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Wang Y, Steinke D, Gavan SP, Chen TC, Carr MJ, Ashcroft DM, Cheung KL, Chen LC. Survival Outcomes in Older Women with Oestrogen-Receptor-Positive Early-Stage Breast Cancer: Primary Endocrine Therapy vs. Surgery by Comorbidity and Frailty Levels. Cancers (Basel) 2024; 16:749. [PMID: 38398140 PMCID: PMC10886896 DOI: 10.3390/cancers16040749] [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: 01/23/2024] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
Primary endocrine therapy (PET) offers non-surgical treatment for older women with early-stage breast cancer who are unsuitable for surgery due to frailty or comorbidity. This research assessed all-cause and breast cancer-specific mortality of PET vs. surgery in older women (≥70 years) with oestrogen-receptor-positive early-stage breast cancer by frailty and comorbidity levels. This study used UK secondary data to analyse older female patients from 2000 to 2016. Patients were censored until 31 May 2019 and grouped by the Charlson comorbidity index (CCI) and hospital frailty risk score (HFRS). Cox regression models compared all-cause and breast cancer-specific mortality between PET and surgery within each group, adjusting for patient preferences and covariates. Sensitivity analyses accounted for competing risks. There were 23,109 patients included. The hazard ratio (HR) comparing PET to surgery for overall survival decreased significantly from 2.1 (95%CI: 2.0, 2.2) to 1.2 (95%CI: 1.1, 1.5) with increasing HFRS and from 2.1 (95%CI: 2.0, 2.2) to 1.4 (95%CI 1.2, 1.7) with rising CCI. However, there was no difference in BCSM for frail older women (HR: 1.2; 0.9, 1.9). There were no differences in competing risk profiles between other causes of death and breast cancer-specific mortality with PET versus surgery, with a subdistribution hazard ratio of 1.1 (0.9, 1.4) for high-level HFRS (p = 0.261) and CCI (p = 0.093). Given limited survival gains from surgery for older patients, PET shows potential as an effective option for frail older women with early-stage breast cancer. Despite surgery outperforming PET, surgery loses its edge as frailty increases, with negligible differences in the very frail.
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Affiliation(s)
- Yubo Wang
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
| | - Douglas Steinke
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
| | - Sean P. Gavan
- Manchester Centre for Health Economics, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK;
| | - Teng-Chou Chen
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
| | - Matthew J. Carr
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
| | - Darren M. Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
- NIHR Greater Manchester Patient Safety Research Collaboration (PSRC), The University of Manchester, Manchester M13 9PT, UK
| | - Kwok-Leung Cheung
- Royal Derby Hospital Centre, School of Medicine, University of Nottingham, Uttoxeter Road, Derby DE22 3DT, UK;
| | - Li-Chia Chen
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester M13 9PT, UK; (D.S.); (T.-C.C.); (M.J.C.); (D.M.A.); (L.-C.C.)
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Seroma in breast surgery: all the surgeons fault? Arch Gynecol Obstet 2018; 298:951-959. [PMID: 30196358 DOI: 10.1007/s00404-018-4880-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 08/22/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Despite a trend for less radical surgical approaches in breast cancer due to better understanding of tumour biology and new treatment options such as neoadjuvant chemotherapy (NAC) and intra-operative radiotherapy (IORT), seroma production remains one of the main surgical side effects that can result in prolonged recovery, delay of radiotherapy and patient discomfort. The aim of this study is to provide an update on risk factors for seroma production after breast cancer surgery considering the latest treatment options. METHODS A retrospective analysis of seroma production in primary breast cancer patients treated between 01.01.2010 and 31.12.2014 at the Breast Cancer Centre, University Hospital Ulm, was performed. Patients with previous breast/axillary surgery or more than one intervention were excluded. Seroma formation was measured using wound drains placed in breast and axilla. RESULTS In total, 581 patients met the inclusion criteria. Median age at diagnosis was 60 years, and median BMI 25.6 kg/m2. 60 (10.3%) patients had a mastectomy, 175 (30.1%) patients received IORT, and 72 (12.4%) patients received NAC. Median amount of seroma production was 82.5 ml (range 0-3012.5 ml). Multivariate analysis revealed that most of the observed variation in seroma production was due to type of surgery (mastectomy vs. breast conserving), length of surgery and number of removed lymph nodes. Both NAC and IORT explained a significant but very small amount of the observed variation in seroma production. CONCLUSION The most important factors for seroma production are extent and duration of breast surgery.
