Variation in use of neoadjuvant chemotherapy in patients with stage III breast cancer: Results of the Dutch national breast cancer audit

Multidisciplinary Implementation of Neoadjuvant Therapy for Early Breast Cancer in a Middle-income Country-Real-world Challenges in Malaysia

AIM

Neoadjuvant therapy (NAT) is not widely employed for the management of patients with early breast cancer (EBC) in Malaysia. We sought to identify barriers to NAT and explore solutions for improving equitable, safe, and timely access to NAT in these patients.

METHODS

We used deliberative stakeholder consultation, a descriptive qualitative study design, for data collection. Sixteen breast cancer specialists (seven breast surgeons, seven clinical oncologists, one radiologist, and one pathologist) from 11 tertiary centers in Malaysia were purposively recruited. Deliberations were recorded, transcribed, and thematically analyzed to generate analytical and deliberative outputs. A literature search was performed to ensure that consensus statements were aligned with scientific evidence and clinical practice guidelines.

RESULTS

Four barrier themes affecting NAT implementation were derived: (1) diagnostic delays, (2) lack of access to oncology services, (3) patient low acceptance of NAT, and (4) high treatment costs. We highlighted potential solutions to address each barrier. Seven key areas for improvement were identified across the EBC care pathway: (1) rational use of imaging modalities, (2) biopsy sampling technique, (3) standardized histopathological reporting, (4) patient selection for NAT, (5) marker clip insertion, (6) monitoring during NAT, and (7) surgical axillary management. Expert recommendations for practice-change interventions were in alignment with published international, national, and institutional guidelines.

CONCLUSION

Barriers to NAT in Malaysia are multifactorial. This study draws on a multidisciplinary stakeholder perspective to define real-world challenges faced by breast cancer specialists and provides recommendations for implementing guideline-recommended practices for NAT utilization in the local healthcare setting.

Interhospital variation in surgical treatment of screen-detected breast cancer in the South of the Netherlands

BACKGROUND

The effectiveness of the Dutch breast cancer screening programme depends on the quality of the full trajectory, from the first screening to the final treatment of a screen-detected breast cancer. Interhospital variation in breast cancer treatment has been explored by several studies, however, not specifically in a screen-detected breast cancer population. The current study compares the treatment strategies of women with screen-detected breast cancer between hospitals in the South of the Netherlands.

METHODS

A total of 1450 women with screen-detected breast cancer, who participated in the Dutch screening programme between January 2009 and July 2019, were included in this retrospective analysis of a prospectively obtained database. Breast cancer treatment (i.e. preoperative MRI, neoadjuvant systemic therapy and type and outcomes of surgery) was compared between hospitals using multivariate analysis.

RESULTS

Statistically significant interhospital variation was observed in the use of preoperative MRI (range 20.8-35.8 %, p < 0.001), neoadjuvant systemic therapy (range 4.0-13.3 %, p < 0.001) and breast conserving surgery (range 70.0-87.1 %, p < 0.001). These differences persisted after adjustment for case-mix. In patients with invasive breast cancer treated by breast conserving surgery, the mean volume of the resection specimen ranged from 381 to 541 ml between hospitals (p < 0.001). However, this was not accompanied by significant differences in the percentage of patients with positive resection margins (range 2.9-5.7 %, p = 0.34).

CONCLUSIONS

We observed significant interhospital variation in the management of women with screen-detected breast cancer. Quality assurance in screen-detected breast cancer may reduce these differences, but evolving breast cancer care and more personalised approaches should be accounted for.

Patterns of chemotherapy receipt among patients with hormone receptor-positive, HER2-negative breast cancer

BACKGROUND

Breast cancer chemotherapy utilization not only may differ by race and age, but also varies by genomic risk, tumor characteristics, and patient characteristics. Studies in demographically diverse populations with both clinical and genomic data are necessary to understand potential disparities by race and age.

METHODS

In the Carolina Breast Cancer Study Phase 3 (2008-2013), chemotherapy receipt (yes/no) and regimen type were assessed in association with age and race among hormone receptor (HR) positive and HER2-negative tumors (n = 1862). Odds ratios were estimated for the association between demographic factors and chemotherapy receipt.

