Recommendation to omit radiation therapy after lumpectomy is not frequently implementedJanuary 27, 2016
Chicago: (January 27, 2016): Nearly two thirds of U.S. women age 70 or older with stage I breast cancer1 who undergo lumpectomy and are eligible to safely omit subsequent radiation therapy (RT) according to national cancer guidelines still receive this treatment, according to new study results. The researchers looked at more than 205,000 cases of breast cancer nationwide, and their study is published as an "article in press" on the Journal of the American College of Surgeons website in advance of print publication.
After a lumpectomy, also called a breast-sparing or breast-conserving operation, radiation usually is given to the breast to reduce the chance of the cancer returning. However, treatment recommendations changed in 2004 for a select group of elderly breast cancer patients after research found that postoperative RT did not significantly prolong their survival over five years compared with women who received no RT.2
In the new study, the researchers compared post-lumpectomy RT utilization before and after 2004 and found that RT use decreased only 3 percent among women for whom the value of this treatment is questionable.
This finding demonstrates a lack of compliance with or poor awareness of the recommended treatment for what probably is a large number of breast cancer patients, said lead author Quyen D. Chu, MD, MBA, FACS, professor of surgery at Louisiana State University (LSU) Health Sciences Center, Shreveport.
"Why are we as a nation mostly not following a national guideline on breast cancer treatment?" Dr. Chu asked. "This guideline applies to a significant proportion of patients. About 30 percent of new diagnoses of invasive breast cancer3 are in women 70 and older."
In 2004 researchers of a multicenter clinical trial, known as the Cancer and Leukemia Group B (CALGB) 9343 trial,2 advised that it is reasonable to omit RT in women with certain characteristics that put them at low risk of dying of cancer. Those characteristics were as follows:
- age 70 or older
- stage I breast cancer measuring 2 cm or less (roughly three-fourths of an inch or smaller) that has not spread to the lymph nodes on clinical examination
- estrogen-receptor-positive tumor status (the most common type of breast cancer)
- surgical removal of the tumor with lumpectomy and negative surgical margins, meaning no more cancer is observed at the edge of the removed tumor
- subsequent long-term anti-hormone therapy such as tamoxifen
Subsequently, organizations including the National Comprehensive Cancer Network and the American Cancer Society updated their stage I breast cancer treatment guidelines to include when to consider omitting RT.4
To find out whether clinical practice changed after the CALGB 9343 trial, Dr. Chu and his co-investigators evaluated RT use using the National Cancer Data Base (NCDB), a joint project of the American College of Surgeons Commission on Cancer (CoC) and the American Cancer Society. NCDB captures an estimated 70 percent of newly diagnosed cancer cases in the United States from approximately 1,500 cancer programs accredited by the CoC.
From 2.8 million breast cancer cases diagnosed between 1998 and 2012 and listed in the database, the researchers identified 205,860 women at least 70 years old who underwent lumpectomy for treatment of hormone-receptor-positive stage I breast cancer. Approximately 50 percent of the women received their cancer diagnosis before publication of the CALGB criteria (1998 to 2004), and the other half, after publication (2005 to 2012).
In the pre-CALGB group 31.2 percent of patients did not undergo RT versus 34.2 percent in the post-CALGB group, a decrease in RT use of 3 percent, the investigators reported. Patients ages 80 and older had the greatest decrease in RT use among the different age groups according to the article. However, Dr. Chu said after the CALGB 9343 trial, 30 percent of patients ages 85 years and older still received RT.
Possible side effects of breast RT include breast swelling, pain, skin discoloration or firmness, and shrinkage in the size of the breast.
The researchers reported a large variation in RT use depending on demographic, tumor, and other characteristics.
Poorer access to cancer care, rather than better adherence to the guideline, may explain some differences observed in RT use, Dr. Chu said. For instance, significant predictors of lowest RT use included residence in the central southeastern states (Kentucky, Tennessee, Mississippi, and Alabama) or in a small rural population not near a metropolitan area, or an increased distance between the patient's home and the hospital that reported the cancer. However, insurance status did not influence RT use, he noted.
