Delayed adjuvant hormonal therapy and its impact on mortality in women with breast cancer

Outperforming Traditional Staging: A Novel Nomogram for HR-Positive Breast Cancer

Background

Hormone receptor-positive breast cancer (HR-positive BC), the most prevalent subtype, typically has a favorable prognosis. However, treatment decision-making and survival prediction remain challenging due to the limitations of traditional staging systems like AJCC. Improved prognostic tools are needed to enhance individualized risk stratification.

Materials and Methods

Clinical information from the Surveillance, Epidemiology, and End Results (SEER) database and the First Affiliated Hospital of Nanchang University were analyzed to evaluate outcomes across HR-positive BC subtypes. Patients were divided into training and validation cohorts. A prognostic nomogram was developed using factors identified by univariate and multivariate Cox regression analyses and evaluated through C-index, Receiver Operating Characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).

Results

The study included 156,378 patients (training) and 67,016 (validation) for breast cancer-specific survival (BCSS) and 165,047 (training) and 70,732 (validation) for overall survival (OS), along with 232 external validation cases. Multivariate Cox regression analysis revealed that the ER-positive/PR-negative (HR=2.317 (2.219-2.419)) and ER-negative/PR-positive (HR=3.498 (3.143-3.894)) subtypes had worse prognosis than ER-positive/PR-positive patients. The prognosis of ER-negative/PR-positive subtype (HR=1.511 (1.686-1.351)) was also worse than that of ER-positive/PR-negative subtype. A nomogram integrating age, race, tumor size, grade, histology, bone, brain, lung, and liver metastases, tumor stage, HER2, marital status, positive lymph node numbers, and radiation therapy. The nomogram had a good C-index values and area under curve values for predicting OS and BCSS in both the training and validation set. Moreover, the DCA revealed that the nomogram performed better than the AJCC (TNM) staging system in predicting the three- and five-year OS and BCSS in both the groups.

Conclusion

This study introduces and validates a novel prognostic nomogram for HR-positive BC, providing enhanced risk stratification, particularly in regions with limited access to comprehensive genetic testing. Further validation through multicenter clinical studies is recommended to confirm its clinical utility.

An Investigation of Travel Distance and Timeliness of Breast Cancer Treatment Among a Diverse Cohort in the United States

Travel to and from distant cancer treatment facilities can place a significant burden on cancer patients, particularly rural and minority survivors. Thus, the purpose of our investigation was to examine the association between patient travel distance and delays in types of treatment for breast cancer (surgery, radiation, chemotherapy, and hormonal therapy) and treatment delays. Using a novel linkage between the state cancer registry and administrative data from Medicaid and a private insurance plan, 2155 BC patients were successfully linked to create the cohort. ArcGIS was used to geocode all case residences and treatment facility addresses and calculate network distance between the residence and each facility. Logistic regression models were used to calculate the adjusted odds of being delayed versus timely by street distance. Odds of late surgery were increased by 1% (95% CI: 1.00, 1.01) for each one-mile increase from the patient's residence to the treatment facility. In race-stratified models, the odds of late treatment for Black patients increased by 3% per mile (95% CI 1.01, 1.06) for radiation. Increased travel distance appears to significantly increase treatment delays for surgical, radiation, and chemotherapeutic treatments for women with BC, especially among Black women.

Factors delaying non-metastatic breast cancer adjuvant therapy and impact on prognosis in a cohort of Brazilian women

OBJECTIVE

To identify factors associated with delays in beginning adjuvant therapy and prognosis impacts on non-metastatic breast cancer patients.

METHODS

This assessment comprised a prospective cohort study concerning breast cancer patients treated at a public oncology centre. A time interval of ≥60 days between surgery and the beginning of the first adjuvant treatment was categorised as a delay. Factors associated with delays were evaluated through logistic regression analysis and the prognosis effects were assessed by a Cox regression analysis.

RESULTS

The median time interval between surgery and the first adjuvant treatment for the 401 women included in this study was of 57.0 days (37.0-93.0). Independent factors associated with delays comprised not presenting an overexpression of the HER-2 protein, not having undergone neoadjuvant chemotherapy, and having undergone chemotherapy or other therapeutic modalities other than hormone therapy and chemotherapy as the first adjuvant treatment. Delays did not affect recurrence, distant metastasis, or death risks. Factors associated with recurrence and distant metastasis risks comprised a clinical staging ≥2B, having undergone neoadjuvant chemotherapy, presenting the luminal molecular subtype B and triple-negative tumours, and having children. Factors associated with death comprised triple-negative molecular tumours and neoadjuvant chemotherapy.