RESULTS

Monotonic decreases in frequency of adjuvant chemotherapy receipt were observed over time during the study period, while neoadjuvant chemotherapy was stable. Younger age was associated with chemotherapy receipt (OR [95% CI]: 2.9 [2.4, 3.6]) and with anthracycline-based regimens (OR [95% CI]: 1.7 [1.3, 2.4]). Participants who had Medicaid (OR [95% CI]: 1.8 [1.3, 2.5]), lived in rural settings (OR [95% CI]: 1.4 [1.0, 2.0]), or were Black (OR [95% CI]: 1.5 [1.2, 1.8]) had slightly higher odds of chemotherapy, but these associations were non-significant with adjustment for stage and grade. Associations between younger age and chemotherapy receipt were strongest among women who did not receive genomic testing.

CONCLUSIONS

While race was not strongly associated with chemotherapy receipt, younger age remains a strong predictor of chemotherapy receipt, even with adjustment for clinical factors and among women who receive genomic testing.

The use of neoadjuvant systemic therapies in breast cancer in Australia and New Zealand: breast surgeons of Australia and New Zealand quality audit

BACKGROUND

Breast surgeons must maintain contemporary knowledge regarding appropriate referral for neoadjuvant chemotherapy (NACT) in breast cancer (BC) patients. To date, the greatest benefit is seen in stage II-III HER2-enriched and triple negative breast cancers (TNBC). This study is the first audit of use of NACT in Australia and New Zealand to stratify data by BC biological subtype.

METHODS

Prospective data from 116,745 patients between 2010 and 2019 was provided by the Breast Surgeons of Australia and New Zealand (BreastSurgANZ) Quality Audit (BQA) of Breast Cancer Care. Annual rates of NACT use were determined and change across time analysed with fractional regression. Data from 2018 to 2019 were combined and stratified by biological subtype (LumA, LumB HER2-neg, LumB HER2-pos, HER2 enriched, TNBC, Other basal-like), and age (<50, 51-74, and ≥75 years) and compared using negative binomial regression.

RESULTS

The use of NACT increased annually (OR 1.26, P < 0.001), and the use of additional adjuvant chemotherapy (ACT) decreased (OR 0.78, P < 0.001). A significantly greater use of NACT was noted in patients with TNBC and HER2+ BC, and in all patients aged <50 years compared with older ages (P < 0.001), regardless of biological subtype.

CONCLUSION

Increased uptake of NACT and decreased use of additional ACT is in keeping with progressive change in practice in response to contemporary evidence. Expansion of BQA data fields related to use of NACT, and detailed audit of NACT rates in Stage II-III TNBC and HER2 enriched BC will allow accurate determination of quality of practice in ANZ.

Breast cancer patients' experiences on their individual care pathway: A qualitative study

INTRODUCTION

Radiographers must be aware of the needs and expectations of women to be able to involve them in the decision making on their own care pathway. The purpose of the study is to describe experiences of women with breast cancer in their individual care pathway.

METHODS

Data was collected with qualitative open-ended online questionnaires via national breast cancer patient organizations in four countries. The subjects were women who had completed their breast cancer treatments at a maximum of six months before responding. Data was analysed using thematic analysis.

RESULTS

Women responding to the survey questionnaire (N = 14) reported 11 main meaningful events in their care pathways. According to respondents, being well informed about the treatment process, a smooth flow of the care process, being treated individually and having a properly organized follow-up were the most important aspects for the optimal breast cancer care pathway.

CONCLUSIONS

The subjects perceived their breast cancer care pathways somewhat differently from the way the pathways are usually described from the health care organizations' viewpoint. In different stages of their individual breast cancer care pathway, positive and less positive experiences of women were somewhat similar, yet contrasting.

IMPLICATIONS FOR PRACTICE

In addition to general forms of support, targeted interventions should be planned to improve the quality of breast cancer care specific to different stages of the treatment process. The findings can be used to promote education for radiographers and other cancer care staff, as well as to develop patient-centred breast cancer care.

Assessment of potential process quality indicators for systemic treatment of breast cancer in Belgium: a population-based study

BACKGROUND

Quality indicators (QIs) for the management of breast cancer (BC) have been published in Europe and internationally. In Belgium, a task force was established to select measurable process indicators of systemic treatment for BC, focusing on appropriateness of delivered care. The objective of this study was to evaluate the results of the selected QIs, both nationally and among individual centres.

PATIENTS AND METHODS

Female Belgian residents with unilateral primary invasive BC diagnosed between 2010 and 2014 were selected from the Belgian Cancer Registry database. The national number enabled linkage with the national reimbursement database, which contains information on all reimbursed medical procedures. A total of 12 process indicators were measured on the population and hospital level. Intercentre variability was assessed by median results and interquartile ranges.

