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Pesavento CM, Kazemi RJ, Kappelman A, Thompson JL, Jobin C, Wang T, Dossett LA. Pilot testing a patient decision aid as a strategy to reduce overtreatment for older women with early-stage breast cancer. Am J Surg 2024; 235:115774. [PMID: 38834420 DOI: 10.1016/j.amjsurg.2024.115774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/23/2024] [Accepted: 05/22/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Despite national guidelines recommending omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy (RT) in older women with early-stage, hormone receptor-positive (HR+) breast cancer, these practices persist. This pilot study assesses whether a decision aid can target patient-level determinants of low-value treatments. METHODS We adapted and pilot-tested a decision aid in women ≥70 years old with early-stage HR + breast cancer. Primary outcomes included acceptability and appropriateness of the decision aid. Secondary outcomes included treatment choice and satisfaction with decision. RESULTS Twenty-three patients enrolled in the trial. 19 completed survey one; 16 completed survey two. Primary outcomes demonstrated that 84% of patients agreed or strongly agreed the aid was acceptable and appropriate. Secondary outcomes demonstrated that 19% of patients underwent SLNB (below pre-intervention baseline), and 85% received adjuvant RT (change not statistically significant). CONCLUSIONS We demonstrate that a decision aid may effectively target patient-level factors contributing to overuse of low-value therapies.
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Affiliation(s)
- Cecilia M Pesavento
- University of Michigan Medical School, Ann Arbor, MI, USA; Vanderbilt University Medical Center, Department of Surgery, Nashville, TN, USA.
| | - Ruby J Kazemi
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Abigail Kappelman
- University of Michigan Medical School, Ann Arbor, MI, USA; University of Michigan, Department of Epidemiology, Ann Arbor, MI, USA
| | - Jessica L Thompson
- Corewell Health West, Department of Cancer Health, Grand Rapids, MI, USA
| | | | - Ton Wang
- Duke University School of Medicine, Department of Surgery, Durham, NC, USA
| | - Lesly A Dossett
- University of Michigan, Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA; University of Michigan, Department of Surgery, Ann Arbor, MI, USA
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2
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McEvoy MP, Feldman S. Prevention and Treatment of Lymphedema in Breast Cancer. Adv Surg 2024; 58:65-77. [PMID: 39089787 DOI: 10.1016/j.yasu.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Breast cancer related lymphedema (BCRL) affects many breast cancer survivors and drastically affects their quality of life. There are several surveillance methods for BCRL that are critical at early detection. Prevention of BCRL involves knowledge of alternatives to aggressive axillary surgery, avoidance of axillary surgery, and de-escalation of axillary surgery. There are also techniques to better delineate the anatomy in the axilla to avoid taking nodes that drain the upper extremity. A multidisciplinary approach with medical oncology and radiation oncology can also help avoid unnecessary surgery or radiation that can together strongly increase the risk of BCRL.
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Affiliation(s)
- Maureen P McEvoy
- Department of Surgery, Division of Breast Surgery, Montefiore Medical Center, Montefiore Breast Care Center, 1250 Waters Place, Tower 1, 7th Floor, Bronx, NY 10461, USA.
| | - Sheldon Feldman
- Department of Surgery, Division of Breast Surgery, Montefiore Medical Center, Montefiore Breast Care Center, 1250 Waters Place, Tower 1, 7th Floor, Bronx, NY 10461, USA
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3
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Speers C, Anderson B. Can Less Be More? Evolving Strategies for Therapy De-escalation in Early-Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2024; 119:1327-1330. [PMID: 39038902 DOI: 10.1016/j.ijrobp.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/13/2024] [Indexed: 07/24/2024]
Affiliation(s)
- Corey Speers
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, OH.
| | - Bethany Anderson
- Department of Radiation Oncology, University of Wisconsin Carbone Cancer Center, Madison, WI.
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4
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Gaffney KA, Karamchandani MM, De La Cruz Ku G, Wareham C, Homsy C, Nardello S, Chatterjee A, Persing SM. Oncoplastic Surgery Outcomes in the Older Breast Cancer Population: A Matched-Cohort Comparison Study. Ann Plast Surg 2024; 93:183-188. [PMID: 38980943 DOI: 10.1097/sap.0000000000004018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
BACKGROUND Oncoplastic breast surgery (OBS) is a form of breast conservation surgery (BCS) that involves a partial mastectomy followed by immediate volume displacement or volume replacement surgical techniques. To date, there are few studies evaluating OBS in older patients. Therefore, we sought to determine if outcomes differed between patients 65 years and older versus younger patients who underwent oncoplastic surgical procedures. METHODS A retrospective chart review was performed for all oncoplastic breast operations within a single health system from 2015 to 2021. Patients were stratified by age, with patients 65 years and older (OBS65+) identified and then matched with younger patients (OBS <65) based on BMI. Primary outcomes were positive margin rates and overall complication rates; secondary outcomes were locoregional recurrence (LR), distant recurrence (DR), disease-free survival (DFS), overall survival (OS), and long-term breast asymmetry. RESULTS A total of 217 patients underwent OBS over the 6-year period, with 22% being OBS65+. Preoperatively, older patients experienced higher American Anesthesia (ASA) scores, Charlson Co-morbidity index (CCI) scores, and higher rates of diabetes mellitus, hypertension, and grade 3 breast ptosis. Despite this, no significant differences were found between primary or secondary outcomes compared to younger patients undergoing the same procedures. CONCLUSIONS Oncoplastic breast reconstruction is a safe option in patients 65 years and older, with overall similar recurrence rates, positive margin rates, and survival when compared to younger patients. Although the older cohort of patients had greater preoperative risk, there was no difference in overall surgical complication rates or outcomes. Supporting the argument that all oncoplastic breast reconstruction techniques should be offered to eligible patients, irrespective of age.
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Affiliation(s)
- Kerry A Gaffney
- From the Department of Surgery, Tufts Medical Center, Boston
| | | | | | - Carly Wareham
- From the Department of Surgery, Tufts Medical Center, Boston
| | | | - Salvatore Nardello
- Division of Surgical Oncology and Breast Surgery, Department of Surgery, Tufts Medical Center, Boston, MA
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5
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Wu VS, Khlopin M, Chadha M, Smith-Graziani DJ, Jagsi R, McClelland S. Out-of-Pocket Cost Modeling of Adjuvant Antiestrogen and Radiation Therapy After Lumpectomy for Early-Stage Breast Cancer Across Medicaid and Medicare Plans. Int J Radiat Oncol Biol Phys 2024; 119:1379-1385. [PMID: 38432284 DOI: 10.1016/j.ijrobp.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/11/2024] [Accepted: 02/18/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The optimal adjuvant therapy (antiestrogen therapy [ET] + radiation therapy or ET alone, or in some reports radiation therapy alone) in older women with early-stage breast cancer has been highly debated. However, granular details on the role of insurance in the out-of-pocket cost for patients receiving ET with or without radiation therapy are lacking. This project disaggregates out-of-pocket costs by insurance plans to increase treatment cost transparency. METHODS AND MATERIALS Several radiation therapy schedules are accepted standards as per the National Comprehensive Cancer Network guidelines. For our financial estimate model, we used the 5-fraction and 15-fraction radiation therapy and ET prescribed over a 5-year duration. The total aggregate out-of-pocket costs were determined from the sum of treatment costs, deductibles, and copays/coinsurance based on Medicaid, Original Medicare, Medigap Plan G, and Medicare Part D Rx plans. The model assumes a Medicare- and/or Medicaid-eligible patient ≥70 years of age with node-negative, early-stage estrogen-receptor-positive breast cancer. Patient out-of-pocket costs were estimated from publicly available insurance data from plan-specific benefit coverage materials using a 5-year time horizon. RESULTS Original Medicare beneficiaries face a total out-of-pocket treatment charge of $2738.52 for ET alone, $2221.26 for 5-fraction radiation therapy alone, $2573.92 for 15-fraction radiation therapy alone, $3361.26 for combined ET+ 5-fraction radiation therapy, and $3713.92 for combined ET + 15-fraction radiation therapy. Medigap Plan G beneficiaries have an out-of-pocket charge of $1130.00 with radiation therapy alone and face an out-of-pocket of $2270.00 for ET alone and combined ET+ radiation therapy. For Medicaid beneficiaries, all treatments approved by Medicaid are covered without limit, resulting in no out-of-pocket expense for either adjuvant treatment option. CONCLUSIONS This model (based on actual cost estimates per insurance plan rather than claims data), by estimating expenses within Medicare and Medicaid plans, provides a level of transparency to patient cost. With knowledge of the costs borne by patients themselves, treatment decisions informed by patients' individual priorities and preferences may be further enhanced.
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Affiliation(s)
- Victoria S Wu
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Martha Khlopin
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Manjeet Chadha
- Department of Radiation Oncology, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Demetria J Smith-Graziani
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Reshma Jagsi
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Shearwood McClelland
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio; Department of Neurological Surgery, University Hospitals Cleveland Medical Center Case Western Reserve University, Cleveland, Ohio.
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Chen YA, Lai HW, Su HC, Loh EW, Huang TW, Tam KW. Efficacy and safety of adjuvant therapies in older patients with breast cancer: a systematic review and meta-analysis of real-world data. Breast Cancer 2024:10.1007/s12282-024-01622-1. [PMID: 39085679 DOI: 10.1007/s12282-024-01622-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 07/29/2024] [Indexed: 08/02/2024]
Abstract
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.
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Affiliation(s)
- Yu-An Chen
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsuan-Wen Lai
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hui-Chen Su
- Department of Pharmacy, Chi Mei Medical Center, Tainan City, Taiwan
| | - El-Wui Loh
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Medical Imaging, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Tsai-Wei Huang
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Ka-Wai Tam
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
- Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan.
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7
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Dalton JC, Crowell KA, Ntowe KW, van den Bruele AB, DiNome ML, Rosenberger LH, Thomas SM, Wang T, Hwang ES, Plichta JK. Utility of Axillary Staging in Older Patients with HER2-Positive Breast Cancer. Ann Surg Oncol 2024:10.1245/s10434-024-15812-w. [PMID: 39014162 DOI: 10.1245/s10434-024-15812-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 07/01/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND The utility of sentinel lymph node biopsy (SLNB) in older patients remains controversial. Advancements in human epidermal growth factor receptor 2 (HER2)-directed therapy have revolutionized disease response rates and prognosis, supporting efforts to re-evaluate the utility of SLNB. We aimed to assess the differences in treatment and overall survival (OS) in older patients with HER2-positive breast cancer based on SLNB. METHODS Using the National Cancer Database (2010-2020), patients ≥ 70 years of age diagnosed with cT1-2/cN0/M0, HER2-positive breast cancer were identified. Logistic regression assessed associations with SLNB, systemic therapy, and radiation. Cox proportional hazard models were used to identify factors associated with OS. Analyses were stratified by treatment sequence, i.e. upfront surgery or neoadjuvant therapy (NAT) followed by surgery. RESULTS Of the 17,609 patients included, 94% underwent upfront surgery (n = 16,492) and the remaining underwent NAT (n = 1117). Those who underwent SLNB were more likely to receive adjuvant therapy, irrespective of nodal status {upfront surgery/systemic therapy (odds ratio [OR] 2.82, 95% confidence interval [CI] 2.17-3.67); upfront surgery/radiation (OR 3.97, 95% CI 3.03-5.21); NAT/radiation (OR 5.69, 95% CI 1.83-17.69)}. The breast pathologic complete response (pCR) rate was highest among the hormone receptor (HR)-negative/HER2-positive subtype (50.0%), of which none were found to be ypN+. Comorbidity burden was associated with significantly lower rates of adjuvant systemic therapy and worse OS. CONCLUSIONS Patients who underwent SLNB, regardless of pN status, were more likely to receive adjuvant therapy. Nodal positivity is exceedingly rare for patients with a breast pCR following NAT, especially among the HR-negative/HER2-positive subtype. It is reasonable to consider omission of SLNB in select subgroups of older patients with HER2-positive breast cancer.
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Affiliation(s)
- Juliet C Dalton
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Koumani W Ntowe
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Astrid Botty van den Bruele
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Maggie L DiNome
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Laura H Rosenberger
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Samantha M Thomas
- Duke Cancer Institute, Duke University, Durham, NC, USA
- Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Ton Wang
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University, Durham, NC, USA
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Jennifer K Plichta
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
- Duke Cancer Institute, Duke University, Durham, NC, USA.
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA.