Alternatively, Dr. Chu suggested that some women might have chosen to receive RT to reduce their worries about a recurrence. In the initial CALGB 9343 trial, women who did not receive RT had a 3 percent higher breast cancer recurrence rate over five years compared with those who did undergo RT.2
Another possible explanation given by Dr. Chu for the apparently low adoption of the guideline is the increasing popularity in the past decade of faster forms of RT, such as brachytherapy. A course of brachytherapy typically takes only five days versus up to six weeks with conventional external beam RT according to Dr. Chu. The newer technique involves implanting radioactive materials (seeds or in catheters) into the breast cavity.
Several other predictors of not receiving RT surprised the researchers, Dr. Chu said. Patients were less likely to undergo RT if they did not adhere to long-term anti-hormone therapy and if they had "residual," or remaining, tumor after lumpectomy. Although Dr. Chu said they could only speculate on the possible reasons why these patients tended to not receive RT as experts recommend, further analysis of the study data showed a correlation between advanced age and residual tumor.
"Surgeons should try to achieve negative lumpectomy margins for patients who are 85 and older because they are less likely to receive radiation treatment," Dr. Chu suggested.
The CALGB 9343 trial results have been confirmed in a 10-year update of that trial and in other recent studies.5
Dr. Chu said he hopes the message of when to withhold this breast cancer treatment receives better awareness in the community.
"Patients often ask a surgeon, do I need this operation? Maybe it's time to ask your doctor, do I need radiation treatment for my breast cancer?" Dr. Chu said.
The university's Charles Knight Sr. Endowed Professorship funded this study.
This study was presented December 9, 2015, at the Southern Surgical Association 127th Annual Meeting in Hot Springs, Va.
Citation: Impact of Cooperative Trial and Sociodemographic Variation on Adjuvant Radiation Therapy Usage in Elderly Women (?70 years) with Stage I, Estrogen Receptor-Positive Breast Cancer: Analysis of the National Cancer Data Base, Journal of the American College of Surgeons. DOI: http://dx.doi.org/10.1016/j.jamcollsurg.2015.12.018
1 American Joint Committee on Cancer. Cancer staging: what you need to know. Available at: https://cancerstaging.org/CSE/Registrar/Documents/needtoknow.pdf. Accessed January 25, 2016.
2 Hughes KS, Schnaper LA, Berry D, et al. for the Cancer and Leukemia Group B, Radiation Therapy Oncology Group, and Eastern Cooperative Oncology Group. 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):971-977.
3 Stages I to IV. Source: American Cancer Society. Breast Cancer Facts & Figures 2015-2016. Atlanta, GA: American Cancer Society Inc; 2015:1. Available at: http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-046381.pdf. Accessed January 15, 2016.
4 National Comprehensive Cancer Network (NCCN). Should I have radiation therapy. In: NCCN Guidelines for Patients Stages 1 and II Breast Cancer, Version 1.2014:52. Available at: http://www.nccn.org/patients/guidelines/stage_i_ii_breast/index.html#54. Accessed January 18, 2016. American Cancer Society. Treatment of invasive breast cancer, by stage. Available at: http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-treating-by-stage. Accessed January 18, 2016.
5 Hughes KS, Schnaper LA, Bellon JR, 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):2382-2387. Kunkler IH, Williams LJ, Jack WJ, Cameron DA, Dixon JM; 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):266-273. Blamey RW, Bates T, Chetty U, et al. Radiotherapy or tamoxifen after conserving surgery for breast cancers of excellent prognosis: British Association of Surgical Oncology (BASO) II trial. Eur J Cancer. 2013;49(10):2294-2302.
About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 79,000 members and is the largest organization of surgeons in the world. For more information, visit http://www.facs.org.
