Time trends in systemic adjuvant treatment for node-negative breast cancer

Provision of breast cancer care and survival in Germany - results from a population-based high resolution study from Saarland

BACKGROUND

Studies on the implementation of Clinical Practice Guidelines (CPG) and particularly its effect on breast cancer (BRC) survival on a population-level are scant. This population-based high resolution study from Germany aims at providing data on the usage of BRC treatment, the extent of adherence to CPG and, as a novelty, survival of BRC patients according to major recommended treatment options.

METHODS

Data from the Saarland Cancer Registry including women diagnosed with invasive BRC without distant metastasis and followed up between 2000 and 2009 were used. Provision of cancer care according to major treatment options is presented by age, clinical subtypes of BRC, and over time. Conventional and modeled period analysis was used to derive estimates of most up-to-date 5-year relative survival (RS) and the effect of non-adherence to CPG on relative excess risk of death (RER).

RESULTS

The study revealed increasing guideline adherence, with high levels already seen for local treatment (e.g. 67% of the BRC patients in 2008/09 received breast conserving surgery), and substantial progress since the millennium change with regard to sentinel node dissection (SND) and adjuvant systemic treatments (e.g. SND and chemotherapy provided to 62% of all patients and 79% of the patients with nodal positive or hormone receptor negative BRC in 2008/09, respectively). It further demonstrated increased cancer related mortality among patients without guideline compliant cancer treatment (e.g. patients with nodal positive and hormone receptor negative BRC who were not treated with chemotherapy had a 5-year RS of 29% (RER: 2.89, 95% CI: 1.46-5.71) compared to 54% for patients obtaining chemotherapy).

CONCLUSIONS

This study provides data on the implementation of CPG in a highly developed European country and extends available population-based survival data of BRC patients and may provide evidence of increased cancer related excess mortality, if BRC patients do not receive guideline compatible treatment.

Adjuvant endocrine therapy initiation and persistence in a diverse sample of patients with breast cancer

Adjuvant endocrine therapy for breast cancer reduces recurrence and improves survival rates. Many patients never start treatment or discontinue prematurely. A better understanding of factors associated with endocrine therapy initiation and persistence could inform practitioners how to support patients. We analyzed data from a longitudinal study of 2,268 women diagnosed with breast cancer and reported to the Metropolitan Detroit and Los Angeles SEER cancer registries in 2005-2007. Patients were surveyed approximately both 9 months and 4 years after diagnosis. At the 4-year mark, patients were asked if they had initiated endocrine therapy, terminated therapy, or were currently taking therapy (defined as persistence). Multivariable logistic regression models examined factors associated with initiation and persistence. Of the 743 patients eligible for endocrine therapy, 80 (10.8 %) never initiated therapy, 112 (15.1 %) started therapy but discontinued prematurely, and 551 (74.2 %) continued use at the second time point. Compared with whites, Latinas (OR 2.80, 95 % CI 1.08-7.23) and black women (OR 3.63, 95 % CI 1.22-10.78) were more likely to initiate therapy. Other factors associated with initiation included worry about recurrence (OR 3.54, 95 % CI 1.31-9.56) and inadequate information about side effects (OR 0.24, 95 % CI 0.10-0.55). Factors associated with persistence included two or more medications taken weekly (OR 4.19, 95 % CI 2.28-7.68) and increased age (OR 0.98, 95 % CI 0.95-0.99). Enhanced patient education about potential side effects and the effectiveness of adjuvant endocrine therapy in improving outcomes may improve initiation and persistence rates and optimize breast cancer survival.

Adoption of gene expression profile testing and association with use of chemotherapy among women with breast cancer

PURPOSE

Gene expression profile (GEP) testing is a relatively new technology that offers the potential of personalized medicine to patients, yet little is known about its adoption into routine practice. One of the first commercially available GEP tests, a 21-gene profile, was developed to estimate the benefit of adjuvant chemotherapy for hormone receptor-positive breast cancer (HR-positive BC).

PATIENTS AND METHODS

By using a prospective registry data set outlining the routine care provided to women diagnosed from 2006 to 2008 with HR-positive BC at 17 comprehensive and community-based cancer centers, we assessed GEP test adoption and the association between testing and chemotherapy use.

