TRENDS IN SURGICAL TREATMENT OF YOUNGER PATIENTS WITH BREAST CANCER IN AUSTRALIA AND NEW ZEALAND

Trends in surgery and adjuvant treatment for early-stage breast cancer: a population-based study in Queensland, Australia

PURPOSE

Our aim was to describe variations in the treatment of early-stage breast cancer and to examine factors associated with disease-specific survival (DSS).

METHODS

The study used linked data for 24,190 women with a T1 (≤ 20 mm) breast cancer who underwent surgery from 2005 to 2019. Multivariate logistic regression was used to model predictors of receiving breast-conserving surgery (BCS) compared to mastectomy and a multinomial model was used to examine factors associated with type(s) of treatment received.

RESULTS

Overall, 70.3% had BCS, with a reduced likelihood of BCS observed for younger women (p < 0.001), rural residence, (p < 0.001), socioeconomic disadvantage (p = 0.004), higher tumour grade (p < 0.001) and surgery in a public versus private hospital (p < 0.001). Compared to women who received BCS and radiation therapy (RT), those having mastectomy alone or mastectomy plus RT were more likely to be younger (p < 0.001), live in a rural area (p < 0.001), have higher-grade tumours (p < 0.001) and positive lymph nodes (p < 0.001). Overall 5-year survival was 95.3% and breast cancer-specific survival was 98.3%. Highest survival was observed for women having BCS and RT and lowest for those having mastectomy and RT (p < 0.001).

CONCLUSION

Our results indicate some variation in the management of early-stage breast cancer. Lower rates of BCS were observed for rural and disadvantaged women and for those treated in a public or low-volume hospital. Whilst survival was high for this cohort, differences in tumour biology likely explain the differences in survival according to treatment type.

A 10-year (1999 ~ 2008) retrospective multi-center study of breast cancer surgical management in various geographic areas of China

PURPOSE

To study the change of surgical treatments for breast cancer in China over the recent 10 years and the relationship between such a changes and social economical development.

METHODS

The data were extracted from the 10-year database of female primary breast cancer at 7 tertiary hospitals from various geographic areas in China. The Chi-square Cochran-Armitage trend test was used to measure the difference.

RESULTS

Over the 10 year period, mastectomy showed a decline trend while breast conserving surgeries increased. The modified radical mastectomy was the primarily surgical treatment. Among various types of mastectomies, modified radical mastectomy was increasing while Halsted radical mastectomy had shown a decrease trend; no significant changes were observed for the simple mastectomy. Halsted radical mastectomy and breast conserving surgery were used in a higher proportion in high economic areas than low economic areas, while the modified radical mastectomy has been underused in hospitals from high economic areas.

CONCLUSIONS

Modified radical mastectomy was the overall most common choice of operation in China. Breast conserving surgery has been less popular but had been showing an increasing trend. Halsted radical mastectomy has still been in use but showing a decrease these years. Surgeries were not adherent to guidelines completely and needed further effective training.

Adherence to recommended treatments for early invasive breast cancer: decisions of women attending surgeons in the breast cancer audit of Australia and New Zealand

AIM

The study aim was to determine the frequency with which women decline clinicians' treatment recommendations and variations in this frequency by age, cancer and service descriptors.

DESIGN

The study included 36,775 women diagnosed with early invasive breast cancer in 1998-2005 and attending Australian and New Zealand breast surgeons. Rate ratios for declining treatment were examined by descriptor, using bilateral and multiple logistic regression analyses. Proportional hazards regression was used in exploratory analyses of associations with breast cancer death.

RESULTS

3.4% of women declined a recommended treatment of some type, ranging from 2.6% for women under 40 years to 5.8% for those aged 80 years or more, and with parallel increases by age presenting for declining radiotherapy (p<0.001) and axillary surgery (p=0.006). Multiple regression confirmed that common predictors of declining various treatments included low surgeon case load, treatment outside major city centres, and older age. Histological features suggesting a favourable prognosis were often predictive of declining various treatments, although reverse findings also applied with women with positive nodal status being more likely to decline a mastectomy and those with larger tumours more likely to decline chemotherapy. While survival analyses lacked statistical power due to small numbers, higher risks of breast cancer death were suggested, after adjusting for age and conventional clinical risk factors, (1) for women not receiving breast surgery for unstated reasons (RR=2.29; p<0.001); and (2) although not approaching statistical significance p≥ 0.200), for women declining radiotherapy (RR=1.22), a systemic therapy (RR1.11), and more specifically, chemotherapy (RR=1.41).

