Survival after lumpectomy and mastectomy for early stage invasive breast cancer

BACKGROUND:

Randomized clinical trials (RCT) have demonstrated equivalent survival for breast‐conserving therapy with radiation (BCT) and mastectomy for early‐stage breast cancer. A large, population‐based series of women who underwent BCT or mastectomy was studied to observe whether outcomes of RCT were achieved in the general population, and whether survival differed by surgery type when stratified by age and hormone receptor (HR) status.

METHODS:

Information was obtained regarding all women diagnosed in the state of California with stage I or II breast cancer between 1990 and 2004, who were treated with either BCT or mastectomy and followed for vital status through December 2009. Cox proportional hazards modeling was used to compare overall survival (OS) and disease‐specific survival (DSS) between BCT and mastectomy groups. Analyses were stratified by age group (< 50 years and ≥ 50 years) and tumor HR status.

RESULTS:

A total of 112,154 women fulfilled eligibility criteria. Women undergoing BCT had improved OS and DSS compared with women with mastectomy (adjusted hazard ratio for OS entire cohort = 0.81, 95% confidence interval [CI] = 0.80‐0.83). The DSS benefit with BCT compared with mastectomy was greater among women age ≥ 50 with HR‐positive disease (hazard ratio = 0.86, 95% CI = 0.82‐0.91) than among women age < 50 with HR‐negative disease (hazard ratio = 0.88, 95% CI = 0.79‐0.98); however, this trend was seen among all subgroups analyzed.

CONCLUSIONS:

Among patients with early stage breast cancer, BCT was associated with improved DSS. These data provide confidence that BCT remains an effective alternative to mastectomy for early stage disease regardless of age or HR status. Cancer 2013. © 2012 American Cancer Society.     

Immediate postmastectomy reconstruction is associated with improved breast cancer‐specific survival

BACKGROUND:

Although immediate breast reconstruction is increasingly offered as part of postmastectomy psychosocial rehabilitation, concerns remain that it may delay adjuvant therapy or impair detection of local recurrence. No single population‐based study has examined the relationship between immediate breast reconstruction and breast cancer‐specific survival.

METHODS:

By using data from the US National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registries, breast cancer‐specific survival was compared for female unilateral mastectomy patients who did or did not undergo immediate breast reconstruction. Cox proportional hazards models were fitted, adjusting for known demographic and disease severity variables and stratifying on reconstruction type (implant or autologous) and age.

RESULTS:

Improved breast cancer‐specific survival was observed among all immediate breast reconstruction patients compared with patients who underwent mastectomy alone (hazard ratio [HR] = 0.74; 95% confidence interval [CI], 0.68 to 0.80). Implant reconstruction patients below 50 years of age demonstrated the greatest apparent survival benefit (HR = 0.47; 95% CI 0.28 to 0.80). Similarly, autologous reconstruction was associated with improved cancer‐specific survival among patients below the age of 50 (HR = 0.58; 95% CI, 0.42 to 0.80) and between ages 50 to 69 (HR = 0.61; 95% CI, 0.43 to 0.85).

CONCLUSIONS:

Immediate breast reconstruction is associated with decreased breast cancer‐specific mortality, particularly among younger women. We believe this association is more likely attributable to imbalances in socioeconomic factors and access to care than to inadequate adjustment for tumor characteristics and disease severity. Further research is needed to identify additional prognostic factors responsible for the improved cancer survival among women undergoing immediate postmastectomy reconstruction. Cancer 2009. © 2009 American Cancer Society.     

Recurrences and second primary breast cancers in older women with initial early-stage disease

BACKGROUND: The association between common breast cancer therapies and recurrences and second primary breast cancers in older women is unclear, although older women are less likely to receive common therapies. METHODS: Women aged >or=65 years who were diagnosed with stage I or II breast cancer and who underwent mastectomy or breast-conserving surgery (BCS) from 1990 to 1994 were identified from automated data from 6 healthcare systems and then were followed for 10 years or until breast cancer recurrence, disenrollment, or death. Trained abstractors reviewed medical records to obtain recurrence, tumor, treatment and demographic data. The authors used proportional hazards models to examine predictors of recurrent and second primary breast cancers adjusted for demographic and tumor factors. RESULTS: Of 1837 eligible women, 34% were ages 65 to 69 years, 46% were ages 70 to 79 years, and 20% were aged >or=80 years. In multivariable models that used mastectomy as the reference group, BCS without radiation therapy was associated with an increased risk of any recurrent and second primary breast cancer (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1-2.3), particularly with the subgroup of women with local and regional recurrence (HR, 3.5; 95% CI, 2.0-6.0). Tamoxifen use for <1 year versus >or=5 years exhibited a borderline association with any recurrent or second primary breast cancer (HR, 1.9; 95% CI, 0.9-4.2). CONCLUSIONS: Radiation therapy after BCS and 5 years of tamoxifen use were beneficial in reducing recurrences and second primary breast cancers in older women, regardless of their age or comorbidity burden.     

