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Iles K, Strassle PD, Agala CB, Button J, Downs-Canner S. Surgical Axillary Staging Before Neoadjuvant Chemotherapy: Who Gets It and Why We Should Avoid It. Ann Surg Oncol 2021; 28:5788-5797. [PMID: 34379251 DOI: 10.1245/s10434-021-10628-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical axillary staging demonstrating positive nodal disease before neoadjuvant chemotherapy (NAC) necessitates axillary lymph node dissection (ALND) post-NAC. Despite evidence supporting post-NAC surgical staging, we hypothesized that there is persistent use of pre-NAC staging and that it is associated with aggressive clinicopathologic features and a higher rate of subsequent ALND. PATIENTS AND METHODS Stage I-III breast cancer patients who underwent lymph node staging surgery and received NAC between 2013 and 2017 in the National Cancer Database were included. Sequence of staging surgery and chemotherapy administration was determined. Multivariable regression was used to assess characteristics associated with pre-NAC staging. Rate of ALND was compared between those who had pre- and post-NAC surgical axillary staging. RESULTS In total, 120,538 met inclusion; 68% received NAC first and 32% had pre-NAC staging. Pre-NAC staging surgery was associated with younger age (age < 30 versus 40-49 years, HR 1.1) and decreased with older age (ages 70-79/80+ versus 40-49 years, HR 0.86 and 0.73). Advancing clinical T stage, lobular subtype, higher grade, and HR+/HER2- subtype were also associated with pre-NAC surgical staging. Women who underwent pre-NAC surgical staging were more likely to undergo ALND. CONCLUSIONS Over 30% of women underwent surgical axillary staging prior to NAC, resulting in higher rates of ALND in this cohort. While certain features suggestive of aggressive behavior (grade and T stage) were associated with pre-NAC surgical axillary staging, women with more aggressive tumor subtypes (triple negative/HER2+) were less likely to undergo pre-NAC surgical axillary staging. Pre-NAC surgical axillary staging should be performed only in rare circumstances to avoid unnecessary ALND.
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Affiliation(s)
- Kathleen Iles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paula D Strassle
- Division of Intramural Research, National Institute on Minority Health and Health Disparities (NIMHD), National Institutes of Health, Bethesda, MD, USA
| | - Chris B Agala
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Julia Button
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie Downs-Canner
- Department of Surgical Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Long-term outcome and axillary recurrence in elderly women (≥70 years) with breast cancer: 10-years follow-up from a matched cohort study. Eur J Surg Oncol 2021; 47:1593-1600. [PMID: 33685727 DOI: 10.1016/j.ejso.2021.02.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/12/2021] [Accepted: 02/22/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The oncological benefit of axillary surgery (AS), with sentinel lymph node biopsy (SLNB) or axillary dissection (ALND), in elderly women affected by breast cancer (BC) is controversial. We evaluated AS trends over a 10-year follow-up period as well as locoregional and survival outcomes in this subset of patients. METHODS Patients aged 70 years or older, treated between 1994 and 2008, were selected and divided in two groups, depending on whether or not AS was performed. A (1:1) matched analysis for all relevant clinicopathological features was performed. Outcomes were analyzed using the Kaplan-Meier method and univariate Cox-proportional hazard ratio analysis. RESULTS A total of 1.748 patients were identified and stratified by age (70-74, 75-79, 80-84). A matched analysis was performed for 252 patients: 122 who underwent AS and 122 who did not. At 10-year follow-up, ipsilateral breast tumor recurrence, distant metastasis and contralateral BC were similar, p = 0.83, p = 0.42 and p = 0.28, respectively. In the no-AS group, a significant increased risk of axillary lymph-node recurrence was identified at 5- and confirmed at 10-years (p = 0.038), without impact on overall survival at 5- and 10-years (p = 0.52). In the non-AS group, higher rate of axillary recurrence at 10-years was observed in patients with poorly differentiated (24.1%, 95% CI 7.2-46.2), highly proliferative (Ki67 ≥ 20%: 17.1%, 95% CI 0.6-33.3) and luminal B tumors (16.8%, 95% CI 5.9-35.5). CONCLUSIONS Axillary staging in elderly women does not impact long-term survival. Tailoring surgery according to tumor biology and age may improve locoregional outcome.