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8
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Oueidat K, Baird GL, Barclay-White B, Kozlowski K, Plaza MJ, Aoun H, Tomkovich K, Littrup PJ, Pigg N, Ward RC. Cryoablation of Primary Breast Cancer in Patients Ineligible for Clinical Trials: A Multiinstitutional Study. AJR Am J Roentgenol 2024. [PMID: 38984781 DOI: 10.2214/ajr.24.31392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
Background: Breast cancer cryoablation clinical trials have strict inclusion criteria that exclude patients with potentially treatable disease. Objective: This study's purpose was to evaluate the safety and outcomes of breast cancer cryoablation without surgical excision in patients ineligible for prospective cryoablation clinical trials due to unfavorable patient or tumor characteristics. Methods: This retrospective study included women who underwent cryoablation of biopsy-proven unifocal primary breast cancer with locally curative intent, without surgical excision, despite being ineligible for (and thus excluded from) cryoablation clinical trials, across seven institutions between January 1, 2000 and August 26, 2021. Adverse events (AEs) were recorded. Cryoablation procedures were classified as technically successful if they were not prematurely terminated and achieved intended treatment parameters and the first imaging follow-up showed no evidence of residual disease. Results of follow-up biopsies were recorded. Ipsilateral breast tumor recurrences (IBTR) diagnosed during follow-up were identified and classified as true recurrence or new primary disease. A competing-risk model was used to estimate the cumulative incidence of IBTR accounting for death before IBTR. Results: The final study sample included 112 patients (median age, 71 years). A total of 7/112 (6.3%) patients had a minor AE; no moderate or major AE occurred. A total of 110/112 (98.2%) cryoablation procedures were technically successful. During median follow-up of 2.0 years, 22/110 (20.0%) patients underwent biopsy for suspicious imaging findings in the ipsilateral breast, yielding benign concordant findings in 9/22 (40.9%) and IBTR in 12/22 (54.5%). Overall, 12/110 (10.9%) patients experienced IBTR, including 7 with true recurrence and 5 with new primary disease; 3/12 (25.0%) patients with IBTR had received earlier adjuvant or neoadjuvant therapy. When accounting for death as a competing risk, the cumulative incidence of IBTR was 5.3%, 12.2%, and 18.2% at 1, 2, and 3 years, respectively. Conclusion: In select individuals with unfavorable patient or tumor characteristics, breast cancer cryoablation provides a safe alternative to surgery with good outcomes. These findings may be particularly relevant in patients who are also poor surgical candidates. Clinical Impact: Breast cancer cryoablation can be safely applied in a larger patient population than defined by clinical trial inclusion criteria.
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Affiliation(s)
- Karim Oueidat
- Post-doctoral research fellow, Warren Alpert Medical School of Brown University, Providence, RI, 02903
| | - Grayson L Baird
- Statistician, Associate Professor of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Providence, RI, 02903
| | | | - Kamilia Kozlowski
- Breast Imaging Radiologist, Knoxville Comprehensive Breast Center, Knoxville, TN, 37909
| | - Michael J Plaza
- Breast Imaging Radiologist, Radiology Partners Bluegrass, Miami, FL
| | - Hussein Aoun
- Interventional Radiologist, Karmanos Cancer Center, Wayne State University, Detroit, MI, 48201
| | - Kenneth Tomkovich
- Breast Imaging and Interventional Radiologist, Princeton Radiology, Princeton, NJ, 08540
| | - Peter J Littrup
- Breast Imaging and Interventional Radiologist, University of Rochester Medical Center, Rochester, NY, 14642
| | - Nicholas Pigg
- Breast Imaging Fellow, Warren Alpert Medical School of Brown University, Providence, RI, 02903
| | - Robert C Ward
- Breast Imaging Radiologist, Rhode Island Medical Imaging, Associate Professor of Diagnostic Imaging, Program Director, Breast Imaging Fellowship, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, 02903
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9
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Boland MR. Modern management of the axilla. J Surg Oncol 2024; 130:23-28. [PMID: 38643485 DOI: 10.1002/jso.27649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/11/2024] [Indexed: 04/23/2024]
Abstract
Surgical management of the axilla has evolved considerably in recent years, with a strong focus on de-escalation to minimise morbidity whilst maintaining oncological outcomes. Current trials will focus on the omission of Sentinel node biopsy in select groups of patients, while axillary lymph node dissection will be reserved for those with more aggressive disease.
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Affiliation(s)
- Michael R Boland
- Department of Breast Surgery, St Vincent's University Hospital, Dublin, Ireland
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10
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Mutter RW, Chauhan C, Goetz MP, Wright JL. Revisiting Combined Modality Therapy in Older Patients With Luminal Breast Cancer Through the Patient Lens. J Clin Oncol 2024; 42:2121-2125. [PMID: 38564696 DOI: 10.1200/jco.23.02289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/08/2024] [Accepted: 02/20/2024] [Indexed: 04/04/2024] Open
Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | | | - Jean L Wright
- Department of Radiation Oncology, John Hopkins University School of Medicine, Baltimore, MD
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11
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Chen JC, Elsaid MI, Handley D, Anderson L, Andersen BL, Carson WE, Beane JD, Kim A, Skoracki R, Pawlik TM, Obeng-Gyasi S. Allostatic load as a predictor of postoperative complications in patients with breast cancer. NPJ Breast Cancer 2024; 10:44. [PMID: 38866818 PMCID: PMC11169387 DOI: 10.1038/s41523-024-00654-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/01/2024] [Indexed: 06/14/2024] Open
Abstract
Allostatic load (AL) is a biological measure of cumulative exposure to socioenvironmental stressors (e.g., poverty). This study aims to examine the association between allostatic load (AL) and postoperative complications (POC) among patients with breast cancer. Females ages 18+ with stage I-III breast cancer who received surgical management between 01/01/2012-12/31/2020 were identified in the Ohio State Cancer registry. The composite AL measure included biomarkers from the cardiovascular, metabolic, immune, and renal systems. High AL was defined as composite scores greater than the cohort's median (2.0). POC within 30 days of surgery were examined. Univariable and multivariable regression analysis examined the association between AL and POC. Among 4459 patients, 8.2% had POC. A higher percentage of patients with POC were unpartnered (POC 44.7% vs no POC 35.5%), government-insured (POC 48.2% vs no POC 38.3%) and had multiple comorbidities (POC 32% vs no POC 20%). Patients who developed POC were more likely to have undergone sentinel lymph node biopsy followed by axillary lymph node dissection (POC 51.2% vs no POC 44.6%). High AL was associated with 29% higher odds of POC (aOR 1.29, 95% CI 1.01-1.63). A one-point increase in AL was associated with 8% higher odds of POC (aOR 1.08, 95% CI 1.02-1.16) and a quartile increase in AL was associated with 13% increased odds of POC (aOR 1.13, 95% CI 1.01-1.26). Among patients undergoing breast cancer surgery, increased exposure to adverse socioenvironmental stressors, operationalized as AL, was associated with higher odds of postoperative complications.
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Affiliation(s)
- J C Chen
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Mohamed I Elsaid
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
- Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH, USA
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Demond Handley
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA
- Center for Biostatistics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Lisa Anderson
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | | | - William E Carson
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Joal D Beane
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Alex Kim
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Roman Skoracki
- Division of Reconstructive Oncologic Plastic Surgery, Department of Plastic Surgery, The Ohio State University, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA.
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12
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Williams AD, Weiss A. Recent Advances in the Upfront Surgical Management of the Axilla in Patients with Breast Cancer. Clin Breast Cancer 2024; 24:271-277. [PMID: 38220539 DOI: 10.1016/j.clbc.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/16/2024]
Abstract
Nodal status is an important prognostic indicator. Upfront axillary surgery for patients with breast cancer has historically been both diagnostic and therapeutic-serving to determine nodal status and inform adjuvant therapies, and to remove clinically significant disease. However, trials of de-escalation or omission of axillary surgery altogether consistently demonstrate noninferior oncologic outcomes in a wide variety of patient subsets. These strategies also reduce the morbidity associated with either sentinel lymphadenectomy or axillary lymph node dissection. Here we will briefly review landmark trials that have shaped upfront axillary surgery as well as recent advances, and discuss areas of ongoing investigation and future needs.
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Affiliation(s)
- Austin D Williams
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Anna Weiss
- Division of Surgical Oncology, Department of Surgery, University of Rochester Medical Center, Rochester, NY.
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13
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Buchheit JT, Schacht D, Kulkarni SA. Update on Management of Ductal Carcinoma in Situ. Clin Breast Cancer 2024; 24:292-300. [PMID: 38216382 DOI: 10.1016/j.clbc.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/15/2023] [Accepted: 12/22/2023] [Indexed: 01/14/2024]
Abstract
Ductal carcinoma in situ (DCIS) represents 18% to 25% of all diagnosed breast cancers, and is a noninvasive, nonobligate precursor lesion to invasive cancer. The diagnosis of DCIS represents a wide range of disease, including lesions with both low and high risk of progression to invasive cancer and recurrence. Over the past decade, research on the topic of DCIS has focused on the possibility of tailoring treatment for patients according to their risk for progression and recurrence, which is based on clinicopathologic, biomolecular and genetic factors. These efforts are ongoing, with recently completed and continuing clinical trials spanning the continuum of cancer care. We conducted a review to identify recent advances on the topic of diagnosis, risk stratification and management of DCIS. While novel imaging techniques have increased the rate of DCIS diagnosis, questions persist regarding the optimal management of lesions that would not be identified with conventional methods. Additionally, among trials investigating the potential for omission of surgery and use of active surveillance, 2 trials have completed accrual and 2 clinical trials are continuing to enroll patients. Identification of novel genetic patterns is expanding our potential for risk stratification and aiding our ability to de-escalate radiation and systemic therapies for DCIS. These advances provide hope for tailoring of DCIS treatment in the near future.
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Affiliation(s)
- Joanna T Buchheit
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David Schacht
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Swati A Kulkarni
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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14
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Chung AP, Dang CM, Karlan SR, Amersi FF, Phillips EM, Boyle MK, Cui Y, Giuliano AE. A Prospective Study of Sentinel Node Biopsy Omission in Women Age ≥ 65 Years with ER+ Breast Cancer. Ann Surg Oncol 2024; 31:3160-3167. [PMID: 38345718 PMCID: PMC10997698 DOI: 10.1245/s10434-024-15000-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/18/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND National guidelines recommend omitting SNB in older patients with favorable invasive breast cancer. However, there is a lack of prospective data specifically addressing this issue. This study evaluates recurrence and survival in estrogen receptor-positive/Her2- (ER+) breast cancer patients, aged ≥ 65 years who have breast-conserving surgery (BCS) without SNB. METHODS This is a prospective, observational study at a single institution where 125 patients aged ≥ 65 years with clinical T1-2N0 ER+ invasive breast cancer undergoing BCS were enrolled. Patients were treated with BCS without SNB. Primary outcome measure was axillary recurrence. Secondary outcome measures include recurrence-free survival (RFS), disease-free survival (DFS), breast cancer-specific survival (BCSS), and overall survival (OS). RESULTS From January 2016 to July 2022, 125 patients were enrolled with median follow-up of 36.7 months [95% confidence interval (CI) 35.0-38.0]. Median age was 77.0 years (range 65-93). Median tumor size was 1 cm (range 0.1-5.0). Most tumors were ductal (95/124, 77.0%), intermediate grade (60/116, 51.7%), and PR-positive (117/123, 91.7%). Radiation therapy was performed in 37 of 125 (29.6%). Only 60 of 125 (48.0%) who were recommended hormonal therapy were compliant at 2 years. Chemotherapy was administered to six of 125 (4.8%) patients. There were two of 125 (1.6%) axillary recurrences. Estimated 3-years rates of regional RFS, DFS, and OS were 98.2%, 91.2%, and 94.8%, respectively. Univariate Cox regression identified hormonal therapy noncompliance to be significantly associated with recurrence (p = 0.02). CONCLUSIONS Axillary recurrence rates were extremely low in this cohort. These results provide prospective data to support omission of SNB in this patient population TRIAL REGISTRATION: ClinicalTrials.gov ID NCT02564848.
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Affiliation(s)
- Alice P Chung
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Catherine M Dang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Scott R Karlan
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Farin F Amersi
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Edward M Phillips
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marissa K Boyle
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yujie Cui
- Department of Statistics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Armando E Giuliano
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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15
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Vo K, Ladbury C, Yoon S, Bazan J, Glaser S, Amini A. Omission of adjuvant radiotherapy in low-risk elderly males with breast cancer. Breast Cancer 2024; 31:485-495. [PMID: 38507145 PMCID: PMC11045584 DOI: 10.1007/s12282-024-01560-y] [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: 01/08/2024] [Accepted: 02/26/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE Randomized clinical trials demonstrate that lumpectomy + hormone therapy (HT) without radiation therapy (RT) yields equivalent survival and acceptable local-regional outcomes in elderly women with early-stage, node-negative, hormone-receptor positive (HR +) breast cancer. Whether these data apply to men with the same inclusion criteria remains unknown. METHODS The National Cancer Database was queried for male patients ≥ 65 years with pathologic T1-2N0 (≤ 3 cm) HR + breast cancer treated with breast-conserving surgery with negative margins from 2004 to 2019. Adjuvant treatment was classified as HT alone, RT alone, or HT + RT. Male patients were matched with female patients for OS comparison. Survival analysis was performed using Cox regression and Kaplan - Meier method. Inverse probability of treatment weighting (IPTW) was applied to adjust for confounding. RESULTS A total of 523 patients met the inclusion criteria, with 24.4% receiving HT, 16.3% receiving RT, and 59.2% receiving HT + RT. The median follow-up was 6.9 years (IQR: 5.0-9.4 years). IPTW-adjusted 5-yr OS rates in the HT, RT, and HT + RT cohorts were 84.0% (95% CI 77.1-91.5%), 81.1% (95% CI 71.1-92.5%), and 93.0% (95% CI 90.0-96.2%), respectively. On IPTW-adjusted MVA, relative to HT, receipt of HT + RT was associated with improvements in OS (HR: 0.641; p = 0.042). RT alone was not associated with improved OS (HR: 1.264; p = 0.420). CONCLUSION Among men ≥ 65 years old with T1-2N0 HR + breast cancer, RT alone did not confer an OS benefit over HT alone. Combination of RT + HT demonstrated significant improvements in OS. De-escalation of treatment through omission of either RT or HT at this point should be done with caution.
