Rates of Neoadjuvant Chemotherapy and Oncoplastic Surgery for Breast Cancer Surgery: A French National Survey

Predictors of mastectomy in breast cancer patients with complete remission of primary tumor after neoadjuvant therapy: A retrospective study

INTRODUCTION

Neoadjuvant therapy (NAT) should increase the rate of breast-conserving surgery (BCS) in non-metastatic breast cancer (BC) patients, especially in those achieving tumor shrinkage. Still, the conversion from a pre-planned mastectomy to BCS in patients responding to NAT is not a widespread standard. We aimed to identify factors influencing surgical choices in this setting.

MATERIALS AND METHODS

We retrospectively collected data of BC patients with complete remission of primitive tumor (ypT0) after NAT, treated with BCS or mastectomy in two Italian breast units. Predictors of mastectomy were explored using logistic regression. Distant recurrence and event-free survival were assessed in the BCS and mastectomy cohort.

RESULTS

243 patients were included, 147 (60.5 %) treated with BCS and 96 (39.5 %) treated with mastectomy. In the mastectomy group, there were more centrally-located, multiple and larger tumors. At univariate regression analysis, central location, baseline tumor extension on ultrasound (US) and magnetic resonance imaging (MRI), multiple foci and clinical stage were significantly associated with the chance of receiving mastectomy. At multivariate analysis, only baseline focality on US and extension on MRI retained significance as predictors of mastectomy. Distant recurrence and event-free survival were significantly longer in patients undergoing BCS.

CONCLUSION

Baseline tumor extension and focality were the main predictors of mastectomy in patients with ypT0 after NAT. However, BCS did not negatively affect survival outcomes in our cohort. An effort should be made to avoid potentially unnecessary mastectomy in this population, aiming at minimizing surgery-associated toxicities and improving patients' quality of life.

Neoadjuvant chemotherapy for breast cancer in Italy: A Senonetwork analysis of 37,215 patients treated from 2017 to 2022

BACKGROUND

Adoption of neoadjuvant chemotherapy (NACT) in the "real world" has been poorly investigated. Aim of this study was to examine the rate of NACT in Italy, trends over time and determinants of therapeutic choices.

METHODS

Senonetwork, the recognized network of Breast Centers in Italy, has developed a voluntary national data warehouse with the aim to monitor and improve treatments quality. A retrospective analysis was conducted among 58,661 breast cancer (BC) patients treated between 2017 and 2022 by 24 high-volume Breast Centers participating in the project.

RESULTS

After subset exclusion, 37,215 primary BC patients were analysed, 32,933 underwent primary-breast-surgery and 4,282 underwent NACT. From 2017 to 2022, the overall NACT incidence increased particularly for HR-/HER2+, Triple-Negative, and HR+/HER2+ BC (p < 0.001). In cN + patients the recommendation to axillary lymph-node dissection after NACT decreased over time along with an increase of <4 lymph-nodes removed (p < 0.001). Immediate breast reconstruction and indication for nipple sparing mastectomy increased significantly over time (OR = 1.10, p = 0.011 and OR 1.14, p < 0.001, respectively). On multivariate analysis, there was a trend towards an increased adoption of conservative treatment for HR-/HER2+ (p = 0.01) and Triple Negative tumors (p = 0.06). Implementation of NACT varied significantly among Breast-Centers from 3.8 to 17.7 % (p < 0.001).

CONCLUSION

The impact of NACT on the subsequent surgical management is substantial and continues to evolve over time, resulting in less-extensive surgery. Even among high-volume Centers NACT implementation rate is still highly variable. Although we registered a significant increase in its use during the study period, these results need to be further improved.

Neoadjuvant Chemotherapy in Breast Cancer: Evaluation of the Impact on Surgical Outcomes and Prognosis

The correlation between TNM staging and histology variations in a sample of patients who underwent neoadjuvant chemotherapy demonstrates a positive impact on both increasing conservative surgery and achieving pCR, resulting in better outcomes in terms of disease-free survival (DFS) and the risk of relapse. Benefits have also been highlighted in terms of cosmetic outcomes, postoperative complications, and psychological benefits. However, the overall outcomes must be evaluated according to the subtype and individual characteristics of the patients.

Long-Term Safety of Level II Oncoplastic Surgery after Neoadjuvant Treatment for Locally Advanced Breast Cancer: A 20-Year Experience

Background: Oncoplastic surgery (OPS) reliability in the post-neoadjuvant chemotherapy (NACT) setting is still debated due to weak scientific evidences in such scenarios. Methods: Our analysis aims to report results obtained in a retrospective series of 111 patients consecutively treated with level II OPS after NACT at the Multidisciplinary Breast Center of the Fondazione Policlinico Universitario Agostino Gemelli IRCCS between 1998 and 2018. The surgical endpoints were the mean specimen volume, rates of positive margins (PMR), re-excision (RR), conversion to mastectomy (CMR), and complications (CR). The oncological endpoints were overall survival (OS), disease-free survival (DFS), and local recurrence (LR). To evaluate the impact of NACT on surgical and oncological outcomes at 302 months, we conducted a propensity score matching, pairing patients in post-NACT and upfront surgery groups. Results: The mean sample volume was 390,796 mm3. We registered a 3.6% of PMR, 1.8% RR, 0.9% CMR, 5% CR. The 10-year OS and 10-year DFS with a median follow-up of 88 months (6-302) were 79% and 76%, respectively, with an LR recurrence rate of 5%. The post-NACT group received significantly larger excised volumes and lower PMR. NACT did not affect surgical and oncological outcomes. Conclusions: Level II OPS can be considered a reliable alternative to mastectomy even in the post-NACT setting.

Transaxillary Single-Port Endoscopic Nipple-Sparing Mastectomy with Immediate Implant-based Breast Reconstruction in Breast Cancer Patients Receiving Neoadjuvant Chemotherapy or Not: A Comparative Study with Analysis of Surgical Complications and Patient-Reported Outcomes

BACKGROUND

In most cases, transaxillary single-port endoscopic nipple-sparing mastectomy with immediate implant-based breast reconstruction (E-NSM-IIBR) is conducted in patients with early-stage breast cancer, ensuring surgical safety while achieving improved breast aesthetics. However, whether E-NSM-IIBR is appropriate in patients undergoing neoadjuvant chemotherapy (NAC) is still unclear. The aim of this study was to report the surgical safety and patient-reported outcomes (PROs) of breast cancer patients who underwent E-NSM-IIBR with NAC in comparison to those who did not receive NAC.

METHODS

A retrospective cohort study was conducted on patients who underwent E-NSM-IIBR with or without NAC at a single center between January 2021 and July 2022. Patient demographics, postoperative complications, and PROs evaluated using the BREAST-Q version 2.0 questionnaire were compared between the two groups. Factors associated with PROs at 9 months after surgery were assessed with linear regression analysis.

