Abstract
PurposeThe large variation in histologic grading of invasive breast cancer (IBC) that has been reported likely influences tailoring adjuvant therapy. The role of grading in therapeutic decision-making in daily practice, was evaluated using the Dutch national guidelines for IBC-management.MethodsSynoptic reports of IBC resection-specimens, obtained between 2013 and 2016, were extracted from the nationwide Dutch Pathology Registry, and linked to treatment-data from the Netherlands Cancer Registry. The relevance of grading for adjuvant chemotherapy (aCT) was quantified by identifying patients for whom grade was the determinative factor. In addition, the relation between grade and aCT-administration was evaluated by multivariate logistic regression for patients with a guideline-aCT-indication.Results30,843 patients were included. Applying the guideline that was valid between 2013 and 2016, grade was the determinative factor for the aCT-indication in 7744 (25.1%) patients, a percentage that even increased according to the current guideline where grade would be decisive for aCT in 10,869 (35.2%) patients. Also in current practice, the indication for adjuvant endocrine therapy (aET) would be based on grade in 9173 (29.7%) patients. Finally, as patients with lower-grade tumors receive aCT significantly less often, grade was also decisive in tailoring aCT de-escalation.ConclusionsIn the largest study published so far we illustrate the increasing importance of histologic grade in tailoring adjuvant systemic breast cancer therapy. Next to playing a key-role in aCT-indication and de-escalation, the role of grading has expanded to the indication for aET. Optimizing histologic grading by pathologists is urgently needed to diminish the risk of worse patient outcome due to non-optimal treatment.
Highlights
Breast cancer is the most common type of cancer in women worldwide, with an incidence of 2.1 million [1]
We have previously shown that substantial grading variation exists between Dutch pathology laboratories in daily practice [15], which makes it highly likely that tumors are under- and over-graded in specific pathology laboratories and/or by specific pathologists
The key-objectives of this study were to evaluate the importance of grading in tailoring adjuvant systemic therapy within the past and current Dutch breast cancer guideline, by identifying specific groups of patients for whom the systemic therapy indication depends on histologic grade
Summary
Breast cancer is the most common type of cancer in women worldwide, with an incidence of 2.1 million [1]. Aiming to provide individual IBC-management, treatment is guided by clinicopathologic biomarkers [4,5,6,7,8,9,10,11,12]. Histologic grade, according to the (globally used) Bloom and Richardson grading classification, is a biomarker that has consistently been found to be associated with breast cancerspecific and disease free-survival [13, 14]. Within the Dutch IBC guideline, in line with global breast cancer guidelines [4,5,6,7,8,9,10], grade plays an important role in the selection of individual patients considered to experience benefit from aCT [11]. In view of its decisive role in personalized treatment, this variation is worrisome to the least since it may lead to under- or over-treatment
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