Evaluating cognitive complaints in breast cancer survivors with the FACT-Cog and quantitative electroencephalography

Purpose

In contrast to other countries, the Dutch breast cancer guideline does not recommend re-excision for focally positive margins after breast-conserving surgery (BCS) in invasive tumor and does recommend whole-breast irradiation including boost. We investigated whether omitting re-excision as compared to performing re-excision affects prognosis with a retrospective population-based cohort study.

Methods

The total cohort included 32,119 women with primary BCS for T1–T3 breast cancer diagnosed between 2003 and 2008 from the nationwide Netherlands cancer registry. The subcohort included 10,433 patients in whom the resection margins were registered. Outcome measures were 5-year ipsilateral breast tumor recurrence (IBTR) rate, 5-year disease-free survival (DFS) rate, and 10-year overall survival (OS) rate.

Results

In the total cohort, 25,878 (80.6%) did not have re-excision, 2368 (7.4%) had re-excision by BCS, and 3873 (12.1%) had re-excision by mastectomy. Five-year IBTR rates were 2.1, 2.8, and 2.9%, respectively (p = 0.001). In the subcohort, 7820 (75.0%) had negative margins without re-excision, 492 (4.7%) had focally positive margins without re-excision, 586 (5.6%) had focally positive margins and underwent re-excision, and 1535 (14.7%) had extensively positive margins and underwent re-excision. Five-year IBTR rate was 2.3, 2.9, 1.1, and 2.9%, respectively (p = 0.099). Compared to omitting re-excision, performing re-excision for focally positive margins was associated with lower risk of IBTR (adjusted HR 0.30, 95% CI 0.11–0.82), but not with DFS (adjusted HR 0.83 95% CI 0.59–1.17) nor with OS (adjusted HR 1.17 95% CI 0.87–1.59).

Conclusion

Omitting re-excision in breast cancer patients for focally positive margins after BCS does not impair DFS and OS, provided that whole-breast irradiation including boost is given.

     

The impact of breast reconstruction on the delivery of chemotherapy

BACKGROUND:

The purpose of this study was to evaluate the impact of postmastectomy breast reconstruction on the timing of chemotherapy.

METHODS:

The authors included stage I‐III breast cancer patients from 8 National Comprehensive Cancer Network institutions for whom guidelines recommended chemotherapy. Surgery type was categorized as breast‐conserving surgery (BCS), mastectomy alone, mastectomy with immediate reconstruction (M + IR), or mastectomy with delayed reconstruction (M + DR). A Cox regression analysis was used to assess the association between surgery type and timing of chemotherapy initiation.

RESULTS:

Of the 3643 patients, only 5.1% received it ≥8 weeks from surgery. In the multivariate analysis, higher stage, Caucasian and Hispanic race/ethnicity, lower body mass index, and absence of comorbid conditions were all significantly associated with earlier time to chemotherapy. There was also significant interaction among age, surgery, and chemotherapy delivery. Among women <60, time to chemotherapy was shorter for all surgery types compared with M + IR (statistical significant for all surgery types in the youngest age group and for BCS in women 40 to <50 years old). In contrast, among women ≥60, time to chemotherapy was shorter among women receiving M + IR or M + DR compared with those undergoing BCS or mastectomy alone, a difference that was statistically significant for the M + IR versus BCS comparison.

CONCLUSIONS:

Immediate postmastectomy breast reconstruction does not appear to lead to omission of chemotherapy, but it is associated with a modest, but statistically significant, delay in initiating treatment. For most, it is unlikely that this delay has any clinical significance. Cancer 2010. © 2010 American Cancer Society.     