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Affiliation(s)
- Kim Vo
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, 309 E 2 ndSt, Pomona, CA, 91766, USA
| | - Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA.
| | - Stephanie Yoon
- Department of Radiation Oncology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Jose Bazan
- Department of Radiation Oncology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Scott Glaser
- Department of Radiation Oncology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA, 91010, USA
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16
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Li M, Tang J, Pan X, Zhang D. Predicting the Survival Benefit of Radiotherapy in Elderly Breast Cancer Patients: A Population-Based Analysis. J Surg Res 2024; 297:26-40. [PMID: 38428261 DOI: 10.1016/j.jss.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/30/2023] [Accepted: 02/05/2024] [Indexed: 03/03/2024]
Abstract
INTRODUCTION This study aimed to establish two prediction tools predicting cancer-specific survival (CSS) and overall survival (OS) in elderly breast cancer patients with or without radiotherapy. METHODS Clinicopathological data of breast cancer patients aged more than 70 y from 2010 to 2018 were retrospectively collected from the Surveillance, Epidemiology, and End Results database. Patients were randomly divided into the training and validation cohorts at 7:3, and the Cox proportional risk model was used to construct the nomograms. The concordance index, the area under the receiver operating characteristic curve, and the calibration plot are used to evaluate the discrimination and accuracy of the nomograms. RESULTS One lakh twenty eight thousand two hundred twenty three elderly breast cancer patients were enrolled, including 57,915 who received radiotherapy. The Cox regression model was used to identify independent factors. These independent influencing factors are used to construct the prediction models. The calibration plots reflect the excellent consistency between the predicted and actual survival rates. The concordance index of nomograms for CSS and OS was more than 0.7 in both the radiotherapy group and the nonradiotherapy group, and similar results are also shown in area under the receiver operating characteristic curve. Decision curve analysis showed that the prognostication accuracy of the model was much higher than that of the traditional tumor, node, metastasis staging. CONCLUSIONS Radiotherapy can benefit elderly breast cancer patients significantly. The two prediction tools provide a personalized survival scale for evaluating the CSS and OS of elderly breast cancer patients, which can better provide clinicians with better-individualized management for these patients.
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Affiliation(s)
- Maoxian Li
- Department of Pediatric Surgery, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China.
| | - Jie Tang
- Department of Biostatistics and Epidemiology, Public Health School, Shenyang Medical College, Shenyang, China
| | - Xiudan Pan
- Department of Biostatistics and Epidemiology, Public Health School, Shenyang Medical College, Shenyang, China
| | - Dianlong Zhang
- Women and Children's Hospital, Qingdao University, Qingdao, China.
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17
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Booth S, Freeman JQ, Li JL, Huo D. Increase in Hypofractionated Radiation Therapy Among Patients with Invasive Breast Cancer or Ductal Carcinoma In Situ: Who is Left Behind? Pract Radiat Oncol 2024:S1879-8500(24)00091-2. [PMID: 38685449 DOI: 10.1016/j.prro.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE We aimed to update the trend of hypofractionated whole-breast irradiation (HF-WBI) use over time in the US and examine factors associated with lack of HF-WBI adoption for patients with early-stage invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS) undergoing a lumpectomy. METHODS AND MATERIALS Among patients who underwent a lumpectomy, we identified 928,034 patients with early-stage IBC and 330,964 patients with DCIS in the 2004 to 2020 National Cancer Database. We defined HF-WBI as 2.5-3.33 Gy/fraction to the breast and conventionally fractionated WBI as 1.8-2.0 Gy/fraction. We evaluated the trend of HF-WBI utilization using a generalized linear model with the log link and binomial distribution. Factors associated with HF-WBI utilization were assessed using multivariable logistic regression in patients diagnosed between 2018 and 2020. RESULTS Among patients with IBC, HF-WBI use has significantly increased from 0.7% in 2004 to 63.9% in 2020. Similarly, HF-WBI usage among patients with DCIS has also increased significantly from 0.4% in 2004 to 56.6% in 2020. Black patients with IBC were less likely than White patients to receive HF-WBI (adjusted odds ratio [AOR] 0.81; 95% CI, 0.77-0.85). Community cancer programs were less likely to administer HF-WBI to patients with IBC (AOR, 0.80; 95% CI, 0.77-0.84) and to those with DCIS (AOR, 0.87; 95% CI, 0.79-0.96) than academic/research programs. Younger age, positive nodes, larger tumor size, low volume programs, and facility location were also associated with lack of HF-WBI adoption in both patient cohorts. CONCLUSIONS HF-WBI utilization among postlumpectomy patients has significantly increased from 2004 to 2020 and can finally be considered standard of care in the US. We found substantial disparities in adoption within patient and facility subgroups. Reducing disparities in HF-WBI adoption has the potential to further alleviate health care costs while improving patients' quality of life.
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Affiliation(s)
- Sara Booth
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Jincong Q Freeman
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois; Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
| | - James L Li
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois; Pritzker School of Medicine, University of Chicago, Illinois
| | - Dezheng Huo
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois; Center for Clinical Cancer Genetics and Global Health, University of Chicago, Chicago, Illinois.
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18
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Kuwatsuru Y, Saito AI, Usui K. Radiation Oncologists' Views on Adjuvant Radiotherapy for Early-Stage Breast Cancer in the Elderly: Comparisons between Japan and the United States. Cancer Invest 2024; 42:309-318. [PMID: 38666473 DOI: 10.1080/07357907.2024.2343860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/12/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE To understand perspective on breast cancer using a survey. MATERIALS & METHODS Questionnaire was distributed to 304 Japanese radiation oncologists (RadOncs) (response rate: 64.1%). Result was compared with a similar US survey. RESULTS In a scenario with an 81-year-old patient with comorbidities, while most US RadOncs chose to tell that radiation might not be necessary, 2% of Japanese chose it. In a scenario with a healthy 65-year-old breast cancer patient with lumpectomy, while most US RadOncs chose to discuss omission of radiation, 24.5% of Japanese chose it. CONCLUSIONS Differences were observed on radiotherapy for older early-stage breast cancer.
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Affiliation(s)
- Yoshiki Kuwatsuru
- Department of Radiology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Anneyuko I Saito
- Department of Radiation Oncology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Keisuke Usui
- Department of Radiation Oncology, Juntendo University Faculty of Medicine, Tokyo, Japan
- Department of Radiological Technology, Juntendo University Faculty of Health Science
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19
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Kazemi RJ, VanWinkle C, Pesavento CM, Wang T, Dossett LA. Understanding Treatment Decision-Making in Older Women With Breast Cancer: A Survey-Based Study. J Surg Res 2024; 296:418-424. [PMID: 38320360 DOI: 10.1016/j.jss.2023.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/21/2023] [Accepted: 12/23/2023] [Indexed: 02/08/2024]
Abstract
INTRODUCTION For women ≥70 y old with early-stage hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer, the national guidelines recommend the omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy. However, national-level data suggest these treatments remain common. We utilized a survey-based approach to explore patient-level factors driving overutilization. METHODS We recruited women ≥70 y old with early-stage hormone receptor-positive/human epidermal growth factor receptor 2-negative breast cancer within 6 mo of surgery. An exploratory cross-sectional survey captured information on offered and pursued treatments, the importance of patient-centered outcomes, and the influence of each outcome on treatment decision-making. Descriptive statistics were used for analysis. RESULTS 31/51 patients completed the survey with a response rate of 61%. Most patients (86%) received a lumpectomy. Twenty-eight percent of patients received SLNB, and 56% of lumpectomy patients underwent adjuvant radiotherapy. When considering treatment options, the patient-centered outcomes, most important for decision-making, were overall survival, breast-specific survival, and preventing local recurrence, while breast appearance, financial costs, and avoiding the need for pills (endocrine therapy) were the least important. CONCLUSIONS Patients' treatment decisions align with their values. The correlation between patient-stated values and treatment decisions suggests a perceived mortality benefit of low-value SLNB and radiotherapy. These findings can inform targeted efforts to deimplement low-value care in breast cancer through patient-focused tools and education.
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Affiliation(s)
- Ruby J Kazemi
- University of Michigan Medical School, Ann Arbor, Michigan.
| | | | - Cecilia M Pesavento
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ton Wang
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Lesly A Dossett
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
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20
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DeLeire T, Mitchell JM, De La Cruz L, Isaacs C. Nonclinical factors associated with the treatment of older women with newly diagnosed low-grade ductal carcinoma in situ. Cancer 2024; 130:1041-1051. [PMID: 37987170 PMCID: PMC10939947 DOI: 10.1002/cncr.35124] [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: 05/17/2023] [Revised: 09/30/2023] [Accepted: 10/27/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Ductal carcinoma in situ (DCIS) is the most common form of noninvasive breast cancer and is associated with an excellent prognosis. As a result, there is concern about overdiagnosis and overtreatment of DCIS because most patients with DCIS are treated as though they have invasive breast cancer and undergo either breast-conserving surgery (BCS)-most commonly followed by radiation therapy (RT)-or mastectomy. Little research to date has focused on nonclinical factors influencing treatments for DCIS. METHODS Population-based data were analyzed from five state cancer registries (California, Florida, New Jersey, New York, and Texas) on women aged 65 years and older newly diagnosed with DCIS during the years 2003 to 2014 using a retrospective cohort design and multinominal logistic modeling. The registry records with Medicare enrollment data and fee-for-service claims to obtain treatments (BCS alone, BCS with RT, or mastectomy) were merged. Surgeon practice structure was identified through physician surveys and internet searches. RESULTS Patients of surgeons employed by cancer centers or health systems were less likely to receive BCS with RT or mastectomy than patients of surgeons in single specialty or multispecialty practices. There also was substantial geographic variation in treatments, with patients in New York, New Jersey, and California being less likely to receive BCS with RT or mastectomy than patients in Texas or Florida. CONCLUSIONS These findings suggest nonclinical factors including the culture of the practice and/or financial incentives are significantly associated with the types of treatment received for DCIS. Increasing awareness and targeted efforts to educate physicians about DCIS management among older women with low-grade DCIS could reduce patient harm and yield substantial cost savings.
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Affiliation(s)
- Thomas DeLeire
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
| | - Jean M. Mitchell
- McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, USA
| | - Lucy De La Cruz
- School of Medicine, Georgetown University, Washington, District of Columbia, USA
| | - Claudine Isaacs
- School of Medicine, Georgetown University, Washington, District of Columbia, USA
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Castresana-Aguirre M, Johansson A, Matikas A, Foukakis T, Lindström LS, Tobin NP. Clinically relevant gene signatures provide independent prognostic information in older breast cancer patients. Breast Cancer Res 2024; 26:38. [PMID: 38454481 PMCID: PMC10921680 DOI: 10.1186/s13058-024-01797-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 02/27/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND The clinical utility of gene signatures in older breast cancer patients remains unclear. We aimed to determine signature prognostic capacity in this patient subgroup. METHODS Research versions of the genomic grade index (GGI), 70-gene, recurrence score (RS), cell cycle score (CCS), PAM50 risk-of-recurrence proliferation (ROR-P), and PAM50 signatures were applied to 39 breast cancer datasets (N = 9583). After filtering on age ≥ 70 years, and the presence of estrogen receptor (ER) and survival data, 871 patients remained. Signature prognostic capacity was tested in all (n = 871), ER-positive/lymph node-positive (ER + /LN + , n = 335) and ER-positive/lymph node-negative (ER + /LN-, n = 374) patients using Kaplan-Meier and multivariable Cox-proportional hazard (PH) modelling. RESULTS All signatures were statistically significant in Kaplan-Meier analysis of all patients (Log-rank P < 0.001). This significance remained in multivariable analysis (Cox-PH, P ≤ 0.05). In ER + /LN + patients all signatures except PAM50 were significant in Kaplan-Meier analysis (Log-rank P ≤ 0.05) and remained so in multivariable analysis (Cox-PH, P ≤ 0.05). In ER + /LN- patients all except RS were significant in Kaplan-Meier analysis (Log-rank P ≤ 0.05) but only the 70-gene, CCS, ROR-P, and PAM50 signatures remained so in multivariable analysis (Cox-PH, P ≤ 0.05). CONCLUSIONS We found that gene signatures provide prognostic information in survival analyses of all, ER + /LN + and ER + /LN- older (≥ 70 years) breast cancer patients, suggesting a potential role in aiding treatment decisions in older patients.
