Is it Wise to Omit Sentinel Node Biopsy in Elderly Patients with Breast Cancer?

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.

Evaluation of Male Breast Cancer and the Application of Sentinel Lymph Node Biopsy: A Multicenter Retrospective Study

Sentinel lymph node biopsy (SLNB) is currently used as a routine treatment for patients with breast cancer. However, it may not be applicable for patients with male breast cancer (MBC), because they have notably different clinicopathological features from those occurring in females. There is a lack of evidence of SLNB application and safe exemption from axillary lymph node dissection (ALND) in patients with MBC. This study aimed to evaluate the application of SLNB to provide information for the standardized treatment of patients with MBC. The MBC patient records from 4 institutions ranging from January 2001 to November 2020 were retrospectively reviewed. There were 220 patients with MBC with a median age of 60 (range 24-88) years and an average tumor size of 2.3 cm (range 0.5 cm-6.5 cm). Sixty-six percent of patients underwent SLNB, and 39% of them showed positive results. A total of 157 patients underwent ALND, while only half of them had positive nodes, causing unnecessary complications. For patients in the clinical early stage, we found that the SLNB showed a noninferiority to the ALND treatment in DFS (P = .18) and OS (P = .055). In conclusion, there are certain obstacles to the broad application of SLNB due to the lower proportion of patients with clinically negative lymph nodes. However, it is undeniable that SLNB can safely and effectively exempt patients with MBC at early stage with clinically negative nodes from ALND to reduce subsequent complications. It is still an ideal criterion for the axillary staging of patients with MBC.

An Australian-based nomogram predicting nodal positivity for breast cancer in older patients

INTRODUCTION

Regional nodal status is one of the most powerful prognosticators in breast cancer. The sentinel lymph node biopsy (SLNB) evaluates the first node in the axillary lymphatic basin theorised to drain the anatomical region of breast cancer. Recent literature has appropriately raised the query of the need for SLNB for breast cancer in older patients (BCOP). Though some early-stage older patients may safely have SLNB omitted, we are potentially missing the under-represented aggressive cancers. No sentinel lymph node metastases nomogram has been developed solely from BCOP data to date. This study aimed to identify older patients with breast cancer at risk for nodal involvement using a nomogram developed from their data alone.

METHODS

A retrospective analysis of prospectively collected data on BCOP (aged ≥70 years) was performed using the Breast Surgery Quality Audit (BQA). Inclusion criteria were T1-2 invasive breast cancer patients that underwent a SLNB from 1st January 2001 to 31st December 2019. The primary outcome was nodal involvement. Data obtained from the dataset included: age, tumour type, tumour size in millimeters, histological grade, lymphovascular invasion, oestrogen receptor status, progesterone receptor status, HER2 status and referral source. Binary logistic regression was used to develop a nomogram. The model was internally validated by splitting the data set (80% for training and 20% for testing). A receiver operating characteristic curve was developed, with the area under the curve (AUC) and a calibration plot.

RESULTS

There were 22,313 patients of which 14,856 (66.6%) were symptomatic presentations and 7457 (33.4%) were screen-detected. Invasive tumour type, tumour size, tumour grade, lymphovascular invasion, oestrogen receptors, and referral source indicated a statistically significant effect on predicting a nodal positivity event (Table 1). The AUC was 0.782 (95% CI 0.776-0.789) (Fig. 1a) and demonstrated good calibration (Fig. 1b). The negative predictive value established was 85%.

CONCLUSION

We have developed an Australian sentinel lymph node metastasis nomogram for BCOP using routine histopathological data obtained pre-operatively (Fig. 2). This is the first Australian nomogram, as well as the first nomogram developed solely for BCOP - and maintains a superior AUC compared to other well-established nomograms.

Impact of Sentinel Lymph Node Biopsy on Treatment Decision and Survival in Patients Aged ≥70 Years with Breast Cancer: A Retrospective Study

Background: Whether sentinel lymph node biopsy should be performed in patients ≥70 years old with early-stage invasive breast cancer is controversial. We examined the effect of sentinel lymph node biopsy on the treatment and outcomes in this population. Materials and Methods: In this retrospective study, patients aged ≥70 years who were treated for invasive breast cancer with sentinel lymph node biopsy followed by mastectomy or lumpectomy between 2010 and 2019 were identified from our database. Patients were compared according to sentinel lymph node status. Outcomes were analyzed using the Kaplan-Meier method and Cox multivariate analysis. Results: Of the 376 patients enrolled in this study, 311 (82.7%) were sentinel lymph node-negative and 65 (17.3%) were sentinel lymph node-positive. The median follow-up duration for all patients was 70 months. Systemic treatment and radiation were similar between sentinel lymph node-negative and -positive groups. Disease-free survival, distant disease-free survival, breast cancer-specific survival, overall survival were not significantly different between groups (88.2% vs 87.6%, 96.7% vs 94.8%, 96.2% vs 93.6%, and 93.5% vs 90.0%, respectively). Sentinel lymph node status, tumor size, chemotherapy, endocrine therapy, and adjuvant radiation were included in Cox multivariate analysis. None of the variables were found to significantly affect disease-free survival, distant disease-free survival, breast cancer-specific survival, and overall survival. Conclusions: Our analysis indicated that sentinel lymph node status may not affect systemic treatment decisions or survival in patients aged ≥70 years with breast cancer.