CONCLUSION

Delays in beginning adjuvant treatment did not affect the prognosis of non-metastatic breast cancer patients. Clinical and treatment-related factors, on the other hand, were associated with delays, and recurrence, distant metastasis, and death risks.

Association of Adjuvant Hormone Therapy Timing With Overall Survival Among Patients With Hormone Receptor-Positive Human Epidermal Growth Factor Receptor-2-Negative Early Breast Cancer Without Chemotherapy

Importance

Studies have shown that delayed initiation of surgery and adjuvant chemotherapy is associated with lower rates of breast cancer survival. However, it remains unclear whether delayed initiation of adjuvant hormone therapy (AHT) is associated with survival.

Objective

To assess the association of time to adjuvant hormone therapy (TTH) with breast cancer survival and evaluate the factors associated with AHT.

Design, Setting, and Participants

This cohort study examined data from the National Cancer Database from 2004 through 2014 to assess the association of TTH (stratified as ≤150 and >150 days) with cancer survival. All patients included were diagnosed with stage I to stage III hormone receptor-positive, human epidermal growth factor receptor-2 (ERBB2; formerly HER2)-negative invasive breast cancer and underwent AHT without chemotherapy. Data were analyzed from April 2019 to May 2020.

Exposures

AHT was administered at different time points following surgical procedures for breast cancer treatment.

Main Outcomes and Measures

An inverse probability of treatment weighting (IPTW) model was constructed to evaluate overall survival by adjusting for treatment facility, patient demographics, tumor characteristics, and treatment; multivariable logistic regression was conducted to assess factors associated with delayed treatment.

Results

A total of 144 103 patients (median [IQR] follow-up, 36.6 months [25.5-49.2 months]; mean [SD] age, 63.7 [11.6] years) were identified, which included 142 916 (99.2%) women, 11 574 (8.0%) Black patients, and 126 013 (87.4%) White patients. Of these, 134 873 patients (93.6%) had a TTH of 150 days or less and 9230 patients (6.4%) had a TTH longer than 150 days. The IPTW-based Cox model demonstrated that patients with delayed AHT (ie, a TTH past 150 days) were associated with decreased survival (hazard ratio [HR], 1.31; 95% CI, 1.26-1.35; P < .001) compared with those receiving the timely treatment (TTH ≤150 days). Several sensitivity analyses (including IPTW with stabilized weight [HR, 1.31; 95% CI, 1.19-1.45; P < .001], propensity score matching [HR, 1.41; 1.13-1.76; P = .002], and propensity score regression adjustment [HR, 1.29; 95% CI, 1.16-1.43; P < .001]) and exploratory subgroup analyses yielded similar trends. Factors associated with delayed AHT included Black racial identity (OR, 1.66; 95% CI, 1.55-1.77), nonprivate insurance (eg, no insurance: OR, 1.46; 95% CI, 1.26-1.70), living in large metropolitan or metropolitan areas (reference vs urban, less urban, or rural: OR, 0.82; 95% CI, 0.76-0.87), treatment in a community hospital (reference vs academic or research: OR, 0.91; 95% CI, 0.84-0.98), Charlson-Deyo Comorbidity Index score 2 or higher (OR, 1.17; 95% CI, 1.04-1.32), poor grade differentiation (OR, 1.42; 95% CI, 1.32-1.53), II and III pathological stage (stage III: OR, 3.13; 95% CI, 2.76-3.54), estrogen receptor-positive (ER+)/progesterone receptor-negative (PR-) or ER-/PR+ (OR, 1.22; 95% CI, 1.13-1.31), receiving breast conservation surgery (reference vs mastectomy: OR, 0.87; 95% CI, 0.79-0.94), and radiotherapy (reference vs no radiotherapy: OR, 0.56; 95% CI, 0.52-0.61).

Conclusions and Relevance

The delay of the initiation of AHT past 150 days was associated with diminished survival in hormone receptor-positive, ERBB2-negative patients with breast cancer who did not receive chemotherapy. Efforts should be made to address factors associated with delayed treatment to improve survival.