Predicting Nodal Positivity in Women 70 Years of Age and Older with Hormone Receptor-Positive Breast Cancer to Aid Incorporation of a Society of Surgical Oncology Choosing Wisely Guideline into Clinical Practice

Implementation of Choosing Wisely guidelines: Omission of lymph node surgery

OBJECTIVES

In 2016, the Choosing Wisely campaign published guidelines recommending omission of sentinel lymph node biopsy in clinically node-negative women ≥70 years with early-stage (cT1-2), hormone receptor-positive, and human epidermal growth factor receptor 2-negative breast cancers. This study aimed to evaluate the implementation of this guideline.

METHODS

The National Cancer Database was queried from 2017 to 2020. All patients who met criteria for lymph node surgery omission were included and compared with those who underwent lymph node surgery.

RESULTS

Of 138,648 patients who met criteria for lymph node surgery omission, 26,070 (21.0%) had lymph node surgery omission and 109,482 (79.0%) underwent lymph node surgery. Those who had lymph node surgery omission were older (median 79 [75-84] vs 75 [72-79] years, P < .01) and had increased comorbidities (28.3% with Charlson/Deyo score ≥3 had lymph node surgery omission vs 20.2% with score 0, P < .01). Academic/research institutions most frequently practiced lymph node surgery omission (25.8% vs 16.5% community cancer programs, 19.3% comprehensive community cancer programs, and 20.6% integrated network cancer programs, P < .01). A greater percentage of lymph node surgery omission was noted with ductal carcinoma (21.4% vs 17.6% lobular and 19.4% mixed, P < .01) and lower-grade tumors (21.7% of grade 1 vs 19.4% of grade 2 and 17.8% of grade 3, P < .01). Throughout the period studied, the overall rate of lymph node surgery omission increased from 17.7% in 2017 to 23.1% in 2020 (P < .01).

CONCLUSION

Despite the evidence-based Choosing Wisely guideline recommending lymph node surgery omission in selected patients with breast cancer, more than 75% of patients meeting criteria were still being subjected to lymph node surgery as of 2020. Future work is warranted to determine factors affecting implementation of the Choosing Wisely guideline.

Is routine axillary staging still required in clinically node negative early breast cancer in women over 74 years?

BACKGROUND

Investigate incidence and identify predictors of axillary lymph node metastases in early breast cancer in women >74 years Australia and New Zealand to inform decision making about sentinel lymph node (SLN) biopsy in this population.

METHODS

Retrospective review of invasive breast cancer in women in Australia and New Zealand between 2010 and 2022 using BreastSurgANZ Quality Audit Database. Data included patient demographics, tumour characteristics, surgery type, axillary nodal status and adjuvant therapy. Descriptive analysis of incidence of axillary nodal metastases and use of adjuvant therapy in various patient and tumour groups was performed, followed by statistical analysis using multivariate logistic regression to identify predictors of axillary nodal positivity and correlation between nodal status and prescription of adjuvant therapy.

RESULTS

Review of 127 436 cases of invasive breast cancer, 17 599 cases >74 years. Two thirds of the overall population and in those >74 years were node negative. In patients >74 years with grade 1-2, T1a-b cancers, ER+/HER2- 94% were node negative. Patient age, tumour size, grade and biomarker profile correlated with axillary nodal status and analysis of adjuvant therapy revealed significant correlation between nodal stage and adjuvant radiotherapy, chemotherapy and endocrine therapy.

CONCLUSION

A total of 94% of patients >74 years with T1a/b, ER positive HER2 negative breast cancer were node negative. Nodal status significantly influences adjuvant treatment in this patient group and therefore, we recommend clinicians consider tumour factors and patient fitness in their decision making about SLN biopsy in the elderly population with hormone receptor positive early breast cancer.

Electronic Health Record-Based Nudge Intervention and Axillary Surgery in Older Women With Breast Cancer: A Nonrandomized Controlled Trial

Importance

Choosing Wisely recommendations advocate against routine use of axillary staging in older women with early-stage, clinically node-negative (cN0), hormone receptor-positive (HR+), and HER2-negative breast cancer. However, rates of sentinel lymph node biopsy (SLNB) in this population remain persistently high.

Objective

To evaluate whether an electronic health record (EHR)-based nudge intervention targeting surgeons in their first outpatient visit with patients meeting Choosing Wisely criteria decreases rates of SLNB.

Design, Setting, and Participants

This nonrandomized controlled trial was a hybrid type 1 effectiveness-implementation study with subsequent postintervention semistructured interviews and lasted from October 2021 to October 2023. Data came from EHRs at 8 outpatient clinics within an integrated health care system; participants included 7 breast surgical oncologists. Data were collected for female patients meeting Choosing Wisely criteria for omission of SLNB (aged ≥70 years with cT1 and cT2, cN0, HR+/HER2- breast cancer). The study included a 12-month preintervention control period; baseline surveys assessing perceived acceptability, appropriateness, and feasibility of the designed intervention; and a 12-month intervention period.

Intervention

A column nudge was embedded into the surgeon's schedule in the EHR identifying patients meeting Choosing Wisely criteria for potential SLNB omission.

Main Outcomes and Measures

The primary outcome was rate of SLNB following nudge deployment into the EHR.

Results

Similar baseline demographic and tumor characteristics were observed before (control period, n = 194) and after (intervention period, n = 193) nudge deployment. Patients in both the control and intervention period had a median (IQR) age of 75 (72-79) years. Compared with the control period, unadjusted rates of SLNB decreased by 23.1 percentage points (46.9% SLNB rate prenudge to 23.8% after; 95% CI, -32.9 to -13.8) in the intervention period. An interrupted time series model showed a reduction in the rate of SLNB following nudge deployment (adjusted odds ratio, 0.26; 95% CI, 0.07 to 0.90; P = .03). The participating surgeons scored the intervention highly on acceptability, appropriateness, and feasibility. Dominant themes from semistructured interviews indicated that the intervention helped remind the surgeons of potential Choosing Wisely applicability without the need for additional clicks or actions on the day of the patient visit, which facilitated use.

Conclusions and Relevance

This study showed that a nudge intervention in the EHR significantly decreased low-value axillary surgery in older women with early-stage, cN0, HR+/HER2- breast cancer. This user-friendly and easily implementable EHR-based intervention could be a beneficial approach for decreasing low-value care in other practice settings or patient populations.

Trial Registration

ClinicalTrials.gov Identifier: NCT06006910.

Nodal Surgery for Patients ≥ 70 Undergoing Mastectomy for DCIS? Choose Wisely

BACKGROUND

Routine sentinel lymphadenectomy (SLNB) for early-stage HR+/HER2- breast cancer in women ≥70 is discouraged by Choosing Wisely, but whether SLNB can be routinely omitted in women ≥70 with DCIS undergoing mastectomy is unclear. This study aims to evaluate rates of axillary surgery and nodal positivity (pN+) in this population to determine the impact of axillary surgery on treatment decisions.

METHODS

Females ≥70 with DCIS undergoing mastectomy were identified from the National Cancer Database (2012-2020). The rate of upstaging to invasive cancer (≥pT1) or pN+ was assessed. Subset analyses were conducted for ER+ patients. Adjuvant therapies were evaluated among ≥pT1 patients after stratifying by nodal status.

RESULTS

Of 9,030 patients, 1,896 (21%) upstaged to ≥pT1. Axillary surgery was performed in 86% of patients, predominantly sentinel lymphadenectomy (SLNB, 65%). Post hoc application of Choosing Wisely criteria demonstrated that 93% of the entire cohort and 97% of ER+ DCIS patients could have avoided axillary surgery. Nodal positivity was 0.3% among those who didn't upstage, and 12% among those upstaging to ≥pT1, with <2% having pN2-3 disease, irrespective of receptor subtype. Node-positive patients had higher adjuvant therapy usage, but there was no recommendation for adjuvant chemotherapy or radiation for 71% and 66% of pN+ patients, respectively.

CONCLUSIONS

Axillary surgery can be omitted for most patients ≥70 undergoing mastectomy for ER+ DCIS, aligning with recommendations for invasive cancer, and omission can be considered in those with ER- disease. Future guidelines incorporating preoperative imaging, as in the SOUND trial, may aid in identifying patients benefiting from axillary surgery.

Can Genomic Testing Help Refine Choosing Wisely the Omission of Axillary Staging in cN0 Breast Cancer?

