The Role of Transanal Endoscopic Surgery for Early Rectal Cancer

Transanal endoscopic surgery (TES), which is performed through a variety of transanal endoluminal multitasking surgical platforms, was developed to facilitate endoscopic en bloc excision of rectal lesions as a minimally invasive alternative to radical proctectomy. Although the oncologic safety of TES in the treatment of malignant rectal tumors has been an area of vigorous controversy over the past two decades, TES is currently accepted as an oncologically safe approach for the treatment of carefully selected early and superficial rectal cancers. TES can also serve as both a diagnostic and potentially curative treatment of partially resected unsuspected malignant polyps. In this article, indications and contraindications for transanal endoscopic excision of early rectal cancer lesions are reviewed, as well as selection criteria for the most appropriate transanal excisional approach. Preoperative preparation and surgical technique for complications of TES will be reviewed, as well as recommended surveillance and management of upstaged tumors.

Impact of the COVID-19 Pandemic on Cancer Care and Quality of Life for Patients With Breast and Gynecologic Malignancies: A Single-Center Survey-Based Study

This study evaluated the mental health and cancer treatment-related impact of the first wave of the COVID-19 pandemic on patients with breast and gynecologic cancers. An 18-question survey was administered in June 2020 at a New York City-based cancer center to assess the quality of life (QOL) and overall health (OH) during both the pandemic time period from March 1, 2020, through June 30, 2020, and the pre-pandemic period (prior to March 1, 2020). Survey questions were answered on a 5-point Likert scale and a 7-point EORTC QLQ-C30 QOL scale. Differences in mean QOL and OH scores were evaluated using a paired t-test. QOL and OH were significantly worsened by the pandemic, with significant increases in anxiety, depression, and mood swings.

Secondary Invasive Breast Events among Patients with Hormone-Positive Breast Cancer and High-Risk Oncotype DX Recurrence Scores 26-30 and ≥31

BACKGROUND

The Oncotype DX Recurrence Score (ODx RS) is the most widely adopted genomic assay used to guide treatment for patients with early-stage, hormone-positive (HR+) breast cancer (BC), with higher scores predicting greater risk of recurrence and benefit from chemotherapy. Patients with ODx RS >25 typically recieve adjuvant chemotherapy; however, data regarding efficacy of chemotherapy for reducing recurrence in this population have been mixed.

OBJECTIVES

This study aimed to evaluate outcomes of patients with early-stage HR+ BC with high-risk ODx RS (26-30 and ≥31) in order to assess treatment patterns and outcomes. We hypothesized that the benefit of chemotherapy in these groups may be minimal and that select patients may forgo chemotherapy in favor of more aggressive endocrine therapy and ovarian suppression.

METHODS

We performed a retrospective analysis of 515 patients with early-stage, HR+ BC with high-risk ODx RS 26-30 and ≥31 treated between 2006 and 2018. Patients were stratified by RS: low-risk (≤10), intermediate-risk (11-25), and high-risk (≥26). The Kaplan-Meier method was used to estimate the time to secondary invasive breast events (SIBE) or distributions overall and among different RS groups with the log rank test used to compare distributions between groups.

RESULTS

Rates of chemotherapy administration were 7% among the low-risk group, 18% among the intermediate-risk group, and 83% among high-risk patients with 41 SIBE (8%) reported. When stratified by ODx RS, 5-year rates of SIBE were 4%, 6%, and 16% for low-risk, intermediate-risk, and high-risk RS, respectively. Among the 27 lymph node (LN)-negative patients with ODx RS 26-30, 74% received chemotherapy. The 5-year rate of SIBE was 25% among patients who received chemotherapy and 33% among those who did not (p = 0.5489). Among the 23 LN-negative patients with ODx RS ≥31, 91% of patients received chemotherapy. The 5-year rate of SIBE was 0% both with and without chemotherapy.

CONCLUSIONS

There was no statistically significant difference in SIBE for patients with high-risk ODx RS based on chemotherapy treatment. More aggressive endocrine therapy with ovarian suppression has become an alternative to chemotherapy among patients with intermediate-risk ODx RS (16-25). This approach may be useful among patients with high-risk ODx RS, with additional studies needed in this patient population.

