsiung Medical University HospitalKaohsiungTaiwanChina
| | - Moshe Inbar
- Tel Aviv Sourasky Medical Center, Tel Aviv, IsraelTel Aviv Sourasky Medical CenterTel AvivIsrael
| | - Hussein Khaled
- National Cancer Institute, Cairo University, Cairo, EgyptNational Cancer InstituteCairo UniversityCairoEgypt
| | - Joanna Kielanowska
- The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, PolandThe Maria Sklodowska-Curie Memorial Cancer Center and Institute of OncologyWarsawPoland
| | - Wing-Hong Kwan
- Comprehensive Oncology Centre, Hong Kong, ChinaComprehensive Oncology CentreHong KongChina
| | - Beela S Mathew
- Regional Cancer Centre, Trivandrum, IndiaRegional Cancer CentreTrivandrumIndia
| | - Bettina Müller
- Chilean Cooperative Group for Oncologic Research (GOCCHI) Santiago, ChileChilean Cooperative Group for Oncologic Research (GOCCHI) SantiagoChile
| | - Antonio Nicolucci
- Consorzio Mario Negri Sud, S Maria Imbaro, ItalyConsorzio Mario Negri SudS Maria ImbaroItaly
| | - Octavio Peralta
- Chilean Cooperative Group for Oncologic Research (GOCCHI) Santiago, ChileChilean Cooperative Group for Oncologic Research (GOCCHI) SantiagoChile
| | - Fany Pernas
- Instituto de Investigaciones Clinicas de Rosario, Rosario, ArgentinaInstituto de Investigaciones Clinicas de RosarioRosarioArgentina
| | - Lubos Petruzelka
- Medical Faculty 1, Charles University, Prague, Czech RepublicMedical Faculty 1Charles UniversityPragueCzech Republic
| | - Tadeusz Pienkowski
- European Health Centre Otwock (ECZO), Warsaw, PolandEuropean Health Centre Otwock (ECZO)WarsawPoland
| | - Balakrishnan Rajan
- The National Oncology Centre, Royal Hospital, OmanThe National Oncology CentreRoyal HospitalOman
| | - Maryna T Rubach
- The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, PolandThe Maria Sklodowska-Curie Memorial Cancer Center and Institute of OncologyWarsawPoland
| | - Sera Tort
- Sant Pau Biomedical Research Institute (IIB Sant Pau-CIBERESP), Barcelona, SpainSant Pau Biomedical Research Institute (IIB Sant Pau-CIBERESP)BarcelonaSpain
| | - Gerard Urrútia
- Sant Pau Biomedical Research Institute (IIB Sant Pau-CIBERESP), Barcelona, SpainSant Pau Biomedical Research Institute (IIB Sant Pau-CIBERESP)BarcelonaSpain
| | - Miriam Valentini
- Consorzio Mario Negri Sud, S Maria Imbaro, ItalyConsorzio Mario Negri SudS Maria ImbaroItaly
| | - Yaochen Wang
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, UKClinical Trial Service Unit and Epidemiological Studies Unit (CTSU)University of OxfordUK
| | - Richard Peto
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, UKClinical Trial Service Unit and Epidemiological Studies Unit (CTSU)University of OxfordUK
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Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005; 365:1687-717. [PMID: 15894097 DOI: 10.1016/s0140-6736(05)66544-0] [Citation(s) in RCA: 5624] [Impact Index Per Article: 296.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Quinquennial overviews (1985-2000) of the randomised trials in early breast cancer have assessed the 5 year and 10-year effects of various systemic adjuvant therapies on breast cancer recurrence and survival. Here, we report the 10-year and 15-year effects. METHODS Collaborative meta-analyses were undertaken of 194 unconfounded randomised trials of adjuvant chemotherapy or hormonal therapy that began by 1995. Many trials involved CMF (cyclophosphamide, methotrexate, fluorouracil), anthracycline-based combinations such as FAC (fluorouracil, doxorubicin, cyclophosphamide) or FEC (fluorouracil, epirubicin, cyclophosphamide), tamoxifen, or ovarian suppression: none involved taxanes, trastuzumab, raloxifene, or modern aromatase inhibitors. FINDINGS Allocation to about 6 months of anthracycline-based polychemotherapy (eg, with FAC or FEC) reduces the annual breast cancer death rate by about 38% (SE 5) for women younger than 50 years of age when diagnosed and by about 20% (SE 4) for those of age 50-69 years when diagnosed, largely irrespective of the use of tamoxifen and of oestrogen receptor (ER) status, nodal status, or other tumour characteristics. Such regimens are significantly (2p=0.0001 for recurrence, 2p<0.00001 for breast cancer mortality) more effective than CMF chemotherapy. Few women of age 70 years or older entered these chemotherapy trials. For ER-positive disease only, allocation to about 5 years of adjuvant tamoxifen reduces the annual breast cancer death rate by 31% (SE 3), largely irrespective of the use of chemotherapy and of age (<50, 50-69, > or =70 years), progesterone receptor status, or other tumour characteristics. 5 years is significantly (2p<0.00001 for recurrence, 2p=0.01 for breast cancer mortality) more effective than just 1-2 years of tamoxifen. For ER-positive tumours, the annual breast cancer mortality rates are similar during years 0-4 and 5-14, as are the proportional reductions in them by 5 years of tamoxifen, so the cumulative reduction in mortality is more than twice as big at 15 years as at 5 years after diagnosis. These results combine six meta-analyses: anthracycline-based versus no chemotherapy (8000 women); CMF-based versus no chemotherapy (14,000); anthracycline-based versus CMF-based chemotherapy (14,000); about 5 years of tamoxifen versus none (15,000); about 1-2 years of tamoxifen versus none (33,000); and about 5 years versus 1-2 years of tamoxifen (18,000). Finally, allocation to ovarian ablation or suppression (8000 women) also significantly reduces breast cancer mortality, but appears to do so only in the absence of other systemic treatments. For middle-aged women with ER-positive disease (the commonest type of breast cancer), the breast cancer mortality rate throughout the next 15 years would be approximately halved by 6 months of anthracycline-based chemotherapy (with a combination such as FAC or FEC) followed by 5 years of adjuvant tamoxifen. For, if mortality reductions of 38% (age <50 years) and 20% (age 50-69 years) from such chemotherapy were followed by a further reduction of 31% from tamoxifen in the risks that remain, the final mortality reductions would be 57% and 45%, respectively (and, the trial results could well have been somewhat stronger if there had been full compliance with the allocated treatments). Overall survival would be comparably improved, since these treatments have relatively small effects on mortality from the aggregate of all other causes. INTERPRETATION Some of the widely practicable adjuvant drug treatments that were being tested in the 1980s, which substantially reduced 5-year recurrence rates (but had somewhat less effect on 5-year mortality rates), also substantially reduce 15-year mortality rates. Further improvements in long-term survival could well be available from newer drugs, or better use of older drugs.
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