INTRODUCTION

Choosing Wisely (CW) recommends women age ≥70 y with cT1-2cN0 ER+/HER2-invasive breast cancer (BC) should forgo routine axillary staging with sentinel lymph node biopsy (SLN) at the time of breast surgery. Despite this longstanding recommendation, acceptance of SLN omission has not been widely adopted. Genomic assays, such as MammaPrint (MP), may supplement the decision to apply CW. We hypothesized that having MP on BC core needle biopsy (CNB) meeting CW could provide additional information to aid in decision-making about the need for axillary staging with SLN.

METHODS

A retrospective single-institution review was conducted for women with BC meeting CW criteria, who also had MP performed on CNB from 2020 to 2021. Categorical characteristics were compared using the chi-square test. Continuous variables were compared using the Mann-Whitney U-test.

RESULTS

MP was available on CNB for 238 BC meeting CW criteria: 70% low risk and 30% high risk. Axillary staging was performed in 195 (82%). Eighty-one percent were pathologically node-negative and 19% were pathologically node-positive. The MP score did not correlate with pathologic nodal stage (P = 0.52). The rate of high nodal burden (pN2) was extremely low (n = 1, 0.5%). The only significant correlation with pathological node positivity was older age (P = 0.03). Appropriately, high-risk MP was strongly associated with increased recurrence risk (n = 4, P = 0.008).

CONCLUSIONS

Having MP on CNB does not provide clinically meaningful information about the pN stage and does not further refine which BC patients within CW could benefit from escalation to SLN or delineate a group more likely to be pathologically node-negative.

Recent Advances in the Upfront Surgical Management of the Axilla in Patients with Breast Cancer

Nodal status is an important prognostic indicator. Upfront axillary surgery for patients with breast cancer has historically been both diagnostic and therapeutic-serving to determine nodal status and inform adjuvant therapies, and to remove clinically significant disease. However, trials of de-escalation or omission of axillary surgery altogether consistently demonstrate noninferior oncologic outcomes in a wide variety of patient subsets. These strategies also reduce the morbidity associated with either sentinel lymphadenectomy or axillary lymph node dissection. Here we will briefly review landmark trials that have shaped upfront axillary surgery as well as recent advances, and discuss areas of ongoing investigation and future needs.

A Prospective Study of Sentinel Node Biopsy Omission in Women Age ≥ 65 Years with ER+ Breast Cancer

BACKGROUND

National guidelines recommend omitting SNB in older patients with favorable invasive breast cancer. However, there is a lack of prospective data specifically addressing this issue. This study evaluates recurrence and survival in estrogen receptor-positive/Her2- (ER+) breast cancer patients, aged ≥ 65 years who have breast-conserving surgery (BCS) without SNB.

METHODS

This is a prospective, observational study at a single institution where 125 patients aged ≥ 65 years with clinical T1-2N0 ER+ invasive breast cancer undergoing BCS were enrolled. Patients were treated with BCS without SNB. Primary outcome measure was axillary recurrence. Secondary outcome measures include recurrence-free survival (RFS), disease-free survival (DFS), breast cancer-specific survival (BCSS), and overall survival (OS).

RESULTS

From January 2016 to July 2022, 125 patients were enrolled with median follow-up of 36.7 months [95% confidence interval (CI) 35.0-38.0]. Median age was 77.0 years (range 65-93). Median tumor size was 1 cm (range 0.1-5.0). Most tumors were ductal (95/124, 77.0%), intermediate grade (60/116, 51.7%), and PR-positive (117/123, 91.7%). Radiation therapy was performed in 37 of 125 (29.6%). Only 60 of 125 (48.0%) who were recommended hormonal therapy were compliant at 2 years. Chemotherapy was administered to six of 125 (4.8%) patients. There were two of 125 (1.6%) axillary recurrences. Estimated 3-years rates of regional RFS, DFS, and OS were 98.2%, 91.2%, and 94.8%, respectively. Univariate Cox regression identified hormonal therapy noncompliance to be significantly associated with recurrence (p = 0.02).

CONCLUSIONS

Axillary recurrence rates were extremely low in this cohort. These results provide prospective data to support omission of SNB in this patient population TRIAL REGISTRATION: ClinicalTrials.gov ID NCT02564848.

Using MammaPrint on core needle biopsy to guide the need for axillary staging during breast surgery

BACKGROUND

At present, the only opportunity to omit axillary staging is with Choosing Wisely criteria for women ages >70 y with cT1 2N0 estrogen receptor-positive/human epidermal growth factor receptor 2-negative breast cancer. However, many women are diagnosed when pathologic node status-negative, raising the question of additional opportunities to omit sentinel lymph node biopsy. We sought to investigate the association between MammaPrint, a genomic test that estimates estrogen receptor-positive breast cancer recurrence risk, and pathologic node status, with the aim that low-risk MammaPrint could be considered for omission of sentinel lymph node biopsy if associated with pathologic node status-negative.

METHODS

A single-institution database was queried for all women with cT1 2N0 estrogen receptor-positive/human epidermal growth factor receptor 2-negative invasive breast cancer with breast surgery as their first treatment and MammaPrint performed from 2020 to 2021. Patient and tumor factors, including MammaPrint score, were compared with axillary node status for correlation.

RESULTS

A total of 668 women met inclusion criteria, with a median age of 66 y. MammaPrint was low-risk luminal A in 481 (72%) and high-risk luminal B in 187 (28%). At the time of breast surgery, 588 (88%) had sentinel lymph node biopsy, 27 (4%) had axillary lymph node dissection, and 53 (7.9%) had no axillary staging. Most women in both the pathologic node status-negative and pathologic node status-positive cohorts had low-risk MammaPrint (355 [73.3%] pathologic node status-negative vs 91 [69.5%] pathologic node status-positive), and women with low-risk MammaPrint did not have a significantly lower risk of pathologic node status-positive (P = .377).

CONCLUSION

Low-risk MammaPrint does not predict lower risk of pathologic node status-positive breast cancer. Based on our results, genomic testing does not appear to provide additional personalization for the ability to omit sentinel lymph node biopsy for patients outside of the Choosing Wisely guidelines.

Luminal A Versus B After Choosing Wisely: Does Lymph Node Surgery Affect Oncologic Outcomes?

BACKGROUND

In 2016, the Choosing Wisely campaign recommended against routine sentinel lymph node biopsy (SLNB) in women ≥ 70 years old diagnosed with early-stage hormone receptor positive (HR+), HER2 negative (HER2-) breast cancer. No distinction is made between luminal A and luminal B phenotypes, despite luminal B being considered more aggressive. This study evaluates the effect of SLNB on oncologic outcomes in HER2- luminal B versus luminal A breast cancer.

PATIENTS AND METHODS

We performed an IRB-approved, single institution, retrospective cohort study from 2010 to 2020 of women aged ≥ 70 years with clinically node negative, HR+ breast cancer undergoing definitive surgical treatment. Luminal status was defined by gene expression panel testing, Ki67%, and/or pathologic grading. Primary endpoints included locoregional recurrence (LRR), disease free survival (DFS), and overall survival (OS).

RESULTS

SLNB did not correlate with significant differences in LRR in luminal A (p = 0.92) or luminal B (p = 0.96) disease. SLNB correlated with improved DFS (p < 0.01) and OS (p < 0.001) in luminal A disease, but not in luminal B disease (DFS p = 0.73; OS p = 0.36). On multivariate analysis, age (HR = 1.17; p < 0.01) and tumor size (HR = 1.03; p < 0.05) were associated with DFS, while SLNB was not (p = 0.71). Luminal status (HR = 0.52, p < 0.05), age (HR = 1.15, p < 0.01), and comorbidities (HR = 1.35, p < 0.05) were associated with OS, but not SLNB (p = 0.71).

CONCLUSIONS

Our results suggest that SLNB may be safely omitted in patients aged ≥ 70 years with luminal B disease given similar LRR in luminal A disease. Our findings suggest that DFS and OS are driven by tumor biology, patient age, and comorbidities rather than receipt of SLNB.

Factors Predictive of Positive Lymph Nodes for Breast Cancer

BACKGROUND

Axillary node status is an important prognostic factor in breast cancer. The primary aim was to evaluate tumor size and other characteristics relative to axillary disease.