Trends in use of ovarian suppression (OS) for premenopausal patients with early-stage hormone positive breast cancer and Intermediate Risk (IR) Oncotype Recurrence Scores (RS) from 2006-2020: A retrospective database analysis

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Background: Oncotype RS is a 21-gene assay used to predict the risk of recurrence and benefit from chemotherapy in early-stage, hormone positive (HR+), node-negative breast cancer (BC). The TAILORx trial showed that many patients with RS<25 can avoid chemotherapy and the small absolute benefit may be due to chemotherapy-induced menopause in premenopausal patients. The SOFT-TEXT trials found that premenopausal women have higher rates of freedom from recurrence and 8-year survival when receiving OS with endocrine therapy (ET). These studies suggest that premenopausal women with IR RS (16-25) benefit from aggressive ET with OS but trends in OS use have not been adequately studied. We predict that OS use has increased in premenopausal patients over time. Methods: We identified 87 premenopausal patients with early-stage, HR+ BC with IR Oncotype RS (16-25) who were treated with ET between 2006-2020 at our large NYC academic cancer center. The Cochran-Armitage test was used for trends in the proportions of patients receiving OS and chemotherapy over time. The log-rank test was used to compare distributions of recurrence rates between RS groups. Results: Median age was 46 years and median RS was 19. Overall, 23 (26%) patients received chemotherapy and 30 (34%) received OS (via leuprolide, goserelin or surgical oophorectomy) with ET. 55 (63%) received tamoxifen alone, 10 (11%) tamoxifen + OS, and 20 (23%) aromatase inhibitor (AI) + OS. Between 2006-2010, 2 (17%) patients received OS and 2 (17%) received chemotherapy compared to 9 (24%) and 12 (32%) between 2011-2015, and 19 (51%) and 9 (24%) between 2016-2020, respectively (Table). There was a significant increasing proportion of patients receiving OS; p=0.0064, but no significant trend in chemotherapy receipt; p=0.8910. There were 8 (9%) patients that recurred, with a borderline significant difference in secondary invasive breast event rates in patients receiving tamoxifen alone (8, 15%) compared to those on tamoxifen + OS or AI + OS (0, 0%), (p=0.0520). There were no significant differences in recurrence rates based on chemotherapy receipt (p=0.1868) or RS group 16-20 vs 21-25 (p= 0.1836). Conclusions: There has been a significant increase in the use of OS with ET in premenopausal women with IR RS in our study population. This study shows how the results of the SOFT-TEXT trial have been adapted into current practice. Future studies are needed to evaluate real-world recurrence rates with the use of increased OS and whether chemotherapy rates have decreased over time.[Table: see text]

Application of RSClin to guide treatment recommendations for premenopausal patients with early-stage hormone-positive breast cancer and intermediate risk oncotype recurrence scores

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Background: The RSClin model, which incorporates the Oncotype Recurrence Score (RS) and clinicopathologic features, was recently developed to further tailor prognosis and prediction of chemotherapy benefit for patients with early-stage hormone positive (HR+) breast cancer (BC) (Sparano et al, 2020). The RSClin calculator is available online to assist treatment planning for situations where chemotherapy benefit is uncertain. Covariates include Oncotype RS, tumor grade, tumor size and patient age. The risk calculator generates a 10-year distant recurrence risk and absolute chemotherapy benefit. This tool may be especially helpful to determine treatment management for premenopausal patients with early-stage HR+ BC with intermediate risk (IR) Oncotype RS (16-25). We retrospectively applied RSClin to this patient population to determine if it would have changed treatment recommendations. Methods: We identified premenopausal women with node-negative early-stage BC with IR RS (16-25) within our large Oncotype database. Using the RSClin model, we selected >5% absolute chemotherapy benefit as a reasonable cutoff to recommend chemotherapy. We compared the treatment recommendation based on RSClin with the treatment previously recommended by breast oncologists at our large academic medical center in New York City. Results: There were 86 patients who met criteria with a median age of 46 years. Of these, 26 patients (30%) were recommended chemotherapy plus endocrine therapy (ET) and 60 (70%) were recommended ET alone. After applying the RSClin model (data available for 83/86 patients), 19 (23%) would have resulted in a change in treatment recommendation and 64 (77%) would have remained unchanged. Overall, 8 (10%) would have withheld chemotherapy when it was previously offered and 11 (13%) would have recommended chemotherapy when it was previously excluded. There were 8 (9%) secondary invasive breast events in this population, with 2 (2%) being ipsilateral, 3 (3%) being contralateral and 3 (3%) metastatic at a median follow up of 46.9 months. Conclusions: The RSClin model would have changed management of premenopausal patients with IR RS in 23% of patients. This model, although not yet prospectively validated, may help individualize therapy for patients with less definitive treatment plans. Using RSClin, we can aim to minimize recurrence rates and avoid unnecessary chemotherapy in selected patients. This model is easy to apply and will have important clinical utility moving forward.