Annals of Surgical Oncology

, Volume 20, Issue 4, pp 1287–1294

Factors Influencing Surgical and Adjuvant Therapy in Stage I Breast Cancer: A SEER 18 Database Analysis

  • Shayna L. Showalter
  • Surbhi Grover
  • Sonam Sharma
  • Lillie Lin
  • Brian J. Czerniecki
Breast Oncology

Abstract

Background

Randomized trials have shown no survival difference for patients with stage I breast cancer treated with mastectomy versus breast-conserving surgery (BCS) with radiotherapy (RT). RT is recommended after BCS in order to decrease local recurrence and mortality. We sought to evaluate the treatment trends in patients with stage I breast cancer.

Methods

We used the Surveillance, Epidemiology, and End Results (SEER) database to identify 194,860 women with stage I breast cancer diagnosed from 1988 to 2007. We evaluated factors that were associated surgical treatment and the utilization of RT after BCS.

Results

There was a progressive decline in the proportion of patients with stage I breast cancer who were treated with mastectomy from 1998 to 2007. Significant predictors for being treated with mastectomy included single/divorced women (p = 0.007), white race (p < 0.001), estrogen receptor negativity (p < 0.001), earlier year of diagnosis (p < 0.001), smaller tumor size (p < 0.001), and region (p < 0.001). Twenty percent of the BCS cohort did not receive RT, and this proportion did not change over time. Significant predictors for not receiving RT included small tumor size (p < 0.001), African American race (p < 0.001), increasing age (p < 0.001), single/divorced women (p < 0.001), estrogen receptor negativity (p < 0.001), and region (p < 0.001). The survival for patients treated with BCS and RT was significantly higher than for those who did not receive RT (p < 0.001).

Conclusions

The use of BCS for the treatment of stage I breast cancer increased over time. A constant proportion of patients did not receive RT after BCS. Omission of RT in BCS is associated with an increase in mortality.

