The impact of young age on breast cancer outcome

Outcomes After Accelerated Partial Breast Irradiation in Women With Triple Negative Subtype and Other "High Risk" Variables Categorized as Cautionary in The ASTRO Guidelines

Purpose

To report a primary objective clinical outcome of ipsilateral breast recurrence following accelerated partial breast irradiation (APBI) in women with triple negative and other high risk breast cancer (as described in 2017 ASTRO guidelines) (i.e., age 40–49, size 2.1–3.0 cm, estrogen receptor negative and invasive lobular breast cancer). Secondary objectives of axillary and regional failure as well as overall survival are also reported.

Methods and Material

Patients from two clinical trials (NCT01185145, NCT01185132) were treated with 38.5 Gy IMRT or 3D-CRT APBI w/3.85 Gy fraction/BID fractionation for 10 fractions. Triple negative and other high risk patients (n=269) were compared to a total of 478 low risk patients which ASTRO defined as “suitable” for APBI. High risk patients, for the purpose of this study, were defined as those who possess one or more high risk criteria: triple negative (n=30), tumor size >2 cm <3 cm (n=50), HER 2+ (n=54), age range 40–50 years (n=120), ER- (n=43), and ILC histology (n=52).

Results

Median follow up was 4.0 years for all patients. No significant difference was found for this high-risk cohort at 5 years for ipsilateral breast, or regional recurrences. Axillary recurrence was significantly adversely impacted by triple negative and ER- statuses (p=0.01, p=0.04). There were significant correlations between triple negative type and axillary recurrence on multivariate analysis (p=0.03). Overall survival for all patients was unaffected by any of the high-risk categories.

Conclusion

The data from this study suggests that women possessing high risk features are at no more meaningful risk for recurrence than other patients considered to be acceptable for APBI treatment. However, the finding of axillary recurrence in patients with triple negative breast cancer does warrant a degree of caution in proceeding with accelerated partial breast irradiation technique in this patient group.

miRNA Expression Analysis: Cell Lines HCC1500 and HCC1937 as Models for Breast Cancer in Young Women and the miR-23a as a Poor Prognostic Biomarker

PURPOSE

The study of breast cancer nearly always involves patients close to menopause or older. Therefore, young patients are mostly underrepresented. Our aim in this study was to demonstrate biological differences in breast cancer of young people using as a model available cell lines derived from people with breast cancer younger than 35 years.

METHODS

Global miRNA expression was analyzed in breast cancer cells from young (HCC1500, HCC1937) and old patients (MCF-7, MDA-MB-231, HCC1806, and MDA-MB-468). In addition, it was compared with same type of results from patients.

RESULTS

We observed a differential profile for 155 miRNAs between young and older cell lines. We identified a set of 24 miRNA associated with aggressiveness that were regulating pluripotency of stem cell-related pathways. Combining the miRNA expression data from cell lines and breast cancer patients, 132 miRNAs were differently expressed between young and old samples, most of them previously found in cell lines. MiR-23a-downregulation was also associated with poor survival in young patients.

CONCLUSIONS

Our results suggest that HCC1500 and HCC1937 cell lines could be suitable cellular models for breast cancer affecting young women. The miR-23a-downregulation could have a potential role as a poor prognosis biomarker in this age group.

Gene expression in "young adult type" breast cancer: a retrospective analysis

Background: Young women with breast cancer experience inferior outcome and commonly manifest aggressive biological subtypes. Data is controversial regarding biological differences between breast tumors in young (diagnosed at <40 years of age) versus older women. We hypothesize there may be age-related expression differences in key genes for proliferation, invasion and metastasis within and across breast cancer subtypes, and that these differences correlate with outcome.

Methods: Using clinically-annotated gene expression data from 778 breast tumors from three public databases, we compared clinico-pathologic characteristics, mRNA expression of 17 selected genes, and outcome, as a function of age (< 40 years vs. ≥ 40 years).

