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Kalvala J, Parks RM, Abdi J, Green AR, Cheung KL. Assessment of the Androgen Receptor in Older Women with Primary Breast Cancer: Association with a Panel of Biomarkers and Breast Cancer Specific Survival. Adv Ther 2023; 40:2820-2835. [PMID: 37118159 DOI: 10.1007/s12325-023-02504-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/22/2023] [Indexed: 04/30/2023]
Abstract
INTRODUCTION Breast cancer in older women tends to have more favourable biology, compared to younger women. Androgen receptor (AR) is significant for breast tumour carcinogenesis; however, the role of AR in older women has not been fully explored. METHODS Surgical specimens were obtained from an existing series of 1758 older women (≥ 70 years) with primary breast cancer, treated in a single institution with long-term (≥ 37 years) follow-up. As part of previous work, it was possible to construct good quality tissue microarrays (TMAs) in 575 surgical specimens and a panel of 24 biomarkers was measured by immunohistochemistry (IHC) in these TMAs. AR positivity was assessed by IHC and defined as H-score ≥ 40. The relationship between AR in this cohort was compared to an equivalent group of younger women (< 70 years, n = 1708); the panel of 24 biomarkers and breast cancer specific survival (BCSS) in the older cohort. RESULTS AR was assessed in 509 samples. Overall, 59% of the older women cohort had positive expression of AR, compared to 63% in the younger cohort. AR positivity (regardless of age) was associated with smaller size of tumour, lower grade of tumour, lower tubule formation, lower nuclear polymorphism and lower mitotic frequency. AR positivity was associated with positive expression of oestrogen receptor (ER), progesterone receptor (PR), breast cancer gene 1 (BRCA1), cytokeratin (CK) 7/8, CK18, CK19, B cell lymphoma (Bcl)2 and Mucin 1 (Muc1) expression. Conversely, AR-positive expression was associated with negative expression of human epidermal growth factor receptor 2 (HER2), Ki-67, CK5, CK17, epidermal growth factor receptor (EGFR), and CD44 expression. Older women with AR-positive tumours had better BCSS compared to AR-negative tumours (p = 0.009). CONCLUSIONS There was no difference in AR expression between older and younger women with breast cancer. AR has prognostic potential in terms of BCSS. Further work is needed to investigate AR as a therapeutic target.
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Affiliation(s)
- Jahnavi Kalvala
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Ruth M Parks
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jamal Abdi
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Andrew R Green
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kwok-Leung Cheung
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK.
- Academic Unit for Translational Medical Sciences, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby, DE22 3DT, UK.
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Chan KS, Chong MTH, Chia CLK, Cheung KL. Revisiting primary endocrine therapy versus surgery in older women with breast cancer: meta-analysis. Br J Surg 2023; 110:420-431. [PMID: 36718056 DOI: 10.1093/bjs/znac435] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 10/26/2022] [Accepted: 11/15/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Old age is associated with increased co-morbidities, resulting in reduced life expectancy. Primary endocrine therapy is an alternative to primary surgical therapy for patients with breast cancer and increased co-morbidities. The aim was to review outcomes of primary endocrine therapy versus primary surgical therapy in older women with breast cancer. METHODS PubMed, Embase (Ovid), Scopus, and the Cochrane Library were searched systematically from January 2000 to May 2022. Single-arm studies were excluded. Primary outcomes were overall survival and breast cancer-specific survival. Secondary outcomes were local and regional failure of primary endocrine therapy, recurrence after primary surgical therapy, and health-related quality of life. RESULTS There were 14 studies including 14 254 patients (primary endocrine therapy 2829, 19.8 per cent; primary surgical therapy 11 425, 80.2 per cent), with the addition of four major studies (9538 patients) compared with the latest review in 2014. Seven studies defined primary surgical therapy as surgery plus adjuvant endocrine therapy, and six studies included patients with oestrogen receptor-positive tumours only. Patients in the primary endocrine therapy group were older than the primary surgical therapy group (mean difference 2.43 (95 per cent c.i. 0.73 to 4.13) years). Primary endocrine therapy led to worse overall survival than primary surgical therapy (HR 1.42, 95 per cent c.i. 1.06 to 1.91). Subgroup analysis of RCTs and prospective studies, however, showed comparable overall survival. Breast cancer-specific survival was also comparable (HR 1.28, 95 per cent c.i. 0.87 to 1.87). At 6 weeks, operated patients had significant arm symptoms and illness burden following major breast surgery compared with patients receiving primary endocrine therapy. Health-related quality of life, measured by the European Organization for Research and Treatment of Cancer QLQ-C30 and EuroQol EQ-5D-5L™, was comparable in the two treatment groups. CONCLUSION Overall survival was worse among older women receiving primary endocrine therapy in an analysis including all studies, but comparable in RCTs and prospective studies. This may be due to confounding by age and co-morbidities in retrospective cohort studies of primary endocrine therapy.
