When May Adjuvant Radiotherapy be Avoided in Operable Breast Cancer?

A nomogram for predicting breast cancer specific survival in elderly patients with breast cancer: a SEER population-based analysis

BACKGROUND

The number of elderly patients diagnosed with breast cancer is increasing worldwide. However, treatment decisions for these patients are highly variable. Although researchers have identified the effects of surgery, radiotherapy, endocrine therapy, and chemotherapy in elderly patients with breast cancer, clinicians still struggle to make appropriate decisions for these patients.

METHODS

We identified 75,525 female breast cancer patients aged ≥ 70 years in the Surveillance, Epidemiology, and End Results (SEER) database treated between January 1, 2010, and December 31, 2016. The patients were further divided into training and testing cohorts. The cumulative occurrence of breast cancer-specific deaths (BCSDs) and other cause-specific deaths (OCSD) was calculated using the cumulative incidence function. In the univariate analysis, risk factors were screened using the Fine-Gray model. In the multivariate analysis for competing risks, the sub-distribution hazard ratio with a 95% confidence interval for each independent predictor associated with BCSD was calculated for the construction of nomograms. Based on the above analyses, a competing risk nomogram was constructed to predict the probability of BCSD in the 1st, 3rd, and 5th years after treatment. During validation, the concordance index (C-index) was selected to quantify the predictive ability of the competing risk model.

RESULTS

A total of 33,118 patients were included in this study, with 24,838 in the training group and 8,280 in the testing group. Age, race, marital status, cancer grade, tumor stage, node stage, estrogen receptor status, progesterone receptor status, human epidermal growth factor receptor--2 status, and treatment including surgery, radiation, and chemotherapy were used to establish a nomogram. The C-index of 0.852 (0.842-0.862) in the training cohort and 0.876 (0.868-0.892) in the testing cohort indicated satisfactory discriminative ability of the nomogram. Calibration plots showed favorable consistency between the nomogram predictions and actual observations in both the training and validation cohorts.

CONCLUSIONS

Our study identified independent predictors of BCSD in elderly patients with breast cancer. A prognostic nomogram was developed and validated to aid clinical decision-making.

External radiotherapy for breast cancer in the elderly

BACKGROUND

Breast cancer is the most common malignancy amongst elderly women and the main cause of mortality. A specific management for elderly woman is not clear because clinical trials are usually not customized for this subset of patients.

AIMS

The aim of this paper is to provide an overview of the available information on the main issues in the field of breast cancer radiotherapy in the elderly population.

MATERIALS AND METHODS

Authors discuss on different radiation treatments for breast cancer in the elderly, based on the data of the literature with a focus on new strategy: hypo-fractionation, accelerated partial breast irradiation, and the utility of a dose boost.

DISCUSSION

The treatment of breast cancer is not standardized in the elderly. The optimal management in this population often requires complex multidisciplinary supportive care due to multiple comorbidities to optimize their cancer care.

CONCLUSIONS

New options such as APBI or HyRT regimens should be taken into consideration and offered as a breach of duty to the elderly population. Furthermore, they should be extensively investigated through randomized clinical trials.

Outcomes in locally advanced rectal cancer with highly selective preoperative chemoradiotherapy

BACKGROUND

This study compared outcomes after surgery alone for stage II/ III rectal cancer in a tertiary cancer unit versus highly selective use of preoperative chemoradiotherapy (CRT).

METHODS

This was a single-centre retrospective cohort study of consecutive patients receiving potentially curative surgery for stage II and III primary rectal cancer. CRT was given only for magnetic resonance imaging-predicted circumferential resection margin (CRM) involvement and nodal disease (at least N2). Primary endpoints were CRM involvement and local recurrence rates. Secondary endpoints were systemic recurrence and overall survival. Data were analysed by log rank test, and univariable and multivariable analysis.

RESULTS

Between 2002 and 2012, 363 patients were treated for rectal cancer. After applying exclusion criteria, 266 patients with stage II/III mid or low rectal cancer were analysed. Of these, 103 received neoadjuvant CRT and 163 proceeded directly to surgery, seven of whom required postoperative radiotherapy; the latter patients were included in the neoadjuvant CRT group for analysis. There was a significant difference in local recurrence between the CRT and surgery-alone groups (6·5 versus 0 per cent at 5 years; P = 0·040), but not in CRM involvement (7·2 versus 5·1 per cent; P = 0·470), 5-year systemic recurrence (37·2 versus 43·0 per cent; P = 0·560) and overall survival (64·2 versus 64·6 per cent; P = 0·628) rates. Metastatic disease developed more frequently in low rectal cancers (odds ratio 0·14; P < 0·001), regardless of whether neoadjuvant treatment was delivered.

CONCLUSION

Locally advanced rectal cancer does not necessarily require neoadjuvant CRT.

