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Combined features of benign breast disease tied to breast cancer risk
“Benign breast disease is a key risk factor for breast cancer risk prediction,” commented presenting investigator Marta Román, PhD, of the Hospital del Mar Medical Research Institute in Barcelona. “Those women who have had a benign breast disease diagnosis have an increased risk that lasts for at least 20 years.”
To assess the combined influence of various attributes of benign breast disease, the investigators studied 629,087 women, aged 50-69 years, in Spain who underwent population-based mammographic breast cancer screening during 1994-2015 and did not have breast cancer at their prevalent (first) screen. The mean follow-up was 7.8 years.
Results showed that breast cancer risk was about three times higher for women with benign breast disease that was proliferative or that was detected on an incident screen, relative to peers with no benign breast disease. When combinations of factors were considered, breast cancer risk was most elevated – more than four times higher – for women with proliferative benign breast disease with atypia detected on an incident screen.
“We believe that these findings should be considered when discussing risk-based personalized screening strategies because these differences between prevalent and incident screens might be important if we want to personalize the screening, whether it’s the first time a woman comes to the screening program or a subsequent screen,” Dr. Román said.
Practice changing?
The study’s large size and population-based design, likely permitting capture of most biopsy results, are strengths, Mark David Pearlman, MD, of the University of Michigan, Ann Arbor, commented in an interview.
But its observational, retrospective nature opens the study up to biases, such as uncertainty as to how many women were symptomatic at the time of their mammogram and the likelihood of heightened monitoring after a biopsy showing hyperplasia, Dr. Pearlman cautioned.
“Moreover, the relative risk in this study for proliferative benign breast disease without atypia is substantially higher than prior observations of this group. This discrepancy was not discussed by the authors,” Dr. Pearlman said.
At present, women’s risk of breast cancer is predicted using well-validated models that include the question of prior breast biopsies, such as the Gail Model, the Tyrer-Cuzick model (IBIS tool), and the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm, Dr. Pearlman noted.
“This study, without further validation within a model, would not change risk assessment,” he said, disagreeing with the investigators’ conclusions. “What I would say is that further study to determine how to use this observation to decide if any change in screening or management should occur would be more appropriate.”
Study details
The 629,087 women studied underwent 2,327,384 screens, Dr. Román reported. In total, screening detected 9,184 cases of benign breast disease and 9,431 breast cancers.
Breast cancer was diagnosed in 2.4% and 3.0% of women with benign breast disease detected on prevalent and incident screens, respectively, compared with 1.5% of women without any benign breast disease detected.
Elevation of breast cancer risk varied across benign breast disease subtype. Relative to peers without any benign disease, risk was significantly elevated for women with nonproliferative disease (adjusted hazard ratio, 1.95), proliferative disease without atypia (aHR, 3.19), and proliferative disease with atypia (aHR, 3.82).
Similarly, elevation of risk varied depending on the screening at which the benign disease was detected. Risk was significantly elevated when the disease was found at prevalent screens (aHR, 1.87) and more so when it was found at incident screens (aHR, 2.67).
There was no significant interaction of these two factors (P = .83). However, when combinations were considered, risk was highest for women with proliferative benign breast disease with atypia detected on incident screens (aHR, 4.35) or prevalent screens (aHR, 3.35), and women with proliferative benign breast disease without atypia detected on incident screens (aHR, 3.83).
This study was supported by grants from Instituto de Salud Carlos III FEDER and by the Research Network on Health Services in Chronic Diseases. Dr. Román and Dr. Pearlman disclosed no conflicts of interest.
SOURCE: Román M et al. EBCC-12 Virtual Conference, Abstract 15.
“Benign breast disease is a key risk factor for breast cancer risk prediction,” commented presenting investigator Marta Román, PhD, of the Hospital del Mar Medical Research Institute in Barcelona. “Those women who have had a benign breast disease diagnosis have an increased risk that lasts for at least 20 years.”
To assess the combined influence of various attributes of benign breast disease, the investigators studied 629,087 women, aged 50-69 years, in Spain who underwent population-based mammographic breast cancer screening during 1994-2015 and did not have breast cancer at their prevalent (first) screen. The mean follow-up was 7.8 years.
Results showed that breast cancer risk was about three times higher for women with benign breast disease that was proliferative or that was detected on an incident screen, relative to peers with no benign breast disease. When combinations of factors were considered, breast cancer risk was most elevated – more than four times higher – for women with proliferative benign breast disease with atypia detected on an incident screen.
“We believe that these findings should be considered when discussing risk-based personalized screening strategies because these differences between prevalent and incident screens might be important if we want to personalize the screening, whether it’s the first time a woman comes to the screening program or a subsequent screen,” Dr. Román said.
Practice changing?
The study’s large size and population-based design, likely permitting capture of most biopsy results, are strengths, Mark David Pearlman, MD, of the University of Michigan, Ann Arbor, commented in an interview.
But its observational, retrospective nature opens the study up to biases, such as uncertainty as to how many women were symptomatic at the time of their mammogram and the likelihood of heightened monitoring after a biopsy showing hyperplasia, Dr. Pearlman cautioned.
“Moreover, the relative risk in this study for proliferative benign breast disease without atypia is substantially higher than prior observations of this group. This discrepancy was not discussed by the authors,” Dr. Pearlman said.
At present, women’s risk of breast cancer is predicted using well-validated models that include the question of prior breast biopsies, such as the Gail Model, the Tyrer-Cuzick model (IBIS tool), and the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm, Dr. Pearlman noted.
“This study, without further validation within a model, would not change risk assessment,” he said, disagreeing with the investigators’ conclusions. “What I would say is that further study to determine how to use this observation to decide if any change in screening or management should occur would be more appropriate.”
Study details
The 629,087 women studied underwent 2,327,384 screens, Dr. Román reported. In total, screening detected 9,184 cases of benign breast disease and 9,431 breast cancers.
Breast cancer was diagnosed in 2.4% and 3.0% of women with benign breast disease detected on prevalent and incident screens, respectively, compared with 1.5% of women without any benign breast disease detected.
Elevation of breast cancer risk varied across benign breast disease subtype. Relative to peers without any benign disease, risk was significantly elevated for women with nonproliferative disease (adjusted hazard ratio, 1.95), proliferative disease without atypia (aHR, 3.19), and proliferative disease with atypia (aHR, 3.82).
Similarly, elevation of risk varied depending on the screening at which the benign disease was detected. Risk was significantly elevated when the disease was found at prevalent screens (aHR, 1.87) and more so when it was found at incident screens (aHR, 2.67).
There was no significant interaction of these two factors (P = .83). However, when combinations were considered, risk was highest for women with proliferative benign breast disease with atypia detected on incident screens (aHR, 4.35) or prevalent screens (aHR, 3.35), and women with proliferative benign breast disease without atypia detected on incident screens (aHR, 3.83).
This study was supported by grants from Instituto de Salud Carlos III FEDER and by the Research Network on Health Services in Chronic Diseases. Dr. Román and Dr. Pearlman disclosed no conflicts of interest.
SOURCE: Román M et al. EBCC-12 Virtual Conference, Abstract 15.
“Benign breast disease is a key risk factor for breast cancer risk prediction,” commented presenting investigator Marta Román, PhD, of the Hospital del Mar Medical Research Institute in Barcelona. “Those women who have had a benign breast disease diagnosis have an increased risk that lasts for at least 20 years.”
To assess the combined influence of various attributes of benign breast disease, the investigators studied 629,087 women, aged 50-69 years, in Spain who underwent population-based mammographic breast cancer screening during 1994-2015 and did not have breast cancer at their prevalent (first) screen. The mean follow-up was 7.8 years.
Results showed that breast cancer risk was about three times higher for women with benign breast disease that was proliferative or that was detected on an incident screen, relative to peers with no benign breast disease. When combinations of factors were considered, breast cancer risk was most elevated – more than four times higher – for women with proliferative benign breast disease with atypia detected on an incident screen.
“We believe that these findings should be considered when discussing risk-based personalized screening strategies because these differences between prevalent and incident screens might be important if we want to personalize the screening, whether it’s the first time a woman comes to the screening program or a subsequent screen,” Dr. Román said.
Practice changing?
The study’s large size and population-based design, likely permitting capture of most biopsy results, are strengths, Mark David Pearlman, MD, of the University of Michigan, Ann Arbor, commented in an interview.