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Affiliation(s)
- Kai Siang Chan
- Breast Surgical Service, Department of General Surgery, Khoo Teck Puat Hospital, Singapore
| | - Michelle Tian Hui Chong
- Breast Surgical Service, Department of General Surgery, Khoo Teck Puat Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Clement Luck Khng Chia
- Breast Surgical Service, Department of General Surgery, Khoo Teck Puat Hospital, Singapore
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Defer surgery in operable breast cancer: how long is too long? Breast Cancer 2021; 29:224-233. [PMID: 34661820 PMCID: PMC8522256 DOI: 10.1007/s12282-021-01302-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 09/28/2021] [Indexed: 11/15/2022]
Abstract
Purpose The aim of this meta-analysis was to evaluate outcomes of surgery compared to primary endocrine therapy (PET) in patients with non-advanced, operable invasive breast cancer, and to determine if PET as initial therapy may safely postpone surgery. Methods The MEDLINE, EMBASE, PubMed, and Cochrane Library were searched from database inception to July 2020 to identify eligible studies. Inclusion criteria were experimental or observational studies with at least one arm treated with PET and a second arm treated with surgery with or without PET. Local recurrence or progression of disease was defined as either failure of non-operative management (tumor failing to decrease in size and/or continuous local or distant tumor growth) or relapse of breast tumor after tumor downsizing following PET. Effect estimates were expressed in hazard ratio and 95% confidence intervals (HR (95% CI)). Results The analysis included six studies with 1499 unique patients. The median time to local progression of disease was 2.3 years. Patients treated with PET alone without surgery had a higher risk of local recurrence and or progression [HR (95% CI): 1.76 (1.33, 2.31); I2 = 84%; p < 0.001]. Patients treated with PET had more favorable outcomes in terms of overall survival [HR (95% CI): 1.24 (1.06, 1.46); I2 = 70%; p = 0.008] and less favorable outcomes in breast cancer-specific survival [HR (95% CI): 1.13 (0.98, 1.31); I2 = 41%; p = 0.10]. The risk of publication bias was assessed to be high in reporting local recurrence rates and low in reporting distant recurrence rates. Conclusion PET alone is inferior to surgery in the treatment of operable invasive breast cancer. However, it may be acceptable to postpone curative breast cancer surgery without risk of progression for 1.1 years or longer. Supplementary Information The online version contains supplementary material available at 10.1007/s12282-021-01302-4.
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Angarita FA, Hoppe EJ, Ko G, Lee J, Vesprini D, Hong NJL. Why do Older Women Avoid Breast Cancer Surgery? A Qualitative Analysis of Decision-making Factors. J Surg Res 2021; 268:623-633. [PMID: 34474211 DOI: 10.1016/j.jss.2021.06.088] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/14/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Few studies have explored why older women (≥70 years old) avoid breast cancer surgery. This study aimed to identify physician- and patient-perceived attitudes that influence the decision to avoid surgery among older women with invasive breast cancer. METHODS Semi-structured in-depth interviews were conducted with multidisciplinary breast cancer specialists and older women (≥70 years old) with breast cancer who declined surgery. Transcripts were iteratively coded using a theoretical framework to guide identification of common themes. Thematic comparison was performed between patients and physicians. RESULTS Ten breast cancer specialists and eleven patients participated. Physicians believed older women declined surgery because they did not perceive breast cancer as a life-threatening ailment compared to other medical comorbidities. Physicians did not discuss breast reconstruction, as it was perceived to be unimportant. Treatment side effects, length of treatment, impact on quality of life, and minimal survival benefit strongly influenced patients' decision to decline surgery. Patients valued independence and quality of life over quantity of life. Patients felt empowered to participate in the decision-making process but appreciated having support. Both phyisicians and patients had congruent beliefs with respect to age impacting treatment decision, cosmesis playing a minor factor in treatment decisions, and importance of quality of life; however, they were discordant in their perceptions about the amount of support that patients have from their families. CONCLUSIONS The decision to avoid surgery in older women stems from a variety of individual beliefs. Acknowledging patient values early in treatment planning may facilitate a patient-centered approach to the decision-making process.