Associations of preoperative breast magnetic resonance imaging with subsequent mastectomy and breast cancer mortality

Purpose

To examine associations between pre-operative magnetic resonance imaging (MRI) use and clinical outcomes among women undergoing breast-conserving surgery (BCS) with or without radiotherapy for early-stage breast cancer.

Methods

We identified women from the Surveillance, Epidemiology, and End Results-Medicare dataset aged 67–94 diagnosed during 2004–2010 with stage I/II breast cancer who received BCS. We compared subsequent mastectomy and breast cancer mortality with versus without pre-operative MRI, using Cox regression and competing risks models. We further stratified by receipt of radiotherapy for subgroup analyses.

Results

Our sample consisted of 24,379 beneficiaries, 4691 (19.2%) of whom received pre-operative MRI. Adjusted rates of subsequent mastectomy and breast cancer mortality were not significantly different with and without MRI: 3.2 versus 4.1 per 1000 person-years [adjusted hazard ratio (AHR) 0.92; 95% confidence interval (CI) 0.70–1.19] and 5.3 versus 8.7 per 1000 person-years (AHR 0.89; 95% CI 0.73–1.08), respectively. In subgroup analyses, women receiving BCS plus radiotherapy had similar rates of subsequent mastectomy (AHR 1.17; 95% CI 0.84–1.61) and breast cancer mortality (AHR 1.00; 95% CI 0.80–1.24) with versus without MRI. However, among women receiving BCS alone, MRI use was associated with lower risks of subsequent mastectomy (AHR 0.60; 95% CI 0.37–0.98) and breast cancer mortality (AHR 0.57; 95% CI 0.36–0.92).

Conclusions

Pre-operative MRI was associated with improved outcomes among older women with breast cancer receiving BCS alone, but not among those receiving BCS plus radiotherapy. Further research is needed to identify appropriate settings for which MRI may be helpful.

     

Antioxidant supplement use after breast cancer diagnosis and mortality in the Life After Cancer Epidemiology (LACE) cohort

BACKGROUND:

There is concern that antioxidant supplement use during chemotherapy and radiation therapy may decrease treatment effects, yet the effects of such supplements on recurrence and survival are largely unknown.

METHODS:

The authors prospectively examined the associations between antioxidant use after breast cancer (BC) diagnosis and BC outcomes in 2264 women in the Life After Cancer Epidemiology (LACE) cohort. The cohort included women who were diagnosed with early stage, primary BC from 1997 to 2000 who enrolled, on average, 2 years postdiagnosis. Baseline data were collected on antioxidant supplement use since diagnosis and other factors. BC recurrence and mortality were ascertained, and hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using delayed entry Cox proportional hazards models. All tests of statistical significance were 2‐sided.

RESULTS:

Antioxidant supplement use after diagnosis was reported by 81% of women. Among antioxidant users, frequent use of vitamin C and vitamin E was associated with a decreased risk of BC recurrence (vitamin C: HR, 0.73; 95% CI, 0.55‐0.97; vitamin E: HR, 0.71; 95% CI, 0.54‐0.94); and vitamin E use was associated with a decreased risk of all‐cause mortality (HR, 0.76; 95% CI, 0.58‐1.00). Conversely, frequent use of combination carotenoids was associated with increased risk of death from BC (HR, 2.07; 95% CI, 1.21‐3.56) and all‐cause mortality (HR, 1.75; 95% CI, 1.13‐2.71).

CONCLUSIONS:

Frequent use of vitamin C and vitamin E in the period after BC diagnosis was associated with a decreased likelihood of recurrence, whereas frequent use of combination carotenoids was associated with increased mortality. The effects of antioxidant supplement use after diagnosis likely differ by type of antioxidant. Cancer 2012. © 2011 American Cancer Society.     

Effect of radiotherapy boost and hypofractionation on outcomes in ductal carcinoma in situ

BACKGROUND:

Boost radiotherapy (RT) improves outcomes for patients with invasive breast cancer, but whether this is applicable to patients with pure ductal carcinoma in situ (DCIS) is unclear. This study examined outcomes from whole breast RT, with or without a boost, and the impact of different dose‐fractionation schedules in a population‐based cohort of women with pure DCIS treated with breast‐conserving surgery (BCS).