RESULTS

Of 7,375 women, 20.4% had GEP testing and 50.2% received chemotherapy. Over time, testing increased (14.7% in 2006 to 27.5% in 2008; P < .01) and use of chemotherapy decreased (53.9% in 2006 to 47.0% in 2008; P < .01). Characteristics independently associated with lower odds of testing included African American versus white race (odds ratio [OR], 0.70; 95% CI, 0.54 to 0.92) and high school or less versus more than high school education (OR, 0.63; 95% CI, 0.52 to 0.76). Overall, testing was associated with lower odds of chemotherapy use (OR, 0.70; 95% CI, 0.62 to 0.80). Stratified analyses demonstrated that for small, node-negative cancers, testing was associated with higher odds of chemotherapy use (OR, 11.13; 95% CI, 5.39 to 22.99), whereas for node-positive and large node-negative cancers, testing was associated with lower odds of chemotherapy use (OR, 0.11; 95% CI, 0.07 to 0.17).

CONCLUSION

There has been a progressive increase in use of this GEP test and an associated shift in the characteristics of and overall reduction in the proportion of women with HR-positive BC receiving adjuvant chemotherapy.

Outcome differences between patients with node-negative breast cancer classified according to the st. Gallen risk categories

PURPOSE

The purpose of this study was to compare the 2007 St. Gallen risk categories with the outcomes of patients with node-negative breast cancer (NNBC).

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 1500 women with pathologically T1-T3 NNBC treated at the Clinic Hospital, Valencia University (Spain) from 1982 to 2000. Systemic adjuvant treatment was administered to 89.9% of the patients in the whole sample (37% received only hormonal therapy and 52.9% chemotherapy). The 2007 St. Gallen criteria were used to divide the whole sample into 1201 patients with intermediate risk (with > or = 1 of the following: pathologic tumor size > 2 cm, grade 2-3, estrogen receptor and progesterone receptor absent, HER2/neu gene overexpressed or amplified, or age < 35 years) and 299 patients with low risk. Of the 1201 patients with intermediate risk, 56% received adjuvant chemotherapy. The intermediate- and low-risk groups were compared for relapse-free survival (RFS) and breast cancer-specific survival (BCSS).

RESULTS

Median follow-up of the entire sample was 61 months (range, 2-251 months). At 5 years, the overall RFS rate was 86%, and the BCSS rate was 95%. For low-risk patients, the RFS rate was 92%, and the BCSS rate was 98%. For intermediate-risk patients, the RFS rate was 84%, and the BCSS rate was 94%. There was a statistically significant difference between the 2 groups in terms of RFS (P = .006) and BCSS (P = .041) independent of received treatment.

CONCLUSION

Using the St. Gallen risk categories resulted in significantly different outcomes for patients with NNBC. The St. Gallen classification might be a valuable clinical tool when assessing patients with NNBC.

Chemotherapy use for hormone receptor-positive, lymph node-negative breast cancer

PURPOSE

To describe the frequency of chemotherapy use for hormone receptor (HR)-positive, lymph node (LN)-negative breast cancer from 1997 to 2004 at eight National Comprehensive Cancer Network institutions, to explore whether chemotherapy use varied over time and between institutions, and to identify factors associated with the decision to forego chemotherapy.

PATIENTS AND METHODS

Among women younger than age 70 years with HR-positive, LN-negative breast cancer measuring more than 1 cm, we analyzed the frequency of chemotherapy use on a yearly basis. A multivariable logistic regression model assessed the relationship between receipt of chemotherapy and year of diagnosis, institution, tumor features, and patient characteristics. Interaction terms were added to the model, and stratified analyses were conducted to further explore the determinants of chemotherapy use.

RESULTS

Fifty-five percent of 3,190 women received chemotherapy. Chemotherapy use was less common for patients with 1.1- to 2-cm tumors than for patients tumors greater 2 cm (47% v 87%, respectively; P < .01) and for women age 60 to 69 years versus women younger than age 50 years (24% v 76%, respectively; P < .01). On multivariable analysis, predictors independently associated with receiving chemotherapy included larger tumor size, higher grade, human epidermal growth factor receptor 2 overexpression, younger age, and institution (P < .01 for all). Institutions exhibited dramatically different rates of chemotherapy use (from 46% to 65%) and patterns of change in chemotherapy use over time (from a 79% relative increase to a 22% relative decrease).