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Hwang ES, Solin L. De-Escalation of Locoregional Therapy in Low-Risk Disease for DCIS and Early-Stage Invasive Cancer. J Clin Oncol 2020; 38:2230-2239. [PMID: 32442066 DOI: 10.1200/jco.19.02888] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- E Shelley Hwang
- Duke Cancer Institute and Duke University Health System, Durham, NC
| | - Lawrence Solin
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.,Deceased
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Louie RJ, Gaber CE, Strassle PD, Gallagher KK, Downs-Canner SM, Ollila DW. Trends in Surgical Axillary Management in Early Stage Breast Cancer in Elderly Women: Continued Over-Treatment. Ann Surg Oncol 2020; 27:3426-3433. [PMID: 32215758 DOI: 10.1245/s10434-020-08388-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION In the past two decades, three prospective randomized trials demonstrated that elderly women with early stage hormone positive breast cancer had equivalent disease-specific mortality regardless of axillary surgery. In 2016, the Choosing Wisely campaign encouraged patients and providers to reconsider the role of axillary surgery in this population. We sought to identify factors that contribute to adopting non-operative management of the axilla in these patients. MATERIALS AND METHODS We performed a retrospective analysis of women ≥ 70 years old with cT1/T2, hormone positive invasive ductal carcinoma who underwent partial or total mastectomy, with/without axillary surgery, and did not receive adjuvant chemotherapy from the National Cancer Database from 2004 to 2015. We used multivariable log-binomial regression to model the risk of undergoing axillary surgery across region, care setting, and Charlson-Deyo scores, and analyzed temporal trends using Poisson regression. From 2004 to 2015, 87,342 of 99,940 women who met inclusion criteria (83%) had axillary surgery. Over time, axillary surgery increased from 78% to 88% (p < 0.001). This rise was consistent across region (p = 0.81) and care setting (p = 0.09), but flattened as age increased (p < 0.001). Omitting axillary surgery was more likely in patients treated in New England (RR 0.88, 95% CI 0.86, 0.89) and patients ≥ 85 (RR 0.66, 95% CI 0.65, 0.67). CONCLUSIONS Axillary surgery continues to be the preferred option of axillary management in elderly women with early stage, clinically node negative, hormone-positive, invasive breast cancer despite no survival benefit. Identifying factors to improve patient selection and dissemination of current recommendations can improve adoption of current evidence on axillary surgery in the elderly.
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Affiliation(s)
- Raphael J Louie
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Charles E Gaber
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paula D Strassle
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kristalyn K Gallagher
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie M Downs-Canner
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - David W Ollila
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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5
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Developing a patient decision aid for women aged 70 and older with early stage, estrogen receptor positive, HER2 negative, breast cancer. J Geriatr Oncol 2019; 10:980-986. [PMID: 31130442 DOI: 10.1016/j.jgo.2019.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/16/2019] [Accepted: 05/03/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Since women ≥70 years with early stage, estrogen receptor positive (ER+), HER2 negative breast cancer face several preference-sensitive treatment decisions, the investigative team aimed to develop a pamphlet decision aid (DA) for such women. MATERIALS AND METHODS The content of the DA was informed by literature review, international criteria, and expert feedback, and includes information on benefits and risks of lumpectomy versus mastectomy, lymph node surgery, radiotherapy after lumpectomy, and endocrine therapy. It considers women's overall health and was written using low literacy principles. Women from two Boston-based hospitals who were diagnosed in the past 6-24 months were recruited to provide feedback on the DA and its acceptability. The DA was iteratively revised based on their qualitative input. RESULTS Of 48 eligible women contacted, 35 (73%) agreed to participate. Their mean age was 74.3 years; 33 (94%) were non-Hispanic white; and 24 (67%) were college graduates. Overall, 26 (74%) thought the length of the DA was just right, 29 (83%) thought all or most of the information was clear, 32 (91%) found the DA helpful, and 33 (94%) would recommend it. In open ended comments, participants noted that the DA was clear, well-organized, and would help women prepare for and participate in treatment decision-making. CONCLUSIONS The investigative team developed a novel breast cancer treatment DA that is acceptable to women ≥70 years with a history of ER+, HER2-, early stage breast cancer. Next, the DA's efficacy needs to be tested with diverse older women newly diagnosed with breast cancer.