METHODS:

Data was analyzed for 957 subjects diagnosed between 1985 and 1999. RT use was analyzed over time. Ten‐year Kaplan‐Meier local control (LC), breast cancer specific survival (BCSS), and overall survival (OS) were compared using the log‐rank test. Cox regression modeling of LC was performed.

RESULTS:

Median follow‐up was 9.3 years. Of the patient cohort 475 (50%) had no RT (NoRT) after BCS, 338 (35%) had RT without a partial breast boost (RTNoB), and 144 (15%) had RT with boost (RT + B). Subjects with risk factors of local recurrence were more likely to receive RT. Subjects receiving adjuvant RT had a trend toward improved LC (15‐year LC: NoRT 87%; RTNoB 94%; RT + B 91%; P = .065). Multivariable analysis showed that RT with or without a boost was significantly associated with improved LC (HR, 0.29 and 0.38, respectively, compared with NoRT, P = .025), with no difference associated with a boost or different dose‐fractionation schedules.

CONCLUSIONS:

Adjuvant RT improves local control in patients with DCIS treated with BCS. Hypofractionation is as effective as standard fractionation schedules. Boost RT was not associated with improved LC compared with whole breast RT alone. Cancer 2011. © 2010 American Cancer Society.     

Survival in stage I–III breast cancer patients by surgical treatment in a publicly funded health care system

BackgroundRecent investigations of breast cancer survival in the United States suggest that patients who receive mastectomy have poorer survival than those who receive breast-conserving surgery (BCS) plus radiotherapy, despite clinically established equivalence. This study investigates breast cancer survival in the publicly funded health care system present in Alberta, Canada.Patients and methodsSurgically treated stage I–III breast cancer cases diagnosed in Alberta from 2002 to 2010 were included. Demographic, treatment and mortality information were collected from the Alberta Cancer Registry. Unadjusted overall and breast cancer-specific mortality was assessed using Kaplan–Meier and cumulative incidence curves, respectively. Cox proportional hazards models were used to calculate stage-specific mortality hazard estimates associated with surgical treatment received.ResultsA total of 14 939 cases of breast cancer (14 633 patients) were included in this study. The unadjusted 5-year all-cause survival probabilities for patients treated with BCS plus radiotherapy, mastectomy, and BCS alone were 94% (95% CI 93% to 95%), 83% (95% CI 82% to 84%) and 74% (95% CI 70% to 78%), respectively. Stage II and III patients who received mastectomy had a higher all-cause (stage II HR = 1.36, 95% CI 1.13–1.48; stage III HR = 1.74, 95% CI 1.24–2.45) and breast cancer-specific (stage II HR = 1.39, 95% CI 1.09–1.76; stage III HR = 1.79, 95% CI 1.21–2.65) mortality hazard compared with those who received BCS plus radiotherapy, adjusting for patient and clinical characteristics. BCS alone was consistently associated with poor survival.ConclusionsStage II and III breast cancer patients diagnosed in Alberta, Canada, who received mastectomy had a significantly higher all-cause and breast cancer-specific mortality hazard compared with those who received BCS plus radiotherapy. We suggest greater efforts toward educating and encouraging patients to receive BCS plus radiotherapy rather than mastectomy when it is medically feasible and appropriate.     

Implications of constructed biologic subtype and its relationship to locoregional recurrence following mastectomy

Introduction

We examined the prognostic value of biologic subtype on locoregional recurrence (LRR) after mastectomy in a cohort of low risk women who did not receive adjuvant radiation therapy.

Methods

A total of 819 patients with invasive breast cancer underwent mastectomy from January 2000 through December 2005. No patient received preoperative chemotherapy. Estrogen receptor (ER) receptor, progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status were used to construct the following 4 subtypes: i) ER+ or PR+ and HER2- (HR+/HER2-), ii) ER+ or PR+ and HER2+ (HR+/HER2+), iii) ER- and PR- and HER2+ (HR-/HER2+)and iv) ER- and PR- and HER2- (HR-/HER2-). LRR-free survival was estimated by the Kaplan-Meier method. Cox proportional hazard models were used to evaluate the association between time-to-event outcomes and patient prognostic factors.