CONCLUSION

Although institutions seemed to agree that not all women with HR-positive, LN-negative breast cancer need chemotherapy, there did not seem to be consensus regarding which women should get chemotherapy. Only prospective randomized controlled trials will conclusively establish which subtypes of HR-positive, LN-negative breast cancer benefit from chemotherapy.

Breast Cancer Guidelines in Canada: A Review of Development and Implementation

A series of specific clinical practice guidelines (CPGs) were published in Canada in 1998. A primary objective of these 'Clinical Practice Guidelines for the Care and Treatment of Breast Cancer' was to decrease the variation in breast cancer care across the country. Prior to this, researchers found moderate compliance with consensus recommendations for breast cancer therapies in several Canadian provinces. However, a recent study concluded that the publication of the Canadian CPGs did not reduce variations in surgical care for breast cancer. If guidelines are to achieve their intended objectives, they must be implemented in ways that support, encourage, and facilitate their use. Evidence strongly suggests the simple publication and passive dissemination of CPGs are usually ineffective in changing how physicians actually care for patients. CPG implementation, therefore, requires active knowledge translation processes to ensure that the evidence is relevant to all with a stake in bettering breast cancer care. For example, implementation strategies that use computerized CPGs can make evidence-based decision-making routine practice in the clinical setting. The breast cancer community can also work with the newly formed Canadian Partnership Against Cancer to find ways to more successfully support and facilitate guideline use considering the local context.

Metastasis-related factors expressed in pT1 pN0 breast cancer: Assessment of recurrence risk

OBJECTIVES

Previous reports have indicated that small breast cancers without lymph node metastasis present a favorable prognosis. However, 10-20% of patients with T1 N0 invasive ductal carcinoma experience recurrence and have a poor prognosis. The objective of this study was to examine whether certain metastasis-related factors are prognostic of cancer recurrence in such patients at risk for relapse.

METHODS

Nineteen patients with the carcinoma who had recurrence 1-15 years after margin-free resection were examined. The control group consisted of 20 patients with pT1 pN0 invasive ductal carcinoma who had no recurrence for > or =10 years after radical surgery. The two groups were compared with respect to clinical profiles, conventional neoplastic features, and immunohistochemical expressions of 16 metastasis-related factors.

RESULTS

No significant difference was found between the two groups in clinical profiles and conventional neoplastic features. However, six factors (MMP-2, MT1-MMP, T1MP-2, VEGF, cMET, and PCNA) were significantly expressed in the recurrence group against the control group. MMP-9 was significantly less expressed in the recurrence group. Of these factors, MMP-2, MT1-MMP, and VEGF showed the highest adjusted odds ratios.

CONCLUSION

MMP family and growth factors may be promising predictors of recurrence risk of early stage breast cancer.

Evaluating the organization and delivery of breast cancer services: use of performance measures to identify knowledge gaps

OBJECTIVES

This paper identifies gaps in our knowledge about the quality of breast cancer care in Canada to understand where programs and resources are required to enhance health services and research capacity.

METHODS

A modified Delphi approach was employed involving a 15-member multidisciplinary panel of health professionals and two rounds of rating followed by deliberation to develop evidence- and consensus-based performance measures. A literature search for Canadian health services research in breast cancer was conducted based on the indicator topics. Eligible articles were identified in indexed databases of medical literature and funded research from 1995 to 2006.

RESULTS

The multidisciplinary panel selected 34 indicators spanning access to services, patient outcomes, diagnosis and staging, surgery, adjuvant therapy, pathology, and follow-up care. A total of 78 articles (66 quantitative; 12 exploratory) on these topics were reviewed. Apart from two aspects of care (communication of treatment options, supportive care), the yield of Canadian breast cancer health services research did not increase subsequent to a review conducted 10 years ago which recommended greater efforts in this area.

CONCLUSIONS

Research involving quantitative and qualitative methods is needed to increase our understanding about the organization and delivery of services for breast cancer diagnosis, treatment and follow-up care. Since it is unclear how to balance competing research demands, innovative strategies are required to assemble resources for health services research on breast cancer. This could include the promotion of partnerships between researchers and policy-makers across jurisdictions, and the pooling of resources between organizations, regions or networks.

