Nodal positivity decreases with age in women with early‐stage, hormone receptor–positive breast cancer

Downs-Canner, Stephanie; Gaber, Charles; Louie, Raphael J.; Strassle, Paula D.; Gallagher, Kristalyn; Muss, Hyman B.; Ollila, David W.

doi:10.1002/cncr.32668

Cited by 16 publications

(4 citation statements)

References 27 publications

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“…Preliminary studies have shown a decrease in rates of ALND and lumpectomy re-excision at both institutional and national levels. 2,11,12 In contrast, other studies suggest more than 80% of women 70 years and older with HR+ breast cancer receive SLNB 2,[13][14][15] and that CPM rates for patients with unilateral cancer are increasing. 2,16 While previous studies have examined some tumor-level, patient-level, and clinicianlevel determinants of persistent use, 17 to our knowledge, variation of deimplementation across facilities and procedures has not been described.…”

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confidence: 94%

Variations in Persistent Use of Low-Value Breast Cancer Surgery

et al. 2021

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IMPORTANCEThrough the Choosing Wisely campaign, surgical specialties identified 4 low-value breast cancer operations. Preliminary data suggest varying rates of deimplementation and have identified patient-level and clinician-level determinants of continued overuse. However, little information exists about facility-level variation or determinants of differential deimplementation.OBJECTIVE To identify variation and determinants of persistent use of low-value breast cancer surgical care.DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study in which reliability-adjusted facility rates of each procedure were calculated using random-intercept hierarchical logistic regression before and after evidence demonstrated that each procedure was unnecessary. The National Cancer Database is a prospective cancer registry of patients encompassing approximately 70% of all new cancer diagnoses from more than 1500 facilities in the United States. Data were analyzed from November 2019 to August 2020. The registry included women 18 years and older diagnosed as having breast cancer between 2004 and 2016 and meeting inclusion criteria for each Choosing Wisely recommendation.MAIN OUTCOMES AND MEASURES Rate of each low-value breast cancer procedure based on facility type and breast cancer volume categories before and after the release of data supporting each procedure's omission. RESULTSThe total cohort included 920 256 women with a median age of 63 years. Overall, 86% self-identified as White, 10% as Black, 3% as Asian, and 4.5% as Hispanic. Most women in this cohort were insured (51% private and 47% public), were living in a metropolitan or urban area (88% and 11%, respectively), and originated from the top half of income-earning households (65.5%). While there was significant deimplementation of axillary lymph node dissection and lumpectomy reoperation in response to guidelines supporting omission of these procedures, rates of contralateral prophylactic mastectomy and sentinel lymph node biopsy in older women increased during the study period. Academic research programs and high-volume facilities overall demonstrated the greatest reduction in use of these low-value procedures. There was significant interfacility variation for each low-value procedure. Facility-level axillary lymph node dissection rates ranged from 7% to 47%, lumpectomy reoperation rates ranged from 3% to 62%, contralateral prophylactic mastectomy rates ranged from 9% to 67%, and sentinel lymph node biopsy rates ranged from 25% to 97%. Pearson correlation coefficient for each combination of 2 of the 4 procedures was less than 0.11, suggesting that hospitals were not consistent in their deimplementation performance across all 4 procedures. Many were high outliers in one procedure but low outliers in another.CONCLUSIONS AND RELEVANCE Interfacility variation demonstrates a performance gap and an opportunity for formal deimplementation efforts targeting each procedure. Several facility-level characteristics were associated with differential deimplementation and perfor...

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confidence: 94%

Variations in Persistent Use of Low-Value Breast Cancer Surgery

et al. 2021

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“…This is supported by other studies that have found the rate of nodal involvement among women 70 years of age or older with cN0, T1, ER+/HER2– IBC to be lower than 10%. 27 …”

Section: Discussionmentioning

confidence: 99%

De-Implementation of Low-Value Care for Women 70 Years of Age or Older with Low-Risk Breast Cancer During the COVID-19 Pandemic