Results

At a median follow-up of 58 months, five-year cumulative incidence of LRR for the entire cohort was 2.5%. Subtype specific LRR rates were 1% for HR+/HER2-, 6.5% in HR+/HER2+, 2% for HR-/HER2+ and 10.9% for HR-/HER2- (P < 0.01). In HER-2+ patients (irrespective of ER/PR status), trastuzumab therapy was not associated with LRR-free survival. On multivariate analysis, one to three positive lymph nodes (HR 4.75 (confidence interval (CI) 1.75 to 12.88, P < 0.01), ?? 4 positive lymph nodes (HR23.4 (CI 4.64 to 117.94, P < 0.01), HR+/HER2+ (HR 4.26 (CI 1.05 to 17.33), P = 0.04), and HR-/HER2- phenotype (HR 13.87 (CI 4.96 to 38.80), P < 0.01) were associated with shorter LRR-free survival whereas age > 50 at diagnosis (HR 0.31 (CI 0.12 to 0.80), P = 0.02) was associated with improved LRR-free survival. Among the HR-/HER2- subtypes, five-year LRR incidence was 23.4% in patients with positive lymph nodes compared to 7.8% for lymph node negative patients (P = 0.01), although this association did not reach significance when the analysis was limited to HR-/HER2- women with only one to three positive lymph nodes (15.6% versus 7.8%, P = 0.11).

Conclusions

Constructed subtype is a prognostic factor for LRR after mastectomy among low risk women not receiving adjuvant radiation therapy, although rates of LRR remain low across subtypes. Patients with node positive, HR-/HER2- type tumors were more likely to experience LRR following mastectomy alone. Prospective studies to further investigate the potential benefit of adjuvant radiation therapy in these women are warranted.     

Predictors of competing mortality in early breast cancer

BACKGROUND:

Death in the absence of disease recurrence (competing mortality) is an important determinant of disease‐free survival (DFS) in early breast cancer. The authors sought to identify predictors of this event using competing risks modeling.

METHODS:

A cohort study was made of 1231 consecutive women with stage I to II invasive breast cancer diagnosed between 1986 and 2004, treated with breast conservation therapy. Median follow‐up was 82 months. The authors used a parametric competing risks regression model to analyze factors associated with the cumulative incidence of competing mortality. They generated a risk score from the model coefficient estimates and stratified patients according to low and high risk score for analysis.

RESULTS:

Ten‐year DFS was 69.7% (95% confidence interval [CI], 66.2%‐72.9%). The 10‐year cumulative incidence of locoregional recurrence (LRR) was 4.4% (95% CI, 3.0%‐5.8%), distant recurrence was 7.1% (95% CI, 5.4%‐8.9%), and competing mortality was 18.7% (95% CI, 15.9%‐21.6%). On multivariate analysis, competing mortality was associated with increasing age (hazard ratio [HR], 1.83 per 10 years; 95% CI, 1.58‐2.12), black race (HR, 1.71; 95% CI, 1.17‐2.51), and comorbid disease (HR, 1.93, 95% CI, 1.40‐2.65). Ten‐year cumulative incidences of competing mortality, locoregional recurrence, and distant recurrence for patients at low (n = 638) versus high (n = 593) risk of competing mortality were 7.2% versus 30.6% (P < .001), 4.4% versus 4.4% (P = .97), and 8.6% versus 5.6% (P = .12), respectively.

CONCLUSIONS:

Competing mortality is an important event influencing 10‐year DFS in early breast cancer and is associated with increasing age, black race, and comorbid disease. Stratifying patients according to competing mortality risk may be useful in designing clinical trials. Cancer 2010. © 2010 American Cancer Society.     

Differences in survival among women with stage III inflammatory and noninflammatory locally advanced breast cancer appear early: a large population-based study

BACKGROUND:

Significant improvements in the survival of women with breast cancer have been observed and are attributed to a multidisciplinary approach and the introduction of polychemotherapy and endocrine regimens. The objective of this population‐based study was to determine whether women with inflammatory breast cancer (IBC) who received treatment in a modern era had a poorer survival compared those with non‐IBC locally advanced breast cancer (LABC).

