Prognostic validation and treatment decision making of the 8th edition of the American Joint Committee on Cancer pathological staging system for elderly women with early-stage breast cancer

Purpose: To determine the prognostication and treatment decision making of the American Joint Committee on Cancer (AJCC) 8^th pathological staging system in elderly women (aged ≥65 years) with T1-2N0M0 breast cancer (BC).

Results: We included 67699 patients, and patients were restaged into stage IA (84.9%), IB (8.9%), and IIA (6.2%) using the 8^th AJCC edition criteria. Overall, 69.4% and 30.6% of them underwent breast-conservation surgery (BCS) and mastectomy (MAST), respectively. In patients who received BCS, 30.3% of them underwent postoperative radiotherapy (RT). Patients with a higher pathological stage were more likely to receive MAST. The 5-year breast cancer-specific mortality rate was 2.2%, 6.5% and 13.7% in stage IA, IB, and IIA, respectively. Patients treated with BCS and RT had significantly lower risk of breast cancer-specific mortality compared to those treated with MAST or with BCS alone regardless of the pathological prognostic stages (P<0.001).

Conclusions: The 8^th AJCC pathological prognostic staging system provides accurate risk stratification and impacts the treatment decision making for elderly women with early-stage BC.

Methods: We identified stage T1-2N0M0 BC patients using the Surveillance, Epidemiology, and End Results database. Statistical analyses were used binomial logistic regression, and multivariable competing risk models in the Cox model framework.

Does persistent use of radiation in women > 70 years of age with early-stage breast cancer reflect tailored patient-centered care?

PURPOSE

Randomized controlled trials demonstrate that omission of radiation therapy (RT) in older women with early-stage cancer undergoing breast conserving surgery (BCS) is an "acceptable choice." Despite this, high RT rates have been reported. The objective was to evaluate the impact of patient- and system-level factors on RT rates in a contemporary cohort.

METHODS

Through the National Cancer Data Base, we identified women with clinical stage I estrogen receptor-positive breast cancer who underwent BCS (n = 84,214). Multivariable logistic regression identified patient, tumor, and system-level factors associated with RT. Joinpoint regression analysis calculated trends in RT use over time stratified by age and facility-type, reporting annual percent change (APC).

RESULTS

RT rates decreased from 2004 (77.2%) to 2015 (64.3%). The decline occurred earliest and was most pronounced in older women treated at academic facilities. At academic facilities, the APC was - 5.6 (95% CI - 8.6, - 2.4) after 2009 for women aged > 85 years, - 6.4 (95% CI - 9.0, - 3.8) after 2010 for women aged 80 -  < 85 years, - 3.7 (95% CI - 5.6, - 1.9) after 2009 for women aged 75 -  < 80, and - 2.4 (95% CI, - 3.1, - 1.6) after 2009 for women aged 70 -  < 75. In contrast, at community facilities rates of RT declined later (2011, 2012, and 2013 for age groups 70-74, 75-79, and 80-84 years).

CONCLUSIONS

RT rates for older women with early-stage breast cancer are declining with patient-level variation based on factors related to life expectancy and locoregional recurrence. Facility-level variation suggests opportunities to improve care delivery by focusing on barriers to de-implementation of routine use of RT.

Addressing frailty in patients with breast cancer: A review of the literature

Various studies have documented variation in the management of older patients with breast cancer, and some of this variation stems from different approaches to balancing the expected benefit of different treatments, with the ability of patients to tolerate them. Frailty is an emerging concept that can help to make clinical decisions for older patients more consistent, not least by providing a measure of 'biological' ageing. This would reduce reliance on 'chronological' age, which is not a reliable guide for decisions on the appropriate breast cancer care for older patients. This article examines the potential of frailty assessment to inform on breast cancer treatments. Overall, the current evidence highlights various benefits from implementing comprehensive geriatric assessment and screening for frailty in breast cancer patients. This includes a role in supporting the selection of appropriate therapies and improving physical fitness prior to treatment. However, there are challenges in implementing routine frailty assessments in a breast cancer service. Studies have used a diverse array of frailty assessment instruments, which hampers the generalisability of research findings. Consequently, a number of issues need to be addressed to clearly establish the optimal timing of frailty assessment and the role of geriatric medicine specialists in the breast cancer care pathway.