Wang,

Weed,

Tseng

et al. 2023

Ann Surg Oncol

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Background Older women with early-stage estrogen receptor-positive (ER+) invasive breast cancer (IBC) are at risk for overtreatment. Guidelines allow for sentinel lymph node biopsy (SLNB) and radiotherapy omission after breast-conserving surgery (BCS) for women 70 years of age or older with T1, clinical node negativity (cN0), and ER+ IBC. The study objective was to evaluate radiotherapy and SLNB de-implementation in older women with low-risk IBC after the resource limitations of the COVID-19 pandemic. Methods An institutional database was analyzed to identify women 70 years of age or older who received BCS for IBC from 2012 to 2022. The patients were divided into two cohorts: (1) patients with low-risk IBC (pT1, cN0, and ER+/HER2–) who were eligible for radiotherapy and SLNB omission and (2) patients with high-risk IBC (pT2-T4, cN+, ER–, or HER2+) who were ineligible for therapy omission. Clinicopathologic variables in both cohorts were analyzed. Results The study enrolled 881 patients. For the patients with low-risk IBC, the annual rates of radiotherapy were stable from 2012 to 2019. However, radiotherapy utilization decreased significantly from 2020 to 2022 (58% in 2012 vs 36% in 2022; p = 0.04). In contrast, radiotherapy usage among the patients with high-risk IBC was stable from 2012 to 2022 (79% in 2012 vs 79% in 2022; p = 0.95). Among the patients with low-risk IBC, SLNB rates decreased from 86% in 2012 to 56% in 2022, but this trend predated those in 2020. The factors significantly associated with SLNB and receipt of radiotherapy among the patients with low-risk IBC were younger age, larger tumors, grade 3 disease, and involved nodal status (p < 0.01). Conclusion This study demonstrated appropriate and sustained de-escalation of radiotherapy in older women with low-risk IBC after the COVID-19 pandemic.

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“…AGING Lower BC-associated mortality in the elderly is notable considering challenges faced with providing aggressive standard of care therapies when limited by performance status and frailty measures, suggesting the development of relatively more indolent disease in the elderly with a less aggressive course. Congruently, multiple studies have characterized BCs in younger patients with higher histological grade, larger size, low or absent expression of ER and/or progesterone receptors (PR), and greater lymph node (LN) positivity [5][6][7][8][9][10]; while LN positivity in patients with early stage disease is found to be decreased with increasing age [11].…”

Section: Introductionmentioning

confidence: 99%

Breast cancer mortality as a function of age

Nasrazadani

Martí

Kip

et al. 2022

Aging

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Background: Incidence of breast cancer (BC) in US women continues to increase with age as the strongest risk factor. We aimed to compare clinical, pathological and sociological variables associated to BC diagnosis, as well as the relative mortality rates of BC patients compared to the general US population. Methods: We performed a retrospective, single-institution study evaluating 52,509 patients diagnosed with unilateral BC at the University of Pittsburgh Medical Center (UPMC) between 1990-2020. Primary outcome was death from any cause with cancer recurrence as a secondary outcome, evaluated for 4 age groups: 20-44, 45-55, 56-69, and 70-90. A dataset of expected mortality for women in the general population over a 10-year period was constructed using the Surveillance, Epidemiology, and End Results (SEER) Program. Observed vs. expected mortality and standardized mortality ratios (SMR) for each age group were calculated. Results: Youngest patients with BC demonstrated the highest SMR at 10-year follow-up from time of diagnosis compared to the general US population (SMR 9.68, 95% CI: 8.99to 10.42), and remained highest compared to other age groups when analysis was limited to Stage 0/1 disease (10-year SMR 3.11, 95% CI: 2.54 to 3.76). SMRs decreased with increasing age at diagnosis with an SMR <1.0 in patients diagnosed with stage 0/1 at ages 70-90 at 5-year follow-up. Conclusions: Younger BC patients have the highest SMR which declines gradually with age. In the elderly, lower stage 0/1 SMR's are found compared to the general population, suggesting the possibility of an associated protective effect.

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Nodal positivity decreases with age in women with early‐stage, hormone receptor–positive breast cancer

Cited by 16 publications

References 27 publications

Variations in Persistent Use of Low-Value Breast Cancer Surgery

Variations in Persistent Use of Low-Value Breast Cancer Surgery

De-Implementation of Low-Value Care for Women 70 Years of Age or Older with Low-Risk Breast Cancer During the COVID-19 Pandemic

Breast cancer mortality as a function of age

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