MATERIALS AND METHODS

Single institution retrospective chart review of stage I-III breast cancer patients collected demographic and clinical/pathologic data from 1998-2019. Student's t-test, Chi-squared test (or Fisher exact test if applicable), and logistic regression models were used for testing the association of pN+ to predictive variables.

RESULTS

Of 728 patients (mean age 59 yrs) with mean follow up of 50 months, 86% were estrogen receptor +, 10% Her2+, 78% ER+HER2-negative, and 10% triple-negative. In total, 351/728 (48.2%) were pN+ and mean tumor size was larger in pN+ cases compared to pN- cases (mean = 27.7 mm versus 15.5 mm) (p < 0.001). By univariate analysis, pN+ was associated with lymphovascular invasion (LVI), higher grade, Her2, and histology (p < 0.005). Tumor-to-nipple distance was shorter in pN+ compared to pN- (45 mm v. 62 mm; p< 0.001). Age < 60, LVI, recurrence, mastectomy, larger tumor size, and shorter tumor-nipple distance were associated with 3+ positive nodes (p < 0.05).

CONCLUSIONS

Larger tumor size and shorter tumor-nipple distance were associated with higher lymph node positivity. Age less than 60, LVI, recurrence, mastectomy, larger tumor size, and shorter tumor-nipple distance were all associated with 3+ positive lymph nodes.

Is Choosing Wisely Wise for Lobular Carcinoma in Patients Over 70 Years of Age? A National Cancer Database Analysis of Sentinel Node Practice Patterns

BACKGROUND

Controversy continues in the treatment of breast cancer in women over 70 years of age. In 2016, the Society of Surgical Oncology recommended against routine use of sentinel lymph node biopsy (SLNBx) as part of the 'Choosing Wisely Campaign'. This study examines the oncologic safety of avoidance of routine SLNBx in patients over 70 years of age with invasive lobular carcinoma (ILC).

METHODS

The National Cancer Database was used to identify women with invasive ductal carcinoma (IDC) and ILC diagnosed between 2012 and 2020. Clinical and pathological staging, axillary staging, surgery type, and lymph node positivity between patients with IDC or ILC were compared.

RESULTS

Among women with T1 tumors, 85,949 (79.6%) patients with IDC and 12,761 (81.5%) patients with ILC underwent SLNBx (p < 0.001). Among patients who underwent SLNBx, those with IDC were more likely to have positive nodes (n = 7535, 8.8%) than those with ILC (n = 1041, 8.2%; p = 0.02). During the time interval of interest, for both IDC and ILC patients, the rate of axillary lymph node dissection decreased and rates of SLNBx or no axillary staging increased. On multivariate analysis, ILC histology was associated with use of SLNBx, but without nodal positivity.

CONCLUSION

A trend de-escalation of axillary staging was identified in this study, however the majority of patients meeting the 'Choosing Wisely' criteria are still undergoing SLNBx. No increased risk of nodal positivity was identified among patients with ILC, suggesting that surgeons can continue to choose wisely and limit the use of SLNBx in women over 70 years of age with T1 ILC tumors.

A nomogram for individually predicting overall survival for elderly patients with early breast cancer: a consecutive cohort study

Background

Elderly patients with breast cancer are highly heterogeneous, and tumor load and comorbidities affect patient prognosis. Prediction models can help clinicians to implement tailored treatment plans for elderly patients with breast cancer. This study aimed to establish a prediction model for breast cancer, including comorbidities and tumor characteristics, in elderly patients with breast cancer.

Methods

All patients were ≥65 years old and admitted to the Peking Union Medical College Hospital. The clinical and pathological characteristics, recurrence, and death were observed. Overall survival (OS) was analyzed using the Kaplan-Meier curve and a prediction model was constructed using Cox proportional hazards model regression. The discriminative ability and calibration of the nomograms for predicting OS were tested using concordance (C)-statistics and calibration plots. Clinical utility was demonstrated using decision curve analysis (DCA).

Results

Based on 2,231 patients, the 5- and 10-year OS was 91.3% and 78.4%, respectively. We constructed an OS prediction nomogram for elderly patients with early breast cancer (PEEBC). The C-index for OS in PEEBC in the training and validation cohorts was 0.798 and 0.793, respectively. Calibration of the nomogram revealed a good predictive capability, as indicated by the calibration plot. DCA demonstrated that our model is clinically useful.

Conclusion

The nomogram accurately predicted the 3-year, 5-year, and 10-year OS in elderly patients with early breast cancer.

Not Too Little, Not Too Much: Optimizing More Versus Less Locoregional Treatment for Older Patients With Breast Cancer

Although undertreatment of older women with aggressive breast cancers has been a concern for years, there is increasing recognition that some older women are overtreated, receiving therapies unlikely to improve survival or reduce morbidity. De-escalation of surgery may include breast-conserving surgery over mastectomy for appropriate candidates and omitting or reducing extent of axillary surgery. Appropriate patients to de-escalate surgery are those with early-stage breast cancer, favorable tumor characteristics, are clinically node-negative, and who may have other major health issues. De-escalation of radiation includes reducing treatment course length through hypofractionation and ultrahypofractionation regimens, reducing treatment volumes through partial breast irradiation, omission of radiation for select patients, and reducing radiation dose to normal tissues. Shared decision making, which aims to facilitate patients making decisions concordant with their values, can guide health care providers and patients through complicated decisions optimizing breast cancer care.

Omitting axillary staging in selected patients: Rationale of Choosing Wisely in breast cancer treatment

Axillary surgery for breast cancer has continually evolved, with sentinel lymph node biopsy for clinically node-negative women with invasive breast cancer having long replaced axillary lymph node dissection. The information obtained from axillary staging has been important in providing prognostic information and guiding adjuvant treatment recommendations. However, recent studies suggest that sentinel lymph node biopsy should be omitted in select low-risk patients whose axillary surgery provides minimal prognostic value. This was highlighted by the Society of Surgical Oncology Choosing Wisely Guidelines, advocating against routine axillary staging in older women with early-stage hormone receptor-positive breast cancer. Since the guideline release, ongoing research has continued to identify the subset of low-risk patients who would benefit from the omission of axillary staging and improve adherence to Choosing Wisely to prevent overtreatment in older people.

Breast-conserving surgery without axillary surgery and radiation versus mastectomy plus axillary dissection in elderly breast cancer patients: A retrospective study

Background

The high relative mortality rate in elderly breast cancer patients is most likely the result of comorbidities rather than the tumor load. Foregoing axillary lymph node dissection or omitting radiotherapy after breast-conserving surgery (BCS) does not affect the prognosis of elderly breast cancer patients. We sought to assess the safety of breast-conserving surgery without axillary lymph node dissection as well as breast and axillary radiotherapy (BCSNR) in elderly patients with early-stage breast cancer.

Methods

We retrospectively included 541 consecutive breast cancer patients aged over 70 years with clinically negative axillary lymph nodes in one clinical center. Of these patients, 181 underwent mastectomy plus axillary lymph node dissection (MALND) with negative axillary cleaning and 360 underwent BCSNR.

Results

After a median follow-up of 5 years, there was no significant difference between the BCSNR and MALND groups in either distant recurrence-free survival (DRFS) (p=0.990) or breast cancer-specific survival (p=0.076). Ipsilateral axillary disease was found in 11 (3.1%) patients in the BCSNR group and 3 (1.7%) patients in the MALND group; this difference was not significant (p=0.334). We did not observe a significant difference in distant recurrence between the groups (p=0.574), with 25 (6.9%) patients in the BCSNR group experiencing distant recurrence compared to 15 (8.3%) patients in the MALND group. Our findings did show a significant difference in ipsilateral breast cancer recurrence (IBTR), with 31 (8.6%) patients in the BCSNR group experiencing IBTR compared to only 2 (1.1%) patients in the MALND group (p=0.003).

Conclusion

BCSNR is a safe treatment option for elderly breast cancer patients with clinically negative axillary lymph nodes.

Preoperative Sonographic Prediction of Limited Axillary Disease in Patients with Primary Breast Cancer Meeting the Z0011 Criteria: an Alternative to Sentinel Node Biopsy?

PURPOSE

To assess the accuracy of preoperative sonographic staging for prediction of limited axillary disease (LAD, one or two metastatic lymph nodes) and to identify factors associated with high prediction-pathology concordance in patients with early-stage breast cancer meeting the Z0011 criteria.

