Abstract
Radiotherapy (RT) is of critical importance in the locoregional management of early breast cancer. Although RT is routinely used following breast conserving surgery (BCS), patients may occasionally be effectively treated with BCS alone. Currently, the selection of patients undergoing BCS who do not need breast irradiation is under investigation. With the advancement of personalized medicine, there is an increasing interest in reduction of aggressive treatments especially in older women. The primary objective of this study was to identify elderly patients who may forego breast irradiation after BCS without measurable consequences on local tumor growth and survival. We analyzed 2384 early breast cancer patients aged 70 and older who were treated in 17 German certified breast cancer centers between 2001 and 2009. We compared RT versus no RT after guideline adherent (GA) BCS. The outcomes studied were breast cancer recurrence (RFS) and breast cancer-specific survival (BCSS). Low-risk patients were defined by luminal A, tumor size T1 or T2 and node-negative whereas higher-risk patients were defined by patients with G3 or T3/T4 or node-positive or other than Luminal A tumors. To test if there is a difference between two or more survival curves, we used the Gp family of tests of Harrington and Fleming. The median age was 77 yrs (mean 77.6±5.6 y) and the median observation time 46 mths (mean 48.9±24.8 mths). 950 (39.8%) patients were low-risk and 1434 (60.2%) were higher-risk. 1298 (54.4%) patients received GA BCS of which 85.0% (1103) received GA-RT and only 15% (195) did not. For low-risk patients with GA-BCS there were no significant differences in RFS (log rank p = 0.651) and in BCSS (p = 0.573) stratified by GA-RT. 5 years RFS in both groups were > 97%. For higher-risk patients with GA-BCS we found a significant difference (p<0.001) in RFS and tumor-associated OS stratified by GA-RT. The results remain the same after adjusting by adjuvant systemic treatment (AST) and comorbidity (ASA and NYHA). Patients aged 70 years and older suffering from low-risk early breast cancer with GA-BCS can avoid breast irradiation with <3% chance of relapse. In the case of higher-risk, breast irradiation should be used routinely following GA-BCS. As a side effect of these results, removing the entire breast of elderly low risk patients to spare them from breast irradiation seems to be not necessary.
Highlights
Breast cancer remains to be the major cancer diagnosis in women
For low-risk patients with guideline adherent (GA)-breast conserving surgery (BCS) there were no significant differences in Recurrence-free survival (RFS) and in breast cancer-specific survival (BCSS) (p = 0.573) stratified by guideline adherent radiotherapy (GA-RT). 5 years RFS in both groups were > 97%
For higher-risk patients with guideline adherent breast conserving therapy (GA-BCS) we found a significant difference (p
Summary
Breast cancer remains to be the major cancer diagnosis in women. Approximately 65% of the invasive breast cancer patients are aged 40–70 years at initial diagnosis and about 30% of the breast cancer patients are 70 years or older [1]. The treatment of elderly breast cancer patients differs from the therapeutic approach in younger ones, as elderly patients are prone to geriatric frailty and comorbidities, such as renal failure, liver disease, and/or cerebrovascular disease [3,4,5]. Those tumors in elderly patients are often of less aggressive tumor biology. Subgroups have been defined that are associated with a low risk for locoregional recurrence (pT1, pN0, R0, HER2-) [11, 12] In those cases, radiotherapy still adds benefits but can most likely be dispensed even after BCS
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