But its observational, retrospective nature opens the study up to biases, such as uncertainty as to how many women were symptomatic at the time of their mammogram and the likelihood of heightened monitoring after a biopsy showing hyperplasia, Dr. Pearlman cautioned.
“Moreover, the relative risk in this study for proliferative benign breast disease without atypia is substantially higher than prior observations of this group. This discrepancy was not discussed by the authors,” Dr. Pearlman said.
At present, women’s risk of breast cancer is predicted using well-validated models that include the question of prior breast biopsies, such as the Gail Model, the Tyrer-Cuzick model (IBIS tool), and the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm, Dr. Pearlman noted.
“This study, without further validation within a model, would not change risk assessment,” he said, disagreeing with the investigators’ conclusions. “What I would say is that further study to determine how to use this observation to decide if any change in screening or management should occur would be more appropriate.”
Study details
The 629,087 women studied underwent 2,327,384 screens, Dr. Román reported. In total, screening detected 9,184 cases of benign breast disease and 9,431 breast cancers.
Breast cancer was diagnosed in 2.4% and 3.0% of women with benign breast disease detected on prevalent and incident screens, respectively, compared with 1.5% of women without any benign breast disease detected.
Elevation of breast cancer risk varied across benign breast disease subtype. Relative to peers without any benign disease, risk was significantly elevated for women with nonproliferative disease (adjusted hazard ratio, 1.95), proliferative disease without atypia (aHR, 3.19), and proliferative disease with atypia (aHR, 3.82).
Similarly, elevation of risk varied depending on the screening at which the benign disease was detected. Risk was significantly elevated when the disease was found at prevalent screens (aHR, 1.87) and more so when it was found at incident screens (aHR, 2.67).
There was no significant interaction of these two factors (P = .83). However, when combinations were considered, risk was highest for women with proliferative benign breast disease with atypia detected on incident screens (aHR, 4.35) or prevalent screens (aHR, 3.35), and women with proliferative benign breast disease without atypia detected on incident screens (aHR, 3.83).
This study was supported by grants from Instituto de Salud Carlos III FEDER and by the Research Network on Health Services in Chronic Diseases. Dr. Román and Dr. Pearlman disclosed no conflicts of interest.
SOURCE: Román M et al. EBCC-12 Virtual Conference, Abstract 15.
FROM EBCC-12 VIRTUAL CONFERENCE
Gene signature found similarly prognostic in ILC and IDC
ILC is enriched with features indicating low proliferative activity, noted investigator Otto Metzger, MD, of the Dana Farber Cancer Institute in Boston.
“Data from retrospective series have indicated no benefit with adjuvant chemotherapy for patients diagnosed with early-stage ILC,” he said. “It’s fair to say that chemotherapy decisions for patients with ILC remain controversial.”
With this in mind, Dr. Metzger and colleagues analyzed data for 5,313 women who underwent surgery for early-stage breast cancer (node-negative or up to three positive lymph nodes) and were risk-stratified to receive or skip adjuvant chemotherapy based on both clinical risk and the MammaPrint score for genomic risk. Fully 44% of women with ILC had discordant clinical and genomic risks.
With a median follow-up of 8.7 years, the 5-year rate of distant metastasis–free survival among all patients classified as genomic high risk was 92.1% in women with IDC and 88.1% in women with ILC, with overlapping 95% confidence intervals. Rates of distant metastasis–free survival for patients with genomic low risk were 96.4% in women with IDC and 96.6% in women with ILC, again with confidence intervals that overlapped.
The pattern was essentially the same for overall survival, and results carried over into 8-year outcomes as well.
“We believe that MammaPrint is a clinically useful test for patients diagnosed with ILC,” Dr. Metzger said. “There are similar survival outcomes for ILC and IDC when matched by genomic risk. This is an important message.”
It should be standard to omit chemotherapy for patients who have ILC classified as high clinical risk but low genomic risk by MammaPrint, Dr. Metzger recommended. “By contrast, MammaPrint should facilitate chemotherapy treatment decisions for patients diagnosed with ILC and high-risk MammaPrint,” he said.
Prognostic, but predictive?
“This is a well-designed prospective multicenter trial and provides the best evidence to date that MammaPrint is an important prognostic tool for ILC,” Todd Tuttle, MD, of University of Minnesota in Minneapolis, said in an interview.
Dr. Tuttle said he mainly uses the MammaPrint test and the OncoType 21-gene recurrence score to estimate prognosis for his patients with ILC.
These new data establish that MammaPrint is prognostic in ILC, but the value of MammaPrint’s genomic high risk result for making the decision about chemotherapy is still unclear, according to Dr. Tuttle.
“I don’t think we know whether MammaPrint can predict the benefit of chemotherapy for patients with stage I or II ILC,” he elaborated. “We need further high-quality studies such as this one to determine the best treatment strategies for ILC, which is a difficult breast cancer.”
Study details
Of the 5,313 patients studied, 487 had ILC (255 classic and 232 variant) and 4,826 had IDC according to central pathology assessment, Dr. Metzger reported.
MammaPrint classified 39% of the IDC group and 16% of the ILC group (10% of those with classic disease and 23% of those with variant disease) as genomically high risk for recurrence. The Adjuvant! Online tool classified 48.3% of ILC and 51.5% of IDC patients as clinically high risk.
Among the 44% of women with ILC having discordant genomic and clinical risk, discordance was usually due to the combination of low genomic risk and high clinical risk, seen in 38%.
The curves for 5-year distant metastasis–free survival stratified by genomic risk essentially overlapped for the IDC and ILC groups. Furthermore, there was no significant interaction of histologic type and genomic risk on this outcome (P = .547).
The 5-year rate of overall survival among women with genomic high risk was 95.6% in the IDC group and 93.5% in the ILC group. Among women with genomic low risk, 5-year overall survival was 98.1% in the IDC group and 97.7% in the ILC group, again with overlapping confidence intervals within each risk category.
The study was funded with support from the Breast Cancer Research Foundation. Dr. Metzger disclosed consulting fees from AbbVie, Genentech, Roche, and Pfizer. Dr. Tuttle disclosed no conflicts of interest.
SOURCE: Metzger O et al. EBCC-12 Virtual Conference. Abstract 6.
ILC is enriched with features indicating low proliferative activity, noted investigator Otto Metzger, MD, of the Dana Farber Cancer Institute in Boston.
“Data from retrospective series have indicated no benefit with adjuvant chemotherapy for patients diagnosed with early-stage ILC,” he said. “It’s fair to say that chemotherapy decisions for patients with ILC remain controversial.”
With this in mind, Dr. Metzger and colleagues analyzed data for 5,313 women who underwent surgery for early-stage breast cancer (node-negative or up to three positive lymph nodes) and were risk-stratified to receive or skip adjuvant chemotherapy based on both clinical risk and the MammaPrint score for genomic risk. Fully 44% of women with ILC had discordant clinical and genomic risks.
With a median follow-up of 8.7 years, the 5-year rate of distant metastasis–free survival among all patients classified as genomic high risk was 92.1% in women with IDC and 88.1% in women with ILC, with overlapping 95% confidence intervals. Rates of distant metastasis–free survival for patients with genomic low risk were 96.4% in women with IDC and 96.6% in women with ILC, again with confidence intervals that overlapped.
The pattern was essentially the same for overall survival, and results carried over into 8-year outcomes as well.
“We believe that MammaPrint is a clinically useful test for patients diagnosed with ILC,” Dr. Metzger said. “There are similar survival outcomes for ILC and IDC when matched by genomic risk. This is an important message.”
It should be standard to omit chemotherapy for patients who have ILC classified as high clinical risk but low genomic risk by MammaPrint, Dr. Metzger recommended. “By contrast, MammaPrint should facilitate chemotherapy treatment decisions for patients diagnosed with ILC and high-risk MammaPrint,” he said.
Prognostic, but predictive?
“This is a well-designed prospective multicenter trial and provides the best evidence to date that MammaPrint is an important prognostic tool for ILC,” Todd Tuttle, MD, of University of Minnesota in Minneapolis, said in an interview.
Dr. Tuttle said he mainly uses the MammaPrint test and the OncoType 21-gene recurrence score to estimate prognosis for his patients with ILC.
These new data establish that MammaPrint is prognostic in ILC, but the value of MammaPrint’s genomic high risk result for making the decision about chemotherapy is still unclear, according to Dr. Tuttle.
