The impact of postmastectomy and regional nodal radiation after neoadjuvant chemotherapy for clinically lymph node-positive breast cancer: a National Cancer Database (NCDB) analysis

Rusthoven, Chad G.; Rabinovitch, R; Jones, Bernard L.; Koshy, Matthew; Amini, Arya; Yeh, Norman; Jackson, Mary; Fisher, Christine M.

doi:10.1093/annonc/mdw046

Cited by 93 publications

(73 citation statements)

References 21 publications

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“…The multivariable logistic regression empirical coverage probability increases as the number of events per confounder increases, while the propensity score empirical coverage probability decreases after 8 or more events per confounder. [24, 25] With 4,415 deaths and 18 confounders, we were well over 8 events per confounder. Therefore, multivariable logistic regression was the optimal method for analyzing this database.…”

Section: Discussionmentioning

confidence: 89%

Postmastectomy Radiation in Breast Cancer Patients With Pathologically Positive Lymph Nodes After Neoadjuvant Chemotherapy: Usage Rates and Survival Trends

Ohri

Moshier

et al. 2017

International Journal of Radiation Oncology*Biology*Physics

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Background To analyze postmastectomy radiation therapy (PMRT) utilization and its association with overall survival (OS) in breast cancer patients with pathologically positive lymph nodes after neoadjuvant chemotherapy (NAC). Methods Using the National Cancer Data Base (NCDB), we identified women with non-metastatic breast cancer diagnosed between 2004 and 2013 who received NAC and underwent mastectomy with macroscopic pathologically positive lymph nodes. Joinpoint regression models were used to assess temporal trends in annual PMRT utilization. Multivariable regression models identified factors associated with PMRT use. A time-dependent Cox model was used to evaluate predictors of mortality. Results The study included 29,270 patients, of whom 62.5% received PMRT. PMRT was markedly underutilized among all nodal subgroups, particularly among ypN2 (68.4%) and ypN3 (67.0%) patients. Hispanic patients and those with Medicaid/Medicare insurance were less likely to receive PMRT compared to non-Hispanics and patients with other insurance carriers. Adjusted 5-year OS rates were similar in ypN1 and ypN2 patients with or without PMRT but were significantly higher in ypN3 patients receiving PMRT (66% vs. 63%, p=0.042). In multivariable analysis, PMRT was associated with improved survival only among ypN3 patients after adjusting for patient, facility, and tumor variables (multivariable hazard ratio 0.85, 95% CI 0.74 to 0.97). Conclusion(s) A considerable portion of breast cancer patients with advanced residual nodal disease after NAC did not receive appropriate adjuvant radiation. There are socioeconomic disparities in national PMRT practice patterns. Patients with ypN3 disease may derive a survival benefit from PMRT.

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Section: Discussionmentioning

confidence: 89%

Postmastectomy Radiation in Breast Cancer Patients With Pathologically Positive Lymph Nodes After Neoadjuvant Chemotherapy: Usage Rates and Survival Trends

Ohri

Moshier

et al. 2017

International Journal of Radiation Oncology*Biology*Physics

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“…We considered women who initiated chemotherapy within the period of 84 to 270 days before surgery as receiving neoadjuvant chemotherapy, and women who initiated chemotherapy within 90 days after surgery as receiving adjuvant chemotherapy, as previous studies have done 22,23 (22,23). BCS and unilateral and bilateral mastectomy with or without reconstruction were classified based on Surgery of the Primary Site codes 24 .…”

Section: Methodsmentioning

confidence: 99%

Rising rates of bilateral mastectomy with reconstruction following neoadjuvant chemotherapy

Pollom

Qian

Chin

et al. 2018

Intl Journal of Cancer

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Neoadjuvant chemotherapy is used to allow more limited breast surgery without compromising local control. We sought to evaluate nationwide surgical trends in patients with operable breast cancer treated with neoadjuvant chemotherapy and factors associated with surgical type. We used the National Cancer Database to identify 235,339 women with unilateral T1–3N0–3M0 breast cancer diagnosed between 2010 and 2014, and treated with surgery and chemotherapy. Of these, 59,568 patients (25.3%) were treated with neoadjuvant chemotherapy. Rates of pathologic complete response to neoadjuvant chemotherapy increased from 33.3% at the start of the study period in 2010 to 46.3% at the end of the period in 2014 (p=0.02). Rates of breast- conserving surgery changed little, from 37.0% to 40.8% (p=0.22). While rates of unilateral mastectomy decreased from 43.3% to 34.7% (p=0.02) and rates of bilateral mastectomy without immediate reconstruction remained similar (11.7% to 11.5%, p=0.82), rates of bilateral mastectomy with immediate reconstruction rose from 8.0% to 13.1% (p=0.02). Patients who were younger, with private/managed care insurance, and diagnosed in more recent years were more likely to achieve pathologic complete response; however, these same characteristics were associated with receipt of bilateral mastectomy (versus breast-conserving surgery). Additionally, non-Hispanic white race and higher area education attainment were both associated with bilateral mastectomy. These findings did not differ by age or molecular subtype. Further study of non-clinical factors that influence selection of more extensive surgery despite excellent response to neoadjuvant chemotherapy is warranted.

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“…Recently published studies from Korea and France have contributed to the hypothesis that the recurrence risk may be low enough to omit RT in selected patients with stage II-III BC after a favourable response to NACT and mastectomy [31,32]. Other publications have found a positive effect of PMRT for all cN+ patients following NACT, such as Rusthoven et al [33] whose study included women with cT1-3 cN1 M0 BC treated with mastectomy after NACT (3,040 ypN0 and 7,243 ypN+ cases). PMRT improved OS in univariate and multivariate analyses for ypN+ as well as for ypN0 cases.…”

Section: Postmastectomy Radiotherapymentioning

confidence: 99%

Recent Developments in Radiation Oncology: An Overview of Individualised Treatment Strategies in Breast Cancer

et al. 2018

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Radiation therapy (RT) for breast cancer has dramatically changed over the past years, leading to individualized risk-adapted treatment strategies. Historically, the choice of RT regimen was limited to conventional fractionation protocols using standard tangential fields. Nowadays, technological and technical improvements in modern RT have added a variety of other RT modalities, different fractionation schedules, and individualised treatment volumes to the portfolio of breast RT. This review aims to give a short overview on the main topics which have recently found their way into clinical practice: hypofractionated treatment protocols, accelerated partial breast irradiation (APBI) for low-risk patients, deep inspiration breath hold (DIBH) for maximal heart protection, extent of regional nodal irradiation for high-risk patients, and the implementation of new radiation techniques such as intensity modulated RT (IMRT) and volumetric modulated RT (VMAT).

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The impact of postmastectomy and regional nodal radiation after neoadjuvant chemotherapy for clinically lymph node-positive breast cancer: a National Cancer Database (NCDB) analysis

Cited by 93 publications

References 21 publications

Postmastectomy Radiation in Breast Cancer Patients With Pathologically Positive Lymph Nodes After Neoadjuvant Chemotherapy: Usage Rates and Survival Trends

Postmastectomy Radiation in Breast Cancer Patients With Pathologically Positive Lymph Nodes After Neoadjuvant Chemotherapy: Usage Rates and Survival Trends

Rising rates of bilateral mastectomy with reconstruction following neoadjuvant chemotherapy

Recent Developments in Radiation Oncology: An Overview of Individualised Treatment Strategies in Breast Cancer

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