References

  1. 1.
    Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347:1233–41.PubMedCrossRefGoogle Scholar
  2. 2.
    Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med. 1985;312:665–73.PubMedCrossRefGoogle Scholar
  3. 3.
    Blichert-Toft M, Brincker H, Andersen JA, et al. A Danish randomized trial comparing breast-preserving therapy with mastectomy in mammary carcinoma. Preliminary results. Acta Oncol. 1988;27(6A):671–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Lichter AS, Lippman ME, Danforth DN Jr, et al. Mastectomy versus breast-conserving therapy in the treatment of stage I and II carcinoma of the breast: a randomized trial at the National Cancer Institute. J Clin Oncol. 1992;10:976–83.PubMedGoogle Scholar
  5. 5.
    Sarrazin D, Lê MG, Arriagada R, et al. Ten-year results of a randomized trial comparing a conservative treatment to mastectomy in early breast cancer. Radiother Oncol. 1989;14:177–84.PubMedCrossRefGoogle Scholar
  6. 6.
    van Dongen JA, Bartelink H, Fentiman IS, et al. Factors influencing local relapse and survival and results of salvage treatment after breast-conserving therapy in operable breast cancer: EORTC trial 10801, breast conservation compared with mastectomy in TNM stage I and II breast cancer. Eur J Cancer. 1992;28A:801–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Veronesi U, Saccozzi R, Del Vecchio M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N Engl J Med. 1981;305:6–11.PubMedCrossRefGoogle Scholar
  8. 8.
    Consensus conference. Treatment of early stage breast cancer. National institutes of health. Conn Med. 1991;55:101–7.Google Scholar
  9. 9.
    Veronesi U, Marubini E, Mariani L, et al. Radiotherapy after breast-conserving surgery in small breast carcinoma: long-term results of a randomized trial. Ann Oncol. 2001;12:997–1003.PubMedCrossRefGoogle Scholar
  10. 10.
    Clarke M, Collins R, Darby S, et al.; Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet. 2005;366(9503):2087–106.PubMedGoogle Scholar
  11. 11.
    Darby S, McGale P, Correa C, et al. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 378(9804):1707–16.Google Scholar
  12. 12.
    Katipamula R, Degnim AC, Hoskin T, et al. Trends in mastectomy rates at the Mayo Clinic Rochester: effect of surgical year and preoperative magnetic resonance imaging. J Clin Oncol. 2009;27:4082–8.PubMedCrossRefGoogle Scholar
  13. 13.
    McGuire KP, Santillan AA, Kaur P, et al. Are mastectomies on the rise? A 13-year trend analysis of the selection of mastectomy versus breast conservation therapy in 5865 patients. Ann Surg Oncol. 2009;16:2682–90.PubMedCrossRefGoogle Scholar
  14. 14.
    Sorbero ME, Dick AW, Beckjord EB, Ahrendt G. Diagnostic breast magnetic resonance imaging and contralateral prophylactic mastectomy. Ann Surg Oncol. 2009;16:1597–605.PubMedCrossRefGoogle Scholar
  15. 15.
    Habermann EB, Abbott A, Parsons HM, Virnig BA, Al-Refaie WB, Tuttle TM. Are mastectomy rates really increasing in the United States? J Clin Oncol. 28:3437–41.Google Scholar
  16. 16.
    Lazovich D, Solomon CC, Thomas DB, Moe RE, White E. Breast conservation therapy in the United States following the 1990 national institutes of health consensus development conference on the treatment of patients with early stage invasive breast carcinoma. Cancer. 1999;86:628–37.PubMedCrossRefGoogle Scholar
  17. 17.
    Polednak AP. Trends in, and predictors of, breast-conserving surgery and radiotherapy for breast cancer in Connecticut, 1988–1997. Int J Radiat Oncol Biol Phys. 2002;53:157–63.PubMedCrossRefGoogle Scholar
  18. 18.
    Collins ED, Moore CP, Clay KF, et al. Can women with early-stage breast cancer make an informed decision for mastectomy? J Clin Oncol. 2009;27:519–25.PubMedCrossRefGoogle Scholar
  19. 19.
    Katz SJ, Lantz PM, Janz NK, et al. Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol. 2005;23:5526–33.PubMedCrossRefGoogle Scholar
  20. 20.
    Jacobs LK, Kelley KA, Rosson GD, Detrani ME, Chang DC. Disparities in urban and rural mastectomy populations: the effects of patient- and county-level factors on likelihood of receipt of mastectomy. Ann Surg Oncol. 2008;15:2644–52.PubMedCrossRefGoogle Scholar
  21. 21.
    Morrow M, White J, Moughan J, et al. Factors predicting the use of breast-conserving therapy in stage I and II breast carcinoma. J Clin Oncol. 2001;19:2254–62.PubMedGoogle Scholar
  22. 22.
    Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin JS. Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med. 1992;326:1102–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Guadagnoli E, Weeks JC, Shapiro CL, Gurwitz JH, Borbas C, Soumerai SB. Use of breast-conserving surgery for treatment of stage I and stage II breast cancer. J Clin Oncol. 1998;16:101–6.PubMedGoogle Scholar
  24. 24.
    Dolan JT, Granchi TS, Miller CC 3rd, Brunicardi FC. Low use of breast conservation surgery in medically indigent populations. Am J Surg. 1999;178:470–4.PubMedCrossRefGoogle Scholar
  25. 25.
    Schroen AT, Brenin DR, Kelly MD, Knaus WA, Slingluff CL Jr. Impact of patient distance to radiation therapy on mastectomy use in early-stage breast cancer patients. J Clin Oncol. 2005;23:7074–80.PubMedCrossRefGoogle Scholar
