1
|
Zhao B, Tsai C, Hunt KK, Blair SL. Adherence to surgical and oncologic standards improves survival in breast cancer patients. J Surg Oncol 2019; 120:148-159. [PMID: 31172534 DOI: 10.1002/jso.25506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/27/2019] [Accepted: 05/03/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Adherence to evidence-based standards can lead to improved outcomes for patients with breast cancer. However, adherence rates to standards and their effects on patient outcomes are unknown. OBJECTIVES To examine adherence rates to standards compiled by the American College of Surgeons Clinical Research Program and its effects on patient outcomes. METHODS Using the National Cancer Database (2004-2015), we identified cohorts of breast cancer patients: clinical T1N0M0 under age of 70 (cT1), clinical T2N0M0 or T3N0M0 (cT2/3), and clinical M0 and pathologic N2 or N3 (pN2/3). Standards included negative margins, any adjuvant therapy, and two or more lymph nodes (LNs) examined (for cT1 or cT2/3 patients) or more than 10 LNs examined (for pN2/3 patients). We performed Kaplan-Meier and Cox proportional hazards analysis. RESULTS We identified 318 853 (65.0%) cT1, 164 593 (67.3%) cT2/3, and 77 626 (67.7%) pN2/3 patients who met the standards. More than 90% of patients had negative margins and adjuvant therapy, but less than 80% met LN standards. The median overall survival (OS) was significantly longer for patients who met the standards. Individual components of the standards were predictors of improved OS. CONCLUSIONS One-third of patients did not meet the evidence-based standards in their treatment for breast cancer. Efforts to improve the knowledge of and adherence to these standards should be emphasized.
Collapse
Affiliation(s)
- Beiqun Zhao
- Department of Surgery, University of California, San Diego, California
| | - Catherine Tsai
- Department of Surgery, University of California, San Diego, California
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Sarah L Blair
- Department of Surgery, University of California, San Diego, California
| |
Collapse
|
2
|
Chapman JAW, Liu S, Leung S, Nielsen TO. Competing Risks of Mortality by PAM50 Intrinsic Subtype of British Columbia Tamoxifen-Treated Cohort of Postmenopausal Patients With Breast Cancer. Clin Breast Cancer 2017; 17:e215-e224. [DOI: 10.1016/j.clbc.2017.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/01/2016] [Accepted: 01/07/2017] [Indexed: 10/20/2022]
|
3
|
Cossetti RJD, Tyldesley SK, Speers CH, Zheng Y, Gelmon KA. Comparison of breast cancer recurrence and outcome patterns between patients treated from 1986 to 1992 and from 2004 to 2008. J Clin Oncol 2014; 33:65-73. [PMID: 25422485 DOI: 10.1200/jco.2014.57.2461] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE To determine whether the patterns of relapse according to estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) status changed in the contemporary era. PATIENTS AND METHODS Female patients referred to the British Columbia Cancer Agency with biopsy-proven stage I to III breast cancer (BC), diagnosed between 1986 and 1992 (cohort 1 [C1]) and between mid-2004 and 2008 (cohort 2 [C2]), and with known ER and HER2 status were eligible. Data were prospectively collected. C2 patients were matched to C1 patients for stage, grade, and ER and HER2 status. The primary end point was hazard rate of relapse (HRR) for BC by study cohort according to biomarker status. Secondary outcomes included HRR according to stage, grade, and age and hazard rate of death (HRD). RESULTS After matching, 7,178 patients were included (3,589 patients in each cohort). BC subtype distribution was as following ER positive/HER2 negative, 70.8%; ER positive/HER2 positive, 6.9%; ER negative/HER2 positive, 6.6%; and ER negative/HER2 negative, 15.8%. For the overall population, the HRR approximately halved in all yearly intervals to year 9 in C2 compared with C1. Differences in HRR between cohorts were greater in the initial five intervals for HER2-positive and ER-negative/HER2-negative BC. The HRR decreased in C2 compared with C1 for all disease stages and grades. The HRD in C2 also decreased compared with C1, although to a lesser extent. CONCLUSION Although the pattern of relapse remains similar, there has been a significant improvement in BC relapse-free survival. Outcomes have improved for all BC subtypes, especially HER2-positive and ER-negative/HER2-negative BC, with the early spike in disease recurrence markedly decreased. These contemporary hazard rates are important for treatment decisions, patient discussions, and planning clinical trials of early BC.
Collapse
Affiliation(s)
| | - Scott K Tyldesley
- All authors: Vancouver Cancer Centre, Vancouver, British Columbia, Canada
| | - Caroline H Speers
- All authors: Vancouver Cancer Centre, Vancouver, British Columbia, Canada
| | - Yvonne Zheng
- All authors: Vancouver Cancer Centre, Vancouver, British Columbia, Canada
| | - Karen A Gelmon
- All authors: Vancouver Cancer Centre, Vancouver, British Columbia, Canada.
| |
Collapse
|
4
|
Hanna WM, Barnes PJ, Chang MC, Gilks CB, Magliocco AM, Rees H, Quenneville L, Robertson SJ, SenGupta SK, Nofech-Mozes S. Human epidermal growth factor receptor 2 testing in primary breast cancer in the era of standardized testing: a Canadian prospective study. J Clin Oncol 2014; 32:3967-73. [PMID: 25385731 DOI: 10.1200/jco.2014.55.6092] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Therapies that target overexpression of human epidermal growth factor receptor 2 (HER2) rely on accurate and timely assessment of all patients with new diagnoses. This study examines HER2 testing of primary breast cancer tissue when performed with immunohistochemistry (IHC) and additional in situ hybridization (ISH) for negative cases (IHC 0/1+). The analysis focuses on the rate of false-negative HER2 tests, defined as IHC 0/1+ with an ISH ratio ≥ 2.0, in eight pathology centers across Canada. PATIENTS AND METHODS Whole sections of surgical resections or tissue microarrays (TMAs) from invasive breast carcinoma tissue were tested by both IHC and ISH using standardized local methods. Samples were scored by the local breast pathologist, and consecutive HER2-negative IHC results (IHC 0/1+) were compared with the corresponding fluorescence or silver ISH result. RESULTS Overall, 711 surgical excisions of primary breast cancer were analyzed by IHC and ISH; HER2 and chromosome 17 centromere (CEP17) counts were available in all cases. The overall rate of false-negative samples was 0.84% (six of 711 samples). Interpretable IHC and ISH scores were available in 1,212 cases from TMAs, and the overall rate of false-negative cases was 1.6% (16 of 978 cases). CONCLUSION Our observation confirms that IHC is an adequate test to predict negative HER2 status in primary breast cancer in surgical excision specimens, even when different antibodies and IHC platforms are used. The study supports the American Society of Clinical Oncology/College of American Pathologists and Canadian testing algorithms of using IHC followed by ISH for equivocal cases.
Collapse
Affiliation(s)
- Wedad M Hanna
- Wedad M. Hanna and Sharon Nofech-Mozes, Sunnybrook Health Sciences Centre, University of Toronto; Wedad M. Hanna, Martin C. Chang, and Sharon Nofech-Mozes, University of Toronto; Martin C. Chang, Mount Sinai Hospital, Toronto; Susan J. Robertson, Ottawa General Hospital and University of Ottawa, Ottawa; Sandip K. SenGupta, Kingston General Hospital and Queen's University, Kingston, Ontario; Penny J. Barnes, Capital Health District Authority and Dalhousie University, Halifax, Nova Scotia; C. Blake Gilks, Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia; Henrike Rees and Louise Quenneville, Saskatoon City Hospital and University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and Anthony M. Magliocco, Esoteric Laboratory Services, Moffitt Cancer Center, Tampa, FL.
| | - Penny J Barnes
- Wedad M. Hanna and Sharon Nofech-Mozes, Sunnybrook Health Sciences Centre, University of Toronto; Wedad M. Hanna, Martin C. Chang, and Sharon Nofech-Mozes, University of Toronto; Martin C. Chang, Mount Sinai Hospital, Toronto; Susan J. Robertson, Ottawa General Hospital and University of Ottawa, Ottawa; Sandip K. SenGupta, Kingston General Hospital and Queen's University, Kingston, Ontario; Penny J. Barnes, Capital Health District Authority and Dalhousie University, Halifax, Nova Scotia; C. Blake Gilks, Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia; Henrike Rees and Louise Quenneville, Saskatoon City Hospital and University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and Anthony M. Magliocco, Esoteric Laboratory Services, Moffitt Cancer Center, Tampa, FL
| | - Martin C Chang
- Wedad M. Hanna and Sharon Nofech-Mozes, Sunnybrook Health Sciences Centre, University of Toronto; Wedad M. Hanna, Martin C. Chang, and Sharon Nofech-Mozes, University of Toronto; Martin C. Chang, Mount Sinai Hospital, Toronto; Susan J. Robertson, Ottawa General Hospital and University of Ottawa, Ottawa; Sandip K. SenGupta, Kingston General Hospital and Queen's University, Kingston, Ontario; Penny J. Barnes, Capital Health District Authority and Dalhousie University, Halifax, Nova Scotia; C. Blake Gilks, Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia; Henrike Rees and Louise Quenneville, Saskatoon City Hospital and University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and Anthony M. Magliocco, Esoteric Laboratory Services, Moffitt Cancer Center, Tampa, FL
| | - C Blake Gilks
- Wedad M. Hanna and Sharon Nofech-Mozes, Sunnybrook Health Sciences Centre, University of Toronto; Wedad M. Hanna, Martin C. Chang, and Sharon Nofech-Mozes, University of Toronto; Martin C. Chang, Mount Sinai Hospital, Toronto; Susan J. Robertson, Ottawa General Hospital and University of Ottawa, Ottawa; Sandip K. SenGupta, Kingston General Hospital and Queen's University, Kingston, Ontario; Penny J. Barnes, Capital Health District Authority and Dalhousie University, Halifax, Nova Scotia; C. Blake Gilks, Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia; Henrike Rees and Louise Quenneville, Saskatoon City Hospital and University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and Anthony M. Magliocco, Esoteric Laboratory Services, Moffitt Cancer Center, Tampa, FL
| | - Anthony M Magliocco
- Wedad M. Hanna and Sharon Nofech-Mozes, Sunnybrook Health Sciences Centre, University of Toronto; Wedad M. Hanna, Martin C. Chang, and Sharon Nofech-Mozes, University of Toronto; Martin C. Chang, Mount Sinai Hospital, Toronto; Susan J. Robertson, Ottawa General Hospital and University of Ottawa, Ottawa; Sandip K. SenGupta, Kingston General Hospital and Queen's University, Kingston, Ontario; Penny J. Barnes, Capital Health District Authority and Dalhousie University, Halifax, Nova Scotia; C. Blake Gilks, Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia; Henrike Rees and Louise Quenneville, Saskatoon City Hospital and University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and Anthony M. Magliocco, Esoteric Laboratory Services, Moffitt Cancer Center, Tampa, FL
| | - Henrike Rees
- Wedad M. Hanna and Sharon Nofech-Mozes, Sunnybrook Health Sciences Centre, University of Toronto; Wedad M. Hanna, Martin C. Chang, and Sharon Nofech-Mozes, University of Toronto; Martin C. Chang, Mount Sinai Hospital, Toronto; Susan J. Robertson, Ottawa General Hospital and University of Ottawa, Ottawa; Sandip K. SenGupta, Kingston General Hospital and Queen's University, Kingston, Ontario; Penny J. Barnes, Capital Health District Authority and Dalhousie University, Halifax, Nova Scotia; C. Blake Gilks, Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia; Henrike Rees and Louise Quenneville, Saskatoon City Hospital and University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and Anthony M. Magliocco, Esoteric Laboratory Services, Moffitt Cancer Center, Tampa, FL
| | - Louise Quenneville
