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Petersen JM, Ranker LR, Barnard-Mayers R, MacLehose RF, Fox MP. A systematic review of quantitative bias analysis applied to epidemiological research. Int J Epidemiol 2021; 50:1708-1730. [PMID: 33880532 DOI: 10.1093/ije/dyab061] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Quantitative bias analysis (QBA) measures study errors in terms of direction, magnitude and uncertainty. This systematic review aimed to describe how QBA has been applied in epidemiological research in 2006-19. METHODS We searched PubMed for English peer-reviewed studies applying QBA to real-data applications. We also included studies citing selected sources or which were identified in a previous QBA review in pharmacoepidemiology. For each study, we extracted the rationale, methodology, bias-adjusted results and interpretation and assessed factors associated with reproducibility. RESULTS Of the 238 studies, the majority were embedded within papers whose main inferences were drawn from conventional approaches as secondary (sensitivity) analyses to quantity-specific biases (52%) or to assess the extent of bias required to shift the point estimate to the null (25%); 10% were standalone papers. The most common approach was probabilistic (57%). Misclassification was modelled in 57%, uncontrolled confounder(s) in 40% and selection bias in 17%. Most did not consider multiple biases or correlations between errors. When specified, bias parameters came from the literature (48%) more often than internal validation studies (29%). The majority (60%) of analyses resulted in >10% change from the conventional point estimate; however, most investigators (63%) did not alter their original interpretation. Degree of reproducibility related to inclusion of code, formulas, sensitivity analyses and supplementary materials, as well as the QBA rationale. CONCLUSIONS QBA applications were rare though increased over time. Future investigators should reference good practices and include details to promote transparency and to serve as a reference for other researchers.
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Affiliation(s)
- Julie M Petersen
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Lynsie R Ranker
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Ruby Barnard-Mayers
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, University of Minnesota, School of Public Health, Minneapolis, MN, USA
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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2
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Wang F, Meszoely I, Pal T, Mayer IA, Bailey CE, Zheng W, Shu XO. Radiotherapy after breast-conserving surgery for elderly patients with early-stage breast cancer: A national registry-based study. Int J Cancer 2020; 148:857-867. [PMID: 32838477 DOI: 10.1002/ijc.33265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 11/10/2022]
Abstract
Considerable controversies exist regarding whether elderly patients with early-stage breast cancer receiving breast-conserving surgery (BCS) should forgo radiotherapy. We utilized the National Cancer Database to analyze data of 115 516 women aged ≥70 years, treated with BCS for T1-2N0-1M0 breast cancer between 2004 and 2014. Multivariable Cox proportional hazards model was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for mortality 3, 5 and 10 years after 90 days of BCS associated with radiotherapy. Patients who received no radiotherapy had a higher mortality rate than those who received radiotherapy (5-year survival rate: 71.2% vs 83.8%), with multivariable-adjusted HRs of 1.65 (95% CI: 1.57-1.72) for 3-year mortality, 1.53 (1.47-1.58) for 5-year mortality and 1.43 (1.39-1.48) for 10-year mortality. The association held even for patients ≥90 years. This association was observed in all strata by reasons for radiotherapy omission, receipt of endocrine therapy or chemotherapy, calendar period and other clinical characteristics, with 40% to 65% increased 5-year mortality for patients without radiotherapy. This positive association persisted when analyses were restricted to patients with T1N0 and estrogen-receptor-positive disease who had received endocrine therapy (5-year mortality: HR 1.47 [1.39-1.57]) and in propensity score weighted analyses. Our study shows, in routine practice, elderly patients who received no post-BCS radiotherapy had higher total mortality than those who received radiotherapy. These findings suggest that the current recommendation of omission of post-BCS radiotherapy for elderly women with early-stage breast cancer may need to be reconsidered, particularly for those without contraindication.
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Affiliation(s)
- Fei Wang
- Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Breast Surgery, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Ingrid Meszoely
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tuya Pal
- Division of Genetic Medicine, Department of Medicine, Vanderbilt Genetics Institute, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ingrid A Mayer
- Division of Hematology/Oncology, Department of Medicine, Breast Cancer Program, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christina E Bailey
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wei Zheng
- Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Xiao-Ou Shu
- Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Six-Year Results From a Phase I/II Trial for Hypofractionated Accelerated Partial Breast Irradiation Using a 2-Day Dose Schedule. Am J Clin Oncol 2019; 41:986-991. [PMID: 28787281 DOI: 10.1097/coc.0000000000000402] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND To report 6-year outcomes from a phase I/II trial using balloon-based brachytherapy to deliver APBI in 2 days. METHODS A total of 45 patients with early-stage breast cancer received adjuvant APBI in 2 days with high-dose rate (HDR) brachytherapy totaling 2800 cGy in 4 fractions (700 cGy BID) using a balloon-based applicator as part of a prospective phase I/II clinical trial. All patients had negative margins and skin spacing ≥8 mm. We evaluated toxicities (CTCAE v3) as well as ipsilateral breast tumor recurrence (IBTR), regional nodal failure (RNF), distant metastasis, disease-free survival, cause-specific survival, and overall survival. RESULTS Median age and tumor size were 66 years old (48 to 83) and 0.8 cm (0.2 to 2.3 cm), respectively. Four percent of patients were N1 (n=2) and 73% were estrogen receptor (ER) positive (n=32). Median follow-up was 6.2 years (2.4 to 8.0 y). Nearly all toxicities at 6 years were grade 1 to 2 except 1 instance of grade 3 telangiectasia (2%). Eleven percent (n=5) of patients had chronic asymptomatic fat necrosis whereas asymptomatic seromas were noted on mammogram in 13% of cases (n=6). Cosmesis at last follow-up was good or excellent in 91% of cases (n=40) and fair in 9% (n=4). Two of the previously reported rib fractures healed with conservative measures. There were no IBTR or RNF (6 y IBTR/RNF rate 0%); however, 2 patients experienced distant metastasis (4% at 6 y). The 6-year actuarial disease-free survival, cause-specific survival, and overall survival were 96%, 100%, and 93%, respectively. CONCLUSIONS Hypofractionated 2-day APBI using brachytherapy resulted in excellent clinical outcomes with acceptable chronic toxicities.
