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Fonseca VC, Sidiropoulou Z. Geriatric Breast Cancer: Staging, Molecular Surrogates, and Treatment. A Review & Meta-analysis. Aging Dis 2023:AD.2023.1002. [PMID: 37962462 DOI: 10.14336/ad.2023.1002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023] Open
Abstract
Breast cancer (BC) is one of the most frequent cancers in females across the globe. Treatment recommendations for BC patients are primarily driven by patient age, staging and tumor molecular subtype. Thus, we updated the general overview of BC staging, molecular surrogates, and treatment choices for women >70 years based on a systematic study encompassing the years 2013-2023. A PRISMA guidelines and PICO framework were followed, and relevant research articles were searched using different data bases (Web of Sciences, PubMed, MEDLINE, and Scopus). Mixed Methods Appraisal Tool was used for studies quality assessment. The research articles that made it into the systematic review were compiled using qualitative criteria. In the meanwhile, heterogeneity was determined using meta-analysis with RevMan 5.4. We applied a random effects model with a 0.05 significance level. Overall, there were 4151 research articles, after screening only 17 articles with 39,906 patients were included. Conclusion: Elderly patients with breast cancer should be treated differently in an adapted way. The treatment should not be the same worldwide due to different health systems. Molecular surrogates are different in geriatric patients. Surgery is the best option for treatment in this subset of patients. We need to have therapeutic decision appointments for elderly patients with breast cancer. The guidelines and medical authority should be used in the best decision.
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Affiliation(s)
- Vasco C Fonseca
- Department of Oncology, Hospital Centre of West Lisbon, Portugal
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Haussmann J, Budach W, Corradini S, Krug D, Bölke E, Tamaskovics B, Jazmati D, Haussmann A, Matuschek C. Whole Breast Irradiation in Comparison to Endocrine Therapy in Early Stage Breast Cancer-A Direct and Network Meta-Analysis of Published Randomized Trials. Cancers (Basel) 2023; 15:4343. [PMID: 37686620 PMCID: PMC10487067 DOI: 10.3390/cancers15174343] [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: 06/30/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Multiple randomized trials have established adjuvant endocrine therapy (ET) and whole breast irradiation (WBI) as the standard approach after breast-conserving surgery (BCS) in early-stage breast cancer. The omission of WBI has been studied in multiple trials and resulted in reduced local control with maintained survival rates and has therefore been adapted as a treatment option in selected patients in several guidelines. Omitting ET instead of WBI might also be a valuable option as both treatments have distinctly different side effect profiles. However, the clinical outcomes of BCS + ET vs. BCS + WBI have not been formally analyzed. METHODS We performed a systematic literature review searching for randomized trials comparing BCS + ET vs. BCS + WBI in low-risk breast cancer patients with publication dates after 2000. We excluded trials using any form of chemotherapy, regional nodal radiation and mastectomy. The meta-analysis was performed using a two-step process. First, we extracted all available published event rates and the effect sizes for overall and breast-cancer-specific survival (OS, BCSS), local (LR) and regional recurrence, disease-free survival, distant metastases-free interval, contralateral breast cancer, second cancer other than breast cancer and mastectomy-free interval as investigated endpoints and compared them in a network meta-analysis. Second, the published individual patient data from the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) publications were used to allow a comparison of OS and BCSS. RESULTS We identified three studies, including a direct comparison of BCS + ET vs. BCS + WBI (n = 1059) and nine studies randomizing overall 7207 patients additionally to BCS only and BCS + WBI + ET resulting in a four-arm comparison. In the network analysis, LR was significantly lower in the BCS + WBI group in comparison with the BCS + ET group (HR = 0.62; CI-95%: 0.42-0.92; p = 0.019). We did not find any differences in OS (HR = 0.93; CI-95%: 0.53-1.62; p = 0.785) and BCSS (OR = 1.04; CI-95%: 0.45-2.41; p = 0.928). Further, we found a lower distant metastasis-free interval, a higher rate of contralateral breast cancer and a reduced mastectomy-free interval in the BCS + WBI-arm. Using the EBCTCG data, OS and BCSS were not significantly different between BCS + ET and BCS + WBI after 10 years (OS: OR = 0.85; CI-95%: 0.59-1.22; p = 0.369) (BCSS: OR = 0.72; CI-95%: 0.38-1.36; p = 0.305). CONCLUSION Evidence from direct and indirect comparison suggests that BCS + WBI might be an equivalent de-escalation strategy to BCS + ET in low-risk breast cancer. Adverse events and quality of life measures have to be further compared between these approaches.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University (LMU), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Alexander Haussmann
- Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
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Rogowski P, Schönecker S, Konnerth D, Schäfer A, Pazos M, Gaasch A, Niyazi M, Boelke E, Matuschek C, Haussmann J, Braun M, Pölcher M, Würstlein R, Harbeck N, Belka C, Corradini S. Adjuvant Therapy for Elderly Breast Cancer Patients after Breast-Conserving Surgery: Outcomes in Real World Practice. Cancers (Basel) 2023; 15:2334. [PMID: 37190263 PMCID: PMC10137115 DOI: 10.3390/cancers15082334] [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: 03/16/2023] [Revised: 04/14/2023] [Accepted: 04/15/2023] [Indexed: 05/17/2023] Open
Abstract
We aimed to evaluate the standard of care of adjuvant radiotherapy (RT) after breast-conserving surgery (BCS) in elderly female patients (≥65 years) treated outside of clinical trials and to identify potential factors related to the omission of RT and the interaction with endocrine therapy (ET). All women treated with BCS at two major breast centers between 1998 and 2014 were evaluated. Data were provided by the Tumor Registry Munich. Survival analyses were conducted using the Kaplan-Meier method. Prognostic factors were identified using multivariate Cox regression analysis. The median follow-up was 88.4 months. Adjuvant RT was performed in 82% (2599/3171) of patients. Irradiated patients were younger (70.9 vs. 76.5 years, p < 0.001) and were more likely to receive additional chemotherapy (p < 0.001) and ET (p = 0.014). Non-irradiated patients more often had non-invasive DCIS tumors (pTis: 20.3% vs. 6.8%, p < 0.001) and did not undergo axillary surgery (no axillary surgery: 50.5% vs. 9.5%, p < 0.001). Adjuvant RT was associated with improved locoregional tumor control after BCS in invasive tumors (10-year local recurrence-free survival (LRFS): 94.0% vs. 75.1%, p < 0.001, 10-year lymph node recurrence-free survival (LNRFS): 98.1% vs. 93.1%, p < 0.001). Multivariate analysis confirmed significant benefits for local control with postoperative RT. Furthermore, RT led to increased locoregional control even in patients who received ET (10-year LRFS 94.8% with ET + RT vs. 78.1% with ET alone, p < 0.001 and 10-year LNRFS: 98.2% vs. 95.0%, p = 0.003). Similarly, RT alone had significantly better locoregional control rates compared to ET alone (10-year LRFS 92.6% with RT alone vs. 78.1% with ET alone, p < 0.001 and 10-year LNRFS: 98.0% vs. 95.0%, p = 0.014). The present work confirms the efficacy of postoperative RT for breast carcinoma in elderly patients (≥65 years) treated in a modern clinical setting outside of clinical trials, even in patients who receive ET.
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Affiliation(s)
- Paul Rogowski
- Department of Radiation Oncology, University Hospital LMU, 81377 Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, University Hospital LMU, 81377 Munich, Germany
| | - Dinah Konnerth
- Department of Radiation Oncology, University Hospital LMU, 81377 Munich, Germany
| | - Annemarie Schäfer
- Department of Radiation Oncology, University Hospital LMU, 81377 Munich, Germany
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital LMU, 81377 Munich, Germany
| | - Aurélie Gaasch
- Department of Radiation Oncology, University Hospital LMU, 81377 Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital LMU, 81377 Munich, Germany
- German Cancer Consortium (DKTK), 81377 Munich, Germany
| | - Edwin Boelke
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany
| | - Jan Haussmann
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany
| | - Michael Braun
- Breast Centre, Red Cross Hospital, 80634 Munich, Germany
| | - Martin Pölcher
- Breast Centre, Red Cross Hospital, 80634 Munich, Germany
| | - Rachel Würstlein
- Breast Centre, Department of Obstetrics and Gynecology, CCC Munich LMU, University Hospital LMU, 81377 Munich, Germany
| | - Nadia Harbeck
- Breast Centre, Department of Obstetrics and Gynecology, CCC Munich LMU, University Hospital LMU, 81377 Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital LMU, 81377 Munich, Germany
- German Cancer Consortium (DKTK), 81377 Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU, 81377 Munich, Germany