American College of Surgeons
Related Breast Cancer Articles:
A new article published by JAMA Oncology compares outcomes for combined mammography and MRI or ultrasonography screenings for new breast cancers in women who have previously undergone breast conservation surgery and radiotherapy for breast cancer initially diagnosed at 50 or younger.
A Clinical Breast Cancer study demonstrates Videssa Breast can inform better next steps after abnormal mammogram results and potentially reduce biopsies up to 67 percent.
The proportion of women in the United States undergoing surgery for early-stage breast cancer who have preventive mastectomy to remove the unaffected breast increased significantly in recent years, particularly among younger women, and varied substantially across states.
Breast cancer patients with dense breast tissue have almost a two-fold increased risk of developing disease in the contralateral breast, according to new research from The University of Texas MD Anderson Cancer.
Breast conserving therapy (BCT) is better than mastectomy for patients with some types of early breast cancer, according to results from the largest study to date, presented at ECC2017.
An annual mammogram is recommended after treatment for breast cancer, but nearly one-third of women diagnosed with breast cancer aren't receiving this follow-up exam, according to new findings presented at the 2016 Annual Clinical Congress of the American College of Surgeons.
Even though dense breast tissue is a risk factor for breast cancer, very low mammographic breast density is associated with a worse prognosis in breast cancer patients.
Young women with early breast cancer face a difficult choice about whether to opt for a mastectomy or breast conserving therapy (BCT).
In a study appearing in the April 26 issue of JAMA, Elizabeth A.
Five years after breast-conserving surgery, radiotherapy focused around the tumor bed is as good at preventing recurrence as irradiating the whole breast, with fewer side effects, researchers from the UK have found in the large IMPORT LOW trial.
Related Breast Cancer Reading:
Chicken Soup for the Soul: Hope & Healing for Your Breast Cancer Journey: Surviving and Thriving During and After Your Diagnosis and Treatment
by Dr. Julie Silver (Author)
Chicken Soup for the Soul: Hope & Healing for Your Breast Cancer Journey will encourage comfort and encourage breast cancer patients and survivors with its inspiring stories and helpful medical information.
A support group from breast cancer diagnosis through treatment to rehabilitation and recovery, this book combines inspiring Chicken Soup for the Soul stories written just for this book and accessible leading-edge medical information from Dr. Julie Silver of Harvard Medical School. Patients and survivors will find comfort, strength and hope. View Details
Breast Cancer Smoothies: 100 Delicious, Research-Based Recipes for Prevention and Recovery
by Daniella Chace (Author)
The statistics are staggering. Breast cancer is the most common type of cancer among women--About 1 in 8 U.S. women (about 12%) will develop invasive breast cancer over the course of her lifetime. Second only to heart disease by a mere one percent, every ounce of prevention and every window of opportunity for healing is critical. In order to reduce the risk of developing this common disease, you need a targeted plan to protect yourself from common breast toxins and to strengthen your immune defenses.
In her delightful new book, Daniella breaks down the complex topic of... View Details
Dear Friend: Letters of Encouragement, Humor, and Love for Women with Breast Cancer
by Gina L Mulligan (Author)
This beautiful collection of handwritten letters offers strength, encouragement, and comfort to women living with breast cancer. Written by compassionate strangers—many of whom have gone through their own health battles—these heartfelt letters were gathered by Girls Love Mail, an organization that provides support to people diagnosed with breast cancer as seen on NBC Nightly News. Presented in an elegant package with metallic endpapers, and a ribbon marker, and brimming with warm messages of empathy, inspiration, and humor, Dear Friend delivers words of wisdom when they're needed... View Details
The Whole-Food Guide for Breast Cancer Survivors: A Nutritional Approach to Preventing Recurrence (The New Harbinger Whole-Body Healing Series)
by Edward Bauman MEd PhD (Author), Helayne Waldman MS EdD (Author), Donald I. Abrams MD (Foreword)
If you’re a breast cancer survivor, chances are you have renewed your commitment to maintaining your good health and taking care of your body. As one of the best preventative measures known to doctors and nutritionists today, a robust, cancer-fighting diet is vital to your personal plan for breast cancer prevention.
