Post-lumpectomy Radiotherapy Research Articles

Breast cancer treatment beliefs and influences among surgeons in areas of scientific uncertainty

Background Breast cancer treatment beliefs in areas of scientific uncertainty may contribute to widely variable practices. We sought to better describe surgeons' beliefs and to identify the relative importance of different information sources on surgeons' decision-making. Methods A total of 2,188 American College of Surgeons (ACoS) members were surveyed on their treatment beliefs in 4 controversial areas and on the perceived influence of various information sources on their decision-making. Responses were analyzed by sex, practice type, oncology training, professional society membership, and breast cancer patient volume. Results Nine hundred twenty-three responses were received, with 459 eligible for analysis. Responses diverged most regarding significance of positive sentinel lymph node biopsy (SNLB) and role of post-lumpectomy radiation for low-risk ductal carcinoma-in-situ (DCIS). Overall, expert opinion ranked as the most influential information source. Conclusions Axillary dissection after positive SLNB and post-lumpectomy radiation in low-risk DCIS denoted areas of greater uncertainty. Breast cancer opinion leaders have substantial influence when standard practice is uncertain.

Oncology care in rural northern new England.

A team from Maine, New Hampshire, and Vermont evaluated quality of care for breast and colon cancers in these predominantly rural states. Central cancer registry records from diagnosis years 2003 to 2004 in Maine, New Hampshire, and Vermont were aggregated. Patient residence was classified into three tiers (small rural, large rural, and urban) using Rural-Urban Commuting Area classification. Among 6,134 women diagnosed with breast cancer, there were significant differences between rural and urban residents in age (P < .001), stage (P < .001), and tumor size (P = .006). Use of breast-conserving surgery was similar, but sentinel lymph node (SLN) dissection was more common in urban (44.1%) than in large rural (39.9%) and small rural (37.6%) areas. Patients who underwent SLN dissection were more likely to receive radiation therapy after lumpectomy than patients who underwent regional lymph node dissection without SLN (85.9% v 75.5%). However, there was no statistically significant association between the rates of postlumpectomy radiation therapy by residence. Among 2,848 patients with colon cancer, patient characteristics in rural and urban areas were similar, but there were differences in their subsequent surgical treatment (P < .001) and lymph node sampling (P = .079). Adjuvant chemotherapy for patients with stage III colon cancer was less frequent in rural (57.3%) than in urban areas (64.7%; P < .001). Central cancer registry data, aggregated among three states, identified differences between rural and urban areas in care for patients with breast and colon cancers. To our knowledge, this is the first time residential category, cancer stage, and treatment data have been analyzed for multiple states using population-based data.

Attitudes of Canadian Radiation Oncologists towards Post-lumpectomy Radiotherapy for Elderly Women with Stage I Hormone-responsive Breast Cancer

Aims Post-lumpectomy breast radiation is the standard of care for all patient subgroups. However, elderly women with stage I breast cancer on adjuvant tamoxifen therapy have a 4% risk of local recurrence after lumpectomy without adjuvant breast radiation. The purpose of this study was to explore the attitudes of Canadian radiation oncologists who treat breast cancer with respect to their use of adjuvant post-lumpectomy radiotherapy, and their willingness to implement a decision aid for this patient population. Materials and methods The questionnaire was mailed to 141 Canadian radiation oncologists who treat breast cancer. The respondents were asked to complete an online survey consisting of four parts: (1) demographic information; (2) factors determining post-lumpectomy radiation treatment decisions; (3) hypothetical case scenarios; (4) interest in using a decision aid in their practice. Results Among the 61 (43%) physicians who completed the survey, there was substantial response variation. After contraindications to radiotherapy, patient overall health and patient preference had the greatest influence on their decision to offer radiotherapy to this patient subgroup. Margin status and use of hormonal therapy were given less importance. For each of the case scenarios, 60–83% of physicians (depending on the case scenario) would offer the patient a choice; far fewer (12–57%) would be comfortable not irradiating. Sixty-four per cent of respondents welcomed the concept of a decision aid for this population. Conclusions Although there is significant variation in practice patterns and attitudes among radiation oncologists regarding post-lumpectomy radiotherapy for elderly, low-risk breast cancer patients, the vast majority value patient choice and would be willing to use a decision aid designed for this population in their practice.

