Inflammatory breast cancer-The Royal Marsden Hospital experience

Conditional Cancer-Specific Survival for Inflammatory Breast Cancer: Analysis of SEER, 2010 to 2016

BACKGROUND

Conditional survival takes into account the time that has elapsed since diagnosis and may have additional informative value. Compared with the static traditional survival evaluation method, conditional survival predictions can be adapted to incorporate the dynamic changes during the disease and provide a more suitable way of identifying time-evolved prognoses.

METHODS

Of 3333 patients diagnosed with inflammatory breast cancer between 2010 and 2016 were extracted from the Surveillance, Epidemiology, and End Results database. The trend of the hazard rate over time was represented by the kernel density smoothing curve. The traditional cancer-specific survival (CSS) rate was estimated by the Kaplan-Meier method. Conditional CSS assessment was defined as the probability that a patient will survive y years given the x years who already survived after diagnosis, and the formula is as follows: CS(y)=CSS(x + y)/CSS(x). 3-year cancer-specific survival (CSS3) and 3-year conditional cancer-specific survival (CS3) were estimated. The Fine-Gray proportional subdistribution hazard model was constructed to screen for time-dependent risk factors associated with cancer-specific death. Subsequently, a nomogram was applied to predict a 5-year survival rate based on the number of years already survived.

RESULTS

Of 3333 patients, the cancer-specific survival (CSS) rate decreased from 57% in the 4th year to 49% in the 6th year, while the comparable 3-year CS (CS3) rate improved from 65% in the first year to 76% in the third year. Overall, the CS3 rate was superior to actuarial cancer-specific survival, which was also found in subgroup analysis, especially in patients with high-risk characteristics. The Fine-Gray's model indicated that remote organ metastasis (M stage), lymph node metastasis (N stage), and surgery all significantly impacted the prognosis for cancer-specific survival. The Fine-Gray's model-based nomogram was constructed to predict 5-year cancer-specific survival immediately after diagnosis and given survival for 1, 2, 3, and 4 years after diagnosis.

CONCLUSION

High-risk patients had a significantly improved cancer-specific survival prognosis after surviving for 1 or more years after diagnosis with inflammatory breast cancer. The probability of reaching 5-year cancer-specific survival following diagnosis improves with each additional year survived. More effective follow-up is required for patients diagnosed at an advanced N stage, remote organ metastasis, or not received surgery. Additionally, a nomogram and web-based calculator may be helpful for patients with inflammatory breast cancer during follow-up counseling (https://ibccondsurv.shinyapps.io/dynnomapp/).

Complete response in the axilla and the non-triple negative subtype are favourable prognostic factors for survival outcomes in inflammatory breast cancer

AIM

To assess real-world outcomes and prognostic factors of non-metastatic inflammatory breast cancer according to immunohistochemistry (IHC)-based subtype and treatment regimen.

METHODS

An institutional retrospective analysis of patients treated with neoadjuvant systemic treatment (NAST) for stage III inflammatory breast cancer diagnosed between 2001 and 2018 was performed. The survival outcomes in relation to patient characteristics, tumour characteristics, treatment modality and response to NAST were analyzed.

RESULTS

225 patients fulfilled the inclusion criteria, 90% of patients were node-positive. IHC-based subtypes: 39.1% were HR+/HER2-, 19.1% HR+/HER2+, 23.1% HR-/HER2+ and 18.7% HR-/HER2-. Treatment was multimodal: NAST (100%), surgery (94.2%) and radiotherapy (94.2%). 53.3% of patients received adjuvant endocrine therapy, 34.3% (neo)adjuvant trastuzumab. Tri-modality therapy was applied in 89.3% of patients. Following NAST, a pathologic complete remission (pCR) in the breast was found in 16.9%, in the axilla in 29.7% and in both the breast and axilla in 10.3% of patients. The axillary pCR rate was significantly higher in HR- subtypes. Median overall survival (OS) was 8.9, 7.2, 5.8 and 2.3 years (p < 0.001) for HR+/HER2-, HR+/HER2+, HR-/HER2+ and HR-/HER2- subtype, respectively. On multivariate analysis, IHC-based subtype, age and axillary pCR were found as independent prognostic factors for RFS and OS. pCR rate and median OS improved over time, 5.8% vs 14.7% and 4.7 vs 10.0 years (2001-2009 vs. 2010-2018), respectively.