RESULTS

A total of 92 patients who underwent E-NSM-IIBR were included in the study, with 27 patients receiving NAC and 65 patients not receiving NAC. There was no significant difference in the incidence of postoperative complications between the two groups. The BREAST-Q version 2.0 questionnaire was completed by 24 out of 27 patients (88.9%) in the NAC group and 59 out of 65 patients (90.8%) in the non-NAC group at 9 months after surgery. The patient-reported outcomes in various domains of the BREAST-Q did not show a significant difference between the two cohorts. The results of the multiple linear regression analysis indicated that in the both groups age (β = - 0.985, 95% CI - 1.598 to - 0.371, p = 0.003 in the NAC group; β = - 0.510, - 1.011 to - 0.009, p = 0.046 in the non-NAC group) and rippling (β = - 21.862, - 36.768 to - 6.955, p = 0.006 in the NAC group; β = - 7.787, - 15.151 to - 0.423, p = 0.039 in the non-NAC group) significantly impacted the patients' satisfaction with breasts, and PMRT was negatively associated with patients' physical well-being of chest (β = - 13.813, - 26.962 to - 0.664, p = 0.040 in the NAC group; β = - 18.574, - 30.661 to - 6.487, p = 0.003 in the non-NAC group). Our findings revealed that patients with larger implant volumes had higher scores in psychosocial well-being (β = 0.082, 0.001 to 0.162, p = 0.047), whereas implant displacement (β = - 14.937, - 28.175 to - 1.700, p=0.028) had a negative impact on patients' psychological well-being in the non-NAC group. However, our results did not demonstrate any significant influencing factors on patients' psychosocial well-being within the NAC group.

CONCLUSION

Our preliminary experiences confirm that E-NSM-IIBR is a safe option for selected patients even after NAC, with favorable patient-reported outcomes comparable with those in the primary surgery setting. The postoperative long-term outcomes of patients who undergo radiation therapy after NAC merit further investigation in the future.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Pre- and Post-Neoadjuvant Clinicopathological Parameters Can Help in the Prognosis and the Prediction of Response in HER2+ and Triple Negative Breast Cancer

Neoadjuvant treatment (NAT) is one of the most widely used options for HER2+ and triple negative (TN) early breast cancer (BC). Since around half of the patients treated with NAT do not achieve a pathologically complete response (pCR), biomarkers to predict resistance are urgently needed. The correlation of clinicopathological factors with pCR was studied in 150 patients (HER2 = 81; TN = 69) and pre- and post-NAT differences in tumour biomarkers were compared. Low estrogen receptor (ER) expression, high tumour-infiltrating lymphocytes (TILs) and low cT-stage were associated with pCR in HER2+ tumours (p = 0.022; p = 0.032 and p = 0.005, respectively). Furthermore, ER expression was also associated with residual cancer burden (RCB; p = 0.046) in the HER2+ subtype. Similarly, pre-NAT, low progesterone receptor expression (PR; 1-10%) was associated with higher RCB (p < 0.001) in TN tumours. Only clinical and pathological T-stage (cpT-stage) had prognostic capacity in HER2+ tumours, whereas pre-NAT cpT-stage and post-NAT TILs had this capacity for the prognosis of TN tumours. We conclude that ER and PR expression may help predict response to NAT in HER2 and TN BC and should be taken into account in residual tumours. Also, changes observed in the phenotype after NAT suggest the need to reevaluate biomarkers in surviving residual tumour cells.

Sometimes it is better to just make it simple. De-escalation of oncoplastic and reconstructive procedures

Simple breast conservation surgery (sBCS) has technically advanced onto oncoplastic breast procedures (OBP) to avoid mastectomy and improve breast cancer patients' psychosocial well-being and cosmetic outcome. Although OBP are time-consuming and expensive, we are witnessing an increase in their use, even for cases that could be managed with sBCS. The choice between keeping it simple or opting for more complex oncoplastic procedures is difficult. This review proposes a pragmatic approach in assisting this decision. Medical literature suggests that OBP and sBCS might be similar regarding local recurrence and overall survival, and patients seem to have higher satisfaction levels with the aesthetic outcome of OBP when compared to sBCS. However, the lack of comprehensive high-quality research assessing their safety, efficacy, and patient-reported outcomes hinders these supposed conclusions. Postoperative complications after OBP may delay the initiation of adjuvant RT. In addition, precise displacement of the breast volume is not effectively recorded despite surgical clips placement, making accurate dose delivery tricky for radiation oncologists, and WBRT preferable to APBI in complex OBP cases. With a critical eye on financial toxicity, patient satisfaction, and oncological outcomes, OBP must be carefully integrated into clinical practice. The thoughtful provision of informed consent is essential for decision-making between sBCS and OBP. As we look into the future, machine learning and artificial intelligence can potentially help patients and doctors avoid postoperative regrets by setting realistic aesthetic expectations.

The Absence of Cancer in the Location of a Breast Tissue Marker After Neoadjuvant Chemotherapy may Predict Pathological Complete Response with High Accuracy: Results from a Phase II Trial

BACKGROUND

It is difficult to determine pathological complete response (pCR) before surgery in clinical complete response (cCR) cases by imaging alone. We designed a prospective study to evaluate whether a breast tissue marker placed in a tumor before neoadjuvant chemotherapy (NAC) can predict a pCR, possibly removing the need for surgery.

METHODS

We recruited patients with primary invasive breast cancer assigned to undergo curative surgery and possible NAC. A breast marker (UltraClip^®) was placed in the primary tumor before standard NAC. We evaluated the probability of no cancer in the marker but cancer in removed specimens from a cCR group.

RESULTS

A total of 102 patients were enrolled. Patients were categorized by cancer stage and subtypes. Seventy-two patients (70.6%) received standard NAC; 23 (34.3%) attained cCR, of whom pCR was obtained in 12 (52.2%). The probability of no cancer in the marker's location but cancer in the removed specimens was 4.3% (95% confidence interval, 0.1-21.9). The false-negative rate was 9.1% (1/11), and the negative predictive value was 92.3% (12/13). In only one case, no cancer was found in the marker's location, but cancer cells were present in the removed specimen.

CONCLUSIONS

The absence of cancer in the location of a breast tissue marker after NAC predicted pCR with high accuracy. Therefore, the rebiopsy of a marker's location might mean surgery is unnecessary.