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Ferrigni E, Bergom C, Yin Z, Szabo A, Kong AL. Breast Cancer in Women Aged 80 Years or Older: An Analysis of Treatment Patterns and Disease Outcomes. Clin Breast Cancer 2019; 19:157-164. [PMID: 30819504 DOI: 10.1016/j.clbc.2019.01.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/16/2019] [Accepted: 01/22/2019] [Indexed: 11/17/2022]
Abstract
No clear standard treatment guidelines exist for older women with breast cancer. In this study we aimed to examine the practice patterns and treatment outcomes of women ≥80 years old with invasive breast cancer. A retrospective chart review at a single academic institution was performed of 124 women diagnosed with stage I to III invasive breast cancer aged ≥80 years between 2005 and 2014. Median age of diagnosis was 84 years. Fifty-nine of the cancers (48%) were detected using mammography. One hundred twelve patients (90%) underwent surgery. There was no difference in comorbidities between the surgical and nonsurgical group (P = .800). In multivariate analysis, age was predictive of receiving surgery (P < .001). Overall survival probability was higher for those who received hormonal therapy (P = .002), radiation therapy (P = .041), and those with lower-stage tumors (P = .018). Surgery was not predictive of survival. It is important to consider comorbidities, complications and, longevity when determining whether elderly women diagnosed with breast cancer benefit from surgery.
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Affiliation(s)
- Erin Ferrigni
- Department of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Carmen Bergom
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Ziyan Yin
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Amanda L Kong
- Department of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI.
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Yao K, Boughey JC. 'Nudging' Surgeons and Patients to De-Escalation of Surgery for Breast Cancer. Ann Surg Oncol 2018; 25:2777-2780. [PMID: 29968025 DOI: 10.1245/s10434-018-6588-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Indexed: 12/24/2022]
Affiliation(s)
- Katharine Yao
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA. .,Pritzker School of Medicine, University of Chicago, Chicago, IL, USA.
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Dominici LS, King TA. How do age and molecular subtypes impact surgical decisions? BREAST CANCER MANAGEMENT 2018. [DOI: 10.2217/bmt-2017-0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Tumor molecular subtype and patient age are the predominant drivers of recommendations for systemic therapy in patients with breast cancer. Yet, the impact of these factors on surgical decision-making remains controversial. Younger women often receive the most extensive surgical therapy despite a lack of evidence that bigger surgery translates into better outcomes. In contrast, among older women, there is a desire to minimize local therapy and its associated morbidity. Here, we review contemporary data highlighting the relationship between patient age and breast cancer molecular subtype, and local therapy outcomes. Our perspective is that tumor biology, rather than age, should be the driving factor in determining appropriate local therapy for breast cancer.
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Affiliation(s)
- Laura S Dominici
- Surgical Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, MA 02215, USA
- Department of Surgery, Brigham & Women's Hospital, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Tari A King
- Surgical Oncology, Dana-Farber/Brigham & Women's Cancer Center, Boston, MA 02215, USA
- Department of Surgery, Brigham & Women's Hospital, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
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Abstract
Management of the axilla in early breast cancer patients has significantly evolved in the last several decades. With the arrival of the sentinel lymph node biopsy, surgical practice for axillary staging in patients with early breast cancer has become gradually less invasive and formal axillary lymph node dissection has been confined to selected patients. Over the last two decades, evidence from randomized clinical trials have allowed for the de-escalation of axillary surgery in the management of early stage breast cancer. Advances in the staging and treatment of the axilla constitute a key component in determining initial surgical planning and therapeutic strategies in the treatment of early breast cancer. This chapter provides an updated review on the history, evolution, and current practices for axillary management in patients with early breast cancer, with particular attention to the surgical recommendations and controversial scenarios of the evolving management of the axilla.