CONCLUSIONS

Axillary pCR and the non-triple-negative IHC-based subtype are favourable prognostic factors for RFS and OS in inflammatory breast cancer. Introduction of taxanes and antiHER2 drugs contributed to improved pCR rate and OS.

Nomograms for Estimating Cause-Specific Death Rates of Patients With Inflammatory Breast Cancer: A Competing-Risks Analysis

Purpose:

Inflammatory breast cancer (IBC) is a rare, aggressive and special subtype of primary breast cancer. We aimed to establish competing-risks nomograms to predict the IBC-specific death (BCSD) and other-cause-specific death (OCSD) of IBC patients.

Methods:

We extracted data on primary IBC patients from the SEER (Surveillance, Epidemiology, and End Results) database by applying specific inclusion and exclusion criteria. Cumulative incidence function (CIF) was used to calculate the cumulative incidence rates and Gray’s test was used to evaluate the difference between groups. Fine-Gray proportional subdistribution hazard method was applied to identify the independent predictors. We then established nomograms to predict the 1-, 3-, and 5-year cumulative incidence rates of BCSD and OCSD based on the results. The calibration curves and concordance index (C-index) were adopted to validate the nomograms.

Results:

We enrolled 1699 eligible IBC patients eventually. In general, the 1-, 3-, and 5-years cumulative incidence rates of BCSD were 15.3%, 41.0%, and 50.7%, respectively, while those of OCSD were 3.0%, 5.1%, and 7.4%. The following 9 variables were independent predictive factors for BCSD: race, lymph node ratio (LNR), AJCC M stage, histological grade, ER (estrogen receptor) status, PR (progesterone receptor) status, HER-2 (human epidermal growth factor-like receptor 2) status, surgery status, and radiotherapy status. Meanwhile, age, ER, PR and chemotherapy status could predict OCSD independently. These factors were integrated for the construction of the competing-risks nomograms. The results of calibration curves and C-indexes indicated the nomograms had good performance.

Conclusions:

Based on the SEER database, we established the first competing-risks nomograms to predict BCSD and OCSD of IBC patients. The good performance indicated that they could be incorporated in clinical practice to provide references for clinicians to make individualized treatment strategies.

The presentation, management and outcome of inflammatory breast cancer cases in the UK: Data from a multi-centre retrospective review

OBJECTIVES

Inflammatory Breast cancer (IBC) is a rare but aggressive form of breast cancer. Its incidence and behaviour in the UK is poorly characterised. We collected retrospective data from hospitals in the UK and Ireland to describe the presentation, pathology, treatment and clinical course of IBC in the UK.

MATERIALS AND METHODS

Patients with IBC diagnosed between 1997-2014 at fourteen UK and Irish hospitals were identified from local breast unit databases. Patient characteristics, tumour pathology and stage, and details of surgical, systemic and radiotherapy treatment and follow-up data were collected from electronic patient records and medical notes.

RESULT

This retrospective review identified 445 patients with IBC accounting for 0.4-1.8% of invasive breast cancer cases. Median follow-up was 4.2 years. 53.2% of tumours were grade 3, 56.2% were oestrogen receptor positive, 31.3% were HER2 positive and 25.1% were triple negative. 20.7% of patients had distant metastases at presentation. Despite trimodality treatment in 86.4%, 40.1% of stage III patients developed distant metastases. Five-year overall survival (OS) was 61.0% for stage III and 21.4% for stage IV patients.

CONCLUSIONS

This is the largest series of UK IBC patients reported to date. It indicates a lower incidence than in American series, but confirms that IBC has a high risk of recurrence with poor survival despite contemporary multi-modality therapy. A national strategy is required to facilitate translational research into this aggressive disease.

Inflammatory breast cancer outcomes by breast cancer subtype: a population-based study

AIM

To assess the outcomes of breast cancer subtype in inflammatory breast cancer (IBC).

METHODS

We retrospectively assessed IBC patients from the SEER program.

