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Breast Cancer Treatment Among Rural and Urban Women at the Veterans Health Administration
Purpose: Women with breast cancer are increasingly being diagnosed and cared for within the VA. Breast cancer specialists are available only at large VA hospitals in urban regions, possibly impacting the outcomes of rural women. The health outcomes of rural women at the VA have not been well described and are currently a research priority. We described the differences between urban and rural women’s demographics and breast cancer characteristics. We then compared urban and rural women with nonmetastatic breast cancer on type of lymph node biopsy, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and hormone therapy.
Methods: Following IRB approval, 4,025 women with nonmetastatic breast cancer from 1995 to 2012 were identified from the Veterans Affairs Central Cancer Registry (VACCR). This dataset contained diagnosis date, histology, tumor size, tumor grade, lymph node status, and estrogen receptor status. The VACCR also gathered type of lymph node surgery, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and adjuvant hormone therapy. Patient-specific data included date of birth, ethnicity, and zip code of residence at the time of diagnosis. The Rural Urban Commuting Areas 2.0 (RUCA) was used to define rural status and collated further into 3 categories of urban, large rural, and small rural. STATA data analysis and statistical software was used to organize and analyze data. The associations between the 3 rural/urban categories and diagnosis year, age, ethnicity, histology and tumor grade were assessed by ordinal logistic regression. Tumor size was compared using rank sum test. Lymph node and estrogen receptor status were compared with logistic regression, and lymph node sampling methods with multinomial regression. All other treatments were compared between small rural and urban women using logistic regression, and further analyzed with adjustments for factors that could influence treatment choices, including diagnosis year, age, ethnicity, tumor size and grade, lymph node status, and estrogen receptor status.
Results: Most women (n = 3,192) with nonmetastatic breast cancer resided in urban regions, 423 women in large rural regions, and 410 in small rural regions. The number of women living in urban and rural regions did not shift significantly over time (P = .48). The age distributions of rural and urban women did not differ. Women with breast cancer in rural regions were more likely to be white (P ≤ .001, 69% white urban; 90% white small rural; 24% black urban, and 6% black small rural). Tumor histology, size, grade, and lymph node and estrogen receptor status did not differ significantly between rural and urban. Mastectomy was more common among rural women initially, but after adjustments for patient demographics and breast cancer characteristics, urban and rural women received similar proportions of mastectomies. After adjustments, urban and rural women received equivalent breast cancer surgery, adjuvant radiation and adjuvant hormone therapy. However, after controlling for confounding factors, a disproportionate number of urban women receive no lymph node biopsy (P = .05). Additionally, women from large rural regions were statistically more likely to receive adjuvant chemotherapy (P = .04), although the chemotherapy administration did not differ statistically between women from urban and small rural regions (P = .7).
Conclusions: Most women diagnosed with breast cancer at the VA from 1995 to 2012 resided in urban areas. Rural women were much more likely to be white, but the age at diagnosis did not differ. Breast cancer characteristics were similar between rural and urban women. Women living in large rural regions were more likely to receive adjuvant chemotherapy than were women from urban or small rural regions; however reporting differences should be considered as an explanation. A higher proportion of urban women received no lymph node biopsy, which merits further investigation. Breast conservation therapy was administered consistently among rural and urban women veterans.
Purpose: Women with breast cancer are increasingly being diagnosed and cared for within the VA. Breast cancer specialists are available only at large VA hospitals in urban regions, possibly impacting the outcomes of rural women. The health outcomes of rural women at the VA have not been well described and are currently a research priority. We described the differences between urban and rural women’s demographics and breast cancer characteristics. We then compared urban and rural women with nonmetastatic breast cancer on type of lymph node biopsy, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and hormone therapy.
Methods: Following IRB approval, 4,025 women with nonmetastatic breast cancer from 1995 to 2012 were identified from the Veterans Affairs Central Cancer Registry (VACCR). This dataset contained diagnosis date, histology, tumor size, tumor grade, lymph node status, and estrogen receptor status. The VACCR also gathered type of lymph node surgery, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and adjuvant hormone therapy. Patient-specific data included date of birth, ethnicity, and zip code of residence at the time of diagnosis. The Rural Urban Commuting Areas 2.0 (RUCA) was used to define rural status and collated further into 3 categories of urban, large rural, and small rural. STATA data analysis and statistical software was used to organize and analyze data. The associations between the 3 rural/urban categories and diagnosis year, age, ethnicity, histology and tumor grade were assessed by ordinal logistic regression. Tumor size was compared using rank sum test. Lymph node and estrogen receptor status were compared with logistic regression, and lymph node sampling methods with multinomial regression. All other treatments were compared between small rural and urban women using logistic regression, and further analyzed with adjustments for factors that could influence treatment choices, including diagnosis year, age, ethnicity, tumor size and grade, lymph node status, and estrogen receptor status.