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Pepping RMC, Portielje JEA, van de Water W, de Glas NA. Primary Endocrine Therapy in Older Women with Breast Cancer. CURRENT GERIATRICS REPORTS 2017; 6:239-246. [PMID: 29238654 PMCID: PMC5719125 DOI: 10.1007/s13670-017-0223-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of Review Breast cancer incidence increases with age. In recent years, primary endocrine therapy has been increasingly used as a treatment option for frail elderly women with breast cancer, although surgery is still the guideline-recommended treatment. In this review, we discuss the evidence for primary endocrine therapy versus surgical treatment in older women with early breast cancer. Recent Findings Both randomised controlled trials and recent observational studies showed a favourable progression-free survival but not overall survival for surgery plus adjuvant endocrine therapy versus primary endocrine therapy. Information about quality of life with either treatment strategy is so far lacking. Deciding who is fit for surgery and has sufficiently long life expectation to be at risk of disease progression can be supported by performing an individual geriatric assessment. Summary This review suggests that primary endocrine therapy is a reasonable alternative to primary surgery in frail older women with breast cancer. Future studies should focus on the long-term effects on quality of life and physical functioning.
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Affiliation(s)
- R M C Pepping
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - J E A Portielje
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands.,Department of Clinical Oncology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - W van de Water
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - N A de Glas
- Department of Clinical Oncology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
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Abstract
Aging poses an unique opportunity to study cancer biology and treatment in older adults. Breast cancer is often studied in young women; however, much investigation remains to be done on breast cancer in our expanding elderly population. Diagnostic and management strategies applicable to younger patients cannot be empirically used to manage older breast cancer patients. Lack of evidence-based data continues to be the major impediment toward delivery of personalized cancer care to elderly breast cancer patients. This article reviews the relevant literature on management of curable breast cancer in the elderly, the role of geriatric assessment, complex treatment decision making within the context of patient's expected life expectancy, comorbidities, physical function, socioeconomic status, barriers to health care delivery, goals of treatment, and therapy-related side effects. Continuing efforts for enrolling elderly breast cancer patients in contemporary clinical trials, and thus improving age-appropriate care, are emphasized.
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Collins K, Reed M, Lifford K, Burton M, Edwards A, Ring A, Brain K, Harder H, Robinson T, Cheung KL, Morgan J, Audisio R, Ward S, Richards P, Martin C, Chater T, Pemberton K, Nettleship A, Murray C, Walters S, Bortolami O, Armitage F, Leonard R, Gath J, Revell D, Green T, Wyld L. Bridging the age gap in breast cancer: evaluation of decision support interventions for older women with operable breast cancer: protocol for a cluster randomised controlled trial. BMJ Open 2017; 7:e015133. [PMID: 28760787 PMCID: PMC5642653 DOI: 10.1136/bmjopen-2016-015133] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION While breast cancer outcomes are improving steadily in younger women due to advances in screening and improved therapies, there has been little change in outcomes among the older age group. It is inevitable that comorbidities/frailty rates are higher, which may increase the risks of some breast cancer treatments such as surgery and chemotherapy, many older women are healthy and may benefit from their use. Adjusting treatment regimens appropriately for age/comorbidity/frailty is variable and largely non-evidence based, specifically with regard to rates of surgery for operable oestrogen receptor-positive disease and rates of chemotherapy for high-risk disease. METHODS AND ANALYSIS This multicentre, parallel group, pragmatic cluster randomised controlled trial (RCT) (2015-18) reported here is nested within a larger ongoing 'Age Gap Cohort Study' (2012-18RP-PG-1209-10071), aims to evaluate the effectiveness of a complex intervention of decision support interventions to assist in the treatment decision making for early breast cancer in older women. The interventions include two patient decision aids (primary endocrine therapy vs surgery/antioestrogen therapy and chemotherapy vs no chemotherapy) and a clinical treatment outcomes algorithm for clinicians. ETHICS AND DISSEMINATION National and local ethics committee approval was obtained for all UK participating sites. Results from the trial will be submitted for publication in international peer-reviewed scientific journals. IRAS REFERENCE 115550. TRIAL REGISTRATION NUMBER European Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2015-004220-61;Pre-results. Sponsor's Protocol Code Number Sheffield Teaching Hospitals STH17086. ISRCTN 32447*.