“I don’t think we know whether MammaPrint can predict the benefit of chemotherapy for patients with stage I or II ILC,” he elaborated. “We need further high-quality studies such as this one to determine the best treatment strategies for ILC, which is a difficult breast cancer.”
Study details
Of the 5,313 patients studied, 487 had ILC (255 classic and 232 variant) and 4,826 had IDC according to central pathology assessment, Dr. Metzger reported.
MammaPrint classified 39% of the IDC group and 16% of the ILC group (10% of those with classic disease and 23% of those with variant disease) as genomically high risk for recurrence. The Adjuvant! Online tool classified 48.3% of ILC and 51.5% of IDC patients as clinically high risk.
Among the 44% of women with ILC having discordant genomic and clinical risk, discordance was usually due to the combination of low genomic risk and high clinical risk, seen in 38%.
The curves for 5-year distant metastasis–free survival stratified by genomic risk essentially overlapped for the IDC and ILC groups. Furthermore, there was no significant interaction of histologic type and genomic risk on this outcome (P = .547).
The 5-year rate of overall survival among women with genomic high risk was 95.6% in the IDC group and 93.5% in the ILC group. Among women with genomic low risk, 5-year overall survival was 98.1% in the IDC group and 97.7% in the ILC group, again with overlapping confidence intervals within each risk category.
The study was funded with support from the Breast Cancer Research Foundation. Dr. Metzger disclosed consulting fees from AbbVie, Genentech, Roche, and Pfizer. Dr. Tuttle disclosed no conflicts of interest.
SOURCE: Metzger O et al. EBCC-12 Virtual Conference. Abstract 6.
ILC is enriched with features indicating low proliferative activity, noted investigator Otto Metzger, MD, of the Dana Farber Cancer Institute in Boston.
“Data from retrospective series have indicated no benefit with adjuvant chemotherapy for patients diagnosed with early-stage ILC,” he said. “It’s fair to say that chemotherapy decisions for patients with ILC remain controversial.”
With this in mind, Dr. Metzger and colleagues analyzed data for 5,313 women who underwent surgery for early-stage breast cancer (node-negative or up to three positive lymph nodes) and were risk-stratified to receive or skip adjuvant chemotherapy based on both clinical risk and the MammaPrint score for genomic risk. Fully 44% of women with ILC had discordant clinical and genomic risks.
With a median follow-up of 8.7 years, the 5-year rate of distant metastasis–free survival among all patients classified as genomic high risk was 92.1% in women with IDC and 88.1% in women with ILC, with overlapping 95% confidence intervals. Rates of distant metastasis–free survival for patients with genomic low risk were 96.4% in women with IDC and 96.6% in women with ILC, again with confidence intervals that overlapped.
The pattern was essentially the same for overall survival, and results carried over into 8-year outcomes as well.
“We believe that MammaPrint is a clinically useful test for patients diagnosed with ILC,” Dr. Metzger said. “There are similar survival outcomes for ILC and IDC when matched by genomic risk. This is an important message.”
It should be standard to omit chemotherapy for patients who have ILC classified as high clinical risk but low genomic risk by MammaPrint, Dr. Metzger recommended. “By contrast, MammaPrint should facilitate chemotherapy treatment decisions for patients diagnosed with ILC and high-risk MammaPrint,” he said.
Prognostic, but predictive?
“This is a well-designed prospective multicenter trial and provides the best evidence to date that MammaPrint is an important prognostic tool for ILC,” Todd Tuttle, MD, of University of Minnesota in Minneapolis, said in an interview.
Dr. Tuttle said he mainly uses the MammaPrint test and the OncoType 21-gene recurrence score to estimate prognosis for his patients with ILC.
These new data establish that MammaPrint is prognostic in ILC, but the value of MammaPrint’s genomic high risk result for making the decision about chemotherapy is still unclear, according to Dr. Tuttle.
“I don’t think we know whether MammaPrint can predict the benefit of chemotherapy for patients with stage I or II ILC,” he elaborated. “We need further high-quality studies such as this one to determine the best treatment strategies for ILC, which is a difficult breast cancer.”
Study details
Of the 5,313 patients studied, 487 had ILC (255 classic and 232 variant) and 4,826 had IDC according to central pathology assessment, Dr. Metzger reported.
MammaPrint classified 39% of the IDC group and 16% of the ILC group (10% of those with classic disease and 23% of those with variant disease) as genomically high risk for recurrence. The Adjuvant! Online tool classified 48.3% of ILC and 51.5% of IDC patients as clinically high risk.
Among the 44% of women with ILC having discordant genomic and clinical risk, discordance was usually due to the combination of low genomic risk and high clinical risk, seen in 38%.
The curves for 5-year distant metastasis–free survival stratified by genomic risk essentially overlapped for the IDC and ILC groups. Furthermore, there was no significant interaction of histologic type and genomic risk on this outcome (P = .547).
The 5-year rate of overall survival among women with genomic high risk was 95.6% in the IDC group and 93.5% in the ILC group. Among women with genomic low risk, 5-year overall survival was 98.1% in the IDC group and 97.7% in the ILC group, again with overlapping confidence intervals within each risk category.
The study was funded with support from the Breast Cancer Research Foundation. Dr. Metzger disclosed consulting fees from AbbVie, Genentech, Roche, and Pfizer. Dr. Tuttle disclosed no conflicts of interest.
SOURCE: Metzger O et al. EBCC-12 Virtual Conference. Abstract 6.
FROM EBCC-12 VIRTUAL CONFERENCE
Study advances personalized treatment for older breast cancer patients
Findings from the study were reported at the 12th European Breast Cancer Conference.
“Primary endocrine therapy is usually reserved for older, less fit, and frail women. Rates of use vary widely,” noted investigator Lynda Wyld, MBChB, PhD, of the University of Sheffield (England).
“Although there is no set threshold for who is suitable, some women are undoubtedly over- and undertreated for their breast cancer,” she added.
Dr. Wyld and colleagues undertook the Age Gap study among women older than 70 years with breast cancer recruited from 56 U.K. breast units during 2013-2018.
The main goals were to determine which women can be safely offered primary endocrine therapy as nonstandard care and to develop and test a tool to help women in this age group make treatment decisions.
The first component of the study was a multicenter, prospective cohort study of women with ER+ disease who were eligible for surgery. Results showed that breast cancer–specific mortality was greater with primary endocrine therapy than with surgery in the entire cohort. However, breast cancer–specific mortality was lower with primary endocrine therapy than with surgery in a cohort matched with propensity scores to achieve similar age, fitness, and frailty.
The second component of the study was a cluster-randomized controlled trial of women with operable breast cancer, most of whom had ER+ disease. Results showed that a decision support tool increased awareness of treatment options and readiness to decide. The tool also altered treatment choices, prompting a larger share of patients with ER+ disease to choose primary endocrine therapy.
Prospective cohort study
The prospective observational study was conducted in 2,854 women with ER+ disease who were eligible for surgery and treated in usual practice. Most women (n = 2,354) were treated with surgery (followed by antiestrogen therapy), while the rest received primary endocrine therapy (n = 500).
In the entire cohort, patients undergoing surgery were younger, had a lower level of comorbidity, and were less often frail. But these characteristics were generally similar in a propensity-matched cohort of 672 patients.
At a median follow-up of 52 months, overall and breast cancer–specific survival were significantly poorer with primary endocrine therapy versus surgery in the entire cohort but not in the propensity-matched cohort.
In the entire cohort, the breast cancer–specific mortality was 9.5% with primary endocrine therapy and 4.9% with surgery. In the propensity-matched cohort, breast cancer–specific mortality was 3.1% and 6.6%, respectively.
The overall mortality was 41.8% with primary endocrine therapy and 14.6% with surgery in the entire cohort, but the gap narrowed to 34.5% and 25.6%, respectively, in the propensity-matched cohort.
In the latter, “although there is a slight divergence in overall survival and it’s likely that with longer-term follow-up this will become significant, at the moment, it isn’t,” Dr. Wyld commented.
Curves for breast cancer–specific survival basically overlapped until 5 years, when surgery started to show an advantage. The rate of locoregional recurrence or progression was low and not significantly different by treatment.
None of the women in the entire cohort died from surgery. “But it’s worth bearing in mind that these were all women selected for surgery, who were thought to be fit for it by their surgeons. The least fit women in this cohort will have obviously been offered primary endocrine therapy,” Dr. Wyld cautioned.