MATERIALS AND METHODS

Patients treated between January 2015 and January 2020 were included in this retrospective, multicentric analysis of prospectively acquired service databases. The accuracy of LAD prediction was assessed separately for patients with one and two suspicious lymph nodes on preoperative sonography. Test validity outcomes for LAD prediction were calculated for both groups, and a multivariate model was used to identify factors associated with high accuracy of LAD prediction.

RESULTS

Of 2059 enrolled patients, 1513 underwent sentinel node biopsy, 436 primary and 110 secondary axillary dissection. For LAD prediction in patients with one suspicious lymph node on preoperative ultrasound, sensitivity was 92% (95% CI 87-95%), negative predictive value (NPV) was 92% (95% CI 87-95%), and the false-negative rate (FNR) was 8% (95% CI 5-13%). For patients with two preoperatively suspicious nodes, the sensitivity, NPV, and FNR were 89% (95% CI 84-93%), 73% (62-83%), and 11% (95% CI 7-16%), respectively. On multivariate analysis, the number of suspicious lymph nodes was associated inversely with correct LAD prediction ([OR 0.01 (95% CI 0.01-0.93), p ≤ 0.01].

CONCLUSIONS

Sonographic axillary staging in patients with one metastatic lymph node predicted by preoperative ultrasound showed high accuracy and a false-negative rate comparable to sentinel node biopsy for prediction of limited axillary disease.

Can We Successfully De-Escalate Axillary Surgery in Women Aged ≥ 70 Years with Ductal Carcinoma in Situ or Early-Stage Breast Cancer Undergoing Mastectomy?

BACKGROUND

Omission of sentinel lymph node biopsy (SLNB) in older women with clinically node-negative, hormone receptor-positive (HR+) early-stage breast cancer undergoing lumpectomy is accepted, given established low rates of regional recurrence. The safety of omitting SLNB in women undergoing mastectomy is unknown and may differ depending on extent of breast disease and variation in radiotherapy use.

PATIENTS AND METHODS

From 2006 to 2018, 123 cTis and 328 cT1-2 HR+/HER2- tumors from 410 women aged ≥ 70 years who underwent mastectomy and SLNB were included (41 bilateral cases). The rate of nodal positivity and effect of nodal positivity on adjuvant therapy use were examined.

RESULTS

Median age was 74 years; 21% of patients had positive sentinel lymph nodes, 7% had micrometastases, and 14% had macrometastases. Of cases of cTis tumors, 31% were upstaged to invasive carcinoma; 1% had macrometastases. Fewer cases of cT1 than cT2 tumors had macrometastases [13% (26/200) versus 29% (37/128); p < 0.001]. Eight percent of patients with pT1 tumors (18/228) and 27% of patients with pT2 tumors (30/113) received chemotherapy. Most patients with pT1, pN1 disease (78%; 25/32) did not receive chemotherapy. Rates of locoregional recurrence were similar between patients with cT1 or cT2 tumors with and without nodal metastases (median follow-up, 4.5 years).

CONCLUSIONS

Women aged ≥ 70 years with cTis and cT1N0 HR+/HER2- tumors who underwent mastectomy had low rates of nodal positivity, similar to rates reported for lumpectomy. Given this and the RxPONDER results, omission of SLNB may be considered, as findings are unlikely to alter adjuvant therapy recommendations.

Low RUFY3 expression level is associated with lymph node metastasis in older women with invasive breast cancer

PURPOSE

Sentinel lymph node biopsy is omitted in older women (≥ 70 years old) with clinical lymph node (LN)-negative hormone receptor-positive breast cancer as it does not influence adjuvant treatment decision-making. However, older women are heterogeneous in frailty while the chance of recurrence increase with improving longevity. Therefore, a biomarker that identifies LN metastasis may facilitate treatment decision-making. RUFY3 is associated with cancer progression. We evaluated RUFY3 expression level as a biomarker for LN-positive breast cancer in older women.

METHODS

Clinical and transcriptomic data of breast cancer patients were obtained from the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC, n = 1903) and The Cancer Genome Atlas (TCGA, n = 1046) Pan-cancer study cohorts.

RESULTS

A total of 510 (METABRIC) and 211 (TCGA) older women were identified. LN-positive breast cancer, which represented 51.4% (METABRIC) and 48.4% (TCGA), demonstrated worse disease-free, disease-specific, and overall survival. RUFY3 levels were significantly lower in LN-positive tumors regardless of age. The area under the curve for the receiver operator characteristic (AUC-ROC) curves showed RUFY3-predicted LN metastasis. Low RUFY3 enriched oxidative phosphorylation, DNA repair, MYC targets, unfolded protein response, and mtorc1 signaling gene sets, was associated with T helper type 1 cell infiltration, and with intratumor heterogeneity and fraction altered. Low RUFY3 expression was associated with LN-positive breast cancer and with worse disease-specific survival among older women.

CONCLUSION

Older women with breast cancers who had low expression level of RUFY3 were more frequently diagnosed with LN-positive tumors, which translated into worse prognosis.

Omission of sentinel node biopsy for breast cancer: Historical context and future perspectives on a modern controversy

For older patients with clinically lymph node-negative breast cancer who have estrogen receptor-positive tumors and are treated with tamoxifen, randomized trials comparing axillary lymph node dissection (ALND) versus no ALND show that the omission of ALND improves patient quality of life and has no adverse effects on mortality. These results have served to justify sentinel node biopsy (SNB) omission in selected older patients with breast cancer. More recently, clinical trials were launched to assess SNB omission in younger patients, with recurrence and survival as the primary outcomes of interest. Three important considerations serve as the basis for these ongoing trials. First, it is assumed that SNB omission will improve patient quality of life, although, to date, there is no level I evidence to support this assumption. Second, axillary surgery has never been shown to reduce breast cancer mortality, but it does reduce the risk of axillary recurrences, although adjuvant systemic therapy and radiotherapy also reduce these recurrence risks. Finally, nodal status is losing importance as a guide for adjuvant systemic therapy decision making because these decisions are now increasingly predicated on tumor biomarkers and gene profiling, but it is gaining importance for adjuvant radiotherapy decision making. Because quality-of-life considerations are the primary motivation for abandoning SNB, there is a need for randomized trials comparing SNB versus no SNB/no axillary surgery, with quality of life as the primary end point (level I evidence). Moreover, suitable alternatives to guide adjuvant radiotherapy decision making will require validation before SNB omission can be justified for patients of all ages who have clinically node-negative breast cancer. LAY SUMMARY: In this review article, the authors provide a brief historical overview of the role of axillary surgery in breast cancer management and discuss additional studies and ramifications that should be considered before abandoning the sentinel node biopsy (SNB) procedure. Specifically, there is a need for level I evidence demonstrating that omission of the SNB procedure will improve patient quality of life and a need to validate suitable alternatives to SNB as a guide for adjuvant radiotherapy decision making.

Axillary Ultrasound Evaluation in Breast Cancer Patients: A Multidisciplinary Viewpoint and Middle Ground

Over the past decade, there has been a trend toward de-escalation of axillary surgery. Certain patients may now forego axillary lymph node dissection even in the setting of a positive sentinel lymph node biopsy (SLNB), and some patients may not even undergo a SLNB. However, there is wide variability in the imaging approach to assessing axillary lymph nodes in patients with breast cancer. Approaches range from performing axillary US in all patients with newly diagnosed breast cancer to omitting axillary imaging evaluation in all patients. This article provides a multidisciplinary middle ground approach for axillary nodal evaluation. The clinical impact and rationale for appropriate axillary nodal imaging are discussed and an imaging algorithm is proposed.

Controversial Areas in Axillary Staging: Are We Following the Guidelines?

Background

Sentinel lymph node biopsy (SLNB) has been the standard of care for clinically node-negative women with invasive breast cancer (IBC); however, there is less agreement on whether to perform SLNB when the risk of metastasis is low or when it does not affect survival or locoregional control.

Methods

An Institutional Review Board-approved survey was sent to members of the American Society of Breast Surgeons asking in which scenarios surgeons would recommend SLNB. Descriptive statistics and multivariable analysis were performed using SPSS software.

