The role of chemotherapy in patients with T1bN0M0 triple-negative breast cancer: a real-world competing risk analysis

Breast Conservation Therapy for Primary Squamous Cell Carcinoma of the Breast in an Elderly Woman: A Case Report

This case report details a rare instance of primary squamous cell carcinoma (PSCC) of the breast in an octogenarian, emphasizing the unique diagnostic and treatment challenges posed by this malignancy in an elderly patient and adding to the scientific literature on PSCC managed with breast conservation therapy (BCT). An 80-year-old woman with medical comorbidities presented with a focal asymmetry in the right breast's retroareolar plane, detected during routine screening mammography. Diagnostic evaluations raised high suspicion for malignancy, confirmed as PSCC by ultrasound-guided biopsy. Histopathological analysis showed atypical keratinizing squamous epithelial nests and cysts. The patient underwent lumpectomy and re-excision of close surgical margins with a sentinel lymph node biopsy, which showed well-differentiated invasive squamous cell carcinoma with no residual carcinoma or nodal involvement. She was treated with adjuvant hypofractionated radiation therapy, experiencing minimal side effects. This case highlights the importance of considering individualized, nuanced approaches to adjuvant therapies in the treatment of PSCC in older patients. It demonstrates that BCT, coupled with carefully selected adjuvant therapy, can be a successful treatment strategy for PSCC in the elderly, contributing valuable insights into the management of this rare condition.

Benefit of adjuvant chemotherapy in lymph node-negative, T1b and T1c triple-negative breast cancer

INTRODUCTION

Current guidelines recommendations regarding chemotherapy in small (T1b and T1c), node-negative triple-negative breast cancer (TNBC) differ due to lack of high-quality data. Our study aimed to assess the benefit of adjuvant chemotherapy in patients with T1bN0M0 and T1cN0M0 TNBC.

METHODS

We obtained data from the Surveillance, Epidemiology, and End Results database for patients with node-negative, T1b/T1c TNBC diagnosed between 2010 and 2020. Logistic regresion models assessed variables associated with chemotherapy administration. We evaluated the effect of chemotherapy on overall survival (OS) and breast cancer specific survival (BCSS) with Kaplan-Meier methods and Cox proportional hazards methods.

RESULTS

We included 11,510 patients: 3,388 with T1b and 8,122 with T1c TNBC. During a median follow-up of 66 months, 305 patients with T1b and 995 with T1c died. After adjusting for clinicopathological, demographic and treatment factors, adjuvant chemotherapy improved OS in T1b TNBC (HR, 0.52; 95% CI, 0.41-0.68 p < 0.001) but did not improve BCSS (HR, 0.70; 95% CI, 0.45-1.07; p = 0.10); the association between chemotherapy and BCSS was not statistically significant in any subgroup. In T1c TNBC, adjuvant chemotherapy improved OS (HR, 0.54; 95% CI, 0.47-0.62; p < 0.001) and BCSS (HR, 0.79; 95% CI, 0.63-0.99; p = 0.043); the benefit of chemotherapy in OS varied by age (Pinteraction=0.024); moreover, the benefit in BCSS was similar in all subgroups.

CONCLUSIONS

Our study results support the use of adjuvant chemotherapy in patients with node-negative, T1c TNBC. Patients with node-negative, T1b TNBC had excellent long-term outcomes; furthermore, chemotherapy was not associated with improved BCSS in these patients.

Treatment optimization in early triple negative breast cancer

INTRODUCTION

The treatment of early-stage triple-negative breast cancer (TNBC) has radically changed in recent years. Response to neoadjuvant treatment has provided prognostic information, and the achievement of a pathological complete response (pCR) is associated with improved prognosis. An exact treatment algorithm that embraces the trade-off of efficacy and toxicity in a risk-adapted manner has, however, not been consolidated.

AREAS COVERED

In this review, we focused on the current treatments used for patients with early triple negative breast cancer, aiming at framing a therapeutic approach toward risk-adapted treatment optimization. We reviewed the clinical trials and other evidence at the foundation of the current clinical practice in early TNBC and identified possible areas of clinical implementation.

EXPERT OPINION

In our opinion, treatment optimization will ensure improved patient-centric outcomes, with less toxicities, better long-term quality of life and risk-adapted treatment modulation. Presently, treatment modulation can be applied in some patients through de-intensification, for small TNBC, informed by novel biomarkers and based on the response to neoadjuvant treatments, especially in the case of pCR. Innovative approaches should incorporate baseline risk and cancer biology, treatment response, and post-surgery biomarkers of prognosis, to deliver risk-adapted treatments for patients with early TNBC.