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Valli M, Cima S, Fanti P, Muoio B, Vanetti A, Azinwi CN, Yordanov K, Martucci F, Pesce GA, Canonica C, Richetti A. The role of radiotherapy in elderly women with early-stage breast cancer treated with breast conserving surgery. TUMORI JOURNAL 2018; 104:429-433. [PMID: 30145939 DOI: 10.1177/0300891618792465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To analyze the impact of adjuvant radiotherapy (RT) on ipsilateral breast recurrence (IBR) and overall survival (OS) in patients older than 69 years with early-stage breast cancer. METHODS From January 2007 to June 2015, we analyzed retrospectively 137 women with estrogen receptor-positive T1-2 invasive breast cancer, with negative axillary lymph nodes, dividing them into 2 subgroups: 70 to 79 years and older than 79 years. RESULTS After a median follow-up of 43.2 months, the 3-year IBR-free survival in patients treated with surgery plus RT was 98.8% and 92.1% in patients treated with surgery alone, with a significant difference (p = .01). Radiotherapy did not impact overall survival (p = .10). A higher percentage of patients aged between 70 and 79 years received RT after conservative surgery if compared with the older subgroup (p < .01). CONCLUSIONS In elderly women, adjuvant RT reduced the IBR, but did not improve OS.
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Affiliation(s)
- Mariacarla Valli
- 1 Radiation Oncology, Oncology Institute of Southern Switzerland, Bellinzona-Lugano, Switzerland.,3 Breast Unit, Centro di Senologia della Svizzera Italiana, Lugano-Bellinzona, Switzerland
| | - Simona Cima
- 1 Radiation Oncology, Oncology Institute of Southern Switzerland, Bellinzona-Lugano, Switzerland.,3 Breast Unit, Centro di Senologia della Svizzera Italiana, Lugano-Bellinzona, Switzerland
| | - Paola Fanti
- 1 Radiation Oncology, Oncology Institute of Southern Switzerland, Bellinzona-Lugano, Switzerland.,3 Breast Unit, Centro di Senologia della Svizzera Italiana, Lugano-Bellinzona, Switzerland
| | - Barbara Muoio
- 1 Radiation Oncology, Oncology Institute of Southern Switzerland, Bellinzona-Lugano, Switzerland
| | - Alessandra Vanetti
- 2 Gynaecology Department, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland
| | - Che N Azinwi
- 1 Radiation Oncology, Oncology Institute of Southern Switzerland, Bellinzona-Lugano, Switzerland
| | - Kaloyan Yordanov
- 1 Radiation Oncology, Oncology Institute of Southern Switzerland, Bellinzona-Lugano, Switzerland
| | - Francesco Martucci
- 1 Radiation Oncology, Oncology Institute of Southern Switzerland, Bellinzona-Lugano, Switzerland
| | - Gianfranco A Pesce
- 1 Radiation Oncology, Oncology Institute of Southern Switzerland, Bellinzona-Lugano, Switzerland
| | - Claudia Canonica
- 2 Gynaecology Department, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland.,3 Breast Unit, Centro di Senologia della Svizzera Italiana, Lugano-Bellinzona, Switzerland
| | - Antonella Richetti
- 1 Radiation Oncology, Oncology Institute of Southern Switzerland, Bellinzona-Lugano, Switzerland.,3 Breast Unit, Centro di Senologia della Svizzera Italiana, Lugano-Bellinzona, Switzerland
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Optical Surface Management System for Patient Positioning in Interfractional Breast Cancer Radiotherapy. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6415497. [PMID: 29511688 PMCID: PMC5817315 DOI: 10.1155/2018/6415497] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/16/2017] [Indexed: 11/17/2022]
Abstract
Background The Optical Surface Management System (OSMS) is a simple, fast, reproducible, and accurate solution for patient set-up and can minimize random day-to-day set-up errors. However, studies in breast cancer patients are rare. Objective To analyze 200 patient set-ups in 20 patients with breast cancer by comparing the OSMS with the conventional cone-beam computed tomography (CBCT). Method Displacements from concurrent OSMS and CBCT registrations were compared in a total of 200 setups of 20 patients to analyze the interfractional displacement and positioning displacement in three dimensions (lateral, longitudinal, and vertical directions). Results The interfractional displacement on the lateral, longitudinal, and vertical directions for OSMS versus CBCT was 0.049 ± 0.254 versus 0.041 ± 0.244 centimeters (cm); 0.018 ± 0.261 versus 0.040 ± 0.242 cm; 0.062 ± 0.254 versus 0.065 ± 0.240 cm, respectively, without any significant difference (all P > 0.05). The duration for CBCT scan was about 60 seconds (s), while that for image processing, matching, and couch displacement was at least 5 minutes (min). The average scanning time with OSMS was less than 20 s, and the total duration for positioning was less than 1 min. Conclusion OSMS is an efficient tool to improve the accuracy and increase the speed for verifying the patient positioning in radiotherapy for breast cancer.