Assessment and Response to Neoadjuvant Treatments in Breast Cancer: Current Practice, Response Monitoring, Future Approaches and Perspectives

Neoadjuvant treatments (NAT) for breast cancer (BC) consist in the administration of chemotherapy-more rarely endocrine therapy-before surgery. Firstly, it was introduced 50 years ago to downsize locally advanced (inoperable) BCs. NAT are now widespread and so effective to be used also at the early stage of the disease. NAT are heterogeneous in terms of therapeutic patterns, class of used drugs, dosage, and duration. The poly-chemotherapy regimen and administration schedule are established by a multi-disciplinary team, according to the stage of disease, the tumor subtype and the age, the physical status, and the drug sensitivity of BC patients. Consequently, an accurate monitoring of treatment response can provide significant clinical advantages, such as the treatment de-escalation in case of early recognition of complete response or, on the contrary, the switch to an alternative treatment path in case of early detection of resistance to the ongoing therapy. Future is going toward increasingly personalized therapies and the prediction of individual response to treatment is the key to practice customized care pathways, preserving oncological safety and effectiveness. To gain such goal, the development of an accurate monitoring system, reproducible and reliable alone or as part of more complex diagnostic algorithms, will be promising.

Nomogram for Early Prediction of Pathological Complete Response to Neoadjuvant Chemotherapy in Breast Cancer Combining Both Clinicopathological and Imaging Indicators

To construct a nomogram for early prediction of pathological complete response (pCR) in patients with breast cancer (BC) after neoadjuvant chemotherapy (NAC). A total of 257 patients with BC from the fourth hospital of Hebei Medical University were included in the study. The patients were divided into training (n = 128) and validation groups (n = 129). Variables were screened using univariate and multivariate logistic regression analyses, and the nomogram model was set up based on the training group. The training and validation groups were validated using the receiver operating characteristic (ROC) curves and calibration plots. The diagnostic value of the nomogram was evaluated using decision curve analysis (DCA). Indicators such as hormone receptor status, clinical TNM stage, and change rate in apparent diffusion coefficient of breast magnetic resonance imaging after two NAC cycles were used for nomogram construction. The calibration plots showed high consistency between nomogram-predicted and actual pCR probabilities in the training and validation groups. The areas under the curve of the ROC curve with discrimination ability were 0.942 and 0.921 in the training and validation groups, respectively. This showed an excellent discrimination ability of our nomogram for pCR prediction. Further, DCA showed favorable diagnostic value in our model. The nomogram may be instructive to clinicians for early prediction of pCR and helpful to adjust the treatment program on time in neoadjuvant management.

Treatment and survival outcomes in older women with primary breast cancer: A retrospective propensity score-matched analysis

PURPOSE

Changes in biological features and functional status make management decisions in older women with primary breast cancer complicated. We aimed to provide an overview of the clinicopathological characteristics and survival outcomes of older breast cancer patients based on the current treatment strategies.

METHODS

Female patients diagnosed with primary invasive breast cancer at Fudan University Shanghai Cancer Centre from 2008 to 2016 were included. Patients were divided into a younger group (<65 years) and older group (≥65 years). Propensity score matching was utilised to generate balanced cohorts.

RESULTS

A total of 13,707 patients met the study criteria. Compared with younger patients, older patients had a higher Charlson Comorbidity Index (p < 0.001), less lymph node metastasis (p = 0.009), more advanced tumour stage (p = 0.038), and a larger proportion of estrogen receptor-positive (p < 0.001) and epidermal growth factor receptor 2-negative (p < 0.001) tumours. Older patients were likely to receive mastectomy and axillary lymph node dissection in addition to a lower proportion of adjuvant chemotherapy. Adjuvant chemotherapy (HR [hazard ratio] 0.69, p = 0.039) was independently correlated with better overall survival in the older patients. This survival benefit (HR 0.58, p = 0.041) was confirmed in matched cohorts. Among the older patients with larger tumours (HR 0.48, p = 0.038) and more lymph node involvement (HR 0.44, p = 0.040), adjuvant chemotherapy was associated with a significant survival benefit.

CONCLUSION

Older breast cancer patients showed less aggressive biological characteristics, intensive surgical and moderate medical preferences. The addition of adjuvant chemotherapy should be considered for older patients, especially for patients with large tumours and more lymph node involvement.

Patterns of care over 10 years in young breast cancer patients in the Netherlands, a nationwide population-based study

INTRODUCTION

Each year, around 600 young (<40 years) breast cancer (BC) patients are registered in the national NABON Breast Cancer Audit (NBCA). The aim of this study is to compare patient and treatment characteristics of young and older age BC patients over time with a focus on outcome of quality indicators (QIs). Furthermore, we analysed whether de-escalation trends of treatment can be recognized to the same degree in both patient groups.

MATERIAL AND METHODS

From October 2011 to October 2020 all patients treated for stage I-III invasive BC were included. Tumour characteristics, treatment variables and outcome of QIs of two age categories young (<40 years) and older patient (≥40 years) were analysed.

RESULTS

In total 114,700 patients were included: 4.6% young patients and 95.4% older patients. Young patients more often presented with a palpable mass, higher stage, and triple-negative BC. Overall, young patients more often started with neoadjuvant systemic treatment (NST) (54.3% vs. 18.6%) and a greater proportion of the young patients retained their breast contour after surgery (73.5% vs. 69.3%). De-escalation trends such as decrease in axillary lymph node dissections and in the use of boost were observed. The omission of radiation treatment after breast conserving surgery was only observed in older patients.

CONCLUSION

Although this study shows that young women more often present with unfavourable tumours, therapeutic procedures are performed with a higher adherence to the QIs than for older patients and young women do benefit from some de-escalation trends to the same extend as older patients.

Level II Oncoplastic Surgery as an Alternative Option to Mastectomy with Immediate Breast Reconstruction in the Neoadjuvant Setting: A Multidisciplinary Single Center Experience

Oncoplastic surgery level II techniques (OPSII) are used in patients with operable breast cancer. There is no evidence regarding their safety and efficacy after neoadjuvant chemotherapy (NAC). The aim of this study was to compare the oncological and aesthetic outcomes of this technique compared with those observed in mastectomy with immediate breast reconstruction (MIBR), in post-NAC patients undergoing surgery between January 2016 and March 2021. Local disease-free survival (L-DFS), regional disease-free survival (R-DFS), distant disease-free survival (D-DFS), and overall survival (OS) were compared; the aesthetic results and quality of life (QoL) were evaluated using BREAST-Q. A total of 297 patients were included, 87 of whom underwent OPSII and 210 of whom underwent MIBR. After a median follow-up of 39.5 months, local recurrence had occurred in 3 patients in the OPSII group (3.4%), and in 13 patients in the MIBR group (6.1%) (p = 0.408). The three-year L-DFS rates were 95.1% for OPSII and 96.2% for MIBR (p = 0.286). The three-year R-DFS rates were 100% and 96.4%, respectively (p = 0.559). The three-year D-DFS rate were 90.7% and 89.7% (p = 0.849). The three-year OS rates were 95.7% and 95% (p = 0.394). BREAST-Q highlighted significant advantages in physical well-being for OPSII. No difference was shown for satisfaction with breasts (p = 0.656) or psychosocial well-being (p = 0.444). OPSII is safe and effective after NAC. It allows oncological and aesthetic outcomes with a high QoL, and is a safe alternative for locally advanced tumors which are partial responders to NAC.