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Affiliation(s)
- Karen Collins
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - Malcolm Reed
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Kate Lifford
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Maria Burton
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Katherine Brain
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Thompson Robinson
- Department of Cardiovascular Sciences, Leicester Royal Infirmary, Infirmary Square, Leicester, UK
| | - Kwok Leung Cheung
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Nottingham, UK
| | - Jenna Morgan
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | | | - Susan Ward
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Paul Richards
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Charlene Martin
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- University of Sheffield, Sheffield, UK
| | - Tim Chater
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Kirsty Pemberton
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anthony Nettleship
- Department of Epigenesys, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher Murray
- Department of Epigenesys, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Stephen Walters
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Oscar Bortolami
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | | | | | - Jacqui Gath
- Yorkshire and Humberside (formerly North Trent Cancer Network) Consumer Research Panel, Sheffield, UK
| | - Deirdre Revell
- Yorkshire and Humberside (formerly North Trent Cancer Network) Consumer Research Panel, Sheffield, UK
| | - Tracy Green
- Yorkshire and Humberside (formerly North Trent Cancer Network) Consumer Research Panel, Sheffield, UK
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- University of Sheffield, Sheffield, UK
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Spring LM, Gupta A, Reynolds KL, Gadd MA, Ellisen LW, Isakoff SJ, Moy B, Bardia A. Neoadjuvant Endocrine Therapy for Estrogen Receptor-Positive Breast Cancer: A Systematic Review and Meta-analysis. JAMA Oncol 2017; 2:1477-1486. [PMID: 27367583 DOI: 10.1001/jamaoncol.2016.1897] [Citation(s) in RCA: 218] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Importance Estrogen receptor-positive (ER+) tumors of the breast are generally highly responsive to endocrine treatment. Although endocrine therapy is the mainstay of adjuvant treatment for ER+ breast cancer, the role of endocrine therapy in the neoadjuvant setting is unclear. Objective To evaluate the effect of neoadjuvant endocrine therapy (NET) on the response rate and the rate of breast conservation surgery (BCS) for ER+ breast cancer. Data Sources Based on PRISMA guidelines, a librarian-led search of PubMed and Ovid MEDLINE was performed to identify eligible trials published from inception to May 15, 2015. The search was performed in May 2015. Study Selection Inclusion criteria were prospective, randomized, neoadjuvant clinical trials that reported response rates with at least 1 arm incorporating NET (n = 20). Two authors independently analyzed the studies for inclusion. Data Extraction and Synthesis Pooled odds ratios (ORs), 95% CIs, and P values were estimated for end points using the fixed- and random-effects statistical model. Results The analysis included 20 studies with 3490 unique patients. Compared with combination chemotherapy, NET as monotherapy with aromatase inhibitors had a similar clinical response rate (OR, 1.08; 95% CI, 0.50-2.35; P = .85; n = 378), radiological response rate (OR, 1.38; 95% CI, 0.92-2.07; P = .12; n = 378), and BCS rate (OR, 0.65; 95% CI, 0.41-1.03; P = .07; n = 334) but with lower toxicity. Aromatase inhibitors were associated with a significantly higher clinical response rate (OR, 1.69; 95% CI, 1.36-2.10; P < .001; n = 1352), radiological response rate (OR, 1.49; 95% CI, 1.18-1.89; P < .001; n = 1418), and BCS rate (OR, 1.62; 95% CI, 1.24-2.12; P < .001; n = 918) compared with tamoxifen. Dual combination therapy with growth factor pathway inhibitors was associated with a higher radiological response rate (OR, 1.59; 95% CI, 1.04-2.43; P = .03; n = 355), but not clinical response rate (OR, 0.76; 95% CI, 0.54-1.07; P = .11; n = 537), compared with endocrine monotherapy. The incidence of pathologic complete response was low (<10%). Conclusions and Relevance Neoadjuvant endocrine therapy, even as monotherapy, is associated with similar response rates as neoadjuvant combination chemotherapy but with significantly lower toxicity, suggesting that NET needs to be reconsidered as a potential option in the appropriate setting. Additional research is needed to develop rational NET combinations and predictive biomarkers to personalize the optimal neoadjuvant strategy for ER+ breast cancer.