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Mott NM, Markovitz NH, Wang T, Hughes TM, Pilewskie M, Jagsi R, Dossett LA. Avoiding Overtreatment of Women ≥70 With Early-Stage Breast Cancer: A Provider-Level Deimplementation Strategy. J Surg Res 2023; 284:124-130. [PMID: 36566589 DOI: 10.1016/j.jss.2022.11.072] [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: 09/17/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION National guidelines recommend against routine axillary staging with sentinel lymph node biopsy (SLNB) and adjuvant radiotherapy (RT) in women ≥70 y with early-stage, hormone receptor-positive, HER2-negative breast cancer and clinically negative axilla; however, these practices remain common. METHODS We conducted a prospective pilot study from August 2021 to 2022 using an intervention targeting breast surgeons and radiation oncologists in Michigan that aimed to reduce SLNB and RT in eligible patients. The intervention consisted of (1) a geriatric assessment, (2) an assessment of the patient's medical maximizing-minimizing preferences, and (3) a tailored script with counterpoints to reasons patients commonly seek SLNB or RT. At the end of the study period, participants completed a survey providing feedback with the primary outcomes being: acceptability, appropriateness, feasibility, and intention and motivation to use the materials based on validated measures. RESULTS Participants (n = 23) included 15 breast surgeons and 8 radiation oncologists. Collectively, the materials were used with 115 patients. Considering all materials holistically, acceptability, appropriateness, and feasibility of the intervention were high; participants also intended and were motivated to use the intervention. Scores across all measures were highest for the geriatric assessment and lowest for the tailored script. The major barriers to using the intervention were limited time and instances of disagreement on treatment recommendations among surgeons and radiation oncologists. CONCLUSIONS The omission of SLNB and adjuvant RT should be discussed in appropriately selected patients. A multifaceted provider-level deimplementation strategy may be an effective means for achieving this goal.
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Affiliation(s)
- Nicole M Mott
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Tasha M Hughes
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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McDuff SGR, Blitzblau RC. Optimizing Adjuvant Treatment Recommendations for Older Women with Biologically Favorable Breast Cancer: Short-Course Radiation or Long-Course Endocrine Therapy? Curr Oncol 2022; 30:392-400. [PMID: 36661681 PMCID: PMC9857309 DOI: 10.3390/curroncol30010032] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
Omission of radiotherapy among older women taking 5 years of adjuvant endocrine therapy following breast conserving surgery for early-stage, hormone sensitive breast cancers is well-studied. However, endocrine therapy toxicities are significant, and many women have difficulty tolerating endocrine therapy, particularly elderly patients with comorbidities. Omission of endocrine therapy among women receiving adjuvant radiation is less well-studied, but available randomized and non-randomized data suggest that this approach may confer equivalent local control and survival for select patients. Herein we review available randomized and non-randomized outcome data for women treated with radiation monotherapy and emphasize the need for future prospective, randomized studies of endocrine therapy omission.
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Affiliation(s)
- Susan G. R. McDuff
- Department of Radiation Oncology, Duke Cancer Center, Durham, NC 27710, USA
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Dhiwar PS, Matada GSP, Raghavendra NM, Ghara A, Singh E, Abbas N, Andhale GS, Shenoy GP, Sasmal P. Current updates on EGFR and HER2 tyrosine kinase inhibitors for the breast cancer. Med Chem Res 2022. [DOI: 10.1007/s00044-022-02934-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Accelerated Partial Breast Irradiation with Intraoperative Radiotherapy Is Effective in Luminal Breast Cancer Patients Aged 60 Years and Older. J Pers Med 2022; 12:jpm12071116. [PMID: 35887613 PMCID: PMC9322635 DOI: 10.3390/jpm12071116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/26/2022] [Accepted: 07/06/2022] [Indexed: 11/16/2022] Open
Abstract
Adjuvant whole breast irradiation (AWBI) improves local control and survival in breast cancer patients after breast-conserving surgery. Between 2010 and 2017, 823 patients ≥ 60 years with ER-positive, Her-2 negative, clinically N0 breast cancer underwent breast-conserving surgery (BCS) at the West Pomeranian Oncology Center. Intraoperative radiotherapy (IORT) with kV photons was applied to 199 (24.2%) patients according to the IORT protocol, and AWBI only was applied to 624 (75.8%). IORT patients in cases with lymph node metastasis, lobular type presence, extensive in situ components, lymphatic vessel invasion, or resection margin < 2 mm, additionally underwent AWBI. Median follow-up was 74 months. There were two (1%) breast relapses in the IORT protocol group and one (0.2%) in the AWBI-only group. In each group, one axillary lymph node relapse was diagnosed (0.5% and 0.2%, respectively). There were two local relapses in the IORT-only group, and they were treated further with BCS and AWBI. Although locoregional relapse-free survival differed between the AWBI-only and IORT protocol groups (98.5% vs. 99.7%, p = 0.048), the local control, distant metastasis-free survival, and breast cancer-specific survival were similar. IORT is a reasonable option to avoid AWBI in ER-positive, Her-2 negative, cN0 women with breast cancer aged ≥ 60 years.