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Affiliation(s)
- Monica G Valero
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Mehra Golshan
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Breast Oncology Program, Susan F. Smith Center for Women's Cancer, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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Patterns of axillary evaluation in older patients with breast cancer and associations with adjuvant therapy receipt. Breast Cancer Res Treat 2017; 167:555-566. [PMID: 28990127 DOI: 10.1007/s10549-017-4528-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Although axillary lymph node status has traditionally been a key factor in informing adjuvant breast cancer therapy recommendations, this information may be less relevant as our focus shifts more towards tumor biology, particularly in older patients where comorbidity influences treatment decisions and nodal staging and/or surgery may not improve outcomes. We examined patterns of axillary surgery and associations between axillary surgery and receipt of adjuvant treatment in older breast cancer patients. METHODS Women aged ≥ 65 years with clinically node-negative, stage I-II breast cancer treated between 2012 and 2013 were identified using the National Cancer Data Base. Using multivariable logistic regression, we examined associations between axillary surgery and age, adjusting for patient, clinical, and facility factors. We also examined receipt of adjuvant treatment by nodal surgery. RESULTS Among 68,205 women, 40.1% were aged 65-70, 24.5% were 71-75, 17.4% were 76-80, and 18.0% were > 80. Overall, 91.2% had axillary surgery (67.8% sentinel lymph node biopsy, 11.7% axillary lymph node dissection, 11.7% unspecified/unknown axillary surgery); 88.0% of those aged ≥ 70 with lower risk, hormone receptor-positive tumors underwent axillary surgery. In adjusted analyses, compared to patients aged 65-70, increasing age was associated with lower odds of any axillary surgery (ages 71-75: OR 0.64, 95% CI 0.57-0.71; ages 76-80: OR 0.33, 95% CI 0.30-0.37; age > 80: OR 0.08, 95% CI 0.07-0.08). Axillary surgery was associated with higher odds of receipt of radiation after breast conservation and receipt of chemotherapy in human epidermal growth factor 2-positive disease. CONCLUSIONS In a large nationwide dataset, the vast majority of older women with clinically node-negative breast cancer underwent axillary staging despite uncertainty about its impact on survival, particularly for those with lower-risk disease. Further study on how to tailor node assessment in older patients is warranted.
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Kantor O, Pesce C, Liederbach E, Wang CH, Winchester DJ, Yao K. Are the ACOSOG Z0011 Trial Findings Being Applied to Breast Cancer Patients Undergoing Neoadjuvant Chemotherapy? Breast J 2017; 23:554-562. [DOI: 10.1111/tbj.12793] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Olga Kantor
- Department of Surgery; University of Chicago Medicine; Chicago Illinois
| | - Catherine Pesce
- Department of Surgery; NorthShore University HealthSystem; Evanston Illinois
- Pritzker School of Medicine; University of Chicago; Chicago Illinois
| | - Erik Liederbach
- Department of Surgery; NorthShore University HealthSystem; Evanston Illinois
| | - Chi-Hsiung Wang
- Center for Biomedical Research Informatics; NorthShore University HealthSystem; Evanston Illinois
| | - David J. Winchester
- Department of Surgery; NorthShore University HealthSystem; Evanston Illinois
- Pritzker School of Medicine; University of Chicago; Chicago Illinois
| | - Katharine Yao
- Department of Surgery; NorthShore University HealthSystem; Evanston Illinois
- Pritzker School of Medicine; University of Chicago; Chicago Illinois
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Omission of axillary staging in elderly patients with early stage breast cancer impacts regional control but not survival: A systematic review and meta-analysis. J Geriatr Oncol 2017; 8:140-147. [DOI: 10.1016/j.jgo.2016.12.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 11/11/2016] [Accepted: 12/01/2016] [Indexed: 12/24/2022]
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Clinically cN0 breast cancer in elderly: What surgery? Int J Surg 2014; 12 Suppl 2:S130-S134. [DOI: 10.1016/j.ijsu.2014.08.364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/15/2014] [Indexed: 12/31/2022]
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Boughey JC, Margenthaler JA. How genomics, research, ethics and advances translate into improved care for breast surgery patients. Ann Surg Oncol 2013; 20:3153-7. [PMID: 23975309 DOI: 10.1245/s10434-013-3179-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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