Results: 14 of 17 genes were differentially expressed in tumors of young vs. older women, 4 of which persisted after correction for subtype and grade (p ≤0.05). BUB1, KRT5, and MYCN were overexpressed and CXCL2 underexpressed in young women. In multivariate analysis, overexpression of cytokeratin genes predicted inferior DFS only for young women. Overexpression of ANGPTL4 strongly predicted inferior DFS in basal but not HER2-enriched tumors in young women. Overexpression of cytokeratin genes and MYBL2 and low SNAI1 expression correlated with inferior DFS in HER2-enriched tumors in younger women. Kaplan-Meier analysis within the basal and HER2-enriched subgroups showed that overexpression of cytokeratin genes was associated with inferior DFS for young, but not older women.

Conclusions: This preliminary study reveals age- and subtype-related differences in expression of key breast cancer genes for proliferation, invasion and metastasis, which correlate with prognostic differences in young women and suggest targeted therapies.

Impact of age on cytotoxic-induced ovarian failure in breast cancer treated with adjuvant chemotherapy and triptorelin

AIM

This study analyzes our single-center, retrospective experience on 63 premenopausal breast cancer patients treated with monthly triptorelin and concomitant chemotherapy.

PATIENTS & METHODS

Concomitant chemotherapy and triptorelin were adopted as part of premature ovarian failure prevention strategy.

RESULTS

Age at diagnosis was the main factor influencing fertility preservation (p = 0.002). Compared with patients aged 41-45 years, the probability of menses resumption was almost threefold than for women aged 35-40 years, and significantly higher for women aged <35 years (hazard ratio: 9.0; p = 0.0001). The cumulative proportion among patients who resumed menses was 33.3% at 6 months, 75% at 12 months and 87.5% at 24 months. Seven patients attempted pregnancy, and five (71%) obtained healthy deliveries.

CONCLUSION

We observed an acceptable rate of fertility preservation. Age at diagnosis influences fertility preservation.

Tumor Invasiveness, Not Lymphangiogenesis, Is Correlated with Lymph Node Metastasis and Unfavorable Prognosis in Young Breast Cancer Patients (≤35 Years)

The morbidity rate of breast cancer is on the rise, and the age of onset appears to be trending toward a young age. Breast cancer in young women (BCYW) has a number of distinctive features that differ from breast cancer in middle-aged or elderly women (BCMEW). Lymphatic metastasis plays an important role in the spread of BCYW; however, the mechanisms of lymph node metastasis (LNM) in BCYW are not clear. This study aimed to investigate the mechanism of lymphatic metastasis in BCYW and to evaluate the relationships between lymphangiogenesis, the expression of matrix metalloproteinase 9 (MMP-9) and vascular endothelial growth factor C (VEGF-C) expression, clinicopathological characteristics, and prognosis. Using immunohistochemistry, MMP-9, VEGF-C and the level of lymphatic microvessel density (LMVD) were analyzed in 106 cases of breast invasive ductal carcinoma and 20 cases of breast proliferative lesions. Compared with BCMEW, BCYW had higher MMP-9 expression, higher LNM, and more adverse prognoses. In BCYW, high MMP-9 expression was positively correlated with LNM and impaired survival time. However, in BCMEW, MMP-9 expression was not correlated with LNM or survival time. In addition, high VEGF-C expression was positively correlated with a high level of LMVD in both BCYW and BCMEW. Nevertheless, a high level of LMVD was not correlated with LNM or survival time in the two groups. More importantly, univariate and multivariate survival analysis showed that MMP-9 expression and LNM were independent prognostic factors in BCYW. Our present study indicates that lymphangiogenesis induced by VEGF-C is augmented in breast cancer; however, a higher level of lymphangiogenesis has no significant impact on LNM or survival time. We suggest that tumor invasiveness, rather than lymphangiogenesis, plays an important role in LNM among BCYW. Moreover, MMP-9 and LNM were independent prognostic factors for BCYW.