Accelerated Hypofractionated Radiotherapy Schedules in Breast Cancer: A Review of the Current Literature

Lumpectomy followed by breast irradiation is an alternative to mastectomy for patients with early-stage breast cancer. The purpose of radiation treatment following lumpectomy is to minimize the risk of recurrent cancer in the treated breast with as little toxicity as possible so that good cosmesis and function are maintained. Conventional fractionation schedules for postlumpectomy radiotherapy give 50 Gy in 2 Gy daily fractions, often with an additional boost to the tumor bed, resulting in treatment being given over 5-7 weeks. Delivering postoperative radiotherapy in a shorter period of time, provided it is as effective as longer treatment regiments, could result in greater convenience for patients. Moreover, given the high incidence of breast cancer, the use of a shorter fractionation schedule would decrease waiting lists in busy radiotherapy departments. We searched the medline (pubmed) and we reviewed all the relevant publications. We concluded that the accelerated hypofractionated schedules are safe in terms of cosmesis and effective in terms of local control.

Postlumpectomy loco-regional breast cancer therapy with liposomal therapeutic agents: Retention and distribution in nude rats

e11562 Background: Post-lumpectomy loco-regional radiation therapy, such as brachytherapy, has been shown to decrease breast cancer recurrence and increase patient survival. Limitations of current brachytherapy are the relatively high radiation absorbed dose delivered to normal breast and the inability to treat potentially involved lymph nodes. Locally administered liposomes are being investigated for delivery of drugs and therapeutic radionuclides. We propose a new post-lumpectomy loco-regional therapy with liposome-carried therapeutic agents. To investigate, radiolabeled liposomes were injected into the surgical cavity of a nude rat model one day following surgical removal of the breast tumor, and in vivo retention and distribution were monitored with nuclear imaging and post- mortem dissection. Methods: Six liposome formulations containing 0.2% molar ratio Rhodamine B-lipid and cationic, neutral, or anionic surface charges were manufactured at diameters of 400 or 100 nm and characterized. Breast cancer xenograft model in female nude rats was set up by inoculating MDA-MB-231 cells into the fat pad of the left breast of each rat. When tumor volumes reached 1.9 cm3 on average, the majority of each tumor was surgically removed, leaving ∼0.05 cm3 tumor tissue in the cavity. Then, each rat (3–4 rats/group) was intracavitarily injected with 0.5 ml of 99mTc-liposomes (4 mCi., 30 mg total lipids/kg body weight). In vivo distribution of 99mTc-activity was measured with planar gamma camera and SPECT imaging at various times. Post-mortem stereo fluorescent images of surgical cavity and the surrounding lymph nodes at 44 h were acquired. Results: All 99mTc-liposome formulations had approximately ≥ 50% retention in the surgical cavity at 44 h after injection. 99mTc-anionic liposomes of 100 nm diameter had an optimal lymph node targeting with ∼6%/g tissue in the surrounding lymph nodes at 44 h. Fluorescence imaging of the liposomes clearly showed their clearance through surrounding lymphatics and retention in lymph nodes. Conclusions: Anionic liposomes of 100 nm diameter are promising carriers for the simultaneous treatment of the surgical cavity and its draining lymph nodes. No significant financial relationships to disclose.