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8
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Ali AA, Tawk R, Xiao H, Semykina A, Montero AJ, Moussa RK, Popoola O, Diaby V. Comparative cost-effectiveness of radiotherapy among older women with hormone receptor positive early-stage breast cancer. Expert Rev Pharmacoecon Outcomes Res 2022; 22:735-741. [PMID: 35189767 PMCID: PMC10791147 DOI: 10.1080/14737167.2022.2044309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 02/16/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The aim was to examine the real-world cost-effectiveness of breast-conserving surgery (BCS) plus hormonal therapy with radiotherapy, compared to hormonal therapy alone among women 66 and older with hormone receptor positive early-stage breast cancer in the United States (US). METHODS This study was conducted from a U.S. Centers for Medicare and Medicaid Services perspective and an eight-year time horizon. Both costs (2020 US$) and health utilities (quality-adjusted life years, QALYs) were obtained from retrospective studies using the SEER linked with Medicare and Medicare Health Outcomes Survey, respectively. The incremental cost-effectiveness ratio (ICER) of the addition of radiotherapy to hormonal therapy versus hormonal therapy alone after BCS was estimated by an unbiased doubly robust estimator. Sensitivity analyses were conducted through bootstrapping to estimate credible intervals. RESULTS The addition of radiotherapy to hormonal therapy after BCS yielded the highest clinical benefits (2.66 QALYs) and costs ($19,424.27) compared to its hormonal therapy alone after BCS (0.77 QALYS; $2,028.58). The ICER was estimated to be $9,174.94/QALY. Sensitivity analyses did not change the direction of the findings. CONCLUSIONS The results implicated that the combination of radiotherapy and hormonal therapy is cost-effective in the US.
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Affiliation(s)
- Askal Ayalew Ali
- Economic, Social & Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Florida A&m University, Tallahassee, FL, USA
| | - Rima Tawk
- Institute of Public Health, College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Florida A&m University, Tallahassee, FL, USA
| | - Hong Xiao
- Solid tumor, Bristol Myers Squibb, Lawrenceville, NJ USA
| | | | - Alberto J. Montero
- Breast Cancer Program, Uh Seidman Cancer Center, CWRU School of Medicine
| | - Richard K. Moussa
- Ecole Nationale Supérieure de Statistiques Et d’Economie Appliquée (ENSEA), Côte d’Ivoire, Abidjan, Côte d’Ivoire
| | - Olayiwola Popoola
- Social & Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Florida A&m University, Tallahassee, FL, USA
| | - Vakaramoko Diaby
- Pharmaceutical Outcomes & Policy (POP), College of Pharmacy, Hpnp 3337, University of Florida, Gainesville, FL, USA
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Experiences and Perceptions of Older Adults with Lower-Risk Hormone Receptor-Positive Breast Cancer about Adjuvant Radiotherapy and Endocrine Therapy: A Patient Survey. Curr Oncol 2021; 28:5215-5226. [PMID: 34940075 PMCID: PMC8700141 DOI: 10.3390/curroncol28060436] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 12/24/2022] Open
Abstract
Older patients with lower-risk hormone receptor-positive (HR+) breast cancer are frequently offered both radiotherapy (RT) and endocrine therapy (ET) after breast-conserving surgery (BCS). A survey was performed to assess older patients’ experiences and perceptions regarding RT and ET, and participation interest in de-escalation trials. Of the 130 patients approached, 102 eligible patients completed the survey (response rate 78%). The median age of respondents was 74 (interquartile range 71–76). Most participants (71%, 72/102) received both RT and ET. Patients felt the role of RT and ET, respectively, was to: reduce ipsilateral tumor recurrence (91%, 90/99 and 62%, 61/99) and improve survival (56%, 55/99 and 49%, 49/99). More patients had significant concerns regarding ET (66%, 65/99) than RT (39%, 37/95). When asked which treatment had the most negative effect on their quality of life, the results showed: ET (35%, 25/72), RT (14%, 10/72) or both (8%, 6/72). Participants would rather receive RT (57%, 41/72) than ET (43%, 31/72). Forty-four percent (44/100) of respondents were either, “not comfortable” or “not interested” in participating in potential de-escalation trials. Although most of the adjuvant therapy de-escalation trials evaluate the omission of RT, de-escalation studies of ET are warranted and patient centered.