- Wedad M. Hanna and Sharon Nofech-Mozes, Sunnybrook Health Sciences Centre, University of Toronto; Wedad M. Hanna, Martin C. Chang, and Sharon Nofech-Mozes, University of Toronto; Martin C. Chang, Mount Sinai Hospital, Toronto; Susan J. Robertson, Ottawa General Hospital and University of Ottawa, Ottawa; Sandip K. SenGupta, Kingston General Hospital and Queen's University, Kingston, Ontario; Penny J. Barnes, Capital Health District Authority and Dalhousie University, Halifax, Nova Scotia; C. Blake Gilks, Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia; Henrike Rees and Louise Quenneville, Saskatoon City Hospital and University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and Anthony M. Magliocco, Esoteric Laboratory Services, Moffitt Cancer Center, Tampa, FL
| | - Susan J Robertson
- Wedad M. Hanna and Sharon Nofech-Mozes, Sunnybrook Health Sciences Centre, University of Toronto; Wedad M. Hanna, Martin C. Chang, and Sharon Nofech-Mozes, University of Toronto; Martin C. Chang, Mount Sinai Hospital, Toronto; Susan J. Robertson, Ottawa General Hospital and University of Ottawa, Ottawa; Sandip K. SenGupta, Kingston General Hospital and Queen's University, Kingston, Ontario; Penny J. Barnes, Capital Health District Authority and Dalhousie University, Halifax, Nova Scotia; C. Blake Gilks, Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia; Henrike Rees and Louise Quenneville, Saskatoon City Hospital and University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and Anthony M. Magliocco, Esoteric Laboratory Services, Moffitt Cancer Center, Tampa, FL
| | - Sandip K SenGupta
- Wedad M. Hanna and Sharon Nofech-Mozes, Sunnybrook Health Sciences Centre, University of Toronto; Wedad M. Hanna, Martin C. Chang, and Sharon Nofech-Mozes, University of Toronto; Martin C. Chang, Mount Sinai Hospital, Toronto; Susan J. Robertson, Ottawa General Hospital and University of Ottawa, Ottawa; Sandip K. SenGupta, Kingston General Hospital and Queen's University, Kingston, Ontario; Penny J. Barnes, Capital Health District Authority and Dalhousie University, Halifax, Nova Scotia; C. Blake Gilks, Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia; Henrike Rees and Louise Quenneville, Saskatoon City Hospital and University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and Anthony M. Magliocco, Esoteric Laboratory Services, Moffitt Cancer Center, Tampa, FL
| | - Sharon Nofech-Mozes
- Wedad M. Hanna and Sharon Nofech-Mozes, Sunnybrook Health Sciences Centre, University of Toronto; Wedad M. Hanna, Martin C. Chang, and Sharon Nofech-Mozes, University of Toronto; Martin C. Chang, Mount Sinai Hospital, Toronto; Susan J. Robertson, Ottawa General Hospital and University of Ottawa, Ottawa; Sandip K. SenGupta, Kingston General Hospital and Queen's University, Kingston, Ontario; Penny J. Barnes, Capital Health District Authority and Dalhousie University, Halifax, Nova Scotia; C. Blake Gilks, Vancouver General Hospital and University of British Columbia, Vancouver, British Columbia; Henrike Rees and Louise Quenneville, Saskatoon City Hospital and University of Saskatchewan, Saskatoon, Saskatchewan, Canada; and Anthony M. Magliocco, Esoteric Laboratory Services, Moffitt Cancer Center, Tampa, FL
| |
Collapse
|
5
|
Krotneva S, Reidel K, Nassif M, Trabulsi N, Mayo N, Tamblyn R, Meguerditchian AN. Rates and predictors of consideration for adjuvant radiotherapy among high-risk breast cancer patients: a cohort study. Breast Cancer Res Treat 2013; 140:397-405. [PMID: 23881523 PMCID: PMC3732766 DOI: 10.1007/s10549-013-2636-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/08/2013] [Indexed: 11/28/2022]
Abstract
Radiotherapy (RT) after breast conserving surgery (BCS) represents the standard for local control of breast cancer (BC). However, variations in practice persist. We aimed to characterize the rate of RT consideration (or referral) after BCS and identify predictors in Quebec, Canada, where universal health insurance is in place. A historical prospective cohort study using the provincial hospital discharge and medical services databases was conducted. All women with incident, non-metastatic BC (stages I–III) undergoing BCS (1998–2005) were identified. Odds ratios (ORs) and 95 % confidence intervals (CIs) for RT consideration were estimated with a generalized estimating equations regression model, adjusting for clustering of patients within physicians. Of the 27,483 women selected, 90 % were considered for RT and 84 % subsequently received it. Relative to women 50–69 years old, younger and older women were less likely to be considered: ORs of 0.82 (95 % CI 0.73–0.93) and 0.10 (0.09–0.12), respectively. Emergency room visits and hospitalizations unrelated to BC were associated with decreased odds of RT consideration: 0.85 (0.76–0.94) and 0.83 (0.71–0.97). Women with regional BC considered for chemotherapy were more likely to be considered for RT: 3.41 (2.83–4.11). RT consideration odds increased by 7 % (OR of 1.07, 95 % CI 1.03–1.10) for every ten additional BCSs performed by the surgeon in the prior year. Social isolation, comorbidities, and greater distance to a referral center lowered the odds. Demographic and clinical patient-related risk factors, health service use, gaps in other aspects of BC management, and surgeon’s experience predicted RT consideration.
Collapse
Affiliation(s)
- Stanimira Krotneva
- Clinical and Health Informatics Research Group, McGill University, 1140 Pine Avenue West, Montreal, QC, H3A 1A3, Canada.
| | | | | | | | | | | | | |
Collapse
|
6
|
Sobrino J, Barnes SA, Dahr N, Kudyakov R, Berryman C, Nathens AB, Hemmila MR, Neal M, Shafi S. Frequency of adoption of practice management guidelines at trauma centers. Proc (Bayl Univ Med Cent) 2013; 26:256-61. [PMID: 23814383 DOI: 10.1080/08998280.2013.11928975] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Evidence-based management guidelines have been shown to improve patient outcomes, yet their utilization by trauma centers remains unknown. This study measured adoption of practice management guidelines or protocols by trauma centers. A survey of 228 trauma centers was conducted over 1 year; 55 completed the survey. Centers were classified into three groups: noncompliant, partially compliant, and compliant with adoption of management protocols. Characteristics of compliant centers were compared with those of the other two groups. Most centers were Level I (58%) not-for-profit (67%) teaching hospitals (84%) with a surgical residency (74%). One-third of centers had an accredited fellowship in surgical critical care (37%). Only one center was compliant with all 32 management protocols. Half of the centers were compliant with 14 of 32 protocols studied (range, 4 to 32). Of the 21 trauma center characteristics studied, only two were independently associated with compliant centers: use of physician extenders and daily attending rounds (both P < .0001). Adoption of management guidelines by trauma centers is inconsistent, with wide variations in practices across centers.
Collapse
Affiliation(s)
- Justin Sobrino
- Baylor Institute for Health Care Research and Improvement, Dallas, Texas (Sobrino, Barnes, Dahr, Kudyakov, Berryman, Shafi); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Nathens); the Section of General Surgery, Trauma Burn Research Laboratory, University of Michigan, Ann Arbor, Michigan (Hemmila); and the Committee on Trauma, American College of Surgeons, Chicago, Illinois (Neal). Ms. Dahr is now affiliated with Integris Health, Oklahoma City
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Cloyd JM, Hernandez-Boussard T, Wapnir IL. Outcomes of Partial Mastectomy in Male Breast Cancer Patients: Analysis of SEER, 1983–2009. Ann Surg Oncol 2013; 20:1545-1550. [DOI: 10.1245/s10434-013-2918-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
8
|
Cloyd JM, Hernandez-Boussard T, Wapnir IL. Poor compliance with breast cancer treatment guidelines in men undergoing breast-conserving surgery. Breast Cancer Res Treat 2013; 139:177-82. [PMID: 23572298 DOI: 10.1007/s10549-013-2517-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 04/01/2013] [Indexed: 11/28/2022]
Abstract
Lumpectomy is performed in a small but growing proportion of men with breast cancer. It is unknown whether men undergoing breast-conserving surgery (BCS) receive care compliant with breast cancer treatment guidelines. Patients with breast cancer in the surveillance, epidemiology, and end results (SEER) database who underwent lumpectomy between 1983 and 2009 were identified. Gender differences in the receipt of lymph node staging and adjuvant radiation therapy were assessed. Multivariate logistic regression was utilized to evaluate the independent association of gender on these outcomes. The influence of gender on breast cancer-specific survival (BCSS) was analyzed. 382,030 of 824,408 (46.3 %) women compared to 712 of 6,039 (11.8 %) men with breast cancer underwent lumpectomy. Men were older, more likely to be black, less likely to have stage I disease and more likely to have stage IV disease. Only 59.2 % of men had lymph nodes sampled at the time of surgery compared to 81.6 % of women (p < 0.0001). In addition, only 35.4 % of men received adjuvant breast radiation therapy compared to 69.8 % of women (p < 0.0001). After controlling for age, race, stage, grade, and year of diagnosis, female gender was significantly associated with receiving adjuvant radiation therapy (OR 2.9, 95 % CI 2.4-3.4) and lymph node staging (OR 1.6, 95 % CI 1.3-1.90). Five- and ten-year BCSS were 88.0 and 83.5 % for men compared to 93.2 and 88.2 % for women (p < 0.001). Men with breast cancer are less likely to receive lymph node staging or adjuvant radiation therapy following BCS compared to women.
Collapse
Affiliation(s)
- Jordan M Cloyd
- Department of Surgery, Stanford University, 300 Pasteur Dr, MC5641, Stanford, CA 94305, USA.
| | | | | |
Collapse
|
9
|
Sacerdote C, Bordon R, Pitarella S, Mano MP, Baldi I, Casella D, Di Cuonzo D, Frigerio A, Milanesio L, Merletti F, Pagano E, Ricceri F, Rosso S, Segnan N, Tomatis M, Ciccone G, Vineis P, Ponti A. Compliance with clinical practice guidelines for breast cancer treatment: a population-based study of quality-of-care indicators in Italy. BMC Health Serv Res 2013; 13:28. [PMID: 23351327 PMCID: PMC3566978 DOI: 10.1186/1472-6963-13-28] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 01/15/2013] [Indexed: 12/03/2022] Open
Abstract
Background It has been documented that variations exist in breast cancer treatment despite wide dissemination of clinical practice guidelines. The aim of this population-based study was to evaluate the impact of regional guidelines (Piedmont guidelines, PGL) for breast cancer diagnosis and treatment on quality-of-care indicators in the Northwestern Italian region of Piedmont. Methods We included two samples of women aged 50–69 years with incident breast cancer treated in Piedmont before and after the introduction of PGL: 600 in 2002 (pre-PGL) and 621 in 2004 (post-PGL). Patients were randomly selected among all incident breast cancer cases identified through the hospital discharge records database. We extracted clinical data on breast cancer cases from medical charts and ascertained vital status through linkage with town offices. We assessed compliance with 14 quality-of-care indicators from PGL recommendations, before and after their introduction in clinical practice. Results Among patients with invasive lesions, 77.1% (N = 368) and 77.5% (N = 383) in the pre-PGL and post-PGL groups, respectively, received breast conservative surgery (BCS) as a first-line treatment. Following BCS, 87.7% received radiotherapy in 2002, compared to 87.9% in 2004. Of all patients at medium-to-high risk of distant metastasis, 65.5% (N = 268) and 63.6% (N = 252) received chemotherapy in 2002 and in 2004, respectively. Among the 117 patients with invasive lesions and negative estrogen receptor status in 2002, hormonal therapy was prescribed in 23 of them (19.6%). The incorrect prescription of hormonal therapy decreased to 10.8% (N = 10) among the 92 estrogen receptor-negative patients in 2004 (p < 0.01). Compliance with PGL recommendations was already high in the pre-PGL group, although some quality-of-care indicators did not reach the standard. In the pre/post analysis, 8 out of 14 quality-of-care indicators showed an improvement from 2002 to 2004, but only 4 out of 14 reached statistical significance. We did not find any change in the risk of mortality in the post-PGL versus the pre-PGL group (adjusted hazard ratio 0.94, 95%CI 0.56–1.56). Conclusions These results highlight the need to continue to improve breast cancer care and to measure adherence to PGL.
