Abstract
Surgery remains the foundation of curative therapy for non-metastatic breast cancer, but many patients do not undergo surgery. Evidence is limited regarding this population. We sought to assess factors associated with lack of surgery and overall survival (OS) in patients not receiving breast cancer surgery. Retrospective cohort study of patients in the US National Cancer Database treated in 2004–2016. The dataset comprised 2,696,734 patients; excluding patients with unknown surgical status or stage IV, cT0, cTx, or pIS, metastatic or recurrent disease resulted in 1,192,294 patients for analysis. Chi-square and Wilcoxon rank-sum tests were used to assess differences between groups. OS was analyzed using the Kaplan–Meier method with a Cox proportional hazards model performed to assess associated factors. In total 50,626 (4.3%) did not undergo surgery. Black race, age >50 years, lower income, uninsured or public insurance, and lower education were more prevalent in the non-surgical cohort; this group was also more likely to have more comorbidities, higher disease stage, and more aggressive disease biology. Only 3,689 non-surgical patients (7.3%) received radiation therapy (RT). Median OS time for the non-surgical patients was 58 months (3-year and 5-year OS rates 63% and 49%). Median OS times were longer for patients who received chemotherapy (80 vs 50 (no-chemo) months) and RT (85 vs 56 (no-RT) months). On multivariate analysis, age, race, income, insurance status, comorbidity score, disease stage, tumor subtype, treatment facility type and location, and receipt of RT were associated with OS. On subgroup analysis, receipt of chemotherapy improved OS for patients with triple negative (HR 0.66, 95% CI 0.59–0.75, P < 0.001) and HER2+ (HR 0.74, 95% CI 0.65–0.84, P < 0.001) subgroups while RT improved OS for ER+ (HR 0.72, 95% CI 0.64–0.82, P < 0.001) and favorable-disease (ER+, early-stage, age >60) (HR 0.61, 95% CI 0.45–0.83, P = 0.002) subgroups. Approximately 4% of women with breast cancer do not undergo surgery, particularly those with more aggressive disease and lower socioeconomic status. Despite its benefits, RT was underutilized. This study provides a benchmark of survival outcomes for patients who do not undergo surgery and highlights a potential role for use of RT.
Highlights
Current therapy for breast cancer (BC) most often involves a multimodality approach, with neoadjuvant systemic therapy, surgical resection, and adjuvant radiation therapy (RT) or chemotherapy/hormonal therapy considered on the basis of tumorand patient-related risk factors[1]
A subgroup analysis was conducted for patients with triplenegative breast cancer (TNBC), HER2+ cancer, ER+, or ‘favorable’ disease to assess whether RT chemotherapy, or hormone therapy was associated with differences in overall survival (OS) in these subgroups (Fig. 2)
This study represents the largest analysis of women who did not undergo surgical resection as part of therapy for breast cancer, and is the first to look at outcomes for these patients according to subtype
Summary
Current therapy for breast cancer (BC) most often involves a multimodality approach, with neoadjuvant systemic therapy, surgical resection, and adjuvant radiation therapy (RT) or chemotherapy/hormonal therapy considered on the basis of tumorand patient-related risk factors[1]. Several studies have evaluated the role of definitive RT with or without systemic therapy for patients who do not undergo surgery; local-regional control rates after this therapy have ranged from 50% to 96%3–11. This approach has been used mostly for elderly women, the group that’s most likely to be offered a non-surgical approach for BC12,13. The limited evidence regarding factors associated with not receiving surgery and oncologic outcomes after such therapy, and the lack of prospective trials, consensus guidelines, or recommended treatment strategies for such patients led us to investigate these gaps on a population level by analyzing the US National Cancer Data Base (NCDB)
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