A Practical Predictive Model Based on Ultrasound Imaging and Clinical Indices for Estimation of Response to Neoadjuvant Chemotherapy in Patients with Breast Cancer

Purpose

Clinical responses of neoadjuvant chemotherapy (NACT) are associated with prognosis in patients with breast cancer. The selection of suitable variables for the prediction of clinical responses remains controversial. Herein, we developed a predictive model based on ultrasound imaging and clinical indices to identify patients most likely to benefit from NACT.

Patients and Methods

We recruited a total of 225 consecutive patients who underwent NACT followed by surgery and axillary lymph node dissection at the Sixth Hospital of Ning Bo City of Zhe Jiang Province between January 1, 2018, and March 31, 2021. All patients had been diagnosed with breast cancer following the clinical examination. First, we created a training cohort of patients who underwent NACT+surgery (N=180) to develop a nomogram. We then validated the performance of the nomogram in a validation cohort of patients who underwent NACT+ surgery (N=45). Multivariate logistic regression was then used to identify independent risk factors that were associated with the response to NACT; these were then incorporated into the nomogram.

Results

Multivariate logistic regression analysis identified several significant differences as to clinical responses of NACT, including neutrophil–lymphocyte ratio (NLR), body mass index (BMI), pulsatility index (PI), resistance index (RI), blood flow, Ki67, histological type, molecular subtyping, and tumor size. The performance of the nomogram score exhibited a robust C-index of 0.89 (95% confidence interval [CI]: 0.83 to 0.95) in the training cohort and a high C-index of 0.87 (95% CI: 0.81 to 0.93) in the validation cohort. Clinical impact curves showed that the nomogram had a good predictive ability.

Conclusion

We successfully established an accurate and optimized nomogram incorporated ultrasound imaging and clinical indices that could be used preoperatively to predict clinical responses of NACT. This model can be used to evaluate the risk of clinical responses to NACT and therefore facilitate the choice of personalized therapy.

Breast conserving surgery versus salvage mastectomy for ipsilateral breast cancer recurrence: a propensity score matching analysis

Salvage mastectomy is regarded as the treatment of first choice for ipsilateral breast cancer recurrence (IBCR), even if a second breast conserving surgery (BCS) is feasible. The purpose of this study was to compare the long-term oncological outcomes of IBCR patients who had undergone either mastectomy or second BCS, performing a propensity score matching (PSM) analysis to reduce the selection bias. All the consecutive patients with IBCR were retrospectively reviewed and divided into two different groups of treatment: repeat BCS versus salvage mastectomy. The propensity score predicting the probability of surgical treatment was determined for each patient and a 1:1 matching was performed. Disease-free survival (DFS), distant disease-free survival (DDFS), overall survival (OS), and breast cancer-specific survival (BCSS) were analyzed and compared between the two groups. A total of 309 patients underwent surgical treatment for IBCR. After PSM, 108 patients treated with repeat BCS and 108 patients treated with salvage mastectomy were included in the analysis. There was no significant difference in terms of DFS between patients with IBCR receiving repeat BCS or salvage mastectomy (p = 0.167). However, patients with IBCR undergoing second BCS had significantly better DDFS, OS, and BCSS compared to salvage mastectomy (p < 0.001). Salvage mastectomy should not be considered the optimal treatment for IBCR and it does not seem to improve prognosis compared to repeat conserving surgery. Second BCS for IBCR is a safe option with encouraging long-term oncological outcomes and should be proposed to all patients, when technically feasible.

Comparison of Segmentation Methods in Assessing Background Parenchymal Enhancement as a Biomarker for Response to Neoadjuvant Therapy

Breast parenchymal enhancement (BPE) has shown association with breast cancer risk and response to neoadjuvant treatment. However, BPE quantification is challenging, and there is no standardized segmentation method for measurement. We investigated the use of a fully automated breast fibroglandular tissue segmentation method to calculate BPE from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) for use as a predictor of pathologic complete response (pCR) following neoadjuvant treatment in the I-SPY 2 TRIAL. In this trial, patients had DCE-MRI at baseline (T0), after 3 weeks of treatment (T1), after 12 weeks of treatment and between drug regimens (T2), and after completion of treatment (T3). A retrospective analysis of 2 cohorts was performed: one with 735 patients and another with a final cohort of 340 patients, meeting a high-quality benchmark for segmentation. We evaluated 3 subvolumes of interest segmented from bilateral T1-weighted axial breast DCE-MRI: full stack (all axial slices), half stack (center 50% of slices), and center 5 slices. The differences between methods were assessed, and a univariate logistic regression model was implemented to determine the predictive performance of each segmentation method. The results showed that the half stack method provided the best compromise between sampling error from too little tissue and inclusion of incorrectly segmented tissues from extreme superior and inferior regions. Our results indicate that BPE calculated using the half stack segmentation approach has potential as an early biomarker for response to treatment in the hormone receptor–negative and human epidermal growth factor receptor 2–positive subtype.

Tongue conservation treatment for oral tongue squamous cell carcinoma with induction chemotherapy, surgery, and risk-adapted adjuvant therapy: A phase II trial

BACKGROUND

To assess the feasibility of tongue conservation treatment with induction chemotherapy (ICT), tongue conservation surgery, and risk-adapted postoperative adjuvant therapy in oral tongue squamous cell carcinoma (OTSCC).

METHODS

Patients with newly diagnosed OTSCC cT2-4 N0-2 M0 were recruited. The ICT with a regimen of docetaxel, cisplatin, and oral tegafur/uracil (DCU) was administrated every 21 days. After the first cycle of ICT (DCU1), patients with a more than 30% decrease in the longest diameter of primary tumor underwent a second cycle of ICT (DCU2). Tongue conservation surgery was performed after ICT, and risk-adapted adjuvant therapy was organized based on pathological features.

RESULTS

From July 2011 to December 2015, a total of 23 patients were enrolled, 87% of whom were classified as stage III-IV. Clinical responders to DCU1 and DCU2 were determined in 90.5% (19/21) and 88.2% (15/17) of patients. Tongue conservation surgery was performed in 16 responders to ICT. Only one patient had a positive margin (6.3%), and a complete pathologic response was achieved in eight patients (50%). Only one patient developed local recurrence after a median follow-up of 58.6 months (range, 7.9-105.2). The 5-year overall survival (0% vs. 87.5%, P = 0.001) and disease-specific survival (0% vs. 93.3%, P = 0.000) were significantly different between the DCU1 nonresponders and responders.

CONCLUSION

Tongue conservation treatment with ICT, followed by conservation surgery and risk-adapted adjuvant therapy, is feasible for patients with OTSCC who are good responders to ICT. However, the outcomes of nonresponders are dismal. Further study in a larger patient population is warranted.