Chemotherapy and Cardiotoxicity in Older Breast Cancer Patients: A Population-Based Study

Purpose

Adjuvant chemotherapy, especially with anthracyclines, is known to cause acute and chronic cardiotoxicity in breast cancer patients. We studied the cardiac effects of chemotherapy in a population-based sample of breast cancer patients aged ≥ 65 years with long-term follow-up.

Patients and Methods

In the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we analyzed treatments and outcomes among women ≥ 65 years of age who were diagnosed with stage I to III breast cancer from January 1, 1992 to December 31, 1999. Propensity scores were used to control for baseline heart disease (HD) and other known predictors of chemotherapy, and Cox proportional hazards models were used to estimate the risk of cardiomyopathy (CM), congestive heart failure (CHF), and HD after chemotherapy.

Results

Of 31,748 women with stage I to III breast cancer, 5,575 (18%) received chemotherapy. Chemotherapy was associated with younger age, fewer comorbidities, hormone receptor negativity, multiple primary tumors, and advanced disease. Patients who received chemotherapy were less likely than other patients to have pre-existing HD (45% v 55%, respectively; P < .001). The hazard ratios for CM, CHF, and HD for patients treated with doxorubicin (DOX) compared with patients who received no chemotherapy were 2.48 (95% CI, 2.10 to 2.93), 1.38 (95% CI, 1.25 to 1.52), and 1.35 (95% CI, 1.26 to 1.44), respectively. The relative risk of cardiotoxicity among patients who received DOX compared with untreated patients remained elevated 5 years after diagnosis.

Conclusion

When baseline HD was taken into account, chemotherapy, especially with anthracyclines, was associated with a substantially increased risk of CM. As the number of long-term survivors grows, identifying and minimizing the late effects of treatment will become increasingly important.

Multivariate prognostic evaluation of the mitotic activity index and fibrotic focus in node-negative invasive breast cancers

We validated with univariate and multivariate (Cox) analysis, the prognostic value of the mitotic activity index (MAI), the fibrotic focus (FF) and other prognosticators in 448 patients with lymph node-negative (LN-) invasive breast cancer <55 years without adjuvant systemic treatment (72.5 months median follow-up, range 4-119). Of these patients, 24.8% developed distant and 1.6% loco-regional recurrence. FF showed excellent inter-observer reproducibility (kappa = 0.93). Strong prognosticators were MAI, grade, nuclear atypia, FF and the St. Gallen criterion (SG). The subgroup with excellent survival selected by SG was only 16% of all patients, implying over-treatment of more than 70% of all LN- patients when using SG as adjuvant therapy selection criterion. If MAI <10, 13% showed distant metastases, contrasting with 41% if MAI > or = 10. FF was prognostic in the ductal and mixed ductal cancers, but not in the lobular and other subtype cancers. Patients with invasive (mixed) ductal cancers with FF absent, FF < 1/3 or FF > 1/3 of the tumour area, had distant metastasis rates of 17%, 35% and 48%; in MAI < 10 and FF absent, FF < 1/3 or FF > 1/3, metastasis rates were 11%, 13% and 42% and if MAI > or = 10, metastasis rates were 31%, 48% and 50%, respectively. In the 12 patients with MAI < 10 and a large FF > 1/3, event-free survival was similar to patients with MAI > or = 10. With multiple regression MAI < 10 versus > or = 10 is the strongest prognosticator (also stronger than the SG). The FF may be important as it has additional prognostic value to the MAI in the small subgroup of invasive ductal or mixed-ductal breast cancer patients with combined MAI < 10 and an FF > 1/3 of the tumour area.

Reducing the Global Breast Cancer Burden: The Importance of Patterns of Care Research

Breast cancer treatment guidelines are not uniformly followed in clinical practice, with evidence for substantial variations in treatment patterns, quality of care, and patient outcomes among and within countries. The factors that drive treatment decisions are unclear. Furthermore, the impact of different treatment strategies on survival is poorly understood outside the clinical trial setting. Sources of patterns of care information often have limitations in completeness, quality, timeliness of reporting, and relevance to the larger population. Patterns of care studies frequently lack details on cancer stage at diagnosis, tumor biology, and treatment received. It is difficult to compare data between studies and/or track changes over time because of variations in data sources and collection techniques. Thus, the design and implementation of a global registry is sorely needed in order to prospectively evaluate worldwide patterns of care and outcomes in patients with breast cancer. Components of this registry should include random selection of centers of variable practice settings in multiple countries and accurate and rapid data reporting at prestudy and follow-up timepoints. Data collected would include tumor and demographic factors, staging information, treatment rendered, and survival. Variables that influenced the treatment selected would be assessed. This unique international effort would allow the development of strategies to improve diagnostic and treatment-related standards of care and survival outcomes, thus reducing the breast cancer burden worldwide.