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Affiliation(s)
| | - Ethan J Hoppe
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gary Ko
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Justin Lee
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Division of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Danny Vesprini
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Division of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nicole J Look Hong
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Surgical Oncology, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Boyce-Fappiano D, Bedrosian I, Shen Y, Lin H, Gjyshi O, Yoder A, Shaitelman SF, Woodward WA. Evaluation of overall survival and barriers to surgery for patients with breast cancer treated without surgery: a National Cancer Database analysis. NPJ Breast Cancer 2021; 7:87. [PMID: 34226566 PMCID: PMC8257645 DOI: 10.1038/s41523-021-00294-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/03/2021] [Indexed: 11/30/2022] Open
Abstract
Surgery remains the foundation of curative therapy for non-metastatic breast cancer, but many patients do not undergo surgery. Evidence is limited regarding this population. We sought to assess factors associated with lack of surgery and overall survival (OS) in patients not receiving breast cancer surgery. Retrospective cohort study of patients in the US National Cancer Database treated in 2004-2016. The dataset comprised 2,696,734 patients; excluding patients with unknown surgical status or stage IV, cT0, cTx, or pIS, metastatic or recurrent disease resulted in 1,192,294 patients for analysis. Chi-square and Wilcoxon rank-sum tests were used to assess differences between groups. OS was analyzed using the Kaplan-Meier method with a Cox proportional hazards model performed to assess associated factors. In total 50,626 (4.3%) did not undergo surgery. Black race, age >50 years, lower income, uninsured or public insurance, and lower education were more prevalent in the non-surgical cohort; this group was also more likely to have more comorbidities, higher disease stage, and more aggressive disease biology. Only 3,689 non-surgical patients (7.3%) received radiation therapy (RT). Median OS time for the non-surgical patients was 58 months (3-year and 5-year OS rates 63% and 49%). Median OS times were longer for patients who received chemotherapy (80 vs 50 (no-chemo) months) and RT (85 vs 56 (no-RT) months). On multivariate analysis, age, race, income, insurance status, comorbidity score, disease stage, tumor subtype, treatment facility type and location, and receipt of RT were associated with OS. On subgroup analysis, receipt of chemotherapy improved OS for patients with triple negative (HR 0.66, 95% CI 0.59-0.75, P < 0.001) and HER2+ (HR 0.74, 95% CI 0.65-0.84, P < 0.001) subgroups while RT improved OS for ER+ (HR 0.72, 95% CI 0.64-0.82, P < 0.001) and favorable-disease (ER+, early-stage, age >60) (HR 0.61, 95% CI 0.45-0.83, P = 0.002) subgroups. Approximately 4% of women with breast cancer do not undergo surgery, particularly those with more aggressive disease and lower socioeconomic status. Despite its benefits, RT was underutilized. This study provides a benchmark of survival outcomes for patients who do not undergo surgery and highlights a potential role for use of RT.
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Affiliation(s)
- D Boyce-Fappiano
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - I Bedrosian
- Departments of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Y Shen
- Departments of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - H Lin
- Departments of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - O Gjyshi
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Yoder
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S F Shaitelman
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - W A Woodward
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Morgan JL, Holmes G, Ward S, Martin C, Burton M, Walters SJ, Cheung KL, Audisio RA, Reed MW, Wyld L. Observational cohort study to determine the degree and causes of variation in the rate of surgery or primary endocrine therapy in older women with operable breast cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:261-268. [PMID: 33046279 PMCID: PMC7526638 DOI: 10.1016/j.ejso.2020.09.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/18/2020] [Accepted: 09/09/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND In the UK there is variation in the treatment of older women with breast cancer, with up to 40% receiving primary endocrine therapy (PET), which is associated with inferior survival. Case mix and patient choice may explain some variation in practice but clinician preference may also be important. METHODS A multicentre prospective cohort study of women aged >70 with operable breast cancer. Patient characteristics (health status, age, tumour characteristics, treatment allocation and decision-making preference) were analysed to identify whether treatment variation persisted following case-mix adjustment. Expected case-mix adjusted surgery rates were derived by logistic regression using the variables age, co-morbidity, tumour stage and grade. Concordance between patients' preferred and actual decision-making style was assessed and associations between age, treatment and decision-making style calculated. RESULTS Women (median age 77, range 70-102) were recruited from 56 UK breast units between 2013 and 2018. Of 2854/3369 eligible women with oestrogen receptor positive breast cancer, 2354 were treated with surgery and 500 with PET. Unadjusted surgery rates varied between hospitals, with 23/56 units falling outside the 95% confidence intervals on funnel plots. Adjusting for case mix reduced, but did not eliminate, this variation between hospitals (10/56 units had practice outside the 95% confidence intervals). Patients treated with PET had more patient-centred decisions compared to surgical patients (42.2% vs 28.4%, p < 0.001). CONCLUSIONS This study demonstrates variation in treatment selection thresholds for older women with breast cancer. Health stratified guidelines on thresholds for PET would help reduce variation, although patient preference should still be respected.