Cost implications of delayed radiotherapy for early stage breast cancer

6549 Background: Delayed radiotherapy (RT) for early invasive breast cancer has been shown to increase recurrence rates, but whether it influences costs of treatment or downstream medical care is unknown. Methods: Using linked SEER-Medicare data from 1992–2005 for 5,905 women ages 66+ diagnosed with stage I breast cancer undergoing post-lumpectomy RT, we estimated mean total monthly costs paid by Medicare by phase of care (treatment, continuing, or terminal care). Continuing care covers costs after treatment including for recurrences, and terminal phase includes costs in the last 6 months of life. We evaluated whether costs were different by timely vs. delayed RT (delay = 12 weeks post-surgery, or 8 weeks post-chemotherapy) and patient characteristics including comorbidity, age, and race. Results: Mean monthly treatment costs were $427 lower for women with delayed RT (p &lt; 0.00001), but monthly continuing-care costs were $129 higher (p &lt; 0.00001). Delayed RT yielded a 26% decrease in monthly treatment costs (p &lt; 0.0001) and 20% increase in continuing-care costs (p &lt; 0.0001) in multivariable analyses, and inpatient comorbidity index&gt;1 yielded cost increases of 12% (p = 0.03) and 70% (p &lt; 0.0001) in those phases, respectively, compared to no comorbidity. Terminal phase costs were affected primarily by inpatient comorbidity index&gt;1 (86% cost increase compared to no comorbidity, p &lt; 0.0001) and black race (52% cost increase compared to white, p = 0.02), but not delayed RT. Treatment phase averaged 2.5 months longer for women with delayed RT (p &lt; 0.00001). Average post-treatment follow-up was 7 years. Conclusions: Delayed RT is associated with lower mean monthly costs for treatment but higher continuing-care phase costs, possibly due to higher recurrence rates. Treatment was longer for women with delayed RT, even if total treatment cost is the same, making the average monthly cost for delayed RT lower. Preliminary analysis suggests that total average costs through follow-up are nearly $11K higher for women experiencing delayed RT. Combined with higher recurrence rates, delayed RT likely is worse in terms of both costs and effectiveness. No significant financial relationships to disclose.

The Lateral Decubitus Breast Boost: Description, Rationale, and Efficacy

To describe and evaluate the modified lateral decubitus boost, a breast irradiation technique. Patients are repositioned and resimulated for electron boost to minimize the necessary depth for the electron beam and optimize target volume coverage. A total of 2,606 patients were treated with post-lumpectomy radiation at our institution between January 1, 2000, and February 1, 2008. Of these, 231 patients underwent resimulation in the lateral decubitus position with electron boost. Distance from skin to the maximal depth of target volume was measured in both the original and boost plans. Age, body mass index (BMI), boost electron energy, and skin reaction were evaluated. Resimulation in the lateral decubitus position reduced the distance from skin to maximal target volume depth in all patients. Average depth reduction by repositioning was 2.12 cm, allowing for an average electron energy reduction of approximately 7 MeV. Mean skin entrance dose was reduced from about 90% to about 85% (p < 0.001). Only 14 patients (6%) experienced moist desquamation in the boost field at the end of treatment. Average BMI of these patients was 30.4 (range, 17.8-50.7). BMI greater than 30 was associated with more depth reduction by repositioning and increased risk of moist desquamation. The lateral decubitus position allows for a decrease in the distance from the skin to the target volume depth, improving electron coverage of the tumor bed while reducing skin entrance dose. This is a well-tolerated regimen for a patient population with a high BMI or deep tumor location.

Ist die Kardiotoxizität der Radiotherapie im Rahmen des Brusterhalts überhaupt noch relevant, und könnte sie durch Mehrfelder-IMRT gesenkt werden?

Postoperative radiotherapy after breast cancer surgery effectively reduces local relapses. A survival benefit after breast conservation, however, has only been proven recently which was in part due to excessive cardiac mortality of patients who had been treated with radiotherapy in the past. The literature on postoperative radiotherapy for breast cancer was reviewed with regard to cardiac toxicity as the basis for hypothesis generation. From numerous publications on cardiac toxicity of breast cancer radiotherapy, the following pattern emerges: in series where a high radiation dose was applied to a significant percentage of the heart (postmastectomy and postlumpectomy series) cardiac toxicity/mortality was increased versus a nonexposed cohort or for left over right disease. If, however, a relevant exposure of cardiac muscle could be more or less excluded based on the technique used (mainly more recent postlumpectomy radiotherapy), no cardiac toxicity was observed. Series for which individual dose exposure varied or could not be clarified also came to varying conclusions. Also due to retrospectively unclear dose distributions, an exact quantification of tolerance doses/effects of different geographic dose distribution patterns could not be performed to date. A particularly difficult question to answer is the threshold volume for clinically relevant cardiotoxicity with tangential radiotherapy at prescription doses. As a consequence, this precludes an estimate in which situations multifield intensity-modulated radiotherapy (IMRT) with its characteristic dose distribution pattern of a larger volume exposed to intermediate doses and higher mean/median heart doses (as shown in Figure 1) might be preferable. This review updates the database on cardiac toxicity of breast cancer radiotherapy with special emphasis regarding the issues related to the clinical use of IMRT. Multifield IMRT may reduce the cardiac risk for a small subset of patients at excessive risk with conventional tangential radiotherapy due to unfavorable thoracic geometry, for whom partial-breast radiotherapy is not an option. Due to further concern about the effects of intermediate doses to larger heart volumes, potentially increased contralateral cancer risk and the long latency of clinically apparent toxicity, the introduction of breast IMRT should be closely followed. Accompanying functional studies may have the potential to detect cardiac toxicity at an earlier time.