RESULTS

We identified 626 patients, including 230 (36.7%),100 (17.6%), 113 (18.1%), and 173 (27.6%) patients with HoR+/HER2-, HoR+/HER2+, HoR-/HER2+, and HoR-/HER2- subtype disease, respectively. Multivariate analysis demonstrated that, using HoR+/HER2- subtype as reference, patients with HoR+/HER2+ subtype had better breast cancer-specific survival (BCSS) and overall survival (OS), and patients with HoR-/HER2- subtype had worse BCSS and OS, while BCSS and OS were comparable for HoR-/HER2+ subtype. Similar trends were observed in patients who received surgery, radiotherapy, chemotherapy or trimodality therapy.

CONCLUSION

Breast cancer subtype is clinically useful for predicting survival outcome in IBC. The HoR+/HER2- subtype shows poorer survival outcome than HoR+/HER2+ subtype.

[Comparative study of inflammatory and non-inflammatory locally advanced breast cancer - the experience of a Moroccan hospital]

OBJECTIVES

The locally advanced breast cancer (LABC) covers large tumor heterogeneity. It consists of non-inflammatory LABC and inflammatory breast cancer (IBC). This study aimed to compare the epidemiological, clinical and pathological, as well as the prognosis of IBC versus non-inflammatory LABC.

METHODS

This is a retrospective study of 150 cases of IBC and non-inflammatory LABC collected in medical oncology department of the CHU Hassan II of Fez during a period of 4 years [January 2009-January 2013]. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Analysis of the various prognostic factors was performed according to the Cox model.

RESULTS

IBC represented 28.7% of LABC. The median age was 47 years. The median tumor size was greater in non-inflammatory LABC compared with IBC (9.5 versus 6cm; P=0.0014). Lymph node invasion was more common in the IBC (49.7% versus 45.9%; P=0.01). An SBR grade 3 was more frequently noted in the IBC (P=0.011). The two groups were well balanced with regard to HR, HER2 status and pathologic complete response. Non-inflammatory LABC had the best OS and DFS (24 vs. 22 months; P=0.03 and 18 vs. 17 months; P=0.025 respectively).

CONCLUSION

IBC has a worse prognosis compared to non-inflammatory LABC. New therapeutic approaches are needed to improve the prognosis of these patients.

Comparative aspects of canine and human inflammatory breast cancer

Inflammatory breast cancer (IBC) in humans is the most aggressive form of mammary gland cancer and shares clinical, pathologic, and molecular patterns of disease with canine inflammatory mammary carcinoma (CIMC). Despite the use of multimodal therapeutic approaches, including targeted therapies, the prognosis for IBC/CIMC remains poor. The aim of this review is to critically analyze IBC and CIMC in terms of biology and clinical features. While rodent cancer models have formed the basis of our understanding of cancer biology, the translation of this knowledge into improved outcomes has been limited. However, it is possible that a comparative "one health" approach to research, using a natural canine model of the disease, may help advance our knowledge on the biology of the disease. This will translate into better clinical outcomes for both species. We propose that CIMC has the potential to be a useful model for developing and testing novel therapies for IBC. Further, this strategy could significantly improve and accelerate the design and establishment of new clinical trials to identify novel and improved therapies for this devastating disease in a more predictable way.

Inflammatory breast cancer: a proposed conceptual shift in the UICC-AJCC TNM staging system

In the absence of histological criteria that distinguish between inflammatory and non-inflammatory breast cancer, diagnosis of inflammatory breast cancer relies entirely on the existence of clinical criteria as outlined by the TNM classification. This classification restricts patients presenting with clinical criteria characteristic of inflammatory breast cancer to subcategory T4d, which immediately relegates all patients with non-metastatic inflammatory breast cancer to stage 3, regardless of tumour size or nodal spread. Patients who present with metastatic disease are consigned to stage 4, and the TNM classification does not distinguish patients on the basis of the presence of inflammatory criteria. Evidence by our group and others suggests that patients with inflammatory breast cancer have significantly reduced overall survival among those who present with distant metastasis at diagnosis (stage 4). In light of these results, this Personal View addresses whether the current TNM staging classification accurately represents a distinction between patients with inflammatory and those with non-inflammatory breast cancer.