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Affiliation(s)
- Miguel Castresana-Aguirre
- Department of Oncology and Pathology, BioClinicum, Karolinska Institutet and University Hospital, Visionsgatan 4, 171 64, Stockholm, Sweden
- Breast Center, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Annelie Johansson
- Department of Oncology and Pathology, BioClinicum, Karolinska Institutet and University Hospital, Visionsgatan 4, 171 64, Stockholm, Sweden
- Breast Cancer Now Research Unit, School of Cancer and Pharmaceutical Sciences, Guy's Cancer Center, King's College London, London, UK
| | - Alexios Matikas
- Department of Oncology and Pathology, BioClinicum, Karolinska Institutet and University Hospital, Visionsgatan 4, 171 64, Stockholm, Sweden
- Breast Center, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Theodoros Foukakis
- Department of Oncology and Pathology, BioClinicum, Karolinska Institutet and University Hospital, Visionsgatan 4, 171 64, Stockholm, Sweden
- Breast Center, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Linda S Lindström
- Department of Oncology and Pathology, BioClinicum, Karolinska Institutet and University Hospital, Visionsgatan 4, 171 64, Stockholm, Sweden
- Breast Center, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Nicholas P Tobin
- Department of Oncology and Pathology, BioClinicum, Karolinska Institutet and University Hospital, Visionsgatan 4, 171 64, Stockholm, Sweden.
- Breast Center, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden.
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Obeng-Gyasi S, Chen JC, Elsaid M, Handley D, Anderson L, Andersen B, Carson W, Beane J, Kim A, Skoracki R, Pawlik T. Allostatic Load as a Predictor of Postoperative Complications in Patients with Breast Cancer. RESEARCH SQUARE 2024:rs.3.rs-3873505. [PMID: 38405905 PMCID: PMC10889069 DOI: 10.21203/rs.3.rs-3873505/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND Allostatic load (AL) is a biological measure of cumulative exposure to socioenvironmental stressors (e.g., poverty). This study aims to examine the association between allostatic load (AL) and postoperative complications (POC) among patients with breast cancer. METHODS Assigned females at birth ages 18 + with stage I-III breast cancer who received surgical management between 01/01/2012-12/31/2020 were identified in the Ohio State Cancer registry. The composite AL measure included biomarkers from the cardiovascular, metabolic, immune, and renal systems. High AL was defined as composite scores greater than the cohort's median (2.0). POC within 30 days of surgery were examined. Univariable and multivariable regression analysis examined the association between AL and POC. RESULTS Among 4,459 patients, 8.2% had POC. A higher percentage of patients with POC were unpartnered (POC 44.7% vs no POC 35.5%), government-insured (POC 48.2% vs no POC 38.3%) and had multiple comorbidities (POC 32% vs no POC 20%). Patients who developed POC were more likely to have undergone sentinel lymph node biopsy followed by axillary lymph node dissection (POC 51.2% vs no POC 44.6%). High AL was associated with 29% higher odds of POC (aOR 1.29, 95% CI 1.01-1.63). A one-point increase in AL was associated with 8% higher odds of POC (aOR 1.08, 95% CI 1.02-1.16) and a quartile increase in AL was associated with 13% increased odds of POC (aOR 1.13, 95% CI 1.01-1.26). CONCLUSION Among patients undergoing breast cancer surgery, increased exposure to adverse socioenvironmental stressors, operationalized as AL, was associated with higher odds of postoperative complications.
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23
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Chua BH. Omission of radiation therapy post breast conserving surgery. Breast 2024; 73:103670. [PMID: 38211516 PMCID: PMC10788792 DOI: 10.1016/j.breast.2024.103670] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/24/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024] Open
Abstract
Radiation therapy (RT) after breast conserving surgery decreases the risks of local recurrence and breast cancer mortality in the multidisciplinary management of patients with breast cancer. However, breast cancer is a heterogeneous disease, and the absolute benefit of post-operative RT in individual patients varies substantially. Clinical trials aiming to identify patients with low-risk early breast cancer in whom post-operative RT may be safely omitted, based on conventional clinical-pathologic variables alone, have not provided sufficiently tailored information on local recurrence risk assessment to guide treatment decisions. The majority of patients with early breast cancer continue to be routinely treated with RT after breast conserving surgery. This approach may represent over-treatment for a substantial proportion of the patients. The clinical impact of genomic signatures on local therapy decisions for early breast cancer has been remarkably modest due to the lack of high-level evidence supporting their clinical validity for assessment of the risk of local recurrence. Efforts to personalise breast cancer care must be supported by high level evidence to enable balanced, informed treatment decisions. These considerations underpin the importance of ongoing biomarker-directed clinical trials to generate the high-level evidence necessary for setting the future standard of care in personalised local therapy for patients with early breast cancer.
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Affiliation(s)
- Boon H Chua
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia; Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, NSW, Australia.
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Takayesu JSK, Jiang SJ, Marsh R, Moncion A, Smith SR, Pierce LJ, Jagsi R, Lipps DB. Pectoralis Muscle Dosimetry and Posttreatment Rehabilitation Utilization for Patients With Early-Stage Breast Cancer. Pract Radiat Oncol 2024; 14:e20-e28. [PMID: 37768242 DOI: 10.1016/j.prro.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/13/2023] [Accepted: 07/11/2023] [Indexed: 09/29/2023]
Abstract
PURPOSE Up to 50% of women treated for localized breast cancer will experience some degree of arm or shoulder morbidity. Although radiation is thought to contribute to this morbidity, the mechanism remains unclear. Prior studies have shown biologic and radiographic changes in the pectoralis muscles after radiation. This study thus aimed to investigate the relationship between radiation to the pectoralis muscles and referrals for rehabilitation services posttreatment for arm and shoulder morbidity. METHODS AND MATERIALS A retrospective 1:1 matched case-control study was conducted for patients with breast cancer who were and were not referred for breast or shoulder rehabilitation services between 2014 and 2019 at a single academic institution. Patients were included if they had a lumpectomy and adjuvant radiation. Patients who underwent an axillary lymph node dissection were excluded. Cohorts were matched based on age, axillary surgery, and use of radiation boost. Muscle doses were converted to equivalent dose in 2 Gy fractions assuming an α:β ratio of 2.5 and were compared between the 2 groups. RESULTS In our cohort of 50 patients of a median age 60 years (interquartile range, 53-68 years), 36 patients (72%) underwent a sentinel lymph node biopsy in addition to a lumpectomy. Although pectoralis muscle doses were generally higher in those receiving rehabilitation services, this was not statistically significant. Pectoralis major V20-40 Gy reached borderline significance, as did pectoralis major mean dose (17.69 vs 20.89 Gy; P = .06). CONCLUSIONS In this limited cohort of patients, we could not definitively conclude a relationship between pectoralis muscle doses and use of rehabilitation services. Given the borderline significant findings, this should be further investigated in a larger cohort.
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Affiliation(s)
- Jamie S K Takayesu
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Shannon J Jiang
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Robin Marsh
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Alexander Moncion
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Sean R Smith
- Department of Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, Michigan
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - David B Lipps
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan
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Saraf A, Tahir I, Hu B, Dietrich ASW, Tonnesen PE, Sharp GC, Tillman G, Roeland EJ, Nipp RD, Comander A, Peppercorn J, Fintelmann FJ, Jimenez RB. Association of Sarcopenia With Toxicity-Related Discontinuation of Adjuvant Endocrine Therapy in Women With Early-Stage Hormone Receptor-Positive Breast Cancer. Int J Radiat Oncol Biol Phys 2024; 118:94-103. [PMID: 37506979 DOI: 10.1016/j.ijrobp.2023.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/27/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023]
Abstract
PURPOSE Sarcopenia, an age-related decline in muscle mass and physical function, is associated with increased toxicity and worse outcomes in women with breast cancer (BC). Sarcopenia may contribute to toxicity-related early discontinuation of adjuvant endocrine therapy (aET) in women with hormone receptor-positive (HR+) BC but remains poorly characterized. METHODS AND MATERIALS This multicenter, retrospective cohort study included consecutive women with stage 0-II HR+ BC who received breast conserving therapy (lumpectomy and radiation therapy) and aET from 2011 to 2017 with a 5-year follow-up. Skeletal muscle index (SMI, cm2/m2) was analyzed using a deep learning model on routine cross-sectional radiation simulation imaging; sarcopenia was dichotomized according to previously validated reports. The primary endpoint was toxicity-related aET discontinuation; logistic regression analysis evaluated associations between SMI/sarcopenia and aET discontinuation. Cox regression analysis evaluated associations with time to aET toxicity, ipsilateral breast tumor recurrence (IBTR), and disease-free survival (DFS). RESULTS A total of 305 women (median follow-up, 89 months) were included with a median age of 67 years and early-stage BC (12% stage 0, 65% stage I). A total of 60 (20%) women experienced toxicity-related aET discontinuation. Sarcopenia was associated with toxicity-related early discontinuation of aET (odds ratio, 2.18; P = .036) and shorter time to aET toxicity (hazard ratio [HR], 1.62; P = .031). SMI or sarcopenia were not independently associated with IBTR or DFS; toxicity-related aET discontinuation was associated with worse IBTR (HR, 9.47; P = .002) and worse DFS (HR, 4.53; P = .001). CONCLUSIONS Among women with early-stage HR+ BC who receive adjuvant radiation therapy and hormone therapy, sarcopenia is associated with toxicity-related early discontinuation of aET. Further studies should validate these findings in women who did not receive adjuvant radiation therapy. These high-risk patients may be candidates for aggressive symptom management and/or alternative treatment strategies to improve outcomes.
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Affiliation(s)
- Anurag Saraf
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Ismail Tahir
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Bonnie Hu
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - P Erik Tonnesen
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Gregory C Sharp
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Gayle Tillman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Eric J Roeland
- Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Ryan D Nipp
- Department of Medical Oncology, University of Oklahoma Stephenson Cancer Center, Oklahoma City, Oklahoma
| | - Amy Comander
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffery Peppercorn
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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Wang T, Weed C, Tseng J, Chung A, Boyle MK, Amersi F, Jutla J, Mirhadi A, Giuliano AE. De-Implementation of Low-Value Care for Women 70 Years of Age or Older with Low-Risk Breast Cancer During the COVID-19 Pandemic. Ann Surg Oncol 2023; 30:8308-8319. [PMID: 37624516 PMCID: PMC10625932 DOI: 10.1245/s10434-023-14156-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Older women with early-stage estrogen receptor-positive (ER+) invasive breast cancer (IBC) are at risk for overtreatment. Guidelines allow for sentinel lymph node biopsy (SLNB) and radiotherapy omission after breast-conserving surgery (BCS) for women 70 years of age or older with T1, clinical node negativity (cN0), and ER+ IBC. The study objective was to evaluate radiotherapy and SLNB de-implementation in older women with low-risk IBC after the resource limitations of the COVID-19 pandemic. METHODS An institutional database was analyzed to identify women 70 years of age or older who received BCS for IBC from 2012 to 2022. The patients were divided into two cohorts: (1) patients with low-risk IBC (pT1, cN0, and ER+/HER2-) who were eligible for radiotherapy and SLNB omission and (2) patients with high-risk IBC (pT2-T4, cN+, ER-, or HER2+) who were ineligible for therapy omission. Clinicopathologic variables in both cohorts were analyzed. RESULTS The study enrolled 881 patients. For the patients with low-risk IBC, the annual rates of radiotherapy were stable from 2012 to 2019. However, radiotherapy utilization decreased significantly from 2020 to 2022 (58% in 2012 vs 36% in 2022; p = 0.04). In contrast, radiotherapy usage among the patients with high-risk IBC was stable from 2012 to 2022 (79% in 2012 vs 79% in 2022; p = 0.95). Among the patients with low-risk IBC, SLNB rates decreased from 86% in 2012 to 56% in 2022, but this trend predated those in 2020. The factors significantly associated with SLNB and receipt of radiotherapy among the patients with low-risk IBC were younger age, larger tumors, grade 3 disease, and involved nodal status (p < 0.01). CONCLUSION This study demonstrated appropriate and sustained de-escalation of radiotherapy in older women with low-risk IBC after the COVID-19 pandemic.
