Factors affecting survival in women with ductal carcinoma in situ (DCIS): Race and the delivery of adjuvant radiotherapy

29

Background: Recent publications questioned the survival impact of adjuvant radiotherapy (A-RT) in the treatment of DCIS. These reports had in common a short follow up. We wanted to know, in a disease where long term follow up is required, the magnitude of improvement in survival and assess any correlation with race and income. Methods: Search in the Surveillance, Epidemiology and End Results database, of patients diagnosed with DCIS between 1988 and 2012, younger than 70 years old. Analyses of age, race, hormonal receptors (HR), tumor size, surgery, ART and household income. Survival analyses with Kaplan-Meier and multifactorial with Cox proportional-hazard regression. Results: 125,805 patients. Mean follow-up 7.9 years. Patients treated with A-RT resulted in a mortality by breast cancer (DBC) significantly lower (-1.10%; HR: 0.54 [IC95%:0.48-0.59]; p < 0.0001). Based on the type of surgery, mastectomy resulted on a DBC significantly higher than those treated with tumorectomy and A-RT (+1.15%; HR: 2.08 [IC95%:1.84-2.36]; p < 0.0001). Patients with HR+ presented a significantly lower DBC. Black race was the one with the lowest household income (43% < 53900$) opposite to the Asian which was the one with the highest (47% > 71520$). Black race, also presented a DBC significantly higher than the other ones. In the multifactorial analyses (see table), the only variables which presented a significantly influence in DBC were -ART (it decreases DBC) and race (black race increases DBC). Conclusions: These results show blacks, which are the ones with lowest household income, have a significantly increase in cancer mortality than the other races, and that A-RT cuts mortality rates quite drastically in women with DCIS. [Table: see text]

Postoperative radiotherapy treatment evolution in prostate cancer patients: A trend moving away from guidelines?

111

Background: Randomized prospective clinical trials have demonstrated the benefit of adding postoperative radiotherapy (P-RT) for patients with prostate cancer with adverse pathological factors who underwent radical prostatectomy. Based on scientific evidence, the American Urological Association and American Society of Therapeutic Radiologists and Oncology, recommend offering P-RT to this type of patients. Methods: Retrospective analysis of 156,795 patients with prostate cancer diagnosed between 2004 and 2012, who underwent radical prostatectomy. The clinic-pathological information has been extracted from the database "Surveillance Epidemiology and End Results Program". Stage IV patients, and those with "Unknown" information on the type of surgery, radiotherapy, stage or grade, were excluded. Results: Stage II was the most common (81.9%), followed by stage III (18% of the patients). A 60% of the patients had Gleason > / = 8. Only 11.7% of the patients were > / = 70 years old. Treatment with P-RT decreased significantly between 2004 and 2012 (-0.44%; p = 0.0003). Analyzed by subgroups, P-RT decreased significantly in stage II (-0.72%; p < 0.0001) and III (-2.69%; p = 0.005), in patients with Gleason 6-7 (-1.05%; p = 0.0002) and > / = 8 (-1.79%; p = 0.0001) and < 70 years (-0.37%; p = 0.0001), whereas in > / = 70 years decreased but not significantly (-0.53%; p = 0.13). Conclusions: The use of P-RT in patients with prostate cancer who underwent radical prostatectomy is declining. What is most striking, is that the magnitude of this decline, is greatest in patients with higher risk factors, as the percentage of patients with Gleason score > / = 8 and/or Stage III (extracapsular invasion and/or involvement of seminal vesicles) receiving P-RT, declined more than the decline in the percentage of patients with Gleason 6-7 and/or stage II receiving P-RT, which clearly departs from the recommendations contained in the main treatment guidelines.