The Effect of Young Age in Hormone Receptor Positive Breast Cancer

Background. Studies have shown that young breast cancer patients have more advanced disease and worse survival compared to older patients. Our objective was to study disease characteristics and survival in the subset of young women with hormone receptor positive (HR+) and HER2 negative (HER2−) cancer. Methods. We retrospectively analyzed HR+/HER2− breast cancer patients who underwent surgery at our institution between 2002 and 2010. We compared clinical characteristics, pathology, treatment, and recurrence-free survival between younger (≤40 years) and older (>40 years) patients. Results. Of 669 HR+/HER2− breast cancer cases, 54 (8.1%) patients were 40 years or younger. Younger patients had more luminal B subtype, high grade, poor differentiation, and increased lymphovascular invasion. Younger women were treated more often with mastectomy and adjuvant chemotherapy. Although the unadjusted recurrence-free survival at median 55-month follow-up was lower in younger women, adjusting for stage, there was no significant difference (90.7% versus 89.3%, p = 0.74) between groups. Conclusion. Younger patients with HR+/HER2− breast cancer had more advanced disease and more aggressive treatment than older patients. The unfavorable pathologic features suggest a biologically different tumor in young women. After adjusting for these factors, younger patients have a recurrence-free survival similar to older patients.

Magnetic resonance imaging characteristics of invasive breast cancer in women aged less than 35 years

BACKGROUND

With regard to clinicopathological findings and disease prognosis, breast cancer in young women is different from that in older women. However, few studies have investigated magnetic resonance imaging (MRI) characteristics of young age-onset breast cancer.

PURPOSE

To retrospectively evaluate and compare the MR images and clinicopathological characteristics of invasive breast cancer in young women (aged <35 years) with those of breast cancers in older premenopausal women (35-45 years).

MATERIAL AND METHODS

A total of 270 invasive breast cancers in 266 premenopausal women aged 45 years and younger who underwent preoperative breast MRI and curative surgery were identified between 2009 and 2013. The subjects were divided into a young group (< 35 years, n = 56) and an older group (35-45 years, n = 214). MRI features and clinicopathological data were compared between the two groups.

RESULTS

The young group had more positive axillary lymph nodes, higher histologic grade, negative estrogen receptor (ER), negative progesterone receptor (PR), and higher p53 and Ki-67 expression compared to the older group. Using MRI, the young group was more likely to display a round/oval or lobular mass shape, a smooth mass margin, and a high signal intensity on T2-weighted images when compared to the older group. In multivariate analysis, positive axillary nodal status (adjusted odds ratio [OR], 4.070; P = 0.002), higher expression of p53 (adjusted OR, 2.902; P = 0.038), lobular mass shape (adjusted OR, 4.979; P = 0.028), and smooth mass margin (adjusted OR, 5.123; P = 0.048) were independently associated with the young group.

CONCLUSION

MR morphologic features, including lobular mass shape and smooth mass margin, were independently associated with breast cancer in young women, in addition to positive axillary nodal status and higher p53 expression status.

Comparison between early and late onset breast cancer in Pakistani women undergoing breast conservative therapy: is there any difference?

BACKGROUND

Early onset breast cancer is associated with poor outcomes but variable results have been reported. It is a significant problem in Pakistani women but remains under reported. Breast conservation plays an important role in surgical management of this younger patient group. The objective of this study was to determine the outcome of breast conservative therapy in patients with early onset breast cancer in our population and compare it with their older counterparts.

MATERIALS AND METHODS

A review of patients with invasive breast cancer who underwent breast conservation surgery at Shaukat Khanum Cancer Hospital from 1997 to 2009 was performed. Patients were divided into two groups i.e. Group I age ≤ 40 and Group II >40 years. A total of 401 patients with breast cancer were identified in Group I and 405 patients in Group II. Demographics, histopathological findings and receptor status of the two groups were compared. The Chi square test was used for categorical variables. Outcome was assessed on basis of 10 year locoregional recurrence free survival (LRRFS), disease free survival (DFS) and overall survival (OS) . For survival analysis Kaplan Meier curves were used and significance was determined using the Log rank test. Cox regression was applied for multivariate analysis.