Population-Based Assessment of Surgical Treatment Trends for Patients With Melanoma in the Era of Sentinel Lymph Node Biopsy

Purpose

The surgical staging of melanoma dramatically changed with the introduction of sentinel lymph node (SLN) biopsy. In this study, Surveillance, Epidemiology, and End Results (SEER) data were examined to determine how surgical treatment is being carried out and whether SLN biopsy is being performed in melanoma patients in conformance with National Comprehensive Cancer Network (NCCN) guidelines.

Patients and Methods

The SEER database (1998 to 2001) was searched for all patients with invasive melanoma. NCCN guidelines were used to define optimal stage-specific surgical treatment. Treatment trends in patients with stages I to III disease were summarized, and multivariate analyses were performed to identify factors associated with nonadherence with treatment guidelines.

Results

A total of 21,867 melanoma patients were identified; 18,499 of these patients met the inclusion criteria. The number of patients diagnosed with stage III melanoma increased by 55.7% over the study period, and this corresponded to a 53% increase in the number of SLN biopsies performed annually. The odds ratios for nonadherence were 2.32, 2.27, and 1.54 for stages IB, II, and III disease, respectively, compared with stage IA melanoma. Multivariate analyses revealed that age more than 65 years, marital status, minority populations, and primary tumor location were associated with nonadherence with guidelines. Treatment patterns among tumor registries also varied significantly.

Conclusion

Stage migration is evident in the SEER registries in consort with increasing use of SLN biopsy. Although treatment trends are improving, SLN biopsy continues to be underused, particularly in the elderly and minority populations, in patients with truncal and head/neck melanomas, and also in some geographic regions of the United States.

The benefit of participating to clinical research

We assessed the impact of participating to clinical research among 1727 women with localized breast cancer. Using as referent individuals not treated according to guidelines for systemic therapy, the adjusted hazard ratio of death was 0.70 (95% confidence interval (CI): 0.54,0.90, p-value: 0.006) in those treated according to current guidelines and 0.45 (95% CI: 0.27,0.73, p-value: 0.001) in participants to research. Participation to clinical trials results in a substantial gain in survival.

A population-based study of the impact of delaying radiotherapy after conservative surgery for breast cancer

BACKGROUND

Practice guidelines have set a maximum waiting time to radiation therapy for breast cancer. We evaluated if delaying radiotherapy resulted in worse outcomes in a large cohort of women with node-negative breast cancer.

METHODS

We selected a random sample of cases among women diagnosed with localized breast cancer in five regions of Québec, Canada, between 1988 and 1994. Only women with pathologically (n = 926) or clinically (n = 136) negative axillary nodes, and stage 1 or 2 disease treated with conservative surgery and radiotherapy were eligible. Information was obtained by chart review, queries to physicians and linkage with administrative databases. Outcomes were estimated by Kaplan-Meier method and Cox proportional hazards analysis. Median follow-up was 7.1 years (range: 0.9-11.8).

RESULTS

Median delay to radiotherapy was 12.4 weeks in those who received chemotherapy and 8.4 weeks in others. Overall survival at 7 years was 85.6%. Local relapse-free and distant disease-free survivals were 77.6 and 76.2%. There was no significant difference in survival according to delay to radiotherapy in crude or multivariate analysis adjusting for several prognostic factors, including systemic treatment. The risk of local failure conditional on survival in women who received radiotherapy more than 12 weeks after surgery was increased (hazard ratio: 1.75, 95% confidence interval: 1.00, 3.08, p-value = 0.052).

CONCLUSIONS

Although longer waiting time to radiotherapy may compromise local control, it does not influence survival at 7 years when other predictors of outcomes are taken into account. Well controlled studies are needed to confirm and better characterize this relationship.