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Affiliation(s)
- Laura M Spring
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - Arjun Gupta
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Kerry L Reynolds
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - Michele A Gadd
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - Leif W Ellisen
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - Steven J Isakoff
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - Beverly Moy
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
| | - Aditya Bardia
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston
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Lee SJ, Kim KM, Brown JK, Brett A, Roh YH, Kang DR, Park BW, Rhee Y. Negative Impact of Aromatase Inhibitors on Proximal Femoral Bone Mass and Geometry in Postmenopausal Women with Breast Cancer. Calcif Tissue Int 2015; 97:551-9. [PMID: 26232103 DOI: 10.1007/s00223-015-0046-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 07/24/2015] [Indexed: 11/25/2022]
Abstract
Aromatase inhibitors (AIs), the standard therapy for estrogen receptor- or progesterone receptor-positive breast cancer in postmenopausal women, lead to increased hip fractures in breast cancer patients. To investigate the mechanism of increased incidence of hip fractures in breast cancer patients treated with AIs, we evaluated bone mineral density (BMD) in the cortical and trabecular compartments and assessed femoral geometry using quantitative computed tomography (QCT) in breast cancer patients. In total, 249 early breast cancer patients who underwent QCT in their fifties (mean age 54.3 years) were retrospectively analyzed. Proximal femoral BMD and geometrical parameters were compared. In all regions of the proximal femur, cortical areal BMDs were lower in the AI group than in the non-AI group (p < 0.05). Cortical thickness of the femoral neck, trochanter, and total hip was significantly lower in the AI group compared with the non-AI group (p < 0.05). Analysis of the narrowest section of the femoral neck showed significantly thinner cortical bone and smaller cortical area in the AI group than in the non-AI group (p < 0.05), especially in the superoposterior quadrant. Bone strength parameters in the femoral neck, such as the section modulus and cross-sectional moment of inertia, were significantly lower in the AI group than in the non-AI group (p < 0.05). In conclusion, AI treatment in breast cancer patients is associated with deterioration of femoral cortical BMD and geometry, which could contribute in site-specific weakened bone strength and increased incidence of hip fractures.
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Affiliation(s)
- Su Jin Lee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea
| | - Kyoung Min Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | | | | | - Yun Ho Roh
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Ryong Kang
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Byeong Woo Park
- Division of Breast Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.
- Avison Biomedical Research Center, Yonsei University College of Medicine, Seoul, Korea.
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Morgan J, Collins K, Robinson T, Cheung KL, Audisio R, Reed M, Wyld L. Healthcare professionals' preferences for surgery or primary endocrine therapy to treat older women with operable breast cancer. Eur J Surg Oncol 2015; 41:1234-42. [DOI: 10.1016/j.ejso.2015.05.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 04/25/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022] Open
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Morgan JL, Burton M, Collins K, Lifford KJ, Robinson TG, Cheung KL, Audisio R, Reed MW, Wyld L. The balance of clinician and patient input into treatment decision-making in older women with operable breast cancer. Psychooncology 2015; 24:1761-6. [PMID: 26043439 DOI: 10.1002/pon.3853] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/16/2015] [Accepted: 04/27/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Primary endocrine therapy (PET) is an alternative to surgery for oestrogen receptor positive operable breast cancer in some older women. However the decision to offer PET involves complex trade-offs and is influenced by both patient choice and healthcare professional (HCP) preference. This study aimed to compare the views of patients and HCPs about this decision and explore decision-making (DM) preferences and whether these are taken into account during consultations. METHODS This multicentre, UK, mixed methods study had three components: (a) questionnaires to older women undergoing counseling about breast cancer treatment options which assessed their DM preferences and realities; (b) qualitative interviews with older women with operable breast cancer offered a choice of either surgery or PET and (c) qualitative interviews with HCPs (both of which focused on DM preferences in this setting). RESULTS Thirty-three patients and 34 HCPs were interviewed. A range of opinions about patient involvement in DM were identified. Patients indicated varying preferences for DM involvement which were variably taken into account by HCPs. These qualitative findings were broadly supported by the questionnaire results. Most patients (536/729; 73.5%) achieved their preferred DM style; however, the remainder felt that their DM preferences had not been taken into consideration. CONCLUSIONS These results suggest that whilst many older women achieve their desired level of DM engagement, some do not, raising the possibility that they may be making choices which are not concordant with their treatment preferences.