Results

There was a 23% response rate; 68% identified as breast surgical oncologists, 6% as surgical oncologists, 24% as general surgeons, and 2% as other. The majority practiced in a community setting (71%) versus an academic setting (29%). In a healthy female with clinical T1N0 hormone receptor-positive (HR+) IBC, 83% favored SLNB if the patient was 75 years of age, versus 35% if the patient was 85 years of age. Academic surgeons were less likely to perform axillary staging in a healthy 75-year-old (odds ratio [OR] 0.51 [0.32–0.80], p = 0.004) or a healthy 85-year-old (OR 0.48 [0.31–0.74], p = 0.001). For DCIS, 32% endorsed SLNB in women undergoing lumpectomy, with breast surgical oncologists and academic surgeons being less likely to endorse this procedure (OR 0.54 [0.36–0.82], p = 0.028; and OR 0.53 [0.34–0.83], p = 0.005, respectively).

Conclusions

Despite studies showing that omitting SLNB in older patients with HR+ IBC does not impact regional control or survival, most surgeons are still opting for axillary staging. In addition, one in three are performing SLNB for lumpectomies for DCIS. Breast surgical oncologists and academic surgeons were more likely to be practicing based on recent data and guidelines. Practice patterns are changing but there is still room for improvement.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10443-x.

Decreasing the Use of Sentinel Lymph Node Surgery in Women Older than 70 Years with Hormone Receptor-Positive Breast Cancer and the Impact on Adjuvant Radiation and Hormonal Therapy

BACKGROUND

In 2016, SSO Choosing Wisely guidelines recommended against routine sentinel lymph node (SLN) surgery in women ≥ 70 with HR+ cN0 breast cancer. Following this, we identified a group of women at low-risk of nodal positivity where SLN may be omitted (grade 1, cT1mi-T1c, or grade 2, cT1mi-T1b). This study evaluates the impact of these changes on our practice.

METHODS

Retrospective chart review of women aged ≥ 70 years with HR+ cN0 breast cancer at our institution from 2010 to 2020. We compared SLN use before (2010-2016)/after (2017-2020) guideline release according to clinical risk and the association with adjuvant therapy.

RESULTS

A total of 1015 breast cancers in 987 women identified. SLN surgery rate significantly decreased from 90.6% (2010-2016) to 62.8% in 2020 (p < 0.001). This was driven by breast-conserving surgery (BCS) with SLN rates of 88.2% (2010-2016) and 46.7% in 2020. During 2017-2020, SLN use varied by risk within BCS patients: 52.2% low-risk, 81.9% higher-risk, p < 0.001. In contrast, in mastectomy patients SLN was performed in ≥ 98% regardless of risk level. SLN positivity was 13.4% overall: 7.4% in low-risk and 20.8% in higher-risk, p < 0.001. After adjusting for age and clinical risk, SLN use was not associated with adjuvant radiation [odds ratio (OR) 1.61, p = 0.11] or endocrine therapy (OR 1.12, p = 0.71).

CONCLUSIONS

The Society of Surgical Oncology guideline release, followed by implementation of a clinical tool to stratify by nodal risk, was associated with decreased SLN use in women aged ≥ 70 years, in those with clinically low-risk HR+ disease surgically treated with BCS. Adjusting for confounders, omission of SLN surgery was not associated with use of subsequent adjuvant radiation or hormonal therapy.

Weathering the Storm: Managing Older Adults With Breast Cancer Amid COVID-19 and Beyond

Caring for older patients with breast cancer presents unique clinical considerations because of preexisting and competing comorbidity, the potential for treatment-related toxicity, and the consequent impact on functional status. In the context of the COVID-19 pandemic, treatment decision making for older patients is especially challenging and encourages us to refocus our treatment priorities. While we work to avoid treatment delays and maintain therapeutic benefit, we also need to minimize the risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposures, myelosuppression, general chemotherapy toxicity, and functional decline. Herein, we propose multidisciplinary care considerations for the aging patient with breast cancer, with the goal to promote a team-based, multidisciplinary treatment approach during the COVID-19 pandemic and beyond. These considerations remain relevant as we navigate the “new normal” for the approximately 30% of breast cancer patients aged 70 years and older who are diagnosed in the United States annually and for the thousands of older patients living with recurrent and/or metastatic disease.

Sentinel Node Biopsy Should Not be Routine in Older Patients with ER-Positive HER2-Negative Breast Cancer Who Are Willing and Able to Take Hormone Therapy

BACKGROUND

The SSO Choosing Wisely campaign recommended selective sentinel lymph node biopsy (SLNB) in clinically node-negative women aged ≥ 70 years with ER+ breast cancer. We sought to assess the association of SLNB positivity, adjuvant treatment, and survival in a population-based cohort.

PATIENTS AND METHODS

Women aged ≥ 70 years treated for ER+ HER2- breast cancer between 2010 and 2016 were identified in our prospective provincial database. Overall survival (OS) and breast cancer-specific survival (BCSS) were assessed using Kaplan-Meier analysis. Multivariable logistic regression was used to assess the association of SLNB positivity with use of adjuvant treatments and survival outcomes.

RESULTS

We identified 2662 patients who met study criteria. SLNB was positive in 25%. Increased use of chemotherapy (ChT), hormone therapy (HT), and radiotherapy (RT) was significantly associated with SLNB positivity. Five-year OS was 86%, and BCSS was 96% with median follow-up of 4.3 years. BCSS was worse with grade 3 disease (HR 4.1, 95% CI 2.1-8.1, p < 0.0001) and better with HT (HR 0.5 95% CI 0.3-0.9, p = 0.01). Patients with a positive SLNB treated without adjuvant therapy had lower BCSS (HR 3.2 95% CI 1.2-8.4, p = 0.017) than those with a negative SLNB, but patients with a positive SLNB treated with any combination of ChT, HT, and/or RT, had similar BCSS to those with a negative SLNB.

CONCLUSIONS

BCSS in this population was excellent at 96%, and BCSS was similar with negative and positive SLNB when patients received HT. SLNB can be omitted in elderly patients willing to take HT.

Accuracy of breast MRI in evaluating nodal status after neoadjuvant therapy in invasive lobular carcinoma

Neoadjuvant therapy in breast cancer can downstage axillary lymph nodes and reduce extent of axillary surgery. As such, accurate determination of nodal status after neoadjuvant therapy and before surgery impacts surgical management. There are scarce data on the diagnostic accuracy of breast magnetic resonance imaging (MRI) for nodal evaluation after neoadjuvant therapy in patients with invasive lobular carcinoma (ILC), a diffusely growing tumor type. We retrospectively analyzed patients with stage 1–3 ILC who underwent pre-operative breast MRI after either neoadjuvant chemotherapy or endocrine therapy at our institution between 2006 and 2019. Two breast radiologists reviewed MRIs and evaluated axillary nodes for suspicious features. All patients underwent either sentinel node biopsy or axillary dissection. We evaluated sensitivity, specificity, negative and positive predictive values, and overall accuracy of the post-treatment breast MRI in predicting pathologic nodal status. Of 79 patients, 58.2% received neoadjuvant chemotherapy and 41.8% neoadjuvant endocrine therapy. The sensitivity and negative predictive value of MRI were significantly higher in the neoadjuvant endocrine therapy cohort than in the neoadjuvant chemotherapy cohort (66.7 vs. 37.9%, p = 0.012 and 70.6 vs. 40%, p = 0.007, respectively), while overall accuracy was similar. Upstaging from clinically node negative to pathologically node positive occurred in 28.0 and 41.7%, respectively. In clinically node positive patients, those with an abnormal post-treatment MRI had a significantly higher proportion of patients with ≥4 positive nodes on pathology compared to those with a normal MRI (61.1 versus 16.7%, p = 0.034). Overall, accuracy of breast MRI for predicting nodal status after neoadjuvant therapy in ILC was low in both chemotherapy and endocrine therapy cohorts. However, post-treatment breast MRI may help identify patients with a high burden of nodal disease (≥4 positive nodes), which could impact pre-operative systemic therapy decisions. Further studies are needed to assess other imaging modalities to evaluate for nodal disease following neoadjuvant therapy and to improve clinical staging in patients with ILC.

A scoping review characterizing "Choosing Wisely®" recommendations for breast cancer management

PURPOSE

Choosing Wisely (CW)® was created by the American Board of Internal Medicine (ABIM) to promote patient-physician conversations about unnecessary medical interventions. Similarly, other countries created their own panels of experts called "CW® campaigns" which review recommendations submitted by that country's oncology societies. We performed a scoping review to consolidate CW® recommendations from different groups with respect to breast cancer care.