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Affiliation(s)
- Ton Wang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christina Weed
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joshua Tseng
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alice Chung
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marissa K Boyle
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Farin Amersi
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jaswinder Jutla
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Amin Mirhadi
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Armando E Giuliano
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Khan SY, Cole J, Habrawi Z, Melkus MW, Layeequr Rahman R. Cryoablation Allows the Ultimate De-escalation of Surgical Therapy for Select Breast Cancer Patients. Ann Surg Oncol 2023; 30:8398-8403. [PMID: 37770723 PMCID: PMC10625946 DOI: 10.1245/s10434-023-14332-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/09/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Widespread use of screening mammography has allowed breast cancer to be detected at earlier stages. This allows for increased customization of treatment and less aggressive management. De-escalation of therapy plays an important role in decreasing treatment burden and improving patient quality of life. This report examines cryoablation as the next step in the surgical de-escalation of breast cancer. METHODS Women with a diagnosis of clinically node-negative, estrogen receptor-positive (ER +), progesterone receptor-positive (PR +), human epidermal growth factor receptor 2-negative (HER2 -) infiltrating ductal carcinomas 1.5 cm or smaller underwent ultrasound-guided cryoablation. Either the Visica 2 treatment system (before 2020) or the ProSense treatment system (since 2020) was used to perform the cryoablation. Patients received mammograms and ultrasounds at a 6 months follow-up visit, and magnetic resonance images at baseline, then at 1 year follow-up intervals. Adjuvant therapy decisions and disease status were recorded. RESULTS This study enrolled 32 patients who underwent 33 cryoablation procedures (1 patient had bilateral cancer). One patient had a sentinel node biopsy in addition to clinical staging of the axilla. For all the patients, adjuvant endocrine therapy was recommended, and six patients (18.75%) received adjuvant radiation. Of the 32 patients, 20 (60.6%) have been followed up for 2 years or longer, with no residual or recurrent disease at the site of ablation. CONCLUSION Cryoablation of the primary tumor foregoing sentinel node biopsy offers an oncologically safe and feasible minimally invasive office-based procedure option in lieu of surgery for patients with early-stage, low-risk breast cancer.
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Affiliation(s)
- Sonia Y Khan
- Breast Center of Excellence and Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jaclyn Cole
- Breast Center of Excellence and Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Zaina Habrawi
- Breast Center of Excellence and Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Michael W Melkus
- Breast Center of Excellence and Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Rakhshanda Layeequr Rahman
- Breast Center of Excellence and Department of Surgery, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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McClelland S, Burnette U, Onyewadume L, Cheatham C. Navigator utilization among African-American breast cancer patients at a Comprehensive Cancer Center. Rep Pract Oncol Radiother 2023; 28:707-709. [PMID: 38179285 PMCID: PMC10764042 DOI: 10.5603/rpor.97509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 09/18/2023] [Indexed: 01/06/2024] Open
Abstract
Background Patient navigation has been demonstrated to improve access to standard-of-care oncologic therapy. However, many patients - particularly those of African-American race - often do not have access to navigation upon receiving a diagnosis of cancer. As the most common cancer among African-American women is breast cancer, we sought to assess the rate of patient navigation among African-American breast cancer patients at our institution, which resides in a regional ZIP code comprised of 46% African-American residents. Materials and methods African-American breast cancer patients who had been discussed at our weekly breast cancer multidisciplinary tumor board over a recent three-month period were assessed by a patient navigator representing the Navigator-Assisted Hypofractionation (NAVAH) program to determine their access to navigation in their cancer care. Responses were assessed from a breast cancer support group and culled to determine a baseline proportion of navigation utilization. Results A total of 18 women of African-American race having been diagnosed with breast cancer were identified and assessed. Of these a total of 4 noted that they had received navigation, yielding a navigation utilization percentage of 22.2% among African-American breast cancer patients at our institution. Conclusion The rate of navigation utilization among African-American breast cancer patients is poor. Despite our center residing in a region comprised of increased African-Americans, such predominance has not translated into optimizing navigation access for African-American breast cancer patients. This 22% rate of navigation utilization serves as a starting benchmark for initiatives such as the NAVAH program to provide tangible improvement in this patient population.
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Affiliation(s)
- Shearwood McClelland
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center Case Western Reserve University School of Medicine, Cleveland, OH, United States
- Department of Neurological Surgery, University Hospitals Seidman Cancer Center Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Ursula Burnette
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Louisa Onyewadume
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Chesley Cheatham
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center Case Western Reserve University School of Medicine, Cleveland, OH, United States
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Haussmann J, Budach W, Corradini S, Krug D, Jazmati D, Tamaskovics B, Bölke E, Pedotoa A, Kammers K, Matuschek C. Comparison of adverse events in partial- or whole breast radiotherapy: investigation of cosmesis, toxicities and quality of life in a meta-analysis of randomized trials. Radiat Oncol 2023; 18:181. [PMID: 37919752 PMCID: PMC10623828 DOI: 10.1186/s13014-023-02365-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE/OBJECTIVE Adjuvant whole breast radiotherapy and systemic therapy are part of the current evidence-based treatment protocols for early breast cancer, after breast-conserving surgery. Numerous randomized trials have investigated the therapeutic effects of partial breast irradiation (PBI) compared to whole breast irradiation (WBI), limiting the treated breast tissue. These trials were designed to achieve equal control of the disease with possible reduction in adverse events, improvements in cosmesis and quality of life (QoL). In this meta-analysis, we aimed to investigate the differences between PBI and WBI in side effects and QoL. MATERIAL/METHODS We performed a systematic literature review searching for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was performed using the published event rates and the effect-sizes for available acute and late adverse events. Additionally, we evaluated cosmetic outcomes as well as general and breast-specific QoL using the EORTC QLQ-C30 and QLQ-BR23 questionnaires. RESULTS Sixteen studies were identified (n = 19,085 patients). PBI was associated with a lower prevalence in any grade 1 + acute toxicity and grade 2 + skin toxicity (OR = 0.12; 95% CI 0.09-0.18; p < 0.001); (OR = 0.16; 95% CI 0.07-0.41; p < 0.001). There was neither a significant difference in late adverse events between the two treatments, nor in any unfavorable cosmetic outcomes, rated by either medical professionals or patients. PBI-technique using EBRT with twice-daily fractionation schedules resulted in worse cosmesis rated by patients (n = 3215; OR = 2.08; 95% CI 1.22-3.54; p = 0.007) compared to WBI. Maximum once-daily EBRT schedules (n = 2071; OR = 0.60; 95% CI 0.45-0.79; p < 0.001) and IORT (p = 0.042) resulted in better cosmetic results grade by medical professionals. Functional- and symptom-based QoL in the C30-scale was not different between PBI and WBI. Breast-specific QoL was superior after PBI in the subdomains of "systemic therapy side effects" as well as "breast-" and "arm symptoms". CONCLUSION The analysis of multiple randomized trials demonstrate a superiority of PBI in acute toxicity as well breast-specific quality of life, when compared with WBI. Overall, late toxicities and cosmetic results were similar. PBI-technique with a fractionation of twice-daily schedules resulted in worse cosmesis rated by patients.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, Ludwig Maximillian University, Munich, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Bálint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alessia Pedotoa
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Kai Kammers
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
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30
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Perry LM, Keegan THM, Li Q, Bold RJ, Antonino NF, Maguire FB, Sauder CAM. Survival After Contralateral Secondary Breast Cancer by Age Group in California. Ann Surg Oncol 2023; 30:6178-6187. [PMID: 37458949 DOI: 10.1245/s10434-023-13902-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/23/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Breast cancer (BC) is the most common secondary cancer and has poorer survival than primary BC (pBC) after any prior malignancy. For BC survivors, developing a contralateral secondary BC (CSBC) is the most frequent second-cancer event and is currently treated similarly to pBC. Identifying survival differences between pBC and CSBC could influence future counseling and treatments for patients with CSBC. METHODS Women (≥15 years) diagnosed with pBC from 1991 to 2015 in the California Cancer Registry (n = 377,176) were compared with those with CSBC (n = 15,586) by age group (15-39 years, n = 406; 40-64 years, n = 6814; ≥ 65 years, n = 8366). Multivariable logistic regression models assessed factors associated with CSBC. Multivariable Cox proportional hazards regression models assessed BC-specific survival (BCSS), while accounting for the competing risk of death. RESULTS Across all ages, CSBC patients were more likely to have smaller tumors (T2 vs. T1a; 15-39 yeras: OR 0.25, CI 0.16-0.38; 40-64 years: OR 0.41, CI 0.37-0.45; ≥ 65 years: OR 0.46, CI 0.42-0.51) and lymph node-negative disease (positive vs. negative; 15-39 years: OR 0.86, CI 0.69-1.08; 40-64 years: OR 0.88, CI 0.83-0.93; ≥ 65 years: OR 0.89, CI 0.84-0.94). Additionally, CSBC was associated with worse survival compared with pBC across all ages (15-39 years: HR 2.73, CI 2.30-3.25; 40-64 years: HR 2.13, CI 2.01-2.26; ≥ 65 years: HR 1.52, CI 1.43-1.61). CONCLUSION BCSS is worse among all women diagnosed with CSBC compared with pBC, with the strongest impact seen in adolescent and young adult women. Worse survival after CSBC, despite associations with smaller tumors and lymph node negativity, suggests that CSBC may need eventual treatment reconsideration.
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Affiliation(s)
- Lauren M Perry
- Division of Surgical Oncology, Department of Surgery, University of California Davis School of Medicine, UC Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Theresa H M Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA, USA
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, USA
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Qian Li
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Richard J Bold
- Division of Surgical Oncology, Department of Surgery, University of California Davis School of Medicine, UC Davis Comprehensive Cancer Center, Sacramento, CA, USA
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, USA
| | - Nicholas F Antonino
- Division of Surgical Oncology, Department of Surgery, University of California Davis School of Medicine, UC Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Frances B Maguire
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Candice A M Sauder
- Division of Surgical Oncology, Department of Surgery, University of California Davis School of Medicine, UC Davis Comprehensive Cancer Center, Sacramento, CA, USA.
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, USA.
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Vasilyeva E, Hamm J, Nichol A, Isaac KV, Bazzarelli A, Brown C, Lohrisch C, McKevitt E. Breast-Conserving Therapy is Associated with Improved Survival Without an Increased Risk of Locoregional Recurrence Compared with Mastectomy in Both Clinically Node-Positive and Node-Negative Breast Cancer Patients. Ann Surg Oncol 2023; 30:6413-6424. [PMID: 37358683 DOI: 10.1245/s10434-023-13784-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/06/2023] [Indexed: 06/27/2023]
Abstract
INTRODUCTION Randomized trials demonstrated equivalent survival between breast-conserving surgery combined with radiotherapy (BCT) and mastectomy alone. Contemporary retrospective studies using pathological stage have reported improved survival with BCT. However, pathological information is unknown before surgery. To mimic real-world surgical decision-making, this study assesses oncological outcomes by using clinical nodal status. METHODS Female patients aged 18-69 years who were treated with upfront BCT or mastectomy between 2006 and 2016 for T1-3N0-3 breast cancer were identified by using prospective, provincial database. The patients were divided into clinically node-positive (cN+) and node-negative (cN0) strata. Multivariable logistic regression was used to assess the effect of local treatment type on overall survival (OS), breast cancer-specific survival (BCSS), and locoregional recurrence (LRR). RESULTS Of 13,914 patients, 8228 had BCT and 5686 had mastectomy. Mastectomy patients had higher-risk clinicopathological factors: pathologically positive axillary staging was 21% in BCT and 38% in mastectomy groups. Most patients received adjuvant systemic therapy. For cN0 patients, 7743 had BCT and 4794 had mastectomy. On multivariable analysis, BCT was associated with improved OS (hazard ratio [HR] 1.37, p < 0.001) and BCSS (HR 1.32, p < 0.001), whereas LRR was not different between the groups (HR 0.84, p = 0.1). For cN+ patients, 485 had BCT and 892 had mastectomy. On multivariable analysis, BCT was associated with improved OS (HR 1.46, p = 0.002) and BCSS (HR 1.44, p = 0.008), whereas LRR was not different between the groups (HR 0.89, p = 0.7). CONCLUSIONS In the era of contemporary systemic therapy, BCT was associated with better survival than mastectomy, without an increased risk of locoregional recurrence for both cN0 and cN+ presentations.
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Affiliation(s)
- Elizaveta Vasilyeva
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
- BC Cancer, Vancouver, BC, Canada.
| | | | - Alan Nichol
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
- BC Cancer, Vancouver, BC, Canada
| | - Kathryn V Isaac
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Amy Bazzarelli
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
- BC Cancer, Vancouver, BC, Canada
| | - Carl Brown
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
- BC Cancer, Vancouver, BC, Canada
| | - Caroline Lohrisch
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Cancer, Vancouver, BC, Canada
| | - Elaine McKevitt
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
- BC Cancer, Vancouver, BC, Canada
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32
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Braunstein LZ. Incorporating Tumor Biology to Select Patients for the Omission of Radiation Therapy. Surg Oncol Clin N Am 2023; 32:725-732. [PMID: 37714639 DOI: 10.1016/j.soc.2023.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Although adjuvant breast radiotherapy has long been a universal component of breast conservation therapy (BCT), it is now clear that "breast cancer" is a broad class of many disparate diseases with varying natural histories and risk profiles. In turn, some breast conservation patients enjoy exceedingly favorable outcomes following surgery alone. Ongoing trials seek to identify such low-risk patient populations, hypothesizing that some may safely forego radiotherapy. Whereas prior-generation trials focused on clinicopathologic features for risk stratification, contemporary studies are employing molecular biomarkers to identify those patients who are unlikely to benefit significantly from radiotherapy.