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Affiliation(s)
- Jenna L Morgan
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
| | - Maria Burton
- Centre for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield, UK
| | - Karen Collins
- Centre for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield, UK
| | - Kate J Lifford
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Thompson G Robinson
- University of Leicester, Department of Cardiovascular Sciences, Robert Kilpatrick Clinical Sciences Building, Leicester, UK
| | - Kwok-Leung Cheung
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby, UK
| | - Riccardo Audisio
- Department of Surgery, University of Liverpool, St Helens Teaching Hospital, Marshalls Cross Road, St Helens, UK
| | - Malcolm W Reed
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
| | - Lynda Wyld
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
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Bates T, Evans T, Lagord C, Monypenny I, Kearins O, Lawrence G. A population based study of variations in operation rates for breast cancer, of comorbidity and prognosis at diagnosis: failure to operate for early breast cancer in older women. Eur J Surg Oncol 2014; 40:1230-6. [PMID: 25081093 DOI: 10.1016/j.ejso.2014.06.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Older women are less likely to have surgery for operable breast cancer. This population-based study examines operation rates by age and identifies groups which present with early or late disease. METHODS 37 000 cancer registrations for 2007 were combined with Hospital Episode Statistics comorbidity data for England. Operation rates were examined by age, ethnicity, deprivation, comorbidity, screen-detection, tumour size, grade and nodal status. Early and late presentation were correlated with Nottingham Prognostic Index (NPI) groups and tumour size. RESULTS The proportion of women not having surgery increased from 7-10% at ages 35-69 to 82% from age 90. From age 70, the proportion not having surgery rose by an average of 3.1% per year of age. Women with a Charlson Comorbidity Index score of ≥1 (which increased with age), with tumours >50 mm or who were node positive, were less likely to have surgery. Although women aged 70-79 were more likely to have larger tumours, their tumours were also more likely to have an excellent or good NPI (p < 0.001). Good prognosis tumours were more likely to be screen-detected, and less likely in women aged 0-39, the deprived and certain ethnic groups (p < 0.02). CONCLUSIONS From age 70 there is an increasing failure to operate for breast cancer. Younger women and certain ethnic groups presented with more advanced tumours. Older women had larger tumours which were otherwise of good prognosis, and this would not account for the failure to operate which may in part be related to comorbidity in this age group.
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Affiliation(s)
- T Bates
- The Breast Unit, William Harvey Hospital, Ashford, Kent TN24 0LZ, UK.
| | - T Evans
- Public Health England, Knowledge and Intelligence Team (West Midlands), Birmingham B3 2PW, UK
| | - C Lagord
- Public Health England, Knowledge and Intelligence Team (West Midlands), Birmingham B3 2PW, UK
| | - I Monypenny
- Llandough University Hospital, Cardiff CF 64 2XX, UK
| | - O Kearins
- Public Health England, Cancer Screening QA Reference Centre, Birmingham B3 2PW, UK
| | - G Lawrence
- Public Health England, Knowledge and Intelligence Team (West Midlands), Birmingham B3 2PW, UK
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Morgan JL, Reed MW, Wyld L. Primary endocrine therapy as a treatment for older women with operable breast cancer - a comparison of randomised controlled trial and cohort study findings. Eur J Surg Oncol 2014; 40:676-84. [PMID: 24703110 DOI: 10.1016/j.ejso.2014.02.224] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 01/29/2014] [Accepted: 02/07/2014] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION One third of all breast cancers occur in women over the age of 70. Primary endocrine therapy (PET) is used in some women to minimise morbidity in a population with higher rates of comorbidity and frailty. In the UK up to 40% of women over 70 are treated with PET although there is a high rate of variability of practice between centres reflecting a lack of guidance about case selection. METHODS A systematic review of the literature was performed to try and establish if this form of treatment is still valid in modern breast practice. RESULTS Six randomised controlled trials (RCTs) and 31 non-randomised studies were deemed eligible. Available data demonstrate an advantage for surgery over PET in terms of disease control and a likely survival benefit in patients with a predicted life expectancy of five years or more. Patients treated only with aromatase inhibitors (AIs) had superior rates of disease control when compared to Tamoxifen. CONCLUSIONS Guidelines to aid selection are needed but PET should be reserved for patients with reduced predicted life expectancy (e.g. less than five years), with AIs being preferable over Tamoxifen.
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Affiliation(s)
- J L Morgan
- Department of Surgical Oncology, E Floor, Medical School, Royal Hallamshire Hospital, University of Sheffield, Glossop Road, Sheffield S10 2JF, UK.
| | - M W Reed
- Department of Surgical Oncology, E Floor, Medical School, Royal Hallamshire Hospital, University of Sheffield, Glossop Road, Sheffield S10 2JF, UK.
| | - L Wyld
- Department of Surgical Oncology, E Floor, Medical School, Royal Hallamshire Hospital, University of Sheffield, Glossop Road, Sheffield S10 2JF, UK.