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LeMasters TJ, Madhavan SS, Sambamoorthi U, Vyas AM. Disparities in the Initial Local Treatment of Older Women with Early-Stage Breast Cancer: A Population-Based Study. J Womens Health (Larchmt) 2017; 26:735-744. [PMID: 28170302 DOI: 10.1089/jwh.2015.5639] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although breast cancer is most prevalent among older women, the majority are diagnosed at an early stage. When diagnosed at an early stage, women have the option of breast-conserving surgery (BCS) plus radiation therapy (RT) or mastectomy for the treatment of early-stage breast cancer (ESBC). Omission of RT when receiving BCS increases the risk for recurrence and poor survival. Yet, a small subset of older women may omit RT after BCS. This study examines the current patterns of local treatment for ESBC among older women. METHODS This study conducted a retrospective observational analysis using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset of women age ≥66 diagnosed with stage I-II breast cancer in 2003-2009. SEER-Medicare data was additionally linked with data from the Area Resource File (ARF) to examine the association between area-level healthcare resources and treatment. Two logistic regression models were used to estimate how study factors were associated with receiving (1) BCS versus BCS+RT and (2) Mastectomy versus BCS+RT. A stratified analysis was also conducted among women aged <70 years. RESULTS Among 45,924 patients, 55% received BCS+RT, 23% received mastectomy, and 22% received BCS only. Women of increasing age, comorbidity, primary care provider visits, stage II disease, and nonwhite race were more likely to have mastectomy or BCS only, than BCS+RT. Women diagnosed in 2004-2006, treated by an oncology surgeon, residing in metro areas, areas of greater education and income, were less likely to receive mastectomy or BCS only, than BCS+RT. While women aged <70 years were more likely to receive BCS+RT, socioeconomic and physician specialties were associated with receiving BCS only. CONCLUSIONS Over half of older women with ESBC initially receive BCS+RT. The likelihood for mastectomy and BCS only increases with age, comorbidity, and vulnerable socio-demographic characteristics. Findings demonstrate continued treatment disparities among certain vulnerable populations.
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Affiliation(s)
- Traci J LeMasters
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
| | - Suresh S Madhavan
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
| | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
| | - Ami M Vyas
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
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7
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Ali AA, Xiao H, Tawk R, Campbell E, Semykina A, Montero AJ, Diaby V. Comparison of health utility weights among elderly patients receiving breast-conserving surgery plus hormonal therapy with or without radiotherapy. Curr Med Res Opin 2017; 33:391-400. [PMID: 27819160 PMCID: PMC5344798 DOI: 10.1080/03007995.2016.1257983] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/02/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND The selection of the most appropriate treatment combinations requires the balancing of benefits and harms of these treatment options as well as the patients' preferences for the resulting outcomes. OBJECTIVE This research aimed at estimating and comparing the utility weights between elderly women with early stage hormone receptor positive (HR+) breast cancer receiving a combination of radiotherapy and hormonal therapy after breast conserving surgery (BCS) and those receiving a combination of BCS and hormonal therapy. METHODS The Surveillance, Epidemiology, and End Results (SEER) linked with Medicare Health Outcomes Survey (MHOS) was used as the data source. Health utility weights were derived from the VR-12 health-related quality of life instrument using a mapping algorithm. Descriptive statistics of the sample were provided. Two sample t-tests were performed to determine potential differences in mean health utility weights between the two groups after propensity score matching. RESULTS The average age at diagnosis was 72 vs. 76 years for the treated and the untreated groups, respectively. The results showed an inverse relationship between the receipt of radiotherapy and age. Patients who received radiotherapy had, on average, a higher health utility weight (0.70; SD = 0.123) compared with those who did not receive radiotherapy (0.676; SD = 0.130). Only treated patients who had more than two comorbid conditions had significantly higher health utility weights compared with patients who were not treated. CONCLUSIONS The mean health utility weights estimated for the radiotherapy and no radiotherapy groups can be used to inform a comparative cost-effectiveness analysis of the treatment options. However, the results of this study may not be generalizable to those who are outside a managed care plan because MHOS data is collected on managed care beneficiaries.
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Affiliation(s)
- Askal Ayalew Ali
- College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, USA
| | - Hong Xiao
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Rima Tawk
- College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, USA
| | - Ellen Campbell
- College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, USA
| | | | | | - Vakaramoko Diaby
- College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, USA
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Hunnicutt JN, Ulbricht CM, Chrysanthopoulou SA, Lapane KL. Probabilistic bias analysis in pharmacoepidemiology and comparative effectiveness research: a systematic review. Pharmacoepidemiol Drug Saf 2016; 25:1343-1353. [PMID: 27593968 DOI: 10.1002/pds.4076] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 06/16/2016] [Accepted: 07/11/2016] [Indexed: 11/06/2022]
Abstract
PURPOSE We systematically reviewed pharmacoepidemiologic and comparative effectiveness studies that use probabilistic bias analysis to quantify the effects of systematic error including confounding, misclassification, and selection bias on study results. METHODS We found articles published between 2010 and October 2015 through a citation search using Web of Science and Google Scholar and a keyword search using PubMed and Scopus. Eligibility of studies was assessed by one reviewer. Three reviewers independently abstracted data from eligible studies. RESULTS Fifteen studies used probabilistic bias analysis and were eligible for data abstraction-nine simulated an unmeasured confounder and six simulated misclassification. The majority of studies simulating an unmeasured confounder did not specify the range of plausible estimates for the bias parameters. Studies simulating misclassification were in general clearer when reporting the plausible distribution of bias parameters. Regardless of the bias simulated, the probability distributions assigned to bias parameters, number of simulated iterations, sensitivity analyses, and diagnostics were not discussed in the majority of studies. CONCLUSION Despite the prevalence and concern of bias in pharmacoepidemiologic and comparative effectiveness studies, probabilistic bias analysis to quantitatively model the effect of bias was not widely used. The quality of reporting and use of this technique varied and was often unclear. Further discussion and dissemination of the technique are warranted. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jacob N Hunnicutt
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.,Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Christine M Ulbricht
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Kate L Lapane
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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9
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LeMasters T, Madhavan SS, Sambamoorthi U. Comparison of the Initial Loco-Regional Treatment Received for Early-Stage Breast Cancer between Elderly Women in Appalachia and a United States - Based Population: Good and Bad News. GLOBAL JOURNAL OF BREAST CANCER RESEARCH 2016; 4:10-19. [PMID: 27517039 DOI: 10.20941/2309-4419.2016.04.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Breast conserving surgery (BCS) followed by radiation therapy (RT) (BCS+RT) is as effective for long-term survival of invasive early-stage breast cancer (ESBC) as mastectomy, and is the local treatment option selected by the majority of women with ESBC. Women of older age and vulnerable socio-demographic characteristics are at greater risk for receiving substandard (BCS only) and non-preferred treatments (mastectomy), such as populations of women from the Appalachian region of United States. METHODS Using a retrospective cohort study design, we identified 26,106 patients from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset and 811 patients from the West Virginia Cancer Registry (WVCR)-Medicare dataset age ≥ 66 diagnosed from 2003 to 2006 with stage I-II breast cancer. Multivariable logistic regression models estimated type of initial treatment received between WVCR-Medicare and SEER-Medicare patients, and the association with type of treatment. RESULTS Overall, women in WV were 0.82 (95% CI 0.68-0.99) and 0.70 (95% CI 0.58-0.84) times less likely to have mastectomy or BCS only vs. BCS+RT, than those in SEER regions. Women in WV of increasing age, greater comorbidity, stage II disease, and non-white race were more likely to have mastectomy or BCS only vs. BCS+RT, whereas, those residing in areas of higher income, higher education, and metro status were less likely, than similarly characterized women from SEER regions. CONCLUSIONS Findings from this study suggest that the magnitude of disparities in breast cancer treatment between groups of women with more and less resources are even greater in the Appalachian region, than they are among US populations. Improving access to oncology treatment services, as well as, the implementation of patient navigation programs are needed to improve patterns of initial treatment for ESBC among at-risk populations.
