Outcome of Treatment After Locoregional Radiation, Neoadjuvant and Adjuvant Chemotherapy for Breast Cancer

Abstract

The addition of systemic therapy to locoregional treatment for women with all stages of breast cancer improves survival. Reliable data are lacking about the outcomes of women with breast cancer in low-middle income countries who are treated with a combination of radiotherapy (RT), surgery, and systemic therapy. report the outcome of women with breast cancer treated with either neoadjuvant chemotherapy (NACT) or adjuvant chemotherapy at the National Centre for Radiotherapy and Nuclear Medicine in Accra, Ghana. The medical charts of all women with breast cancer managed at the National Centre for Radiotherapy and Nuclear Medicine from 2005 to 2014 were reviewed. Available patient specific demographic data, tumor stage, treatment sequence, and follow-up information were recorded. Logistic regression was used to estimate the presence of locoregional (LRR) and distant recurrence (DR) between two chemotherapy groups. Overall survival (OS) and disease-free survival (DFS) were used as time dependent outcomes and were analyzed using cox proportional hazard (CPH) model. All the models were adjusted with clinico-pathologic variables and estimates were reported along with their 95% confidence interval (CI). A total of 387 patients with a median follow up of 48 months were included in the study. The median age at diagnosis was 51 years. 49.6% of women had advanced pathologic stage ≥pT3. 58.9% (n = 228) received adjuvant chemotherapy whereas 41.1 % (n = 159) received NACT. The majority of women (94.1%, n = 365) received RT. 18.4% (n = 67) underwent breast conservation therapy followed by RT to a mean dose of 48.8 Gy in 10-30 fractions, and 81.6% (n = 298) had a mastectomy followed by RT to a mean dose of 47.92 Gy in 10-30 fractions. In an adjusted logistic model, no difference was observed in LRR between patients receiving NACT compared to those receiving adjuvant chemotherapy (OR = 1.05, 95% CI {0.44 - 2.47}, p = 0.9). However, NACT recipients had a higher likelihood of DR (OR = 1.97, 95% CI, {1.24 – 3.15}, p = 0.004). In a multivariate analysis, no differences were observed in survival between the two chemotherapy groups (HR = 1.43, 95% CI, {0.91 – 2.26}, p = 0.1). There was a trend towards lower DFS within the NACT group compared to the adjuvant chemotherapy group, with patients receiving NACT having a 52% likelihood of lower DFS (HR = 1.52, 95% CI, {0.96 – 2.39}, p = 0.06). While many women present with late stage disease in Ghana, outcomes after trimodal therapy are comparable to what is observed in developed countries. Advanced stage of disease is significantly associated with recurrence and survival, hence early detection in a resource limited setting is crucial to optimal outcomes. To our knowledge, this is the first and largest study to report on the outcomes of women with breast cancer who receive standard of care treatment in Ghana.