RESULTS

Median follow up was 4.31 (0.1-15.5) years. Median age at presentation was 34.6 years (17-40) and 51.9 years (41-82) for the two groups. Groups were significantly different from each other with respect to grade, receptor status, tumor stage and use of neoadjuvant therapy. No significant difference was present between the two groups for estimated 10 year LRRFS (86% vs 95%) (p=0.1), DFS (70% vs 70%) (p=0.5) and OS (75% vs 63%) (p=0.1). On multivariate analysis, tumor stage was an independent predictor of LRRFS, DFS and OS.

CONCLUSIONS

Early onset breast cancer is associated with a distinct biology but does not lead to poorer outcomes in our population.

Prospective observational study of breast cancer treatment outcomes for UK women aged 18-40 years at diagnosis: the POSH study

BACKGROUND

Breast cancer at a young age is associated with poor prognosis. The Prospective Study of Outcomes in Sporadic and Hereditary Breast Cancer (POSH) was designed to investigate factors affecting prognosis in this patient group.

METHODS

Between 2000 and 2008, 2956 patients aged 40 years or younger were recruited to a UK multicenter prospective observational cohort study (POSH). Details of tumor pathology, disease stage, treatment received, and outcome were recorded. Overall survival (OS) and distant disease-free interval (DDFI) were assessed using Kaplan-Meier curves. All statistical tests were two-sided.

RESULTS

Median age of patients was 36 years. Median tumor diameter was 22 mm, and 50% of patients had positive lymph nodes; 59% of tumors were grade 3, 33.7% were estrogen receptor (ER) negative, and 24% were human epidermal growth factor receptor 2 (HER2) positive. Five-year OS was higher for patients with ER-positive than ER-negative tumors (85.0%, 95% confidence interval [CI] = 83.2% to 86.7% vs 75.7%, 95% CI = 72.8% to 78.4%; P < .001), but by eight years, survival was almost equal. The eight-year OS of patients with ER-positive tumors was similar to that of patients with ER-negative tumors in both HER2-positive and HER2-negative subgroups. The flexible parametric survival model for OS shows that the risk of death increases steadily over time for patients with ER-positive tumors in contrast to patients with ER-negative tumors, where risk of death peaked at two years.

CONCLUSIONS

These results confirm the increased frequency of ER-negative tumors and early relapse in young patients and also demonstrate the equally poor longer-term outlook of young patients who have ER-positive tumors with HER2-negative or -positive disease.

Clinicopathologic characteristics at diagnosis and the survival of patients with medullary breast carcinoma in China: a comparison with infiltrating ductal carcinoma-not otherwise specified

BACKGROUND

Few studies have addressed the biological features of medullary breast carcinoma (MBC) in the context of clinical outcomes. We sought to compare the baseline demographics, standard pathologic factors and long-term clinical outcomes between MBC and infiltrating ductal carcinoma-not otherwise specified (IDC-NOS) using a large database.

METHODS

A total of 2,202 cases with pure IDC-NOS and 188 cases with typical MBC meeting the inclusion criteria were identified. The clinical and biological features, the overall survival (OS) and recurrence/metastasis-free survival (RFS) were compared for both groups.

RESULTS

There were a higher proportion of patients diagnosed prior to 40 years of age in the MBC group compared to the IDC-NOS group. MBC cases demonstrated less aggressive tumor features such as lower tumor stage, smaller tumor size and a lower proportion of nodal involvement than IDC-NOS; however, immunohistochemical staining revealed that MBC displayed the triple-negative phenotype more often than IDC-NOS cases (40.4% versus 26.2%; P <0.001). Although the clinical behavior of MBC was not commensurate with its pathologic features, women diagnosed with MBC had a lower frequency of recurrence/metastasis (P = 0.032) and death (P = 0.042) than those with IDC-NOS, and the 10-year OS and RFS were significantly higher for MBC (91% and 74%) compared to IDC-NOS (81% and 64%). Moreover, multivariate analysis revealed that TNM stage was a statistically significant factor for survival.