Receipt of Guideline-Concordant Care Among Older Women With Stage I-III Breast Cancer: A Population-Based Study

Background: This study examined receipt of guideline-concordant care (GCC) according to evidence-based treatment guidelines and quality measures and specific types of treatment among older women with breast cancer. Patients and Methods: A total of 142,433 patients aged ≥66 years diagnosed with stage I-III breast cancer between 2007 and 2011 were identified in the SEER-Medicare linked database. Algorithms considering cancer characteristics and the appropriate course of care as per guidelines versus actual care received determined receipt of GCC. Multivariable logistic regression estimated the likelihood of GCC and specific types of treatment for women aged ≥75 versus 66 to 74 years. Results: Overall, 39.7% of patients received GCC. Patients diagnosed at stage II or III, with certain preexisting conditions, and of nonwhite race were less likely to receive GCC. Patients with hormone-negative tumors, higher grade tumors, and greater access to oncology care resources were more likely to receive GCC. Patients aged ≥75 years were approximately 40% less likely to receive GCC or adjuvant endocrine therapy, 78% less likely to have any surgery, 61% less likely to have chemotherapy, and about half as likely to have radiation therapy than those aged 66 to 74 years. Conclusions: Fewer than half of older women with breast cancer received GCC, with the lowest rates observed among the oldest age groups, racial/ethnic minorities, and women with later-stage cancers. However, patients with more aggressive tumor characteristics and greater access to oncology resources were more likely to receive GCC. Considering that older women have the highest incidence of breast cancer and that many are diagnosed at stages requiring more aggressive treatment, efforts to increase rates of earlier stage diagnosis and the development of less toxic treatments could help improve GCC and survival while preserving quality of life.

Are Providers and Patients Following Hormonal Therapy Guidelines for Patients Over the Age of 70? The Influence of CALGB 9343

BACKGROUND

The Cancer and Leukemia Group B (CALGB) 9343 clinical trial proved that omission of radiotherapy (RT) in patients 70 and older with T1cN0M0, estrogen receptor-positive tumors who undergo breast conservation therapy (BCT) and receive 5 years of endocrine therapy (ET) had no change in overall survival, distant disease-free survival, or breast preservation. We examined our institution's practice with this patient subset.

PATIENTS AND METHODS

A single-institution retrospective chart review was performed on patients 70 years and older with T1N0M0, estrogen receptor-positive tumors, and who underwent BCT between April 2010 and October 2015.

RESULTS

A total of 123 patients met inclusion criteria: 46% received RT and 73% received ET. The ET group had a mean age of 76.2 years, whereas the non-ET group had a mean age of 80.2 years (P = .00006). Race did not influence if patients received ET (P = .4). In patients who received ET, mean age at time of diagnosis for those that completed 5 years of therapy was 75.5 years, whereas those who stopped therapy early had a mean age of 77.6 years (P = .053). In patients who received ET but stopped early, reasons for cessation included side-effect profile (67%), death (22%), and noncompliance (11%). Of the 27% of patients that did not receive ET, 62% were not offered therapy, 24% refused, and 14% were lost to postoperative follow-up.

CONCLUSION

Increasing age showed significant association to not receive ET. Contraindication to ET and provider's assessment of minimal benefit are the most common reasons why patients are not prescribed ET. If patients are non-compliant with ET, RT should be reconsidered.

Disparities in the Initial Local Treatment of Older Women with Early-Stage Breast Cancer: A Population-Based Study

BACKGROUND

Although breast cancer is most prevalent among older women, the majority are diagnosed at an early stage. When diagnosed at an early stage, women have the option of breast-conserving surgery (BCS) plus radiation therapy (RT) or mastectomy for the treatment of early-stage breast cancer (ESBC). Omission of RT when receiving BCS increases the risk for recurrence and poor survival. Yet, a small subset of older women may omit RT after BCS. This study examines the current patterns of local treatment for ESBC among older women.