METHODS

A systematic search of Medline and Embase was designed by an information specialist for publications presenting CW® recommendations for breast cancer care practices from 2011-2020. We also reviewed the websites of all CW® campaigns and reference sections of each CW® recommendation. Two reviewers independently screened studies for inclusion and performed data extraction. Findings were summarized narratively.

RESULTS

Review of ABIM CW® recommendations showed 19 breast cancer-related recommendations pertaining to; screening (n = 4), radiological staging (n = 2), treatment (n = 10), surveillance (n = 2), and miscellaneous (genetic testing; n = 1). Of 22 countries with CW® campaigns, 10 published recommendations for breast cancer. Over half (57%) of recommendations were supported by more than one country. No recommendations were refuted between campaigns. Two campaigns developed 3 novel recommendations on new topics, including chemotherapy in ductal carcinoma in situ (Italy) and comparison of screening imaging modalities (Portugal).

CONCLUSIONS

CW® recommendations focus on reducing overutilization of investigations and treatments. There was a high rate of consensus between different CW® campaigns. As health care systems globally move attention to reduce low-value care, further studies are required to address adherence to these current recommendations and develop new recommendations.

Association of Axillary Lymph Node Evaluation With Survival in Women Aged 70 Years or Older With Breast Cancer

Background

Survival in elderly patients undergoing sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) has not been specifically analyzed. This study aimed to explore the association between different types of axillary lymph node (ALN) evaluations and survival of elderly breast cancer patients.

Methods

A retrospective cohort study was conducted of invasive ductal breast cancer patients 70 years and older in the Surveillance, Epidemiology, and End Results database (2004–2016). Analyses were performed to compare the characteristics and survival outcomes of patients who received surgical lymph node dissection and those who did not. Breast cancer specific survival (BCSS) and overall survival were compared by using Cox proportional hazards regression analysis and propensity score matching (PSM) methods to account for selection bias from covariate imbalance.

Results

Of the 75,950 patients analyzed, patients without ALN evaluation had a significantly worse prognosis, while there was no significant difference for BCSS between using a sentinel lymph node biopsy (SLNB) and an axillary lymph node dissection (ALND) after adjustment for known covariates [adjusted hazard ratio (HR) = 0.991, 95% confidence interval (CI) = 0.925–1.062, p = 0.800]. In the stratification analyses after PSM, the ALND did not show a significant BCSS advantage compared with SLNB in any subgroups except for the pN1 stage or above. Furthermore, after PSM of the pN1 stage patients, SLNB was associated with a significantly worse BCSS in hormone receptor negative (HR−) patients (HR = 1.536, 95%CI = 1.213–1.946, p < 0.001), but not in the hormone receptor positive (HR+) group (HR = 1.150, 95%CI = 0.986–1.340, p = 0.075).

Conclusion

In our study, ALND does not yield superior survival compared with SLNB for elderly patients with pN1 stage HR+ breast cancer. Although our findings are limited by the bias associated with retrospective study design, we believe that in the absence of results from randomized clinical trials, our findings should be considered when recommending the omission of ALND for elderly breast cancer patients.

Omitting radiotherapy is safe in breast cancer patients ≥ 70 years old after breast-conserving surgery without axillary lymph node operation

To verify whether omitting radiotherapy from breast cancer treatment for patients ≥ 70 years old following breast-conserving surgery (BCS) without axillary lymph node dissection is safe. Previous studies have shown that omitting breast radiotherapy after BCS and axillary lymph node dissection is safe for elderly breast cancer patients. We aimed to evaluate the safety of BCS without axillary surgery or breast radiotherapy (BCSNR) in elderly patients with breast cancer and clinically negative axillary lymph nodes. We performed a retrospective analysis of 481 patients with breast cancer, aged ≥ 70 years, between 2010 and 2016. Of these, 302 patients underwent BCSNR and 179 underwent other, larger scope operations. Local recurrence rate, ipsilateral breast tumor recurrence (IBTR) rate, distant metastasis rate, breast-related death, disease-free survival (DFS), and overall survival (OS) were compared between the two groups. After a median follow-up of 60 months, no significant differences in local recurrence, distant metastasis rate, breast-related death, and DFS were noted. The OS was similar (P = 0.56) between the BCSNR group (91.7%) and other operations group (93.0%). The IBTR rate was considered low in both groups, however resulted greater (P = 0.005) in the BCSNR group (5.3%) than in other operations group (1.6%). BCSNR did not affect the survival of elderly patients with breast cancer with clinically negative axillary lymph nodes. IBTR was infrequent in both groups; however, there was a significant difference between the two groups. BCSNR is a feasible treatment modality for patients with breast cancer ≥ 70 years old with clinically negative axillary lymph nodes.

Could lymph node evaluation be eliminated in nearly 50% of women with early stage ER/PR positive breast cancer?

BACKGROUND

The Society of Surgical Oncology introduced guidance discouraging routine axillary staging in women 70 years or older with invasive, clinically node negative, hormone-receptor positive breast cancer. Due to concerns this could result in patients missing necessary treatment, researchers from the Mayo Clinic developed a rule to distinguish between those at low/high-risk of having positive nodes. The purpose of this study was to validate the Mayo Clinic rule in women of all ages.

METHODS

A retrospective review was conducted on patients seen in one breast surgeon's practice from January 1, 2006 through March 1, 2018. The Mayo Clinic rule was applied, and accuracy was evaluated.

RESULTS

Utilizing the Mayo Clinic rule, 46.8% (n = 289) of women met low-risk criteria. Unexpected positive lymph nodes in low-risk women was 10.0% (n = 29), which was similar to the Mayo Clinic study finding (7.8%, P = 0.167).

CONCLUSIONS

These data suggest the Mayo Clinic rule is reproducible. Nearly 50% of women with hormone receptor positive breast cancer could avoid axillary staging, but about 10% will have unexpected positive lymph nodes.

Nodal staging affects adjuvant treatment choices in elderly patients with clinically node-negative, estrogen receptor-positive breast cancer

Background

In response to Choosing Wisely recommendations that sentinel lymph node biopsy (slnb) should not be routinely performed in elderly patients with node-negative (cN0), estrogen receptor-positive (er+) breast cancer, we sought to evaluate how nodal staging affects adjuvant treatment in this population.

Methods

From a prospective database, we identified patients 70 or more years of age with cN0 breast cancer treated with surgery for er+ her2-negative invasive disease during 2012-2016. We determined rates of, and factors associated with, nodal positivity (pN+), and compared the use of adjuvant radiation (rt) and systemic therapy by nodal status.

Results

Of 364 patients who met the inclusion criteria, 331 (91%) underwent slnb, with 75 (23%) being pN+. Axillary node dissection was performed in 11 patients (3%). On multivariate analysis, tumour size was the only factor associated with pN+ (p = 0.007). Nodal positivity rates were 0%, 13%, 23%, 33%, and 27% for lesions preoperatively sized at 0-0.5 cm, 0.5-1 cm, 1.1-2.0 cm, 2.1-5.0 cm, and more than 5.0 cm. Compared with patients assessed as node-negative, those who were pN+ were more likely to receive axillary rt (lumpectomy: 53% vs. 1%, p < 0.001; mastectomy: 43% vs. 2%, p < 0.001), and adjuvant systemic therapy (endocrine: 82% vs. 69%; chemotherapy plus endocrine: 7% vs. 2%, p = 0.002).

Conclusions

Of elderly patients with cN0 er+ breast cancer, 23% were pN+ on slnb. Size was the primary predictor of nodal status, and yet significant rates of nodal positivity were observed even in tumours preoperatively sized at 1 cm or less. The use of rt and systemic adjuvant therapies differed by nodal status, although the long-term oncologic implications require further investigation. Multidisciplinary input on a case-by-case basis should be considered before omission of slnb.

Breast cancer care during a pandemic: an opportune time for cryoablation?

Purpose

Cryoablation is a minimally-invasive percutaneous procedure that is capable of reducing the psychosocial burden of surgical delay while also decreasing the morbidity of breast cancer therapy. The purpose of this editorial is to discuss the potential role of cryoablation for reducing the psychosocial burden of surgical delay during the COVID-19 pandemic by expediting the management of breast cancer while also lessening demand on limited healthcare resources.

Methods

This editorial critiques current expert opinion recommendations that aim to reduce viral transmission and preserve healthcare resources during the COVID-19 pandemic by advocating delay of elective breast cancer surgery.

