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Radiation Therapy After Breast-Conserving Surgery in Women 70 Years of Age and Older: How Wisely Do We Choose?

  • Stephanie Downs-Canner
  • Emily C. Zabor
  • Tyler Wind
  • Armend Cobovic
  • Beryl McCormick
  • Monica Morrow
  • Alexandra HeerdtEmail author
Breast Oncology

Abstract

Background

Despite data from randomized trials supporting omission of radiation therapy (RT) for women ≥ 70 years of age with T1, estrogen receptor-positive (ER+) tumors undergoing breast-conserving therapy (BCT), RT usage remains high. We reviewed our institutional experience to determine if risk factors for local recurrence or comorbidities influenced use.

Methods

Women ≥ 70 years of age with T1, ER+, human epidermal growth factor receptor 2-negative (HER2−) tumors undergoing BCT in 2010–2012 were identified from a prospectively maintained database. Ten-year estimated mortality was calculated using the Suemoto index. The associations of clinicopathological features and mortality risk on receipt of RT were examined.

Results

Overall, 323 patients with 327 cancers were identified. Median age was 75 years, median tumor size was 1 cm, and all were clinically node negative; 53.7% of patients received RT. RT usage decreased with age (73.6%, age 70–74 years; 49.5%, age 75–79 years; 33.3%, age 80–84 years; 10.7%, ≥ 85 years; p < 0.001). Within age groups, estimated mortality did not impact RT usage. On multivariable analysis, only younger age and larger tumor size were associated with RT use. Recurrence-free survival was 98% versus 93% with and without RT, respectively (p = 0.011). Those who received adjuvant radiation also had improved overall survival (92% vs. 89%), although this effect did not reach statistical significance (p = 0.051).

Conclusion

Neither the factors associated with risk of local recurrence nor the estimated risk of death in 10 years were associated with use of adjuvant radiation in a large cohort of women ≥ 70 years of age with small ER+ breast cancers treated with breast-conserving surgery.

Notes

DISCLOSURES

The preparation of this manuscript was funded in part by NIH/NCI Cancer Center Support Grant No. P30 CA008748 to Memorial Sloan Kettering Cancer Center, and this study was presented in poster format at the 71st Society of Surgical Oncology Annual Cancer Symposium, March 21–24, 2018, Chicago, IL. Dr. Monica Morrow has received speaking honoraria from Roche and Genomic Health. The findings presented in this manuscript have not been published elsewhere.