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Affiliation(s)
- Traci LeMasters
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, USA
| | - S Suresh Madhavan
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, USA
| | - Usha Sambamoorthi
- Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, USA
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10
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Factors associated with radiation therapy incompletion for patients with early-stage breast cancer. Breast Cancer Res Treat 2015; 155:187-99. [PMID: 26683609 DOI: 10.1007/s10549-015-3660-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 12/09/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The purpose of the study was to examine factors associated with adjuvant radiation treatment (RT) incompletion for women with breast cancer within a large national cancer database. METHODS We identified 394,334 women diagnosed with stage I-III breast cancer during 2004-2012 in the national cancer database who initiated adjuvant external beam adjuvant RT and examined the proportion of women not completing treatment. We used multivariable logistic regression to examine patient, clinical, and facility factors associated with RT incompletion for those who had breast-conserving surgery (BCS), defined as <15 fractions and <3990 centiGray [cGy] (accounting for adoption of hypofractionation), and mastectomy (PMRT, defined as <5000 cGy and <25 fractions), separately. We also examined RT incompletion after BCS using more traditional definitions of <25 fractions and <4500 cGy for diagnosis years ≤2010. RESULTS Among the 319,003 women who underwent BCS and the 75,331 women who underwent mastectomy and initiated RT, 98.4 and 97.8 % completed radiation, respectively. In adjusted analyses, older age was associated with RT incompletion (odds ratio [O.R.] for age ≥80 = 2.53 for BCS-treated, 95 % confidence interval [CI] 2.19-2.92; O.R. for PMRT incompletion = 2.33, 95 % CI 1.84-2.96; both versus age <50). In addition, those with ≥2 comorbidities and lower-risk disease had higher odds of RT incompletion. After defining RT completion using more traditional definitions, 94.0 % completed treatment. CONCLUSIONS Reassuringly, we found a very low proportion of patients not completing RT, though we observed a higher likelihood for treatment incompletion in some sub-groups, most notably older women. Further studies should focus on reasons for treatment discontinuation in populations at risk for suboptimal treatment.
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Abstract
Breast radiotherapy after lumpectomy is considered standard for nearly all patients with invasive breast cancer and is recommended for many patients after lumpectomy for ductal carcinoma in situ (DCIS). However, there is recognition that lumpectomy alone can achieve optimal cancer control for some patients with invasive breast cancer and DCIS. Patients with breast cancers with lower risk of recurrence are less likely to derive benefit from breast radiotherapy. This review will focus on defining populations of patients with invasive breast cancer and DCIS with a low risk of recurrence post-lumpectomy and the evidence supporting omission of breast radiotherapy post-lumpectomy.
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Affiliation(s)
- Julia White
- From the Department of Radiation Oncology, The James, Ohio State University Comprehensive Cancer Center
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12
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Hennequin C, Guillerm S, Quero L. [Radiotherapy in elderly patients, recommendations for the main localizations: Breast, prostate and gynaecological cancers]. Cancer Radiother 2015; 19:397-403. [PMID: 26282214 DOI: 10.1016/j.canrad.2015.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 05/21/2015] [Indexed: 11/18/2022]
Abstract
Modifications of radiotherapy indications or schedules because of age could be discussed in view of a different evolution of the disease or because of specific toxicities. One important aim is to decrease the number of hospital transports. For breast cancer, the rate of local relapse after lumpectomy is lower in old patients; moreover, characteristics of the disease are often more favourable (hormonosensitivity, low grade). However, adjuvant irradiation decreases significantly the incidence of breast relapse and must be systematically proposed. Hypofractionnated schedules must be recommended; limited data are available for accelerated partial breast irradiation in old women and these techniques must not be used in routine. For low or intermediate risk prostate cancer, assessment of comorbidities is crucial before considering any invasive treatment. A life expectancy of at least 10 years is required if a curative approach, potentially toxic is proposed. In this case, radiotherapy is often the good choice, giving less sequelae than surgery. The indication of androgen deprivation must take into account cardiovascular and bone history. Management of gynaecological cancers must follow the same recommendations as in young women. Exclusive postoperative brachytherapy must be recommended in early stage endometrial carcinomas. Brachytherapy must be also systematically integrated in the radiotherapy program for cervix cancers, even in old women.