Results

The editorial summarizes the current state of the evidence that supports the selective use of cryoablation as a definite or stopgap measure in the management of breast cancer during the COVID-19 pandemic or when healthcare resources are limited.

Conclusions

As an office-based procedure performed under local anesthesia, cryoablation eliminates the need for operating room personnel and equipment while also reducing the psychosocial impact of delayed breast cancer surgery. By reducing the number of patient and healthcare provider interactions, cryoablation not only decreases the risk of viral transmission but also the need for personal protective devices during resource-limited times.

Impact of older age on local treatment decisionss

Managing elderly breast cancer patients brings challenges both to physicians and patients themselves. There are certain controversial issues regarding local treatment of early breast cancer in this population. Since elderly patients are more likely to have comorbidities and functional limitations, they are more prone to undertreatment. Although surgical treatment in elderly patients were reported to be safe, severity and number of comorbidities are shown to be related with increased complications, hence may lead to higher mortality and lower life quality. Therefore, frailty is one of the concerns which prevents elderly patients to receive standard-of-care local treatment. Nevertheless, breast cancers developing in elderly are more likely to be low grade and luminal type. Until now, primary endocrine treatment without surgical resection, omitting whole breast irradiation after partial mastectomy and avoiding sentinel lymph node biopsy, which are otherwise accepted as standard-of-care, were questionned in healthy, low-risk, elderly fit patients. Two main issues were suggested to be considered when assessing the impact of local treatment options in this patient group; the clinical significance of treatments' effects, and the patients' expectations. Due to their vulnerability, baseline geriatric assessment should be the initial step for management in elderly breast cancer patients. Even in those who are healthy and fit with long life-expectancy, de-escalation in management might be an option in low-risk patients after considering patients' individual expectations and limited clinical benefits of standard local treatment options.

Trends in Surgical Axillary Management in Early Stage Breast Cancer in Elderly Women: Continued Over-Treatment

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.

Evaluating the role of sentinel lymph node biopsy in patients with DCIS treated with breast conserving surgery

INTRODUCTION

The role of sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in-situ (DCIS) is limited given the rarity of nodal metastasis in non-invasive disease. Although SLNB is typically a safe procedure, there are potential complications and associated costs. The purpose of this study is to assess national surgical practice patterns and clinical outcomes with respect to the use of SLNB for DCIS in patients undergoing breast conserving surgery (BCS).

METHODS

Case-level data from the National Cancer Data Base (NCDB) was assessed to identify adult patients ≥ 18 with DCIS, who underwent BCS and SLNB. Patient demographics and hospital characteristics were grouped for analytic purposes. A multivariate analysis was performed for patient and hospital characteristics.

RESULTS

We identified 15,422 patients with DCIS undergoing BCS in 2015, of which 2,698 (18%) underwent SLNB. A multivariate analysis demonstrated a significant association between greater frequency of SLNB in patients age range of 60-69, receipt of care at a community facility, and higher nuclear grade DCIS. Positive sentinel nodes metastasis was identified in 0.9% patients undergoing BCS and SLNB for DCIS.

CONCLUSION

The role of SLNB in patients with DCIS undergoing BCS is limited and does not routinely provide meaningful information or benefit to clinical management. Despite this, nearly one in five patients undergoing BCS for DCIS had lymph node sampling performed. Given the potential increased morbidity and financial implications, this finding represents an opportunity for further education and improvement in patient selection for SLNB.

Trends in utilization of sentinel node biopsy and adjuvant radiation in women ≥ 70

BACKGROUND AND OBJECTIVES

Omission of routine axillary staging and adjuvant radiation (XRT) in women ≥ 70 years old with early stage, hormone receptor-positive, clinically node-negative breast cancer has been endorsed based on several landmark studies. We sought to determine how much omission of axillary staging/XRT has been adopted.

METHODS

Using the National Cancer Data Base, we selected malignant breast cancer cases in women ≥ 70 with ER + tumors, ≤2 cm with clinically negative lymph nodes who underwent breast conservation and had known XRT status in 2005-2015. The use of sentinel lymph node biopsy (SNB) and XRT status was summarized by year to determine trends over time.

RESULTS

In total, 57 230/69 982 patients underwent SNB. Of the 12 752 patients in whom SNB was omitted, 6296 were treated at comprehensive community cancer programs. Regarding XRT, 33 891/70 114 received adjuvant XRT. There were no significant trends with regards to patients receiving SNB or those receiving XRT.

CONCLUSION

Since 2005, there has been no change in SNB or XRT for early stage ER + breast tumors. However, there was a difference in omission of SNB based on facility type and setting. Future monitoring is needed to determine if these trends persist following the recently released Choosing Wisely^® recommendations.

Nodal positivity decreases with age in women with early-stage, hormone receptor-positive breast cancer

BACKGROUND

Despite data demonstrating the safety of omitting axillary surgery in older women with early-stage breast cancer, the incidence of axillary surgery remains high. It was hypothesized that the prevalence of nodal positivity would decrease with advancing age.

METHODS

The National Cancer Data Base was used to construct a cohort of adult women with early-stage, clinically node-negative, estrogen receptor-positive (ER+), human epidermal growth factor receptor 2-negative breast cancer treated between 2013 and 2015. Multivariable logistic regression was used to assess the relationship between age and nodal positivity, and this was stratified by the axillary surgery category. Modified Poisson regression was used to estimate the proportion of women receiving adjuvant therapy according to age and nodal status.

RESULTS

The incidence of axillary surgery among women aged 70 and older (n = 51,917) remained high nationwide (86%). There was a significant decrease in nodal positivity with advancing age in women with early-stage, ER+, clinically node-negative breast cancer from the youngest cohort up to patients aged 70 to 89 years, and this was independent of histologic subtype (ductal vs lobular), race, comorbidities, and socioeconomic factors. Overall, less than 10% of women aged 70 or older who underwent surgery had node-positive disease, regardless of axillary surgery type, and almost 95% of node-positive patients aged 70 or older were at pathological stage N1mi or N1.

CONCLUSIONS

Axillary surgery may be safely omitted for many older women with ER+, clinically node-negative, early-stage breast cancer. Nodal positivity declines with advancing age, and this suggests varied biology in older patients versus younger patients.

Increasing omission of radiation therapy and sentinel node biopsy in elderly patients with early stage, hormone-positive breast cancer

Prospective evidence demonstrates that there is limited benefit of axillary staging with sentinel lymph node biopsy (SLNB) or radiation therapy (RT) in patients over age 70 with clinical stage I, hormone-positive breast cancer. The clinical impact of this literature is unknown. Our hypothesis is that omission of SLNB and RT has increased over time in these patients, and patient and tumor characteristics can predict when omission strategies are used. A single-center tumor registry was queried for all patients over age 70 with ER+, Her2/neu-negative, clinical T1N0 invasive breast cancer from 2009 to 2017, who underwent breast conservation (n = 141). Date of treatment, age, tumor characteristics, use of SLNB, and use of RT were evaluated. The trend of treatment strategy over time was evaluated. Multivariable analysis was performed on the subgroup of patients after publication of the long-term follow-up CALGB 9343 data¹ . Patients undergoing treatment with omission of RT and SLNB increased over the study period (P = .0006). Patients who did not receive RT were older (78.76 years ± 5.48 vs 73.37 ± 3.63, P < .01). There was no difference between tumor grade and size between uses of RT. Of patients who received SLNB (n = 84), only 3 (3.5%) had a positive LN. On multivariable analysis of patients who were treated after publication of the CALGB 9343 data (2014-2017), only age was predictive of being treated with RT (OR, 0.77; 95% CI, 0.67-0.88). Omission of both RT and SLNB are increasing in clinical practice in appropriately selected patients. The likelihood that patients are offered omission of these interventions increases with age. Low nodal positivity rates suggest that this strategy may be underutilized. Tumor grade and size were not predictive of omission of RT in this group of low-risk patients. Long-term data are needed as these approaches are increasingly adopted.

Worse survival in breast cancer in elderly may not be due to underutilization of medical procedures as observed upon changing healthcare system in Poland

Background

Evidence is emerging that older women may tolerate breast cancer therapies equally well as the young ones, providing that they receive good supportive care. It has also been reported that these patients remain outside the current therapeutic standards. The aim of this observational study was to assess the access of breast cancer patients to medical procedures.