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Affiliation(s)
- Jenna L Morgan
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK.
| | - Geoff Holmes
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Sue Ward
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Charlene Martin
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
| | - Maria Burton
- Centre for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield, UK
| | - Stephen J Walters
- Clinical Trials Research Unit, School for Health and Related Research, ScHARR, University of Sheffield, UK
| | - Kwok Leung Cheung
- University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
| | - Riccardo A Audisio
- University of Gothenberg, Sahlgrenska Universitetssjukhuset, 41345, Göteborg, Sweden
| | | | - Lynda Wyld
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
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Dodwell D, Jauhari Y, Gathani T, Cromwell D, Gannon M, Clements K, Horgan K. Treatment variation in early breast cancer in the UK. BMJ 2020; 371:m4237. [PMID: 33262116 DOI: 10.1136/bmj.m4237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Yasmin Jauhari
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Toral Gathani
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, UK
| | - Melissa Gannon
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, UK
| | | | - Kieran Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, UK
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Treatment strategies and survival outcomes in older women with breast cancer: A comparative study between the FOCUS cohort and Nottingham cohort. J Geriatr Oncol 2018; 9:635-641. [DOI: 10.1016/j.jgo.2018.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/14/2018] [Accepted: 05/04/2018] [Indexed: 11/18/2022]
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Patients electing to have PET rather than surgery for operable breast cancer are a high risk of treatment failure. Breast Cancer Res Treat 2018; 172:597-601. [PMID: 30159785 DOI: 10.1007/s10549-018-4943-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Primary endocrine therapy (PET) is a treatment option for elderly patients with ER-positive breast cancer enabling frail patients to avoid surgery. As a long-term treatment option, it has been shown to be inferior to surgery in controlling local disease. Decision-making in these patients is crucial in avoiding treatment failure. We examined the influence of decision-making on outcomes of PET failure as a secondary analysis as part of a large observational study. METHODS Consecutive patients treated with PET between 2005 and 2015 for operable breast cancers were included in a retrospective observational study in 3 breast centres in the North-East. Treatment decision processes were examined by case note review and outcomes of treatment success or failure recorded. RESULTS 488 patients were included with mean follow-up of 31 months. Overall 63 (12%) experienced treatment failure. 227 (46.6%) were given a choice between surgery and PET at diagnosis. Logistic regression identified older age [OR 0.94 (0.91-0.96) p < 0.001] and reduced mobility [OR 0.6 (0.37-0.97) p 0.036] to be less likely offered surgery. Those offered surgery were more likely to experience treatment failure with PET [SHR 1.78 (1.05-3.02) p 0.033]. CONCLUSIONS Despite a low failure rate in our series (literature failure rates vary between 12 and 85%), these results suggest that those actively offered a choice between surgery and PET are at greater risk of failure when choosing PET.
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Pepping RMC, Portielje JEA, van de Water W, de Glas NA. Primary Endocrine Therapy in Older Women with Breast Cancer. CURRENT GERIATRICS REPORTS 2017; 6:239-246. [PMID: 29238654 PMCID: PMC5719125 DOI: 10.1007/s13670-017-0223-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose of Review Breast cancer incidence increases with age. In recent years, primary endocrine therapy has been increasingly used as a treatment option for frail elderly women with breast cancer, although surgery is still the guideline-recommended treatment. In this review, we discuss the evidence for primary endocrine therapy versus surgical treatment in older women with early breast cancer. Recent Findings Both randomised controlled trials and recent observational studies showed a favourable progression-free survival but not overall survival for surgery plus adjuvant endocrine therapy versus primary endocrine therapy. Information about quality of life with either treatment strategy is so far lacking. Deciding who is fit for surgery and has sufficiently long life expectation to be at risk of disease progression can be supported by performing an individual geriatric assessment. Summary This review suggests that primary endocrine therapy is a reasonable alternative to primary surgery in frail older women with breast cancer. Future studies should focus on the long-term effects on quality of life and physical functioning.