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Charehbili A, Fontein D, Kroep J, Liefers G, Mieog J, Nortier J, van de Velde C. Neoadjuvant hormonal therapy for endocrine sensitive breast cancer: A systematic review. Cancer Treat Rev 2014; 40:86-92. [DOI: 10.1016/j.ctrv.2013.06.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 06/04/2013] [Accepted: 06/06/2013] [Indexed: 10/26/2022]
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Mrózek E, Povoski SP, Shapiro CL. The challenges of individualized care for older patients with localized breast cancer. Expert Rev Anticancer Ther 2013; 13:963-73. [PMID: 23984898 DOI: 10.1586/14737140.2013.820568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Individualized care is achieved when the appropriate screening and/or evaluative tests are used, the treatment plan is driven by evidence-based data and the patient's functional ability, physical and mental health, preference and social situation are incorporated into treatment decisions. Breast cancer is a disease of aging; yet, the management of breast cancer in older women in most cases lacks evidence from prospective randomized clinical trials (i.e., level 1 evidence) to support treatment recommendations. Older women are underrepresented in therapeutic clinical studies, even though studies show that selected fit older women enrolled on clinical trials derive similar benefits as younger women. Very few studies have focused on the distribution and biological behavior of different molecular subtypes of breast cancer in older women making it difficult to conclude whether old age adds extra biological complexity. A comprehensive geriatric assessment that includes a multidimensional process designed to assess functional ability, physical health, cognitive and mental health, social issues and environmental situation of elderly person should be an integral part of individualized care for older patients with breast cancer. However, incorporation of this tool into standard oncology practice is very slow despite the expected steep increase in older individuals with cancer projected over the next 25 years. All of the factors mentioned above hinder progress in delivering individualized care to older patients with breast cancer. This article provides an overview on progress and challenges of individualized and personalized health care in older women with breast cancer.
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Affiliation(s)
- Ewa Mrózek
- Division of Medical Oncology, The Wexner Medical Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University, Columbus, OH, USA.
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Baydoun E, Bibi M, Iqbal MA, Wahab AT, Farran D, Smith C, Sattar SA, Rahman AU, Choudhary MI. Microbial transformation of anti-cancer steroid exemestane and cytotoxicity of its metabolites against cancer cell lines. Chem Cent J 2013; 7:57. [PMID: 23537428 PMCID: PMC3637571 DOI: 10.1186/1752-153x-7-57] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 03/12/2013] [Indexed: 11/20/2022] Open
Abstract
Background Microbial transformation of steroids has been extensively used for the synthesis of steroidal drugs, that often yield novel analogues, not easy to obtain by chemical synthesis. We report here fungal transformation of a synthetic steroidal drug, exemestane, used for the treatment of breast cancer and function through inhibition of aromatase enzyme. Results Microbial transformation of anti-cancer steroid, exemestane (1), was investigated by using two filamentous fungi. Incubation of 1 with fungi Macrophomina phaseolina, and Fusarium lini afforded three new, 11α-hydroxy-6-methylene-androsta-1, 4-diene-3,17-dione (2), 16β, 17β-dihydroxy-6-methylene-androsta-1, 4-diene-3-one (3), and 17β-hydroxy-6-methylene-androsta-1, 4-diene-3, 16-dione (4), and one known metabolites, 17β-hydroxy-6-methylene-androsta-1, 4-diene-3-one (5). Their structures were deduced spectroscopically. Compared to 1 (steroidal aromatase inactivator), the transformed metabolites were also evaluated for cytotoxic activity by using a cell viability assay against cancer cell lines (HeLa and PC3). Metabolite 2 was found to be moderately active against both the cell lines. Conclusions Biotransformation of exemestane (1) provides an efficient method for the synthesis of new analogues of 1. The metabolites were obtained as a result of reduction of double bond and hydroxylation. The transformed product 2 exhibited a moderate activity against cancer cell lines (HeLa and PC3). These transformed products can be studied for their potential as drug candidates.
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Affiliation(s)
- Elias Baydoun
- American University of Beirut, Beirut, 1107 2020, Lebanon.
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Current World Literature. Curr Opin Obstet Gynecol 2013; 25:81-9. [DOI: 10.1097/gco.0b013e32835cc6b6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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