Skip to main content

Advertisement

SpringerLink
Log in

Comparative Analysis of Proposed Strategies for Incorporating Biologic Factors into Breast Cancer Staging

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Tumor biology is an important prognostic factor in breast cancer. This study aimed to compare three staging systems incorporating both biologic factors and anatomic staging (AJCC 8th-edition pathologic prognostic staging, Bioscore, and Risk Score) in a large population-based cohort.

Methods

The Surveillance, Epidemiology and End Results program was used to select patients with primary stages 1–4 breast cancer diagnosed in 2010. Patients with inflammatory carcinoma, those with missing data for biologic factors, and those with stages 1–3 disease not treated with surgery were excluded from the study. Estimates of 5-year disease-specific survival (DSS) were calculated using the Kaplan–Meier method. The Harrel concordance index (C-index) and the Akaike Information Criterion were used to compare each model in terms of predicting DSS.

Results

The study included 21,901 patients with a median age of 60 years. The median follow-up period was 52 months. All the staging models stratified DSS, with a stepwise decrease in DSS for each increase in risk category or score. The C-index of each model incorporating biologic factors was higher than the C-index for anatomic staging alone (C-index: 0.832 vs. 0.856 for AJCC pathologic prognostic staging, 0.856 for Bioscore, and 0.864 for Risk Score, all p < 0.001). The staging systems incorporating biologic factors did not differ significantly in terms of model fit.

Conclusion

Staging systems incorporating biologic factors perform better than anatomic staging alone. Implementation of the AJCC 8th-edition pathologic prognostic staging was an important initial step in the inclusion of tumor biology in staging. Given its simplicity and ease of use, the Risk Score should be given consideration as an alternative staging system.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Harris LN, Ismalla N, McShane LM, et al. Use of biomarkers to guide decisions on adjuvant systemic therapy for women with early-stage invasive breast cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016;34:1134–50.

    Article  CAS  Google Scholar 

  2. Park YH, Lee SJ, Cho EY, et al. Clinical relevance of TNM staging system according to breast cancer subtypes. Ann Oncol. 2011;22:1554–60.

    Article  CAS  Google Scholar 

  3. Schwartz AM, Henson DE, Chen D, et al. Histologic grade remains a prognostic factor for breast cancer regardless of the number of positive lymph nodes and tumor size: a study of 161,708 cases of breast cancer from the SEER Program. Arch Pathol Lab Med. 2014;138:1048–52.

    Article  Google Scholar 

  4. Fragomeni SM, Sciallis A, Jeruss JS. Molecular subtypes and local-regional control of breast cancer. Surg Oncol Clin North Am. 2018;27:95–120.

    Article  Google Scholar 

  5. Bagaria SP, Ray PS, Sim MS, et al. Personalizing breast cancer staging by the inclusion of ER, PR, and HER2. JAMA Surg. 2014;149:125–9.

    Article  Google Scholar 

  6. Plichta JK, Campbell BM, Mittendorf EA, Hwang ES. Anatomy and breast cancer staging: is it still relevant? Surg Oncol Clin North Am. 2018;27:51–67.

    Article  Google Scholar 

  7. Giuliano AE, Edge SB, Hortobagyi GN. Eighth edition of the AJCC Cancer Staging Manual: breast cancer. Ann Surg Oncol. 2018;25:1783–5.

    Article  Google Scholar 

  8. Mittendorf EA, Chavez-MacGregor M, Vila J, et al. Bioscore: A staging system for breast cancer patients that reflects the prognostic significance of underlying tumor biology. Ann Surg Oncol. 2017;24:3502–9.

    Article  Google Scholar 

  9. Chavez-MacGregor M, Mittendorf EA, Clark CA, et al. Incorporating tumor characteristics to the American Joint Committee on Cancer Breast Cancer Staging System. Oncologist. 2017;22:1292–300.

    Article  CAS  Google Scholar 

  10. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 8th ed. Springer Chicago, IL, 2017.

    Google Scholar 

  11. Weiss A, Chavez-MacGregor M, Lichtensztajn DY, et al. Validation study of the American Joint Committee on Cancer eighth edition prognostic stage compared with the anatomic stage in breast cancer. JAMA Oncol. 2018;4:203–9.