RESULTS

A total of 48  872 patients were included in the study. QIs concerning specific BC subtypes only applied to patients diagnosed in 2014 (n = 9855). Clinical stage (cStage) I patients (n = 17 116) were staged with positron emission tomography/computed tomography. Among patients who were pT1aN0 human epidermal growth factor receptor 2 (HER2) positive (n = 47), 25.5% (n = 12) received adjuvant trastuzumab. Among patients with de novo metastatic luminal A/B-like HER2-negative BC (n = 295), 17.3% (n = 51) received upfront chemotherapy. (Neo)adjuvant chemotherapy was administered in 52.4% (n = 12 592) of operated women with cStage I-III, in 37.0% (n = 1270) of operated women with cStage I-III luminal A/B-like HER2-negative BC, and in 19.1% of operated women with cStage I luminal A/B-like HER2-negative BC. In the population of operated patients with cStage I-III, of those younger than 70 years that started adjuvant endocrine therapy (n = 3591), 81.7% (n = 2932) continued treatment for ≥4.5 years. Among patients in cStage I-III older than 70 years (n = 8544), 19.0% (n = 1622) received (neo)adjuvant chemotherapy, whereas among patients with cStage I-III luminal A/B-like HER2-negative BC (n = 1388), 13.0% (n = 181) received (neo)adjuvant chemotherapy. In patients with cStage I-II luminal A/B-like HER2-negative BC older than 70 years (n = 1477), 11.6% (n = 171) were not operated and received upfront endocrine treatment.

CONCLUSION

Well-considered QIs using population-based data can evaluate quality of care and expose disparities among treatment centres. Their use in daily practice should be implemented in all centres treating BC.

Do hospital type or caseload make a difference in chemotherapy treatment patterns for early breast cancer? Results from 104 German institutions, 2008-2017

BACKGROUND

Over the past decade, chemotherapy has been used more selectively in early breast cancer (EBC) due to better risk stratification. Neoadjuvant chemotherapy (NACT) has evolved to the primary treatment option. The type and size of hospitals is known to have a substantial influence on the kinds of treatment they provide, and therefore on patient outcomes (e.g. rates for pathological complete response, pCR), but it is not yet known how this has affected delivery of chemotherapy for EBC in Germany.

METHODS

This study analyzed chemotherapy use and pCR rates after NACT for EBC patients treated at 104 German institutions 2008-2017. Institutions were separated into associated hospital type (university hospital; teaching hospital; community hospital) and annual caseload (≤100; 101-250; >250 cases/year).

RESULTS

Overall, 124,084 patients were included, of whom 11.6% were treated at university hospitals, 63.1% at teaching hospitals, and 25.3% at community hospitals. In total, 46,274 (37.3%) received chemotherapy, of whom 44,765 had information available about systemic treatment and surgery. From 2008 to 2017, chemotherapy use declined from 48.3% to 36.4% for university hospitals, from 40.7% to 30.3% for teaching hospitals, and from 42.4% to 33.7% for community hospitals. Furthermore, the proportion of NACT increased the most in university hospitals (from 32.0% to 68.1%); whereas, the rate of pCR (defined as ypT0 ypN0) increased irrespective of institutional type. Analyses regarding annual caseload did not show any differences.

CONCLUSIONS

The results from this large, nationwide cohort reflect a more selective use of chemotherapy in Germany, irrespective of institutional type or case load.

New Frontiers for Fairer Breast Cancer Care in a Globalized World

In early 2020, the book "Breast cancer: Global Quality Care" was published by Oxford University Press. In the year since then, publications, interviews (by ecancer), presentations, webinars, and virtual congress have been organized to disseminate further the main message of the project: "A call for Fairer Breast Cancer Care for all Women in a Globalized World." Special attention is paid to increasing the "value-based healthcare" putting the patient in the center of the care pathway and sharing information on high-quality integrated breast cancer care. Specific recommendations are made considering the local resource facilities. The multidisciplinary breast conference is considered "the jewel in the crown" of the integrated practice unit, connecting multiple specializations and functions concerned with patients with breast cancer. Management and coordination of medical expertise, facilities, and their interfaces are highly recommended. The participation of two world-leading cancer research programs, the CONCORD program and Breast Health Global Initiative, in this project has been particularly important. The project is continuously under review with feedback from the faculty. The future plan is to arrive at an openaccess publication that is freely available to all interested people. This project is designed to help ease the burden and suffering of women with breast cancer across the globe.