  26. 26.
    Hawley ST, Hofer TP, Janz NK, et al. Correlates of between-surgeon variation in breast cancer treatments. Med Care. 2006;44:609–16.PubMedCrossRefGoogle Scholar
  27. 27.
    Dragun AE, Huang B, Tucker TC, Spanos WJ. Disparities in the application of adjuvant radiotherapy after breast-conserving surgery for early stage breast cancer: impact on overall survival. Cancer. 117:2590–8.Google Scholar
  28. 28.
    Du Xianglin L, Gor BJ. Racial disparities and trends in radiation therapy after breast-conserving surgery for early-stage breast cancer in women, 1992 to 2002. Ethn Dis. 2007;17:122–8.PubMedGoogle Scholar
  29. 29.
    Freedman RA, He Y, Winer EP, Keating NL. Trends in racial and age disparities in definitive local therapy of early-stage breast cancer. J Clin Oncol. 2009;27:713–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Smith GL, Shih YC, Xu Y, et al. Racial disparities in the use of radiotherapy after breast-conserving surgery: a national Medicare study. Cancer. 116:734–41.Google Scholar
  31. 31.
    National Cancer Institute. Surveillance, epidemiology, and end results (SEER). About SEER. http://www.seer.cancer.gov/about.
  32. 32.
    Garcia-Etienne CA, Tomatis M, Heil J, et al. Mastectomy trends for early-stage breast cancer: a report from the EUSOMA multi-institutional European database. Eur J Cancer. 2012;48(13):1947–56Google Scholar
  33. 33.
    Staradub VL, Hsieh YC, Clauson J, Langerman A, Rademaker AW, Morrow M. Factors that influence surgical choices in women with breast carcinoma. Cancer. 2002;95:1185–90.PubMedCrossRefGoogle Scholar
  34. 34.
    Staradub VL, Rademaker AW, Morrow M. Factors influencing outcomes for breast conservation therapy of mammographically detected malignancies. J Am Coll Surg. 2003;196:518–24.PubMedCrossRefGoogle Scholar
  35. 35.
    Al-Refaie W, Kuerer HM, Khuwaja A, et al. Determinants of mastectomy in breast conservation therapy candidates. Am J Surg. 2005;190:602–5.PubMedCrossRefGoogle Scholar
  36. 36.
    Jagsi R, Abrahamse P, Hawley ST, Graff JJ, Hamilton AS, Katz SJ. Underascertainment of radiotherapy receipt in surveillance, epidemiology, and end results registry data. Cancer. 2012;118(2):333–1Google Scholar
  37. 37.
    Buchholz TA, Theriault RL, Niland JC, et al. The use of radiation as a component of breast conservation therapy in national comprehensive cancer network centers. J Clin Oncol. 2006;24(3):361–9Google Scholar
  38. 38.
    Smith BD, Smith GL, Roberts KB, Buchholz TA. Baseline utilization of breast radiotherapy before institution of the medicare practice quality reporting initiative. Int J Radiat Oncol Biol Phys. 2009;74(5):1506–12Google Scholar
  39. 39.
    Du Xianglin, Freeman JL, Nattinger AB, Goodwin JS. Survival of women after breast conserving surgery for early stage breast cancer. Breast Cancer Res Treat. 2002;72:23–31.PubMedCrossRefGoogle Scholar
  40. 40.
    Hughes KS, Schnaper LA, Berry D, et al. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med. 2004;351:971–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Goodwin JS, Hunt WC, Key CR, Samet JM. The effect of marital status on stage, treatment, and survival of cancer patients. J Am Med Assoc. 1987;258:3125–30.PubMedCrossRefGoogle Scholar
  42. 42.
    Chang SM, Barker FG 2nd. Marital status, treatment, and survival in patients with glioblastoma multiforme: a population based study. Cancer. 2005;104:1975–84.PubMedCrossRefGoogle Scholar
  43. 43.
    Kravdal O. The impact of marital status on cancer survival. Soc Sci Med. 2001;52:357–68.PubMedCrossRefGoogle Scholar
  44. 44.
    Silliman RA, Troyan SL, Guadagnoli E, Kaplan SH, Greenfield S. The impact of age, marital status, and physician–patient interactions on the care of older women with breast carcinoma. Cancer. 1997;80:1326–34.PubMedCrossRefGoogle Scholar
  45. 45.
    Dragun AE, Pan J, Riley EC, et al. Increasing use of elective mastectomy and contralateral prophylactic surgery among breast conservation candidates: a14-year report from a comprehensive cancer center. Am J Clin Oncol. 2012;21(5):408–2Google Scholar
  46. 46.
    Stucky CC, Gray RJ, Wasif N, Dueck AC, Pockaj BA. Increase in contralateral prophylactic mastectomy: echoes of a bygone era? Surgical trends for unilateral breast cancer. Ann Surg Oncol. 2010;17(Suppl 3):330–7Google Scholar
  47. 47.
    Tuttle TM, Habermann EB, Grund EH, Morris TJ, Virnig BA. Increasing use of contralateral prophylactic mastectomy for breast cancer patients: a trend toward more aggressive surgical treatment. J Clin Oncol. 2007;25(33):5203–09Google Scholar
  48. 48.
    Bedrosian I, Hu CY, Chang GJ. Population-based study of contralateral prophylactic mastectomy and survival outcomes of breast cancer patients. J Natl Cancer Inst. 2010;102(6):401–9Google Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  • Shayna L. Showalter
    • 1
  • Surbhi Grover
    • 2
  • Sonam Sharma
    • 2
  • Lillie Lin
    • 2
  • Brian J. Czerniecki
    • 1
  1. 1.Department of SurgeryUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of Radiation OncologyUniversity of PennsylvaniaPhiladelphiaUSA

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