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Affiliation(s)
- C Hennequin
- Service de cancérologie-radiothérapie, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefeaux, 75475 Paris, France; Université Paris Diderot, 1, avenue Claude-Vellefeaux, 75475 Paris, France.
| | - S Guillerm
- Service de cancérologie-radiothérapie, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefeaux, 75475 Paris, France; Université Paris Diderot, 1, avenue Claude-Vellefeaux, 75475 Paris, France
| | - L Quero
- Service de cancérologie-radiothérapie, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefeaux, 75475 Paris, France; Université Paris Diderot, 1, avenue Claude-Vellefeaux, 75475 Paris, France
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Martelli G, Boracchi P, Guzzetti E, Marano G, Lozza L, Agresti R, Ferraris C, Piromalli D, Greco M. Omission of radiotherapy in elderly patients with early breast cancer: 15-Year results of a prospective non-randomised trial. Eur J Cancer 2015; 51:1358-64. [PMID: 26003208 DOI: 10.1016/j.ejca.2015.04.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/06/2015] [Accepted: 04/24/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Whether radiotherapy (RT) is beneficial in elderly (⩾ 70 years) patients undergoing conservative surgery for early breast cancer has long been controversial. Recent randomised trials show that most elderly patients do not benefit from RT. We started a prospective non-randomised trial to address this issue in 1987 and now present results for the 627 consecutive pT1/2cN0 patients recruited, and treated by conservative surgery (quadrantectomy) and tamoxifen, and assigned non-randomly to RT or no RT. METHODS We used multivariate competing risks models to estimate 15-crude cumulative incidence (CCI) of ipsilateral breast tumour recurrence (IBTR), distant metastasis and breast cancer mortality. The models incorporated a propensity score as a measure of probability of receiving RT based on baseline characteristics, to account for the lack of randomisation. RESULTS For pT1 patients, 15-year CCIs of IBTR, distant metastasis and breast cancer death were indistinguishable in the RT and no RT groups. For pT2 patients, 15-year CCI of IBTR was much higher in those not given RT (14.6% versus 0.8%, p = 0.004), although breast cancer mortality and distant metastasis did not differ significantly between RT and no RT. CONCLUSIONS Consistent with the findings of recent randomised trials, our long-term data indicate that most elderly, ER-positive patients with pT1 cN0 breast cancer treated by quadrantectomy do not benefit from RT. The 14.6% CCI of IBTR in our pT2 patients is an additional finding not presented in the trials and suggests that RT should be administered to elderly patients with pT2 disease.
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Affiliation(s)
- Gabriele Martelli
- Breast Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Patrizia Boracchi
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Eleonora Guzzetti
- Breast Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Giuseppe Marano
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Laura Lozza
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Roberto Agresti
- Breast Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Cristina Ferraris
- Breast Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Domenico Piromalli
- Breast Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marco Greco
- Breast Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Smith GL, Huo J, Giordano SH, Hunt KK, Buchholz TA, Smith BD. Utilization and Outcomes of Breast Brachytherapy in Younger Women. Int J Radiat Oncol Biol Phys 2015; 93:91-101. [PMID: 26279027 DOI: 10.1016/j.ijrobp.2015.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 03/09/2015] [Accepted: 05/08/2015] [Indexed: 01/13/2023]
Abstract
PURPOSE To directly compare (1) radiation treatment utilization patterns; (2) risks of subsequent mastectomy; and (3) costs of radiation treatment in patients treated with brachytherapy versus whole-breast irradiation (WBI), in a national, contemporary cohort of women with incident breast cancer, aged 64 years and younger. METHODS AND MATERIALS Using MarketScan health care claims data, we identified 45,884 invasive breast cancer patients (aged 18-64 years), treated from 2003 to 2010 with lumpectomy, followed by brachytherapy (n = 3134) or whole-breast irradiation (n = 42,750). We stratified patients into risk groups according to age (Age < 50 vs Age ≥ 50) and endocrine therapy status (Endocrine- vs Endocrine+). "Endocrine+" patients filled an endocrine therapy prescription within 1 year after lumpectomy. Pathologic hormone receptor status was not available in this dataset. In brachytherapy versus WBI patients, utilization trends and 5-year subsequent mastectomy risks were compared. Stratified, adjusted subsequent mastectomy risks were calculated using proportional hazards regression. RESULTS Brachytherapy utilization increased from 2003 to 2010: in patients Age < 50, from 0.6% to 4.9%; patients Age ≥ 50 from 2.2% to 11.3%; Endocrine- patients, 1.3% to 9.4%; Endocrine+ patients, 1.9% to 9.7%. Age influenced treatment selection more than endocrine status: 17% of brachytherapy patients were Age < 50 versus 32% of WBI patients (P < .001); whereas 41% of brachytherapy patients were Endocrine-versus 44% of WBI patients (P = .003). Highest absolute 5-year subsequent mastectomy risks occurred in Endocrine-/Age < 50 patients (24.4% after brachytherapy vs 9.0% after WBI (hazard ratio [HR] 2.18, 95% confidence interval [CI] 1.37-3.47); intermediate risks in Endocrine-/Age ≥ 50 patients (8.6% vs 4.9%; HR 1.76, 95% CI 1.26-2.46); and lowest risks in Endocrine+ patients of any age: Endocrine+/Age < 50 (5.5% vs 4.5%; HR 1.18, 95% CI 0.61-2.31); Endocrine+/Age ≥ 50 (4.2% vs 2.4%; HR 1.71, 95% CI 1.16-2.51). CONCLUSION In this younger cohort, endocrine status was a valuable discriminatory factor predicting subsequent mastectomy risk after brachytherapy versus WBI and therefore may be useful for selecting appropriate younger brachytherapy candidates.
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Affiliation(s)
- Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jinhai Huo
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kelly K Hunt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A Buchholz
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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15
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Radiation Treatment Strategies in Patients Undergoing Breast-Conserving Surgery. CURRENT BREAST CANCER REPORTS 2015. [DOI: 10.1007/s12609-014-0171-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Chen K, Su F, Jacobs LK. A Nomogram to Predict the Benefit of Radiation Therapy After Breast-Conserving Surgery in Elderly Patients with Stage I & ER-Negative, or Stage II/III Disease. Ann Surg Oncol 2015; 22:3497-503. [PMID: 25665951 DOI: 10.1245/s10434-015-4393-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Radiotherapy (RT) may be omitted for elderly (age >70 years) breast cancer patients with favorable disease [stage I and estrogen receptor (ER)-positive with endocrine therapy]. This study sought to develop a nomogram to predict the survival benefit of RT in elderly patients with stage I & ER-negative or stage II/III (regardless of ER status) disease. METHODS We used surveillance, epidemiology and end results data to identify 9,079 patients (age ≥70 years) with stage I & ER-negative or stage II/III (regardless of ER status) disease who received breast-conserving surgery between 1990 and 2005. Cancer-specific survival (CSS) was estimated using Kaplan-Meier analysis. Competing-risk regression was used to determine the effect of predictors on CSS. A nomogram was then developed and validated using bootstrapped technique. RESULTS With a median follow-up of 83 months, the overall 10- and 15-year CSS were 82.1 and 75.8 %, respectively. RT was significantly associated with improved CSS in the multivariate analysis. A nomogram was developed for the prediction of 10-year CSS and showed a bootstrapped-corrected area under the curve value of 0.679. RT did not deliver any survival benefit to patients with predicted CSS >90 %. In addition, RT significantly increased the 10-year CSS by 3.6 and 10.1 % in patients with predicted CSS from 0.80 to 0.90 and <0.80, respectively. CONCLUSIONS This nomogram is a useful tool to predict the 10-year CSS in patients with stage I and ER-negative or stage II/III (regardless of ER status) disease. The benefit of RT varied among patients with different predicted CSS.
