Population-level impact of adjuvant trastuzumab emtansine on the incidence of metastatic breast cancer: an epidemiological prediction model of women with HER2-positive early breast cancer and residual disease following neoadjuvant therapy

PURPOSE

Treating early-stage breast cancer (eBC) may delay or prevent subsequent metastatic breast cancer (mBC). In the phase 3 KATHERINE study, women with human epidermal growth factor receptor 2 (HER2)-positive eBC with residual disease following neoadjuvant therapy containing trastuzumab and a taxane experienced 50% reductions in disease recurrence or death when treated with adjuvant trastuzumab emtansine (T-DM1) vs adjuvant trastuzumab. We predicted the population-level impact of adjuvant T-DM1 on mBC occurrence in five European countries (EU5) and Canada from 2021-2030.

METHODS

An epidemiological prediction model using data from national cancer registries, observational studies, and clinical trials was developed. Assuming 80% population-level uptake of adjuvant treatment, KATHERINE data were extrapolated prospectively to model projections. Robustness was evaluated in alternative scenarios.

RESULTS

We projected an eligible population of 116,335 women in Canada and the EU5 who may be diagnosed with HER2-positive eBC and have residual disease following neoadjuvant therapy from 2021-2030. In EU5, the cumulative number of women projected to experience relapsed mBC over the 10-year study period was 36,009 vs 27,143 under adjuvant trastuzumab vs T-DM1, a difference of 8,866 women, equivalent to 25% fewer cases with the use of adjuvant T-DM1 in EU5 countries from 2021-2030. Findings were similar for Canada.

CONCLUSION

Our models predicted greater reductions in the occurrence of relapsed mBC with adjuvant T-DM1 vs trastuzumab in the indicated populations in EU5 and Canada. Introduction of T-DM1 has the potential to reduce population-level disease burden of HER2-positive mBC in the geographies studied.

A Qualitative Study on the Needs of Women with Metastatic Breast Cancer

Few studies have investigated the needs of patients with metastatic breast cancer (MBC), and none have been conducted in Italy. Three categories of needs have been identified from the literature: information, support, and practical resources. The present study aims to achieve an in-depth understanding of the patients' needs related to the MBC care pathway. In-depth interviews were conducted and analyzed by thematic analysis. The participants were 9 women with MBC (age range 36-74) who were enrolled at the Fondazione IRCCS Istituto Nazionalde dei tumori, in Milan. The analysis enabled us to identify four themes (which reflect the needs of the participants), each divided into numerous sub-themes: (1) the need for clinical recognition, (2) the need for more attention from healthcare professionals, (3) the need for more and better services to be available at the hospital, (4) the need for specific public health policies. Since the metastatic phase of breast cancer seems to elicit additional, specific needs and multi-level management, changes in attitudes and multidisciplinary practices should be tested in order to ascertain how these needs can be met.

How Can the EU Beating Cancer Plan Help in Tackling Lung Cancer, Colorectal Cancer, Breast Cancer and Melanoma?

Cancer is the second leading cause of mortality in EU countries, and the needs to tackle cancer are obvious. New scientific understanding, techniques and methodologies are opening up horizons for significant improvements in diagnosis and care. However, take-up is uneven, research needs and potential outstrip currently available resources, manifestly beneficial practices—such as population-level screening for lung cancer—are still not generalised, and the quality of life of patients and survivors is only beginning to be given attention it merits. This paper, mainly based on a series of multistakeholder expert workshops organised by the European Alliance for Personalised Medicine (EAPM), looks at some of those specifics in the interest of planning a way forward. Part of this exercise also involves taking account of the specific nature of Europe and its constituent countries, where the complexities of planning a way forward are redoubled by the wide variations in national and regional approaches to cancer, local epidemiology and the wide disparities in health systems. Despite all the differences between cancers and national and regional resources and approaches to cancer care, there is a common objective in pursuing broader and more equal access to the best available care for all European citizens.

Compliance with clinical guidelines for breast cancer management: A population-based study of quality-of-care indicators in France

Background

The European Society of Breast Cancer Specialists (EUSOMA), which aims to standardize the quality of patient care in Europe, has defined quality indicators (QIs) for breast cancer (BC) care to assess compliance to current care standards. These QIs are a useful tool to evaluate care organizations. Only population-based studies are able to assess health system performance in “real-life” situations. This population-based study aimed to describe compliance with several EUSOMA QIs overall and according to patient and organizational factors in France.

Methods

1 560 adult women with primary invasive non-metastatic BC diagnosed in 2012 were randomly selected among all incident BC from 16 French geographical areas covered by cancer registries. Twelve EUSOMA QIs were selected regarding diagnosis, treatment and staging.

Results

The minimum standard as proposed by EUSOMA was met for nine QIs related to pre-operative definitive diagnosis, multidisciplinary discussion and treatment (single surgery, breast conserving surgery (BCS) for small BC (<3cm), radiotherapy after BCS or mastectomy for regional BC (pN≥2a), hormonotherapy, adjuvant chemotherapy and trastuzumab). Low compliance was observed for sentinel lymph node biopsy (SLNB) and staging imaging. Adherence to guidelines was usually lower in older patients and in patients with comorbidities. Multidisciplinary discussion was positively related to adherence to guidelines for diagnosis, staging practices (SNLB, imaging) and systemic treatments. Compliance also varied by area of residence and by place of first treatment.