Internal Mammary Node Drainage and its Role in Sentinel Lymph Node Biopsy: The Initial ALMANAC Experience

This study was designed to identify the frequency of internal mammary drainage in patients undergoing sentinel lymph node (SLN) lymphoscintigraphy in a controlled clinical trial. The practicability and relevance of internal mammary SLN biopsy as a method to improve nodal staging and treatment in breast cancer were investigated. A total of 707 evaluable patients with invasive breast cancer underwent SLN biopsy based on lymphoscintigraphy, intraoperative g probe detection, and blue dye mapping using technetium Tc 99m albumin colloid and Patent Blue V injected peritumorally. This was followed by standard axillary treatment in the same operation in all patients. Lymphoscintigraphy showed internal mammary sentinel nodes in 62 patients (9%), and internal mammary drainage was identified perioperatively in an additional 7 patients (1%) using g probe detection. Sampling of the internal mammary basin, based on the results of lymphoscintigraphy and g probe detection, was done in 31 of 69 patients (45%). One patient had a pneumothorax and 2 experienced bleeding during internal mammary sampling. Internal mammary metastases were detected in 4 of 31 patients (13%). In 2 of the patients (6%), internal mammary nodes (IMNs) showed metastatic involvement without accompanying axillary metastases. One of these 2 patients would have received adjuvant endocrine systemic therapy because of the characteristics of the tumor, but may not have been recommended to receive adjuvant chemotherapy. Sampling of the internal mammary basin led to a change of management in these 2 patients, ie, institution of adjuvant chemotherapy. Therefore, a change in management occurred in only 2 of the 69 patients in our series, but 38 patients with unbiopsied "hot" IMNs remained with unknown internal mammary status. Biopsy of IMNs alters staging in few patients, and the impact on indication for adjuvant treatment was low. Internal mammary SLN biopsy may be associated with some additional morbidity. Current evidence suggests that internal mammary SLN biopsy is still a research tool.

Compliance With Consensus Recommendations for Systemic Therapy Is Associated With Improved Survival of Women With Node-Negative Breast Cancer

Purpose

The impact of consensus recommendations for systemic therapy on outcome of disease is unclear. We evaluated if compliance with guidelines for systemic adjuvant treatment is associated with improved survival of women with node-negative breast cancer.

Patients and Methods

The study population included women diagnosed with invasive node-negative breast cancer in Québec, Canada, in 1988 to 1989, 1991 to 1992, and 1993 to 1994. Information was collected by chart review, linkage with administrative databases, and queries to attending physicians. Guidelines from the 1992 St Gallen conference were used as standard of care. Survival was estimated by Kaplan-Meier and Cox proportional hazards analyses.

Results

Among 1,541 women, 358 died before December 1999. Median follow-up was 6.8 years. Seven-year event-free and overall survivals were 66% and 81%, respectively. Survival was 88%, 84%, and 74% in women at minimal, moderate, or high risk of recurrence. Virtually all women at minimal risk were treated according to the consensus (98.4% of 370). In comparison, adjusted hazard ratios of death were 1.0 (95% CI, 0.6 to 1.7) and 2.3 (95% CI, 1.3 to 4.0) among women at moderate risk treated according to the consensus or not, respectively. Among women at high risk, adjusted hazard ratios of death were 2.0 (95% CI, 1.4 to 2.8) and 2.7 (95% CI, 1.9 to 3.9), respectively. Both risk category (P < .0005) and compliance with guidelines (P < .0005) were independent significant predictors of survival.

Conclusion

Treatment according to consensus recommendations is associated with improved survival of women with breast cancer in the community. Promoting the adoption of guidelines for treatment is an effective strategy for disease control.

Determinants and prognoses of locoregional and distant progression in breast cancer

PURPOSE

To describe locoregional and distant progression in a population-based breast cancer sample.

METHODS AND MATERIALS

Between 1978 and 1998, the Munich Cancer Registry evaluated 14,429 patients. The mean follow-up of survivors was 8.3 years. Metastases (MET), local recurrence (LR), and lymph node recurrence (LNR) were considered as outcome measures. The prognostic factor for, and effects of, LR and MET were assessed multivariately by the Cox and dynamic Aalen models.