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Affiliation(s)
- Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 22, New York, NY 10065, USA.
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Lee E, Hines RB, Zhu J, Rovito MJ, Dharmarajan KV, Mazumdar M. Association between adjuvant radiation treatment and breast cancer-specific mortality among older women with comorbidity burden: A comparative effectiveness analysis of SEER-MHOS. Cancer Med 2023; 12:18729-18744. [PMID: 37706222 PMCID: PMC10557861 DOI: 10.1002/cam4.6493] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/04/2023] [Accepted: 08/23/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND The National Comprehensive Cancer Network suggested that older women with low-risk breast cancer (LRBC; i.e., early-stage, node-negative, and estrogen receptor-positive) could omit adjuvant radiation treatment (RT) after breast-conserving surgery (BCS) if they were treated with hormone therapy. However, the association between RT omission and breast cancer-specific mortality among older women with comorbidity is not fully known. METHODS 1105 older women (≥65 years) with LRBC in 1998-2012 were queried from the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data resource and were followed up through July 2018. Latent class analysis was performed to identify comorbidity burden classes. A propensity score-based inverse probability of treatment weighting (IPTW) was applied to Cox regression models to obtain subdistribution hazard ratios (HRs) and 95% CI for cancer-specific mortality considering other causes of death as competing risks, overall and separately by comorbidity burden class. RESULTS Three comorbidity burden (low, moderate, and high) groups were identified. A total of 318 deaths (47 cancer-related) occurred. The IPTW-adjusted Cox regression analysis showed that RT omission was not associated with short-term, 5- and 10-year cancer-specific death (p = 0.202 and p = 0.536, respectively), regardless of comorbidity burden. However, RT omission could increase the risk of long-term cancer-specific death in women with low comorbidity burden (HR = 1.98, 95% CI = 1.17, 3.33), which warrants further study. CONCLUSIONS Omission of RT after BCS is not associated with an increased risk of cancer-specific death and is deemed a reasonable treatment option for older women with moderate to high comorbidity burden.
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Affiliation(s)
- Eunkyung Lee
- Department of Health SciencesUniversity of Central Florida College of Health Professions and SciencesFloridaOrlandoUSA
| | - Robert B. Hines
- Department of Population Health SciencesUniversity of Central Florida College of MedicineFloridaOrlandoUSA
| | - Jianbin Zhu
- Department of Statistics and Data ScienceUniversity of Central Florida College of SciencesFloridaOrlandoUSA
- Research Institute, Advent HealthFloridaOrlandoUSA
| | - Michael J. Rovito
- Department of Health SciencesUniversity of Central Florida College of Health Professions and SciencesFloridaOrlandoUSA
| | - Kavita V. Dharmarajan
- Department of Radiation Oncology, Department of Geriatrics Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Madhu Mazumdar
- Institute for Healthcare Delivery ScienceIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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Haussmann J, Budach W, Corradini S, Krug D, Bölke E, Tamaskovics B, Jazmati D, Haussmann A, Matuschek C. Whole Breast Irradiation in Comparison to Endocrine Therapy in Early Stage Breast Cancer-A Direct and Network Meta-Analysis of Published Randomized Trials. Cancers (Basel) 2023; 15:4343. [PMID: 37686620 PMCID: PMC10487067 DOI: 10.3390/cancers15174343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Multiple randomized trials have established adjuvant endocrine therapy (ET) and whole breast irradiation (WBI) as the standard approach after breast-conserving surgery (BCS) in early-stage breast cancer. The omission of WBI has been studied in multiple trials and resulted in reduced local control with maintained survival rates and has therefore been adapted as a treatment option in selected patients in several guidelines. Omitting ET instead of WBI might also be a valuable option as both treatments have distinctly different side effect profiles. However, the clinical outcomes of BCS + ET vs. BCS + WBI have not been formally analyzed. METHODS We performed a systematic literature review searching for randomized trials comparing BCS + ET vs. BCS + WBI in low-risk breast cancer patients with publication dates after 2000. We excluded trials using any form of chemotherapy, regional nodal radiation and mastectomy. The meta-analysis was performed using a two-step process. First, we extracted all available published event rates and the effect sizes for overall and breast-cancer-specific survival (OS, BCSS), local (LR) and regional recurrence, disease-free survival, distant metastases-free interval, contralateral breast cancer, second cancer other than breast cancer and mastectomy-free interval as investigated endpoints and compared them in a network meta-analysis. Second, the published individual patient data from the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) publications were used to allow a comparison of OS and BCSS. RESULTS We identified three studies, including a direct comparison of BCS + ET vs. BCS + WBI (n = 1059) and nine studies randomizing overall 7207 patients additionally to BCS only and BCS + WBI + ET resulting in a four-arm comparison. In the network analysis, LR was significantly lower in the BCS + WBI group in comparison with the BCS + ET group (HR = 0.62; CI-95%: 0.42-0.92; p = 0.019). We did not find any differences in OS (HR = 0.93; CI-95%: 0.53-1.62; p = 0.785) and BCSS (OR = 1.04; CI-95%: 0.45-2.41; p = 0.928). Further, we found a lower distant metastasis-free interval, a higher rate of contralateral breast cancer and a reduced mastectomy-free interval in the BCS + WBI-arm. Using the EBCTCG data, OS and BCSS were not significantly different between BCS + ET and BCS + WBI after 10 years (OS: OR = 0.85; CI-95%: 0.59-1.22; p = 0.369) (BCSS: OR = 0.72; CI-95%: 0.38-1.36; p = 0.305). CONCLUSION Evidence from direct and indirect comparison suggests that BCS + WBI might be an equivalent de-escalation strategy to BCS + ET in low-risk breast cancer. Adverse events and quality of life measures have to be further compared between these approaches.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University (LMU), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Alexander Haussmann
- Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
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Fleck JL, Hooijenga D, Phan R, Xie X, Augusto V, Heudel PE. Adjuvant therapeutic strategy decision support for an elderly population with localized breast cancer: A monocentric cohort retrospective study. PLoS One 2023; 18:e0290566. [PMID: 37616325 PMCID: PMC10449163 DOI: 10.1371/journal.pone.0290566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/09/2023] [Indexed: 08/26/2023] Open
Abstract
Guidelines for the management of elderly patients with early breast cancer are scarce. Additional adjuvant systemic treatment to surgery for early breast cancer in elderly populations is challenged by increasing comorbidities with age. In non-metastatic settings, treatment decisions are often made under considerable uncertainty; this commonly leads to undertreatment and, consequently, poorer outcomes. This study aimed to develop a decision support tool that can help to identify candidate adjuvant post-surgery treatment schemes for elderly breast cancer patients based on tumor and patient characteristics. Our approach was to generate predictions of patient outcomes for different courses of action; these predictions can, in turn, be used to inform clinical decisions for new patients. We used a cohort of elderly patients (≥ 70 years) who underwent surgery with curative intent for early breast cancer to train the models. We tested seven classification algorithms using 5-fold cross-validation, with 80% of the data being randomly selected for training and the remaining 20% for testing. We assessed model performance using accuracy, precision, recall, F1-score, and AUC score. We used an autoencoder to perform dimensionality reduction prior to classification. We observed consistently better performance using logistic regression and linear discriminant analysis models when compared to the other models we tested. Classification performance generally improved when an autoencoder was used, except for when we predicted the need for adjuvant treatment. We obtained overall best results using a logistic regression model without autoencoding to predict the need for adjuvant treatment (F1-score = 0.869).
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Affiliation(s)
- Julia L. Fleck
- Mines Saint-Etienne, Univ Clermont Auvergne, CNRS, UMR 6158 LIMOS, Centre CIS, Saint-Etienne, France
| | - Daniëlle Hooijenga
- Mines Saint-Etienne, Univ Clermont Auvergne, CNRS, UMR 6158 LIMOS, Centre CIS, Saint-Etienne, France
| | - Raksmey Phan
- Mines Saint-Etienne, Univ Clermont Auvergne, CNRS, UMR 6158 LIMOS, Centre CIS, Saint-Etienne, France
| | - Xiaolan Xie
- Mines Saint-Etienne, Univ Clermont Auvergne, CNRS, UMR 6158 LIMOS, Centre CIS, Saint-Etienne, France
| | - Vincent Augusto
- Mines Saint-Etienne, Univ Clermont Auvergne, CNRS, UMR 6158 LIMOS, Centre CIS, Saint-Etienne, France
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Bartholomew K, Ghafel M, Tin Tin S, Aye PS, Elwood JM, Hardie C, Scott N, Kidd J, Ramsaroop R, Campbell I. Receipt of mastectomy and adjuvant radiotherapy following breast conserving surgery (BCS) in New Zealand women with BCS-eligible breast cancer, 2010-2015: an observational study focusing on ethnic differences. BMC Cancer 2023; 23:766. [PMID: 37592208 PMCID: PMC10436661 DOI: 10.1186/s12885-023-11248-9] [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: 06/01/2023] [Accepted: 08/02/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Women with early breast cancer who meet guideline-based criteria should be offered breast conserving surgery (BCS) with adjuvant radiotherapy as an alternative to mastectomy. New Zealand (NZ) has documented ethnic disparities in screening access and in breast cancer treatment pathways. This study aimed to determine whether, among BCS-eligible women, rates of receipt of mastectomy or radiotherapy differed by ethnicity and other factors. METHODS The study assessed management of women with early breast cancer (ductal carcinoma in situ [DCIS] and invasive stages I-IIIA) registered between 2010 and 2015, extracted from the recently consolidated New Zealand Breast Cancer Registry (now Te Rēhita Mate Ūtaetae NZBCF National Breast Cancer Register). Specific criteria were applied to determine women eligible for BCS. Uni- and multivariable analyses were undertaken to examine differences by demographic and clinicopathological factors with a primary focus on ethnicity (Māori, Pacific, Asian, and Other; the latter is defined as NZ European, Other European, and Middle Eastern Latin American and African). RESULTS Overall 22.2% of 5520 BCS-eligible women were treated with mastectomy, and 91.1% of 3807 women who undertook BCS received adjuvant radiotherapy (93.5% for invasive cancer, and 78.3% for DCIS). Asian ethnicity was associated with a higher mastectomy rate in the invasive cancer group (OR 2.18; 95%CI 1.72-2.75), compared to Other ethnicity, along with older age, symptomatic diagnosis, advanced stage, larger tumour, HER2-positive, and hormone receptor-negative groups. Pacific ethnicity was associated with a lower adjuvant radiotherapy rate, compared to Other ethnicity, in both invasive and DCIS groups, along with older age, symptomatic diagnosis, and lower grade tumour in the invasive group. Both mastectomy and adjuvant radiotherapy rates decreased over time. For those who did not receive radiotherapy, non-referral by a clinician was the most common documented reason (8%), followed by patient decline after being referred (5%). CONCLUSION Rates of radiotherapy use are high by international standards. Further research is required to understand differences by ethnicity in both rates of mastectomy and lower rates of radiotherapy after BCS for Pacific women, and the reasons for non-referral by clinicians.
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MESH Headings
- Female
- Humans
- Breast Neoplasms/epidemiology
- Breast Neoplasms/ethnology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Intraductal, Noninfiltrating/epidemiology
- Carcinoma, Intraductal, Noninfiltrating/ethnology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Maori People/statistics & numerical data
- Mastectomy/statistics & numerical data
- Mastectomy, Segmental/statistics & numerical data
- New Zealand/epidemiology
- Radiotherapy, Adjuvant/statistics & numerical data
- Pacific Island People/statistics & numerical data
- Asian/statistics & numerical data
- European People/statistics & numerical data
- Middle Eastern People/statistics & numerical data
- African People/statistics & numerical data
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Affiliation(s)
- Karen Bartholomew
- Te Whatu Ora Waitematā, Auckland, New Zealand
- Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
| | - Mazin Ghafel
- Te Whatu Ora Waitematā, Auckland, New Zealand
- Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
| | - Sandar Tin Tin
- University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Phyu S Aye
- Te Whatu Ora Waitematā, Auckland, New Zealand.