Collapse
Affiliation(s)
- Carlotta Sacerdote
- Cancer Epidemiology Unit, San Giovanni Battista Hospital, CPO Piemonte and University of Turin, Turin, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Bajpai J, Puri A, Shah K, Susan D, Jambhekar N, Rekhi B, Desai S, Gulia A, Gupta S. Chemotherapy compliance in patients with osteosarcoma. Pediatr Blood Cancer 2013; 60:41-4. [PMID: 22488836 DOI: 10.1002/pbc.24155] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 03/06/2012] [Indexed: 11/09/2022]
Abstract
PURPOSE Histological response (HR) to neoadjuvant-chemotherapy (NACT) is considered as a robust prognostic marker in treated osteosarcomas. Chemotherapy compliance can affect both, dose intensity and density and may affect the final outcome in these cases. This vital aspect has been inadequately addressed and therefore merits further investigation. METHOD A retrospective study of NACT-treated osteosarcoma patients, during the year 2010 was conducted. Compliance was defined as receipt of planned cycles of chemotherapy in the planned doses, within the planned duration or up to 25% additional time. HR was assessed by grading for histological necrosis (HN). Good responders (GR) included those with tumors showing ≥90% HN. RESULTS Of 124 patients, 115 were analyzed for post-NACT HR. Of the 73 (64%) compliant patients, 47 were GR and of the 42 (36%) non-compliant patients, 18 were GR. There was significant association between GR and compliance (P = 0.031). However, at a median follow-up of 7.9 months, there was no significant difference in survival between the noncompliant versus compliant group. Non-compliance was justifiable in 26 patients and not justifiable in 16 patients. Using univariate analysis, T-size, pain, performance status, albumin, LDH, and education were identified as significant factors, while in multivariate analysis, only poor performance status was identified as an independent variable for non-compliance. CONCLUSIONS Two-thirds patients were found to be compliant with NACT. There was a significant association between GR and compliant patients. Significant correlation between compliance and survival may be established with a longer follow-up particularly since "good necrosis" is generally predictive of good survival.
Collapse
Affiliation(s)
- Jyoti Bajpai
- Department of Medical Oncology, Tata Memorial Center, Mumbai, India.
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Salloum RG, Smith TJ, Jensen GA, Lafata JE. Factors associated with adherence to chemotherapy guidelines in patients with non-small cell lung cancer. Lung Cancer 2012; 75:255-60. [PMID: 21816502 PMCID: PMC3210900 DOI: 10.1016/j.lungcan.2011.07.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 06/28/2011] [Accepted: 07/09/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Evidence-based guidelines recommend chemotherapy for medically fit patients with stages II-IV non-small cell lung cancer (NSCLC). Adherence to chemotherapy guidelines has rarely been studied among large populations, mainly because performance status (PS), a key component in assessing chemotherapy appropriateness, is missing from claims-based datasets. Among a large cohort of patients with known PS, we describe first line chemotherapy use relative to guideline recommendations and identify patient factors associated with guideline concordant use. PATIENTS AND METHODS Insured patients, ages 50+, with stages II-IV NSCLC between 2000 and 2007 were identified via tumor registry (n=406). Chart abstracted PS, automated medical claims, Census tract information, and travel distance were linked to tumor registry data. Chemotherapy was considered appropriate for patients with PS 0-2. Multivariate logit models were fit to evaluate patient characteristics associated with chemotherapy over- and under-use per guideline recommendations. Tests of statistical significance were two sided. RESULTS Overall compliance with first line chemotherapy guidelines was 71%. Significant (p<0.05) predictors of chemotherapy underuse (19%) included increasing age (odds ratio [OR], 1.09), higher income (OR, 1.02), diagnosed before 2003 (OR, 2.05), and vehicle access (OR, 6.96) in the patient's neighborhood. Significant predictors of chemotherapy overuse (10%) included decreasing age (OR, 0.92), diagnosed after 2003 (OR, 3.24), and higher income (OR, 1.05) in the patient's neighborhood. Among NSCLC patients 29% do not receive guideline recommended chemotherapy treatment missing opportunities for cure or beneficial palliation, or receiving chemotherapy with more risk of harm than benefit. Care concordant with guidelines is influenced by age, economic considerations such as income and transportation barriers.
Collapse
Affiliation(s)
- Ramzi G. Salloum
- Center for Health Services Research, Henry Ford Health System, One Ford Place, Suite, 3A Detroit, MI, 48202 USA
| | - Thomas J. Smith
- Division of Hematology/Oncology and Palliative Care and Massey Cancer Center, School of Medicine, Virginia Commonwealth University, 1101 E Marshall Street, PO Box 980230, Richmond, VA, 23298 USA
| | - Gail A. Jensen
- Institute of Gerontology and Department of Economics, Wayne State University, 87 E Ferry Street, 225 Knapp, Detroit, MI, 48202 USA
| | - Jennifer Elston Lafata
- Social and Behavioral Health and Massey Cancer Center, School of Medicine, Virginia Commonwealth University, 1112 E Clay Street, PO Box 980149, Richmond, VA 23298, and Center for Health Services Research, Henry Ford Health System, Detroit, MI, USA
| |
Collapse
|
12
|
Shirvani SM, Pan IW, Buchholz TA, Shih YCT, Hoffman KE, Giordano SH, Smith BD. Impact of evidence-based clinical guidelines on the adoption of postmastectomy radiation in older women. Cancer 2011; 117:4595-605. [DOI: 10.1002/cncr.26081] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Revised: 02/04/2011] [Accepted: 02/09/2011] [Indexed: 11/12/2022]
|
13
|
Ess S, Joerger M, Frick H, Probst-Hensch N, Vlastos G, Rageth C, Lütolf U, Savidan A, Thürlimann B. Predictors of state-of-the-art management of early breast cancer in Switzerland. Ann Oncol 2010; 22:618-624. [PMID: 20705910 DOI: 10.1093/annonc/mdq404] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate predictors of state-of-the-art management of early breast cancer in Switzerland. PATIENTS AND METHODS The study included 3499 women aged 25-79 years diagnosed with invasive breast cancer stages I-IIIA in 2003-2005. Patients were identified through population-based cancer registries and treated in all kinds of settings. Concordance with national and international recommendations was assessed for 10 items covering surgery, radiotherapy, systemic adjuvant therapy and histopathology reporting. We used multivariate logistic regression to identify independent predictors of high (10 points) and low (≤7 points) concordance. RESULTS In one-third of the patients, management met guidelines in all items, whereas in about one-fifth, three or more items did not comply. Treatment by a surgeon with caseload in the upper tercile and team involved in clinical research were independent predictors of a high score, whereas treatment by a surgeon with a caseload in the lower tercile was associated with a low score. Socioeconomic characteristics such as income and education were not independent predictors, but patient's place of residence and age independently predicted management according to recommendations. CONCLUSION Specialization and involvement in clinical research seem to be key elements for enhancing the quality of early breast cancer management at population level.
Collapse
Affiliation(s)
- S Ess
- Cancer Registry St Gallen-Appenzell, Cancer League St. Gallen-Appenzell, St Gallen.
| | - M Joerger
- Cancer Registry St Gallen-Appenzell, Cancer League St. Gallen-Appenzell, St Gallen; Oncology Department, Cantonal Hospital St Gallen, St Gallen
| | - H Frick
- Cancer Registry Grison-Glarus and Department of Pathology, Cantonal Hospital Graubünden, Chur
| | - N Probst-Hensch
- Cancer Registry Zurich (former); Swiss Tropical and Public Health Institute, University of Basel, Basel
| | - G Vlastos
- Senology Unit, Geneva University Hospitals, Geneva
| | | | - U Lütolf
- Department of Radio-Oncology, Zurich University Hospital, Zurich
| | - A Savidan
- Cancer Registry St Gallen-Appenzell, Cancer League St. Gallen-Appenzell, St Gallen
| | - B Thürlimann
- Breast Center, Cantonal Hospital St Gallen, St Gallen, Switzerland
| |
Collapse
|
14
|
Chiu CG, Masoudi H, Leung S, Voduc DK, Gilks B, Huntsman DG, Wiseman SM. HER-3 Overexpression Is Prognostic of Reduced Breast Cancer Survival: A Study of 4046 Patients. Ann Surg 2010; 251:1107-16. [DOI: 10.1097/sla.0b013e3181dbb77e] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
15
|
Voduc KD, Cheang MCU, Tyldesley S, Gelmon K, Nielsen TO, Kennecke H. Breast cancer subtypes and the risk of local and regional relapse. J Clin Oncol 2010; 28:1684-91. [PMID: 20194857 DOI: 10.1200/jco.2009.24.9284] [Citation(s) in RCA: 892] [Impact Index Per Article: 63.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE The risk of local and regional relapse associated with each breast cancer molecular subtype was determined in a large cohort of patients with breast cancer. Subtype assignment was accomplished using a validated six-marker immunohistochemical panel applied to tissue microarrays. PATIENTS AND METHODS Semiquantitative analysis of estrogen receptor (ER), progesterone receptor (PR), Ki-67, human epidermal growth factor receptor 2 (HER2), epidermal growth factor receptor (EGFR), and cytokeratin (CK) 5/6 was performed on tissue microarrays constructed from 2,985 patients with early invasive breast cancer. Patients were classified into the following categories: luminal A, luminal B, luminal-HER2, HER2 enriched, basal-like, or triple-negative phenotype-nonbasal. Multivariable Cox analysis was used to determine the risk of local or regional relapse associated the intrinsic subtypes, adjusting for standard clinicopathologic factors. RESULTS The intrinsic molecular subtype was successfully determined in 2,985 tumors. The median follow-up time was 12 years, and there have been a total of 325 local recurrences and 227 regional lymph node recurrences. Luminal A tumors (ER or PR positive, HER2 negative, Ki-67 < 1%) had the best prognosis and the lowest rate of local or regional relapse. For patients undergoing breast conservation, HER2-enriched and basal subtypes demonstrated an increased risk of regional recurrence, and this was statistically significant on multivariable analysis. After mastectomy, luminal B, luminal-HER2, HER2-enriched, and basal subtypes were all associated with an increased risk of local and regional relapse on multivariable analysis. CONCLUSION Luminal A tumors are associated with a low risk of local or regional recurrence. Molecular subtyping of breast tumors using a six-marker immunohistochemical panel can identify patients at increased risk of local and regional recurrence.
Collapse
Affiliation(s)
- K David Voduc
- Department of Radiation Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada V5Z 4E6.
| | | | | | | | | | | |
Collapse
|
16
|
Massard C, Tran Ba Loc P, Haddad V, Pignon JP, Girard P, Monnet I, Trédaniel J, Besse B, Soria JC. Use of Adjuvant Chemotherapy in Non-small Cell Lung Cancer in Routine Practice. J Thorac Oncol 2009; 4:1504-10. [DOI: 10.1097/jto.0b013e3181bbf1c9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
17
|
Van Erps J, Aapro M, MacDonald K, Soubeyran P, Turner M, Warrinnier H, Albrecht T, Abraham I. Promoting evidence-based management of anemia in cancer patients: concurrent and discriminant validity of RESPOND, a web-based clinical guidance system based on the EORTC guidelines for supportive care in cancer. Support Care Cancer 2009; 18:847-58. [PMID: 19904563 DOI: 10.1007/s00520-009-0718-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Accepted: 08/03/2009] [Indexed: 11/28/2022]
Abstract
GOAL OF WORK The goal of this study is to test the validity of RESPOND, a web-based decision support system to assess and manage anemia in cancer patients as per the European Organisation for Research and Treatment of Cancer (EORTC) guidelines. The intraclass correlation metrics for the algorithmic definitions were reported previously. Reported here are the concurrent validity, the extent to which clinicians' anemia management is guidelines-congruent when using the system; and discriminant validity, the extent to which clinicians practice in congruence with guidelines when vs. when not using the system. PATIENTS AND METHODS Hybrid matched design with precohort (retrospective; clinicians not using RESPOND) and postcohort (prospective; clinicians using RESPOND) of anemic patients matched on cancer type and chemotherapy regimen and followed up over 4 months after treatment initiation with erythropoietic proteins (34 patients per cohort; total N = 68). Congruence scores quantified the extent to which anemia management was congruent with the EORTC guidelines (range 0-10). MAIN RESULTS Hemoglobin (Hb) increased significantly for both cohorts, but the postcohort group showed more rapid rate of Hb increase over time (p < 0.006), higher Hb by visit 4 (p = 0.007), and greater Hb increase by visit 4 (p = 0.006). Concurrent validity was high with mean postcohort congruence scores of 8.18 +/- 1.38. Discriminant validity was inferred from statistically significant differences in mean congruence scores between cohorts (p < 0.001) and from the postcohort having odds ratios of 3.64 for patients to reach Hb >or= 11 g/dL and 2.91 to achieve Hb >or= 12 g/dL. CONCLUSIONS RESPOND, a validated computerized clinical guidance system with an incremental effect beyond the pharmacotherapeutic effect of erythropoietic proteins, offers clinicians accurate and safe guidance in managing anemia in cancer patients.