RESULTS

The LR and MET rate increased with increasing tumor size, with the latter described by pT category. Distant MET occurred earlier than local progression. MET was recorded even earlier for MET alone. The mean time from diagnosis to MET for MET and LR was 54.9, 43.4, 29.4, and 24.7 months and for MET only was 36.5, 31.0, 22.6, and 12.9 months for pT1, pT2, pT3, and pT4, respectively. After MET, survival varied only slightly by pT stage; after LR, a more favorable prognosis, especially for pT1 and pT2, was evident. The prognosis after MET depended mainly on the MET location; 50% of patients with cerebral or nervous system MET survived <1 year and 50% of those with skeletal MET survived >2 years. In the Cox model, the relative risk of LR for MET was 3.0. In the Aalen model, after 30 months, when the hazard rates of MET began to decline, there was still an excess risk of MET after LR.

CONCLUSION

This disease description highlights the importance of long-term observational studies. Empiric evidence that LR is both an indicator for, and in part a cause of, MET has been provided. In the future, the MET location should be reported. Variations in guidelines or health care systems that influence the time to MET and survival after MET through different diagnostic procedures should also be considered.

Long-term quality of life in premenopausal women with node-negative localized breast cancer treated with or without adjuvant chemotherapy

Our purpose was to evaluate the late physical and psychosocial difficulties of premenpausal patients treated for a localized breast cancer and to weigh the impact of chemotherapy on long-term quality of life. Two self-administered questionnaires, the EORTC core QLQ-C30 and the breast module (BR23) were mailed to 179 premenopausal node-negative women continuously disease-free, previously enrolled in a trial testing the efficacy of adjuvant CMF chemotherapy (Espié et al, 1997). The core questionnaire evaluates the physical, role, emotional, cognitive and social functioning and global health status. The breast module includes four functional scales: body image, sexual functioning, sexual enjoyment and future perspective. It also includes symptom scales such as arm or breast symptoms. Some specific professional and social states were added. 119 (68%) patients (mean age 54 years, range 30-69) participated. Mean follow-up time since diagnosis was 9.6 years (4-16). 68% had conservative and 32% radical surgery (with reconstructive surgery in 50%). CMF was given to 77 (65%) patients. Irradiation was administered in 75% of patients irrespective of adjuvant therapy. QLQ-C30 scale scores were similar in patients who had or had not received chemotherapy. Disturbance in body image, sex life and breast symptoms did not differ between patients who had or had not received adjuvant CMF. No major socioprofessional difficulties were reported except problems in borrowing from banks not related to past chemotherapy. With long follow-up, most premenopausal women treated for a localized breast cancer cope with the disease and its treatments. Adjuvant CMF chemotherapy does not appear to impair quality of life nor social and professional life in these patients.

Clinical relevance of sentinel lymph nodes outside the axilla in patients with breast cancer

BACKGROUND

Lymphatic mapping in patients with breast cancer can reveal sentinel lymph nodes that are not located at level I-II of the axilla. Little is known about the clinical relevance of these nodes.

METHODS

Some 113 consecutive patients with clinical stage T1-3 N0 M0 breast cancer were studied. Based on preoperative lymphoscintigraphy, sentinel node biopsy was performed guided by a gamma probe and patent blue dye. All sentinel nodes that were visible on lymphoscintigraphy were sought. Pathological examination of the sentinel nodes included step-sections and staining with CAM 5. 2. Axillary node dissection was performed regardless of sentinel lymph node status.

RESULTS

Twenty-one (19 per cent) of 113 patients had sentinel lymph nodes outside level I-II of the axilla, mostly in the internal mammary chain. Twenty-two of the 30 sentinel nodes at these sites were harvested. Three patients had sentinel nodes only outside the axilla. Four other patients had metastases outside the axilla. This changed postoperative treatment in three patients. No postoperative complication occurred.

CONCLUSION

Sentinel lymph nodes outside level I-II of the axilla were present in 19 per cent of patients with breast cancer in this series. Biopsy of these nodes was technically demanding but was performed without additional morbidity. The clinical impact was limited; treatment changed in only 3 per cent. Presented to the 52nd annual meeting of the Society of Surgical Oncology in Orlando, Florida, USA, March 1999 and the First International Congress on the Sentinel Node in Diagnosis and Treatment of Cancer in Amsterdam, The Netherlands, April 1999, and published in abstract form as Eur J Nucl Med 1999; 26(Suppl): S71