Conclusion

This study provides the first current, comprehensive overview of BC quality care at a population level in France. The guidelines were correctly applied in percentage satisfying the EUSOMA standards for the diagnosis and treatment of BC, although staging practices (SLNB, imaging) can be improved. These results highlight the need for continuous measurement of adherence to guidelines to improve BC care.

Female breast cancers (T1-2, N0, M0, HR+, HER2-) with an intermediate genetic-based recurrence risk: a real-world estimate in Italy

OBJECTIVES

Prognostic definition and treatment of breast cancer are supported by multigene testing. A recent trial (TAILORx) provided evidence against the use of adjuvant chemotherapy in early breast cancer (HR+ HER2-) with an intermediate result (11-25) in a multigene test (Oncotype DX). These results consequently fueled great discussion among oncologists. We aimed to estimate the burden of Italian incident breast cancer patients who, each year, may be involved in such decision-making.

METHODS

We used the data collected in the Romagna Cancer Registry to estimate the number of cases with the inclusion criteria of the TAILORx trial. Adjustments based on geographical variability in breast cancer incidence in Italy were applied to national estimates. Cases were estimated by Oncotype DX recurrence risk groups: ⩽10, 11-25, ⩾26. We also estimated the proportion of grade 1, 2, or 3 disease among breast cancer cases.

RESULTS

An overall 52,300 breast cancer cases were estimated to be diagnosed in Italy in 2018. Of these, 18,225 fit the TAILORx inclusion criteria: 3,025 were expected to have a low risk of recurrence (⩽10), 11,536 (63.3% of all cases) an intermediate risk (11-25), and 3,664 a high risk (⩾26). Among the group at intermediate risk, who may benefit from less aggressive therapy, 2,414 were estimated to have grade 1 disease, 7,618 grade 2, and 1,983 grade 3.

CONCLUSIONS

This article provides reliable estimates on the burden of Italian women with breast cancer who, once tested with multigene testing, could potentially have their treatment changed to hormone therapy only.

Metastatic breast cancers: Estimates for Italy

Purpose:

Breast is the leading site of cancer onset and death in Italy. Cases diagnosed in stage IV or that progress in metastatic phase represent a specific and challenging task for oncologists. Estimates on the burden of breast cancer (BC) in stage IV in Italy are not available.

Methods:

We applied mortality-incidence age-specific ratios measured in the United States in 2013 for BC in stage IV at diagnosis (de novo) or following a previous diagnosis in a localized stage (distant recurrence) to the age-specific BC deaths observed in Italy in 2014. The US mortality-prevalence age-specific ratios were used for estimating de novo and distant recurrence prevalent metastatic BC.

Results:

In 2014 in Italy, there were 12,330 deaths due to BC. We estimated that in the same year about 3400 BC were newly diagnosed in stage IV (7.1% of all the new cases); moreover, more than 10,000 other BC progressed to stage IV. In addition, in 2014, the overall number of BC in stage IV, whenever diagnosed, was about 37,100 (5.6% of all the estimated prevalent BC).

Conclusions:

These estimates quantify, for the first time in Italy, the burden of BC in stage IV, at diagnosis or during the clinical course, providing useful figures for clinicians and policy makers.

A Breast Cancer Clinical Registry in An Italian Comprehensive Cancer Center: An Instrument for Descriptive, Clinical, and Experimental Research

In clinical research, many potentially useful variables are available via the routine activity of cancer center-based clinical registries (CCCR). We present the experience of the breast cancer clinical registry at Fondazione IRCCS “Istituto Nazionale dei Tumori” to give an example of how a CCCR can be planned, implemented, and used. Five criteria were taken into consideration while planning our CCCR: (a) available clinical and administrative databases ought to be exploited to the maximum extent; (b) open source software should be used; (c) a Web-based interface must be designed; (d) CCCR data must be compatible with population-based cancer registry data; (e) CCCR must be an open system, able to be connected with other data repositories. The amount of work needed for the implementation of a CCCR is inversely linked with the amount of available coded data: the fewer data are available in the input databases as coded variables, the more work will be necessary, for information technology staff, text mining analysis, and registrars (for collecting data from clinical records). A cancer registry in a comprehensive cancer center can be used for several research aspects, such as estimate of the number of cases needed for clinical studies, assessment of biobank specimens with specific characteristics, evaluation of clinical practice and adhesion to clinical guidelines, comparative studies between clinical and population sets of patients, studies on cancer prognosis, and studies on cancer survivorship.

Research in cancer care disparities in countries with universal healthcare: mapping the field and its conceptual contours

The paper reviews published studies focused on disparities in receipt of cancer treatments and supportive care services in countries where cancer care is free at the point of access. We map these studies in terms of the equity stratifiers they examined, the countries in which they took place, and the care settings and cancer populations they investigated. Based on this map, we reflect on patterns of scholarly attention to equity and disparity in cancer care. We then consider conceptual challenges and opportunities in the field, including how treatment disparities are defined, how equity stratifiers are defined and conceptualized and how disparities are explained, with special attention to the challenge of psychosocial explanations.