References

  1. 1.
    Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347(16):1227–32.CrossRefGoogle Scholar
  2. 2.
    Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, 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(16):1233–41.CrossRefGoogle Scholar
  3. 3.
    Fisher B, Bryant J, Dignam JJ, Wickerham DL, Mamounas EP, Fisher ER, et al. Tamoxifen, radiation therapy, or both for prevention of ipsilateral breast tumor recurrence after lumpectomy in women with invasive breast cancers of one centimeter or less. J Clin Oncol. 2002;20(20):4141–9.CrossRefGoogle Scholar
  4. 4.
    Early Breast Cancer Trialists’ Collaborative Group, Darby S, McGale P, Correa C, Taylor C, Arriagada R, et al. 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. 2011;378(9804):1707–16.CrossRefGoogle Scholar
  5. 5.
    Hughes KS, Schnaper LA, Berry D, Cirrincione C, McCormick B, Shank B, 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(10):971–7.CrossRefGoogle Scholar
  6. 6.
    Hughes KS, Schnaper LA, Bellon JR, Cirrincione CT, Berry DA, McCormick B, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013;31(19):2382–7.CrossRefPubMedCentralGoogle Scholar
  7. 7.
    Kunkler IH, Williams LJ, Jack WJ, Cameron DA, Dixon JM, on behalf of the PRIME II Investigators. Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial. Lancet Oncol. 2015;16(3):266–73.Google Scholar
  8. 8.
    Gradishar WJ, Anderson BO, Balassanian R, Blair SL, Burstein HJ, Cyr A, et al. Breast cancer, Version 4.2017, NCCN clinical practice guidelines in oncology. J Natl Compr Cancer Netw. 2018;16(3):310–20.Google Scholar
  9. 9.
    Levinson W, Born K, Wolfson D. Choosing wisely campaigns: a work in progress. JAMA. 2018;319(19):1975–6.CrossRefGoogle Scholar
  10. 10.
    Palta M, Palta P, Bhavsar NA, Horton JK, Blitzblau RC. The use of adjuvant radiotherapy in elderly patients with early-stage breast cancer: changes in practice patterns after publication of Cancer and Leukemia Group B 9343. Cancer. 2015;121(2):188–93.CrossRefGoogle Scholar
  11. 11.
    McCormick B, Ottesen RA, Hughes ME, Javid SH, Khan SA, Mortimer J, Niland JC, et al. Impact of guideline changes on use or omission of radiation in the elderly with early breast cancer: practice patterns at National Comprehensive Cancer Network institutions. J Am Coll Surg. 2014;219(4):796–802.CrossRefGoogle Scholar
  12. 12.
    Suemoto CK, Ueda P, Beltran-Sanchez H, Lebrao ML, Duarte YA, Wong R, et al. Development and validation of a 10-year mortality prediction model: meta-analysis of individual participant data from five cohorts of older adults in developed and developing countries. J Gerontol A Biol Sci Med Sci. 2017;72(3):410–6.CrossRefGoogle Scholar
  13. 13.
    Herskovic AC, Wu X, Christos PJ, Nagar H. Omission of adjuvant radiotherapy in the elderly breast cancer patient: Missed opportunity? Clin Breast Cancer. 2018;18(5):418–431.CrossRefGoogle Scholar
  14. 14.
    Chu QD, Zhou M, Peddi P, Medeiros KL, Wu XC. Outcomes in real-world practice are different than cooperative trial for elderly patients with early breast cancer treated with adjuvant radiation therapy. Surgery. 2018;163(6):1213–9.CrossRefGoogle Scholar
  15. 15.
    Chesney TR, Yin JX, Rajaee N, Tricco AC, Fyles AW, Acuna SA, et al. Tamoxifen with radiotherapy compared with Tamoxifen alone in elderly women with early-stage breast cancer treated with breast conserving surgery: a systematic review and meta-analysis. Radiother Oncol. 2017;123(1):1–9.CrossRefGoogle Scholar
  16. 16.
    Fyles AW, McCready DR, Manchul LA, Trudeau ME, Merante P, Pintilie M, Weir LM, et al. Tamoxifen with or without breast irradiation in women 50 years of age or older with early breast cancer. N Engl J Med. 2004;351(10):963–70.CrossRefGoogle Scholar
  17. 17.
    Soulos PR, Yu JB, Roberts KB, Raldow AC, Herrin J, Long JB, et al. Assessing the impact of a cooperative group trial on breast cancer care in the medicare population. J Clin Oncol. 2012;30(14):1601–7.CrossRefPubMedCentralGoogle Scholar
  18. 18.
    Shumway DA, Griffith KA, Sabel MS, Jones RD, Forstner JM, Bott-Kothari TL, et al. Surgeon and radiation oncologist views on omission of adjuvant radiotherapy for older women with early-stage breast cancer. Ann Surg Oncol. 2017;24(12):3518–26.CrossRefGoogle Scholar
  19. 19.
    Cao KI, Salviat F, Laki F, Falcou MC, Carton M, Poortmans P, et al. Outcomes of postoperative radiation therapy for breast cancer in older women according to age and comorbidity status: an observational retrospective study in 752 patients. J Geriatr Oncol. 2018;9(6):600–605.CrossRefGoogle Scholar
  20. 20.
    Sen S, Wang SY, Soulos PR, Frick KD, Long JB, Roberts KB, et al. Examining the cost-effectiveness of radiation therapy among older women with favorable-risk breast cancer. J Natl Cancer Inst. 2014;106(3):dju008.Google Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Stephanie Downs-Canner
    • 1
  • Emily C. Zabor
    • 2
  • Tyler Wind
    • 1
  • Armend Cobovic
    • 1
  • Beryl McCormick
    • 3
  • Monica Morrow
    • 1
  • Alexandra Heerdt
    • 1
    Email author
  1. 1.Breast Service, Department of SurgeryMemorial Sloan Kettering Cancer CenterNew YorkUSA
  2. 2.Biostatistics Service, Department of Epidemiology and BiostatisticsMemorial Sloan Kettering Cancer CenterNew YorkUSA
  3. 3.Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkUSA

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