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Affiliation(s)
- Kai Chen
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.,Departments of Surgery and Oncology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Fengxi Su
- Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.
| | - Lisa K Jacobs
- Departments of Surgery and Oncology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Rhieu BH, Rajagopalan MS, Sukumvanich P, Kelley JL, Ahrendt GM, Heron DE, Beriwal S. Patterns of care for omission of radiation therapy for elderly women with early-stage breast cancer receiving hormonal therapy. Pract Radiat Oncol 2015; 5:e267-73. [PMID: 25620165 DOI: 10.1016/j.prro.2014.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 12/16/2014] [Accepted: 12/17/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE For well-selected elderly women who undergo segmental mastectomy for early-stage, estrogen receptor-positive breast cancer, hormonal therapy alone is emerging as an acceptable adjuvant therapy option since the initial publication of Cancer and Leukemia Group B 9343 study in 2004 and update in 2013. The rate of adoption of adjuvant hormonal therapy alone in lieu of radiation therapy (RT) and its associated patterns of care is not known in the United States and was the subject of this study. METHODS AND MATERIALS We used the National Cancer Data Base to identify women aged ≥70 diagnosed with T1N0/T1Nx invasive breast cancer who underwent segmental mastectomy between 1998 and 2011. Because hormone receptor status was not specifically and reliably coded, only those who received hormonal therapy were included in this analysis. Univariate and multivariable exploratory analyses of factors associated with the use of RT were performed using SPSS, version 17.0. RESULTS Of the 182,115 patients who met inclusion criteria, 97,530 (53.6%) patients underwent hormonal therapy and were included in the analysis. The RT utilization rate in this subset decreased with time from 84.9% in 1998 to 75.1% in 2011 (P< .001). Multivariable analysis revealed that the factors associated with decreased use of RT include (in order of association): older age, later year of diagnosis, greater comorbidity score, low grade, lack of insurance, treatment at academic facility, race, rural location, lower median income, and distance from facility. CONCLUSIONS This study assesses the patterns of care associated with the omission of RT in elderly women with early-stage breast cancer who received adjuvant hormonal therapy. Since the publication of major clinical trials, this strategy has been increasingly adopted. The strongest predictors of using this strategy included advanced patient age, high comorbidity score, and low-grade disease.
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Affiliation(s)
- Byung-Han Rhieu
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Malolan S Rajagopalan
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Paniti Sukumvanich
- Division of Gynecologic Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Joseph L Kelley
- Division of Gynecologic Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Gretchen M Ahrendt
- Department of Surgery, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania.
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Le Saux O, Ripamonti B, Bruyas A, Bonin O, Freyer G, Bonnefoy M, Falandry C. Optimal management of breast cancer in the elderly patient: current perspectives. Clin Interv Aging 2015; 10:157-74. [PMID: 25609933 PMCID: PMC4293298 DOI: 10.2147/cia.s50670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Breast cancer (BC) is the most common female malignancy in the world and almost one third of cases occur after 70 years of age. Optimal management of BC in the elderly is a real challenge and requires a multidisciplinary approach, mainly because the elderly population is heterogeneous. In this review, we describe the various possibilities of treatment for localized or metastatic BC in an aging population. We provide an overview of the comprehensive geriatric assessment, surgery, radiotherapy, and adjuvant therapy for early localized BC and of chemotherapy and targeted therapies for metastatic BC. Finally, we attempt to put into perspective the necessary balance between the expected benefits and risks, especially in the adjuvant setting.
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Affiliation(s)
- Olivia Le Saux
- Medical Oncology Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Bertrand Ripamonti
- Gynaecology-Obstetrics Department, University Hospital, Saint-Etienne, France
| | - Amandine Bruyas
- Croix Rousse University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France ; Lyon University, Lyon, France
| | | | - Gilles Freyer
- Medical Oncology Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France ; Lyon University, Lyon, France
| | - Marc Bonnefoy
- Lyon University, Lyon, France ; Geriatric Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Claire Falandry
- Lyon University, Lyon, France ; Geriatric Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
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19
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Abstract
Breast cancer is a disease of aging. The average age at diagnosis is 61, and the majority of deaths occur after age 65. Caring for older women with breast cancer is a major challenge, as many have coexisting illness that can preclude optimal breast cancer treatment and which frequently have greater effect than the breast cancer itself. Older patients with cancer should be screened or have a brief geriatric assessment to detect potentially remediable problems not usually assessed by oncologists (e.g., self-care, falls, social support, nutrition). Older women with early-stage breast cancer should be treated initially with surgery unless they have an exceedingly short life expectancy. Primary endocrine therapy should be considered for patients who have hormone receptor-positive tumors and a very short life expectancy, an acute illness that delays surgery, or tumors that need to be downstaged to be resectable. Sentinel node biopsy should be considered for patients in whom it might affect treatment decisions. Breast irradiation after breast-conserving surgery may be omitted for selected older women, especially for those with hormone receptor-positive early-stage breast cancer that are compliant with adjuvant endocrine therapy. The majority of older women with stage I and II breast cancer have hormone receptor-positive, HER2-negative tumors, and endocrine therapy provides them with optimal systemic treatment. If these patients have life expectancies exceeding at least 5 years, they should be considered for genetic assays to determine the potential value of chemotherapy. Partnering care with geriatricians or primary care physicians trained in geriatrics should be considered for all vulnerable and frail older patients.