METHODS:

The Surveillance, Epidemiology, and End Results program registry was searched to identify women with stage IIIB/C breast cancer diagnosed between 2004 and 2007 who had undergone surgery and radiotherapy. Patients were categorized as either having IBC or non‐IBC LABC according the sixth edition of the American Joint Committee on Cancer (AJCC) criteria. Breast cancer‐specific survival (BCS) was estimated using the Kaplan‐Meier product limit method and compared across groups using the log‐rank statistic. Cox models were then fitted to compare the association between breast cancer type and BCS after adjusting for patient and tumor characteristics.

RESULTS:

A total of 828 (19.2%) women and 3476 (80.8%) women had stage IIIB/C IBC and non‐IBC LABC, respectively. The median follow‐up was 19 months. The 2‐year BCS rate was 90% (95% confidence interval [95% CI], 88%‐91%) for the entire cohort and 84% (95%CI, 80%‐87%) and 91% (95%CI, 90%‐91%) among women with IBC and non‐IBC LABC, respectively. In the multivariable model, patients with IBC were found to have a 43% increased risk of death from breast cancer compared with patients with non‐IBC LABC (hazard ratio, 1.43; 95%CI, 1.10‐1.86 [P = .008]).

CONCLUSIONS:

In the era of multidisciplinary management and anthracycline‐based and taxane‐based polychemotherapy regimens, women with IBC continue to have worse survival outcomes compared with those with non‐IBC LABC. Cancer 2011. © 2010 American Cancer Society.     

Possible influence of mammographic density on local and locoregional recurrence of breast cancer

Introduction

It is debated whether mammographic density gives rise to more aggressive cancers. We therefore aimed to study the influence of mammographic density on prognosis.

Methods

This is a case-only study within a population-based case-control study. Cases were all postmenopausal women in Sweden with incident breast cancer, diagnosed 1993-1995, and aged 50-74 years. Women with pre-diagnostic/diagnostic mammograms were included (n = 1774). Mammographic density of the unaffected breast was assessed using a computer-assisted thresholding technique. The Cox proportional hazards model was used to study recurrence and survival with and without stratification on surgical procedure (breast-conserving surgery vs. mastectomy).

Results

Percentage density (PD) was associated with both local and locoregional recurrence even after adjustment for established prognosticators; hazards ratio (HR) 1.92, p = 0.039, for local recurrence and HR 1.67, p = 0.033, for locoregional recurrence for women with PD≥25% compared to PD<25%. Stratification on surgical procedure showed that the associations were also present in mastectomized women. PD was neither associated with distant recurrence nor survival.

Conclusions

High mammographic density is an independent risk factor of local and locoregional recurrence but is neither associated with distant metastasis nor survival. The relationships with local and locoregional recurrences were also present in women treated with mastectomy, indicating that they are not merely explained by density masking residual disease in women treated with breast-conserving surgery. Rather there appears to be a true association. Thus, mammographic density should possibly influence adjuvant therapy decisions in the future.     

Omission of radiation therapy after breast-conserving surgery in the United States: a population-based analysis of clinicopathologic factors

BACKGROUND:

Radiation therapy (RT) after breast‐conserving surgery (BCS) is associated with a significant reduction in ipsilateral breast tumor recurrence and breast cancer mortality rates in patients with early stage breast cancer. The authors of this report sought to determine which patients with breast cancer do not receive RT after BCS in the United States.

METHODS:

The Surveillance, Epidemiology, and End Results registry was used to determine the rates of RT after BCS for women with stage I through III breast cancer in the United States from 1992 through 2007. A multivariate analysis was performed to identify independent predictors of omission of RT.

RESULTS:

In total, 294,254 patients with invasive, nonmetastatic breast cancer were identified who underwent surgery from 1992 through 2007. Most patients (57%) underwent BCS; among those, 21.1% did not receive RT after BCS. The omission of RT increased significantly from 1992 (15.5%) to 2007 (25%). The receipt of RT also decreased significantly for patients with increased cancer stage, age <55 years, high‐grade tumors, large tumors, positive or untested lymph node status, African American or Hispanic race, and negative or unknown estrogen receptor status. Significant geographic variation was observed in the rates of RT after BCS.

CONCLUSIONS:

The omission of RT after BCS was more common in recent years, especially among women who had an increased risk of breast cancer recurrence. This trend represents a serious health care concern because of the potential increased risk of local recurrence and breast cancer mortality. Cancer 2012. © 2011 American Cancer Society.     

