Patterns of Axillary Management in Stages 2 and 3 Hormone Receptor-Positive Breast Cancer by Initial Treatment Approach
- 107 Downloads
Data regarding axillary management after neoadjuvant endocrine therapy (NET) are lacking. This study examined axillary management of hormone receptor-positive (HR+) patients based on initial treatment with NET, neoadjuvant chemotherapy (NAC), or upfront surgery.
Patients with stage 2 or 3 HR+/HER2− breast cancer treated between 2012 and 2015 were identified in the National Cancer Database. The study examined axillary surgery [sentinel lymph node biopsy (SLNB), SLNB followed by axillary lymph node dissection (ALND), or upfront ALND] by initial treatment stratified by cN0/N1 using pairwise comparisons and multivariable logistic regression.
Of 92,204 eligible patients, 2138 (2.3%) received NET, 11,014 (12%) received NAC, and 79,052 (85.7%) received surgery. Among 60,998 cN0 patients, attempted SLNB was more likely for surgery patients (86.2%, 47,159/54,684) and NET patients (85.8%, 1342/1564) than for NAC patients (79.9%, 3793/4750) (both p < 0.001). Among 31,206 cN1 patients, attempted SLNB was more likely for the surgery patients (46.0%, 11,201/24,368) than for the NET patients (41.8%, 240/574; p = 0.05) or the NAC patients (39.8%, 2491/6264; p < 0.0001). The differences between surgery and NET did not persist in the adjusted analyses. Among both the cN0 patients (n = 13,856) and the cN1 patients (n = 8688) with pN1 disease shown by SLNB, the NET patients were treated with ALND less frequently than those receiving NAC or surgery (p < 0.0001 for all comparisons). In the multivariate analysis, for the patients with pN1 disease shown by SLNB, NET use was associated with increased odds of undergoing SLNB alone [cN0 patients: odds ratio (OR), 1.31, 95% confidence interval (CI), 1.04–1.64; cN1 patients: OR 1.45; 95% CI 1.00–2.10].
For stages 2 and 3 HR+/HER2− patients, SLNB use after NET was similar to that for upfront surgery. Among those with pN1 disease, the NET patients were less likely to undergo ALND. Additional outcomes data are needed to guide axillary management after NET.
R. Freedman receives institutional funding from Eisai, and Puma. O. Metzger receives honoraria from Grupo Oncoclinicas and Roche Brasil; institutional funding from Susan G. Komen for the Cure, Pfizer, Roche/Genentech, Eisai, Cascadian Therapeutics, and Abbvie; and travel, accommodations, and expenses from Grupo Oncoclinicas. J. Bellon receives honoraria from UpToDate, Wolters Kluwer, The International Journal of Radiation Oncology, Biology and Physics, Leidos Pharmaceuticals, Accuray, and research funding from Prosigna. E. Mittendorf receives compensation for serving on advisory boards at Astra-Zeneca/Medimmune, Celgene, Genentech, Genomic Health, Merck, Peregrine Pharmaceuticals, SELLAS Lifesciences, and TapImmune. While at a previous institution (MD Anderson), E. Mittendorf received institutional funding from Astra-Zeneca/Medimmune, EMD-Serono, Galena Biopharma, and Genentech. T. King receives an honorarium (speaker fee) from Genomic Health. None of the other authors report disclosures.
- 7.Giuliano AE, Ballman K, McCall L, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 randomized trial. Ann Surg. 2016;264:413–20.CrossRefGoogle Scholar
- 9.Savolt A, Peley G, Polgar C, et al. Eight-year follow-up result of the OTOASOR trial: the optimal treatment of the axilla: surgery or radiotherapy after positive sentinel lymph node biopsy in early-stage breast cancer: a randomized, single-centre, phase III, non-inferiority trial. Eur J Surg Oncol. 2017;43:672–9.CrossRefGoogle Scholar
- 10.Parulekar WR, Berrang T, Kong I, et al. Cctg MA.39 tailor RT: a randomized trial of regional radiotherapy in biomarker low-risk node-positive breast cancer (NCT03488693). J Clin Oncol. 2019;37(15_suppl):abstract TPS602.Google Scholar
- 15.Boughey JC, Ballman KV, Le-Petross HT, et al. Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0-T4, N1-N2) who receive neoadjuvant chemotherapy: results from ACOSOG Z1071 (Alliance). Ann Surg. 2016;263:802–7.CrossRefGoogle Scholar
- 17.Romano PS, Roos LL, Jollis JG. Adapting a clinical comorbidity index for use with ICD-9-CM administrative data: differing perspectives. J Clin Epidemiol. 1993;46:1075–9; discussion 1081–90.Google Scholar
- 22.Weiss A, Mittendorf EA, DeSnyder SM, et al. Expanding implementation of ACOSOG Z0011 in surgeon practice. Clin Breast Cancer. 2017;13:30412–3.Google Scholar
- 23.Al-Hilli Z, Hoskin TL, Day CN, Habermann EB, Boughey JC. Impact of neoadjuvant chemotherapy on nodal disease and nodal surgery by tumor subtype. Ann Surg Oncol. 2017;27:017–6263.Google Scholar
- 25.Ellis MJ, Suman VJ, Hoog J, et al. Randomized phase II neoadjuvant comparison between letrozole, anastrozole, and exemestane for postmenopausal women with estrogen receptor-rich stage 2 to 3 breast cancer: clinical and biomarker outcomes and predictive value of the baseline PAM50-based intrinsic subtype—ACOSOG Z1031. J Clin Oncol. 2011;29:2342–9.CrossRefGoogle Scholar
- 27.Ellis MJ, Suman VJ, Hoog J, et al. Ki67 Proliferation Index as a tool for chemotherapy decisions during and after neoadjuvant aromatase inhibitor treatment of breast cancer: results from the American College of Surgeons Oncology Group Z1031 Trial (Alliance). J Clin Oncol. 2017;35:1061–9.CrossRefGoogle Scholar
- 31.A Randomized Phase III Clinical Trial Evaluating Post-Mastectomy Chestwall and Regional Nodal XRT and Post-Lumpectomy Regional Nodal XRT in Patients With Positive Axillary Nodes Before Neoadjuvant Chemotherapy Who Convert to Pathologically Negative Axillary Nodes After Neoadjuvant Chemotherapy. Retrieved 15 December 2018 at https://clinicaltrials.gov/ct2/show/NCT01872975.
- 35.A Randomized Phase III Trial Comparing Axillary Lymph Node Dissection to Axillary Radiation in Breast Cancer Patients (cT1–3N1) Who Have Positive Sentinel Lymph Node Disease After Neoadjuvant Chemotherapy. Retrieved 15 December 2018 at https://clinicaltrials.gov/ct2/show/NCT01901094.