Overall survival differences between patients with inflammatory and noninflammatory breast cancer presenting with distant metastasis at diagnosis

Inflammatory breast cancer (IBC) is a rare and aggressive disease. Previous studies have shown that among patients with stage III breast cancer, IBC is associated with a worse prognosis than noninflammatory breast cancer (non-IBC). Whether this difference holds true among patients with stage IV breast cancer has not been studied. We tested the hypothesis that overall survival (OS) is worse in patients with IBC than in those with non-IBC among patients with distant metastasis at diagnosis (stage IV disease). We reviewed the records of 1504 consecutive patients with stage IV breast cancer (IBC: 206; non-IBC: 1298) treated at our institution from 1987 through 2012. Survival curves for IBC and non-IBC subcohorts were compared. The Cox proportional hazards model was used to determine predictors of OS. The median follow-up period was 4.7 years. IBC was associated with shorter median OS time than non-IBC (2.27 vs. 3.40 years; P = 0.0128, log-rank test). In a multicovariate Cox model that included 1389 patients, the diagnosis of IBC was a significant independent predictor of worse OS (hazard ratio = 1.431, P = 0.0011). Other significant predictors of worse OS included Black (vs. White) ethnicity, younger age at diagnosis, negative HER2 status, and visceral (vs. nonvisceral) site of metastasis. IBC is associated with shorter OS than non-IBC in patients with distant metastasis at diagnosis. The prognostic impact of IBC should be taken into consideration among patients with stage IV breast cancer.

Lack of prognostic value of human epidermal growth factor-like receptor 2 status in inflammatory breast cancer (IBC): a meta-analysis

Inflammatory breast cancer (IBC) is a rare, aggressive form of breast cancer which is more likely to be her-2/ neu amplified. While the her-2/neu status has been utilised to predict prognosis, the published data are inconsistent. The present meta-analysis was conducted to determine whether the her-2/neu status predicts outcomes. Papers were selected from the PubMed database based on defined inclusion and exclusion criteria. Parameters such as total patients, follow-up time and outcome statistics (i.e. overall survival (OS), relapse-free survival (RFS) were collected. The analysis included 6 studies with 2,838 IBC patients. The summary hazards ratio (HR) estimating the association of OS with HER-2-positive disease was 0.96 (95% confidence interval (95%CI: 0.85-1.10)), with similar findings for RFS (HR=0.81, 95%CI: 0.61-1.09). No obvious statistical heterogeneity was detected. This meta-analysis suggests that HER-2-positive status is not an independent adverse prognostic factor for survival among IBC patient cases.

Breast cancer in Morocco: a literature review

In Morocco, breast cancer is the most prevalent cancer in women and a major public health problem. Several Moroccan studies have focused on studying this disease, but more are needed, especially at the genetic and molecular levels. It is therefore interesting to establish the genetic and molecular profile of Moroccan patients with breast cancer. In this paper, we will highlight some pertinent hypotheses that may enhance breast cancer care in Moroccan patients. This review will give a precise description of breast cancer in Morocco and propose some new markers for detection and prediction of breast cancer prognosis.

Primary tumor resection as a component of multimodality treatment may improve local control and survival in patients with stage IV inflammatory breast cancer

BACKGROUND

To the authors' knowledge, the benefit of primary tumor resection among patients with metastatic inflammatory breast cancer (IBC) is unknown.

METHODS

The authors reviewed 172 cases of metastatic IBC. All patients received chemotherapy with or without radiotherapy and/or surgery. Patients were classified as responders or nonresponders to chemotherapy. The 5-year overall survival (OS) and distant progression-free survival (DPFS) and local control at the time of last follow-up were evaluated.