The NeST (Neoadjuvant systemic therapy in breast cancer) study: National Practice Questionnaire of United Kingdom multi-disciplinary decision making

BACKGROUND

Neoadjuvant systemic therapy (NST) is increasingly used in the treatment of breast cancer, yet it is clear that there is significant geographical variation in its use in the UK. This study aimed to examine stated practice across UK breast units, in terms of indications for use, radiological monitoring, pathological reporting of treatment response, and post-treatment surgical management.

METHODS

Multidisciplinary teams (MDTs) from all UK breast units were invited to participate in the NeST study. A detailed questionnaire assessing current stated practice was distributed to all participating units in December 2017 and data collated securely usingREDCap. Descriptive statistics were calculated for each questionnaire item.

RESULTS

Thirty-nine MDTs from a diverse range of hospitals responded. All MDTs routinely offered neoadjuvant chemotherapy (NACT) to a median of 10% (range 5-60%) of patients. Neoadjuvant endocrine therapy (NET) was offered to a median of 4% (range 0-25%) of patients by 66% of MDTs. The principal indication given for use of neoadjuvant therapy was for surgical downstaging. There was no consensus on methods of radiological monitoring of response, and a wide variety of pathological reporting systems were used to assess tumour response. Twenty-five percent of centres reported resecting the original tumour footprint, irrespective of clinical/radiological response. Radiologically negative axillae at diagnosis routinely had post-NACT or post-NET sentinel lymph node biopsy (SLNB) in 73.0 and 84% of centres respectively, whereas 16% performed SLNB pre-NACT. Positive axillae at diagnosis would receive axillary node clearance at 60% of centres, regardless of response to NACT.

DISCUSSION

There is wide variation in the stated use of neoadjuvant systemic therapy across the UK, with general low usage of NET. Surgical downstaging remains the most common indication of the use of NAC, although not all centres leverage the benefits of NAC for de-escalating surgery to the breast and/or axilla. There is a need for agreed multidisciplinary guidance for optimising selection and management of patients for NST. These findings will be corroborated in phase II of the NeST study which is a national collaborative prospective audit of NST utilisation and clinical outcomes.

Effect of Case-Mix and Random Variation on Breast Cancer Care Quality Indicators and Their Rankability

OBJECTIVES

Hospital comparisons to improve quality of care require valid and reliable quality indicators. We aimed to test the validity and reliability of 6 breast cancer indicators by quantifying the influence of case-mix and random variation.

METHODS

The nationwide population-based database included 79 690 patients with breast cancer from 91 Dutch hospitals between 2011 and 2016. The indicator-scores calculated were: (1) irradical breast-conserving surgery (BCS) for invasive disease, (2) irradical BCS for ductal carcinoma-in-situ, (3) breast contour-preserving treatment, (4) magnetic resonance imaging (MRI) before neo-adjuvant chemotherapy, (5) radiotherapy for locally advanced disease, and (6) surgery within 5 weeks from diagnosis. Case-mix and random variation adjustments were performed by multivariable fixed and random effect logistic regression models. Rankability quantified the between-hospital variation, representing unexplained differences that might be the result of the level of quality of care, as low (<50%), moderate (50%-75%), or high (>75%).

RESULTS

All of the indicators showed between-hospital variation with wide (interquartile) ranges. Case-mix adjustment reduced variation in indicators 1 and 3 to 5. Random variation adjustment (further) reduced the variation for all indicators. Case-mix and random variation adjustments influenced the indicator-scores of individual hospitals and their ranking. Rankability was poor for indicator 1, 2, and 5, and moderate for 3, 4, and 6.

CONCLUSIONS

The 6 indicators lacked validity and/or reliability to a certain extent. Although measuring quality indicators may stimulate quality improvement in general, comparisons and judgments of individual hospital performance should be made with caution if based on indicators that have not been tested or adjusted for validity and reliability, especially in benchmarking.

Breast-contour preserving procedures for early-stage breast cancer: a population-based study of the trends, variation in practice and predictive characteristics in Denmark and the Netherlands

PURPOSE

Breast-contour preservation (BCP) is possible for most women treated for early-stage breast cancer. BCP can be defined as primary breast-conserving treatment (BCT), neoadjuvant chemotherapy (NAC) followed by BCT and immediate postmastectomy breast reconstruction (IBR). This study provides insight in current BCP strategies in Denmark and the Netherlands and aims to identify opportunities for improvement within both countries.