CONCLUSIONS

MBC in Chinese women demonstrated less aggressive behavior and better prognosis than IDC-NOS. This favorable outcome was maintained after 10 years.

Radiotherapy boost dose-escalation for invasive breast cancer after breast-conserving surgery: 2093 patients treated with a prospective margin-directed policy

PURPOSE

To investigate the outcome of invasive early breast cancer patients that underwent breast-conserving surgery and adjuvant radiotherapy (RT), treated with a prospective margin-directed institutional policy for RT boost dose, based on final margins status (FMS).

METHODS AND MATERIALS

A total of 2093 patients were treated between 2000 and 2008. 10 Gy boost was prescribed in case of FMS>5mm; 16 Gy boost with FMS between 2 and 5mm; 20 Gy boost in case of FMS<2mm or positive.

RESULTS

After a median follow up of 5.2 years, we recorded 41 local relapse (LR, 2%). Concerning LR free survival, age at diagnosis, nuclear grade, hormonal status, T-stage, adjuvant hormonal therapy and adjuvant chemotherapy emerged as significant parameters (p-values from log rank test <0.05). FMS, that directed the RT boost dose, did not have significant impact on LRFS (p=0.46). LR rates were 2.3% for FMS<2mm, 2.6% for 2-5mm FMS and 1.8% for FMS>5mm. At multivariate analysis, higher nuclear grade (p=0.045), triple negative subtype (p=0.036) and higher T-stage (p=0.02) resulted as the independent predictors of LR occurrence.

CONCLUSIONS

Our experience showed that a margin-directed policy of RT boost dose-escalation seems to reduce the negative impact of FMS on LR, but it is not able to overcome the unfavorable effect of higher nuclear grade, higher T stage and triple negative subtype.

Age at diagnosis and breast cancer survival in iran

Background. Tumour characteristics are the most important prognostic factors in breast cancer. Patient-related factors such as young age at diagnosis, obesity, and smoking behaviour may also modify disease outcome. Due to the absence of a unique definition for "young age breast cancer" and the resulting variation in disease management, findings on the association between young age and prognosis of breast cancer are controversial. Methods. This study included 1500 patients with a primary diagnosis of breast cancer in six Iranian hospitals from 5 provinces. We modelled the relative excess risk (RER) of breast cancer death to age at diagnosis and tumour characteristics. Results. Excess risks of death were observed for stage IV disease and poorly differentiated tumours: RER of 4.3 (95% CI: 1.05-17.65) and 3.4 (95% CI: 1.17-9.87), respectively. "Older" patients, particularly those aged 50 and over, presented more often with advanced and poorly differentiated tumours (P = 0.001). After adjustment for stage, histological grade, Her-2 expression, estrogen and progesterone receptors, and place of residency, breast cancer mortality was not significantly different across age groups. Conclusion. We conclude that there is no prognostic effect of age at diagnosis of breast cancer among breast cancer patients treated at cancer centres in different parts of Iran; young and relatively old women have similar risks of dying from breast cancer.

Improvement in breast cancer outcomes over time: are older women missing out?

PURPOSE

Women aged ≥ 75 years account for 40,000 breast cancers/yr and are the most rapidly growing demographic. Recent data demonstrated that breast cancer death rates in the US population are declining, but it is not known whether death rates have declined similarly for older and younger women. We examined the following two outcomes: the rate of breast cancer death in the general population and the risk of breast cancer death in newly diagnosed patients, and we compared change over time in these outcomes for older versus younger women.