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Joseph K, Wong J, Abraham A, Zebak J, Patel A, Jones Thachuthara A, Iqbal U, Pham TM, Menon A, Ghosh S, Warkentin H, Walker J, Jha N, Faruqi S, Salopek TG, Smylie M. Patterns and predictors of relapse in Merkel cell carcinoma: Results from a population-based study. Radiother Oncol 2021; 166:110-117. [PMID: 34838888 DOI: 10.1016/j.radonc.2021.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/02/2021] [Accepted: 11/17/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE Prospective data evaluating the role of adjuvant radiotherapy (RT) for Merkel Cell Carcinoma(MCC) is lacking. To better understand the efficacy of adjuvant RT, a population-based patterns of failure study was conducted. METHODS We identified MCC patients treated from 1988 to 2018.Primary outcome measures were recurrence-free survival (RFS), overall survival (OS) and MCC-specific survival (MCC-SS). Charlson Co-morbidity Index (CCI) was also calculated. RESULTS 217 patients with mean age 79 (range: 33-96) were analyzed. The median follow-up was 40 months. Treatments were: surgery(S) alone (n = 101, 45%) or S + RT(n = 116, 55%).Local recurrence (LR) was low in stage I (n = 6, 6.5%) with clear margin of ≥1 cm, negative sentinel lymph node biopsy (SLNB) without high-risk factors, irrespective of adjuvant RT. Tumor size ≥ 2 cm (HR:2.95; p = 0.024) and immunosuppression(HR:3.98; p = 0.001) were associated with high risk of nodal failure. Adjuvant RT was associated with significant reduction in regional failure (HR:0.36; p = 0.002). Distant metastases (DM) were infrequent in stage I (4/90) and stage II (4/34), compared to stage III (32/93). Adjuvant RT improvedRFS but did not influence MCC-SS and OS. CCI was a significant predictor of OS. CONCLUSIONS Adjuvant RT improvedRFS, withoutimpact on MCC-SS and OS. Co-morbidity rather than RT influenced OS. Adjuvant RT may be avoided instage I patients with negative SLNB and no associated high-risk factors. Prophylactic RNI could be considered in stage II with high risk features, inspite of negative SLNB. Stage III patients benefited from adjuvant RNI, but no impact on prevention of DM.
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Affiliation(s)
- Kurian Joseph
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Canada.
| | - Justina Wong
- School of Radiation Therapy, University of Alberta, Canada
| | - Aswin Abraham
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Canada
| | - Julia Zebak
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Canada
| | - Anushree Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Canada
| | | | - Umar Iqbal
- Cancer Research & Analytics, Alberta Health Services, Edmonton, Canada
| | - Truong-Minh Pham
- Cancer Research & Analytics, Alberta Health Services, Edmonton, Canada
| | - Anjali Menon
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Canada
| | - Sunita Ghosh
- Division of Medical Oncology, Department of Oncology, University of Alberta, & Cross Cancer Institute, Edmonton, Canada
| | - Heather Warkentin
- Department of Medical Physics, University of Alberta, & Cross Cancer Institute, Edmonton, Canada
| | - John Walker
- Division of Medical Oncology, Department of Oncology, University of Alberta, & Cross Cancer Institute, Edmonton, Canada
| | - Naresh Jha
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Canada
| | - Salman Faruqi
- Department of Radiation Oncology, Tom Baker Cancer Centre, University of Calgary, Canada
| | - Thomas G Salopek
- Division of Dermatology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Michael Smylie
- Division of Medical Oncology, Department of Oncology, University of Alberta, & Cross Cancer Institute, Edmonton, Canada
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Hannoun-Levi JM, Chamorey E, Boulahssass R, Polgar C, Strnad V. Endocrine therapy with accelerated Partial breast irradiati On or exclusive ultra-accelerated Partial breast irradiation for women aged ≥ 60 years with Early-stage breast cancer (EPOPE): The rationale for a GEC-ESTRO randomized phase III-controlled trial. Clin Transl Radiat Oncol 2021; 29:1-8. [PMID: 33997321 PMCID: PMC8102143 DOI: 10.1016/j.ctro.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 04/06/2021] [Accepted: 04/11/2021] [Indexed: 11/20/2022] Open
Abstract
Epidemiologic data confirm the increase of breast cancer incidence in the elderly. The risk of recurrence of breast cancer is basically low. De-escalation breast cancer adjuvant therapy is justified in selected elderly patients. Ultra-accelerated breast irradiation with endocrine therapy omission is under debate. Prospective randomized trial is warranted.