- University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.
| | - J Mark Elwood
- University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Claire Hardie
- Te Whatu Ora MidCentral, Palmerston North, New Zealand
| | - Nina Scott
- University of Auckland, Waikato Campus, Hamilton, New Zealand
| | - Jacquie Kidd
- Auckland University of Technology, Auckland, New Zealand
| | | | - Ian Campbell
- University of Auckland, Waikato Campus, Hamilton, New Zealand
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Chen C, Wang R, Wang B, Wu Y, Jiang J. The effect of adjuvant radiotherapy after breast-conserving surgery in elderly women with T1-2N0 estrogen receptor-negative breast cancer. PLoS One 2023; 18:e0288078. [PMID: 37535561 PMCID: PMC10399868 DOI: 10.1371/journal.pone.0288078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/19/2023] [Indexed: 08/05/2023] Open
Abstract
PURPOSE To evaluate whether adjuvant radiotherapy (RT) following breast-conserving surgery (BCS) results in better survival among women ≥ 70 years with T1-2N0 estrogen receptor (ER)-negative breast cancer. METHODS In this retrospective cohort study, we included patients who met the inclusion criteria between 2010 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) program. Univariate and Multivariate Cox proportional analysis were used to identify the risk factors for overall survival (OS) and breast cancer-specific survival (BCSS). Kaplan-Meier survival analysis was used to compare the prognosis of patients with or without adjuvant RT. Propensity score matching (PSM) was applied to perform a 1:1 matched case-control analysis. RESULTS A total of 4201 women were included in this study, with a median follow-up time of 64 months (range: 0-107 months). Of these patients, 2811 (66.9%) received adjuvant RT, while 1390 (33.1%) did not. Patients who did not receive adjuvant RT were more likely to be aged ≥ 80 years old, have a single marital status, larger tumors, and HER2-positive status (p < 0.05). Multivariate Cox proportional analysis indicated that receiving adjuvant RT was an independent factor associated with better OS and BCSS before and after PSM (P < 0.001). The survival curves before and after PSM showed that patients achieved an improved OS and BCSS from adjuvant RT (P < 0.005). In the subgroup analysis, there was no survival benefit trend from adjuvant RT in patients who were ≥ 80 years, or those with T1mic+T1a, T1b tumors. CONCLUSIONS The use of RT following BCS in older women with T1-2N0 ER-negative breast cancer is associated with improve OS and BCSS. However, the potential benefit may be relatively limited for patients ≥ 80 years, or those with T1mic+T1a, T1b tumors.
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Affiliation(s)
- Can Chen
- Department of Oncology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu Province, China
| | - Runlu Wang
- Respiratory Division, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Bing Wang
- Department of Rheumatology and Immunology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu Province, China
| | - Yue Wu
- Department of Tumor Biological Treatment, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu Province, China
| | - Jingting Jiang
- Department of Tumor Biological Treatment, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu Province, China
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Andraos TY, Skalina KA, Feldman S, Mehta K, Tome WA, McEvoy MP, Gupta AM, Fox JL. Experience with intraoperative radiation therapy in an urban cancer center. Radiat Oncol 2023; 18:123. [PMID: 37491260 PMCID: PMC10367245 DOI: 10.1186/s13014-023-02299-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/15/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND/OBJECTIVE Intra-operative radiation therapy (IORT) is a newer partial breast irradiation technique that has been well studied in 2 large randomized trials, the TARGIT-A and ELIOT trials. We initiated our IORT program in 2018 in the context of a registry trial, and aim to report our early results thus far. METHODS We instituted an IORT practice using Intrabeam® low energy 50kVp x-rays for selected breast cancer cases in 2018. Patients were enrolled on our institutional registry protocol which allowed for IORT in ER + patients with grade 1-2 DCIS ≤ 2.5 cm or invasive disease ≤ 3.5 cm in patients of at least 45 years of age. RESULTS Between January 2018 and December 2021, 181 patients with clinical stage 0-IIA ER + breast cancer were evaluated. One hundred sixty-seven patients ultimately received IORT to 172 sites. The majority of patients received IORT at the time of initial diagnosis and surgery (160/167; 95.8%). Re-excision post IORT occurred in 16/167 patients (9.6%) due to positive margins. Adjuvant RT to the whole breast +/- LN was ultimately given to 23/167 (13.8%) patients mainly due to positive sentinel LN found on final pathology (12/23; 52%); other reasons were close margins for DCIS (3/23; 13%), tumor size (3/23; 4.3%), and multifactorial (5/23; 17.4%). Five patients (3%) had post-operative complications of wound dehiscence. There were 3 local recurrences (1.6%) at a median follow-up of 27.9 months (range: 0.7- 54.8 months). CONCLUSIONS IORT has been proven to be a safe and patient-centered form of local adjuvant RT for our population, in whom compliance with a longer course of external beam radiation can be an issue. Long term efficacy remains to be evaluated through continued follow up. In the era of COVID-19 and beyond, IORT has been an increasingly attractive option, as it greatly minimizes toxicities and patient visits to the clinic. TRIAL REGISTRATION All patients were prospectively enrolled on an institutional review board-approved registry trial (IRB number: 2018-9409).
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Affiliation(s)
- Therese Youssef Andraos
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Karin A Skalina
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sheldon Feldman
- Department of Breast Surgical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Keyur Mehta
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Wolfgang A Tome
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maureen P McEvoy
- Department of Breast Surgical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Anjuli M Gupta
- Department of Breast Surgical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jana L Fox
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
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Rodin D, Sutradhar R, Jerzak KJ, Hahn E, Nguyen L, Castelo M, Fatiregun O, Fong C, Mata DGMM, Trebinjac S, Paszat L, Rakovitch E. Impact of non-adherence to endocrine therapy on recurrence risk in older women with stage I breast cancer after breast-conserving surgery. Breast Cancer Res Treat 2023:10.1007/s10549-023-06989-x. [PMID: 37326765 DOI: 10.1007/s10549-023-06989-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/24/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE We examined the impact of non-adherence to adjuvant endocrine therapy (ET) on the risk and site of recurrence among older women with early stage, hormone receptor positive (HR+) breast cancer (EBC). METHODS A population-based cohort of women age ≥ 65 years with T1N0 HR + EBC who were diagnosed between 2010 and 2016 and treated with breast-conserving surgery (BCS) + ET was identified. Treatment and outcomes were ascertained through linkage with administrative databases. ET non-adherence was examined as a time-dependent covariate in multivariable cause-specific Cox regression models to evaluate its effect on the risks of ipsilateral local recurrence (LR), contralateral breast cancer, and distant metastases. RESULTS The population cohort includes 2637 women; 73% (N = 1934) received radiation (RT) + ET and 27% (N = 703) received ET alone. At a median follow-up of 8.14 years, the first event was LR in 3.6% of women treated with ET alone and 1.4% for those treated with RT + ET (p < 0.001); the risk of distant metastases was < 1% in both groups. The proportion of time adherent to ET was 69.0% among those treated with RT + ET and 62.8% for those treated with ET alone. On multivariable analysis, increasing proportion of time non-adherent to ET was associated with increased risk of LR ((HR = 1.52 per 20% increase in time; 95%CI 1.25, 1.85; p < 0.001), contralateral BC (HR = 1.55; 95%CI 1.30, 1.84; p < 0.001), and distant metastases (HR = 1.44; 95%CI 1.08, 1.94; p = 0.01) but absolute risks were low. CONCLUSION Non-adherence to adjuvant ET was associated with an increased risk of recurrence, but absolute recurrence rates were low.
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Affiliation(s)
- Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Katarzyna J Jerzak
- Department of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ezra Hahn
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Lena Nguyen
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Matthew Castelo
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Omolara Fatiregun
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Cindy Fong
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | | | - Sabina Trebinjac
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lawrence Paszat
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Eileen Rakovitch
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Heidinger M, Maggi N, Dutilh G, Mueller M, Eller RS, Loesch JM, Schwab FD, Kurzeder C, Weber WP. Use of sentinel lymph node biopsy in elderly patients with breast cancer - 10-year experience from a Swiss university hospital. World J Surg Oncol 2023; 21:176. [PMID: 37287038 DOI: 10.1186/s12957-023-03062-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/04/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND The Choosing Wisely initiative recommended the omission of routine sentinel lymph node biopsy (SLNB) in patients ≥ 70 years of age, with clinically node-negative, early stage, hormone receptor (HR) positive and human epidermal growth factor receptor 2 (Her2) negative breast cancer in August 2016. Here, we assess the adherence to this recommendation in a Swiss university hospital. METHODS We conducted a retrospective single center cohort study from a prospectively maintained database. Patients ≥ 18 years of age with node-negative breast cancer were treated between 05/2011 and 03/2022. The primary outcome was the percentage of patients in the Choosing Wisely target group who underwent SLNB before and after the initiative went live. Statistical significance was tested using chi-squared test for categorical and Wilcoxon rank-sum tests for continuous variables. RESULTS In total, 586 patients met the inclusion criteria with a median follow-up of 2.7 years. Of these, 163 were ≥ 70 years of age and 79 were eligible for treatment according to the Choosing Wisely recommendations. There was a trend toward a higher rate of SLNB (92.7% vs. 75.0%, p = 0.07) after the Choosing Wisely recommendations were published. In patients ≥ 70 years with invasive disease, fewer received adjuvant radiotherapy after omission of SLNB (6.2% vs. 64.0%, p < 0.001), without differences concerning adjuvant systemic therapy. Both short-term and long-term complication rates after SLNB were low, without differences between elderly patients and those < 70 years. CONCLUSIONS Choosing Wisely recommendations did not result in a decreased use of SLNB in the elderly at a Swiss university hospital.
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Affiliation(s)
- Martin Heidinger
- Breast Center, University Hospital Basel, Basel, Switzerland.
- University of Basel, Basel, Switzerland.
- Universitätsspital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Nadia Maggi
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Gilles Dutilh
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | | | - Ruth S Eller
- Breast Center, University Hospital Basel, Basel, Switzerland
| | - Julie M Loesch
- Breast Center, University Hospital Basel, Basel, Switzerland
| | - Fabienne D Schwab
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Christian Kurzeder
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Lee W, Carlson JJ, Basu A, Veenstra D. Quantifying the value of older adult-specific clinical trials: Post-lumpectomy irradiation among older adults with early-stage breast cancer. J Geriatr Oncol 2023; 14:101487. [PMID: 37075565 DOI: 10.1016/j.jgo.2023.101487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 02/26/2023] [Accepted: 03/27/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION Although there is increasing interest in conducting cancer clinical trials in older adults, the benefit of such trials is unclear. We aimed to quantify the real-world clinical and economic effects of two phase 3 trials (CALGB 9343 and PRIME II) which showed that post-lumpectomy radiation therapy (RT) improves loco-regional recurrence but makes no improvement in overall survival among older women with early-stage breast cancer (ESBC). MATERIALS AND METHODS We developed a health-transition model to quantify the incremental clinical and economic outcomes between scenarios with vs. without older adult-specific trial results from a societal perspective between 2004 and 2018. The transition probabilities in the model were mainly derived from the 10-year results of CALGB 9343. The total number of the affected patient population in the US and the change in the probability of omitting post-lumpectomy RT due to the CALGB 9343 and PRIME II results were derived from a retrospective analysis of the SEER registry data for patients with ESBC. Sensitivity analyses were conducted to calculate the 95% credible interval (CR) of the incremental clinical and economic outcomes between the two scenarios. RESULTS Between 2004 and 2018, 32,936 (95% CR: 31,512, 34,357) fewer patients received post-lumpectomy RT among those aged 70 years or older diagnosed with ESBC in the US and there was a decrease cost of $419 M USD (95% CR: -$238 M, -$689 M) in scenarios with vs. without older adult-specific trial results. The difference in projected life years (1083 years, 95% CI: -2542, 7985) and QALYs (866 years, 95% CI: -2561, 7780) were not significant. At a willingness-to-pay threshold of $100 k/QALY, the probability of older adult-specific trial results generating a positive net monetary benefit was 98%. DISCUSSION The CALGB 9343 and PRIME II trial results were associated with a substantial cost-saving in the US society. Our results suggest that older adult-specific clinical trials that demonstrate no survival benefit of an intervention in older adults could be correlated with a significant monetary benefit. Further case studies are needed for different types of older adult-specific trials to understand the value of older adult-specific trials comprehensively.