METHODS

A total of 92,881 patients with early-stage breast cancer who were operated in Denmark and the Netherlands between 2012 and 2017 were selected from the Danish Breast Cancer Group and the Dutch National Breast Cancer Audit databases. BCP procedures and predictive factors were analyzed within and between both countries.

RESULTS

BCP was achieved in 76.7% (n = 16,355) of the Danish and in 74.5% (n = 53,328) of the Dutch patients. While BCP rate did not change significantly over time in Denmark (p = 0.250), a significant increase in BCP rate from 69.5% in 2012 to 78.5% in 2017 (p < 0.001) was observed in the Netherlands. In both countries, variation in BCP rates between hospitals decreased over time. NAC followed by BCT and postmastectomy IBR was substantially more often used in the Netherlands compared to Denmark, specifically in patients younger than 50 years.

CONCLUSIONS

In more than 75% of all Danish and Dutch patients, surgically treated for early-stage breast cancer, the breast-contour was preserved. The different use of BCP strategies within Denmark and the Netherlands and the differences observed between hospitals in both countries emphasize the need for more (inter)national consensus on treatment modalities.

What are the appropriate thresholds for High Quality Performance Indicators for breast surgery in Australia and New Zealand?

Aim

To evaluate BreastSurgANZ members’ compliance at various threshold rates for 4 evaluable High-Quality Performance Indicators (HQPIs) introduced to improve patient care. To benchmark global best practice to assist in determining the eventual threshold standards.

Method

BreastSurgANZ Quality Audit data 2012–2016 & 2018 was used to determine rates of attainment through a range of thresholds for 4 HQPI’s. Rates were assessed for different volume surgeons and comparison made to international standards.

Results

1.3761 patients needing mastectomy for in situ disease, if the threshold rate for immediate breast reconstruction (IBR) was ≥ 40% then 30% of all members and 78% of very high-volume surgeons achieved that rate, which is comparable to international recommendations.

2.26,007 patients requiring mastectomy, if the threshold rate for IBR was ≥ 20% then 28% of all surgeons and 78% very high-volume surgeons met the standard. This is below most international recommendations.

3. For 31,698 invasive tumours ≤ 2 cm, if the threshold rate for breast conservation was ≥ 70% then 64% of all surgeons met the standard; 70% is comparable internationally.

4.1382 women =<50 years if the threshold rate for neoadjuvant chemotherapy was set at ≥ 15% then 36% of surgeons complied; 15% is below most international recommendations.

Conclusions

Even at these modest thresholds there are low levels of achievement by BreastSurgANZ members with high volume surgeons more likely to comply. These thresholds are either comparable or lower than globally accepted standards. Members should strive to meet, even exceed these important goals as they are a metric of improved patient care.

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High quality performance indicators are important for driving improvements in care.

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Our threshold standards for IBR for insitu disease are comparable internationally.

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Threshold indicators for invasive breast cancer are well below international standards.

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Members are achieving internationally comparable rates of breast conservation.

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Use of neoadjuvant chemotherapy for women <50yrs is below international standards.

The NeST (neoadjuvant systemic therapy in breast cancer) study - Protocol for a prospective multi-centre cohort study to assess the current utilization and short-term outcomes of neoadjuvant systemic therapies in breast cancer

INTRODUCTION

Neoadjuvant systemic therapy (NST) has several potential advantages in the treatment of breast cancer. However, there is currently considerable variation in NST use across the UK. The NeST study is a national, prospective, multicentre cohort study that will investigate current patterns of care with respect to NST in the UK.

METHODS AND ANALYSIS

Phase 1 - a national practice questionnaire (NPQ) to survey current practice.Phase 2 - a multi-centre prospective cohort study of breast cancer patients, undergoing NST.Women undergoing NST as their MDT recommended primary breast cancer treatment between December 2017 and May 2018 will be included. The breast surgery and oncological professional associations and the trainee research collaborative networks will encourage participation by all breast cancer centres.Patient demographics, radiological, oncological, surgical and pathological data will be collected, including complications and the need for further intervention/treatment. Data will be collated to establish current practice in the UK, regarding NST usage and variability of access and provision of these therapies. Prospective data on 600 patients from ~50 centres are anticipated.Trial registration: ISRCTN11160072.