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Affiliation(s)
- Rinaa S Punglia
- From Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA; Avon Comprehensive Breast Evaluation Center, Harvard Medical School and Bermuda Cancer Genetics and Risk Assessment Clinic, Massachusetts General Hospital, Boston, MA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kevin S Hughes
- From Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA; Avon Comprehensive Breast Evaluation Center, Harvard Medical School and Bermuda Cancer Genetics and Risk Assessment Clinic, Massachusetts General Hospital, Boston, MA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Hyman B Muss
- From Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA; Avon Comprehensive Breast Evaluation Center, Harvard Medical School and Bermuda Cancer Genetics and Risk Assessment Clinic, Massachusetts General Hospital, Boston, MA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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20
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Smith GL, Smith BD. Radiation treatment in older patients: a framework for clinical decision making. J Clin Oncol 2014; 32:2669-78. [PMID: 25071132 DOI: 10.1200/jco.2014.55.1168] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
In older patients, radiation treatment plays a vital role in curative and palliative cancer therapy. Radiation treatment recommendations should be informed by a comprehensive, personalized risk-benefit assessment that evaluates treatment efficacy and toxicity. We review several clinical factors that distinctly affect efficacy and toxicity of radiation treatment in older patients. First, locoregional tumor behavior may be more indolent in older patients for some disease sites but more aggressive for other sites. Assessment of expected locoregional relapse risk informs the magnitude and timeframe of expected radiation treatment benefits. Second, assessment of the competing cancer versus noncancer mortality and morbidity risks contextualizes cancer treatment priorities holistically within patients' entire spectrum and time course of health needs. Third, assessment of functional reserve helps predict patients' acute treatment tolerance, differentiating those patients who are unlikely to benefit from treatment or who are at high risk for treatment complications. Potential radiation treatment options include immediate curative treatment, delayed curative treatment, and no treatment, with additional consideration given to altered radiation target, dose, or sequencing with chemotherapy and/or surgery. Finally, when cure is not feasible, palliative radiation therapy remains valuable for managing symptoms and achieving meaningful quality-of-life improvements. Our proposed decision-making framework integrates these factors to help radiation oncologists formulate strategic treatment recommendations within a multidisciplinary context. Future research is still needed to identify how advanced technologies can be judiciously applied in curative and palliative settings to enhance risk-benefit profiles of radiation treatment in older patients and more accurately quantify treatment efficacy in this group.
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Affiliation(s)
- Grace L Smith
- All authors: University of Texas MD Anderson Cancer Center, Houston, TX
| | - Benjamin D Smith
- All authors: University of Texas MD Anderson Cancer Center, Houston, TX.
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Canavan J, Truong PT, Smith SL, Lu L, Lesperance M, Olivotto IA. Local recurrence in women with stage I breast cancer: declining rates over time in a large, population-based cohort. Int J Radiat Oncol Biol Phys 2014; 88:80-6. [PMID: 24331653 DOI: 10.1016/j.ijrobp.2013.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 09/30/2013] [Accepted: 10/01/2013] [Indexed: 12/19/2022]
Abstract
PURPOSE To evaluate whether local recurrence (LR) risk has changed over time among women with stage I breast cancer treated with breast-conserving therapy. METHODS AND MATERIALS Subjects were 5974 women aged ≥50 years diagnosis with pT1N0 breast cancer from 1989 to 2006, treated with breast-conserving surgery and radiation therapy. Clinicopathologic characteristics, treatment, and LR outcomes were compared among 4 cohorts stratified by year of diagnosis: 1989 to 1993 (n=1077), 1994 to 1998 (n=1633), 1999 to 2002 (n=1622), and 2003 to 2006 (n=1642). Multivariable analysis was performed, with year of diagnosis as a continuous variable. RESULTS Median follow-up time was 8.6 years. Among patients diagnosed in 1989 to 1993, 1994 to 1998, 1999 to 2002, and 2003 to 2006, the proportions of grade 1 tumors increased (16% vs 29% vs 40% vs 39%, respectively, P<.001). Surgical margin clearance rates increased from 82% to 93% to 95% and 88%, respectively (P<.001). Over time, the proportions of unknown estrogen receptor (ER) status decreased (29% vs 10% vs 1.2% vs 0.5%, respectively, P<.001), whereas ER-positive tumors increased (56% vs 77% vs 86% vs 86%, respectively, P<.001). Hormone therapy use increased (23% vs 23% vs 62% vs 73%, respectively, P<.001), and chemotherapy use increased (2% vs 5% vs 10% vs 13%, respectively, P<.001). The 5-year cumulative incidence rates of LR over the 4 time periods were 2.8% vs 1.7% vs 0.9% vs 0.8%, respectively (Gray's test, P<.001). On competing risk multivariable analysis, year of diagnosis was significantly associated with decreased LR (hazard ratio, 0.92 per year, P=.0003). Relative to grade 1 histology, grades 2, 3, and unknown were associated with increased LR. Hormone therapy use was associated with reduced LR. CONCLUSION Significant changes in the multimodality management of stage I breast cancer have occurred over the past 2 decades. More favorable-risk tumors were diagnosed, and margin clearance and systemic therapy use increased. These changes contributed to the observed declining LR rates among patients treated with breast-conserving therapy.