RESULTS

A total of 79 patients (46%) underwent surgery. OS and DPFS were better among patients treated with surgery versus no surgery (47% vs 10%, respectively [P<.0001] and 30% vs 3%, respectively [P<.0001]). Surgery plus radiotherapy was associated with better survival compared with treatment with surgery or radiotherapy alone (OS rate: 50% vs 25% vs 14%, respectively; DPFS rate: 32% vs 18% vs 15%, respectively [P<.0001 for both]). Surgery was associated with better survival for both responders (OS rate for surgery vs no surgery: 49% vs 23% [P<.0001] and DPFS rate for surgery vs no surgery: 31% vs 8% [P<.0001]) and nonresponders (OS rate for surgery vs no surgery: 40% vs 6% [P<.0001] and DPFS rate for surgery vs no surgery: 30% vs 0% [P<.0001]). On multivariate analysis, treatment with surgery plus radiotherapy and response to chemotherapy were found to be significant predictors of better OS and DPFS. Local control at the time of last follow-up was 4-fold more likely in patients who underwent surgery with or without radiotherapy compared with patients who received chemotherapy alone (81% vs 18%; P<.0001). Surgery and response to chemotherapy independently predicted local control on multivariate analysis.

CONCLUSIONS

The results of the current study demonstrate that for select patients with metastatic IBC, multimodality treatment including primary tumor resection may result in better local control and survival. However, a randomized trial is needed to validate these findings.

A comparison of epidemiology, biology, and prognosis of inflammatory breast cancer in Japanese and US populations

BACKGROUND

The epidemiology of inflammatory breast cancer (IBC) in East Asia has not been fully investigated. We hypothesized the epidemiologic factors associated with IBC in Japanese populations are different from other populations. To determine this, we conducted a comparison study assessing multiple clinically relevant risk factors.

PATIENTS AND METHODS

Patients diagnosed with IBC at St. Luke's International Hospital (SLIH) in Tokyo, Japan, and at the University of Texas MD Anderson Cancer Center (MDA) in Houston, Texas, from 2003 to 2009 were identified via the electronic medical records. Stage IV patients were excluded. Epidemiological, biological, and overall survival (OS) data were collected and compared. After all patient populations were combined, Cox proportional hazard regression analysis was performed.

RESULTS

Twenty-two patients at SLIH and 384 patients at MDA were identified. No differences were found for IBC between SLIH and MDA regarding age at diagnosis (P = .898), hormone receptor status (P = .144), overexpression of HER2 (P = .136), or OS (P = .323), however, BMI (P < .01) and nuclear grade (NG) (P < .01) in Japanese patients were lower than those of US patients. Cox proportional hazard regression analysis revealed ER status and race were associated with OS.

CONCLUSION

Despite the small number of patients enrolled, IBC in a Japanese population demonstrated lower BMI and lower NG than IBC in a US population with no difference in survival. ER status and race were prognostic factors when the 2 populations were combined. To more robustly define IBC among East Asian individuals, we have started to register Japanese patients with an International IBC Registry.

How do I treat inflammatory breast cancer?

Inflammatory breast cancer (IBC) is an uncommon and aggressive presentation of locally advanced breast cancer that is potentially curable when localized but may be associated with distant metastasis in up to one-third of patients at presentation. The diagnosis of IBC is made based on clinical features, including the presence of skin edema and erythema involving at least one-third of the breast, with or without a mass, and usually associated with dermal lymphatic invasion (DLI) on skin biopsy. Management requires combined modality therapy, including neoadjuvant chemotherapy with an anthracycline and taxane-based regimen, followed by surgery and radiotherapy, plus concurrent anti-HER2 therapy for HER2-positive disease, and endocrine therapy for at least 5 years after surgery for estrogen-receptor-positive disease (Fig. 1). There have been few large clinical trials focused on IBC; therefore, most data regarding treatment are derived from retrospective analyses, small studies, and extrapolation of results from trials of noninflammatory locally advanced breast cancer. Patients with IBC should be encouraged to enroll in clinical trials whenever possible. In addition, further research into the biology of IBC may help to elucidate the mechanisms underlying its aggressive clinical behavior and to assist in the development of therapies targeted for this specific population.

Management of inflammatory breast cancer: focus on radiotherapy with an evidence-based approach

Inflammatory breast cancer represents a rare and extremely aggressive subtype of breast cancer. Due to its rarity, prospective studies are a difficult goal to obtain in this field. Nowadays a multimodal approach seems to be the standard approach. Role and timing of surgery, radiotherapy and chemotherapy are still debated issues. In this scenario interest is rising in molecular and target therapies. We performed a review analyzing the management of this unfavorable disease focusing on the role of radiotherapy, with particular emphasis on levels of evidence.