Accelerated Partial Breast Irradiation: Where Do We Stand?

Accelerated partial breast irradiation (APBI) is a new form of postlumpectomy radiotherapy delivered over 1 to 5 days. Early trials showed high local recurrence rates. More recent single and multiinstitutional studies, as well as a single phase III trial, have shown local control more comparable to whole breast radiotherapy. Patient selection and surgical technique are important variables preparatory to irradiation, which is delivered using 1 of 4 accelerated radiotherapy methods. Phase I/II studies have produced most of the information currently available regarding APBI. Additional phase III studies are underway to determine whether any or all of these accelerated radiotherapy approaches may safely substitute for whole breast radiotherapy in women seeking breast conservation.

Roles of Radiotherapy and Chemotherapy in the Development of Contralateral Breast Cancer

Few studies have examined whether modern radiotherapy and chemotherapy affect the risk of contralateral breast cancer (CBC), and results are inconclusive. We assessed long-term risk of CBC in a predominantly young breast cancer (BC) population (n = 7,221), focusing on the effects of radiation dose, chemotherapy, and family history of BC. Risk of CBC was evaluated using Cox proportional hazards regression models. Radiotherapy-associated risk of CBC increased with decreasing age at first treatment (age < 35 years, hazard ratio [HR] = 1.78; 95% CI, 0.85 to 3.72; age > 45 years, HR = 1.09; 95% CI, 0.82 to 1.45). Postmastectomy radiotherapy using direct electron fields led to a significantly lower radiation exposure to the contralateral breast than postlumpectomy radiotherapy using tangential fields. Women treated before age 45 years with postlumpectomy radiotherapy experienced 1.5-fold increased risk of CBC compared with those who had postmastectomy radiotherapy. The joint effects of postlumpectomy radiotherapy and strong family history for BC on risk of CBC were greater than expected when individual risks were summed (HR = 3.52; 95% CI, 2.07 to 6.02; P(departure from additivity) = .043). Treatment with adjuvant chemotherapy (cyclophosphamide, methotrexate, and fluorouracil) was associated with a nonsignificantly decreased risk of CBC in the first 5 years of follow-up but did not reduce CBC risk in subsequent years. Young patients with BC irradiated with breast tangentials experience increased risk of CBC, especially in those with a positive family history of BC. This finding should be taken into account when advising breast radiation with tangential fields to young patients with BC. Adjuvant chemotherapy seemed to reduce the risk of CBC during the first 5 years after treatment only.

Biopsy Findings After Breast Conservation Therapy for Early-Stage Invasive Breast Cancer