ETHICS AND DISSEMINATION

Research ethics approval is not required for this study, as per the online Health Research Authority decision tool. The information obtained will provide valuable insights to help patients make informed decisions about their treatment. These data should establish current practice in the UK concerning NST, inform future service delivery as well as identifying further research questions.This protocol will be disseminated through the Mammary Fold Academic Research Collaborative (MFAC), the Reconstructive Surgery Trials Network and the Association of Breast Surgery. Participating units will have access to their own data and collective results will be presented at relevant conferences and published in appropriate peer-reviewed journals, as well as being made accessible to relevant patient groups.

Impact of Second Opinions in Breast Cancer Diagnostics and Treatment: A Retrospective Analysis

BACKGROUND

Breast cancer care is becoming increasingly complex, and patients with breast cancer are increasingly aware of the different treatment options, resulting in requests for second opinions (SOs). The current study investigates the impact of breast cancer SOs on final diagnosis and treatment in the Netherlands Cancer Institute (NCI) using a newly designed Breast Cancer Second Opinion (BCSO) classification system.

METHODS

Patients who visited the NCI for an SO between October 2015 and September 2016 were included. Demographics, diagnostics, and treatment proposals were compared between first and SO. Discrepancy was categorized using our BCSO classification system, categorizing SOs into (1) noncomparable, (2) identical, and (3) minor or (4) major discrepancy.

RESULTS

The majority of SOs (n = 591) were patient initiated (90.7%). A total of 121 patients underwent treatment prior to their SO, leaving 470 patients for assessment of discrepancies according to our BCSO classification system. More than 45% of these SOs resulted in at least one discrepancy, with comparable rates for physician- and patient-initiated SOs (42.5% vs. 45.6%, p = 0.708). Significantly more discrepancies were observed in patients with additional imaging (51.3% vs. 37.2%, p = 0.002) and biopsies (53.7% vs. 40.3%, p = 0.005). Almost 60% of all discrepancies were categorized as major (neoadjuvant systemic treatment instead of primary surgery, breast-conserving surgery instead of mastectomy, and proposing postmastectomy immediate breast reconstruction).

CONCLUSIONS

Our findings show substantial differences in diagnostic and treatment options in breast cancer patients visiting the Netherlands Cancer Institute for an SO, thereby emphasizing more consensus for the indications of these treatment modalities.

Breast-Contour-Preserving Procedure as a Multidisciplinary Parameter of Esthetic Outcome in Breast Cancer Treatment in The Netherlands

BACKGROUND

The rate of breast-conserving surgery (BCS) is used as an esthetic outcome parameter, while other treatments contribute also, such as neoadjuvant chemotherapy (NAC) enabling BCS or immediate breast reconstruction (IBR). This study explores these efforts to preserve the patient's breast contour.

PATIENTS AND METHODS

All patients who underwent surgery for invasive breast cancer in The Netherlands between January 2011 and December 2015 were selected from the Dutch national breast cancer audit (n = 61,309). The breast-contour-preserving procedures (BCPP) rate was defined as the rate of primary BCS, BCS after NAC, or mastectomy with IBR. BCPP rates were calculated and compared by year of diagnosis, age categories, and individual hospitals.

RESULTS

The rate of primary BCS remained stable (53%) while the BCPP rate increased from 63% in 2011 to 71% in 2015 due to an increase in patients receiving BCS after NAC and mastectomy with IBR. Primary BCS rates increased with age (from 17% in patients aged < 30 years to 63% in patients aged 60-69 years), while the proportion of patients undergoing mastectomy with IBR decreased from 44% in patients < 30 years to 1% in patients ≥ 70 years. The BCPP rate was similar for all age groups except for patients > 70 years. BCPP rates varied between the different hospitals in The Netherlands, ranging from 47 to 88%.

CONCLUSIONS

The chance of preserving the breast contour for patients with breast cancer has increased substantially over recent years. BCPP provides a comprehensive parameter of esthetic outcome of breast cancer surgery.

A real-life study on the implementation and effectiveness of exemestane plus everolimus per hospital type in patients with advanced breast cancer. A study of the Southeast Netherlands Advanced Breast Cancer registry

PURPOSE

We aimed to assess the implementation and effectiveness of exemestane plus everolimus treatment per hospital type in real-life, shortly after approval of everolimus.

METHODS

Advanced breast cancer patients treated with exemestane plus everolimus in 2012-2014 were included from the SONABRE registry. Progression-free survival (PFS) and a 12-week conditional PFS (post-hoc) were estimated by Kaplan-Meier method. The multivariable Cox proportional hazards model was performed by type of hospital and adjusted for patient, tumour and treatment characteristics.