Collapse
Affiliation(s)
- Joanna Van Erps
- Afdeling Oncologie en Hematologie, Algemeen Stedelijk Ziekenhuis Aalst, Aalst, Belgium
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Cheang MCU, Chia SK, Voduc D, Gao D, Leung S, Snider J, Watson M, Davies S, Bernard PS, Parker JS, Perou CM, Ellis MJ, Nielsen TO. Ki67 index, HER2 status, and prognosis of patients with luminal B breast cancer. J Natl Cancer Inst 2009; 101:736-50. [PMID: 19436038 PMCID: PMC2684553 DOI: 10.1093/jnci/djp082] [Citation(s) in RCA: 1512] [Impact Index Per Article: 100.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Gene expression profiling of breast cancer has identified two biologically distinct estrogen receptor (ER)-positive subtypes of breast cancer: luminal A and luminal B. Luminal B tumors have higher proliferation and poorer prognosis than luminal A tumors. In this study, we developed a clinically practical immunohistochemistry assay to distinguish luminal B from luminal A tumors and investigated its ability to separate tumors according to breast cancer recurrence-free and disease-specific survival. Methods Tumors from a cohort of 357 patients with invasive breast carcinomas were subtyped by gene expression profile. Hormone receptor status, HER2 status, and the Ki67 index (percentage of Ki67-positive cancer nuclei) were determined immunohistochemically. Receiver operating characteristic curves were used to determine the Ki67 cut point to distinguish luminal B from luminal A tumors. The prognostic value of the immunohistochemical assignment for breast cancer recurrence-free and disease-specific survival was investigated with an independent tissue microarray series of 4046 breast cancers by use of Kaplan–Meier curves and multivariable Cox regression. Results Gene expression profiling classified 101 (28%) of the 357 tumors as luminal A and 69 (19%) as luminal B. The best Ki67 index cut point to distinguish luminal B from luminal A tumors was 13.25%. In an independent cohort of 4046 patients with breast cancer, 2847 had hormone receptor–positive tumors. When HER2 immunohistochemistry and the Ki67 index were used to subtype these 2847 tumors, we classified 1530 (59%, 95% confidence interval [CI] = 57% to 61%) as luminal A, 846 (33%, 95% CI = 31% to 34%) as luminal B, and 222 (9%, 95% CI = 7% to 10%) as luminal–HER2 positive. Luminal B and luminal–HER2-positive breast cancers were statistically significantly associated with poor breast cancer recurrence-free and disease-specific survival in all adjuvant systemic treatment categories. Of particular relevance are women who received tamoxifen as their sole adjuvant systemic therapy, among whom the 10-year breast cancer–specific survival was 79% (95% CI = 76% to 83%) for luminal A, 64% (95% CI = 59% to 70%) for luminal B, and 57% (95% CI = 47% to 69%) for luminal–HER2 subtypes. Conclusion Expression of ER, progesterone receptor, and HER2 proteins and the Ki67 index appear to distinguish luminal A from luminal B breast cancer subtypes.
Collapse
Affiliation(s)
- Maggie C U Cheang
- Genetic Pathology Evaluation Centre, Vancouver Coastal Health Research Institute, British Columbia Cancer Agency, and University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Liu S, Chia SK, Mehl E, Leung S, Rajput A, Cheang MCU, Nielsen TO. Progesterone receptor is a significant factor associated with clinical outcomes and effect of adjuvant tamoxifen therapy in breast cancer patients. Breast Cancer Res Treat 2009; 119:53-61. [PMID: 19205877 DOI: 10.1007/s10549-009-0318-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2009] [Accepted: 01/13/2009] [Indexed: 01/20/2023]
Abstract
Estrogen receptor status in breast cancer is associated with response to hormonal therapy and clinical outcome. The additional value of progesterone receptor (PR) has remained controversial. We examine the value of PR for prognosis and response to tamoxifen on a population-based series of 4,046 invasive early stage breast cancer patients. Clinical information for age at diagnosis, stage, pathology, treatment and outcome was assembled for the study cohort; the median follow-up was 12.4 years. PR status was determined by immunohistochemistry using a rabbit monoclonal antibody on tissue microarrays built from breast tumor surgical excisions. Survival analyses, Kaplan-Meier functions and Cox proportional hazards regression models were applied to assess the associations between PR and breast cancer specific survival. Progesterone receptor was positive in 51% of all cases and 67% of estrogen receptor positive (ER+) cases. Survival analyses for both the whole cohort and ER+ cases given tamoxifen therapy showed that patients with PR+ tumors had 24% higher relative probability for breast cancer specific survival as compared to PR- patients, adjusted for ER, HER2, age at diagnosis, grade, tumor size, lymph node status and lymphovascular invasion covariates. Higher PR expression showed stronger association with patient survival. Log-likelihood ratio tests of multivariate Cox proportional hazards regression models demonstrated that PR was an independent statistically significant factor for breast cancer specific survival in both the whole cohort and among ER+ cases treated with tamoxifen. PR adds significant prognostic value in breast cancer beyond that obtained with estrogen receptor alone.
Collapse
Affiliation(s)
- Shuzhen Liu
- Genetic Pathology Evaluation Centre at Vancouver General Hospital, Prostate Center, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | | | | |
Collapse
|
20
|
Olivotto IA, Lesperance ML, Truong PT, Nichol A, Berrang T, Tyldesley S, Germain F, Speers C, Wai E, Holloway C, Kwan W, Kennecke H. Intervals longer than 20 weeks from breast-conserving surgery to radiation therapy are associated with inferior outcome for women with early-stage breast cancer who are not receiving chemotherapy. J Clin Oncol 2008; 27:16-23. [PMID: 19018080 DOI: 10.1200/jco.2008.18.1891] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine the interval from breast-conserving surgery (BCS) to radiation therapy (RT) that affects local control or survival. PATIENTS AND METHODS The 10-year Kaplan-Meier (KM) local recurrence-free survival (LRFS), distant recurrence-free survival (DRFS), and breast cancer-specific survival (BCSS) were computed for 6,428 women who had T1 to 2, N0 to 1, M0 breast cancer that was diagnosed in British Columbia between 1989 and 2003, and who were treated with BCS and RT without chemotherapy. Intervals from BCS to RT were grouped by weeks as follows: < or = 4 (n = 83), greater than 4 to 8 (n = 2,288; reference group); greater than 8 to 12 (n = 2,606); greater than 12 to 16 (n = 961); greater than 16 to 20 (n = 358); and greater than 20 weeks (n = 132). Cox proportional hazards models and matching were used to control for confounding variables. RESULTS The median follow-up time was 7.5 years. The 10-year KM outcomes were as follows: LRFS, 95.4%; DRFS, 90.5%; and BCSS, 92.5%. Compared with the greater than 4 to 8 weeks group, hazard ratios (HR) were not significantly different for any outcome among patients who were treated up to 20 weeks after BCS. However, LRFS (hazard ratio [HR], 2.00; P = .15), DRFS (HR, 1.86; P = .02) and BCSS (HR, 2.15; P = .009) were inferior for women with BCS-to-RT intervals greater than 20 weeks compared with those greater than 4 to 8 weeks. The matched analysis yielded similar results. CONCLUSION Outcomes were statistically similar for BCS-to-RT intervals up to 20 weeks, but they were inferior for intervals beyond 20 weeks. Time can be reasonably allowed for the breast to heal and for patients to consider treatment options, but RT should start within 20 weeks of BCS.
Collapse
Affiliation(s)
- Ivo A Olivotto
- BC Cancer Agency-Vancouver Island Centre, Victoria, British Columbia, Canada.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Cheang MCU, Voduc D, Bajdik C, Leung S, McKinney S, Chia SK, Perou CM, Nielsen TO. Basal-like breast cancer defined by five biomarkers has superior prognostic value than triple-negative phenotype. Clin Cancer Res 2008; 14:1368-76. [PMID: 18316557 DOI: 10.1158/1078-0432.ccr-07-1658] [Citation(s) in RCA: 858] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Basal-like breast cancer is associated with high grade, poor prognosis, and younger patient age. Clinically, a triple-negative phenotype definition [estrogen receptor, progesterone receptor, and human epidermal growth factor receptor (HER)-2, all negative] is commonly used to identify such cases. EGFR and cytokeratin 5/6 are readily available positive markers of basal-like breast cancer applicable to standard pathology specimens. This study directly compares the prognostic significance between three- and five-biomarker surrogate panels to define intrinsic breast cancer subtypes, using a large clinically annotated series of breast tumors. EXPERIMENTAL DESIGN Four thousand forty-six invasive breast cancers were assembled into tissue microarrays. All had staging, pathology, treatment, and outcome information; median follow-up was 12.5 years. Cox regression analyses and likelihood ratio tests compared the prognostic significance for breast cancer death-specific survival (BCSS) of the two immunohistochemical panels. RESULTS Among 3,744 interpretable cases, 17% were basal using the triple-negative definition (10-year BCSS, 6 7%) and 9% were basal using the five-marker method (10-year BCSS, 62%). Likelihood ratio tests of multivariable Cox models including standard clinical variables show that the five-marker panel is significantly more prognostic than the three-marker panel. The poor prognosis of triple-negative phenotype is conferred almost entirely by those tumors positive for basal markers. Among triple-negative patients treated with adjuvant anthracycline-based chemotherapy, the additional positive basal markers identified a cohort of patients with significantly worse outcome. CONCLUSIONS The expanded surrogate immunopanel of estrogen receptor, progesterone receptor, human HER-2, EGFR, and cytokeratin 5/6 provides a more specific definition of basal-like breast cancer that better predicts breast cancer survival.
Collapse
Affiliation(s)
- Maggie C U Cheang
- Genetic Pathology Evaluation Centre, Vancouver Coastal Health Research Institute, British Columbia Cancer Agency, and University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Folkes A, Urquhart R, Zitzelsberger L, Grunfeld E. Breast Cancer Guidelines in Canada: A Review of Development and Implementation. ACTA ACUST UNITED AC 2008; 3:108-113. [PMID: 21373213 DOI: 10.1159/000121732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A series of specific clinical practice guidelines (CPGs) were published in Canada in 1998. A primary objective of these 'Clinical Practice Guidelines for the Care and Treatment of Breast Cancer' was to decrease the variation in breast cancer care across the country. Prior to this, researchers found moderate compliance with consensus recommendations for breast cancer therapies in several Canadian provinces. However, a recent study concluded that the publication of the Canadian CPGs did not reduce variations in surgical care for breast cancer. If guidelines are to achieve their intended objectives, they must be implemented in ways that support, encourage, and facilitate their use. Evidence strongly suggests the simple publication and passive dissemination of CPGs are usually ineffective in changing how physicians actually care for patients. CPG implementation, therefore, requires active knowledge translation processes to ensure that the evidence is relevant to all with a stake in bettering breast cancer care. For example, implementation strategies that use computerized CPGs can make evidence-based decision-making routine practice in the clinical setting. The breast cancer community can also work with the newly formed Canadian Partnership Against Cancer to find ways to more successfully support and facilitate guideline use considering the local context.
Collapse
Affiliation(s)
- Amy Folkes
- Cancer Outcomes Research Program, Cancer Care Nova Scotia, Halifax, Nova Scotia, Canada
| | | | | | | |
Collapse
|
23
|
Crabb SJ, Bajdik CD, Leung S, Speers CH, Kennecke H, Huntsman DG, Gelmon KA. Can clinically relevant prognostic subsets of breast cancer patients with four or more involved axillary lymph nodes be identified through immunohistochemical biomarkers? A tissue microarray feasibility study. Breast Cancer Res 2008; 10:R6. [PMID: 18194560 PMCID: PMC2374957 DOI: 10.1186/bcr1847] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Revised: 12/10/2007] [Accepted: 01/14/2008] [Indexed: 01/03/2023] Open
Abstract
Introduction Primary breast cancer involving four or more axillary lymph nodes carries a poor prognosis. We hypothesized that use of an immunohistochemical biomarker scoring system could allow for identification of variable risk subgroups. Methods Patients with four or more positive axillary nodes were identified from a clinically annotated tissue microarray of formalin-fixed paraffin-embedded primary breast cancers and randomized into a 'test set' and a 'validation set'. A prospectively defined prognostic scoring model was developed in the test set and was further assessed in the validation set combining expression for eight biomarkers by immunohistochemistry, including estrogen receptor, human epidermal growth factor receptors 1 and 2, carbonic anhydrase IX, cytokeratin 5/6, progesterone receptor, p53 and Ki-67. Survival outcomes were analyzed by the Kaplan–Meier method, log rank tests and Cox proportional-hazards models. Results A total of 313 eligible patients were identified in the test set for whom 10-year relapse-free survival was 38.3% (SEM 2.9%), with complete immunohistochemical data available for 227. Tumor size, percentage of positive axillary nodes and expression status for the progesterone receptor, Ki-67 and carbonic anhydrase IX demonstrated independent prognostic significance with respect to relapse-free survival. Our combined biomarker scoring system defined three subgroups in the test set with mean 10-year relapse-free survivals of 75.4% (SEM 7.0%), 35.3% (SEM 4.1%) and 19.3% (SEM 7.0%). In the validation set, differences in relapse-free survival for these subgroups remained statistically significant but less marked. Conclusion Biomarkers assessed here carry independent prognostic value for breast cancer with four or more positive axillary nodes and identified clinically relevant prognostic subgroups. This approach requires refinement and validation of methodology.