Purpose Breast cancer in the elderly has become a public health concern; there is a need to re-design its treatment with a view to de-escalation. Our paper sets out the rationale for a phase 3 randomized trial to evaluate less burdensome adjuvant procedures that remain effective and efficient. Materials and methods For low-risk breast cancer in the elderly, adjuvant treatment has been adjusted in order to make it more suitable and efficient. Hypofractionated radiation therapy based on accelerated or non-accelerated regimens as well as accelerated and ultra-accelerated partial breast irradiation (APBI) protocols were reviewed. Withdrawal of radiation (RT) or endocrine therapies (ET) from the adjuvant procedure were also investigated. Based on molecular and APBI classifications, inclusion criteria were discussed. Results Phase 3 randomized trials which compared standard vs. accelerated/non-accelerated hypofractionated regimens confirmed that the latter were non-inferior in terms of local control. Similarly, except for intraoperative-based techniques, APBI achieved non-inferior local control rates compared to whole breast irradiation for low-risk breast cancer. In phase 2 prospective trials using ultra APBI, encouraging results were observed regarding oncological outcome and toxicity profile. In phase 3 trials, adjuvant ET without RT significantly increased the rate of local relapse with no impact on overall survival while RT alone proved effective. Elderly patients aged 60 or more with low-risk, luminal A breast cancer were chosen as the target population in a phase 3 randomized trial comparing APBI + 5-year ET vs. uAPBI (16 Gy 1f) alone. Conclusion To investigate de-escalation adjuvant treatment for elderly breast cancer patients, we have defined a road map for testing more convenient strategies. This EPOPE phase 3 randomized trial is supported by the GEC-ESTRO breast cancer working group.
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Key Words
- ABS, American Brachytherapy Society
- APBI, Accelerated and partial breast irradiation
- ASTRO, American Society of Radiation Oncology
- BCS, Breast cancer surgery
- BCWG, Breast Cancer Working Group
- Brachytherapy
- Breast cancer in the elderly
- DCIS, Ductal carcinoma in situ
- DFS, Disease-free survival
- EPOPE, Endocrine therapy with accelerated Partial breast irradiatiOn or exclusive ultra-accelerated Partial breast irradiation for women aged ≥ 60 years with Early stage breast cancer
- EQD2, Equivalent Dose in 2Gy fractions
- ET, Endocrine therapy
- Endocrine therapy
- GEC-ESTRO, Groupe Européen de Curiethérapie/European Society for Therapeutic Radiation and Oncology
- HDB, High-dose rate Brachytherapy
- LCIS, Lobular carcinoma in situ
- MAPBI, Molecular and APBI GEC-ESTRO
- MIB, Multicatheter Interstitial Brachytherapy
- Oncogeriatric assessment
- QoL, Quality of Life
- RT, Radiotherapy
- Radiation therapy
- WBI, Whole breast irradiation
- uAPBI, ultra-Accelerated Partial Breast Irradiation
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Affiliation(s)
- Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Centre, University of Côte d'Azur, Nice, France
| | - Emmanuel Chamorey
- Department of Epidemiology and Biostatistics, Antoine Lacassagne Cancer Centre, University of Cote d'Azur, Nice, France
| | - Rabia Boulahssass
- Geriatric Unit. CHU de NICE, FHU ONCOAGE, University of Cote d'Azur, Nice, France
| | - Csaba Polgar
- Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Vratislav Strnad
- Department of Radiation Oncology, Erlangen University Hospital, Erlangen, Germany
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Ma SJ, Yu B, Oladeru OT, Bartl AJ, Farrugia M, Fekrmandi F, Singh AK. Evaluation of adjuvant radiation and endocrine therapy in elderly patients with early-stage breast cancer. Breast J 2021; 27:562-563. [PMID: 33720487 DOI: 10.1111/tbj.14228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Brian Yu
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | | | - Austin J Bartl
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, USA
| | - Mark Farrugia
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Fatemeh Fekrmandi
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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