  12. Plichta JK, Ren Y, Thomas SM, et al. Implications for breast cancer restaging based on the 8th-edition AJCC Staging Manual. Ann Surg. 2020;271:169–76.

    Article  Google Scholar 

  13. Abdel-Rahman O. Assessment of the prognostic and discriminating value of the novel bioscore system for breast cancer; a SEER database analysis. Breast Cancer Res Treat. 2017;164:231–6.

    Article  CAS  Google Scholar 

  14. Seow YH, Wong TX, Lim JHC, et al. Validation of a risk score incorporating tumor characteristics into the American Joint Committee on Cancer anatomic stage for breast cancer. J Breast Cancer. 2019;22:260–73.

    Article  Google Scholar 

  15. National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Retrieved 2 July 2019 at https://seer.cancer.gov/data.

  16. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 7th ed. Springer, Chicago, IL, 2010.

    Book  Google Scholar 

  17. Ross JS, Slodkowska EA, Symmans WF, et al. The HER-2 receptor and breast cancer: ten years of targeted anti-HER-2 therapy and personalized medicine. Oncologist. 2009;14:320–68.

    Article  CAS  Google Scholar 

  18. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Davies C, Godwin J, et al. Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials. Lancet. 2011;378:771–84.

  19. Weiss A, King TA, Hung KK, Mittendorf EA. Incorporating biologic factors into the American Joint Committee staging system: review of the supporting evidence. Surg Clin North Am. 2018;98:687–702.

    Article  Google Scholar 

  20. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. Version 2.2019. Retrieved 10 July 2019 at http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.

  21. Kim I, Choi HJ, Ryu JM, et al. Prognostic validation of the American Joint Committee on Cancer 8th Staging System in 24,014 Korean patients with breast cancer. J Breast Cancer. 2018;21:173–81.

    Article  Google Scholar 

  22. Paik S, Shak S, Kim C, et al. Gene expression and benefit of chemotherapy in women with node-negative, estrogen receptor-positive breast cancer. J Clin Oncol. 2006;24:3726–34.

    Article  CAS  Google Scholar 

  23. Yi M, Mittendorf EA, Cormier JN, et al. Novel staging system for predicting disease-specific survival in patients with breast cancer treated with surgery as the first intervention: time to modify the current American Joint Committee on Cancer staging system. J Clin Oncol. 2011;29:4654–61.

    Article  Google Scholar 

Download references

Acknowledgment

This work was supported by NIH/NCI P30CA016672, Susan G. Komen SAC150061, and CPRIT-CERCIT 2.0 RP 160674. Mariana Chavez-MacGregor, MD, MS, is supported by the Conquer Cancer Foundation.

DISCLOURES

Kelly K. Hunt is a participant on scientific advisory boards for Armada Health and Merck and provides research support to institutions through Endomagnetics and Lumicell. Tari A. King receives as a speaker fee from Genomic Health. Elizabeth A. Mittendorf is a participant on scientific advisory boards for Genomic Health and Merck and receives clinical trial funding from Genetech via SU2C. Mariana Chavez-MacGregor is a consultant for Pfizer, Eisai, Abbott, and Roche, and receives research funding from Novartis.

Author information

Authors and Affiliations

  1. Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA

    Olga Kantor MD, MS, Tari A. King MD & Elizabeth A. Mittendorf MD, PhD

  2. Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA, USA

    Olga Kantor MD, MS, Tari A. King MD & Elizabeth A. Mittendorf MD, PhD

  3. Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Jiangong Niu PhD, MS, Hui Zhao PhD, Sharon H. Giordano MD, MPH & Mariana Chavez-MacGregor MD, MS

  4. Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Sharon H. Giordano MD, MPH & Mariana Chavez-MacGregor MD, MS

  5. Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Kelly K. Hunt MD

Authors
  1. Olga Kantor MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jiangong Niu PhD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hui Zhao PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sharon H. Giordano MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kelly K. Hunt MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Tari A. King MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Elizabeth A. Mittendorf MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Mariana Chavez-MacGregor MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mariana Chavez-MacGregor MD, MS.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 74 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kantor, O., Niu, J., Zhao, H. et al. Comparative Analysis of Proposed Strategies for Incorporating Biologic Factors into Breast Cancer Staging. Ann Surg Oncol 27, 2229–2237 (2020). https://doi.org/10.1245/s10434-019-08169-y

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-019-08169-y

Search

Navigation