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Affiliation(s)
- R M C Pepping
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - J E A Portielje
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands.,Department of Clinical Oncology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - W van de Water
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - N A de Glas
- Department of Clinical Oncology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
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Thomas R, Pieri A, Cain H. A systematic review of generic and breast cancer specific life expectancy models in the elderly. Eur J Surg Oncol 2017; 43:1816-1827. [DOI: 10.1016/j.ejso.2017.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 06/05/2017] [Accepted: 06/23/2017] [Indexed: 12/20/2022] Open
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Thomas R, Rowell R, Crichton S, Cain H. An observational study investigating failure of primary endocrine therapy for operable breast cancer in the elderly. Breast Cancer Res Treat 2017; 167:73-80. [PMID: 28879429 DOI: 10.1007/s10549-017-4494-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 09/01/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Elderly patients are more likely to have oestrogen receptor positive cancers that can be treated without surgery with primary endocrine therapy (PET). Few studies have sought to identify predictors of failure of PET and so the aim of this study was to evaluate treatment failures in elderly breast cancer patients treated with PET and to determine predictors of failure. METHODS A retrospective observational study was performed on consecutive patients with ER-positive early stage breast cancer treated with PET between 2005 and 2015 in the three breast units in the North East of England. The primary outcome measure was treatment failure and secondary outcome measure was disease progression. RESULTS 488 patients were included with mean follow-up 31 months (SD 23). Overall, 206 patients were still alive with their disease controlled at the end of follow-up, 219 had died with their disease controlled and 63 (12%) experienced treatment failure. Younger age [SHR 0.96 (95% CI 0.94-0.99) p 0.013], larger tumours [SHR 1.03 (1.01-1.06) p 0.015], grade 3 cancers [SHR 3.58 (1.93-6.63) p < 0.001] and axillary lymph node metastases [SHR 1.93 (1.06-3.52) p 0.030] were all independent predictors of treatment failure. Disease progression was reported in 86 (17.6%) of patients. CONCLUSIONS This is the largest retrospective series evaluating PET treatment failure. Clear predictors of failure have been identified, which can be used to facilitate treatment decision making. These results support previous analyses, further validating our results.
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Affiliation(s)
- Robert Thomas
- Queen Elizabeth Hospital, Gateshead, NE9 6SX, UK. .,, 48 Larkspur Terrace, Jesmond, Newcastle upon Tyne, NE2 2DU, UK.
| | - Rachel Rowell
- Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Siobhan Crichton
- Medical Research Council Clinical Trials Unit, University College London, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - Henry Cain
- Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
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Morgan JL, Walters SJ, Collins K, Robinson TG, Cheung KL, Audisio R, Reed MW, Wyld L. What influences healthcare professionals' treatment preferences for older women with operable breast cancer? An application of the discrete choice experiment. Eur J Surg Oncol 2017; 43:1282-1287. [PMID: 28237423 DOI: 10.1016/j.ejso.2017.01.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/14/2016] [Accepted: 01/08/2017] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Primary endocrine therapy (PET) is used variably in the UK as an alternative to surgery for older women with operable breast cancer. Guidelines state that only patients with "significant comorbidity" or "reduced life expectancy" should be treated this way and age should not be a factor. METHODS A Discrete Choice Experiment (DCE) was used to determine the impact of key variables (patient age, comorbidity, cognition, functional status, cancer stage, cancer biology) on healthcare professionals' (HCP) treatment preferences for operable breast cancer among older women. Multinomial logistic regression was used to identify associations. RESULTS 40% (258/641) of questionnaires were returned. Five variables (age, co-morbidity, cognition, functional status and cancer size) independently demonstrated a significant association with treatment preference (p < 0.05). Functional status was omitted from the multivariable model due to collinearity, with all other variables correlating with a preference for operative treatment over no preference (p < 0.05). Only co-morbidity, cognition and cancer size correlated with a preference for PET over no preference (p < 0.05). CONCLUSION The majority of respondents selected treatment in accordance with current guidelines, however in some scenarios, opinion was divided, and age did appear to be an independent factor that HCPs considered when making a treatment decision in this population.