To determine the patterns and factors predictive of positive ipsilateral breast biopsy after conservation therapy for early-stage breast cancer. We performed a retrospective review of Stage I-II breast cancer patients initially treated with lumpectomy and radiotherapy between 1977 and 1996, who later underwent post-treatment ipsilateral breast biopsies. A total of 223 biopsies were performed in 193 treated breasts: 171 single and 22 multiple biopsies. Of the 223 biopsies, 56% were positive and 44% were negative for recurrence. The positive biopsy rate (PBR) was 59% for the first and 32% for subsequent biopsies. The median time to the first post-treatment biopsy was 49 months. Of the patients with negative initial biopsy findings, 11% later developed local recurrence. The PBR was 40% among patients with physical examination findings only, 65% with mammographic abnormalities only, and 79% with both findings (p = 0.001). Analysis of the procedure type revealed a PBR of 86% for core and 58% for excisional biopsies compared with 28% for aspiration cytology alone (p = 0.025). The PBR varied inversely with age at the original diagnosis: 49% if >or=51 years, 57% if 36-50 years, and 83% if <or=35 years (p = 0.05). The PBR correlated directly with the interval after radiotherapy: 49% if <or=60 months, 59% if 60.1-120 months, 77% if 120.1-180 months, and 100% if >180 months after completing postlumpectomy radiotherapy (p = 0.01). The PBR was not linked with recurrence location, initial pathologic T or N stage, estrogen receptor/progesterone receptor status, or final pathologic margins (all p >or= 0.15). After definitive radiotherapy for early-stage breast cancer, a greater PBR was associated with the presence of both mammographic and clinical abnormalities, excisional or core biopsies, younger age at the initial diagnosis, and longer intervals after radiotherapy completion.

Defining the Need for Breast Cancer Radiotherapy in the General Population: a Criterion-based Benchmarking Approach

Aims Determining the appropriate rate of radiotherapy is important for ensuring optimal radiotherapy utilisation and accessibility. A criterion-based benchmark (CBB) was developed for estimating the need for radiotherapy in incident breast cancer cases. Our primary objective was to compare an evidence-based estimate (Ebest) of need against the CBB. These estimates were then compared with radiotherapy rates in Ontario, Canada and the USA. Surgical rates were also examined. Materials and methods Benchmarks were defined in Ontario as communities in proximity to cancer centres and without long waiting lists. Patient data from 1997 to 2001 were prospectively collected from radiotherapy cancer centres. Surgical data were obtained from the Canadian Institute for Health Information database. The public use file of Surveillance, Epidemiology and End Results (SEER) described treatment in the USA. Results In total, 4241 cases of breast cancer were diagnosed in benchmark communities. The overall radiotherapy rate by Ebest was 64.0% (95% confidence interval: 58.1–69.8%) compared with the CBB of 60.7% (59.3–62.1%). In comparison, Ontario's overall radiotherapy rate was 55.6% (55.0–56.1%) and in SEER it was 49.3% (48.9–49.6%). Adjuvant radiotherapy rates after lumpectomy were 100% in Ebest and 83.6% (82.0–85.1%) by the CBB. The Ebest and CBB post-mastectomy rates were 21.9% (20.6–23.3%) and 34.6% (32.5–36.7%), respectively. Observed post-lumpectomy radiotherapy rates were 75.1% in Ontario and 65.3% in SEER. Post-mastectomy radiotherapy rates were 29.5% in Ontario and 17.0% in SEER. Conclusions CBB provides a reasonable estimate of the overall need for radiotherapy in breast cancer. Observed radiotherapy rates in Ontario and the USA suggest an age-related decrease in the use of radiotherapy. The benchmark estimate suggests a shortfall of adjuvant breast radiotherapy utilisation in Ontario.

Long-term Clinical Outcomes of Whole-Breast Irradiation Delivered in the Prone Position

The aim of this study was to evaluate retrospectively the effectiveness and toxicity of post-lumpectomy whole-breast radiation therapy delivered with prone positioning. Between September 1992 and August 2004, 245 women with 248 early-stage invasive or in situ breast cancers were treated using a prone breast board. Photon fields treated the whole breast to 46 to 50.4 Gy with standard fractionation. The target volume was clinically palpable breast tissue; no attempt was made to irradiate chest wall lymphatics. Tumor bed boosts were delivered in 85% of cases. Adjuvant chemotherapy and hormonal therapy were administered to 42% and 62% of patients, respectively. After a median follow-up of 4.9 years, the 5 year actuarial true local and elsewhere ipsilateral breast tumor recurrence rates were 4.8% and 1.3%, respectively. The 5-year actuarial rates of regional nodal recurrence and distant metastases were 1.6% and 7.4%. Actuarial disease-free, disease-specific, and overall survival rates at 5 years were 89.4%, 97.3%, and 93%, respectively. Treatment breaks were required by 2.4% of patients. Grade 3 acute dermatitis and edema were each limited to 2% of patients. Only 4.9% of patients complained of acute chest wall discomfort. Chronic Grade 2 to 3 skin and subcutaneous tissue toxicities were reported in 4.4% and 13.7% of patients, respectively. Prone position breast radiation results in similar long-term disease control with a favorable toxicity profile compared with standard supine tangents. The anatomic advantages of prone positioning may contribute to improving the therapeutic ratio of post-lumpectomy radiation by improving dose homogeneity and minimizing incidental cardiac and lung dose.