The Whole-Food Guide for Breast Cancer Survivors is an essential guide for every woman seeking to understand the effect of nutritional deficiencies and environmental factors on her overall health and wellness. Based on Edward Bauman’s groundbreaking Eating for... View Details
The Breast Cancer Survival Manual, Sixth Edition: A Step-by-Step Guide for Women with Newly Diagnosed Breast Cancer
by John Link M.D. (Author), James Waisman M.D. (Author), Nancy Link R.N. (Author)
One of the most comprehensive and bestselling books on breast cancer treatment and survival, completely revised and updated
The sixth edition of Breast Cancer Survival Manual provides essential updates on treatment and care, enhancing the basic information that has made this the most trusted guide for women diagnosed with breast cancer for the past two decades. This edition includes the most current advice on:
· The new genomic classification of breast cancer and its importance in treatment planning
· Cancer gene testing, which determines if a woman will benefit... View Details
Dr. Susan Love's Breast Book (A Merloyd Lawrence Book)
by Susan M. Love (Author), Karen Lindsey (Contributor), Elizabeth Love (Contributor)
"The Bible for women with breast cancer" --New York Times
For more than two decades, readers faced with a diagnosis of breast cancer have relied on Dr. Susan Love's Breast Book to guide them through the frightening thicket of research and opinion to find the best options for their particular situations. This sixth edition explains advances in targeted treatments, hormonal therapies, safer chemotherapy, and immunologic approaches as well as new forms of surgery and radiation. There is extensive guidance for the many women now living for years with metastatic breast... View Details
Heal Breast Cancer Naturally: 7 Essential Steps to Beating Breast Cancer
by Dr. Veronique Desaulniers (Author)
One out of eight women will be diagnosed with Breast Cancer. One out of 3 women will experience some form of cancer in their life time.
I was one of those statistics even though I was living a healthy lifestyle that consisted of organic foods, regular exercise, massage, Chiropractic care and colonics. How could somebody like me develop Breast Cancer?
That very question led to thousands of hours of research, study, soul-searching and prayer. It all came together as The 7 Essentials – 7 basic steps that are necessary for preventing and healing cancer, or any dis-ease for... View Details
Just Get Me Through This! - Revised and Updated: A Practical Guide to Coping with Breast Cancer
by Deborah A. Cohen (Author), Robert M. Gelfand M.D. (Author)
You Can Get Through This
Your doctor told you it was breast cancer. So now what?! You'll need plenty of essential advice--the kind that only comes from someone who's been there.
In Just Get Me Through This! Deborah A. Cohen and Robert M. Gelfand, M.D. help you deal with all the ups and downs of the breast cancer experience. From the shock of diagnosis to getting through treatment to getting on with your life, they pack it with plenty of straight talk and practical tips. This newly updated edition also includes advice from two prominent breast cancer... View Details
Breast Cancer Husband: How to Help Your Wife (and Yourself) during Diagnosis, Treatment and Beyond
by Marc Silver (Author)
A unique guide, like none other on the market-packed with medical information, practical tips, psychological insight, and coping strategies-to help men help the women they love through this trying time.
When Marc Silver became a breast cancer husband three years ago, he learned firsthand how frightened and helpless the breast cancer husband feels. He searched in vain for a book that would give him the information and advice he so desperately sought. Now this award-winning journalist has compiled just the kind of emotionally supportive and useful resource that he wished he had been... View Details
Chicken Soup for the Breast Cancer Survivor's Soul: Stories to Inspire, Support and Heal (Chicken Soup for the Soul)
by Jack Canfield (Author), Mark Victor Hansen (Author), Mary Olsen Kelly (Author)
You'll find your own strength as you read these revealing stories in which women and their loved ones talk openly about their own fights with breast cancer and how they made it through the dark times to become survivors, with a new understanding of themselves and their capabilities. View Details