Trends in breast cancer treatment in United States from 2000 to 2011: Consequences of 2004 National Comprehensive Cancer Network (NCCN) guidelines change

69

Background: In 2004, the NCCN, changed the guidelines for the treatment of stage 1, HR+, > 70 years(y) breast cancer patients, based mainly on the CALGB/RTOG trial, which showed that in these patients, the addition of radiotherapy (RT) to surgery and tamoxifen did not improve overall survival, but significantly decreased local relapse at 5 y. Methods: Retrospective analysis about trends in breast cancer treatment in USA from years 2000 to 2011, searching the National Cancer Data Base, reviewing 458.386 cases of breast cancer stage I, HR+, with special focus in patients >70y. Chi square test was used. Results: Between years 2000-2011, in the group reviewed, mastectomy (MT) increased in women <40y (+25%) and between 40-69y (+13%), while RT decreased in both groups (-20%, -3%). In women >70y, MT decreased (-27%) progressively along these years, but radiotherapy increased until year 2003 (+3%), and begun to decrease in 2004 (-4%), with a final difference between 2003 and 2011 of -9%. In patients >70 y, chemotherapy (CH) treatments, increased progressively (+3%) from year 2000 to 2011 (p<0.001). Conclusions: Changes in NCCN breast cancer guidelines made in 2004, seem to have changed trends of breast cancer treatment in USA in patients > 70y, stage I, HR+. Since then, less aggressive “local” treatments (-4% for MT and -9% for RT) are been performed. Despite this trend for less local therapy chemotherapy utilization has increased even though the risk of systemic disease is very low. The main risk for these patients is local failure with the associated physical, psychological and family impact as well as cost of re-staging. Local RT has demonstrated a significant reduction of this risk. Today's life expectancy for a 70 y/o woman is >10y consequently local relapses and its consequences are expected. New RT techniques, such as partial breast irradiation delivered in few days are convenient and associated with very low toxicity and no mortality. Perhaps a re-look of the NCCN guidelines might be in order. [Table: see text]

Utilization of breast preservation treatments in Hispanic patients with breast cancer: An analysis from the National Cancer Data Base (NCDB) from 2000 to 2011

76

Background: In contrast to mastectomy, radiotherapy (RT) treatments for breast cancer (BC) patients, allows for the benefits of breast preservation therapy and brachytherapy (BT) is a very convenient and short course of RT. BT use in BC has increased since FDA approval in 2002, however, has it been used evenly among races? Methods: Trends of treatment were analyzed for BC patients stages Tis to IV using the NCDB and 2.015.671 cases were found. Specific analysis of treatment differences between Black, White and Hispanic races, and the use of BT was performed. Results: The use of surgery as the only treatment in BC patients has decreased in stages 0 to IV (-7%, -11%, -8%, -6% and -6%; p<0.0001), while the use of RT has increased in stages 0 to III (+5%, +1%, +3%, +8%; p<0.0001). The use of chemotherapy has also increased in stages 0, I, III, IV (+3%, +4%, +7%, +5%; p<0.0001), while decreased in stage II (-3%; p<0.0001). Hispanic patients, received less RT in stages I to III (-4.11%, -5.46%, -4.84%; p<0.05), while White’s in stage I and III (58.11%, 65.98%), and Black’s in stage II (52.19%) received more RT (p<0.05). In addition, Hispanic’s received significantly more mastectomy in stages I, II and IV. BT as a type of RT was used mainly in stages 0 to II. In stages III and IV its use was <0.13%. 50.836 patients stage 0-II received BT. In this group of patients, BT increased from 0.35% in 2000 to 9,76% in 2008 (p<0,0001), and from then, decreased to 8.28% in 2011 (p<0.0001). There are also significant differences between races. In White’s BT increased 11.33% in 2008 which is 1.46 more times than in Black’s and 1.79 more than Hispanic, and then decreased to 9.52% in 2011 which is 1.61 more than in Black’s, and 1.64 more than Hispanic’s. Conclusions: The use of breast preservation RT has increased significantly in stages 0 to III from year 2000 to 2011. BT use increased until year 2008, when it begun to decrease until year 2009, stabilizing in 2010 and 2011 at around 8%. There are significant differences between races in the use of RT in general, and BT in particular, being Hispanic’s the ones which significantly received less breast preservation RT treatment. This finding raises important questions.