Is mastectomy with immediate reconstruction safe for patients undergoing neoadjuvant chemotherapy? A nationwide study from Korean Breast Cancer Society

PURPOSE

In this study, we compared the prognoses of patients who underwent mastectomy with immediate breast reconstruction (IBR) after neoadjuvant chemotherapy with those who underwent mastectomy.

METHODS

This retrospective study included 87,995 patients who were surgically treated for primary breast cancer between 2008 and 2014. We compared the three groups of patients who were divided based on the following surgeries: breast-conserving surgery (BCS), mastectomy, and mastectomy with IBR.

RESULTS

Of the 3295 patients who were treated with neoadjuvant chemotherapy, 482 patients achieved a pathological complete response (pCR) and 2813 patients did not (non-pCR). In survival analysis of the pCR patients, the 5-year Overall Survival (5 yr OS) between those who underwent mastectomy with IBR and mastectomy (P = 0.639) In the non-pCR group, 5 yr OS of the mastectomy with IBR group was 90.0%, while those of the mastectomy group was 84.4% in patients with clinical stage II (P = 0.032). In a multivariate analysis by Cox regression method revealed that the prognoses of the patients who underwent mastectomy with IBR were not different from those of patients who underwent mastectomy group in both groups (the pCR group and the non-pCR group).

CONCLUSION

In the pCR group, the prognoses of patients who underwent mastectomy with IBR were not different from those of patients who underwent mastectomy. In the non-pCR group, women in the mastectomy with IBR group had shown worse prognoses than the mastectomy group in advanced clinical stage. Appropriate operation should be determined depending on the status of individualized patients.

Nomogram-derived prediction of pathologic complete response (pCR) in breast cancer patients treated with neoadjuvant chemotherapy (NCT)

BACKGROUND

Previous research results on the predictive factors of neoadjuvant chemotherapy (NCT) efficacy in breast cancer are inconsistent, suggesting that the ability of a single factor to predict efficacy is insufficient. Combining multiple potential efficacy-related factors to build a model may improve the accuracy of prediction. This study intends to explore the clinical and biological factors in breast cancer patients receiving NCT and to establish a nomogram that can predict the pathologic complete response (pCR) rate of NCT.

METHODS

We selected 165 breast cancer patients receiving NCT from July 2017 to May 2019. Using pretreatment biopsy materials, immunohistochemical studies to assess estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER-2), and Ki-67 expression. The correlation between biological markers and pCR was analyzed. These predictors were used to develop a binary logistic regression model with cross-validation and to show the established predictive model with a nomogram.

RESULTS

The nomogram for pCR based on lymphovascular invasion, anemia (hemoglobin≤120 g/L), ER, Ki67 expression levels and NCT regimen had good discrimination performance (area under the curve [AUC], 0.758; 95% confidence interval [CI], 0.675-0.841) and calibration coordination. According to the Hosmer-Lemeshow test, the calibration chart showed satisfactory agreement between the predicted and observed probabilities. The final prediction accuracy of cross-validation was 76%.

CONCLUSIONS

We developed a nomogram based on multiple clinical and biological covariations that can provide an early prediction of NCT response and can help to quickly assess the individual benefits of NCT.

FZR1 as a novel biomarker for breast cancer neoadjuvant chemotherapy prediction

The concept of breast-conserving surgery is a remarkable achievement of breast cancer therapy. Neoadjuvant chemotherapy is being used increasingly to shrink the tumor prior to surgery. Neoadjuvant chemotherapy is reducing the tumor size to make the surgery with less damaging to surrounding tissue and downstage locally inoperable disease to operable. However, non-effective neoadjuvant chemotherapy could increase the risks of delaying surgery, develop unresectable disease and metastatic tumor spread. The biomarkers for predicting the neoadjuvant chemotherapy effect are scarce in breast cancer treatment. In this study, we identified that FZR1 can be a novel biomarker for breast cancer neoadjuvant chemotherapy according to clinical patient cohort evaluation and molecular mechanism investigation. Transcriptomic data analysis indicated that the expression of FZR1 is correlated with the effect of neoadjuvant chemotherapy. Mechanistically, we demonstrate that FZR1 is pivotal to the chemotherapy drugs induced apoptosis and cell cycle arrest. FZR1 is involved in the stability of p53 by impairing the phosphorylation at ser15 site. We demonstrate that the expression of FZR1 detected by quantification of IHC can be an effective predictor of neoadjuvant chemotherapy in animal experiment and clinical patient cohort. To obtain more benefit for breast cancer patient, we propose that the FZR1 IHC score using at the clinical to predict the effect of neoadjuvant chemotherapy.

Axillary Response in Patients Undergoing Neoadjuvant Endocrine Treatment for Node-Positive Breast Cancer: Systematic Literature Review and NCDB Analysis

Background

Several studies have proven that neoadjuvant endocrine therapy (NET) has a similar beneficial therapeutic effect in estrogen-positive (ER⁺) breast cancer (BC) with improved breast conservation rate in patients undergoing NET versus neoadjuvant chemotherapy (NAC). The impact of axillary complete pathologic response (pCR) is less clear. We evaluate the impact of NET on axillary downstaging and surgical management.

Methods

Using the National Cancer Database (NCDB), we identified all patients with node positive (N⁺), ER⁺, HER²⁻ BC undergoing NET and performed a systemic review of literature using PRISMA guidelines.

Results

The literature review identified 1479 clinically N⁺ patients in four studies, 148 of whom had axillary pCR (10.0%). In the two studies of patients with invasive lobular carcinoma (ILC), 7.8% (69/883) of clinically N⁺ patients had axillary pCR. The NCDB query identified 4580 female patients with clinically N⁺ ER⁺ HER²⁻ BC who underwent NET from 2010 to 2016 with mean age of 61.4 years. Patients who achieved a pCR were more likely to have N1 disease (p 0.008), moderately differentiated tumors (p 0.003), and ductal histology (p 0.04). There was no statistically significant difference in race, comorbidity score, education, income, hospital setting, or clinical tumor stage. Of the 4580 total patients, 663 (14.48%) had an axillary pCR (pN0) after NET, and 3917 (85.52%) remained pN+.

Conclusions

We found that patients who underwent NET for N⁺ disease had a higher axillary pCR than previously reported (10%) in smaller studies. Although NET is not a common treatment option for women with N⁺ ER⁺ HER²⁻ BC, it may be a suitable option for axillary downstaging, which is currently underutilized.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-08905-9) contains supplementary material, which is available to authorized users.