Collapse
Affiliation(s)
- Simon J Crabb
- Department of Medical Oncology, BC Cancer Agency, 600 West 10th Avenue, Vancouver, BC, Canada, V5Z 4E6
| | | | | | | | | | | | | |
Collapse
|
24
|
Jensen KC, Turbin DA, Leung S, Miller MA, Johnson K, Norris B, Hastie T, McKinney S, Nielsen TO, Huntsman DG, Gilks CB, West RB. New cutpoints to identify increased HER2 copy number: analysis of a large, population-based cohort with long-term follow-up. Breast Cancer Res Treat 2008; 112:453-9. [PMID: 18193353 DOI: 10.1007/s10549-007-9887-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2007] [Accepted: 12/27/2007] [Indexed: 01/08/2023]
Abstract
BACKGROUND HER2 gene amplification and/or protein overexpression in breast cancer is associated with a poor prognosis and predicts response to anti-HER2 therapy. We examine the natural history of breast cancers in relationship to increased HER2 copy numbers in a large population-based study. PATIENTS AND METHODS HER2 status was measured by fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) in approximately 1,400 breast cancer cases with greater than 15 years of follow-up. Protein expression was evaluated with two different commercially-available antibodies. RESULTS We looked for subgroups of breast cancer with different clinical outcomes, based on HER2 FISH amplification ratio. The current HER2 ratio cut point for classifying HER2 positive and negative cases is 2.2. However, we found an increased risk of disease-specific death associated with FISH ratios of >1.5. An 'intermediate' group of cases with HER2 ratios between 1.5 and 2.2 was found to have a significantly better outcome than the conventional 'amplified' group (HER2 ratio >2.2) but a significantly worse outcome than groups with FISH ratios less than 1.5. CONCLUSION Breast cancers with increased HER2 copy numbers (low level HER2 amplification), below the currently accepted positive threshold ratio of 2.2, showed a distinct, intermediate outcome when compared to HER2 unamplified tumors and tumors with HER2 ratios greater than 2.2. These findings suggest that a new cut point to determine HER2 positivity, at a ratio of 1.5 (well below the current recommended cut point of 2.2), should be evaluated.
Collapse
Affiliation(s)
- K C Jensen
- Stanford University, Stanford, CA 94305, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Kennecke H, McArthur H, Olivotto IA, Speers C, Bajdik C, Chia SK, Ellard S, Norris B, Hayes M, Barnett J, Gelmon KA. Risk of early recurrence among postmenopausal women with estrogen receptor-positive early breast cancer treated with adjuvant tamoxifen. Cancer 2008; 112:1437-44. [DOI: 10.1002/cncr.23320] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
26
|
McWhirter E, Yogendran G, Wright F, Pharm GDM, Clemons M. Baseline radiological staging in primary breast cancer: impact of educational interventions on adherence to published guidelines. J Eval Clin Pract 2007; 13:647-50. [PMID: 17683309 DOI: 10.1111/j.1365-2753.2007.00804.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
RATIONALE The purpose of baseline radiological staging in newly diagnosed breast cancer patients is to rule out overt metastatic disease. We have previously compared the use of radiological staging at our institution with the recommendations of the Cancer Care Ontario Practice Guidelines Initiative (CCOPGI). Our results demonstrated that between January 2000 to December 2002, a high proportion of our cohort (n = 135) of patients underwent unnecessary investigations. OBJECTIVES To implement and assess an educational intervention to encourage staging guideline utilization in a cohort of early breast cancer patients. METHODS In January 2003, multidisciplinary educational rounds were held, highlighting the CCOPGI guidelines, and reporting results of the audit of staging investigations. The staging guidelines were then included in the Clinical Practice Guidelines of the Breast Disease Site Group, Toronto-Sunnybrook Regional Cancer Centre. A retrospective chart review was completed that assessed staging investigations from a random sample of a similar group of patients (n = 134) from January 2003 to April 2005, to explore the effects of these educational interventions on clinical practice. RESULTS For patients with Stage I breast cancer, there was a significant decrease (P < 0.004) in each type of investigation: a twofold decrease in chest X-rays; 2.5-fold decrease bone scans and fourfold decrease in the number of abdominal ultrasounds. For patients in Stage II, there was no significant change in the proportion of patients undergoing radiological investigations. There was a non-significant trend towards appropriately receiving all three investigations for patients with Stage III disease. CONCLUSIONS Our results demonstrate that prior to the educational intervention, many patients with early breast cancer were undergoing inappropriate radiological staging. Since 2003 however, for Stage I patients there has been a significant improvement in adherence with the guidelines. We hypothesize that our educational intervention had a positive impact on improving the utilization of baseline radiological staging in patients with primary breast cancer.
Collapse
Affiliation(s)
- Elaine McWhirter
- Division of Medical Oncology/Hematology, Toronto Sunnybrook Regional Cancecr Centre, Toronto, ON, Canada.
| | | | | | | | | |
Collapse
|
27
|
Yun YH, Park SM, Noh DY, Nam SJ, Ahn SH, Park BW, Lee ES. Trends in breast cancer treatment in Korea and impact of compliance with consensus recommendations on survival. Breast Cancer Res Treat 2007; 106:245-53. [DOI: 10.1007/s10549-006-9490-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 12/14/2006] [Indexed: 10/23/2022]
|
28
|
Kennecke HF, Olivotto IA, Speers C, Norris B, Chia SK, Bryce C, Gelmon KA. Late risk of relapse and mortality among postmenopausal women with estrogen responsive early breast cancer after 5 years of tamoxifen. Ann Oncol 2007; 18:45-51. [PMID: 17030545 DOI: 10.1093/annonc/mdl334] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Letrozole after 5 years of adjuvant tamoxifen results in a significant reduction in risk of recurrence from estrogen receptor (ER) positive breast cancer. An individualized estimate of the risk of relapse and death after 5 years of tamoxifen could improve decisions regarding extended hormonal therapy. METHODS The British Columbia Breast Cancer Outcomes database was used to identify women aged 45 years or older at the time of diagnosis with early-stage (I-IIIA) breast cancer who received tamoxifen and were disease free 5 years after diagnosis. Ten-year breast cancer event rates and mortality were calculated as well as annualized hazard rates of recurrence. RESULTS A total of 1086 women were identified with a median age of 64 years and follow-up of 10.5 years. The relative risk (RR) of death was 3.1 (P=0.003) and for recurrence was 1.7 (P=0.037) for N1 (one to three positive nodes) versus N0 (zero nodes positive) disease. N2 (four to nine nodes positive) had a RR of 5.8 (P<0.001) for death and 3.0 (P=0.002) for recurrence. Low tumor grade and high ER level subgroups had a more favorable prognosis. Annual breast cancer risk between years 6 and 10 was, respectively, 2.2%, 3.5% and 7.6% for N0, N1 and N2 disease and 2.6% and 4.5% for T1 and T2 breast cancer. CONCLUSION T and N stages predicted late relapse and death from breast cancer in a population-based cohort of postmenopausal women. Risk estimates reported herein may be used to optimize decision making regarding adjuvant therapy after 5 years of tamoxifen.
Collapse
MESH Headings
- Aged
- Aged, 80 and over
- Antineoplastic Agents, Hormonal/therapeutic use
- Aromatase Inhibitors/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/mortality
- British Columbia
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Lobular/drug therapy
- Carcinoma, Lobular/mortality
- Chemotherapy, Adjuvant
- Female
- Humans
- Letrozole
- Middle Aged
- Neoplasm Invasiveness
- Neoplasm Recurrence, Local/mortality
- Neoplasm Staging
- Neoplasms, Hormone-Dependent/drug therapy
- Neoplasms, Hormone-Dependent/mortality
- Nitriles/therapeutic use
- Postmenopause
- Prognosis
- Risk Factors
- Survival Rate
- Tamoxifen/therapeutic use
- Triazoles/therapeutic use
Collapse
Affiliation(s)
- H F Kennecke
- Division of Medical Oncology, British Columbia (BC) Cancer Agency; Department of Medicine, University of British Columbia, Vancouver, BC; Breast Cancer Outcomes Unit.
| | - I A Olivotto
- Department of Medicine, University of British Columbia, Vancouver, BC; Breast Cancer Outcomes Unit; Population and Preventive Oncology Programs; Victoria
| | - C Speers
- Breast Cancer Outcomes Unit; Population and Preventive Oncology Programs
| | - B Norris
- Department of Medicine, University of British Columbia, Vancouver, BC; Breast Cancer Outcomes Unit; Fraser Valley, BC Cancer Agency, Canada
| | - S K Chia
- Division of Medical Oncology, British Columbia (BC) Cancer Agency; Department of Medicine, University of British Columbia, Vancouver, BC; Breast Cancer Outcomes Unit
| | - C Bryce
- Division of Medical Oncology, British Columbia (BC) Cancer Agency; Department of Medicine, University of British Columbia, Vancouver, BC; Breast Cancer Outcomes Unit
| | - K A Gelmon
- Division of Medical Oncology, British Columbia (BC) Cancer Agency; Department of Medicine, University of British Columbia, Vancouver, BC; Breast Cancer Outcomes Unit
| |
Collapse
|
29
|
Hébert-Croteau N, Roberge D, Brisson J. Provider’s volume and quality of breast cancer detection and treatment. Breast Cancer Res Treat 2006; 105:117-32. [PMID: 17186361 DOI: 10.1007/s10549-006-9439-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Accepted: 10/24/2006] [Indexed: 11/26/2022]
Abstract
For many health conditions, the process or result of medical procedures improves with increasing caseload. The evidence about breast cancer has not been thoroughly assessed. This review synthesizes the literature about provider's volume and performance in either breast cancer screening with mammography or treatment. Articles published in English between 1990 and 2006 were identified by a computerized search and by review of reference lists. In screening with mammography, the reading volume of the radiologist and the screening volume of the facility influence different components of performance. The most conclusive evidence for breast cancer treatment concerns the association between the surgeon's caseload and the process or end-results of therapeutic interventions. Although the mechanisms of these associations still need to be clarified, large provider's volume in screening mammography or breast cancer treatment is often related to the quality of medical interventions.
Collapse
Affiliation(s)
- Nicole Hébert-Croteau
- Direction des Systèmes de Soins et Services, Institut National de Santé Publique du Québec, 190 Boul. Crémazie Est, Bureau 2.24, Montréal, Quebec, Canada.
| | | | | |
Collapse
|
30
|
Cheang MCU, Treaba DO, Speers CH, Olivotto IA, Bajdik CD, Chia SK, Goldstein LC, Gelmon KA, Huntsman D, Gilks CB, Nielsen TO, Gown AM. Immunohistochemical detection using the new rabbit monoclonal antibody SP1 of estrogen receptor in breast cancer is superior to mouse monoclonal antibody 1D5 in predicting survival. J Clin Oncol 2006; 24:5637-44. [PMID: 17116944 DOI: 10.1200/jco.2005.05.4155] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Estrogen receptor (ER) expression predicts improved breast cancer-specific survival and reduced risk of recurrence and is targeted in breast cancer therapy. A high-quality antibody to identify ER-positive patients plays an important role in clinical decision making for women with breast cancer. This study evaluates immunohistochemistry using two anti-ER antibodies, a new rabbit monoclonal antibody (SP1) and the mouse monoclonal antibody (1D5), in relation to biochemical ER assay results and clinical data on survival and adjuvant systemic therapy. PATIENTS AND METHODS A population-based tissue microarray series of 4,150 invasive breast cancers was constructed. All patients had staging, pathology, treatment, and follow-up information. The median follow-up was 12.4 years and the median age at diagnosis 60 years. Survival analysis and log-rank tests were used to evaluate the prognostic value of ER status and correlations with clinical data. RESULTS Among the 4,105 samples interpretable for both antibodies, SP1 detected ER positivity in 69.5% and 1D5 in 63.1% of cases. Both monoclonal antibodies are demonstrated to be good prognostic indictors for breast cancer-specific and relapse-free survival. In multivariate analysis, including age, tumor size, grade, and lymphovascular and nodal status, SP1 was a better independent prognostic factor than 1D5. Among patients with discrepant ER results, the 8% of patients who were SP1 positive/1D5 negative showed good outcomes, and the 2% SP1-negative/1D5 positive had poor outcomes. Maintaining the same 92% specificity and 98% positive predictive value, SP1 is 8% more sensitive than 1D5 using biochemical assay as gold standard. CONCLUSION SP1 represents an improved standard for ER immunohistochemistry assessment in breast cancer.