METHODS

This study conducted a retrospective observational analysis using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset of women age ≥66 diagnosed with stage I-II breast cancer in 2003-2009. SEER-Medicare data was additionally linked with data from the Area Resource File (ARF) to examine the association between area-level healthcare resources and treatment. Two logistic regression models were used to estimate how study factors were associated with receiving (1) BCS versus BCS+RT and (2) Mastectomy versus BCS+RT. A stratified analysis was also conducted among women aged <70 years.

RESULTS

Among 45,924 patients, 55% received BCS+RT, 23% received mastectomy, and 22% received BCS only. Women of increasing age, comorbidity, primary care provider visits, stage II disease, and nonwhite race were more likely to have mastectomy or BCS only, than BCS+RT. Women diagnosed in 2004-2006, treated by an oncology surgeon, residing in metro areas, areas of greater education and income, were less likely to receive mastectomy or BCS only, than BCS+RT. While women aged <70 years were more likely to receive BCS+RT, socioeconomic and physician specialties were associated with receiving BCS only.

CONCLUSIONS

Over half of older women with ESBC initially receive BCS+RT. The likelihood for mastectomy and BCS only increases with age, comorbidity, and vulnerable socio-demographic characteristics. Findings demonstrate continued treatment disparities among certain vulnerable populations.

Comparison of the Initial Loco-Regional Treatment Received for Early-Stage Breast Cancer between Elderly Women in Appalachia and a United States - Based Population: Good and Bad News

BACKGROUND

Breast conserving surgery (BCS) followed by radiation therapy (RT) (BCS+RT) is as effective for long-term survival of invasive early-stage breast cancer (ESBC) as mastectomy, and is the local treatment option selected by the majority of women with ESBC. Women of older age and vulnerable socio-demographic characteristics are at greater risk for receiving substandard (BCS only) and non-preferred treatments (mastectomy), such as populations of women from the Appalachian region of United States.

METHODS

Using a retrospective cohort study design, we identified 26,106 patients from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset and 811 patients from the West Virginia Cancer Registry (WVCR)-Medicare dataset age ≥ 66 diagnosed from 2003 to 2006 with stage I-II breast cancer. Multivariable logistic regression models estimated type of initial treatment received between WVCR-Medicare and SEER-Medicare patients, and the association with type of treatment.

RESULTS

Overall, women in WV were 0.82 (95% CI 0.68-0.99) and 0.70 (95% CI 0.58-0.84) times less likely to have mastectomy or BCS only vs. BCS+RT, than those in SEER regions. Women in WV of increasing age, greater comorbidity, stage II disease, and non-white race were more likely to have mastectomy or BCS only vs. BCS+RT, whereas, those residing in areas of higher income, higher education, and metro status were less likely, than similarly characterized women from SEER regions.

CONCLUSIONS

Findings from this study suggest that the magnitude of disparities in breast cancer treatment between groups of women with more and less resources are even greater in the Appalachian region, than they are among US populations. Improving access to oncology treatment services, as well as, the implementation of patient navigation programs are needed to improve patterns of initial treatment for ESBC among at-risk populations.

Impact of pitch angle setup error and setup error correction on dose distribution in volumetric modulated arc therapy for prostate cancer