RESULTS

We included 122 patients, comprising 48 patients treated in academic (N = 1), 56 in teaching (N = 4), and 18 in non-teaching (N = 2) hospitals. The median PFS was 6.3 months (95% Confidence Interval (CI) 4.0-8.6) overall, and 8.5 months (95% CI 7.7-9.3), 4.2 months (95% CI 2.0-6.3), and 5.5 months (95% CI 4.2-6.7) for the patients treated in academic, teaching and non-teaching hospitals, respectively. The adjusted Hazard Ratio (HR) for PFS-events was 1.5 (95% CI 1.0-2.2) and 1.0 (95% CI 0.5-1.9) respectively for patients treated at teaching and non-teaching hospitals versus the academic hospital. The adjusted HR for 12-week conditional PFS-events was not different between hospital types. In the first 12-week treatment period, treatment was discontinued due to early progression in one out of 48 patients in the academic versus nine out of 74 patients in the non-academic hospitals, confirmed by imaging in one and two patients, respectively.

CONCLUSIONS

In our study, the median PFS was borderline significantly different between hospital types, possibly the result of a different assessment approach in the first 12-week treatment period.

The association of socioeconomic status with receipt of neoadjuvant chemotherapy

BACKGROUND

There are advantages to neoadjuvant chemotherapy in operable breast cancer, particularly for those with higher-risk cancers, but little is known about factors that are associated with the use of neoadjuvant chemotherapy outside of clinical trials. We examined whether use of neoadjuvant chemotherapy instead of adjuvant chemotherapy varies by nonclinical factors such as patient socioeconomic status or rural residence.

METHODS

Women diagnosed with breast cancer in 2013-2014 at eight medical institutions were surveyed by mail regarding their experiences with breast cancer treatment, and this information was linked to hospital-based cancer registries. We examined the use of neoadjuvant chemotherapy among women with histologically confirmed invasive stage I-III breast cancer and used regression models to examine the association of socioeconomic status with chemotherapy timing. We also explored potential mechanisms for those differences.

RESULTS

Over 29% of the chemotherapy sample overall received neoadjuvant chemotherapy. Neoadjuvant receipt was lower for those with income < $100,000 (AOR 0.56, 95% CI 0.2-0.9) even with adjustment for other demographics, stage, and biomarker status, and findings for education and a variable for both lowest education and income < $100,000 were similar. Rural/urban residence was not associated with neoadjuvant receipt. Differences by income in perceptions of the importance of neoadjuvant chemotherapy advantages and disadvantages did not appear to explain the differences in use by income.

CONCLUSIONS

In a multicenter sample of breast cancer patients, lower income was strongly associated with less receipt of neoadjuvant chemotherapy. Since patients with lower socioeconomic status are more likely to present with later-stage disease, this pattern has the potential to contribute to breast cancer outcome disparities.

Hospital transfer after a breast cancer diagnosis: A population-based study in the Netherlands of the extent, predictive characteristics and its impact on time to treatment

PURPOSE

Patients may transfer of hospital for clinical reasons but this may delay time to treatment. The purpose of this study is to provide insight in the extent of hospital transfer in breast cancer care; which type of patients transfer and what is the impact on time to treatment.

METHODS

We included 41,413 breast cancer patients registered in the Netherlands Cancer Registry between 2014 and 2016. We investigated transfer of hospital between diagnosis and first treatment being surgery or neoadjuvant chemotherapy (NAC). Co-variate adjusted characteristics predictive for hospital transfer were determined. To adjust for possible treatment by indication bias we used propensity score matching (PSM). Time to treatment in patients with and without hospital transfer was compared.

RESULTS

Among 41,413 patients, 8.5% of all patients transferred to another hospital between diagnosis and first treatment; 4.9% before primary surgery and 24.8% before NAC. Especially young (aged <40 years) patients and those who underwent a mastectomy with immediate breast reconstruction (IBR) were more likely to transfer. The association of mastectomy with IBR with hospital transfer remained when using PSM. Hospital transfer after diagnosis significantly prolonged time to treatment; breast-conserving surgery by 5 days, mastectomy by 7 days, mastectomy with IBR by 9 days and NAC by 1 day.

CONCLUSIONS

While almost 5% of Dutch patients treated with primary surgery transfer hospital after diagnosis and up to 25% for patients treated with NAC, our findings suggest that especially those treated with primary surgery are at risk for additional treatment delay by hospital transfer.

Current decisions on neoadjuvant chemotherapy for early breast cancer: Experts' experiences in the Netherlands

PURPOSE

To evaluate the opinion of surgical and medical oncologists on neoadjuvant chemotherapy (NAC) for early breast cancer.