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Affiliation(s)
- J L Morgan
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
| | - S J Walters
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - K Collins
- Centre for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield, S10 2BA, UK
| | - T G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Robert Kilpatrick Clinical Sciences Building, P.O. Box 65, Leicester, LE2 7LX, UK
| | - K-L Cheung
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby, DE22 3DT, UK
| | - R Audisio
- Department of Surgery, University of Liverpool, St Helens Teaching Hospital, Marshalls Cross Road, St Helens, WA9 3DA, UK
| | - M W Reed
- Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PX, UK
| | - L Wyld
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
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Sowerbutts AM, Griffiths J, Todd C, Lavelle K. Why are older women not having surgery for breast cancer? A qualitative study. Psychooncology 2015; 24:1036-42. [PMID: 25645068 PMCID: PMC4671254 DOI: 10.1002/pon.3764] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 12/19/2014] [Accepted: 01/02/2015] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Surgery is the mainstay of treatment for breast cancer. However, there is evidence that older women are not receiving this treatment. This study explores reasons why older women are not having surgery. METHODS Twenty eight in-depth interviews were conducted with women over 70 years old with operable breast cancer receiving primary endocrine therapy (PET) as their primary treatment. The interviews focused on their perceptions of why they were being treated with PET rather than surgery. Transcripts were analysed using the Framework method. RESULTS Based on reasons for PET, patients were divided into three groups: 'Patient Declined', 'Patient Considered' or 'Surgeon Decided'. The first group 'Patient Declined' absolutely ruled out surgery to treat their breast cancer. These patients were not interested in maximising their survival and rejected surgery citing their age or concerns about impact of treatment on their level of functioning. The second group 'Patient Considered' considered surgery but chose to have PET most specifying if PET failed then they could have the operation. Patients viewed this as offering them two options of treatment. The third group 'Surgeon Decided' was started by the surgeon on PET. These patients had comorbidities and in most cases the surgeon asserted that the comorbidities were incompatible with surgery. CONCLUSIONS Older women represent a diverse group and have multifaceted reasons for foregoing surgery. Discussions about breast cancer treatment should be patient centred and adapted to differing patient priorities.
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Affiliation(s)
- Anne Marie Sowerbutts
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
| | - Jane Griffiths
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
| | - Chris Todd
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
| | - Katrina Lavelle
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
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15
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Morgan J, Collins K, Robinson T, Cheung KL, Audisio R, Reed M, Wyld L. Healthcare professionals' preferences for surgery or primary endocrine therapy to treat older women with operable breast cancer. Eur J Surg Oncol 2015; 41:1234-42. [DOI: 10.1016/j.ejso.2015.05.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 04/25/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022] Open
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16
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Morgan J, Richards P, Ward S, Francis M, Lawrence G, Collins K, Reed M, Wyld L. Case-mix analysis and variation in rates of non-surgical treatment of older women with operable breast cancer. Br J Surg 2015; 102:1056-63. [PMID: 26095684 DOI: 10.1002/bjs.9842] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 11/26/2014] [Accepted: 04/01/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Non-surgical management of older women with oestrogen receptor (ER)-positive operable breast cancer is common in the UK, with up to 40 per cent of women aged over 70 years receiving primary endocrine therapy. Although this may be appropriate for frailer patients, for some it may result in treatment failure, contributing to the poor outcomes seen in this age group. Wide variation in the rates of non-operative management of breast cancer in older women exists across the UK. Case mix may explain some of this variation in practice. METHODS Data from two UK regional cancer registries were analysed to determine whether variation in treatment observed between 2002 and 2010 at hospital and clinician level persisted after adjustment for case mix. Expected case mix-adjusted surgery rates were derived by logistic regression using the variables age, proxy Charlson co-morbidity score, deprivation quintile, method of cancer detection, tumour size, stage, grade and node status. RESULTS Data on 17,129 women aged 70 years or more with ER-positive operable breast cancer were analysed. There was considerable variation in rates of surgery at both hospital and clinician level. Despite adjusting for case mix, this variation persisted at hospital level, although not at clinician level. CONCLUSION This study demonstrates variation in selection criteria for older women for operative treatment of early breast cancer, indicating that some older women may be undertreated or overtreated, and may partly explain the inferior disease outcomes in this age group. It emphasizes the urgent need for evidence-based guidelines for treatment selection criteria in older women with breast cancer.
