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Miller K, Gannon MR, Medina J, Clements K, Dodwell D, Horgan K, Park MH, Cromwell DA. Variation in Rates of Post-Mastectomy Radiotherapy Among Women with Early Invasive Breast Cancer in England and Wales: A Population-Based Cohort Study. Clin Oncol (R Coll Radiol) 2023; 35:e549-e560. [PMID: 37321887 DOI: 10.1016/j.clon.2023.05.016] [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: 09/27/2022] [Revised: 04/28/2023] [Accepted: 05/25/2023] [Indexed: 06/17/2023]
Abstract
AIMS This study examined whether patterns of post-mastectomy radiotherapy (PMRT) among women with early invasive breast cancer (EIBC) varied within England and Wales and explored the role of different patient factors in explaining any variation. MATERIALS AND METHODS The study used national cancer data on women aged ≥50 years diagnosed with EIBC (stage I-IIIa) in England and Wales between January 2014 and December 2018 who had a mastectomy within 12 months of diagnosis. A multilevel mixed-effects logistic regression model was used to calculate risk-adjusted rates of PMRT for geographical regions and National Health Service acute care organisations. The study examined the variation in these rates within subgroups of women with different risks of recurrence (low: T1-2N0; intermediate: T3N0/T1-2N1; high: T1-2N2/T3N1-2) and investigated whether the variation was linked to patient case-mix within regions and organisations. RESULTS Among 26 228 women, use of PMRT increased with greater recurrence risk (low: 15.0%; intermediate: 59.4%; high: 85.1%). In all risk groups, use of PMRT was more common among women who had received chemotherapy and decreased among women aged ≥80 years. There was weak or no evidence of an association between use of PMRT and comorbidity or frailty, for each risk group. In women with an intermediate risk, unadjusted rates of PMRT varied substantially between geographical regions (range 40.3-77.3%), but varied less for the high-risk (range 77.1-91.6%) and low-risk groups (range 4.1-32.9%). Adjusting for patient case-mix reduced the variation in regional and organisational PMRT rates to a small degree. CONCLUSIONS Rates of PMRT are consistently high across England and Wales among women with high-risk EIBC, but variation exists across regions and organisations for women with intermediate-risk EIBC. Effort is required to reduce unwarranted variation in practice for intermediate-risk EIBC.
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Affiliation(s)
- K Miller
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.
| | - M R Gannon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - J Medina
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - K Clements
- National Cancer Registration and Analysis Service, NHS Digital, Birmingham, UK
| | - D Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - K Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, UK
| | - M H Park
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - D A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
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Byun HK, Chang JS, Im SH, Kirova YM, Arsene-Henry A, Choi SH, Cho YU, Park HS, Kim JY, Suh CO, Keum KC, Sohn JH, Kim GM, Lee IJ, Kim JW, Kim YB. Risk of Lymphedema Following Contemporary Treatment for Breast Cancer: An Analysis of 7617 Consecutive Patients From a Multidisciplinary Perspective. Ann Surg 2021; 274:170-178. [PMID: 31348041 DOI: 10.1097/sla.0000000000003491] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study was to identify the comprehensive risk factors for lymphedema, thereby enabling a more informed multidisciplinary treatment decision-making. SUMMARY BACKGROUND DATA Lymphedema is a serious long-term complication in breast cancer patients post-surgery; however, the influence of multimodal therapy on its occurrence remains unclear. METHODS We retrospectively collected treatment-related data from 5549 breast cancer patients who underwent surgery between 2007 and 2015 at our institution. Individual radiotherapy plans were reviewed for regional nodal irradiation (RNI) field design and fractionation type. We identified lymphedema risk factors and used them to construct nomograms to predict individual risk of lymphedema. Nomograms were validated internally using 100 bootstrap samples and externally using 2 separate datasets of 1877 Asian and 191 Western patients. RESULTS Six hundred thirty-nine patients developed lymphedema during a median follow-up of 60 months. The 3-year lymphedema incidence was 10.5%; this rate increased with larger irradiation volumes (no RNI vs RNI excluding axilla I-II vs RNI including axilla I-II: 5.7% vs 16.8% vs 24.1%) and when using conventional fractionation instead of hypofractionation (13.5% vs 6.8%). On multivariate analysis, higher body mass index, larger number of dissected nodes, taxane-based regimen, total mastectomy, larger irradiation field, and conventional fractionation were strongly associated with lymphedema (all P < 0.001). Nomograms constructed based on these variables showed good calibration and discrimination internally (concordance index: 0.774) and externally (0.832 for Asian and 0.820 for Western patients). CONCLUSIONS Trimodality breast cancer treatment factors interact to promote lymphedema. Lymphedema risk can be decreased by deintensifying node dissection, chemotherapy regimen, and field and dose of radiotherapy. Deescalation strategies on a multidisciplinary basis might minimize lymphedema risk.