Radiation Therapy, Cardiac Risk Factors, and Cardiac Toxicity in Early-Stage Breast Cancer Patients

The benefits of adjuvant radiation therapy (RT) for breast cancer may be counterbalanced by the risk of cardiac toxicity. We studied the cardiac effects of RT and the impact of pre-existing cardiac risk factors (CRFs) in a population-based sample of older patients with breast cancer. In the Surveillance, Epidemiology and End-Results (SEER)-Medicare database of women > or = 65 years diagnosed with Stages I to III breast cancer from January 1, 1992 to December 31, 2000, we used multivariable logistic regression to model the associations of demographic and clinical variables with postmastectomy and postlumpectomy RT. Using Cox proportional hazards regression, we then modeled the association between treatment and myocardial infarction (MI) and ischemia in the 10 or more years after diagnosis, taking the predictors of treatment into account. Among 48,353 women with breast cancer; 19,897 (42%) were treated with lumpectomy and 26,534 (55%) with mastectomy; the remainder had unknown surgery type (3%). Receipt of RT was associated with later year of diagnosis, younger age, fewer comorbidities, nonrural residence, and chemotherapy. Postlumpectomy RT was also associated with white ethnicity and no prior history of heart disease (HD). The RT did not increase the risk of MI. Presence of MI was associated with age, African American ethnicity, advanced stage, nonrural residence, more than one comorbid condition, a hormone receptor-negative tumor, CRFs and HD. Among patients who received RT, tumor laterality was not associated with MI outcome. The effect of RT on the heart was not influenced by HD or CRFs. It appears unlikely that RT would increase the risk of MI in elderly women with breast cancer, regardless of type of surgery, tumor laterality, or history of CRFs or HD, for at least 10 years.

A treatment planning study comparing whole breast radiation therapy against conformal, IMRT and tomotherapy for accelerated partial breast irradiation

Purpose and background Conventional early breast cancer treatment consists of a lumpectomy followed by whole breast radiation therapy. Accelerated partial breast irradiation (APBI) is an investigational approach to post-lumpectomy radiation for early breast cancer. The purpose of this study is to compare four external beam APBI techniques, including tomotherapy, with conventional whole breast irradiation for their radiation conformity index, dose homogeneity index, and dose to organs at risk. Methods and materials Small-field tangents, three-dimensional conformal radiation therapy, intensity-modulated radiation therapy and helical tomotherapy were compared for each of 15 patients (7 right, 8 left). One radiation conformity and two dose homogeneity indices were used to evaluate the dose to the target. The mean dose to organs at risk was also evaluated. Results All proposed APBI techniques improved the conformity index significantly over whole breast tangents while maintaining dose homogeneity and without a significant increase in dose to organs at risk. Conclusion The four-field IMRT plan produced the best dosimetric results; however this technique would require appropriate respiratory motion management. An alternative would be to use a four-field conformal technique that is less sensitive to the effects of respiratory motion.