Methods

We retrospectively reviewed a database of breast cancer patients registered in the National Cancer Registry in Poland, searching for the numbers of new cases and deaths in the years 2010–2015. We obtained the numbers and costs of key medical procedures provided for these patients from the National Health Fund in Poland. Breast cancer survival in the years 2010–2015 was estimated based on the mortality/incidence ratio. The t-Student test and Spearman correlation coefficient were used for the analysis of data obtained from both databases.

Results

There was no increase in survival throughout the years 2010–2015 in both analysed subpopulations of all breast cancer patients below and over 65 years of age, despite an unprecedented rise in healthcare funding in Poland. We noted 37% lower probability of 5-year survival in patients older than 65 years. The average number of outpatient visits and surgical procedures per person per year were slightly, yet significantly (p < 0.01), higher in younger vs. older patients (3.9 vs. 3.4 and 1.18 vs. 1.02, respectively). Outpatient chemotherapy was more common in older patients (6.0 vs. 5.25 cycles a year per person on average, p < 0.01). There were no significant differences in the average numbers of hospitalisations for chemotherapy, frequencies of radiotherapy and in the use of targeted therapy programmes (calculated per person per year), between younger and older patients.

Conclusions

Older women with breast cancer are treated similarly to younger patients, but have significantly worse chances to survive breast cancer in Poland. A simple increase in healthcare financing will not improve the survival in the elderly with breast cancer without developing funded individualised care and survivorship programmes.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5930-8) contains supplementary material, which is available to authorized users.

Highlights of the 16th St Gallen International Breast Cancer Conference, Vienna, Austria, 20-23 March 2019: personalised treatments for patients with early breast cancer

The 16th St Gallen International Breast Cancer Conference took place in Vienna for the third time, from 20–23 March 2019. More than 3000 people from all over the world were invited to take part in this important bi-annual critical review of the ‘state of the art’ in the primary care of breast cancer (BC), independent of political and industrial pressure, with the aim to integrate the most recent research data and most important developments in BC therapies since St Gallen International Breast Cancer Conference 2017, with the ultimate goal of drawing up a consensus for the current optimal treatment and prevention of BC.

This year, the St Gallen Breast Cancer Award was won by Monica Morrow (Memorial Sloan Kettering Cancer Center, USA) for her extraordinary contribution in research and practise development in the treatment of BC. She opened the session with the lecture ‘Will surgery be a part of BC treatment in the future?’ Improved systemic therapy has decreased BC mortality and increased pathologic complete response (pCR) rates after neoadjuvant chemotherapy (NACT). Improved imaging and increased screening uptake have led to detect smaller cancers. These factors have highlighted two possible scenarios to omit surgery: for patients with small low-grade ductal carcinoma in situ (DCIS) and for those who have received NACT and had a clinical and radiological complete response. However, considering that 7%–20% of `low-risk’ DCIS patients have co-existing invasive cancer at diagnosis, that surgery has become progressively less morbid and less toxic than some systemic therapies with a lower cost-effectiveness ratio, and that identification of pathologic complete response (pCR) without surgery requires more intensive imaging follow-up (more biopsies, higher cost and more anxiety for the patient), surgery still appears to be an essential treatment for BC.

The Umberto Veronesi Memorial Award went to Lesley Fallowfield (Brighton and Sussex Medical School, UK) for her important research and activity in the field of the development of patient outcome, of better communication skills and quality of life for women. In her lecture, she remarked on the importance of improving BC personalised treatments, especially through co-operation between scientists, always considering the whole woman and not just her breast disease. This award was given by Paolo Veronesi, after a moving introduction which culminated with the following words of Professor Umberto Veronesi:

‘It is not possible to take care of the people’s bodies without taking care of their mind. My duty, the duty of all doctors, is to listen and be part of the emotions of those we treat every day’.

Breast Cancer in Women Aged 80 Years or Older: An Analysis of Treatment Patterns and Disease Outcomes

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.

Axillary Nodal Evaluation in Elderly Breast Cancer Patients: Potential Effects on Treatment Decisions and Survival

BACKGROUND

Recent studies suggest that surgical lymph node (LN) evaluation may be omitted in select elderly breast cancer patients as it may not influence adjuvant therapy decisions. To evaluate differences in adjuvant therapy receipt and overall survival (OS), we compared clinically node-negative (cN0) elderly patients who did and did not undergo axillary surgery.

METHODS

Patients aged ≥70 years in the National Cancer Database (2004-2014) with cT1-3, cN0 breast cancer were divided into two cohorts-those with surgical LN evaluation (one or more nodes removed) and those without (no nodes removed). Propensity scores were used to match patients based on age, year of diagnosis, tumor grade, cT stage, estrogen receptor status, and Charlson-Deyo comorbidity score. A Cox proportional hazards model was used to estimate the effect of LN surgery on OS.

RESULTS

Overall, 133,778 patients were matched, of whom 102,247 patients (76.4%) underwent nodal surgery. Patients undergoing nodal surgery were more likely to receive chemotherapy (pN1-3: 22.2%; pN0: 5.8%; cN0-no nodal surgery: 2.8%; p < 0.001), radiation (pN1-3: 49.7%; pN0: 47.5%; cN0-no nodal surgery: 26%; p < 0.001), and endocrine therapy (pN1-3: 72%; pN0: 58.5%; cN0-no nodal surgery: 46.5%; p < 0.001). After adjustment for known covariates, patients who did not undergo nodal surgery had a worse OS (hazard ratio 1.66, 95% confidence interval 1.61-1.70).

CONCLUSIONS

For elderly cN0 breast cancer patients, axillary surgery was associated with higher rates of adjuvant therapy and improved OS. A selective approach to omitting nodal surgery should be considered in elderly patients with cN0 breast cancer as axillary staging may influence subsequent treatment decisions and long-term outcomes.

ASBRS Great Debate: Sentinel Node Biopsy in Patients Over 70 Years of Age

INTRODUCTION

Controversy over the need for sentinel node biopsy (SNB) continues to exist for the optimal treatment of breast cancer in patients ≥ 70 years of age, especially in those with lower-risk disease. Clinicians must balance competing risks to give the best individualized care.

METHODS

The American Society of Breast Surgeons (ASBrS) conducted a debate discussing the pros and cons of routinely performing SNB in this age group. Small, randomized studies have been conducted that show no overall survival benefit to axillary intervention (either axillary dissection or SNB) in patients with clinically T1N0 estrogen receptor (ER)- and progesterone receptor (PR)-positive, HER2/neu-negative tumors. There may be a small local recurrence benefit to axillary staging in patients who do not undergo radiation. Alternatively, axillary ultrasound, which carries a low false-negative rate for heavy disease burden, can be used to select patients who can avoid SNB.

CONCLUSION

Surgeons must continue to individualize care of breast cancer patients over 70 years of age in whom competing comorbidities may dictate care. No randomized clinical trials (RCTs) have found a survival benefit to axillary staging in this low-risk population. However, in healthy patients, axillary staging may improve local control, provide prognostic information, and help guide decisions regarding adjuvant therapy such as chemotherapy and radiation. Ongoing RCTs are evaluating the benefit of SNB in patients with a negative axillary ultrasound. Until those results are available, clinicians and patients must balance the risk and benefits to determine if SNB adds significant value to their overall care.

Choosing wisely in oncology: necessity and obstacles

In the last decades, the survival of many patients with cancer improved thanks to modern diagnostic methods and progresses in therapy. Still for several tumours, especially when diagnosed at an advanced stage, the benefits of treatment in terms of increased survival or quality of life are at best modest when not marginal, and should be weighed against the potential discomfort caused by medical procedures. As in other specialties, in oncology as well the dialogue between doctor and patient should be encouraged about the potential overuse of diagnostic procedures or treatments. Several oncological societies produced recommendations similar to those proposed by other medical disciplines adhering to the Choosing Wisely (CW) campaign. In this review, we describe what was reported in the medical literature concerning adequacy of screening, diagnostic, treatment and follow-up procedures and the potential impact on them of the CW. We only marginally touch on the more complex topic of treatment appropriateness, for which several evaluation methods have been developed (including the European Society for Medical Oncology-magnitude of clinical benefit scale). Finally, we review the possible obstacles for the development of CW in the oncological setting and focus on the strategies which could allow CW to evolve in the cancer field, so as to enhance the therapeutic relationship between medical professionals and patients and promote more appropriate management.