METHODS

By using data from National Vital Statistics Reports that spanned from 1990 to 2007, the yearly change in the age-specific rate of breast cancer death was characterized with linear regression. With the use of the Surveillance, Epidemiology, and End Results nine-registry cohort that spanned from 1980 to 1997, the yearly change in age-specific risk of breast cancer death was characterized by using competing-risks regression adjusted for race and stage.

RESULTS

Relative to 1990, the rate of breast cancer death in the general population decreased by 2.5%/yr for women age 20 to 49 years, 2.1%/yr for women age 50 to 64 years, 2.0%/yr for women age 65 to 74 years, and 1.1%/yr for women age ≥ 75 years. From 1980 to 1997, the adjusted risk of breast cancer death in newly diagnosed patients decreased by 3.6%/yr for women age less than 75 years versus 1.3%/yr for women age ≥ 75 years (P < .001). Over this time interval, the 10-year absolute risk of breast cancer death decreased by 15.3% for women age 50 to 64 years (from 31.9% to 16.6%) but by only 7.5% (from 24.8% to 17.4%) for women age ≥ 75 years.

CONCLUSION

Breast cancer outcomes have preferentially improved in women age less than 75 years. Focused research is needed to improve outcomes in older women.

Younger age as a prognostic indicator in breast cancer: a cohort study

Background

The debate continues as to whether younger women who present with breast cancer have a more aggressive form of disease and a worse prognosis. The objectives of this study were to determine the incidence of breast cancer in women under 40 years old and to analyse the clinicopathological characteristics and outcome compared to an older patient cohort.

Methods

Data was acquired from a review of charts and the prospectively reviewed GUH Department of Surgery database. Included in the study were 276 women diagnosed with breast cancer under the age of forty and 2869 women over forty. For survival analysis each women less than 40 was matched with two women over forty for both disease stage and grade.

Results

The proportion of women diagnosed with breast cancer under the age of forty in our cohort was 8.8%. In comparison to their older counterparts, those under forty had a higher tumour grade (p = 0.044) and stage (p = 0.046), a lower incidence of lobular tumours (p < 0.001), higher estrogen receptor negativity (p < 0.001) and higher HER2 over-expression (p = 0.002); there was no statistical difference as regards tumour size (p = 0.477). There was no significant difference in overall survival (OS) for both groups; and factors like tumour size (p = 0.026), invasion (p = 0.026) and histological type (p = 0.027), PR (p = 0.031) and HER2 (p = 0.002) status and treatment received were independent predictors of OS

Conclusion

Breast cancer in younger women has distinct histopathological characteristics; however, this does not result in a reduced survival in this population.

Influence of a family history of breast and/or ovarian cancer on breast cancer outcomes

Various published studies have been inconclusive in attempting to relate a family history of breast and/or ovarian cancer (BOC) to the survival of breast cancer patients. The aim of the study was to investigate the association of a family history of BOC with tumor characteristics, treatment response and the difference between the prognosis of familial breast cancer (FBC) patients and sporadic breast cancer (SBC) patients. Data on 348 operable FBC patients and 345 SBC patients were retrospectively analyzed. The overall survival (OS) and recurrence/metastasis-free survival (RFS) were compared for both groups. FBC cases were diagnosed at a relatively younger age (51.1±10.4 vs. 53.7±11.0 years, P=0.054) and presented a lower T stage (P=0.000) than the SBC cases. Patients with a family history of BOC had a significantly greater risk of recurrence/metastasis (P= 0.04) and a non-significantly increased risk of death (P=0.06) compared to the SBC patients. In a multivariate analysis, family history of BOC was an independent predictive factor for both recurrence/metastasis rate (P=0.01, HR=0.012, 95% CI 0.02-0.57) and mortality (P=0.044, HR=0.43, 95% CI 0.19-0.98) in the hormone receptor-positive population. Our results found that women diagnosed with FBC had an early onset of disease in the population studied, and the poor outcome of patients with a family history of BOC associated with survival was restricted to the hormone receptor-positive population.