Lessons learned from an unusual case of inflammatory breast cancer

Inflammatory breast cancer (IBC) is a rare breast malignancy that is associated with poor long-term outcomes despite aggressive surgical and chemotherapeutic interventions. We recently treated a 56-year-old woman with right-sided IBC and biopsy-proven cutaneous metastases to her back and left breast. She underwent chemotherapy, bilateral modified radical mastectomy, and radiation therapy. One year after diagnosis, she is currently disease-free based on positron-emission tomography (PET) imaging and repeat skin biopsies. To provide insight into the management of IBC, we present this interesting case with a reflection on important lessons to be learned.

Primary chemo-radiotherapy in the treatment of locally advanced and inflammatory breast cancer

BACKGROUND

The best management of large, diffuse or inflammatory breast cancers is uncertain and the place of radiotherapy and/or surgery is not clearly defined.

METHODS

A cohort of 123 patients with non-metastatic locally advanced or inflammatory breast cancer 3 cm or more in diameter or T4, was treated between 1989 and 2006. All patients received primary chemotherapy followed by radiotherapy, 40 Gy in 15 fractions with 10 Gy boost. Patients with ER positive tumours received Tamoxifen. Assessment was carried out 8 weeks post-treatment and surgery was reserved for residual or recurrent disease.

RESULTS

For each stage there were T2/3: 63, T4b: 31 and T4d: 29 patients. 80 had complete clinical response (65%) but 18 patients were never free of inoperable local disease. 25 patients had residual operable disease at assessment and 12 patients who initially had a complete response developed operable local recurrence (LR). 37 Patients (30%) had surgery at a mean of 15 months post diagnosis. At 5 years, overall survival (OS) of the two surgical groups was not significantly different from those 68 patients who had complete remission without surgery, p=0.218, HR 1.46 (0.80-2.55). Surgery as an independent variable to predict survival was not significant on a Cox proportional hazards model (p=0.97). LR in the surgical groups was 13.5% vs 17.5% in the non-surgical patients. The median OS was 64.5 months and disease-free survival (DFS) was 52.5 months. 5-Year OS was 54% and DFS survival 43%.

CONCLUSION

In patients with a complete or partial response to chemo-radiotherapy for locally advanced or inflammatory breast cancer, reserving surgery for those with residual or recurrent local disease did not appear to compromise survival. This finding would support examination of this treatment strategy by a randomised controlled trial.

Identifying factors that impact survival among women with inflammatory breast cancer

BACKGROUND

The objective of this retrospective study was to determine factors impacting survival among women with inflammatory breast cancer (IBC).

METHODS

The Surveillance, Epidemiology and End Results Registry (SEER) was searched to identify women with stage III/IV IBC diagnosed between 2004 and 2007. IBC was identified within SEER as T4d disease as defined by the sixth edition of the American Joint Committee on Cancer. The Kaplan-Meier product-limit method was used to describe inflammatory breast cancer-specific survival (IBCS). Cox models were fitted to assess the multivariable relationship of various patient and tumor characteristics and IBCS.

RESULTS

Two thousand three hundred and eighty-four women with stage IIIB/C and IV IBC were identified. Two-year IBCS among women with stage IIIB, IIIC and IV disease was 81%, 67% and 42%, respectively (P < 0.0001). In the multivariable model, patients with stage IIIB disease and those with stage IIIC disease had a 63% [hazard ratio (HR) 0.373, 95% confidence interval (CI) 0.296-0.470, P < 0.001] and 31% (HR 0.691, 95% CI 0.512-0.933, P = 0.016) decreased risk of death from IBC, respectively, compared with women with stage IV disease. Other factors significantly associated with decreased risk of death from IBC included low-grade tumors, being of white/other race, undergoing surgery, receiving radiation therapy and hormone receptor-positive disease. Among women with stage IV disease, those who underwent surgery of their primary had a 51% decreased risk of death compared with those who did not undergo surgery (HR = 0.489, 95% CI 0.339-0.704, P < 0.0001).

CONCLUSIONS

Although IBC is an aggressive subtype of locally advanced breast cancer, it is heterogeneous with various factors affecting survival. Furthermore, our results indicate that a subgroup of women with stage IV IBC may benefit from aggressive combined modality management.