Breast Cancer in Geriatric Patients: Current Landscape and Future Prospects

Breast cancer is the most common cancer diagnosed among women worldwide and more than half are diagnosed above the age of 60 years. Life expectancy is increasing and the number of breast cancer cases diagnosed among older women are expected to increase. Undertreatment, mostly due to unjustifiable fears of advanced-age and associated comorbidities, is commonly practiced in this group of patients who are under-represented in clinical trials and their management is not properly addressed in clinical practice guidelines. With modern surgery and anesthesia, breast surgeries are considered safe and is usually associated with very low complication rates, regardless of extent of surgery. However, oncoplastic surgery and management of the axilla can be tailored based on patients’- and disease-related factors. Most of chemotherapeutic agents, along with targeted therapy and anti-Human epidermal growth factor receptor-2 (HER2) drugs can be safely given for older patients, however, dose adjustment and close monitoring of potential adverse events might be needed. The recently introduced cyclin-D kinase (CDK) 4/6-inhibitors in combination with aromatase inhibitors (AI) or fulvestrant, which changed the landscape of breast cancer therapy, are both safe and effective in older patients and had substituted more aggressive and potentially toxic interventions. Despite its proven efficacy, adjusting or even omitting adjuvant radiation therapy, at least in low-risk older patients, is safe and frequently practiced. In this paper, we review existing data related to breast cancer management among older patients across the continuum; from resection of the primary tumor through adjuvant chemotherapy, radiation and endocrine therapy up to the management of recurrent and advanced-stage disease.

Long-term survival in elderly women receiving chemotherapy for non-metastatic breast cancer: a population-based analysis

BACKGROUND

Older women are poorly represented in trials evaluating chemotherapy for breast cancer (BC). This study aimed to describe survival and associated factors among elderly women receiving chemotherapy for non-metastatic BC.

METHODS

This was a population-based cohort study including women ≥ 70 years old diagnosed with invasive, non-metastatic BC from 2010 to 2017 in SEER. Among those who received chemotherapy, overall survival (OS) was determined using Kaplan-Meier curves and hazard ratios were reported with 95% confidence intervals (CIs). Adjustment was made for available confounders. Co-morbidity is not available in SEER. BC-specific survival (BCSS) and subdistribution hazard ratios were determined using competing risks analysis.

RESULTS

The cohort consisted of 109,239 women aged 70+, of whom 17,961 (16%) received chemotherapy. Chemotherapy patients were younger (median 73.0 years vs. 77.0), had more advanced disease (25% stage III vs. 5.2%), and were more likely to receive mastectomy (50% vs. 33%). Among chemotherapy patients, 5-year OS was 77.8% (95% CI 76.9-78.6%), and for women 80+ was 60.2% (95% CI 57.5-63.1%). More recent diagnoses, no previous history of cancer, and receipt of radiotherapy were all associated with improved BCSS. Conversely, older age, higher tumour grade, advanced stage, and human epidermal growth factors receptor (HER)2 negative tumours were associated with worse BCSS. 56% of deaths were due to BC, and women aged 80+ had worse BCSS compared to those aged 70-79 (adjusted sdHR 1.62, 95% CI 1.43-1.84).

CONCLUSIONS

Elderly women with advanced disease can achieve good survival after chemotherapy for non-metastatic BC. Those with HER2+ disease have superior survival, reinforcing benefit in this population.

Omission of Axillary Staging and Survival in Elderly Women With Early Stage Breast Cancer: A Population-Based Cohort Study

Objectives

Determine if axillary staging is associated with survival in elderly women with breast cancer.

Background

Axillary staging in women ≥ 70 years with early-stage breast cancer is controversial. Older randomized evidence has not shown axillary staging improves survival, but recent observational studies have been mixed and widespread de-implementation of the practice has not occurred.

Methods

This was a population-based cohort study using the Surveillance, Epidemiology, and End Results registry. Women ≥ 70 years diagnosed with T1-T2 invasive breast cancer from 2005 to 2015 were included. Overlap propensity score weighting was used to adjust for confounders. Overall survival (OS) was determined and hazard ratios (HRs) reported with 95% confidence intervals (CIs). Breast cancer-specific survival (BCSS) was determined using competing risks analysis and subdistribution hazard ratios (sdHRs) reported. Additional adjustment was performed for receipt of chemotherapy and radiotherapy.

