Abstract We compared the health-related quality of life, impact of the disease, risk perception of recurrence and dying of breast cancer, and understanding of diagnosis of patients with ductal ...carcinoma in situ (DCIS) and invasive breast cancer 2–3 years after treatment. We included all women ( N = 211) diagnosed with DCIS or invasive breast cancer TNM stage I (T1, N0, and M0) in three community hospitals in the southern part of The Netherlands in the period 2002–2003. After verifying the medical files, 180 disease free patients proved eligible for study entry, 47 of whom had DCIS and 133 stage I invasive breast cancer. One-hundred and thirty-five patients returned a completed questionnaire (75% response). No significant differences were found between women with DCIS and invasive breast cancer on the physical and mental component scale of the RAND SF-36, nor on the WHO-5, which assesses well-being. In contrast, women with DCIS reportedly had a better physical health, better sex life and better relationships with friends/acquaintances than women with invasive breast cancer. Despite their better prognosis, the DCIS-group had comparable perceptions of the risk of recurrence and dying of breast cancer as women with invasive breast cancer. However, this did not appear to affect their well-being significantly.
Abstract Breast cancer will increasingly become a disease affecting the lives of older women, especially in more developed countries, the prevalence rising up to 7% over age 70 in the near future. A ...review of the population-based literature and an analysis of the data of the Eindhoven Cancer Registry and European data regarding the diagnosis, treatment and prognosis showed that the proportion with unstaged and advanced disease (stages III and IV) is higher among elderly patients compared to younger ones and that their treatment is generally less aggressive, although the proportion receiving chemotherapy is increasing since the early 1990s. Disease specific (or relative) survival of elderly breast cancer patients is generally lower and the prevalence of serious (life expectancy affecting) co-morbidity is higher (>50% in patients over age 70). Because of large individual variations in physical and mental conditions, limited evidence from RCTs and personal preferences prevailing in the decision-making process, treatment of older breast cancer patients seems difficult to fit into guidelines. Therefore, alternative research strategies are needed to understand and improve the care for the elderly breast cancer population, such as descriptive (registry-based) studies and a qualitative, individual-based approach.
Background
Although evidence for the benefits of preoperative MRI in breast cancer is lacking, use of MRI is increasing and characterized by large interhospital variation. The aim of the study was to ...evaluate MRI use and surgical outcomes retrospectively.
Methods
Women with invasive breast cancer (pT1–3) or ductal carcinoma in situ (DCIS), diagnosed in 2011–2013, were selected from the Netherlands Cancer Registry and subdivided into the following groups: invasive cancer, high‐grade DCIS, non‐palpable cancer, age 40 years or less, and invasive lobular cancer. Associations between preoperative MRI use and initial mastectomy, resection margin after breast‐conserving surgery (BCS), re‐excision after BCS, and final mastectomy were analysed.
Results
In total, 5514 women were included in the study; 1637 (34·1 per cent) of 4801 women with invasive cancer and 150 (21·0 per cent) of 713 with DCIS had preoperative MRI. Positive resection margins were found in 18·1 per cent women who had MRI and in 15·1 per cent of those who did not (adjusted odds ratio (OR) 1·20, 95 per cent c.i. 1·00 to 1·45), with no differences in subgroups. Re‐excision rates were 9·8 per cent in the MRI group and 7·2 per cent in the no‐MRI group (adjusted OR 1·33, 1·04 to 1·70), with no differences in subgroups. In the MRI group, 38·8 per cent of patients ultimately underwent mastectomy, compared with 24·2 per cent in the no‐MRI group (adjusted OR 2·13, 1·87 to 2·41). This difference was not found for patients aged 40 years or less, or for those diagnosed with lobular cancer.
Conclusion
No subgroup was identified in which preoperative MRI influenced the risk of margin involvement or re‐excision rate after BCS. MRI was significantly associated with more extensive surgery, except in patients aged 40 years or less and those with invasive lobular cancer. These results suggest that use of preoperative MRI should be more targeted, and that general, widespread use be discouraged.
Leads to more extensive surgery
Background
This study was conducted to determine the impact of neoadjuvant chemotherapy (NAC) on the likelihood of breast-conserving surgery (BCS) performed for patients with invasive lobular breast ...carcinoma (ILC) and invasive ductal carcinoma (IDC).
Methods
Female patients with a diagnosis of ILC or IDC in The Netherlands between July 2008 and December 2012 were identified through the population-based Netherlands Cancer Registry.