Although 19% of patients had a surgical complication, only 2.1% had a systemic surgical complication.
Cluster-randomized controlled trial
In the cluster-randomized controlled trial, researchers compared a decision support tool to usual care. The tool was developed using U.K. registry data from almost 30,000 older women and input from women in this age group on their preferred format and method of presentation, according to Dr. Wyld.
The tool consists of an algorithm available to clinicians online (for input of tumor stage and biology, comorbidities, and functional status) plus a booklet and outcome sheets for patients to take home after discussions that can be personalized to their particulars.
Intention-to-treat analyses were based on 1,339 patients with operable breast cancer, 1,161 of whom had ER+ disease. Per-protocol analyses were based on the subset of 449 patients who were offered a choice between surgery and primary endocrine therapy, presumably because they were less fit and frailer.
Results showed that, at 6 months, mean scores for global quality of life on the EORTC questionnaire did not differ between decision support and usual care in the intention-to-treat population (69.0 vs. 68.9; P = .900), but scores were more favorable with decision support in the per-protocol population (70.7 vs. 66.8; P = .044).
The tool also altered treatment choices, with a larger share of ER+ patients choosing primary endocrine therapy (21.0% vs. 15.4%; P = .029) but still having similar disease outcomes.
Although ER+ patients in the decision support group more often selected primary endocrine therapy, at a median follow-up of 36 months, the groups did not differ significantly on overall survival, cause-specific survival, or time to recurrence in either intention-to-treat or per-protocol analyses.
Larger shares of women in the decision support group reported that they had adequate knowledge about the treatment options available to them (94% vs. 74%), were aware of the advantages and disadvantages of each option (91% vs. 76%), knew which option they preferred (96% vs. 91%), and were ready to make a decision (99% vs. 90%).
Applying results to practice
“Most women over the age of 70 are relatively fit, and the aim should be to treat them with surgery,” Dr. Wyld said. “For the less fit, a point is reached where the oncology benefits of surgery disappear and surgery may just cause harm. This threshold appears to be for women in their mid-80s with moderate to poor health.”
“Use of the Age Gap online tool may enhance shared decision-making for these women while increasing knowledge. And whilst it does seem to increase the use of primary endocrine therapy, this does not seem to have an adverse impact on survival at 36 months of follow-up,” she added.
“The study by Dr. Wyld and colleagues adds to the available literature regarding the scenarios in which some treatments may be omitted without impacting overall survival in older women with breast cancer,” Lesly A. Dossett, MD, of Michigan Medicine in Ann Arbor, commented in an interview.
In her own practice, Dr. Dossett emphasizes the generally favorable prognosis for older women with hormone receptor–positive breast cancer, she said. However, tools that help communicate risk and clarify the value of various therapies are welcome.
“The decision support tool appears to be a promising tool in helping to avoid treatments that are unlikely to benefit older women with breast cancer,” Dr. Dossett said. “The results will be widely applicable, as there is growing recognition that this patient population is at risk for overtreatment.”
The study was funded by the U.K. National Institute for Health Research programme grant for applied research. Dr. Wyld and Dr. Dossett said they had no relevant conflicts of interest.
SOURCES: Wyld L et al. EBCC-12 Virtual Congress. Abstract 8A and Abstract 8B.
Findings from the study were reported at the 12th European Breast Cancer Conference.
“Primary endocrine therapy is usually reserved for older, less fit, and frail women. Rates of use vary widely,” noted investigator Lynda Wyld, MBChB, PhD, of the University of Sheffield (England).
“Although there is no set threshold for who is suitable, some women are undoubtedly over- and undertreated for their breast cancer,” she added.
Dr. Wyld and colleagues undertook the Age Gap study among women older than 70 years with breast cancer recruited from 56 U.K. breast units during 2013-2018.
The main goals were to determine which women can be safely offered primary endocrine therapy as nonstandard care and to develop and test a tool to help women in this age group make treatment decisions.
The first component of the study was a multicenter, prospective cohort study of women with ER+ disease who were eligible for surgery. Results showed that breast cancer–specific mortality was greater with primary endocrine therapy than with surgery in the entire cohort. However, breast cancer–specific mortality was lower with primary endocrine therapy than with surgery in a cohort matched with propensity scores to achieve similar age, fitness, and frailty.
The second component of the study was a cluster-randomized controlled trial of women with operable breast cancer, most of whom had ER+ disease. Results showed that a decision support tool increased awareness of treatment options and readiness to decide. The tool also altered treatment choices, prompting a larger share of patients with ER+ disease to choose primary endocrine therapy.
Prospective cohort study
The prospective observational study was conducted in 2,854 women with ER+ disease who were eligible for surgery and treated in usual practice. Most women (n = 2,354) were treated with surgery (followed by antiestrogen therapy), while the rest received primary endocrine therapy (n = 500).
In the entire cohort, patients undergoing surgery were younger, had a lower level of comorbidity, and were less often frail. But these characteristics were generally similar in a propensity-matched cohort of 672 patients.
At a median follow-up of 52 months, overall and breast cancer–specific survival were significantly poorer with primary endocrine therapy versus surgery in the entire cohort but not in the propensity-matched cohort.
In the entire cohort, the breast cancer–specific mortality was 9.5% with primary endocrine therapy and 4.9% with surgery. In the propensity-matched cohort, breast cancer–specific mortality was 3.1% and 6.6%, respectively.
The overall mortality was 41.8% with primary endocrine therapy and 14.6% with surgery in the entire cohort, but the gap narrowed to 34.5% and 25.6%, respectively, in the propensity-matched cohort.
In the latter, “although there is a slight divergence in overall survival and it’s likely that with longer-term follow-up this will become significant, at the moment, it isn’t,” Dr. Wyld commented.
Curves for breast cancer–specific survival basically overlapped until 5 years, when surgery started to show an advantage. The rate of locoregional recurrence or progression was low and not significantly different by treatment.
None of the women in the entire cohort died from surgery. “But it’s worth bearing in mind that these were all women selected for surgery, who were thought to be fit for it by their surgeons. The least fit women in this cohort will have obviously been offered primary endocrine therapy,” Dr. Wyld cautioned.
Although 19% of patients had a surgical complication, only 2.1% had a systemic surgical complication.
Cluster-randomized controlled trial
In the cluster-randomized controlled trial, researchers compared a decision support tool to usual care. The tool was developed using U.K. registry data from almost 30,000 older women and input from women in this age group on their preferred format and method of presentation, according to Dr. Wyld.
The tool consists of an algorithm available to clinicians online (for input of tumor stage and biology, comorbidities, and functional status) plus a booklet and outcome sheets for patients to take home after discussions that can be personalized to their particulars.
Intention-to-treat analyses were based on 1,339 patients with operable breast cancer, 1,161 of whom had ER+ disease. Per-protocol analyses were based on the subset of 449 patients who were offered a choice between surgery and primary endocrine therapy, presumably because they were less fit and frailer.
Results showed that, at 6 months, mean scores for global quality of life on the EORTC questionnaire did not differ between decision support and usual care in the intention-to-treat population (69.0 vs. 68.9; P = .900), but scores were more favorable with decision support in the per-protocol population (70.7 vs. 66.8; P = .044).
The tool also altered treatment choices, with a larger share of ER+ patients choosing primary endocrine therapy (21.0% vs. 15.4%; P = .029) but still having similar disease outcomes.
Although ER+ patients in the decision support group more often selected primary endocrine therapy, at a median follow-up of 36 months, the groups did not differ significantly on overall survival, cause-specific survival, or time to recurrence in either intention-to-treat or per-protocol analyses.
Larger shares of women in the decision support group reported that they had adequate knowledge about the treatment options available to them (94% vs. 74%), were aware of the advantages and disadvantages of each option (91% vs. 76%), knew which option they preferred (96% vs. 91%), and were ready to make a decision (99% vs. 90%).
Applying results to practice
“Most women over the age of 70 are relatively fit, and the aim should be to treat them with surgery,” Dr. Wyld said. “For the less fit, a point is reached where the oncology benefits of surgery disappear and surgery may just cause harm. This threshold appears to be for women in their mid-80s with moderate to poor health.”
“Use of the Age Gap online tool may enhance shared decision-making for these women while increasing knowledge. And whilst it does seem to increase the use of primary endocrine therapy, this does not seem to have an adverse impact on survival at 36 months of follow-up,” she added.