Quantitative Comparison of Prone and Supine PERCIST Measurements in Breast Cancer

Positron emission tomography (PET) is typically performed in the supine position. However, breast magnetic resonance imaging (MRI) is performed in prone, as this improves visibility of deep breast tissues. With the emergence of hybrid scanners that integrate molecular information from PET and functional information from MRI, it is of great interest to determine if the prognostic utility of prone PET is equivalent to supine. We compared PERCIST (PET Response Criteria in Solid Tumors) measurements between prone and supine FDG-PET in patients with breast cancer and the effect of orientation on predicting pathologic complete response (pCR). In total, 47 patients were enrolled and received up to 6 cycles of neoadjuvant therapy. Prone and supine FDG-PET were performed at baseline (t₀; n = 46), after cycle 1 (t₁; n = 1) or 2 (t₂; n = 10), or after all neoadjuvant therapy (t₃; n = 19). FDG uptake was quantified by maximum and peak standardized uptake value (SUV) with and without normalization to lean body mass; that is, SUV_max, SUV_peak, SUL_max, and SUL_peak. PERCIST measurements were performed for each paired baseline and post-treatment scan. Receiver operating characteristic analysis for the prediction of pCR was performed using logistic regression that included age and tumor size as covariates. SUV and SUL metrics were significantly different between orientation (P < .001), but were highly correlated (P > .98). Importantly, no differences were observed with the PERCIST measurements (P > .6). Overlapping 95% confidence intervals for the receiver operating characteristic analysis suggested no difference at predicting pCR. Therefore, prone and supine PERCIST in this data set were not statistically different.

Neoadjuvant Chemotherapy Plays an Adverse Role in the Prognosis of Grade 2 Breast Cancer

Background: The role of neoadjuvant chemotherapy (NAC) in the prognosis of breast cancer among patients with grade 2 tumors remains unclear. As such, we aimed to explore the relationships between NAC and survival outcomes among patients with grade 2 breast cancer.

Materials and Methods: We collected data on 726 breast cancer patients with grade 2 tumors and at least 5-years of follow-up from the date of diagnosis. We then conducted survival analyses to examine the association between NAC and disease-free survival (DFS) and overall survival (OS). The role of NAC in prognosis was further examined in subgroup analyses, with patients stratified according to molecular subtypes, histological grade, ER status, PR status, HER2 status and Ki67 index. We also determined the main sites of local recurrence, as well as these organs involved in distant metastasis among patients receiving NAC. Finally, we analyzed independent predictive factors for DFS and OS using Cox regression analyses.

Results: Among patients who received NAC, the prevalence of pathologic complete response (pCR) was 9.87% (23/233), with 32.6% of patients (76/233) experiencing partial response. Survival analyses demonstrated that NAC had an overall adverse effect on DFS and OS. Subgroup analyses showed that patients who received NAC had shorter DFS in all molecular subgroups of breast cancer, with exception of triple negative breast cancer (TNBC) patients. NAC was also associated with shorter OS among patients with histological grade of 2 and a low Ki67 index. The main recurrence site was the chest well, while distant metastasis occurred in the bone, liver and lung. In Cox regression analyses, we found that NAC was an independent predictor for DFS, but not for OS.

Conclusions: NAC may have an adverse effect on breast cancer prognosis among patients with grade 2 tumors. These patients need not receive NAC, except when the patient has a strong desire for breast conservation, and this is unlikely to be achieved in the absence of NAC.

Do early HER2-overexpression breast cancer patients benefit from undergoing neoadjuvant trastuzumab and mastectomy? A meta-analysis

Purpose

To assess the overall survival (OS) of early human epidermal growth factor receptor 2 (HER2)-enriched breast cancer patients after receiving neoadjuvant trastuzumab (NAT) compared to adjuvant trastuzumab (AT) treatment and the difference in local-regional relapse (LRR) rate with this tumor and treatment between women after mastectomy and women after breast-conserving therapy (BCT).

Methods

Articles were retrieved from PubMed, Embase, Web of Science, and Cochrane Library. A pooled odds ratio (OR) with a 95% confidential interval (CI) was calculated. The StataSE version 12.0 software was employed for meta-analysis.

Results

Twelve available clinical studies containing 2366 subjects were included. The OS of NAT compared with that of AT was not significantly different (pooled OR=1.04; 95% CI, 0.47–2.33). There was a significantly lower LRR rate for patients with mastectomy compared to those with BCT (pooled OR=0.58; 95% CI, 0.38–0.89); however, subgroup analysis revealed that the significant advantage of LRR for mastectomy compared to BCT was only represented in women without trastuzumab treatment (pooled OR=0.52; 95% CI, 0.31–0.88) compared to those who received trastuzumab treatment (pooled OR=0.71; 95% CI, 0.34–1.49).

Conclusion

Early stage HER2-overexpression breast cancer patients benefit with an equivalent OS from NAT treatment compared to AT. Patients who underwent mastectomy and BCT experienced a similar LRR rate if they received anti-HER2 targeted therapy of trastuzumab, but the LRR rate was discernibly reduced in patients who received mastectomy compared to BCT if they did not also receive trastuzumab treatment.

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Long-term Results After Oncoplastic Surgery for Breast Cancer: A 10-year Follow-up

OBJECTIVE

The aim of this study was to evaluate the long-term oncologic outcome after oncoplastic surgery (OPS).

BACKGROUND

OPS combines wide tumor excision with reduction mammoplasty techniques thus extending breast conserving surgery to large tumors that might else be proposed a mastectomy. Little data are available about the oncologic results for breast conserving surgery of these larger tumors.

METHODS

From January 2004 until March 2016, a total of 350 oncoplastic breast reductions were prospectively entered into a database. Patients were included if their breast reshaping included a reduction mammoplasty with skin excision (Level 2 oncoplastic techniques).

RESULTS

Histologic subtypes were: invasive ductal carcinoma in 219 cases (62.6%), ductal carcinoma in situ (DCIS) in 88 cases (25.1%), and invasive lobular carcinoma in 43 (12.3%) cases. Seventy-three of the invasive cancers (27.9%) received neoadjuvant chemotherapy. The mean resection weight was 177 grams. The mean pathological tumor size was 26 mm (range 0-180 mm) and varied from 23 mm (4-180 mm) for invasive cancers to 32 mm (0-100 mm) for DCIS. Specimen margins were involved in 12.6% of the cases; 10.5% of invasive ductal, 14.7% of DCIS, and 20.9% of invasive lobular. The overall breast conservation rate was 92% and varied from 87.4% for DCIS to 93.5% for the invasive cancers. Thirty-one patients (8.9%) developed one or more postoperative complications, inducing a delay in postoperative treatments in 4.6% of patients. The median follow up was 55 months. The cumulative 5-year incidences for local, regional, and distant recurrences were 2.2%, 1.1%, and 12.4%, respectively.

CONCLUSIONS

Oncoplastic breast reductions allow wide resections with free margins and can be used for large cancers as an alternative to mastectomy.