Results
A total of 466 ILC patients received NAC compared with 3622 IDC patients. Downstaging by NAC was seen in 49.7 % of the patients with ILC and in 69.6 % of the patients with IDC, and a pathologic complete response (pCR) was observed in 4.9 and 20.2 % of these patients, respectively (
P
< 0.0001). Breast-conserving surgery was performed for 24.4 % of the patients with ILC receiving NAC versus 39.4 % of the patients with IDC. In the ILC group, 8.2 % of the patients needed surgical reinterventions after BCS due to tumor-positive resection margins compared with 3.4 % of the patients with IDC (
P
< 0.0001). Lobular histology was independently associated with a higher mastectomy rate (odds ratio 1.91; 95 % confidence interval 1.49–2.44). Among the patients with clinical T2 and T3 disease, BCS was achieved more often when NAC was administered in ILC as well as IDC.
Conclusion
The patients with ILC receiving NAC were less likely to experience a pCR and less likely to undergo BCS than the patients with IDC. With regard to BCS, the impact of NAC for ILC patients was lower than for patients receiving surgery without NAC. However, despite the high number to treating in order to achieve BCS, a small subset of ILC patients, especially cT2 and cT3 patients, still may benefit from NAC.
It is likely that the shift from post- to pre-operative radiotherapy and the introduction of total mesorectal excision (TME) surgery have contributed to the observed improved survival of rectal ...cancer in the south of the Netherlands. However, no improvement was seen for patients aged 70 or older. To investigate possible causes of this lack of improvement, we examined the risk of treatment-related complications and overall survival. Therefore, a random sample of 455 patients with rectal cancer aged 60 years or older, diagnosed between 1995 and 2001 was extracted from in the Eindhoven Cancer Registry database. Fifty-one percent of patients aged 60–69 years-old had any complication within one year of diagnosis compared to 65% of patients aged 70 or older (
p
=
0.007). Older patients were at higher risk of developing treatment-related complications (odds ratio (OR) 1.8;
p
=
0.01), as were patients with comorbidity (OR 1.7;
p
=
0.07), and those who received pre-operative radiotherapy (OR 1.8;
p
=
0.02). In a multivariable analysis, age older than 70 (hazard ratio (HR) 2.2;
p
<
0.0001), comorbidity (HR 1.7;
p
=
0.03), and having two or more complications (HR
=
2.2;
p
=
0.0002) had a negative effect on survival. The lack of improvement in the prognosis of elderly patients with rectal cancer after a shift from post- to preoperative radiotherapy might partially be explained by a higher risk of treatment-related complications. In order to optimise the risk/benefit ratio of elderly patients, individualisation of treatment by means of a comprehensive geriatric assessment will be of critical importance.
Background
Determinants of the use of breast MRI in patients with ductal carcinoma in situ (DCIS) in the Netherlands were studied, and whether using MRI influenced the rates of positive resection ...margins and mastectomies.
Methods
All women aged less than 75 years, and diagnosed with DCIS between 2011 and 2015, were identified from the Netherlands Cancer Registry. Multivariable logistic regression analyses were performed, adjusting for incidence year, age, hospital type, DCIS grade and multifocality.
Results
Breast MRI was performed in 2382 of 10 415 DCIS cases (22·9 per cent). In multivariable analysis, patients aged less than 50 years, those with high‐ or intermediate‐grade DCIS and patients with multifocal disease were significantly more likely to have preoperative MRI. Patients undergoing MRI were more likely to have a mastectomy, either as first surgical treatment or following breast‐conserving surgery (BCS) in the event of positive margins (odds ratio (OR) 2·11, 95 per cent c.i. 1·91 to 2·33). The risk of positive surgical margins after BCS was similar for those with versus without MRI. The secondary mastectomy rate after BCS was higher in patients who had MRI, especially in women aged less than 50 years (OR 1·94, 1·31 to 2·89). All findings were similar for low‐ and intermediate/high‐grade DCIS.
Conclusion
Adding MRI to conventional breast imaging did not improve surgical outcome in patients diagnosed with primary DCIS. The likelihood of undergoing a mastectomy was twice as high in the MRI group, and no reduction in the risk of margin involvement was observed after BCS.
Antecedentes
Se estudiaron los determinantes del uso de la resonancia magnética (RM) de mama en pacientes con carcinoma ductal in situ (ductal carcinoma in situ, DCIS) en los Países Bajos y si el uso de la RM influía en las tasas de márgenes de resección positivos y de mastectomías.