“The study by Dr. Wyld and colleagues adds to the available literature regarding the scenarios in which some treatments may be omitted without impacting overall survival in older women with breast cancer,” Lesly A. Dossett, MD, of Michigan Medicine in Ann Arbor, commented in an interview.
In her own practice, Dr. Dossett emphasizes the generally favorable prognosis for older women with hormone receptor–positive breast cancer, she said. However, tools that help communicate risk and clarify the value of various therapies are welcome.
“The decision support tool appears to be a promising tool in helping to avoid treatments that are unlikely to benefit older women with breast cancer,” Dr. Dossett said. “The results will be widely applicable, as there is growing recognition that this patient population is at risk for overtreatment.”
The study was funded by the U.K. National Institute for Health Research programme grant for applied research. Dr. Wyld and Dr. Dossett said they had no relevant conflicts of interest.
SOURCES: Wyld L et al. EBCC-12 Virtual Congress. Abstract 8A and Abstract 8B.
Findings from the study were reported at the 12th European Breast Cancer Conference.
“Primary endocrine therapy is usually reserved for older, less fit, and frail women. Rates of use vary widely,” noted investigator Lynda Wyld, MBChB, PhD, of the University of Sheffield (England).
“Although there is no set threshold for who is suitable, some women are undoubtedly over- and undertreated for their breast cancer,” she added.
Dr. Wyld and colleagues undertook the Age Gap study among women older than 70 years with breast cancer recruited from 56 U.K. breast units during 2013-2018.
The main goals were to determine which women can be safely offered primary endocrine therapy as nonstandard care and to develop and test a tool to help women in this age group make treatment decisions.
The first component of the study was a multicenter, prospective cohort study of women with ER+ disease who were eligible for surgery. Results showed that breast cancer–specific mortality was greater with primary endocrine therapy than with surgery in the entire cohort. However, breast cancer–specific mortality was lower with primary endocrine therapy than with surgery in a cohort matched with propensity scores to achieve similar age, fitness, and frailty.
The second component of the study was a cluster-randomized controlled trial of women with operable breast cancer, most of whom had ER+ disease. Results showed that a decision support tool increased awareness of treatment options and readiness to decide. The tool also altered treatment choices, prompting a larger share of patients with ER+ disease to choose primary endocrine therapy.
Prospective cohort study
The prospective observational study was conducted in 2,854 women with ER+ disease who were eligible for surgery and treated in usual practice. Most women (n = 2,354) were treated with surgery (followed by antiestrogen therapy), while the rest received primary endocrine therapy (n = 500).
In the entire cohort, patients undergoing surgery were younger, had a lower level of comorbidity, and were less often frail. But these characteristics were generally similar in a propensity-matched cohort of 672 patients.
At a median follow-up of 52 months, overall and breast cancer–specific survival were significantly poorer with primary endocrine therapy versus surgery in the entire cohort but not in the propensity-matched cohort.
In the entire cohort, the breast cancer–specific mortality was 9.5% with primary endocrine therapy and 4.9% with surgery. In the propensity-matched cohort, breast cancer–specific mortality was 3.1% and 6.6%, respectively.
The overall mortality was 41.8% with primary endocrine therapy and 14.6% with surgery in the entire cohort, but the gap narrowed to 34.5% and 25.6%, respectively, in the propensity-matched cohort.
In the latter, “although there is a slight divergence in overall survival and it’s likely that with longer-term follow-up this will become significant, at the moment, it isn’t,” Dr. Wyld commented.
Curves for breast cancer–specific survival basically overlapped until 5 years, when surgery started to show an advantage. The rate of locoregional recurrence or progression was low and not significantly different by treatment.
None of the women in the entire cohort died from surgery. “But it’s worth bearing in mind that these were all women selected for surgery, who were thought to be fit for it by their surgeons. The least fit women in this cohort will have obviously been offered primary endocrine therapy,” Dr. Wyld cautioned.
Although 19% of patients had a surgical complication, only 2.1% had a systemic surgical complication.
Cluster-randomized controlled trial
In the cluster-randomized controlled trial, researchers compared a decision support tool to usual care. The tool was developed using U.K. registry data from almost 30,000 older women and input from women in this age group on their preferred format and method of presentation, according to Dr. Wyld.
The tool consists of an algorithm available to clinicians online (for input of tumor stage and biology, comorbidities, and functional status) plus a booklet and outcome sheets for patients to take home after discussions that can be personalized to their particulars.
Intention-to-treat analyses were based on 1,339 patients with operable breast cancer, 1,161 of whom had ER+ disease. Per-protocol analyses were based on the subset of 449 patients who were offered a choice between surgery and primary endocrine therapy, presumably because they were less fit and frailer.
Results showed that, at 6 months, mean scores for global quality of life on the EORTC questionnaire did not differ between decision support and usual care in the intention-to-treat population (69.0 vs. 68.9; P = .900), but scores were more favorable with decision support in the per-protocol population (70.7 vs. 66.8; P = .044).
The tool also altered treatment choices, with a larger share of ER+ patients choosing primary endocrine therapy (21.0% vs. 15.4%; P = .029) but still having similar disease outcomes.
Although ER+ patients in the decision support group more often selected primary endocrine therapy, at a median follow-up of 36 months, the groups did not differ significantly on overall survival, cause-specific survival, or time to recurrence in either intention-to-treat or per-protocol analyses.
Larger shares of women in the decision support group reported that they had adequate knowledge about the treatment options available to them (94% vs. 74%), were aware of the advantages and disadvantages of each option (91% vs. 76%), knew which option they preferred (96% vs. 91%), and were ready to make a decision (99% vs. 90%).
Applying results to practice
“Most women over the age of 70 are relatively fit, and the aim should be to treat them with surgery,” Dr. Wyld said. “For the less fit, a point is reached where the oncology benefits of surgery disappear and surgery may just cause harm. This threshold appears to be for women in their mid-80s with moderate to poor health.”
“Use of the Age Gap online tool may enhance shared decision-making for these women while increasing knowledge. And whilst it does seem to increase the use of primary endocrine therapy, this does not seem to have an adverse impact on survival at 36 months of follow-up,” she added.
“The study by Dr. Wyld and colleagues adds to the available literature regarding the scenarios in which some treatments may be omitted without impacting overall survival in older women with breast cancer,” Lesly A. Dossett, MD, of Michigan Medicine in Ann Arbor, commented in an interview.
In her own practice, Dr. Dossett emphasizes the generally favorable prognosis for older women with hormone receptor–positive breast cancer, she said. However, tools that help communicate risk and clarify the value of various therapies are welcome.
“The decision support tool appears to be a promising tool in helping to avoid treatments that are unlikely to benefit older women with breast cancer,” Dr. Dossett said. “The results will be widely applicable, as there is growing recognition that this patient population is at risk for overtreatment.”
The study was funded by the U.K. National Institute for Health Research programme grant for applied research. Dr. Wyld and Dr. Dossett said they had no relevant conflicts of interest.
SOURCES: Wyld L et al. EBCC-12 Virtual Congress. Abstract 8A and Abstract 8B.
FROM EBCC-12 VIRTUAL CONFERENCE
Breast Cancer Journal Scan: October 2020
Screening mammography has led to decreased breast cancer-specific mortality, and both digital mammography (DM) and digital breast tomosynthesis (DBT) are available modalities. A study by Lowry and colleagues evaluated DM and DBT performance in over 1,500,000 women age 40-79 without a prior history of breast cancer and demonstrated greater DBT benefit on initial screening exam. DBT benefit persisted on subsequent screening for women with heterogeneously dense breasts and scattered fibroglandular density, while no improvement in recall or cancer detection rates was seen for women with extremely dense breasts with DBT on subsequent exams. A physician survey showed 30% utilization of DBT, with higher uptake in academic settings and those with higher number of breast imagers and mammography units. Interestingly, 16% of respondents used mammographic density as a criterion to select patients to undergo DBT. Guidelines to help determine which women benefit from DBT would be a useful asset to clinicians and help optimize resources.
Although the majority of breast cancers are detected by screening mammography, a significant proportion are first noticed by a patient. Interval breast cancers, those detected between a normal mammogram and next scheduled mammogram, have more unfavorable features and worse survival compared with those detected by screening. Niraula et al found that interval breast cancers accounted for approximately 20% of cases, were over 6 times more likely to be higher grade, nearly 3 times more likely to be estrogen receptor-negative, and had a hazard ratio of 3.5 for breast cancer-specific mortality compared to screening-detected breast cancers. These findings are not entirely surprising as tumors with more aggressive biology are expected to have a faster onset and progression. Development of more personalized screening strategies may help address breast cancer heterogeneity.