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Affiliation(s)
- Joycelin Canavan
- Radiation Therapy Program and Breast Cancer Outcomes Unit, British Columbia Cancer Agency, Vancouver Island Centre, University of British Columbia, Victoria, British Columbia, Canada.
| | - Pauline T Truong
- Radiation Therapy Program and Breast Cancer Outcomes Unit, British Columbia Cancer Agency, Vancouver Island Centre, University of British Columbia, Victoria, British Columbia, Canada
| | - Sally L Smith
- Radiation Therapy Program and Breast Cancer Outcomes Unit, British Columbia Cancer Agency, Vancouver Island Centre, University of British Columbia, Victoria, British Columbia, Canada
| | - Linghong Lu
- Department of Mathematics and Statistics, University of Victoria, British Columbia, Canada
| | - Mary Lesperance
- Department of Mathematics and Statistics, University of Victoria, British Columbia, Canada
| | - Ivo A Olivotto
- Department of Radiation Oncology, Tom Baker Cancer Centre, University of Calgary
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Smith GL, Jiang J, Buchholz TA, Xu Y, Hoffman KE, Giordano SH, Hunt KK, Smith BD. Benefit of adjuvant brachytherapy versus external beam radiation for early breast cancer: impact of patient stratification on breast preservation. Int J Radiat Oncol Biol Phys 2013; 88:274-84. [PMID: 24268788 DOI: 10.1016/j.ijrobp.2013.07.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 06/28/2013] [Accepted: 07/08/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE Brachytherapy after lumpectomy is an increasingly popular breast cancer treatment, but data concerning its effectiveness are conflicting. Recently proposed "suitability" criteria guiding patient selection for brachytherapy have never been empirically validated. METHODS Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we compared women aged 66 years or older with invasive breast cancer (n=28,718) or ductal carcinoma in situ (n=7229) diagnosed from 2002 to 2007, treated with lumpectomy alone, brachytherapy, or external beam radiation therapy (EBRT). The likelihood of breast preservation, measured by subsequent mastectomy risk, was compared by use of multivariate proportional hazards, further stratified by American Society for Radiation Oncology (ASTRO) brachytherapy suitability groups. We compared 1-year postoperative complications using the χ(2) test and 5-year local toxicities using the log-rank test. RESULTS For patients with invasive cancer, the 5-year subsequent mastectomy risk was 4.7% after lumpectomy alone (95% confidence interval [CI], 4.1%-5.4%), 2.8% after brachytherapy (95% CI, 1.8%-4.3%), and 1.3% after EBRT (95% CI, 1.1%-1.5%) (P<.001). Compared with lumpectomy alone, brachytherapy achieved a more modest reduction in adjusted risk (hazard ratio [HR], 0.61; 95% CI, 0.40-0.94) than achieved with EBRT (HR, 0.22; 95% CI, 0.18-0.28). Relative risks did not differ when stratified by ASTRO suitability group (P=.84 for interaction), although ASTRO "suitable" patients did show a low absolute subsequent mastectomy risk, with a minimal absolute difference in risk after brachytherapy (1.6%; 95% CI, 0.7%-3.5%) versus EBRT (0.8%; 95% CI, 0.6%-1.1%). For patients with ductal carcinoma in situ, EBRT maintained a reduced risk of subsequent mastectomy (HR, 0.40; 95% CI, 0.28-0.55; P<.001), whereas the small number of patients treated with brachytherapy (n=179) precluded definitive comparison with lumpectomy alone. In all patients, brachytherapy showed a higher postoperative infection risk (16.5% vs 9.9% after lumpectomy alone vs 11.4% after EBRT, P<.001); higher incidence of breast pain (22.9% vs 11.2% vs 16.7%, P<.001); and higher incidence of fat necrosis (15.3% vs 5.3% vs 7.7%, P<.001). CONCLUSIONS In this study era, brachytherapy showed lesser breast preservation benefit compared with EBRT. Suitability criteria predicted differential absolute, but not relative, benefit in patients with invasive cancer.
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Affiliation(s)
- Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Jiang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thomas A Buchholz
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ying Xu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Karen E Hoffman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H Giordano
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kelly K Hunt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Luu C, Goldstein L, Goldner B, Schoellhammer HF, Chen SL. Trends in Radiotherapy After Breast-Conserving Surgery in Elderly Patients with Early-Stage Breast Cancer. Ann Surg Oncol 2013; 20:3266-73. [DOI: 10.1245/s10434-013-3150-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Indexed: 01/20/2023]
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Smith BD, Buchholz TA. Radiation Treatments After Breast-Conserving Therapy for Elderly Patients. J Clin Oncol 2013; 31:2367-8. [DOI: 10.1200/jco.2012.48.0939] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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25
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Vrana D, Gatek J, Lukesova L, Vazan T, Melichar B, Pospiskova M, Svach I. Omission of adjuvant radiation therapy in elderly patients with low risk breast cancer undergoing breast-conserving surgery--two center experience. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 158:461-4. [PMID: 23681308 DOI: 10.5507/bp.2013.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 04/18/2013] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Breast cancer is, now often diagnosed in patients older than 70 years due to longer life expectancy. The usual treatment is mastectomy to obviate radiotherapy or breast-conserving surgery followed by radiotherapy. The aim of this study was to investigate the need for adjuvant radiotherapy in older patients and the consequences of omitting radiotherapy following conservative surgery. METHODS An extensive database search was made of patients who had been treated for breast cancer at the Department of Oncology, University Hospital Olomouc and the Atlas Hospital in Zlin (2004-2008). We identified 738 patients of whom 190 patients (25.7%) were older than 70 years of age. These were followed up for progression-free and overall survival. The cause of death was checked for breast cancer relapse. RESULTS In total only 9 patients undergoing breast saving surgery were ultimately identified. No patient had confirmed local recurrence during the follow up period: Two patients have died due to distant metastasis without local relapse and one patient has died for reasons other than breast cancer. CONCLUSION Omitting radiotherapy after breast saving surgery provides an opportunity for women to undergo breast saving surgery and avoid 7 weeks of radiotherapy. This could significantly improve patient quality of life. In our of many years experience and from published randomized data, this procedure is safe for a select group of patients 70 years of age and older.
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Affiliation(s)
- David Vrana
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
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26
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Adjuvant chemotherapy and differential invasive breast cancer specific survival in elderly women. J Geriatr Oncol 2013; 4:148-56. [DOI: 10.1016/j.jgo.2012.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Revised: 10/18/2012] [Accepted: 12/27/2012] [Indexed: 11/17/2022]
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