Comparative effectiveness study of breast-conserving surgery and mastectomy in the general population: A NCDB analysis

Purpose

Recent studies have revealed that breast-conserving surgery (BCS) with radiotherapy (RT) led to better survival than mastectomy in some populations. We compared the efficacy of BCS+RT and mastectomy using the National Cancer Database (NCDB, USA).

Methods

Non-metastatic breast cancers in the NCDB from 2004–2011 were identified. The Kaplan-Meier method, Coxregression and propensity score analysis were used to compare the overall survival (OS) among patients with BCS+RT, mastectomy alone and mastectomy+RT.

Results

A total of 160,880 patients with a median follow-up of 43.4 months were included. The respective 8-year OS values were 86.5%, 72.3% and 70.4% in the BCS+RT, mastectomy alone and mastectomy+RT group, respectively (P < 0.001). After exclusion of patients with comorbidities, mastectomy (alone or with RT) remained associated with a lower OS in N0 and N1 patients. However, the OS of mastectomy+RT was equivalent to BCS+RT in N2–3 patients. Among patients aged 50 or younger, the OS benefit of BCS+RT over mastectomy alone was statistically significant (HR1.42, 95% CI 1.16–1.74), but not clinically significant (<5%) in N0 patients, whereas in N2–3 patients, the OS of BCS+RT was equivalent to mastectomy+RT (85.2% vs. 84.8%). The results of the propensity analysis were similar.

Conclusions

BCS+RT resulted in improved OS compared with mastectomy ± RT in N0 and N1 patients. In N2–3 patients, BCS+RT has an OS similar to mastectomy+RT when patients with comorbidities were excluded. Among patients aged 50 or younger, the OS of BCS+RT is equivalent to mastectomy ± RT.     

Trends and clinical implications of preoperative breast MRI in Medicare beneficiaries with breast cancer

While there has been increasing interest in the use of preoperative breast magnetic resonance imaging (MRI) for women with breast cancer, little is known about trends in MRI use, or the association of MRI with surgical approach among older women. Using the Surveillance, Epidemiology and End Results–Medicare database, we identified a cohort of women diagnosed with breast cancer from 2000 to 2009 who underwent surgery. We used Medicare claims to identify preoperative breast MRI and surgical approach. We evaluated temporal trends in MRI use according to age and type of surgery, and identified factors associated with MRI. We assessed the association between MRI and surgical approach: breast-conserving surgery (BCS) versus mastectomy, bilateral versus unilateral mastectomy, and use of contralateral prophylactic mastectomy. Among the 72,461 women in our cohort, 10.1 % underwent breast MRI. Preoperative MRI use increased from 0.8 % in 2000–2001 to 25.2 % in 2008–2009 (p < 0.001). Overall, 43.3 % received mastectomy and 56.7 % received BCS. After adjustment for clinical and demographic factors, MRI was associated with an increased likelihood of having a mastectomy compared to BCS (adjusted odds ratio = 1.21, 95 % CI 1.14–1.28). Among women who underwent mastectomy, MRI was significantly associated with an increased likelihood of having bilateral cancer diagnosed (9.7 %) and undergoing bilateral mastectomy (12.5 %) compared to women without MRI (3.7 and 4.1 %, respectively, p < 0.001 for both). In conclusion, the use of preoperative breast MRI has increased substantially among older women with breast cancer and is associated with an increased likelihood of being diagnosed with bilateral cancer, and more invasive surgery.     

Palliative Local Surgery for Locally Advanced Breast Cancer Depending on Hormone Receptor Status in Elderly Patients

Background

Many elderly breast cancer patients might just receive palliative local surgery, especially those with locally advanced breast cancer (LABC). However, palliative tumor removal might lead to perioperative residual tumor growth. In this study, we aimed to determine the survival effect of palliative local surgery without definitive axillary surgery for LABC in elderly patients.

Clinical outcome analysis of 98 elderly women with early-stage breast cancer undergoing modified radical mastectomy or simple mastectomy

Objective

The aim of our study was to analyze the clinical results and prognosis for early elderly patients after surgery and to explore the rational treatment.

Methods

Between January 1992 and December 2008, 98 early elderly breast cancer patients aged ≥ 65 years were treated with surgery, of which 52 patients received modified radical mastectomy and 46 patients received simple mastectomy.