Breast cancer diagnosed in women ≥70 years of age tends to be early stage and hormone receptor (HR)-positive. These cancers carry an excellent prognosis, and omission of routine sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy (assuming endocrine therapy is given) are acceptable strategies. However, these modalities are still utilized at fairly high rates nationally. Wang and colleagues conducted a qualitative study in women ≥70 years of age without a diagnosis of breast cancer, to evaluate treatment preferences in the setting of a hypothetical diagnosis of low-risk HR-positive breast cancer. A total of 40% stated they would elect to undergo SLNB, regarding the procedure as low-risk and providing prognostic information. Most women (73%) would choose to avoid radiation, due to perception of risk/benefit ratio and inconvenience. This study highlights the importance of effective communication regarding the excellent prognosis of these cancers in older women, and that de-escalation strategies are presented to reduce overtreatment and potential harms while achieving similar benefit.
Higher rates of genetic mutations (non-BRCA 1/2) have been observed in patients with breast cancer and another primary cancer compared to those with single primary breast cancer. Maxwell et al demonstrated rates of 7-9% compared to 4-5% for those with multiple primary breast cancer and single breast cancer, respectively. Further, they showed gene mutations (other than BRCA) are found in up to 25% of patients with breast cancer and another primary with their first breast cancer diagnosed ≤30 years old. Genetic testing is not a one-size fits all method and many patients are offered multigene panel testing. A multidisciplinary approach is key to identifying patients at higher risk, implementing effective screening and hopefully preventing future cancer development.
Erin Roesch, MD
The Cleveland Clinic
References:
Hardesty LA, Kreidler SM, Glueck DH. Digital breast tomosynthesis utilization in the United States: A survey of physician members of the society of breast imaging. J Am Coll Radiol 2016; 11S:R67-R73.
Bellio G, Marion R, Giudici F, Kus S, Tonutti M, Zanconati F, Bortul M. Interval breast cancer versus screen-detected cancer: comparison of clinicopathologic characteristics in a single-center analysis. Clin Breast Cancer. 2017;17:564-71.
Piccinin C, Panchal S, Watkins N, Kim, RH. An update on genetic risk assessment and prevention: the role of genetic testing panels in breast cancer. Expert Rev Anticancer Ther. 2019; 19:787-801.
Screening mammography has led to decreased breast cancer-specific mortality, and both digital mammography (DM) and digital breast tomosynthesis (DBT) are available modalities. A study by Lowry and colleagues evaluated DM and DBT performance in over 1,500,000 women age 40-79 without a prior history of breast cancer and demonstrated greater DBT benefit on initial screening exam. DBT benefit persisted on subsequent screening for women with heterogeneously dense breasts and scattered fibroglandular density, while no improvement in recall or cancer detection rates was seen for women with extremely dense breasts with DBT on subsequent exams. A physician survey showed 30% utilization of DBT, with higher uptake in academic settings and those with higher number of breast imagers and mammography units. Interestingly, 16% of respondents used mammographic density as a criterion to select patients to undergo DBT. Guidelines to help determine which women benefit from DBT would be a useful asset to clinicians and help optimize resources.
Although the majority of breast cancers are detected by screening mammography, a significant proportion are first noticed by a patient. Interval breast cancers, those detected between a normal mammogram and next scheduled mammogram, have more unfavorable features and worse survival compared with those detected by screening. Niraula et al found that interval breast cancers accounted for approximately 20% of cases, were over 6 times more likely to be higher grade, nearly 3 times more likely to be estrogen receptor-negative, and had a hazard ratio of 3.5 for breast cancer-specific mortality compared to screening-detected breast cancers. These findings are not entirely surprising as tumors with more aggressive biology are expected to have a faster onset and progression. Development of more personalized screening strategies may help address breast cancer heterogeneity.
Breast cancer diagnosed in women ≥70 years of age tends to be early stage and hormone receptor (HR)-positive. These cancers carry an excellent prognosis, and omission of routine sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy (assuming endocrine therapy is given) are acceptable strategies. However, these modalities are still utilized at fairly high rates nationally. Wang and colleagues conducted a qualitative study in women ≥70 years of age without a diagnosis of breast cancer, to evaluate treatment preferences in the setting of a hypothetical diagnosis of low-risk HR-positive breast cancer. A total of 40% stated they would elect to undergo SLNB, regarding the procedure as low-risk and providing prognostic information. Most women (73%) would choose to avoid radiation, due to perception of risk/benefit ratio and inconvenience. This study highlights the importance of effective communication regarding the excellent prognosis of these cancers in older women, and that de-escalation strategies are presented to reduce overtreatment and potential harms while achieving similar benefit.
Higher rates of genetic mutations (non-BRCA 1/2) have been observed in patients with breast cancer and another primary cancer compared to those with single primary breast cancer. Maxwell et al demonstrated rates of 7-9% compared to 4-5% for those with multiple primary breast cancer and single breast cancer, respectively. Further, they showed gene mutations (other than BRCA) are found in up to 25% of patients with breast cancer and another primary with their first breast cancer diagnosed ≤30 years old. Genetic testing is not a one-size fits all method and many patients are offered multigene panel testing. A multidisciplinary approach is key to identifying patients at higher risk, implementing effective screening and hopefully preventing future cancer development.
Erin Roesch, MD
The Cleveland Clinic
References:
Hardesty LA, Kreidler SM, Glueck DH. Digital breast tomosynthesis utilization in the United States: A survey of physician members of the society of breast imaging. J Am Coll Radiol 2016; 11S:R67-R73.
Bellio G, Marion R, Giudici F, Kus S, Tonutti M, Zanconati F, Bortul M. Interval breast cancer versus screen-detected cancer: comparison of clinicopathologic characteristics in a single-center analysis. Clin Breast Cancer. 2017;17:564-71.
Piccinin C, Panchal S, Watkins N, Kim, RH. An update on genetic risk assessment and prevention: the role of genetic testing panels in breast cancer. Expert Rev Anticancer Ther. 2019; 19:787-801.
Screening mammography has led to decreased breast cancer-specific mortality, and both digital mammography (DM) and digital breast tomosynthesis (DBT) are available modalities. A study by Lowry and colleagues evaluated DM and DBT performance in over 1,500,000 women age 40-79 without a prior history of breast cancer and demonstrated greater DBT benefit on initial screening exam. DBT benefit persisted on subsequent screening for women with heterogeneously dense breasts and scattered fibroglandular density, while no improvement in recall or cancer detection rates was seen for women with extremely dense breasts with DBT on subsequent exams. A physician survey showed 30% utilization of DBT, with higher uptake in academic settings and those with higher number of breast imagers and mammography units. Interestingly, 16% of respondents used mammographic density as a criterion to select patients to undergo DBT. Guidelines to help determine which women benefit from DBT would be a useful asset to clinicians and help optimize resources.
Although the majority of breast cancers are detected by screening mammography, a significant proportion are first noticed by a patient. Interval breast cancers, those detected between a normal mammogram and next scheduled mammogram, have more unfavorable features and worse survival compared with those detected by screening. Niraula et al found that interval breast cancers accounted for approximately 20% of cases, were over 6 times more likely to be higher grade, nearly 3 times more likely to be estrogen receptor-negative, and had a hazard ratio of 3.5 for breast cancer-specific mortality compared to screening-detected breast cancers. These findings are not entirely surprising as tumors with more aggressive biology are expected to have a faster onset and progression. Development of more personalized screening strategies may help address breast cancer heterogeneity.
Breast cancer diagnosed in women ≥70 years of age tends to be early stage and hormone receptor (HR)-positive. These cancers carry an excellent prognosis, and omission of routine sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy (assuming endocrine therapy is given) are acceptable strategies. However, these modalities are still utilized at fairly high rates nationally. Wang and colleagues conducted a qualitative study in women ≥70 years of age without a diagnosis of breast cancer, to evaluate treatment preferences in the setting of a hypothetical diagnosis of low-risk HR-positive breast cancer. A total of 40% stated they would elect to undergo SLNB, regarding the procedure as low-risk and providing prognostic information. Most women (73%) would choose to avoid radiation, due to perception of risk/benefit ratio and inconvenience. This study highlights the importance of effective communication regarding the excellent prognosis of these cancers in older women, and that de-escalation strategies are presented to reduce overtreatment and potential harms while achieving similar benefit.