Métodos
Todas las mujeres menores de 76 años de edad y diagnosticadas de DCIS fueron identificadas a partir del Registro de Cáncer de los Países Bajos de 2011‐2015. Se realizaron análisis de regresión logística multivariable, ajustando por año de incidencia, edad, tipo de hospital, grado de DCIS y multifocalidad.
Resultados
Se realizó una RM de mama en 2.382 de 10.415 (23%) pacientes con DCIS. En el análisis multivariable, en las pacientes de edad < 50 años, con DCIS de grado alto o intermedio y enfermedad multifocal era estadísticamente significativo más probable que se sometieran a una RM preoperatoria. Las pacientes que se sometieron a RM tuvieron más probabilidades de que se efectuara una mastectomía, ya fuera como primer tratamiento quirúrgico o después de una cirugía conservadora de mama (breast conserving surgery, BCS) en el caso de presentar márgenes positivos (razón de oportunidades, odds ratio, OR = 2,1, i.c. del 95%: 1,9‐2,3). El riesgo de obtener márgenes quirúrgicos positivos después de la BCS fue similar para aquellas pacientes con RM versus sin RM. Sin embargo, la tasa de mastectomía secundaria después de la BCS fue mayor en pacientes con RM, especialmente en mujeres menores de 50 años (OR = 1,9, i.c. del 95%: 1,3‐2,9).
Conclusión
Agregar la RM a las imágenes radiológicas convencionales de mama no mejoró el resultado quirúrgico en pacientes diagnosticadas de DCIS primario. En el grupo de RM, la probabilidad de someterse a una mastectomía fue dos veces más alta, sin observarse una reducción en el riesgo de afectación del margen después de la BCS.
Adding MRI to conventional breast imaging did not improve surgical outcomes in patients diagnosed with ductal carcinoma in situ. In the MRI group, the likelihood of undergoing a mastectomy was twice as high as that in the no‐MRI group.
Avoid routine MRI
To compare overall survival between women with unilateral breast cancer (UBC) and contralateral breast cancer (CBC). Women with UBC (
N
= 182,562; 95 %) and CBC (
N
= 8,912; 5 %) recorded in the ...Netherlands Cancer Registry between 1989 and 2008 were included and followed until 2010. We incorporated CBC as a time-dependent covariate to compute the overall mortality rate ratio between women with CBC and UBC. Prognostic factors for overall death were examined according to age at first breast cancer. Women with CBC exhibited a 30 % increase in overall mortality (Hazard Ratio (HR), 95 % Confidence Interval: 1.3, 1.3–1.4) compared with UBC, decreasing with rising age at diagnosis of first breast cancer (<50 years: 2.3, 2.2–2.5 vs. ≥70 years: 1.1, 1.0–1.1). Women older than 50 years at CBC diagnosis and diagnosed 2–5 years after their first breast cancer exhibited a 20 % higher death risk (1.2, 1.0–1.3) compared to those diagnosed within the first 2 years. In women younger than 50 years, the HR was significantly lower if the CBC was diagnosed >5 years after the first breast cancer (0.7, 0.5–0.9). The prognosis for women with CBC significantly improved over time (2004–2008: 0.6, 0.5-0.7 vs. 1989–1993). Women with CBC had a lower survival compared to women with UBC, especially those younger than 50 years at first breast cancer diagnosis. A tailored follow-up strategy beyond current recommendations is needed for these patients who, because of their age and absence of known familial risk, are currently not invited for population-based screening.
The aim of this study was to investigate the nature and severity of the arm complaints among breast cancer patients after axillary lymph node dissection (ALND) and to study the effects of this ...treatment-related morbidity on daily life and well-being. 400 women, who underwent ALND as part of breast cancer surgery, filled out a treatment-specific quality of life questionnaire. The mean time since ALND was 4.7 years (range 0.3–28 years). More than 20% of patients reported pain, numbness, or loss of strength and 9% reported severe oedema. None of the complaints appeared to diminish over time. Irradiation of the axilla and supraclavicular irradiation were associated with a 3.57-fold higher risk of oedema (ods ratio (OR) 3.57; 95% confidence interval (CI) 1.66–7.69) causing many patients to give up leisure activities or sport. Women who underwent irradiation of the breast or chest wall more often reported to have a sensitive scar than women who did not receive radiotherapy. Women <45 years of age had an approximately 6 times higher risk of numbness of the arm (OR 6.49; 95% CI 2.58–16.38) compared with those ⩾65 years of age; they also encountered more problems doing their household chores. The results of the present study support the introduction of less invasive techniques for the staging of the axilla, sentinel node biopsy being the most promising.