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Affiliation(s)
- J Morgan
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield, UK
| | - P Richards
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - S Ward
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - M Francis
- Knowledge and Intelligence Team (West Midlands), Public Health England, Birmingham, UK
| | - G Lawrence
- Knowledge and Intelligence Team (West Midlands), Public Health England, Birmingham, UK
| | - K Collins
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - M Reed
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield, UK
| | - L Wyld
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield, UK
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17
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Morgan JL, Burton M, Collins K, Lifford KJ, Robinson TG, Cheung KL, Audisio R, Reed MW, Wyld L. The balance of clinician and patient input into treatment decision-making in older women with operable breast cancer. Psychooncology 2015; 24:1761-6. [PMID: 26043439 DOI: 10.1002/pon.3853] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/16/2015] [Accepted: 04/27/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Primary endocrine therapy (PET) is an alternative to surgery for oestrogen receptor positive operable breast cancer in some older women. However the decision to offer PET involves complex trade-offs and is influenced by both patient choice and healthcare professional (HCP) preference. This study aimed to compare the views of patients and HCPs about this decision and explore decision-making (DM) preferences and whether these are taken into account during consultations. METHODS This multicentre, UK, mixed methods study had three components: (a) questionnaires to older women undergoing counseling about breast cancer treatment options which assessed their DM preferences and realities; (b) qualitative interviews with older women with operable breast cancer offered a choice of either surgery or PET and (c) qualitative interviews with HCPs (both of which focused on DM preferences in this setting). RESULTS Thirty-three patients and 34 HCPs were interviewed. A range of opinions about patient involvement in DM were identified. Patients indicated varying preferences for DM involvement which were variably taken into account by HCPs. These qualitative findings were broadly supported by the questionnaire results. Most patients (536/729; 73.5%) achieved their preferred DM style; however, the remainder felt that their DM preferences had not been taken into consideration. CONCLUSIONS These results suggest that whilst many older women achieve their desired level of DM engagement, some do not, raising the possibility that they may be making choices which are not concordant with their treatment preferences.
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Affiliation(s)
- Jenna L Morgan
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
| | - Maria Burton
- Centre for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield, UK
| | - Karen Collins
- Centre for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield, UK
| | - Kate J Lifford
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Thompson G Robinson
- University of Leicester, Department of Cardiovascular Sciences, Robert Kilpatrick Clinical Sciences Building, Leicester, UK
| | - Kwok-Leung Cheung
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby, UK
| | - Riccardo Audisio
- Department of Surgery, University of Liverpool, St Helens Teaching Hospital, Marshalls Cross Road, St Helens, UK
| | - Malcolm W Reed
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
| | - Lynda Wyld
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
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18
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Stotter A, Reed MW, Gray LJ, Moore N, Robinson TG. Comprehensive Geriatric Assessment and predicted 3-year survival in treatment planning for frail patients with early breast cancer. Br J Surg 2015; 102:525-33; discussion 533. [PMID: 25708660 DOI: 10.1002/bjs.9755] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/02/2014] [Accepted: 11/21/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Endocrine therapy alone has been a popular treatment for oestrogen receptor-positive breast cancer in elderly patients, although it may be inadequate in those surviving more than 2-3 years. The aim of this study was to estimate 3-year survival in frail patients with early breast cancer, to inform treatment decisions. METHODS A risk score was created to estimate 3-year survival in individual patients using data from patients who had Comprehensive Geriatric Assessment (CGA) in a specialist clinic before decisions about their breast cancer treatment were made. The data were analysed using logistic regression. RESULTS Ninety-seven (29·6 per cent) of the 328 patients had died by 3 years. Four components of the assessment proved strongly associated with survival: Mini Mental State Examination, Barthel Index of Activities of Daily Living, instrumental Activities of Daily Living and American Association of Anesthesiologists fitness grade. The derived CGA risk score gave an adequate level of discrimination and calibration, with an area under the receiver operating characteristic (ROC) curve of 0·75 (95 per cent c.i. 0·67 to 0·82) (Hosmer-Lemeshow statistic χ(2) = 7·9, P = 0·448). CONCLUSION Detailed assessment can allow prediction of survival probability in frail elderly patients. Good scores indicate good survival prospects and a likely benefit from surgery; poor scores are associated with reduced survival, although with wide variation. CGA is recommended before making decisions on best treatment.