In volumetric modulated arc therapy (VMAT) for prostate cancer, a positional and rotational error correction is performed according to the position and angle of the prostate. The correction often involves body leaning, and there is concern regarding variation in the dose distribution. Our purpose in this study was to evaluate the impact of body pitch rotation on the dose distribution regarding VMAT. Treatment plans were obtained retrospectively from eight patients with prostate cancer. The body in the computed tomography images for the original VMAT plan was shifted to create VMAT plans with virtual pitch angle errors of ±1.5° and ±3°. Dose distributions for the tilted plans were recalculated with use of the same beam arrangement as that used for the original VMAT plan. The mean value of the maximum dose differences in the dose distributions between the original VMAT plan and the tilted plans was 2.98 ± 0.96 %. The value of the homogeneity index for the planning target volume (PTV) had an increasing trend according to the pitch angle error, and the values of the D 95 for the PTV and D 2ml, V 50, V 60, and V 70 for the rectum had decreasing trends (p < 0.05). However, there was no correlation between differences in these indexes and the maximum dose difference. The pitch angle error caused by body leaning had little effect on the dose distribution; in contrast, the pitch angle correction reduced the effects of organ displacement and improved these indexes. Thus, the pitch angle setup error in VMAT for prostate cancer should be corrected.

A Nomogram to Predict the Benefit of Radiation Therapy After Breast-Conserving Surgery in Elderly Patients with Stage I & ER-Negative, or Stage II/III Disease

BACKGROUND

Radiotherapy (RT) may be omitted for elderly (age >70 years) breast cancer patients with favorable disease [stage I and estrogen receptor (ER)-positive with endocrine therapy]. This study sought to develop a nomogram to predict the survival benefit of RT in elderly patients with stage I & ER-negative or stage II/III (regardless of ER status) disease.

METHODS

We used surveillance, epidemiology and end results data to identify 9,079 patients (age ≥70 years) with stage I & ER-negative or stage II/III (regardless of ER status) disease who received breast-conserving surgery between 1990 and 2005. Cancer-specific survival (CSS) was estimated using Kaplan-Meier analysis. Competing-risk regression was used to determine the effect of predictors on CSS. A nomogram was then developed and validated using bootstrapped technique.

RESULTS

With a median follow-up of 83 months, the overall 10- and 15-year CSS were 82.1 and 75.8 %, respectively. RT was significantly associated with improved CSS in the multivariate analysis. A nomogram was developed for the prediction of 10-year CSS and showed a bootstrapped-corrected area under the curve value of 0.679. RT did not deliver any survival benefit to patients with predicted CSS >90 %. In addition, RT significantly increased the 10-year CSS by 3.6 and 10.1 % in patients with predicted CSS from 0.80 to 0.90 and <0.80, respectively.

CONCLUSIONS

This nomogram is a useful tool to predict the 10-year CSS in patients with stage I and ER-negative or stage II/III (regardless of ER status) disease. The benefit of RT varied among patients with different predicted CSS.

Deviation from the Standard of Care for Early Breast Cancer in the Elderly: What are the Consequences?

BACKGROUND

For elderly patients with early-stage breast cancer, the standards of care often are not strictly followed due to either clinician biases or patient preferences. The authors hypothesized that forgoing radiation and lymph node (LN) staging for elderly patients with early-stage breast cancer would have a negative impact on survival.

METHODS

From the Surveillance, Epidemiology, and End Results Program database, 53,619 women older than 55 years with stage 1 breast cancer who underwent breast conservation surgery were identified. Analyses were performed to compare the characteristics and outcomes of patients who received the standards of care with LN sampling and radiation and those of patients who did not, with control used for confounders. To account for selection bias from covariate imbalance, propensity score matching was performed. Survival was analyzed using the Kaplan-Meier method.

RESULTS

Older patients were less likely to receive radiation and LN sampling. These standards of care were associated with improved overall survival rates of 15.8 and 27.1 % after 10 years, respectively (p ≤ 0.0001). This survival advantage persisted after propensity score matching, with a 7.4 % higher survival rate for patients who received radiation and a 16.8 % higher survival rate for those who underwent LN staging (p < 0.0001). Lymph node sampling and radiation therapy also conferred a statistically significant improvement in breast cancer-specific survival, with 1.3 and 2.6 % lower mortality rates respectively in the radiated and LN biopsy groups (p < 0.0001).