Results

One hundred forty-four thousand three hundred twenty-nine elderly women were included, of whom 22,621 (15.7%) did not undergo axillary staging. After overlap propensity score weighting, baseline characteristics were well balanced between the 2 groups. Women who did not undergo axillary staging were significantly less likely to receive chemotherapy (adjusted relative risk, 0.58; 95% CI, 0.54-0.62) or radiotherapy (adjusted relative risk, 0.53; 95% CI, 0.52-0.54), and had significantly worse OS (adjusted HR, 1.22; 95% CI, 1.19-1.25), and BCSS (adjusted sdHR, 1.14; 95% CI, 1.08-1.21) compared to those that had staging.

Conclusions

These findings suggest elderly women with early-stage breast cancer who do not undergo axillary staging experience worse outcomes. Reasons for this disparity may be multifactorial and require further investigation.

A novel nomogram and risk classification system for predicting lymph node metastasis of breast mucinous carcinoma: A SEER-based study

BACKGROUND

Mucinous breast cancer (MBC) is a rare disease, and patients with lymph node metastasis (LNM) have a poor prognosis. We aimed to explore the predictive factors of LNM and to construct a nomogram for predicting the risk of LNM and to identify the suitable axillary surgery for patients with diverse risks.

PATIENTS AND METHODS

Data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Chi-square and rank-sum tests were used to analyze the differences between groups. Survival analysis was performed with Kaplan-Meier curves and log-rank tests. Independent factor identification and nomogram construction were performed with logistic regression analysis. The nomogram was qualified with a discrimination and calibration plot. Propensity score matching was performed to balance the disparities between groups.

RESULTS

Patients with metastatic lymph nodes have a worse prognosis. Univariate and multivariate analyses indicated that tumor size, grade, and age were independent risk factors for LNM. The nomogram constructed with these three factors can predict the risk of LNM with high accuracy (AUC: 0.767, 95% CI: 0.697-0.838) and good calibration. Based on the nomogram, a risk classification system satisfactorily stratified the patients into 3 groups with diverse risks of LNM. In the low-risk group, there were no significant differences between sentinel lymph node biopsy and no axillary surgery. In the middle- and high-risk groups, both SLNB and axillary lymph node dissection were superior to no axillary surgery, with similar survival benefits.

CONCLUSIONS

The nomogram based on tumor size, grade, and age could conveniently and accurately predict the risk of LNM in MBC and assist clinicians in optimizing surgical strategies.

Breast surgical oncology in elderly and unfit patients: a systematic review

INTRODUCTION

Breast cancer treatment in elderly women remains a complex issue due to pre-existing comorbidities, therapy-related toxicities, and the lack of evidence-based data in this population, leading to both overtreatment and undertreatment.

EVIDENCE ACQUISITION

The aim was to investigate the literature on breast surgical oncology in the older woman as a major therapeutic challenge: the 86 more consistent articles amongst 1440 potential citations according to PRISMA guidelines were retained.

EVIDENCE SYNTHESIS

Studies demonstrated that despite low-grade tumor types, lower incidence of axillary lymph node involvement, ER+ disease, and less aggressive tumor biology, elderly breast cancer patients often receive less than the standard-of-care when compared to their younger counterparts. The surgery omission in elderlies and the preference for the primary endocrine treatment is associated with worse survival, especially in patients aged 80 years or over - a cohort with no specific recommendations concerning breast and axillary surgical procedures. On the other hand, a higher mastectomy rate is still considered the standard treatment in older women with higher T2:T1 tumor ratio and greater difficulties to attend radiotherapy due to severe comorbidities. Surgical de-escalation procedures even in an-ambulatory setting are recognized as a feasible option in these patients to prevent or palliate breast or chest wall symptoms.

CONCLUSIONS

Benefits and disadvantages from surgery only or coupled with adjuvant therapies for elderly women were analyzed in literature, outlining a growing need for a proper geriatric assessment and short-stay surgical programs which are feasible today owing to the availability of less invasive approaches.

Omitting SLNB in Breast Cancer: Is a Nomogram the Answer?

BACKGROUNDS

Sentinel lymph node biopsy (SLNB) is standard care as a staging procedure in patients with invasive breast cancer. The axillary recurrence rate, even after positive SLNB, is low. This raises serious doubts regarding the clinical value of SLNB in early breast cancer. The purpose of this study is to select patients with low suspected axillary burden in whom SLNB might be omitted.