Collapse
Affiliation(s)
- Maggie C U Cheang
- Genetic Pathology Evaluation Centre at Vancouver General Hospital, Prostate Centre, and University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Albain KS, de la Garza Salazar J, Pienkowski T, Aapro M, Bergh J, Caleffi M, Coleman R, Eiermann W, Icli F, Pegram M, Piccart M, Snyder R, Toi M, Hortobagyi GN. Reducing the Global Breast Cancer Burden: The Importance of Patterns of Care Research. Clin Breast Cancer 2005; 6:412-20. [PMID: 16381624 DOI: 10.3816/cbc.2005.n.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Breast cancer treatment guidelines are not uniformly followed in clinical practice, with evidence for substantial variations in treatment patterns, quality of care, and patient outcomes among and within countries. The factors that drive treatment decisions are unclear. Furthermore, the impact of different treatment strategies on survival is poorly understood outside the clinical trial setting. Sources of patterns of care information often have limitations in completeness, quality, timeliness of reporting, and relevance to the larger population. Patterns of care studies frequently lack details on cancer stage at diagnosis, tumor biology, and treatment received. It is difficult to compare data between studies and/or track changes over time because of variations in data sources and collection techniques. Thus, the design and implementation of a global registry is sorely needed in order to prospectively evaluate worldwide patterns of care and outcomes in patients with breast cancer. Components of this registry should include random selection of centers of variable practice settings in multiple countries and accurate and rapid data reporting at prestudy and follow-up timepoints. Data collected would include tumor and demographic factors, staging information, treatment rendered, and survival. Variables that influenced the treatment selected would be assessed. This unique international effort would allow the development of strategies to improve diagnostic and treatment-related standards of care and survival outcomes, thus reducing the breast cancer burden worldwide.
Collapse
Affiliation(s)
- Kathy S Albain
- Loyola University Chicago Strich School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL 60153, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Nakhlis F, Lazarus L, Hou N, Acharya S, Khan SA, Staradub VL, Rademaker AW, Morrow M. Tamoxifen Use in Patients with Ductal Carcinoma In Situ and T1a/b N0 Invasive Carcinoma. J Am Coll Surg 2005; 201:688-94. [PMID: 16256910 DOI: 10.1016/j.jamcollsurg.2005.06.195] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2005] [Revised: 06/07/2005] [Accepted: 06/08/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND The purpose of this study was to determine how often patients with ductal carcinoma in situ and T1a/b N0 cancer are offered and accept tamoxifen for secondary chemoprevention. STUDY DESIGN A retrospective review of 284 patients with T1a/b N0 invasive cancer treated between February 1995 and December 2001 and 129 patients with DCIS treated after September 1998 was carried out. Patient and tumor characteristics associated with being offered and accepting tamoxifen were compared. RESULTS Tamoxifen was offered to 67% of the invasive cancer patients and accepted by 76% (51% of the entire group). Hormone receptor status was the only significant predictor of being offered tamoxifen (p = 0.004). Older age (p = 0.04), Caucasian race (p = 0.01), and parity (p = 0.04) in premenopausal women were significant predictors of tamoxifen acceptance on univariate analysis. After the publication of the National Surgical Adjuvant Breast and Bowel Project P-1 trial, significantly more patients were offered tamoxifen (p = 0.02), but acceptance rates did not change. Tamoxifen was offered to 91% of the ductal carcinoma in situ patients and accepted by 73% (67% overall). Lumpectomy was associated with significantly higher rates of being offered (p = 0.02) and accepting tamoxifen (p = 0.002) on univariate analysis. CONCLUSIONS Factors associated with tamoxifen risks and benefits correlate poorly with the use of the drug.
Collapse
MESH Headings
- Antineoplastic Agents, Hormonal/therapeutic use
- Breast Neoplasms/drug therapy
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/drug therapy
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Humans
- Mastectomy
- Middle Aged
- Neoplasm Staging
- Retrospective Studies
- Tamoxifen/therapeutic use
Collapse
Affiliation(s)
- Faina Nakhlis
- Department of Surgery, Lynn Sage Breast Program, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Ottevanger PB, De Mulder PHM. The quality of chemotherapy and its quality assurance. Eur J Surg Oncol 2005; 31:656-66. [PMID: 15893906 DOI: 10.1016/j.ejso.2005.02.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2004] [Revised: 11/11/2004] [Accepted: 02/10/2005] [Indexed: 11/27/2022] Open
Abstract
AIMS Assessment of the quality of chemotherapy care and its quality assurance in clinical trials and daily practice. METHODS Using Medline, literature was searched combining the following words: quality assurance or quality of care, combined with anti-neoplastic agents. The bibliography of each article was reviewed for additional literature. Those reports in English, French, German or Dutch focusing quality assurance or quality of care and chemotherapy were selected. RESULTS One hundred and five articles were selected by Medline and after review and adding of additional literature 53 articles remained. In clinical trials information on quality of chemotherapy is sparse. Different cooperative groups reported on suboptimal dosing, suboptimal registration of chemotherapy and several trials indicated that suboptimal dosing led to impaired outcome. Most quality assurance activities in clinical trials are concerned with audit and feedback and on-site visits. In daily practice the quality of chemotherapy is mostly impaired by the fact that it is not given although indicated and if it is given non-evidence based chemotherapy or administration schedules and reduced dose intensity decrease the quality of care. Especially, age, comorbidity and socio-economic status reduce the chance of receiving good quality of care regarding chemotherapy. Activities mostly used for quality assurance are generation of guidelines, specialisation and multidisciplinary care. CONCLUSIONS Most quality assurance activities in clinical trials and daily practice are directed to structure and process parameters. More evidence that quality of care is related to outcome should be sought. Quality assurance in daily practice should aim at guideline implementation, specialisation and multidisciplinary care and should pay attention especially to the older patients, patients with comorbidity and patients from lower socio-economic classes.
Collapse
Affiliation(s)
- P B Ottevanger
- Division Medical Oncology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
| | | |
Collapse
|
34
|
Olivotto IA, Bajdik CD, Ravdin PM, Speers CH, Coldman AJ, Norris BD, Davis GJ, Chia SK, Gelmon KA. Population-based validation of the prognostic model ADJUVANT! for early breast cancer. J Clin Oncol 2005; 23:2716-25. [PMID: 15837986 DOI: 10.1200/jco.2005.06.178] [Citation(s) in RCA: 372] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Adjuvant! (www.adjuvantonline.com) is a web-based tool that predicts 10-year breast cancer outcomes with and without adjuvant systemic therapy, but it has not been independently validated. METHODS Using the British Columbia Breast Cancer Outcomes Unit (BCOU) database, demographic, pathologic, staging, and treatment data on 4,083 women diagnosed between 1989 and 1993 in British Columbia with T1-2, N0-1, M0 breast cancer were abstracted and entered into Adjuvant! to calculate predicted 10-year overall survival (OS), breast cancer-specific survival (BCSS), and event-free survival (EFS) for each patient. Individual BCOU observed outcomes at 10 years were independently determined. Predicted and observed outcomes were compared. RESULTS Across all 4,083 patients, 10-year predicted and observed outcomes were within 1% for OS, BCSS, and EFS (all P > .05). Predicted and observed outcomes were within 2% for most demographic, pathologic, and treatment-defined subgroups. Adjuvant! overestimated OS, BCSS, and EFS in women younger than age 35 years (predicted-observed = 8.6%, 9.6%, and 13.6%, respectively; all P < .001) or with lymphatic or vascular invasion (LVI; predicted-observed = 3.6%, 3.8%, and 4.2%, respectively; all P < .05); these two prognostic factors were not automatically incorporated within the Adjuvant! algorithm. After adjusting for the distribution of LVI, using the prognostic factor impact calculator in Adjuvant!, 10-year predicted and observed outcomes were no longer significantly different. CONCLUSION Adjuvant! performed reliably. Patients younger than age 35 or with known additional adverse prognostic factors such as LVI require adjustment of risks to derive reliable predictions of prognosis without adjuvant systemic therapy and the absolute benefits of adjuvant systemic therapy.
Collapse
Affiliation(s)
- Ivo A Olivotto
- Breast Cancer Outcomes Unit, Vancouver Island Centre, 2410 Lee Avenue, Victoria, BC V8R 6V5, Canada.
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Hodgson DC, Brierley JD, Cernat G, Bondy S, Slaughter PM, Pinfold SP, Paszat LF. The consistency of panelists’ appropriateness ratings: do experts produce clinically logical scores for rectal cancer treatment? Health Policy 2005; 71:57-65. [PMID: 15563993 DOI: 10.1016/j.healthpol.2004.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To quantify the clinical consistency of expert panelists' ratings of appropriateness of pre-operative and post-operative chemotherapy plus radiation for rectal cancer. METHODS A panel of nine physicians (two surgeons, four medical oncologists, three radiation oncologists) rated the appropriateness of providing pre-operative and post-operative treatments for rectal cancer, utilizing a modified-Delphi (RAND/UCLA) approach. Clinical scenarios were paired so that each component of a pair differed by only one clinical feature (e.g. tumor stage). A pair of appropriateness ratings was defined as inconsistent when the clinical scenario that should have had the higher (or at least equal) appropriateness rating was given a lower rating. The rate of inconsistency was analyzed for panelists' ratings of pre- and post-operative chemotherapy plus radiation. RESULTS The final panel rating was inconsistent for 1.19% of pre-operative scenario pairs, and 0.77% of post-operative scenario pairs. Using the conventional RAND/UCLA definition of appropriateness, the magnitude of the inconsistency would produce inconsistent appropriateness ratings in 0.43% of pre-operative and 0.11% of post-operative scenario pairs. There was significant variation in the rate of inconsistency among individual panelists' final ratings of both pre-operative (range: 0.43-5.17%, P < 0.001) and post-operative (range: 0.51-2.34%, P < 0.001) scenarios. Panelists' overall average rate of inconsistency improved significantly after the panel meeting and discussion (from 5.62 to 2.25% for pre-operative scenarios, and from 1.47 to 1.24% for post-operative scenarios, both P < 0.05). There was no clear difference between specialty groups. Inconsistency was related to the structure of the rating manual: in the second round there were no inconsistent ratings when scenario pairs occurred on the same page of the manual. CONCLUSIONS The RAND/UCLA appropriateness method can produce ratings for cancer treatment that are highly clinically consistent. Modifications to the structure of rating manuals to facilitate direct assessment of consistency at the time of rating may reduce inconsistency further.
Collapse
Affiliation(s)
- David C Hodgson
- Department of Radiation Oncology, Princess Margaret Hospital, 610 University Ave., Toronto, Ont., Canada M5G 2M9.
| | | | | | | | | | | | | |
Collapse
|
36
|
Gaudette LA, Gao RN, Spence A, Shi F, Johansen H, Olivotto IA. Declining use of mastectomy for invasive breast cancer in Canada, 1981-2000. Can J Public Health 2004; 95:336-40. [PMID: 15490921 [PMID: 15490921 DOI: 10.1007/bf03405141] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the rate and magnitude of change in surgical practice for breast cancer in Canada in relation to publication dates of clinical trials and consensus conferences. METHODS Hospital separations with a diagnosis of invasive breast cancer were extracted from the Hospital Morbidity File from 1981 to 2000. Age-standardized rates of in-patient procedures for breast-conserving surgery and mastectomy were analyzed by province and age group and by geographic region. RESULTS In Canada, mastectomy rates decreased from 62.2 to 37.9 per 100,000 between 1981 and 2000; declines were largest between 1984 and 1985, following publication of the NSABP B-06 clinical trial in March 1985, and between 1991 and 1993, after the US NIH Consensus Conference in February 1991. Mastectomy rates plateaued between 1985 and 1991, and from 1993 to 2000; the transitory peak in 1988 corresponded to publicity surrounding Nancy Reagan's choice of mastectomy in 1987. Regional variations from the main pattern led to increasingly divergent mastectomy rates over time. Women aged 80+ were less likely to be treated by any surgery. INTERPRETATION Publication of clinical trial results and consensus conferences were associated with changes in surgical treatment for breast cancer in Canada. However, divergent mastectomy rates among Canadian regions point to inconsistent adoption of less invasive therapy despite a publicly-funded health care system and national consensus guidelines.