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Affiliation(s)
- Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hee Im
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
- University Versailles St Quentin, France
| | | | - Seo Hee Choi
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Young Up Cho
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Ye Kim
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
- Department of Radiation Oncology, Bundang CHA Medical Center, CHA University, Gyeonggi-do, Korea
| | - Ki Chang Keum
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Hyuk Sohn
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Gun Min Kim
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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Li FY, Lian CL, Lei J, Wang J, Hua L, He ZY, Wu SG. Real-world impact of postmastectomy radiotherapy in T1-2 breast cancer with one to three positive lymph nodes. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:489. [PMID: 32395533 PMCID: PMC7210210 DOI: 10.21037/atm.2020.03.49] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background The utility of postmastectomy radiotherapy (PMRT) in breast cancer patients with T1-2 (tumor size ≤5 cm) and N1 (one to three lymph nodes involved) disease remains controversial. The aim of this population-based study was to investigate the effectiveness of PMRT in this patient subset in the current clinical practice. Methods We included T1-2N1 breast cancer patients treated with mastectomy from 2004 to 2012 using the data form the Surveillance, Epidemiology, and End Results program. The association of PMRT administration with breast cancer-specific survival was determined using multivariable Cox analysis. Results We identified 10,248 patients of this study, including 3,725 (36.3%) received PMRT and 6,523 (63.7%) patients did not receive PMRT. Use of PMRT showed increase from 2008 onward; the percentage of patients receiving PMRT was 30.6% in 2004 and was 47.1% in 2012 (P<0.001). Patients diagnosis after 2008, aged <50 years, high tumor grade, T2 stage, and ≥2 positive lymph nodes were independently related to PMRT receipt. Multivariate analysis indicated that PMRT was not related to better breast cancer-specific survival compared to those without PMRT both before (P=0.186) and after propensity score matching (P=0.137). Conclusions In breast cancer with T1-2N1 disease, PMRT does not appear to improve survival in the era of modern systemic therapy.
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Affiliation(s)
- Feng-Yan Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, China
| | - Chen-Lu Lian
- Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, China
| | - Jian Lei
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, China
| | - Jun Wang
- Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, China
| | - Li Hua
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, China
| | - Zhen-Yu He
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou 510060, China
| | - San-Gang Wu
- Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Teaching Hospital of Fujian Medical University, Xiamen 361003, China
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Lee S, Park IH, Park S, Sohn J, Jeong J, Ahn SG, Lee IJ, Lee HK, Lee SA, Park W, Lee KH, Kim SW, Han SA, Jung KH, Son BH. Meeting Highlights: The Second Consensus Conference for Breast Cancer Treatment in Korea. J Breast Cancer 2017; 20:228-233. [PMID: 28970847 PMCID: PMC5620436 DOI: 10.4048/jbc.2017.20.3.228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/21/2017] [Indexed: 01/18/2023] Open
Abstract
The Korean clinical practice guideline recently developed by the Korean Breast Cancer Society to address the national clinical situation is currently under revision ahead of a seventh recommendation. A second consensus conference was held to further develop this guideline by soliciting opinions regarding important issues related to surgery, radiotherapy, and medical oncology. Several issues were discussed, and the discussion progressed to pros and cons in the context of cases in various clinical situations. The panels discussed and voted on issues regarding surgical treatment for non-axillary regional lymph nodes, regional nodal irradiation of pN1 disease, and ovarian functional suppression (OFS) as an adjuvant treatment in premenopausal patients with hormone receptor-positive breast cancer. Regarding the surgical treatment of non-axillary regional lymph node, most panelists agreed with the recommendation of preoperative chemotherapy and postoperative radiotherapy for patients with biopsy-diagnosed metastases, whereas surgery or radiotherapy of non-axillary regional lymph nodes was suggested for clinical partial responders. Discussions on radiotherapy addressed the need for adjuvant radiotherapy and radiation field of regional lymph node in the context of various N1 breast cancer cases. The participants reached a consensus to recommend that N1 patients should receive regional nodal irradiation for a large tumor burden (e.g., three positive nodes, perinodal extension, or large primary tumor). Finally, the panels favored OFS in addition to endocrine therapy for premenopausal women with high risk factors such as a large tumor size, involvement of more than three nodes, and a high histologic grade.
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Affiliation(s)
- Seeyoun Lee
- Center for Breast Cancer, National Cancer Center, Goyang, Korea
| | - In Hae Park
- Center for Breast Cancer, National Cancer Center, Goyang, Korea
| | - Seho Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Joohyuk Sohn
- Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Seung Ah Lee
- Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Hun Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Won Kim
- Department of Surgery, Breast Care Center, Daerim St. Mary's Hospital, Seoul, Korea
| | - Sang-Ah Han
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kyung Hae Jung
- Department of Oncology, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Ho Son
- Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
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