PATIENTS AND METHODS

We retrospectively analyzed 2015 primary breast cancer patients between 2007 and 2015, with 982 patients allocated to the training and 961 to the validation cohort. Variables associated with nodal disease were analyzed and used to build a nomogram for predicting nodal disease.

RESULTS

A total of 32.8% of patients had macrometastatic disease. A predictive model was constructed based on age, cN0, morphology, grade, multifocality, and tumor size with an area under the receiver operating characteristic curve (AUC) of 0.83. Considering a false-negative rate of 5%, 32.8% of patients could be spared axillary surgery. In a subanalysis of patients with relatively favorable characteristics, 26.8% had less than 5% chance of macrometastases.

CONCLUSIONS

We present a model with excellent predictive value that can select one-third of patients in whom SLNB is deemed not necessary because of less than 5% chance of nodal involvement. Whether missing 1 in 20 patients with macrometastatic disease is worthwhile balanced against preventing side-effects of the SLN procedure remains to be established. A number of ongoing large prospective trials evaluating the outcome of omitting SLNB are awaited. Meanwhile, this nomogram may be used for individual decision-making.

Intraoperative Radiotherapy with Balloon-Based Electronic Brachytherapy System-A Systematic Review and First Bulgarian Experience in Breast Cancer Patients

(1) Background: We aimed to analyze currently available studies with intraoperative radiotherapy (IORT) as a choice of treatment where the Xoft Axxent^® electronic brachytherapy (eBx) system was used as a single-dose irradiation and an exclusive radiotherapy approach at the time of surgery in patients with early breast cancer (EBC). We also compared the results of the systematic review to the Bulgarian experience. (2) Methods and Materials: We performed a systematic review of the studies published before February 2021, which investigate the application of a single-fraction 20 Gy radiation treatment, delivered at the time of lumpectomy in EBC patients with the Xoft Axxent^® eBx System. A systematic search in PubMed, Scopus, and ScienceDirect was performed. The results are reported following the PRISMA guidelines. The criteria on patients’ selection for IORT (the additional need for EBRT), cosmetic outcomes, and recurrence rate from the eligible studies are compared to the treatment results in Bulgarian patients. (3) Results: We searched through 1032 results to find 17 eligible studies. There are no published outcomes from randomized trials. When reported, the cosmetic outcomes in most of the studies are defined as excellent. The observed recurrence rate is low (1–5.8%). Still, the number of patients additionally referred to postoperative external breast radiotherapy (EBRT) is up to 31%. Amongst the 20 patients treated in Bulgaria, the cosmetic outcomes are also evaluated as excellent, five of which (25%) are referred for EBRT. Within median follow-up of 39 months, there was one local and one distal recurrence. (4) Conclusions: Current evidence demonstrates the Xoft Axxent^® eBx system as a safe and feasible technique for IORT delivery in EBC patients. There are no randomized controlled trials conducted at this time point to prove its long-term effectiveness. Better patient selection and a reimbursement strategy have to be proposed to extend the application of this technique in Bulgaria.

Long-term outcome and axillary recurrence in elderly women (≥70 years) with breast cancer: 10-years follow-up from a matched cohort study

BACKGROUND AND OBJECTIVES

The oncological benefit of axillary surgery (AS), with sentinel lymph node biopsy (SLNB) or axillary dissection (ALND), in elderly women affected by breast cancer (BC) is controversial. We evaluated AS trends over a 10-year follow-up period as well as locoregional and survival outcomes in this subset of patients.

METHODS

Patients aged 70 years or older, treated between 1994 and 2008, were selected and divided in two groups, depending on whether or not AS was performed. A (1:1) matched analysis for all relevant clinicopathological features was performed. Outcomes were analyzed using the Kaplan-Meier method and univariate Cox-proportional hazard ratio analysis.

RESULTS

A total of 1.748 patients were identified and stratified by age (70-74, 75-79, 80-84). A matched analysis was performed for 252 patients: 122 who underwent AS and 122 who did not. At 10-year follow-up, ipsilateral breast tumor recurrence, distant metastasis and contralateral BC were similar, p = 0.83, p = 0.42 and p = 0.28, respectively. In the no-AS group, a significant increased risk of axillary lymph-node recurrence was identified at 5- and confirmed at 10-years (p = 0.038), without impact on overall survival at 5- and 10-years (p = 0.52). In the non-AS group, higher rate of axillary recurrence at 10-years was observed in patients with poorly differentiated (24.1%, 95% CI 7.2-46.2), highly proliferative (Ki67 ≥ 20%: 17.1%, 95% CI 0.6-33.3) and luminal B tumors (16.8%, 95% CI 5.9-35.5).

CONCLUSIONS

Axillary staging in elderly women does not impact long-term survival. Tailoring surgery according to tumor biology and age may improve locoregional outcome.