Tumor Bed Boost Omission After Negative Re-Excision in Breast-Conservation Treatment

We evaluated the necessity of a tumor bed boost after whole-breast radiotherapy for early-stage breast cancer after breast-conserving surgery and negative re-excision. Of patients treated at the Virginia Commonwealth and Tufts Universities with breast-conservation therapy for early-stage breast cancer between 1983 and 1999, 205 required re-excision of the tumor cavity to obtain clear margins and were found to be without residual disease. Adjuvant conventionally fractionated whole-breast radiotherapy was given to a total dose of 50 Gy in 25 fractions. The tumor bed boost was omitted. The median follow-up was 98 months (range, 6-229 months). The tumor histological diagnosis was primarily infiltrating ductal carcinoma (183 cases; 89%). Nodal involvement was documented in 49 cases (24%). There were four documented recurrences at the tumor bed site. Five in-breast recurrences were documented to be in a location removed from the tumor bed. The overall Kaplan-Meier 15-year in-breast control rate was 92.4%, and the freedom from true recurrence rate was 97.6%. The findings support the concept that postlumpectomy radiotherapy can be tailored according to the degree of surgical resection. There is an easily identifiable subgroup of patients who can avoid a tumor bed boost, thus resulting in a reduced treatment time and improved cosmesis, while maintaining local control rates that approach 100%. The data suggest that in patients who undergo a negative re-excision, treatment with whole-breast radiotherapy to 50 Gy is a sufficient dose to maximally reduce the risk of local recurrence.

Cause-specific mortality in long-term survivors of breast cancer: A 25-year follow-up study

To assess long-term cause-specific mortality in breast cancer patients. We studied mortality in 7425 patients treated for early breast cancer between 1970 and 1986. Follow-up was 94% complete until January 2000. Treatment-specific mortality was evaluated by calculating standardized mortality ratios (SMRs) based on comparison with general population rates and by using Cox proportional hazards regression. After a median follow-up of 13.8 years, 4160 deaths were observed, of which 76% were due to breast cancer. Second malignancies showed a slightly increased SMR of 1.2 (95% confidence interval [CI], 1.0-1.3). Radiotherapy (RT) as compared with surgery was associated with a 1.7-fold (95% CI, 1.2-2.5) increased mortality from cardiovascular disease (CVD). After postlumpectomy RT, no increased mortality from CVD was observed (hazard ratio, 1.0; 95% CI, 0.5-1.9). Postmastectomy RT administered before 1979 and between 1979 and 1986 was associated with a 2-fold (95% CI, 1.2-3.4) and 1.5-fold (95% CI, 0.9-2.7) increase, respectively. Patients treated before age 45 experienced a higher SMR (2.0) for both solid tumors (95% CI, 1.6-2.7) and CVD (95% CI, 1.3-3.1). Currently, a large population of breast cancer survivors is at increased risk of death from CVDs and second cancers, especially when treated with RT at a young age. Patients irradiated after 1979 experience low (postmastectomy RT) or no (postlumpectomy RT) excess mortality from CVD.

The role of age and race in receiving breast cancer treatment: A cross-sectional survey of an urban population

6047 Background: Breast cancer treatment differences in older patients and in certain groups. These differences may be due to a variety of factors, in addition to age and race, which include: comorbid illnesses, performance status, socioeconomic status, and education. Methods: The sample consisted of a cross-sectional survey of 257 Latina, African American and White women living in Los Angeles County, age 55 or older from the Los Angeles County Cancer Surveillance Program’s (CSP) rapid ascertainment program (the Tumor Registry) who were between three and nine months of diagnosis and at least one month post treatment. These patients were interviewed, their medical records abstracted, and the doctor’s surveyed. The primary outcomes for this analysis were surgical, radiation, hormone, and chemotherapy treatment options. Logistic regression analysis was used controlling for age, race/ethnicity, socio-demographic characteristics, Katz comorbidity, functional status, and stage of disease. Results: Univariate analysis demonstrated significant trends with age and race across most treatment choices. In multivariate analysis, the effect of age and race was less pronounced. Factors such as insurance status, comorbidity, and education were very significant for treatment selection. Medi-Cal patients were less likely to receive lumpectomy (Odds Ratio, OR=0.19) and none received reconstruction post mastectomy. Educated patients were more likely to have an axillary lymph node dissection, LND, (OR=7.5) and post-lumpectomy radiation (OR=3.94). Those with higher Katz comorbidity were less likely to receive a LND (OR=0.70) or chemotherapy (OR=0.76). Nevertheless, older women were less likely to have LND (OR=0.49) and chemotherapy (OR=0.24) compared to younger women. African-American women were less likely to have adjuvant hormone therapy (OR=0.50) compared to Caucasians and Latinas. Conclusion: Although age and race are factors in certain breast cancer treatment decisions, other factors such as education and insurance status and may serve as important targets in order to improve care. No significant financial relationships to disclose.