Results: Most women (n = 3,192) with nonmetastatic breast cancer resided in urban regions, 423 women in large rural regions, and 410 in small rural regions. The number of women living in urban and rural regions did not shift significantly over time (P = .48). The age distributions of rural and urban women did not differ. Women with breast cancer in rural regions were more likely to be white (P ≤ .001, 69% white urban; 90% white small rural; 24% black urban, and 6% black small rural). Tumor histology, size, grade, and lymph node and estrogen receptor status did not differ significantly between rural and urban. Mastectomy was more common among rural women initially, but after adjustments for patient demographics and breast cancer characteristics, urban and rural women received similar proportions of mastectomies. After adjustments, urban and rural women received equivalent breast cancer surgery, adjuvant radiation and adjuvant hormone therapy. However, after controlling for confounding factors, a disproportionate number of urban women receive no lymph node biopsy (P = .05). Additionally, women from large rural regions were statistically more likely to receive adjuvant chemotherapy (P = .04), although the chemotherapy administration did not differ statistically between women from urban and small rural regions (P = .7).
Conclusions: Most women diagnosed with breast cancer at the VA from 1995 to 2012 resided in urban areas. Rural women were much more likely to be white, but the age at diagnosis did not differ. Breast cancer characteristics were similar between rural and urban women. Women living in large rural regions were more likely to receive adjuvant chemotherapy than were women from urban or small rural regions; however reporting differences should be considered as an explanation. A higher proportion of urban women received no lymph node biopsy, which merits further investigation. Breast conservation therapy was administered consistently among rural and urban women veterans.
Purpose: Women with breast cancer are increasingly being diagnosed and cared for within the VA. Breast cancer specialists are available only at large VA hospitals in urban regions, possibly impacting the outcomes of rural women. The health outcomes of rural women at the VA have not been well described and are currently a research priority. We described the differences between urban and rural women’s demographics and breast cancer characteristics. We then compared urban and rural women with nonmetastatic breast cancer on type of lymph node biopsy, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and hormone therapy.
Methods: Following IRB approval, 4,025 women with nonmetastatic breast cancer from 1995 to 2012 were identified from the Veterans Affairs Central Cancer Registry (VACCR). This dataset contained diagnosis date, histology, tumor size, tumor grade, lymph node status, and estrogen receptor status. The VACCR also gathered type of lymph node surgery, type of breast surgery, adjuvant radiation, adjuvant chemotherapy, and adjuvant hormone therapy. Patient-specific data included date of birth, ethnicity, and zip code of residence at the time of diagnosis. The Rural Urban Commuting Areas 2.0 (RUCA) was used to define rural status and collated further into 3 categories of urban, large rural, and small rural. STATA data analysis and statistical software was used to organize and analyze data. The associations between the 3 rural/urban categories and diagnosis year, age, ethnicity, histology and tumor grade were assessed by ordinal logistic regression. Tumor size was compared using rank sum test. Lymph node and estrogen receptor status were compared with logistic regression, and lymph node sampling methods with multinomial regression. All other treatments were compared between small rural and urban women using logistic regression, and further analyzed with adjustments for factors that could influence treatment choices, including diagnosis year, age, ethnicity, tumor size and grade, lymph node status, and estrogen receptor status.
Results: Most women (n = 3,192) with nonmetastatic breast cancer resided in urban regions, 423 women in large rural regions, and 410 in small rural regions. The number of women living in urban and rural regions did not shift significantly over time (P = .48). The age distributions of rural and urban women did not differ. Women with breast cancer in rural regions were more likely to be white (P ≤ .001, 69% white urban; 90% white small rural; 24% black urban, and 6% black small rural). Tumor histology, size, grade, and lymph node and estrogen receptor status did not differ significantly between rural and urban. Mastectomy was more common among rural women initially, but after adjustments for patient demographics and breast cancer characteristics, urban and rural women received similar proportions of mastectomies. After adjustments, urban and rural women received equivalent breast cancer surgery, adjuvant radiation and adjuvant hormone therapy. However, after controlling for confounding factors, a disproportionate number of urban women receive no lymph node biopsy (P = .05). Additionally, women from large rural regions were statistically more likely to receive adjuvant chemotherapy (P = .04), although the chemotherapy administration did not differ statistically between women from urban and small rural regions (P = .7).