Systemic Therapy De-Escalation in Early-Stage Triple-Negative Breast Cancer: Dawn of a New Era?

Simple Summary

Triple-negative breast cancer is a life-threatening disease, even when identified at early stages. Recent advances have allowed the improvement of life expectancy via a personalized approach with the addition of newer chemotherapies, immunotherapies, and targeted therapies, but at the cost of added side effects. It has become increasingly clear that not all patients need such aggressive treatment. Here, we provide an overview of emerging opportunities to use less toxic therapies in patients at lower risk of recurrence or with mutations that can be effectively targeted using novel approaches. We provide a comprehensive review of completed and ongoing clinical trials with information on how to best stratify these patients for treatments to obtain maximum benefit without unnecessary toxicities.

Abstract

Early-stage triple negative breast cancer (TNBC) has been traditionally treated with surgery, radiation, and chemotherapy. The current standard of care systemic treatment of early-stage II and III TNBC involves the use of anthracycline-cyclophosphamide and carboplatin-paclitaxel with pembrolizumab in the neoadjuvant setting followed by adjuvant pembrolizumab per KEYNOTE-522. It is increasingly clear that not all patients with early-stage TNBC need this intensive treatment, thus paving the way for exploring opportunities for regimen de-escalation in selected subgroups. For T1a tumors (≤5 mm), chemotherapy is not used, and for tumors 6–10 mm (T1b) in size with negative lymph nodes, retrospective studies have failed to show a significant benefit with chemotherapy. In low-risk patients, anthracycline-free chemotherapy may be as effective as conventional therapy, as shown in some studies where replacing anthracyclines with carboplatin has shown non-inferior results for pathological complete response (pCR), which may form the backbone of future combination therapies. Recent advances in our understanding of TNBC heterogeneity, mutations, and surrogate markers of response such as pCR have enabled the development of multiple treatment options in the (neo)adjuvant setting in order to de-escalate treatment. These de-escalation studies based on tumor mutational status, such as using Poly ADP-ribose polymerase inhibitors (PARPi) in patients with BRCA mutations, and new immunotherapies such as PD1 blockade, have shown a promising impact on pCR. In addition, the investigational use of (bio)markers, such as high levels of tumor-infiltrating lymphocytes (TILs), low levels of tumor-associated macrophages (TAMs), and complete remission on imaging, also look promising. In this review, we cover the current standard of care systemic treatment of early TNBC and review the opportunities for treatment de-escalation based on clinical risk factors, biomarkers, mutational status, and molecular subtype.

Nomogram for Predicting Overall Survival and Assessing the Survival Benefit of Adjuvant Treatment in pT1-2N0M0 Triple-Negative Breast Cancer: A Surveillance, Epidemiology, and End Results-Based Study

Background

Accurate survival prediction of triple-negative breast cancer (TNBC) is essential in the decision-making of adjuvant treatment. The aim of this prospective study was to develop a nomogram that predicts overall survival and assists adjuvant treatment formulation.

Methods

A total of 16,977 patients with pT1-2N0M0 TNBC between 2010 and 2015 from the SEER database were enrolled. Independent prognostic factors associated with overall survival (OS) were identified using univariate and multivariate Cox regression hazards method and utilized to compose the nomogram. The survival benefit of adjuvant treatment on OS were analyzed after stratification by nomogram sum-score.

Results

Patients were randomized 7:3 into the training and validation cohorts. Multivariate analysis revealed that age at diagnosis, grade, tumor size, laterality, and mastectomy type were independent prognostic factors of OS and were integrated to develop a nomogram for predicting prognosis. Patients were stratified into 3 prognostic subgroups according to the sum-score of our nomogram. There were no significant differences found in OS between surgery alone and other adjuvant treatment strategies in low risk group. In moderate risk group, patients receiving chemotherapy or the combination of chemotherapy and radiotherapy showed better OS than those receiving surgery alone or radiotherapy alone. For patients in high risk group, the combination of chemotherapy and radiotherapy could maximally improve the overall survival rate of patients.

Conclusion

A novel nomogram for OS prediction and risk stratification in patients with pT1-2N0M0 TNBC was developed. This cohort study reveals the prognostic roles of different adjuvant treatment strategies in subgroups, which may provide a reference for the decision-making of postoperative treatment, eventually improving prognosis for individual patients.