Background
Axillary lymph node dissection (ALND) in patients with breast cancer provides prognostic information. For many years, positive nodes were the most important indication for adjuvant ...systemic therapy. It was also believed that regional control could not be achieved without axillary clearance in a positive axilla. However, during the past 20 years the treatment and staging of the axilla has undergone many changes. This large population‐based study was conducted in the south‐east of the Netherlands to evaluate the changing patterns of care regarding the axilla, including the introduction of sentinel lymph node biopsy (SLNB) in the late 1990s, implementation of the results of the American College of Surgeons Oncology Group Z0011 study, and the initial effects of the European Organization for Research and Treatment of Cancer AMAROS study.
Methods
Data from the population‐based Eindhoven Cancer Registry of all women diagnosed with invasive breast cancer in the south of the Netherlands between January 1993 and July 2014 were used.
Results
The proportion of 34 037 women staged by SLNB without completion ALND increased from 0 per cent in 1993–1994 to 69·0 per cent in 2013–2014. In the same period the proportion undergoing ALND decreased from 88·8 to 18·7 per cent. Among women with one to three positive lymph nodes, the proportion undergoing SLNB alone increased from 10·6 per cent in 2011–2012 to 37·6 per cent in 2013–2014.
Conclusion
This population‐based study demonstrated the radical transformation in management of the axilla since the introduction of SLNB and following the recent publication of trials on management of the axilla with a low metastatic burden.
Big changes
Several factors may increase the risk of recurrence of patients diagnosed with hormone receptor-positive human epidermal growth factor receptor 2-negative (HR+/HER2−) breast cancer (BC). We aim to ...determine the proportion of patients with high-risk HR+/HER2− BC within the total HR+/HER2− BC cohort and compare their systemic treatments and survival rates with those of patients with low- and intermediate-risk HR+/HER2− BC and triple-negative (TN) BC.
Women diagnosed with nonmetastatic invasive HR+/HER2− BC and TNBC in the Netherlands between 2011 and 2019 were identified from the Netherlands Cancer Registry. Patients with HR+/HER2− BC were categorised according to risk profile, defined by nodal status, tumour size, and histological grade. High-risk HR+/HER2− BC was defined by either four or more positive lymph nodes or one to three positive lymph nodes with a tumour size of ≥5 cm or a histological grade 3 tumour. Overall survival (OS) and relative survival (RS) were calculated using the Kaplan–Meier and Pohar–Perme method.
In this study of 87 455 patients with HR+/HER2− BC, 44 078 (50%) patients were diagnosed with low risk, 28 452 (33%) with intermediate risk, and 11 285 (13%) with high-risk HR+/HER2− BC. In 3640 (4%) patients, the risk profile could not be defined. Endocrine therapy and chemotherapy were used in 38% and 7% of low-risk, 90% and 47% of intermediate-risk, and 94% and 73% of high-risk patients, respectively. The 10-year OS and RS rates were 84.1% 95% confidence interval (95% CI) 83.5% to 84.7% and 98.7% (95% CI 97.3% to 99.4%) in low-risk, 75.1% (95% CI 74.2% to 76.0%) and 91.7% (95% CI 89.7% to 93.3%) in intermediate-risk, and 63.4% (95% CI 62.0% to 64.7%) and 72.3% (70.1% to 74.3%) in high-risk patients. The 10-year OS and RS rates of 12 689 patients with TNBC were 69.7% (95% CI 68.6% to 70.8%) and 79.1% (95% CI 77.0% to 80.9%), respectively.
The poor prognosis of patients with high-risk HR+/HER2− BC highlights the need for a better acknowledgement of this subgroup and supports ongoing clinical trials aimed at optimising systemic therapy.
•High-risk HR+/HER2− BC was defined by ≥4 positive nodes or 1-3 positive nodes + a tumour size of ≥5 cm or a grade 3 tumour.•One in eight women with HR+/HER2− BC were diagnosed with high-risk disease in the Netherlands between 2011 and 2019.•In the real world, 94% and 73% of patients with high-risk HR+/HER2− BC received endocrine therapy and chemotherapy.•The 10-year OS (63.4%) and RS rates (72.3%) of patients with high-risk HR+/HER2− BC were poor.•Survival rates of patients with high-risk HR+/HER2− BC remained constant over the years.
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