Collapse
|
37
|
Hébert-Croteau N, Brisson J, Latreille J, Rivard M, Abdelaziz N, Martin G. Compliance With Consensus Recommendations for Systemic Therapy Is Associated With Improved Survival of Women With Node-Negative Breast Cancer. J Clin Oncol 2004; 22:3685-93. [PMID: 15289491 DOI: 10.1200/jco.2004.07.018] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The impact of consensus recommendations for systemic therapy on outcome of disease is unclear. We evaluated if compliance with guidelines for systemic adjuvant treatment is associated with improved survival of women with node-negative breast cancer. Patients and Methods The study population included women diagnosed with invasive node-negative breast cancer in Québec, Canada, in 1988 to 1989, 1991 to 1992, and 1993 to 1994. Information was collected by chart review, linkage with administrative databases, and queries to attending physicians. Guidelines from the 1992 St Gallen conference were used as standard of care. Survival was estimated by Kaplan-Meier and Cox proportional hazards analyses. Results Among 1,541 women, 358 died before December 1999. Median follow-up was 6.8 years. Seven-year event-free and overall survivals were 66% and 81%, respectively. Survival was 88%, 84%, and 74% in women at minimal, moderate, or high risk of recurrence. Virtually all women at minimal risk were treated according to the consensus (98.4% of 370). In comparison, adjusted hazard ratios of death were 1.0 (95% CI, 0.6 to 1.7) and 2.3 (95% CI, 1.3 to 4.0) among women at moderate risk treated according to the consensus or not, respectively. Among women at high risk, adjusted hazard ratios of death were 2.0 (95% CI, 1.4 to 2.8) and 2.7 (95% CI, 1.9 to 3.9), respectively. Both risk category (P < .0005) and compliance with guidelines (P < .0005) were independent significant predictors of survival. Conclusion Treatment according to consensus recommendations is associated with improved survival of women with breast cancer in the community. Promoting the adoption of guidelines for treatment is an effective strategy for disease control.
Collapse
Affiliation(s)
- Nicole Hébert-Croteau
- Direction des systèmes de soins et services, Institut national de santé publique du Québec, Montreal, Québec H2J 3G8, Canada.
| | | | | | | | | | | |
Collapse
|
38
|
Chia SK, Speers CH, Bryce CJ, Hayes MM, Olivotto IA. Ten-Year Outcomes in a Population-Based Cohort of Node-Negative, Lymphatic, and Vascular Invasion–Negative Early Breast Cancers Without Adjuvant Systemic Therapies. J Clin Oncol 2004; 22:1630-7. [PMID: 15117985 DOI: 10.1200/jco.2004.09.070] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeTo discuss the absolute benefits from adjuvant systemic therapy knowledge of long-term outcomes and baseline risks of relapse and disease-specific survival are required. We assessed the 10-year outcomes in a population-based cohort of node-negative (N−) lymphovascular negative (LV−) early breast cancers diagnosed from 1989 to 1991 who did not receive adjuvant systemic therapy.MethodsOne thousand one hundred eighty-seven cases of pT1–2N0LV− breast cancers with a median follow-up of 10.4 years were reviewed. Kaplan-Meier survival curves for relapse free survival (RFS), breast cancer–specific survival (BCSS) and overall survival (OS) were compared with log-rank tests with cohorts stratified for tumor size and grade.ResultsThe median age of this series was 62 years. Four hundred thirty tumors were ≤ 1 cm in diameter (cohort 1), 507 were 1.1–2 cm (cohort 2), and 250 were 2.1 to 5 cm in diameter (cohort 3). The 10-year outcomes for cohorts 1, 2, and 3, respectively, were significantly different: RFS, 82%, 75%, and 66%; BCSS, 92%, 90%, and 77%; and OS, 79%, 78%, and 66%. Tumor grade significantly altered outcome within size cohorts, particularly in pT1N0breast cancers.ConclusionThis study provides detailed information on the continued relapse and breast cancer death rate to 10 years of follow-up. Specifically, without adjuvant systemic therapy, patients with LV−, N − breast cancer had a ≥ 25% 10-year risk of relapse and a corresponding 10-year breast cancer death rate of ≥ 10% if they had either a grade 3 tumor ≤ 1 cm, a grade 2 to 3 tumor from 1.1 to 2 cm, or any grade tumor greater than 2 cm.
Collapse
Affiliation(s)
- Stephen K Chia
- Division of Medical Oncology, Breast Cancer Outcomes Unit, British Columbia Cancer Agency, 600 West 10th Ave, Vancouver, BC Canada, V5Z 4E6.
| | | | | | | | | |
Collapse
|
39
|
Abstract
This study was to determine if the use of regional radiotherapy (RT) changed in British Columbia after publication of new randomized trial data in 1997. Women with pathologic T1-3N1, nonmetastatic breast cancer treated with a mastectomy or breast-conserving surgery (BCS) were included. The use of regional RT was compared in two cohorts: cohort 1, July 1, 1995-June 30, 1997 (n = 834); and cohort 2, July 1, 1998-June 30, 2000 (n = 1072). All p-values were two-sided. Adjuvant systemic therapy was given to 96% and 95% of women in cohorts 1 and 2, respectively. Forty-five percent of cohort 1 and 48% of cohort 2 had BCS. Regional RT was received by 44% of cohort 1 and 66% of cohort 2 (p < 0.001). Eighty-eight percent and 90% of women with four or more positive nodes in cohorts 1 and 2 received regional RT, respectively. For women in cohorts 1 and 2 with one to three positive nodes, regional RT use increased from 32% to 54% after mastectomy, and from 23% to 59% after BCS, respectively (p < 0.001 for both). Publication of randomized trials and a coordinated guideline implementation process in British Columbia was associated with a significant increase in the use of regional RT in women with one to three positive nodes.
Collapse
Affiliation(s)
- Boon Chua
- Radiation Therapy and Systemic Therapy Programs, British Columbia Cancer Agency, Vancouver Island Center, Victoria, British Columbia, Canada
| | | | | | | | | | | |
Collapse
|
40
|
Laskin JJ, Erridge SC, Coldman AJ, D'yachkova Y, Speers C, Westeel V, Hislop TG, Olivotto IA, Murray N. Population-based outcomes for small cell lung cancer: impact of standard management policies in British Columbia. Lung Cancer 2004; 43:7-16. [PMID: 14698532 DOI: 10.1016/j.lungcan.2003.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Survival data for small cell lung cancer (SCLC) is typically reported from clinical trials or institutional series that include patients fit enough to meet treatment criteria. The denominator of all SCLC patients from which the treated population is derived is rarely reported and the impact of new treatment strategies on population-based outcomes is difficult to measure. The British Columbia Cancer Agency (BCCA) is a single centralized agency that coordinates cancer treatment services in the province and develops and circulates province-wide treatment guidelines. All SCLC cases diagnosed in BC in 1990 and 1995 (n=331 and 297, respectively) were identified. These 2 years were chosen specifically to examine the impact of a change in practice guidelines from consolidative to early concurrent thoracic radiation (RT) for patients with limited stage disease. Demographic, staging, treatment, and outcome details were obtained for 100% of cases. A total of 628 patients were reviewed, 207 with limited stage disease (LSCLC) and 407 with extensive stage disease (ESCLC); 14 cases diagnosed at post-mortem were excluded. Of the 207 patients with LSCLC disease, 170 (82%) received chemotherapy, and 138 (81%) of those that received chemotherapy also received thoracic radiation. A similar proportion (73 and 70%) of LSCLC patients received thoracic RT in both years but more patients in 1995 received early concurrent versus consolidative thoracic RT compared to those treated in 1990 (64% versus 17%, respectively, P=0.001). Of the 407 patients with ESCLC, 71% received chemotherapy. The median overall survival for all patients was 7 months. Patients with LSCLC who received any chemotherapy had a median survival of 14.3 months (26.9 and 9.9% for 2- and 5-year survival, respectively). Patients with LSCLC who received chemotherapy plus thoracic RT had a median survival of 15.1 months (32 and 12% for 2- and 5-year survival, respectively). Early concurrent thoracic RT in LSCLC was associated with an improved 5-year survival from 9.6 to 16.3% (P=0.91). Patients with ESCLC who received any chemotherapy had a median survival of 8.4 months (7.3 and 2.3% for 2- and 5-year survival, respectively). Standard treatment guidelines generated population-based survival outcomes that are similar to published clinical trials.
Collapse
Affiliation(s)
- Janessa J Laskin
- Division of Medical Oncology, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, BC, Canada V5Z 4E6.
| | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Abstract
British Columbian provincial practice guidelines (PPGs) have recommended breast-conserving surgery (BCS), axillary node dissection, and radiation therapy following BCS for specific subgroups of breast cancer patients. Patient-, disease-, and physician-specific factors associated with these therapies were investigated in nonmetastatic invasive breast cancer patients. Temporal trends in BCS and physicians' experiences with PPGs were also examined. Sources of data for patient, disease, treatment, and treating physician factors included medical records, source documents, and the British Columbia Medical Directory for 967 nonmetastatic invasive breast cancer patients diagnosed in British Columbia in 1995. BCS utilization among 496 patients with pathologically node-negative breast cancer (NNBC) was compared to earlier British Columbian data. Family physicians and surgeons were surveyed in 1997 regarding their experience with PPGs. 57% of "ideal" candidates received BCS; 87% of patients received axillary node dissection; and 95% of women treated with BCS also received radiation therapy. Tumor size, tumor location, and extent of ductal carcinoma in situ (DCIS) were associated with BCS use; age, tumor size, and tumor location were associated with axillary node dissection; and age alone was associated with radiation therapy following BCS. Fifty-four percent of NNBC patients received BCS in 1995, compared to 44% in 1991, with increases seen in most patient-, disease-, and physician-specific comparisons. The increase in BCS, and high proportion completing radiation therapy, are encouraging and may be due in part to greater exposure to PPGs.
Collapse
Affiliation(s)
- T Gregory Hislop
- Population and Preventative Oncology Program, BC Cancer Agency, Vancouver, British Columbia, Canada.
| | | | | | | | | |
Collapse
|
42
|
Balasubramanian SP, Murrow S, Holt S, Manifold IH, Reed MW. Audit of compliance to adjuvant chemotherapy and radiotherapy guidelines in breast cancer in a cancer network. Breast 2003; 12:136-41. [PMID: 14659343 DOI: 10.1016/s0960-9776(02)00263-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The North Trent Cancer Network Breast Group in the United Kingdom revised its adjuvant treatment guidelines in breast cancer management in 1998. We aimed to check the compliance to the guidelines, 8 months after their introduction. Data were collected, retrospectively, from the medical records of patients with invasive breast cancer who underwent definitive surgery (in a 3-month period) in different cancer units and the cancer centre within the North Trent Cancer Network. The overall compliance to treatment guidelines was 82% (90% and 74% for chemotherapy and radiotherapy, respectively), which was similar across the network. In 5% of cases, compliance could not be determined. On case review, 22% of the non-compliant incidents were justified and 16% seemed to be due to variation in guideline interpretation. We discuss the possible reasons for non-compliance and show a need to periodically monitor compliance to adjuvant treatment guidelines.
Collapse
Affiliation(s)
- S P Balasubramanian
- Surgical Oncology, K Floor, Royal Hallamshire Hospital, University of Sheffield, Sheffield S10 2JF, UK
| | | | | | | | | |
Collapse
|
43
|
Nagel G, Röhrig B, Hoyer H, Wedding U, Katenkamp D. A population-based study on variations in the use of adjuvant systemic therapy on postmenopausal patients with early stage breast cancer. J Cancer Res Clin Oncol 2003; 129:183-91. [PMID: 12709795 DOI: 10.1007/s00432-003-0417-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2002] [Accepted: 12/23/2002] [Indexed: 10/25/2022]
Abstract
PURPOSE To assess adherence to treatment recommendations regarding adjuvant systemic therapy of postmenopausal patients with early stage breast cancer. METHODS A population-based cohort of women from Eastern Thuringia/Germany with first diagnosis of breast cancer in 1995-2000 was studied. The use of adjuvant therapy was assessed separately for patients with positive and negative nodal status fitting polytomous logistic regression models. RESULTS Among 396 women with positive lymph nodes and 832 with negative lymph nodes, 92.9% and 87.3% received an adjuvant systemic treatment, respectively. Age, comorbidity, hormone receptor status, histological grading, and additionally, in nodal positives, the number of involved lymph nodes, were associated with treatment patterns. Age had the strongest impact on treatment decision. Older women more often received hormone- or no adjuvant therapy. However, 26.3% of the women with lymph node involvement and positive hormone receptor status received no hormone therapy, whereas 35.7% of women with negative hormone receptor status received hormone therapy. CONCLUSION The number of patients with adjuvant systemic therapy is high in women with positive and those with negative lymph nodes, reflecting adherence to the recommendations. Better outcome could be expected if hormone therapy was used adequately in receptor positives. Further follow-up is required to monitor the outcome and changes in adherence to treatment recommendations.