CONCLUSIONS

As patients age, they are less likely to receive the standard of care for stage 1 breast cancer. Even after controlling for other factors, the study showed that failure to adhere to the standards of LN sampling and radiation therapy may have a negative impact in survival.

Accelerated partial breast irradiation in the elderly: 5-year results of high-dose rate multi-catheter brachytherapy

Objective

To evaluate clinical outcome after accelerated partial breast irradiation (APBI) in the elderly after high-dose-rate interstitial multi-catheter brachytherapy (HIBT).

Methods and materials

Between 2005 and 2013, 70 patients underwent APBI using HIBT. Catheter implant was performed intra or post-operatively (referred patients) after lumpectomy and axillary sentinel lymph node dissection. Once the pathological results confirmed the indication of APBI, planification CT-scan was performed to deliver 34 Gy/10f/5d or 32 Gy/8f/4d. Dose-volume adaptation was manually achieved (graphical optimization). Dosimetric results and clinical outcome were retrospectively analyzed. Physician cosmetic evaluation was reported.

Results

With a median follow-up of 60.9 months [4.6 – 90.1], median age was 80.7 years [62 – 93.1]. Regarding APBI ASTRO criteria, 61.4%, 18.6% and 20% were classified as suitable, cautionary and non-suitable respectively. Axillary sentinel lymph node dissection was performed in 94.3%; 8 pts (11.5%) presented an axillary involvement. A median dose of 34 Gy [32 – 35] in 8 to 10 fractions was delivered. Median CTV was 75.2 cc [16.9 – 210], median D90 EQD2 was 43.3 Gy [35 – 72.6] and median DHI was 0.54 [0.19 – 0.74]. One patient experienced ipsilateral recurrence (5-year local free recurrence rate: 97.6%. Five-year specific and overall survival rates were 97.9% and 93.2% respectively. Thirty-four patients (48%) presented 47 late complications classified grade 1 (80.8%) and grade 2 (19.2%) with no grade ≥ 3. Cosmetic results were considered excellent/good for 67 pts (95.7%).

Conclusion

APBI using HIBT and respecting strict rules of implantation and planification, represents a smart alternative between no post-operative irradiation and whole breast irradiation delivered over 6 consecutive weeks.

Long-term outcome of neoadjuvant endocrine therapy with aromatase inhibitors in elderly women with hormone receptor-positive breast cancer

Background

Aromatase inhibitors (AIs) are more effective than tamoxifen as neoadjuvant endocrine therapy (NET) for hormone receptor (HR)-positive breast cancer. Here we report the surgical and long-term outcome of elderly postmenopausal patients with locally advanced, HR-positive breast cancer treated with preoperative AIs.

Methods

Between January 2003 and December 2012, 144 postmenopausal patients inoperable with breast conservative surgery (BCS) received letrozole, anastrozole, or exemestane as NET. Patients underwent breast surgery and received adjuvant AIs. Adjuvant systemic therapy, chemotherapy and/or trastuzumab, and adjuvant radiotherapy were administered as appropriate, but limited to high-risk patients with few or no comorbidities.

Results

After a median follow-up of 49 months, 4 (3.0 %) patients had local relapse, 18 (12.5 %) had distant metastases, and 24 (17.0 %) died. BCS was performed in 121 (84.0 %) patients. A tumor size <3 cm and human epidermal growth factor receptor 2 (HER2) negativity were predictors of BCS. The achievement of BCS and grade G1 were significantly associated with longer disease-free survival (DFS) (p = 0.009 and p = 0.01, respectively) and overall survival (p = 0.002 and p = 0.005, respectively). Residual tumor ≤2 cm (yT0–yT1) in the longest diameter after NET was also statistically associated with longer DFS (p = 0.005).

Conclusions

The results of this retrospective study indicate that elderly breast cancer patients with a tumor size <3 cm at diagnosis and HER2 negativity have a higher probability of achieving BCS after NET. Moreover, patients treated with BCS and with grade G1 tumor have a reduced risk of recurrence and death in the long-term follow-up.