Whole genome sequencing of breast cancer

Breast cancer was the first to take advantage of targeted therapy using endocrine therapy, and for up to 20% of all breast cancer patients a further significant improvement has been obtained by HER2‐targeted therapy. Greater insight in precision medicine is to some extent driven by technical and computational progress, with the first wave of a true technical advancement being the application of transcriptomic analysis. Molecular subtyping further improved our understanding of breast cancer biology and has through a new tumor classification enabled allocation of personalized treatment regimens. The next wave in technical progression must be next‐generation‐sequencing which is currently providing new and exciting results. Large‐scale sequencing data unravel novel somatic and potential targetable mutations as well as allowing the identification of new candidate genes predisposing for familial breast cancer. So far, around 15% of all breast cancer patients are genetically predisposed with most genes being factors in pathways implicated in genome maintenance. This review focuses on whole‐genome sequencing and the new possibilities that this technique, together with other high‐throughput analytic approaches, provides for a more individualized treatment course of breast cancer patients.

Optimise not compromise: The importance of a multidisciplinary breast cancer patient pathway in the era of oncoplastic and reconstructive surgery

Modern breast cancer care is a complex multidisciplinary undertaking in which the integrated function of multiple constituent parts is critical, and where changes to one therapeutic component may profoundly influence the delivery and outcomes of another. Oncoplastic and reconstructive breast surgery has evolved in the era of longer survival rates for women with breast cancer and aims to enhance oncological and cosmetic outcomes. However, concurrently there has been an expansion in the indications for post-mastectomy radiation therapy (Abdulkarim et al., 2011; Early Breast Cancer Trialists' Collaborative Group (EBCTCG), 2014; Poortmans et al., 2015; Wang et al., 2011), the recognition of several biologically distinct breast cancer subtypes (Perou et al., 2000; Sørlie et al., 2001, 2003; Cheang et al., 2008, 2009; Sotiriou et al., 2003; Millar et al., 2011; Blows et al., 2010; Schnitt, 2010; Haque et al., 2012; Dai et al., 2015) and the development of recommendations for prophylactic surgery for high-risk women, including BRCA-mutation carriers (James et al., 2006; Domchek et al., 2010). Primary systemic therapy is increasingly utilised yet has varying efficacy depending on tumour biology (Cortazar et al., 2014). In this paper we review the evidence which informs the multidisciplinary team opinion in the era of oncoplastic and reconstructive breast surgery. We aim to describe an optimal multidisciplinary approach which balances competing risks of multimodal therapies to optimise oncological and cosmetic outcomes.

Breast conserving therapy after neoadjuvant chemotherapy; data from the Dutch Breast Cancer Audit

INTRODUCTION

NAC has led to an increase in breast conserving surgery (BCS) worldwide. This study aims to analyse trends in the use of neoadjuvant chemotherapy (NAC) and the impact on surgical outcomes.

METHODS

We reviewed all records of cT1-4N0-3M0 breast cancer patients diagnosed between July 2011 and June 2016 who have been registered in the Dutch National Breast Cancer Audit (NBCA) (N = 57.177). The surgical outcomes of 'BCS after NAC' were compared with 'primary BCS', using a multivariable logistic regression model.

RESULTS

Between 2011 and 2016, the use of NAC increased from 9% to 18% and 'BCS after NAC' (N = 4170) increased from 43% to 57%. We observed an involved invasive margin rate (IMR) of 6,7% and a re-excision rate of 6,6%. As compared to 'primary BCS', the IMR of 'BCS after NAC' is higher for cT1 (12,3% versus 8,3%; p < 0.005), equal for cT2 (14% versus 14%; p = 0.046) and lower for cT3 breast cancer (28,3% versus 31%; p < 0.005). Prognostic factors associated with IMR for both 'primary BCS' as for 'BCS after NAC' are: lobular invasive breast cancer and a hormone receptor positive receptor status (all p < 0,005).

CONCLUSION

The use of NAC and the incidence of 'BCS after NAC' increased exponentially in time for all stages of invasive breast cancer in the Netherlands. This nationwide data confirms that 'BCS after NAC' compared to 'primary BCS' leads to equal surgical outcomes for cT2 and improved surgical outcomes for cT3 breast cancer. These promising results encourage current developments towards de-escalation of surgical treatment.

Oncoplastic Breast-Conserving Surgery in Iceland: A Population-Based Study

BACKGROUND AND AIMS

In Iceland, oncoplastic breast-conservation surgery has been performed since 2008. The aim of this population-based study was to assess and compare the efficacy and patient satisfaction of standard breast-conservation surgery with oncoplastic breast-conservation surgery.

MATERIALS AND METHODS

This is a population-based, retrospective, observational cohort study on all women undergoing breast-conservation surgery in Iceland from the 1 January 2008 to 31 December 2014. A multivariate logistic regression and linear regression were performed to assess differences in outcomes and a patient satisfaction questionnaire was used to assess certain patient-related outcome measures.

RESULTS AND CONCLUSION

A total of 750 women underwent breast-conserving surgery, 665 had standard breast-conservation surgery and 85 oncoplastic breast-conservation surgery. Oncoplastic breast-conservation surgery was associated with a significantly larger mean size (2.4 cm vs 1.7 cm, p < 0.001) and weight (181.8 g vs 63.4 g, p < 0.001) of breast specimen excised when compared to standard breast-conservation surgery. After correcting for confounding factors, there was no significant difference in surgical margin involvement (odds ratio = 0.97, confidence interval = 0.44-1.97), frequency of complications (odds ratio = 1.06, confidence interval = 0.46-2.18), frequency of reoperations (odds ratio = 0.98; confidence interval = 0.50-1.81), or time to first adjuvant therapy (-0.23 days for oncoplastic breast-conservation surgery, p = 0.95). Patient satisfaction was high in both groups, although not statistically different (96% in oncoplastic breast-conservation surgery group vs 89% in the standard breast-conservation surgery group, p = 0.84). Our results show that oncoplastic breast-conservation surgery is at least as safe as standard breast-conservation surgery in selected cases and may be preferable in ductal carcinoma in situ.

Long-term outcomes for neoadjuvant versus adjuvant chemotherapy in early breast cancer: meta-analysis of individual patient data from ten randomised trials

BACKGROUND

Neoadjuvant chemotherapy (NACT) for early breast cancer can make breast-conserving surgery more feasible and might be more likely to eradicate micrometastatic disease than might the same chemotherapy given after surgery. We investigated the long-term benefits and risks of NACT and the influence of tumour characteristics on outcome with a collaborative meta-analysis of individual patient data from relevant randomised trials.

METHODS

We obtained information about prerandomisation tumour characteristics, clinical tumour response, surgery, recurrence, and mortality for 4756 women in ten randomised trials in early breast cancer that began before 2005 and compared NACT with the same chemotherapy given postoperatively. Primary outcomes were tumour response, extent of local therapy, local and distant recurrence, breast cancer death, and overall mortality. Analyses by intention-to-treat used standard regression (for response and frequency of breast-conserving therapy) and log-rank methods (for recurrence and mortality).