Collapse
Affiliation(s)
- G Nagel
- Comprehensive Cancer Centre/Field Study Breast Cancer, Friedrich-Schiller University, Jena, Thuringia, Germany.
| | | | | | | | | |
Collapse
|
44
|
White J, Morrow M, Moughan J, Owen J, Pajak T, DesHarnais S, Winchester DP, Wilson JF. Compliance with breast-conservation standards for patients with early-stage breast carcinoma. Cancer 2003; 97:893-904. [PMID: 12569588 DOI: 10.1002/cncr.11141] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Multiple treatment guidelines and practice standards have been developed regarding the management of patients with breast carcinoma. Few evaluations of the penetration and utility of these practice standards have been performed. In 1992, the American College of Surgeons (ACOS), the American College of Radiology, the College of American Pathologists, and the Society of Surgical Oncology collaborated in establishing standards for breast-conservation treatment (BCT). The authors sought to determine whether practice patterns for patients with breast carcinoma who underwent BCT were consistent with these standards 2 years after their dissemination and to establish whether compliance varied by the same patient and hospital variables that predicted for the amount of BCT performed. METHODS A study specific questionnaire was circulated to cancer registrars through the Commission on Cancer of the ACOS asking them to submit reports on patients with Stage I and II breast carcinoma who were diagnosed in 1994. Eight hundred forty-two predominantly community hospitals throughout the United States responded, yielding a total of 16,643 analyzable patients. The frequency of compliance to the 1992 published practice standards for 7097 patients who received BCT was determined. The variation in compliance rates by patient age, race, and insurance status and the treating hospital's geographic locations and cancer programs were evaluated. RESULTS Of the 22 standards that were evaluated in the areas of preoperative mammography (2 standards), labeling of the surgical specimen (3 standards), pathology report content (10 standards), radiation after lumpectomy (6 standards), and systemic therapy for patients with positive lymph nodes (1 standard), treatment adherence was > or = 80% for 16 standards (73%). Poor compliance was demonstrated for six standards: the documentation of an abnormality's size in the mammogram report, labeling the lumpectomy specimen with the affected quadrant of the breast, spatial orientation of the lumpectomy specimen and inclusion of lymphatic/vascular invasion, ductal carcinoma in situ, and macroscopic margin assessment in the pathology report. Variation in compliance to a standard occurred frequently across the type of hospital cancer program and geographic region (77% for both), and variation occurred less across the patient variables of age (32%), race (41%), and payer (23%). There was not a pattern of more frequent compliance among variables associated with more BCT use. CONCLUSIONS Large-scale evaluation of the penetration of treatment standards is feasible. For patients who underwent lumpectomy, practice appeared to be consistent (> or = 80% compliance), with 73% of 22 treatment standards evaluated. The standards with poor compliance represent areas for targeted physician education and reevaluation. Significant differences in adherence to a standard were seen frequently based on a hospital's geographic location and type of cancer program. This emphasizes the importance of adequate dissemination of treatment standards to ensure penetration into medical practices of all types.
Collapse
Affiliation(s)
- Julia White
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Chua B, Olivotto IA, Donald JC, Hayashi AH, Doris PJ, Turner LJ, Cuddington GD, Davis NL, Rusnak CH. Outcomes of sentinel node biopsy for breast cancer in British Columbia, 1996 to 2001. Am J Surg 2003; 185:118-26. [PMID: 12559440 DOI: 10.1016/s0002-9610(02)01215-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND This study evaluated the outcomes of the first 5 years of sentinel node biopsy (SNB) in British Columbia (BC), Canada, 1996 to 2001. METHODS There were 547 SNB procedures for breast cancer performed by 29 surgeons at 12 hospitals in BC between October 1996 and July 2001. Identification, accuracy, and false-negative rates were determined and correlated to patient, tumor, and surgical factors with the chi-square test. RESULTS SNB mapping was performed using blue dye alone (15%), radiopharmaceutical alone (6%), or both (79%). A completion axillary dissection was performed in 93%. A median of 2 (range 1 to 16) sentinel nodes was biopsied. The overall identification rate was 88%, accuracy was 92%, and false-negative rate was 22%. All rates were improved in younger (age <50 years) compared with older women. A positive lymphoscintiscan and the mapping agent used were associated with higher identification rates but not accuracy or false negative rates. Increasing surgeon experience was not significantly associated with improvements in identification or false-negative rates. CONCLUSIONS The potential of SNB was not fully translated into surgical practice in BC by 2001.
Collapse
Affiliation(s)
- Boon Chua
- Radiation Therapy Program, BC Cancer Agency, Vancouver Island Centre, 2410 Lee Avenue, Victoria, BC, V8R 6V5, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Lesperance ML, Olivotto IA, Forde N, Zhao Y, Speers C, Foster H, Tsao M, MacPherson N, Hoffer A. Mega-dose vitamins and minerals in the treatment of non-metastatic breast cancer: an historical cohort study. Breast Cancer Res Treat 2002; 76:137-43. [PMID: 12452451 DOI: 10.1023/a:1020552501345] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Alternative therapies such as mega-dose vitamins and minerals are commonly used by women with breast cancer, but their effect on recurrence and survival have rarely been evaluated. METHODS Survival and recurrence outcomes for 90 women with unilateral non-metastatic breast cancer diagnosed between 1989 and 1998, and who had been prescribed mega-doses of beta-carotene, vitamin C, niacin, selenium, coenzyme Q10, and zinc in addition to standard therapies were compared with matched controls. The 90 treated patients were prescribed combinations from three to six of the vitamins and minerals listed above. The controls were matched (2:1) to the vitamin/mineral patients for age at diagnosis, presence of axillary lymph node metastasis, tumor stage, grade, estrogen receptor status, year of diagnosis, and prescription of systemic therapy. All subjects were patients of the British Columbia Cancer Agency, Vancouver Island Centre. FINDINGS Median follow-up of surviving patients was 68 months (minimum 20 months, 133 months maximum). The vitamin/mineral patients and controls were well matched. Two endpoints were considered. Breast cancer-specific survival (p = 0.19) and disease-free survival (p = 0.08) times for the vitamin/mineral treated group were shorter, after adjusting for diagnostic variables using a Cox proportional hazards model. The hazard ratios for the vitamin/mineral treated group versus the control group were estimated at 1.75 (95% CI = 0.83-2.69) for disease-specific survival and 1.55 (95% CI = 0.94-2.54) for disease-free survival. Overall survival was similar for the two groups (log-rank test, p = 0.36). INTERPRETATION Breast cancer-specific survival and disease-free survival times were not improved for the vitamin/mineral treated group over those for the controls.
Collapse
Affiliation(s)
- M L Lesperance
- Department of Mathematics and Statistics, University of Victoria, Victoria, British Columbia, Canada.
| | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
PURPOSE To critically review studies that describe patterns of care for breast cancer patients and to examine the data sources used for case identification and determining patterns of care. METHODS We searched the MEDLINE database (National Library of Medicine, Bethesda, MD) in August 2001 for studies of breast cancer care published from January 1985 to June 2001. Thirty-eight articles, describing 32 studies, met the inclusion criteria for this review. RESULTS According to the patterns of care literature, approximately 10% of women do not have an axillary lymph node dissection, 11% to 26% do not have their hormone receptor status reported, 20% do not receive radiation after breast-conserving surgery, and 30% to 70% of women with lymph node-positive breast cancer are not prescribed tamoxifen. Twenty-five (78%) of the studies relied on cancer registries for case identification. Cancer registries (47%) and the medical record (38%) were the most frequent sources of data on process of care. Twenty percent of the articles reported using more than one data source to determine patterns of care. CONCLUSION Although more patterns of care research has taken place in breast cancer than in any other oncologic condition, we found the available data had many limitations. These limitations highlight the challenges of quality-of-care research. To track changes in the quality of cancer care that may result from our rapidly transforming health care system, we need reliable data on the quality of current practice.
Collapse
Affiliation(s)
- Jennifer L Malin
- Department of Medicine, Jonsson Comprehensive Cancer Center, University of California Los Angeles, 90095-1736, USA.
| | | | | | | |
Collapse
|
48
|
McKee MD, Cropp MD, Hyland A, Watroba N, McKinley B, Edge SB. Provider case volume and outcome in the evaluation and treatment of patients with mammogram-detected breast carcinoma. Cancer 2002; 95:704-12. [PMID: 12209712 DOI: 10.1002/cncr.10737] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Practice volume may affect the outcome of patients with breast carcinoma. Defining factors that influence the relation of volume and outcome for the diagnosis and treatment of breast carcinoma is important, because breast carcinoma is common, and care is decentralized. METHODS Community-wide diagnosis and treatment of mammogram-detected breast carcinoma was examined using claims data from a single insurer representing 25% of the regional population. Among 1001 mammogram-directed breast biopsies, the rate of breast carcinoma diagnosed by stereotactic core needle biopsy (SCNB) or excisional biopsy with needle localization (EBNL) and the rate at which breast-conserving surgery (BCS) was used were analyzed. Outcome and practice volume were examined for surgeons, radiologists, and medical centers. RESULTS Two hundred twenty-four tumors were diagnosed by EBNL (604 diagnoses) and SCNB (397 tumors), for a 22.4% positive biopsy rate. The median number of procedures per physician was one. Positive biopsy rates for radiologists, surgeons, and medical centers did not correlate with practice volume. Positive biopsy rates for high-volume physician providers and medical centers ranged from 9% to 46%. The BCS rate was 45% and 64% for surgeons treating one or more than one claim, respectively. Tumor stage and surgeon case volume were the only independent predictors of BCS (P < 0.05). CONCLUSIONS There is wide variation in diagnosis and treatment outcomes for patients with mammogram-detected breast carcinoma. Overall, practice volume was correlated with the use of BCS but not with the rate of positive biopsy. A wide variation in the positive biopsy rate among high-volume providers and medical centers suggests that volume of practice is not a surrogate for quality in the diagnosis of breast carcinoma.
Collapse
Affiliation(s)
- Mark D McKee
- Roswell Park Cancer Institute, Buffalo, New York 14263, USA
| | | | | | | | | | | |
Collapse
|
49
|
Foroudi F, Tyldesley S, Walker H, Mackillop WJ. An evidence-based estimate of appropriate radiotherapy utilization rate for breast cancer. Int J Radiat Oncol Biol Phys 2002; 53:1240-53. [PMID: 12128126 DOI: 10.1016/s0360-3016(02)02821-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Current estimates of the proportion of cancer patients who will require radiotherapy (RT) are based almost entirely on expert opinion. We sought to use an evidence-based approach to estimate the proportion of incident cases of breast cancer that will require RT at any point in the evolution of the illness. METHODS AND MATERIALS We undertook a systematic review of the literature to identify indications for RT for breast cancer and to ascertain the level of evidence that supported each indication. An epidemiologic approach was then used to estimate the incidence of each indication for RT in a typical North American population of breast cancer patients. The effect of sampling error on the estimated appropriate rate of RT was calculated mathematically, and the effect of systematic error was estimated by sensitivity analysis. RESULTS It was estimated that 66.4% +/- 4.8% of breast cancer patients develop one or more indications for RT at some point in the course of the illness. The plausible range for this rate was 56.3%-72.4% on sensitivity analysis. Of all breast cancer patients, 57.3% +/- 4.7% require RT in their initial treatment and 9.1% +/- 1.0% do so later for recurrence or progression. The proportion of patients who ever require RT is stage dependent: 39.8% +/- 1.1% in ductal carcinoma in situ; 68.6% +/- 4.1% in Stage I invasive carcinoma; 81.5% +/- 2.3% in Stage II; 95.3% +/- 0.3% in Stage III; and 63.7% +/- 0.3% in Stage IV. CONCLUSION This method provides a rational starting point for the long-term planning of RT services and for the audit of access to RT at the population level. By completing such evaluations in the major cancer sites, it will be possible to estimate the appropriate RT treatment rate for the cancer population as a whole.
Collapse
Affiliation(s)
- Farshad Foroudi
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute and Kingston Regional Cancer Centre, Kingston, Ontario, Canada
| | | | | | | |
Collapse
|
50
|
|