Higher rates of genetic mutations (non-BRCA 1/2) have been observed in patients with breast cancer and another primary cancer compared to those with single primary breast cancer. Maxwell et al demonstrated rates of 7-9% compared to 4-5% for those with multiple primary breast cancer and single breast cancer, respectively. Further, they showed gene mutations (other than BRCA) are found in up to 25% of patients with breast cancer and another primary with their first breast cancer diagnosed ≤30 years old. Genetic testing is not a one-size fits all method and many patients are offered multigene panel testing. A multidisciplinary approach is key to identifying patients at higher risk, implementing effective screening and hopefully preventing future cancer development.
Erin Roesch, MD
The Cleveland Clinic
References:
Hardesty LA, Kreidler SM, Glueck DH. Digital breast tomosynthesis utilization in the United States: A survey of physician members of the society of breast imaging. J Am Coll Radiol 2016; 11S:R67-R73.
Bellio G, Marion R, Giudici F, Kus S, Tonutti M, Zanconati F, Bortul M. Interval breast cancer versus screen-detected cancer: comparison of clinicopathologic characteristics in a single-center analysis. Clin Breast Cancer. 2017;17:564-71.
Piccinin C, Panchal S, Watkins N, Kim, RH. An update on genetic risk assessment and prevention: the role of genetic testing panels in breast cancer. Expert Rev Anticancer Ther. 2019; 19:787-801.
Interval breast cancer has higher hazard for breast cancer death than screen-detected breast cancer
Key clinical point: Interval breast cancers (IBC) were six times more likely to be grade III and had 3.5 times increased hazards of death compared with screen-detected cancers (SBC).
Major finding: Breast cancer–specific mortality was significantly higher for IBC compared with SBC cancers (hazard ratio [HR] 3.55; 95% CI, 2.01-6.28; P < .001).
Study details: A cohort study of 69,000 women aged 50-64 years
Disclosures: Dr Hu is the holder of a Manitoba Medical Services Foundation (MMSF) Allen Rouse Basic Science Career Development Research Award.
Source: Niraula, Saroj, MD, MSc, et al. JAMA Netw Open. 2020;3(9):e2018179. doi:10.1001/jamanetworkopen.2020.18179
Key clinical point: Interval breast cancers (IBC) were six times more likely to be grade III and had 3.5 times increased hazards of death compared with screen-detected cancers (SBC).
Major finding: Breast cancer–specific mortality was significantly higher for IBC compared with SBC cancers (hazard ratio [HR] 3.55; 95% CI, 2.01-6.28; P < .001).
Study details: A cohort study of 69,000 women aged 50-64 years
Disclosures: Dr Hu is the holder of a Manitoba Medical Services Foundation (MMSF) Allen Rouse Basic Science Career Development Research Award.
Source: Niraula, Saroj, MD, MSc, et al. JAMA Netw Open. 2020;3(9):e2018179. doi:10.1001/jamanetworkopen.2020.18179
Key clinical point: Interval breast cancers (IBC) were six times more likely to be grade III and had 3.5 times increased hazards of death compared with screen-detected cancers (SBC).
Major finding: Breast cancer–specific mortality was significantly higher for IBC compared with SBC cancers (hazard ratio [HR] 3.55; 95% CI, 2.01-6.28; P < .001).
Study details: A cohort study of 69,000 women aged 50-64 years
Disclosures: Dr Hu is the holder of a Manitoba Medical Services Foundation (MMSF) Allen Rouse Basic Science Career Development Research Award.
Source: Niraula, Saroj, MD, MSc, et al. JAMA Netw Open. 2020;3(9):e2018179. doi:10.1001/jamanetworkopen.2020.18179
Ductal carcinoma in situ increases risk of dying from breast cancer by threefold
Key clinical point: Women with ductal carcinoma in situ (DCIS) had a 3-fold increased risk of dying from breast cancer than women without DCIS.
Major finding: Among the cohort, 1,540 women with DCIS died of breast cancer. The expected number of deaths from breast cancer in the cancer-free cohort was 458.
Study details: Cohort study of 144,524 women diagnosed with DCIS from 1995 to 2014.
Disclosures: The authors report no conflicts of interest.
Source: Giannakeas, V, et al. JAMA Netw Open. 2020;3(9):e2017124. doi:10.1001/jamanetworkopen.2020.17124
Key clinical point: Women with ductal carcinoma in situ (DCIS) had a 3-fold increased risk of dying from breast cancer than women without DCIS.
Major finding: Among the cohort, 1,540 women with DCIS died of breast cancer. The expected number of deaths from breast cancer in the cancer-free cohort was 458.
Study details: Cohort study of 144,524 women diagnosed with DCIS from 1995 to 2014.
Disclosures: The authors report no conflicts of interest.
Source: Giannakeas, V, et al. JAMA Netw Open. 2020;3(9):e2017124. doi:10.1001/jamanetworkopen.2020.17124
Key clinical point: Women with ductal carcinoma in situ (DCIS) had a 3-fold increased risk of dying from breast cancer than women without DCIS.
Major finding: Among the cohort, 1,540 women with DCIS died of breast cancer. The expected number of deaths from breast cancer in the cancer-free cohort was 458.
Study details: Cohort study of 144,524 women diagnosed with DCIS from 1995 to 2014.
Disclosures: The authors report no conflicts of interest.
Source: Giannakeas, V, et al. JAMA Netw Open. 2020;3(9):e2017124. doi:10.1001/jamanetworkopen.2020.17124
Women 70 and older are divided on age-based guidelines for breast cancer treatment
Key clinical point: In women aged 70 or older, there are skeptical views on age-based guidelines for breast cancer treatment and difficulty in interpretating the rationale for treatment de-escalation in low-risk, early-stage hormone receptor–positive breast cancer.
Major finding: Approximately 40% of participants stated they would proceed with sentinel lymph node biopsy (SLNB) despite evidence that omission is safe. Conversely, 73% stated they would omit postlumpectomy radiotherapy.
Study details: A qualitative study with 30 female participants, with a median age of 72 years and without a previous diagnosis of breast cancer.
Disclosures: Dr Jagsi reported receiving grants from the National Institutes of Health (NIH), Komen Foundation, Doris Duke Foundation, Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium, and Genentech; grants and personal fees from Greenwall Foundation; personal fees from Amgen, Vizient, Sherinian & Hassostock, and Dressman, Benziger, and Lavelle; and options as compensation for her advisory board role from Equity Quotient; she also reported being an uncompensated founding member of TIME’S UP Healthcare and a member of the American Society of Clinical Oncology Board of Directors. No other disclosures were reported.
Source: Wang, T, et al. JAMA Netw Open. 2020;3(9):e2017129. doi:10.1001/jamanetworkopen.2020.17129
Key clinical point: In women aged 70 or older, there are skeptical views on age-based guidelines for breast cancer treatment and difficulty in interpretating the rationale for treatment de-escalation in low-risk, early-stage hormone receptor–positive breast cancer.
Major finding: Approximately 40% of participants stated they would proceed with sentinel lymph node biopsy (SLNB) despite evidence that omission is safe. Conversely, 73% stated they would omit postlumpectomy radiotherapy.
Study details: A qualitative study with 30 female participants, with a median age of 72 years and without a previous diagnosis of breast cancer.
Disclosures: Dr Jagsi reported receiving grants from the National Institutes of Health (NIH), Komen Foundation, Doris Duke Foundation, Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium, and Genentech; grants and personal fees from Greenwall Foundation; personal fees from Amgen, Vizient, Sherinian & Hassostock, and Dressman, Benziger, and Lavelle; and options as compensation for her advisory board role from Equity Quotient; she also reported being an uncompensated founding member of TIME’S UP Healthcare and a member of the American Society of Clinical Oncology Board of Directors. No other disclosures were reported.
Source: Wang, T, et al. JAMA Netw Open. 2020;3(9):e2017129. doi:10.1001/jamanetworkopen.2020.17129
Key clinical point: In women aged 70 or older, there are skeptical views on age-based guidelines for breast cancer treatment and difficulty in interpretating the rationale for treatment de-escalation in low-risk, early-stage hormone receptor–positive breast cancer.