CONCLUSIONS

Women have the right to choose their treatments but reasons for declining recommendations require further study to ensure that choices are well informed and clinical outcomes are optimized.

Survival from breast cancer: an analysis of Australian data by surgeon case load, treatment centre location, and health insurance status

OBJECTIVE

Early invasive breast cancer data from the Australian National Breast Cancer Audit were used to compare case fatality by surgeon case load, treatment centre location and health insurance status.

METHOD

Deaths were traced to 31 December 2007, for cancers diagnosed in 1998-2005. Risk of breast cancer death was compared using Cox proportional hazards regression.

RESULTS

When adjustment was made for age and clinical risk factors: (i) the relative risk of breast cancer death (95% confidence limit) was lower when surgeons' annual case loads exceeded 20 cases, at 0.87 (0.76, 0.995) for 21-100 cases and 0.83 (0.72, 0.97) for higher case loads. These relative risks were not statistically significant when also adjusting for treatment centre location (P ≥ 0.15); and (ii) compared with major city centres, inner regional centres had a relative risk of 1.32 (1.18, 1.48), but the risk was not elevated for more remote sites at 0.95 (0.74, 1.22). Risk of death was not related to private insurance status.

CONCLUSION

Higher breast cancer mortality in patients treated in inner regional than major city centres and in those treated by surgeons with lower case loads requires further study.

Age effects on survival from early breast cancer in clinical settings in Australia

BACKGROUND

  The study aim was to determine whether age is an independent risk factor for survival from early invasive breast cancer in contemporary Australian clinical settings.

METHODS

  The study included 31 493 breast cancers diagnosed in 1998-2005. Risk of death from breast cancer was compared by age, without and with adjustment for clinical risk factors, using Cox proportional hazard regression.

RESULTS

  Risk of breast cancer death was elevated for cancers of larger size, higher grade, positive nodal status, oestrogen receptor negative status, vascular invasion and multiple foci. Ductal lesions presented a higher risk than other lesions. Adjusting for these factors, the relative risk of breast cancer death (95% confidence limits) was lower for 40-49-year-olds at 0.80 (0.66, 0.96) than for the reference category under 40 years, but higher for 70-79-year-olds at 1.64 (1.36, 1.98) and women aged 80 years or more at 2.19 (1.79, 2.69). The risk for 50-69-year-olds and women under 40 years was similar. Risk-factor adjustment reduced the difference in risk between the reference category under 40 years and 40-49-year-olds, largely eliminated the lower relative risk for 50-69-year-olds, and increased the relative risks for women aged 70-79 years and older.

DISCUSSION

  Survivals in women under 40 and over 70 years of age are poorer than for 40-69-year-olds. Research is needed into the best treatment modalities for younger women and older women with co-morbidity.

Patterns of surgical treatment for women with breast cancer in relation to age

Although treatment recommendations have been advocated for all women with early breast cancer regardless of age, it is generally accepted that different treatments are preferred based on the age of the patient. The aim of this study was to assess the pattern of breast cancer surgery after adjusting for other major prognostic factors in relation to patient age. Data on cancer characteristics and surgical procedures in 31,298 patients with early breast cancer reported to the National Breast Cancer Audit between 1999 and 2006 were used for the study. There was a close association between age and surgical treatment pattern after adjusting for other prognostic factors, including tumor size, histologic grade, number of tumors, lymph node positivity, lymphovascular invasion (LVI), and extensive intraduct component. Breast Conserving Surgery (BCS) was highest among women aged <or=40 years (OR = 1.140; 95% CI: 1.004-1.293) compared to women aged 51-70 years (reference group). BCS was lowest in women aged >70 years (OR = 0.498, 95% CI: 0.455-0.545). Significantly more women aged <or=50 years underwent more than one operation for breast conservation (20.4-24.8%) compared with women aged >50 years (11.4-17.0%). Women aged >70 years were more likely to receive no surgical treatment, 3.5% versus 1.0-1.3% in all other age groups (<or=40, 41-50 51-70 years). There is an association between patient age and the type of breast cancer surgery for women in Australia and New Zealand. Women age <or=40 years are more likely to undergo BCS despite having adverse histologic features and have more than one procedure to achieve breast conservation. Older women (>70 years) more commonly undergo mastectomy and are more likely to receive no surgical treatment.