Paclitaxel After Doxorubicin Plus Cyclophosphamide As Adjuvant Chemotherapy for Node-Positive Breast Cancer: Results From NSABP B-28

The primary aim of National Surgical Adjuvant Breast and Bowel Project (NSABP) B-28 was to determine whether four cycles of adjuvant paclitaxel (PTX) after four cycles of adjuvant doxorubicin/cyclophosphamide (AC) will prolong disease-free survival (DFS) and overall survival (OS) compared with four cycles of AC alone in patients with resected operable breast cancer and histologically positive axillary nodes. Between August 1995 and May 1998, 3,060 patients were randomly assigned (AC, 1,529; AC followed by PTX [AC --> PTX], 1,531). Patients > or = 50 years and those younger than 50 years with estrogen receptor (ER) or progesterone receptor (PR) -positive tumors also received tamoxifen for 5 years, starting with the first dose of AC. Postlumpectomy radiotherapy was mandated. Postmastectomy or regional radiotherapy was prohibited. Median follow-up is 64.6 months. The addition of PTX to AC significantly reduced the hazard for DFS event by 17% (relative risk [RR], 0.83; 95% CI, 0.72 to 0.95; P = .006). Five-year DFS was 76% +/- 2% for patients randomly assigned to AC --> PTX compared with 72% +/- 2% for those randomly assigned to AC. Improvement in OS was small and not statistically significant (RR, 0.93; 95% CI, 0.78 to 1.12; P = .46). Five-year OS was 85% +/- 2% for both groups. Subset analysis of the effect of paclitaxel according to hormone receptors or tamoxifen administration did not reveal statistically significant interaction (for DFS, P = .30 and P = .44, respectively). Toxicity with the AC --> PTX regimen was acceptable for the adjuvant setting. The addition of PTX to AC resulted in significant improvement in DFS but no significant improvement in OS with acceptable toxicity. No significant interaction between treatment effect and receptor status or tamoxifen administration was observed.

Breast Cancer Treatment Guidelines in Older Women

To determine patterns and predictors of concordance with institutional treatment guidelines among older women with breast cancer. The study population included 1,568 patients aged 55 years and older who were treated at M.D. Anderson Cancer Center between July 1997 and January 2002 for stage I to IIIA invasive ductal and lobular breast cancer. Concordance with institutional guidelines was determined for definitive surgical therapy, radiotherapy after breast-conserving surgery, radiation therapy after mastectomy, adjuvant chemotherapy use, and adjuvant hormonal therapy use. The following variables were considered as possible modifiers of concordance: patient age, marital status, race, educational level, Eastern Cooperative Oncology Group performance status, comorbidity score, clinical stage, hormone receptor status, HER2-neu status, tumor grade, pathologic tumor size, lymphatic invasion, and number of lymph nodes involved. Logistic regression modeling was performed to determine the independent effect of each variable on guideline concordance. Older women were less likely to receive treatment in concordance with guidelines for definitive surgical therapy (P < .001), postlumpectomy radiation (P = .03), adjuvant chemotherapy (P < .001), and adjuvant hormonal therapy (P < .001). In multivariate analysis, age > or = 75 years predicted a deviation from guidelines for definitive surgical therapy, adjuvant chemotherapy, and adjuvant hormonal therapy. Nonwhite race was associated with decreased likelihood of adjuvant radiation therapy after breast conservation. After adjustment for comorbidity score, race, marital status, educational status, clinical stage, and tumor characteristics, increasing patient age was independently associated with decreased guideline concordance for definitive surgery, adjuvant chemotherapy, and adjuvant hormonal therapy. Future research should focus on delineating the possible reasons for guideline discordance.