Major finding: Approximately 40% of participants stated they would proceed with sentinel lymph node biopsy (SLNB) despite evidence that omission is safe. Conversely, 73% stated they would omit postlumpectomy radiotherapy.
Study details: A qualitative study with 30 female participants, with a median age of 72 years and without a previous diagnosis of breast cancer.
Disclosures: Dr Jagsi reported receiving grants from the National Institutes of Health (NIH), Komen Foundation, Doris Duke Foundation, Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium, and Genentech; grants and personal fees from Greenwall Foundation; personal fees from Amgen, Vizient, Sherinian & Hassostock, and Dressman, Benziger, and Lavelle; and options as compensation for her advisory board role from Equity Quotient; she also reported being an uncompensated founding member of TIME’S UP Healthcare and a member of the American Society of Clinical Oncology Board of Directors. No other disclosures were reported.
Source: Wang, T, et al. JAMA Netw Open. 2020;3(9):e2017129. doi:10.1001/jamanetworkopen.2020.17129
Beyond baseline, DBT no better than mammography for dense breasts
Key clinical point: In women with extremely dense breasts, digital breast tomosynthesis (DBT) does not outperform digital mammography (DM) after the initial exam.
Major finding: For baseline screening in women aged 50-59 years, recall rates per 1,000 exams dropped from 241 with DM to 204 with DBT. Cancer detection rates per 1,000 exams in this age group increased from 5.9 with DM to 8.8 with DBT. On follow-up exams, recall and cancer detection rates varied by patients’ age and breast density.
Study details: Review of 1,584,079 screenings in women aged 40-79 years.
Disclosures: The research was funded by the National Cancer Institute and the Patient-Centered Outcomes Research Institute through the Breast Cancer Surveillance Consortium. The study lead reported grants from GE Healthcare.
Source: Lowry K et al. JAMA Netw Open. 2020 Jul 1;3(7):e2011792.
Key clinical point: In women with extremely dense breasts, digital breast tomosynthesis (DBT) does not outperform digital mammography (DM) after the initial exam.
Major finding: For baseline screening in women aged 50-59 years, recall rates per 1,000 exams dropped from 241 with DM to 204 with DBT. Cancer detection rates per 1,000 exams in this age group increased from 5.9 with DM to 8.8 with DBT. On follow-up exams, recall and cancer detection rates varied by patients’ age and breast density.
Study details: Review of 1,584,079 screenings in women aged 40-79 years.
Disclosures: The research was funded by the National Cancer Institute and the Patient-Centered Outcomes Research Institute through the Breast Cancer Surveillance Consortium. The study lead reported grants from GE Healthcare.
Source: Lowry K et al. JAMA Netw Open. 2020 Jul 1;3(7):e2011792.
Key clinical point: In women with extremely dense breasts, digital breast tomosynthesis (DBT) does not outperform digital mammography (DM) after the initial exam.
Major finding: For baseline screening in women aged 50-59 years, recall rates per 1,000 exams dropped from 241 with DM to 204 with DBT. Cancer detection rates per 1,000 exams in this age group increased from 5.9 with DM to 8.8 with DBT. On follow-up exams, recall and cancer detection rates varied by patients’ age and breast density.
Study details: Review of 1,584,079 screenings in women aged 40-79 years.
Disclosures: The research was funded by the National Cancer Institute and the Patient-Centered Outcomes Research Institute through the Breast Cancer Surveillance Consortium. The study lead reported grants from GE Healthcare.
Source: Lowry K et al. JAMA Netw Open. 2020 Jul 1;3(7):e2011792.
Study supports multigene panel testing for all breast cancer patients with second primary cancers
Key clinical point: All patients with breast cancer who develop a second primary cancer should undergo multigene panel testing, according to researchers.
Major finding: Mutation rates in BRCA1/2-negative breast cancer patients with multiple primary cancers were approximately 7% to 9%, compared with about 4% to 5% in BRCA1/2-negative patients with a single breast cancer.
Study details: A comparison of mutation rates in 1,000 high-risk breast cancer patients (551 with multiple primary cancers and 449 with a single breast cancer) and 1,804 familial breast cancer patients (340 with multiple primaries and 1,464 with a single breast cancer).
Disclosures: This research was supported by grants from government agencies and foundations as well as the University of Pennsylvania. Some authors disclosed relationships with a range of companies.
Source: Maxwell KN et al. JCO Precis Oncol. 2020. doi: 10.1200/PO.19.00301.
Key clinical point: All patients with breast cancer who develop a second primary cancer should undergo multigene panel testing, according to researchers.
Major finding: Mutation rates in BRCA1/2-negative breast cancer patients with multiple primary cancers were approximately 7% to 9%, compared with about 4% to 5% in BRCA1/2-negative patients with a single breast cancer.
Study details: A comparison of mutation rates in 1,000 high-risk breast cancer patients (551 with multiple primary cancers and 449 with a single breast cancer) and 1,804 familial breast cancer patients (340 with multiple primaries and 1,464 with a single breast cancer).
Disclosures: This research was supported by grants from government agencies and foundations as well as the University of Pennsylvania. Some authors disclosed relationships with a range of companies.
Source: Maxwell KN et al. JCO Precis Oncol. 2020. doi: 10.1200/PO.19.00301.
Key clinical point: All patients with breast cancer who develop a second primary cancer should undergo multigene panel testing, according to researchers.
Major finding: Mutation rates in BRCA1/2-negative breast cancer patients with multiple primary cancers were approximately 7% to 9%, compared with about 4% to 5% in BRCA1/2-negative patients with a single breast cancer.
Study details: A comparison of mutation rates in 1,000 high-risk breast cancer patients (551 with multiple primary cancers and 449 with a single breast cancer) and 1,804 familial breast cancer patients (340 with multiple primaries and 1,464 with a single breast cancer).
Disclosures: This research was supported by grants from government agencies and foundations as well as the University of Pennsylvania. Some authors disclosed relationships with a range of companies.
Source: Maxwell KN et al. JCO Precis Oncol. 2020. doi: 10.1200/PO.19.00301.
AI algorithm on par with radiologists as mammogram reader
Key clinical point: An artificial intelligence computer algorithm performed on par with, and in some cases exceeded, radiologists in reading mammograms from women undergoing routine screening.
Major finding: When operating at a specificity of 96.6%, the sensitivity was 81.9% for the algorithm, 77.4% for first-reader radiologists, and 80.1% for second-reader radiologists.
Study details: A comparison of algorithm and radiologist assessments of mammograms in 8,805 women, 739 of whom were diagnosed with breast cancer.
Disclosures: The research was funded by the Stockholm County Council. The investigators disclosed financial relationships with the Swedish Research Council, the Swedish Cancer Society, Stockholm City Council, Collective Minds Radiology, and Pfizer.
Source: Salim M et al. JAMA Oncol. 2020 Aug 27. doi: 10.1001/jamaoncol.2020.3321.
Key clinical point: An artificial intelligence computer algorithm performed on par with, and in some cases exceeded, radiologists in reading mammograms from women undergoing routine screening.
Major finding: When operating at a specificity of 96.6%, the sensitivity was 81.9% for the algorithm, 77.4% for first-reader radiologists, and 80.1% for second-reader radiologists.
Study details: A comparison of algorithm and radiologist assessments of mammograms in 8,805 women, 739 of whom were diagnosed with breast cancer.
Disclosures: The research was funded by the Stockholm County Council. The investigators disclosed financial relationships with the Swedish Research Council, the Swedish Cancer Society, Stockholm City Council, Collective Minds Radiology, and Pfizer.
Source: Salim M et al. JAMA Oncol. 2020 Aug 27. doi: 10.1001/jamaoncol.2020.3321.
Key clinical point: An artificial intelligence computer algorithm performed on par with, and in some cases exceeded, radiologists in reading mammograms from women undergoing routine screening.
Major finding: When operating at a specificity of 96.6%, the sensitivity was 81.9% for the algorithm, 77.4% for first-reader radiologists, and 80.1% for second-reader radiologists.
Study details: A comparison of algorithm and radiologist assessments of mammograms in 8,805 women, 739 of whom were diagnosed with breast cancer.
Disclosures: The research was funded by the Stockholm County Council. The investigators disclosed financial relationships with the Swedish Research Council, the Swedish Cancer Society, Stockholm City Council, Collective Minds Radiology, and Pfizer.
Source: Salim M et al. JAMA Oncol. 2020 Aug 27. doi: 10.1001/jamaoncol.2020.3321.