Results

Sixty-four (65.3%) patients had comorbidities including coronary heart disease, hypertension, diabetes, etc. After a median follow up of 56 months (21 to 280 months), the 5-year cumulative survival rate of breast modified radical mastectomy group and mastectomy group were 84.0% and 82.7%, separately (P = 0.653). The 5-year recurrence rate were 3.8% and 8.1%, separately (P = 0.504).

Conclusion

The simple mastectomy is suitable for the treatment of early elderly breast cancer patients for its lower complication and recurrence rate. Early old women with breast cancer may be safely treated by simple mastectomy. Our findings suggest that modified radical mastectomy does not significantly increase the overall survival.     

Association between contralateral prophylactic mastectomy and breast cancer outcomes by hormone receptor status

BACKGROUND:

The effect of contralateral prophylactic mastectomy (CPM) on the survival of patients with early‐stage breast cancer remains controversial. The objective of this study was to evaluate the benefits of CPM using a propensity scoring approach that reduces selection bias from the nonrandom assignment of patients in observational studies.

METHODS:

A total of 3889 female patients with stage I to III breast cancer were identified who were treated at The University of Texas MD Anderson Cancer Center from 1997 to 2009. We assessed the association between CPM and disease‐free (DFS) and overall survival (OS), by using Cox proportional hazards models to estimate hazard ratios (HRs), and by matching patients in the CPM and no‐CPM groups using propensity scores (n = 497 pairs).

RESULTS:

With a median follow‐up time of 4.5 years, CPM was associated with improved DFS (HR, 0.75; 95% confidence interval [CI], 0.59‐0.97) and OS (HR, 0.74; 95% CI, 0.56‐0.99), adjusted for prognostic factors. The improved DFS was seen predominantly among hormone receptor–negative (HR, 0.60; 95% CI, 0.38‐0.95) compared with hormone receptor–positive patients (HR, 0.80; 95% CI, 0.58‐1.10). For the matched patient cohort, stratified survival analysis also showed an improvement in DFS with CPM (HR, 0.48; 95% CI, 0.22‐1.01) in hormone receptor–negative patients that was nearly statistically significant.

CONCLUSIONS:

CPM was associated with improved DFS for some patients with hormone receptor–negative breast cancer, after reducing selection bias. Identifying subsets of patients most likely to benefit from CPM may have important implications for a more personalized approach to treatment decisions about CPM. Cancer 2012. © 2012 American Cancer Society.     

Clinicopathologic factors of the recurrent tumor predict outcome in patients with ipsilateral breast tumor recurrence

BACKGROUND:

The role of clinicopathologic characteristics of the recurrent tumor in determining survival in a cohort of patients with ipsilateral breast tumor recurrence (IBTR) was investigated.

METHODS:

Among 6020 women with pT1‐T2, pN0‐1, M0 treated with breast‐conserving surgery from 1989 to 1999, 269 developed isolated IBTR. Ten‐year Kaplan‐Meier breast cancer‐specific survival (BCSS) and overall survival (OS), calculated from date of IBTR, were analyzed according to clinicopathologic characteristics.

RESULTS:

Factors that were associated with diminished OS and BCSS on univariate analysis were: time to IBTR ≤48 months, lymphovascular invasion positive status, estrogen receptor (ER) negative status, high grade, clinical IBTR detection, biopsy alone, and close/positive margins (all P < .05). On multivariate analysis, time to IBTR ≤48 months (hazard ratio [HR], 1.87, P = .012), lymphovascular invasion positive status (HR, 2.46; P < .001), ER negative status (HR, 2.08; P = .013), high‐grade recurrent disease (HR, 1.88; P = .013), and close/positive margins after surgery for IBTR (HR, 1.94; P = .013) retained significance for prediction of diminished OS. When stratified according to number of adverse prognostic features, 10‐year OS was 70.4% in patients with 1 factor, 35.8% with 2 factors, and 19.9% with 3 or more factors (P < .001).

CONCLUSIONS:

Time to recurrence ≤48 months, lymphovascular invasion positive status, ER negative status, high‐grade histology, and close/positive margins in association with the recurrent tumor are independent prognostic factors for survival after IBTR. The presence of 2 or more of these features at recurrence is significantly associated with poor OS. These criteria can be used to prognosticate and guide clinical decisions after recurrence. Cancer 2011. © 2010 American Cancer Society.