METHODS

Surgical and medical oncologists (N = 292) participating in breast cancer care in the Netherlands were invited for a 20-question survey on the influence of patient, disease, and management related factors on their decisions towards NAC.

RESULTS

A total of 138 surgical and medical oncologists from 64 out of 89 different Dutch hospitals completed the survey. NAC was recommended for locally advanced breast cancer (94%) and for downstaging to enable breast conserving surgery (BCS) (75%). Despite willingness to downstage, 64% of clinicians routinely recommended NAC when systemic therapy was indicated preoperatively. Reported reasons to refrain from NAC are comorbidities (68%), age >70 years (52%), and WHO-performance status ≥2 (93%). Opinions on NAC and surgical management were inconclusive; while 75% recommends NAC to enable BCS, some stated that BCS after NAC increases the risk of a non-radical resection (21%), surgical complications (9%) and recurrence of disease (5%).

CONCLUSION

This article emphasizes the need for more consensus among specialists on the indications for NAC in early BC patients. Unambiguous and evidence-based treatment information could improve doctor-patient communication, supporting the patient in chemotherapy timing decision-making.

Breast conserving therapy after neoadjuvant chemotherapy; data from the Dutch Breast Cancer Audit

INTRODUCTION

NAC has led to an increase in breast conserving surgery (BCS) worldwide. This study aims to analyse trends in the use of neoadjuvant chemotherapy (NAC) and the impact on surgical outcomes.

METHODS

We reviewed all records of cT1-4N0-3M0 breast cancer patients diagnosed between July 2011 and June 2016 who have been registered in the Dutch National Breast Cancer Audit (NBCA) (N = 57.177). The surgical outcomes of 'BCS after NAC' were compared with 'primary BCS', using a multivariable logistic regression model.

RESULTS

Between 2011 and 2016, the use of NAC increased from 9% to 18% and 'BCS after NAC' (N = 4170) increased from 43% to 57%. We observed an involved invasive margin rate (IMR) of 6,7% and a re-excision rate of 6,6%. As compared to 'primary BCS', the IMR of 'BCS after NAC' is higher for cT1 (12,3% versus 8,3%; p < 0.005), equal for cT2 (14% versus 14%; p = 0.046) and lower for cT3 breast cancer (28,3% versus 31%; p < 0.005). Prognostic factors associated with IMR for both 'primary BCS' as for 'BCS after NAC' are: lobular invasive breast cancer and a hormone receptor positive receptor status (all p < 0,005).

CONCLUSION

The use of NAC and the incidence of 'BCS after NAC' increased exponentially in time for all stages of invasive breast cancer in the Netherlands. This nationwide data confirms that 'BCS after NAC' compared to 'primary BCS' leads to equal surgical outcomes for cT2 and improved surgical outcomes for cT3 breast cancer. These promising results encourage current developments towards de-escalation of surgical treatment.

Patients' experiences with decisions on timing of chemotherapy for breast cancer

INTRODUCTION

Despite potential advantages, application of chemotherapy in the neo-adjuvant (NAC) instead of adjuvant (AC) setting for breast cancer (BC) patients varies among hospitals. The aim of this study was to gain insight in patients' experiences with decisions on the timing of chemotherapy for stage II and III BC.

MATERIALS AND METHODS

A 35-item online questionnaire was distributed among female patients (age>18) treated with either NAC or AC for clinical stage II/III invasive BC in 2013-2014 in the Netherlands. Outcome measures were the experienced exchange of information on the possible choice between both options and patients' involvement in the final decision on chemotherapy timing. Chemotherapy treatment experience was measured with the Cancer Therapy Satisfaction Questionnaire (CTSQ).

RESULTS

Of 805 invited patients, 49% responded (179 NAC, 215 AC). NAC-treated patients were younger and more often treated in teaching/academic hospitals and high-volume hospitals. Information on the possibility of NAC was given to a minority of AC-treated patients (AC, stage II:14%, stage III: 31%). Information on pros and cons of both NAC and AC was rated sufficient in about three fourth of respondents. Respondents not always felt having a choice in the timing of chemotherapy (stage II: 54% NAC vs 36% AC; stage III: 26% NAC, 54% AC).

CONCLUSION

The need to make a treatment decision on NAC was found to be made explicit in only a small number of adjuvant treated patients, in particular in BC stage II. Less than half of the respondents felt they had a real choice.