Abstract
Overtreatment of early-stage breast cancer with favorable tumor biology in older patients may be harmful without affecting recurrence and survival. Guidelines that recommend deimplementation of sentinel lymph node biopsy (SLNB) (Choosing Wisely) and radiotherapy (RT) (National Comprehensive Cancer Network) have been published. To describe the use rates and association with disease recurrence of SLNB and RT in older women with breast cancer. This cohort study obtained patient and clinical data from an integrated cancer registry and electronic health record of a single health care system in Pennsylvania. The cohort was composed of consecutive female patients 70 years or older who were diagnosed with early-stage, estrogen receptor-positive, ERBB2 (formerly HER2)-negative, clinically node-negative breast cancer from January 1, 2010, to December 31, 2018, who were treated at 15 community and academic hospitals within the health system. Sentinel lymph node biopsy and adjuvant RT. Primary outcomes were 5-year locoregional recurrence-free survival (LRFS) rate and disease-free survival (DFS) rate after SLNB and after RT. Secondary outcomes included recurrence rate, subgroups that may benefit from SLNB or RT, and use rate of SLNB and RT over time. Propensity scores were used to create 2 cohorts to separately evaluate the association of SLNB and RT with recurrence outcomes. Cox proportional hazards regression model was used to estimate hazard ratios (HRs). From 2010 to 2018, a total of 3361 women 70 years or older (median [interquartile range {IQR}] age, 77.0 [73.0-82.0] years) with estrogen receptor-positive, ERBB2-negative, clinically node-negative breast cancer were included in the study. Of these women, 2195 (65.3%) received SLNB and 1828 (54.4%) received adjuvant RT. Rates of SLNB steadily increased (1.0% per year), a trend that persisted after the 2016 adoption of the Choosing Wisely guideline. Rates of RT decreased slightly (3.4% per year). To examine patient outcomes and maximize follow-up time, the analysis was limited to cases from 2010 to 2014, identifying 2109 patients with a median (IQR) follow-up time of 4.1 (2.5-5.7) years. In the propensity score-matched cohorts, no association was found between SLNB and either LRFS (HR, 1.26; 95% CI, 0.37-4.30; P = .71) or DFS (HR, 1.92; 95% CI, 0.86-4.32; P = .11). In addition, RT was not associated with LRFS (HR, 0.33; 95% CI, 0.09-1.24; P = .10) or DFS (HR, 0.99; 95% CI, 0.46-2.10; P = .97). Subgroup analysis showed that stratification by tumor grade or comorbidity was not associated with LRFS or DFS. Low absolute rates of recurrence were observed when comparing the groups that received SLNB (3.5%) and those that did not (4.5%) as well as the groups that received RT (2.7%) and those that did not (5.5%). This study found that receipt of SLNB or RT was not associated with improved LRFS or DFS in older patients with ER-positive, clinically node-negative breast cancer. Despite limited follow-up time and wide 95% CIs, this study supports the continued deimplementation of both SLNB and RT in accordance with the Choosing Wisely and National Comprehensive Cancer Network guidelines.
Highlights
As the population in the United States ages, the incidence of cancers in older patients is estimated to increase, and these cancers are expected to account for nearly 70% of all cases diagnosed by 2030.1 A critical risk factor for the development of breast cancer is age, with most of those diagnosed being older than 65 years and nearly 20% being older than 75 years.[1]
In the propensity score–matched cohorts, no association was found between sentinel lymph node biopsy (SLNB) and either locoregional recurrence-free survival (LRFS) (HR, 1.26; 95% CI, 0.37-4.30; P = .71) or disease-free survival (DFS) (HR, 1.92; 95% CI, 0.86-4.32; P = .11)
RT was not associated with LRFS (HR, 0.33; 95% CI, 0.09-1.24; P = .10) or DFS (HR, 0.99; 95% CI, 0.46-2.10; P = .97)
Summary
As the population in the United States ages, the incidence of cancers in older patients is estimated to increase, and these cancers are expected to account for nearly 70% of all cases diagnosed by 2030.1 A critical risk factor for the development of breast cancer is age, with most of those diagnosed being older than 65 years and nearly 20% being older than 75 years.[1]. Many treatment-associated morbidities may be low in younger women with breast cancer, older patients are more prone to adverse effects that can have a substantial impact on quality of life and the ability to perform functions of daily living.[4] Older populations can be subjected to both overtreatment and undertreatment[5]; because they are more likely to have comorbidities and functional limitations, physicians are less likely to treat cancers aggressively, leading to increased risk for locoregional recurrence and decreased overall survival.[4,6,7] overtreatment of a cancer that will not lead to death subjects these patients to unnecessary tests and procedures.[8,9]
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