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Affiliation(s)
- Woojung Lee
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA.
| | - Josh J Carlson
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA
| | - David Veenstra
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, USA
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Akkila S, Mahal S, Dawdy K, Cao X, Szumacher E. Functional decline and resilience in older adults over the age of 70 receiving radiotherapy for breast cancer: A pilot study. J Geriatr Oncol 2023; 14:101476. [PMID: 36989937 DOI: 10.1016/j.jgo.2023.101476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 02/03/2023] [Accepted: 03/07/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Radiotherapy (RT) as an adjuvant, post-lumpectomy treatment has been shown to improve local control and survival in people with breast cancer. While adverse events because of cancer treatments are common, many older adults have demonstrated the ability to return to their baseline levels of physical functioning. There are limited reports on the functional decline and recovery of older patients undergoing RT. The primary objective of this study was to investigate physical function at various time points during RT in people with breast cancer over age 70 and their ability to recover post-decline. MATERIALS AND METHODS Seventy-nine patients with breast cancer aged 70+ undergoing adjuvant RT at Sunnybrook Health Science Centre, Toronto, Ontario, Canada were enrolled for a prospective observational study. Participants completed the EORTC QLQ-C30 quality of life questionnaire before their first RT, after their final RT, and at three- and six-months post-RT to assess changes in physical function. Descriptive statistics were utilized to evaluate EORTC QLQ-C30 scores. A higher score was indicative of poorer physical function. Physical decline was a 10+ point increase in EORTC QLQ-C30 score from baseline to the last RT, and resilience was a return to <10 points from the baseline score within six months post-RT. Resistance was a post-RT change from the baseline score by fewer than 10 points. RESULTS Nine patients (11%) experienced physical decline following their last RT, and two of them (22%) displayed resilience within six months. There were no demographic or symptom variables associated with functional decline from the baseline to post-RT, nor with resilience. Nausea, pain, and diarrhea post-RT were associated with functional decline at six months post-RT (P = 0.0185, P = 0.0449, P = 0.0007, respectively). Nausea and diarrhea at baseline were associated with resistance to decline (P = 0.0055, P = 0.019, respectively), and with decline at the six-month follow-up (P ≤0.0001, P = 0.0235, respectively). DISCUSSION This study highlights the incidence of physical decline in patients over age 70 receiving RT for breast cancer and identifies risk factors for decline. Future research with a larger sample, longer follow-up period, and incorporating geriatric assessments pre-RT is warranted to better understand functional decline and resilience in this population.
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Sperk E. Bestrahlen oder nicht bestrahlen bei älteren Patientinnen mit Low-Risk-Mammakarzinom? Erkenntnisse aus den 10-Jahres-Daten der PRIME-II-Studie. Strahlenther Onkol 2023; 199:520-521. [PMID: 36971810 PMCID: PMC10133080 DOI: 10.1007/s00066-023-02071-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Elena Sperk
- Mannheim Cancer Center, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
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Lee W, Basu A, Carlson JJ, Veenstra D. How does cumulative evidence from older adult-specific trials influence clinical practice? A difference-in-differences analysis in early-stage breast cancer. Contemp Clin Trials 2023; 128:107135. [PMID: 36868347 DOI: 10.1016/j.cct.2023.107135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 02/12/2023] [Accepted: 02/22/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Despite increasing focus on conducting cancer clinical trials in older adults, it is unclear whether such evidence influences practice patterns. We aimed to estimate the impact of cumulative evidence from older adult-specific trial results from the CALGB 9343 and PRIME II trials that found post-lumpectomy irradiation has little benefit among older adults with early-stage breast cancer (ESBC). METHODS Patients diagnosed with ESBC between 2000 and 2018 were identified from the SEER registry data. We examined the incremental immediate effect, incremental average yearly effect, and cumulative effect of a series of CALGB 9343 and PRIME II results on the utilization level of post-lumpectomy irradiation. We conducted difference-in-differences analyses, comparing those aged 70 or older vs. <65 years old. RESULTS The initial 5-year CALGB 9343 results in 2004 led to a significant immediate (-0.038, 95% CI: -0.064, -0.012) and average yearly decrease (-0.008, 95% CI: -0.013, -0.003) in the probability of irradiation use among those aged 70 or older compared to those below 65 years of age. 11-year CALGB 9343 results in 2010 significantly accelerated the average yearly effect by 1.7 percentage points (95% CI: -0.030, -0.004). The other later results did not significantly change the time trend. The cumulative effect of all results between 2004 and 2018 was -26.3 percentage points (95% CI: -0.29, -0.24). CONCLUSION Cumulative evidence from older adult-specific trials in ESBC led to decreasing use of irradiation over time among elderly patients. The rate of decrease after the initial results was accelerated by long-term follow-up results.
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Affiliation(s)
- Woojung Lee
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Health Sciences Building, 1956 NE Pacific St H362, Seattle, WA, 98195, United States.
| | - Anirban Basu
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Health Sciences Building, 1956 NE Pacific St H362, Seattle, WA, 98195, United States.
| | - Josh J Carlson
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Health Sciences Building, 1956 NE Pacific St H362, Seattle, WA, 98195, United States.
| | - David Veenstra
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Health Sciences Building, 1956 NE Pacific St H362, Seattle, WA, 98195, United States.
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Thompson JL, Wright GP. Contemporary approaches to the axilla in breast cancer. Am J Surg 2023; 225:583-587. [PMID: 36522219 DOI: 10.1016/j.amjsurg.2022.11.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Over the past decade, axillary management in breast cancer has fundamentally shifted. The former notion that any degree of axillary nodal involvement warrants axillary lymph node dissection (ALND) has been challenged. Following publication of the ACOSOG Z0011 trial, national trends demonstrated significant reductions in ALND performance. Axillary radiotherapy in lieu of ALND is a consideration for select patients with a positive sentinel lymph node, while ongoing studies are investigating the role of adjuvant regional radiotherapy in women with positive nodes prior to neoadjuvant chemotherapy. Efforts toward de-escalation of axillary surgery continue to evolve, as do the indications for sentinel node biopsy omission in select subsets of patients. This review highlights the recent advances and neoteric approaches to local therapy of the axilla in breast cancer.
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Affiliation(s)
- Jessica L Thompson
- Spectrum Health Medical Group Comprehensive Breast Clinic, 145 Michigan Street NE, Suite 4400, Grand Rapids, MI, 49503, USA; Michigan State University College of Human Medicine, Department of Surgery, 15 Michigan Street NE, Grand Rapids, MI, 49503, USA.
| | - G Paul Wright
- Spectrum Health Medical Group Comprehensive Breast Clinic, 145 Michigan Street NE, Suite 4400, Grand Rapids, MI, 49503, USA; Michigan State University College of Human Medicine, Department of Surgery, 15 Michigan Street NE, Grand Rapids, MI, 49503, USA; Spectrum Health Medical Group, Division of Surgical Oncology, 145 Michigan Street NE, Suite 5500, Grand Rapids, MI, 49503, USA.
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Ward KA, Muller DA, Dutta SW, Malhi J, Sanders JC, Luminais CK, Millard TA, Showalter TN, Showalter SL, Janowski EM. Long-Term Adherence to Adjuvant Endocrine Therapy Following Various Radiotherapy Modalities in Early Stage Hormone Receptor Positive Breast Cancer. Clin Breast Cancer 2023; 23:369-377. [PMID: 36868913 DOI: 10.1016/j.clbc.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 12/24/2022] [Accepted: 01/25/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION We compared the rates of long-term adjuvant endocrine therapy (AET) adherence after various radiation therapy (RT) modalities among patients with early stage breast cancer. MATERIALS AND METHODS Medical records from patients with stage 0, I, or IIA (tumors ≤3 cm), hormone receptor (HR) positive breast cancer that received adjuvant radiation therapy (RT) from 2013 to 2015 at a single institution were retrospectively reviewed. All patients received breast conserving surgery (BCS) followed by adjuvant RT via one of the following modalities: whole breast radiotherapy (WBI), partial breast irradiation (PBI) with either external beam radiation therapy (EBRT) or fractionated intracavitary high-dose rate (HDR) brachytherapy, or single fraction HDR-brachytherapy intraoperative-radiation therapy (IORT). RESULTS One hundred fourteen patients were reviewed. Thirty patients received WBI, 41 PBI, and 43 IORT with a median follow up of 64.2, 72.0, and 58.6 months, respectively. For the entire cohort, AET adherence was approximately 64% at 2 years and 56% at 5 years. Among patients in the IORT clinical trial, adherence to AET was approximately 51% at 2 years and 40% at 5 years. After controlling for additional factors, DCIS histology (vs invasive disease) and IORT (compared to other radiation modalities) were associated with decreased endocrine therapy adherence (P < 0.05). CONCLUSION DCIS histology and receipt of IORT were associated with lower rates of adherence to AET at 5 years. Our findings suggest that examination of the efficacy of RT interventions such as PBI and IORT in patients who do not receive AET is warranted.
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Affiliation(s)
- Kristin A Ward
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA.
| | - Donald A Muller
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Sunil W Dutta
- Department of Radiation Oncology, Emory University, Atlanta, GA
| | - Jasmine Malhi
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Jason C Sanders
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | | | - Trish A Millard
- Department of Hematology/Oncology, University of Virginia, Charlottesville, VA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
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Knape N, Park JH, Agala CB, Spanheimer P, Morrow M, Downs-Canner S, Baldwin XL. Can We Forgo Sentinel Lymph Node Biopsy in Women Aged ≥ 50 Years with Early-Stage Hormone-Receptor-Positive HER2-Negative Special Histologic Subtype Breast Cancer? Ann Surg Oncol 2023; 30:1042-1050. [PMID: 36217063 DOI: 10.1245/s10434-022-12626-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/13/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Breast cancer has significant biologic heterogeneity, which influences treatment decisions. We hypothesized that in postmenopausal women (≥ 50 years) with clinical T1-2, N0, hormone receptor positive (HR+), HER2 negative (HER2-) breast cancer of special histology (mucinous, tubular, cribriform, papillary), information from sentinel lymph node biopsy (SLNB) may not change adjuvant therapy recommendations. PATIENTS AND METHODS We constructed a cohort from the National Cancer Database of women aged ≥ 18 years with cT1-2 N0 HR+ HER2- invasive breast cancer. We calculated the frequency of nodal positivity by histology. We measured the frequency of N2/N3 disease, the distribution of Oncotype DX 21-gene assay recurrence score (ODX RS) across special histology by nodal status, and frequency of chemotherapy use by ODX RS and pathologic N stage. RESULTS In women with cN0 HR+/HER2- special histologic subtype breast cancer, the likelihood of pathologic nodal positivity is less than 5%, and 99.7% of patients had N0 or N1 disease. Among women aged ≥ 50 years with HR+/HER2- special histologic subtype breast cancer, there was low prevalence of high ODX RS > 25 in both N0 and N1 patients (7% overall). Receipt of chemotherapy correlated with Oncotype DX scores as anticipated, with the lowest use in women with a low/intermediate RS (from 2 to 6% for N0 and 6-24% for N1) and the highest use in women with high risk Oncotype scores (from 74 to 92%). CONCLUSIONS Our study suggests that SLNB could potentially be omitted in select postmenopausal women with cT1-2 N0 HR+/HER2- special histologic subtype breast cancer when ODX RS is available.
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Affiliation(s)
- Nicole Knape
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Ji-Hye Park
- Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chris B Agala
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Philip Spanheimer
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Monica Morrow
- Breast Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Xavier L Baldwin
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Gellings JA, Cortina CS, Jorns JM, Johnson MK, Huang CC, Kong AL. Annual cost-savings with the implementation of estrogen-receptor-only testing on Ductal Carcinoma in Situ specimens. Am J Surg 2023; 225:304-308. [PMID: 36283883 DOI: 10.1016/j.amjsurg.2022.09.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/08/2022] [Accepted: 09/29/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND In DCIS, ER status is an important marker. The utility of concomitant PR testing remains unclear. METHODS A single-institution retrospective cohort study was performed with a comparative analysis of the NCDB to assess annual cost-savings with omission of routine PR testing. National Medicare payment standards determined PR staining costs to be $124.92. RESULTS 150 institutional DCIS cases with receptor data were identified. 104 (69%) were ER+/PR+, 16 (11%) were ER+/PR-, and none were ER-/PR+. Omission of routine PR testing would have resulted in $18,738 saved annually. Within the NCDB, 34,100 DCIS cases had receptor data: 29,277 (85.9%) patients were ER+, and 26,008 (76%) were both ER/PR+. 211 (0.6%) patients were ER-/PR+. Annual national cost-savings with omission of routine PR-testing would have been $4.3 million. CONCLUSION PR testing for DCIS should be reserved only for patients with ER- DCIS undergoing breast conservation to determine the utility of adjuvant endocrine therapy.
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Affiliation(s)
- Jaclyn A Gellings
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Chandler S Cortina
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA; Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA.
| | - Julie M Jorns
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Morgan K Johnson
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chiang-Ching Huang
- Joseph J. Zilber School of Public Health, University of Wisconsin, 1240 N 10th St., Milwaukee, WI, 53205, USA.
| | - Amanda L Kong
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA; Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA.
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Knape N, Downs-Canner S, Baldwin XL. ASO Author Reflections: Using Population-Level Data to Individualize Surgical Decision-Making and Reduce Morbidity. Ann Surg Oncol 2023; 30:1051-1052. [PMID: 36255515 DOI: 10.1245/s10434-022-12675-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Nicole Knape
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | | | - Xavier L Baldwin
- Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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Schwartz T, Marumoto AD, Giuliano AE. Surgical Management of the Axilla in Breast Cancer: Evolving but Still Necessary. Ann Surg Oncol 2023; 30:1008-1013. [PMID: 36194309 DOI: 10.1245/s10434-022-12605-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/14/2022] [Indexed: 01/10/2023]
Affiliation(s)
- Theresa Schwartz
- Department of Surgery, Henry Ford Cancer Institute, Detroit, MI, USA
| | - Ashley D Marumoto
- Department of Surgery, University of Hawai'i John A. Burns School of Medicine, Honolulu, HI, USA
| | - Armando E Giuliano
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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