Selective use of whole breast radiotherapy after breast conserving surgery for invasive breast cancer and DCIS

BACKGROUND

Radiotherapy following breast conservation is routine in the treatment of invasive breast cancer and is commonly used in ductal carcinoma in situ to decrease local recurrence. However, adjuvant breast radiotherapy has significant short and longer-term side effects and consumes substantial health care resources. We aimed to review the randomised controlled trials and attempted to identify clinico-pathological factors and molecular markers associated with the risk of local recurrence.

METHODS

A literature search using the Medline and Ovid databases between 1965 and 2011 was conducted using the terms 'breast conservation' and radiotherapy, and radiotherapy and DCIS. Only papers with randomised clinical trials published in English in adult were included. Only Level 2 evidence and above was included.

RESULTS

Three meta-analyses and 17 randomised controlled trials have been published in invasive disease and one meta-analysis and four randomised controlled trials for DCIS. Overall, adjuvant radiotherapy provides a 15.7% decrease in local recurrence and 3.8% decrease in 15-year risk of breast cancer death. The key clinico-pathological factors, which enable stratification into high, intermediate or low risk groups include age, oestrogen receptor positivity, use of tamoxifen and extent of surgery. Absolute reductions in 15-year risk of breast cancer death in these three prediction categories are 7.8%, 1.1%, and 0.1% respectively Adjuvant radiotherapy provides a 60% risk reduction in local recurrence in DCIS with no impact on distal metastases or overall survival. Size, pathological subtype and margins are major risk factors for local recurrence in DCIS.

CONCLUSIONS

Adjuvant radiotherapy consistently decreases local recurrence across all subtypes of invasive and in-situ disease. While it has a survival advantage in those with invasive disease, this is not seen with DCIS and is minimal in invasive disease where the risk of local recurrence is low. This group includes women over 70 with node negative, ER positive tumours<2 cm.

Do all patients require radiotherapy after breast-conserving surgery?

Radiotherapy following breast conservation is routine in the treatment of breast cancer. This creates a large demand for radiotherapy services with implicit cost effects and potential morbidity to patients. Radiotherapy is administered to decrease local recurrence, but is radiotherapy required for all breast cancers? A literature search using the Medline and Ovid databases was conducted between 1965 and 2010 using the terms ‘role of radiotherapy’, ‘early breast cancer’, and omission of radiotherapy’. Papers with clinical trials published in English in adult humans were included. Fourteen randomized controlled trials were included. Local recurrence rates range from 0.8–35% in patients in whom radiotherapy was omitted. Low risk characteristics include older age, small tumor size, no lymphovascular invasion and low to moderate grade. At present, there is no clearly defined low risk group of patients in whom radiotherapy can be omitted.

Nodal Ratios in Node-Positive Breast Cancer—Long-Term Study to Clarify Discrepancy of Role of Supraclavicular and Axillary Regional Radiotherapy

PURPOSE

To study the absolute number of involved nodes/the number of nodes examined or the nodal ratio (NR) in breast cancer. The primary study endpoint was to evaluate the role of supraclavicular and axillary radiotherapy (SART) according to the NR.

METHODS AND MATERIALS

From the Saskatchewan provincial registry of 1981-1995, the charts of 5,996 consecutive patients were retrieved to collect detailed prognostic factors. Among these patients, 1,985 were node positive. Because the NRs are more reliable the greater the number of nodes examined, we analyzed 1,255 patients with > or =10 nodes examined. Of these 1,255 patients, 667, 389, and 199 were categorized into three NR groups--low (< or =25%), medium (>25% to < or =75%), and high (>75%) nodal involvement, respectively.

RESULTS

The NR correlated significantly with the primary tumor size (< or =2 cm, >2 to < or =5 cm, and >5 cm; p = 2.2 x 10(-16)), clinical stage group (p = 5.5 x 10(-16)), pathologic stage group (p < 2.2 x 10(-16)), and the risk of any first recurrence (p = 5.0 x 10(-15)) using chi-square tests. For a low NR, the 10-year overall survival rate with and without SART was 57% and 58% (p = 0.18), and the cause-specific survival rate was 68% and 71% (p = 0.32), respectively. For a medium NR, the 10-year overall survival rate with and without SART was 48% and 34% (p = 0.007), and the cause-specific survival rate was 57% and 43% (p = 0.002), respectively. For a high NR, the 10-year overall survival rate with and without SART was 19% and 10% (p = 0.005), and the cause-specific survival rate was 26% and 14% (p = 0.005), respectively.

CONCLUSION

This is the first study demonstrating that for patients with > or =10 nodes examined, SART significantly improved the survival for the median and high NR groups but not for the low NR group.

Impact of Radiotherapy on Breast Reconstruction

Breast reconstruction in the face of radiotherapy poses a unique set of challenges to the plastic surgeon and thus alters the algorithm of the reconstruction. The impact of radiation changes on alloplastic and autologous breast reconstruction is unpredictable. This article reviews the pathophysiology of radiation changes and the alterations to the reconstructive process.