FINDINGS

Patients entered the trials from 1983 to 2002 and median follow-up was 9 years (IQR 5-14), with the last follow-up in 2013. Most chemotherapy was anthracycline based (3838 [81%] of 4756 women). More than two thirds (1349 [69%] of 1947) of women allocated NACT had a complete or partial clinical response. Patients allocated NACT had an increased frequency of breast-conserving therapy (1504 [65%] of 2320 treated with NACT vs 1135 [49%] of 2318 treated with adjuvant chemotherapy). NACT was associated with more frequent local recurrence than was adjuvant chemotherapy: the 15 year local recurrence was 21·4% for NACT versus 15·9% for adjuvant chemotherapy (5·5% increase [95% CI 2·4-8·6]; rate ratio 1·37 [95% CI 1·17-1·61]; p=0·0001). No significant difference between NACT and adjuvant chemotherapy was noted for distant recurrence (15 year risk 38·2% for NACT vs 38·0% for adjuvant chemotherapy; rate ratio 1·02 [95% CI 0·92-1·14]; p=0·66), breast cancer mortality (34·4% vs 33·7%; 1·06 [0·95-1·18]; p=0·31), or death from any cause (40·9% vs 41·2%; 1·04 [0·94-1·15]; p=0·45).

INTERPRETATION

Tumours downsized by NACT might have higher local recurrence after breast-conserving therapy than might tumours of the same dimensions in women who have not received NACT. Strategies to mitigate the increased local recurrence after breast-conserving therapy in tumours downsized by NACT should be considered-eg, careful tumour localisation, detailed pathological assessment, and appropriate radiotherapy.

FUNDING

Cancer Research UK, British Heart Foundation, UK Medical Research Council, and UK Department of Health.

Therapeutic escalation - De-escalation: Data from 15.508 early breast cancer treated with upfront surgery and sentinel lymph node biopsy (SLNB)

INTRODUCTION

The aim of this study was to examine changes in therapeutic practices for early breast cancer T0-2 N0 managed by upfront surgery and SLNB.

POPULATION

Between 1999 and 2012, 15.508 patients were treated. Four periods were determined: 1999-2003, 2004-2006, 2007-2009 and > 2009. Five tumor subtypes were defined according to hormonal receptors (HR) and Her2: Luminal A (HR + Her2- Grade 1-2), Her2 (Her2+ HR-), Triple-negative (HR- Her2-), Luminal B Her2- (HR + Her2- Grade 3), Luminal B Her2+ (HR + HER2+).

METHODS

Rates of axillary lymph node dissection (ALND), adjuvant chemotherapy ± trastuzumab, endocrine treatment, mastectomy and post mastectomy radiotherapy (PMRT) were analyzed according to treatment periods with univariate and multivariate analysis. Overall and disease-free survivals were analyzed according to treatment periods adjusted for HR and then for tumor subtypes.

RESULTS

Rates of ALND, adjuvant chemotherapy and endocrine treatment varied significantly according to treatment periods, for HR positive and negative tumors. ALND rate decreased for all tumor subtypes with a decrease of adjuvant chemotherapy rate for Luminal A tumors and an increase for Luminal B Her2+ and Her2-tumors. Endocrine treatment rate decreased for Luminal A and increased for Luminal B Her2+ tumors. In multivariate analysis, these modifications with time remained significant. Mastectomy and PMRT rates increased. In multivariate analysis, overall and disease-free survivals increased during successive periods.

CONCLUSION

A global therapeutic de-escalation in ALND and adjuvant systemic treatment, combined with an actual escalation in some specific subsets was demonstrated, but without negative impact on survival.

[Not Available]

REFLEXIONS ABOUT NEW STRATEGIES OF RADIOTHERAPY FOR EARLY BREAST CANCER: Radiotherapy (RT) remains a major treatment element in early breast cancer, with a major impact on local control and survival. For ductal carcinoma in situ (DCIS), RT reduces local recurrence (LR) rates by 50 to 60 % after conservative surgery (both in situ and invasive). This was confirmed by four randomized trials and one meta-analysis. For infiltrating breast cancers (IBC), RT also reduces LR rates by 65 to 75 % after conservative surgery. Boost allows an additional reduction of LR. RT is efficient in all age categories, but hypofractionated schemes are particularly adapted to elderly women. Partial breast irrradiation techniques are very much heterogeneous and lack follow-up. They should be used in LR low-risk patients only and in the frame of controlled studies. Locoregional RT for high-risk patients (especially in pN+) remains essential to reduce the locoregional recurrence rate and to increase survival, as confirmed in several meta-analyses. Four studies showed a survival benefit (2-3 %), thanks to internal mammary chain irradiation in LR high-risk patients. Moreover, axillary RT seems to be a likely valuable alternative to axillary dissection in case of sentinel node invasion. Finally, with the modern techniques and dosimetric optimization, RT toxicity was reduced, or even cancelled, arousing hope for a better increased benefit for the patients in the future.

Economic Impact of Gene Expression Profiling in Patients with Early-Stage Breast Cancer in France

Background and Aims

The heterogeneous nature of breast cancer can make decisions on adjuvant chemotherapy following surgical resection challenging. Oncotype DX is a validated gene expression profiling test that predicts the likelihood of adjuvant chemotherapy benefit in early-stage breast cancer. The aim of this study is to determine the costs of chemotherapy in private hospitals in France, and evaluate the cost-effectiveness of Oncotype DX from national insurance and societal perspectives.

Methods

A multicenter study was conducted in seven French private hospitals, capturing retrospective data from 106 patient files. Cost estimates were used in conjunction with a published Markov model to assess the cost-effectiveness of using Oncotype DX to inform chemotherapy decision making versus standard care. Sensitivity analyses were performed.

Results

The cost of adjuvant chemotherapy in private hospitals was estimated at EUR 8,218 per patient from a national insurance perspective and EUR 10,305 from a societal perspective. Cost-effectiveness analysis indicated that introducing Oncotype DX improved life expectancy (+0.18 years) and quality-adjusted life expectancy (+0.17 QALYs) versus standard care. Oncotype DX was found cost-effective from a national insurance perspective (EUR 2,134 per QALY gained) and cost saving from a societal perspective versus standard care. Inclusion of lost productivity costs in the modeling analysis meant that costs for eligible patients undergoing Oncotype DX testing were on average EUR 602 lower than costs for those receiving standard care.

Conclusions

As Oncotype DX was found both cost and life-saving from a societal perspective, the test was considered to be dominant to standard care. However, the delay in coverage has the potential to erode the quality of the French healthcare system, thus depriving patients of technologies that could improve clinical outcomes and allow healthcare professionals to better allocate hospital resources to improve the standard of care for all patients.