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Affiliation(s)
- A Stotter
- Departments of Breast Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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Bates T, Evans T, Lagord C, Monypenny I, Kearins O, Lawrence G. A population based study of variations in operation rates for breast cancer, of comorbidity and prognosis at diagnosis: failure to operate for early breast cancer in older women. Eur J Surg Oncol 2014; 40:1230-6. [PMID: 25081093 DOI: 10.1016/j.ejso.2014.06.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Older women are less likely to have surgery for operable breast cancer. This population-based study examines operation rates by age and identifies groups which present with early or late disease. METHODS 37 000 cancer registrations for 2007 were combined with Hospital Episode Statistics comorbidity data for England. Operation rates were examined by age, ethnicity, deprivation, comorbidity, screen-detection, tumour size, grade and nodal status. Early and late presentation were correlated with Nottingham Prognostic Index (NPI) groups and tumour size. RESULTS The proportion of women not having surgery increased from 7-10% at ages 35-69 to 82% from age 90. From age 70, the proportion not having surgery rose by an average of 3.1% per year of age. Women with a Charlson Comorbidity Index score of ≥1 (which increased with age), with tumours >50 mm or who were node positive, were less likely to have surgery. Although women aged 70-79 were more likely to have larger tumours, their tumours were also more likely to have an excellent or good NPI (p < 0.001). Good prognosis tumours were more likely to be screen-detected, and less likely in women aged 0-39, the deprived and certain ethnic groups (p < 0.02). CONCLUSIONS From age 70 there is an increasing failure to operate for breast cancer. Younger women and certain ethnic groups presented with more advanced tumours. Older women had larger tumours which were otherwise of good prognosis, and this would not account for the failure to operate which may in part be related to comorbidity in this age group.
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Affiliation(s)
- T Bates
- The Breast Unit, William Harvey Hospital, Ashford, Kent TN24 0LZ, UK.
| | - T Evans
- Public Health England, Knowledge and Intelligence Team (West Midlands), Birmingham B3 2PW, UK
| | - C Lagord
- Public Health England, Knowledge and Intelligence Team (West Midlands), Birmingham B3 2PW, UK
| | - I Monypenny
- Llandough University Hospital, Cardiff CF 64 2XX, UK
| | - O Kearins
- Public Health England, Cancer Screening QA Reference Centre, Birmingham B3 2PW, UK
| | - G Lawrence
- Public Health England, Knowledge and Intelligence Team (West Midlands), Birmingham B3 2PW, UK
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Layfield DM, Mohamud M, Odofin O, Walsh C, Royle GT, Cutress RI. Tumour grade on core biopsy and evidence of axillary involvement on ultrasound predicts response in elderly co-morbid patients treated with primary hormone therapy for oestrogen receptor positive breast carcinoma. Surgeon 2014; 13:61-8. [PMID: 24411703 DOI: 10.1016/j.surge.2013.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 11/01/2013] [Accepted: 11/21/2013] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Treatment of women with oestrogen-receptor positive breast cancer who are high risk for general anaesthetic remains controversial. Current guidance is based on studies pre-dating aromatase inhibitors (AIs) which may have also included hormone-receptor negative patients. Such studies have demonstrated improved disease-free survival and local disease control following surgery when compared with primary hormone therapy (PHT) alone. However uncertainty persists regarding benefit of surgery over optimal hormone treatment in patients with significant co-morbidity. METHOD Retrospective cohort study comparing efficacy of PHT in oestrogen-receptor positive breast cancer patients considered unsuitable for surgery. Co-morbidity was scored retrospectively using the Charlson Index. Overall survival and disease specific survival were noted and multivariate analysis performed to identify predictors of treatment failure. RESULTS 106 patients treated for breast cancer at Southampton University Hospital with PHT without surgery were identified (Mean age 84.1 years, range 48-101). 94.3% had a probability of 10 year survival of 2.25% or less according to the age-weighted Charlson score. Kaplan-Meier analysis demonstrated a four-year survival of 30% and breast cancer specific survival of 60%. Cox proportional hazards model demonstrated high-grade disease (grade III vs. grade I/II: HR = 2.007; 95% Confidence Interval (CI) = 1.004-4.014. P = 0.049) and ultrasound axillary staging (indeterminate/definite lymphatic involvement vs. no involvement: HR = 1.944; 95% CI = 1.010-3.742. P = 0.047) independently predicted early failure of PHT. CONCLUSION A high proportion of elderly and comorbid patients die with breast cancer rather than from breast cancer. Elderly comorbid patients who initially respond to primary hormone therapy have a less than 30% incidence of delayed treatment failure during their life time; however patients with grade III disease or an abnormal axillary ultrasound are twice as likely to fail first choice PHT.
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Affiliation(s)
- D M Layfield
- University of Southampton, UK; Southampton Breast Surgical Unit, University Hospitals Southampton, UK.
| | | | - O Odofin
- Southampton Breast Surgical Unit, University Hospitals Southampton, UK
| | - C Walsh
- Southampton Breast Surgical Unit, University Hospitals Southampton, UK
| | - G T Royle
- Southampton Breast Surgical Unit, University Hospitals Southampton, UK
| | - R I Cutress
- University of Southampton, UK; Southampton Breast Surgical Unit, University Hospitals Southampton, UK
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