Conclusions: Most women diagnosed with breast cancer at the VA from 1995 to 2012 resided in urban areas. Rural women were much more likely to be white, but the age at diagnosis did not differ. Breast cancer characteristics were similar between rural and urban women. Women living in large rural regions were more likely to receive adjuvant chemotherapy than were women from urban or small rural regions; however reporting differences should be considered as an explanation. A higher proportion of urban women received no lymph node biopsy, which merits further investigation. Breast conservation therapy was administered consistently among rural and urban women veterans.
Gender Disparity in Breast Cancer: A Veteran Population Based Comparison
Introduction: Male breast cancer (MBC) comprises < 1% of all cancers in men and continues to rise. Because of MBC rarity, there is paucity in the literature. Management of MBC is generalized from female breast cancer (FBC). The Veterans Affairs Central Cancer Registry (VACCR) provides a unique source for the study of MBC. The objective of this retrospective analysis was to compare and contrast the characteristics and outcomes of MBC with FBC in the VA population.
Methods: VACCR data from 153 VAMCs were used to analyze the database of VA patients who had breast cancer diagnosed between 1998 and 2013. Primary site codes were identified for breast cancer (50.0-50.9). Data were entered and analyzed using biostatistical software (SAS 9.3).
Results: In total, 6,443 patient records were reviewed, and 1,123 MBC patients were compared with 5,320 FBC patients. The mean age at diagnosis was 70 years for MBS and 57 years for FBC (P < .0001). In patients aged > 50 years, higher numbers of MBC diagnosis (95%) were made compared with FBC diagnosis (72%). Seventy-five percent of patients with breast cancer were white in both genders. More MBC patients (40% in men vs 24% in women) presented with higher disease stage (3 and 4) compared with FBC (21% had ductal carcinoma in situ and 53% stage 1). The dominant histology was ductal carcinoma. No difference in laterality was observed. Estrogen and progesterone receptor-positive tumors were more common in MBC compared with FBC. Forty-five percent and 36% of patients with MBC or FBC, respectively, received hormonal treatment as first course, but fewer MBC patients received chemotherapy and radiation. The mean follow up time was 754 days. As of December 2013, 355 (32%) MBC and 791 (15%) FBC patients died during the course of the study. Males had higher odds of death compared with that of females, but when adjusted for age, race, stage, and grade, survival was better among males.
Conclusions: To the authors’ knowledge, this is the largest series of MBC and FBC completed to date in the veteran population. The results suggested that males were older at presentation and had higher stage of breast cancer compared with that of FBC. The higher mortality rate in MBC may be due to higher stage and/or tumor biology.
Introduction: Male breast cancer (MBC) comprises < 1% of all cancers in men and continues to rise. Because of MBC rarity, there is paucity in the literature. Management of MBC is generalized from female breast cancer (FBC). The Veterans Affairs Central Cancer Registry (VACCR) provides a unique source for the study of MBC. The objective of this retrospective analysis was to compare and contrast the characteristics and outcomes of MBC with FBC in the VA population.
Methods: VACCR data from 153 VAMCs were used to analyze the database of VA patients who had breast cancer diagnosed between 1998 and 2013. Primary site codes were identified for breast cancer (50.0-50.9). Data were entered and analyzed using biostatistical software (SAS 9.3).
Results: In total, 6,443 patient records were reviewed, and 1,123 MBC patients were compared with 5,320 FBC patients. The mean age at diagnosis was 70 years for MBS and 57 years for FBC (P < .0001). In patients aged > 50 years, higher numbers of MBC diagnosis (95%) were made compared with FBC diagnosis (72%). Seventy-five percent of patients with breast cancer were white in both genders. More MBC patients (40% in men vs 24% in women) presented with higher disease stage (3 and 4) compared with FBC (21% had ductal carcinoma in situ and 53% stage 1). The dominant histology was ductal carcinoma. No difference in laterality was observed. Estrogen and progesterone receptor-positive tumors were more common in MBC compared with FBC. Forty-five percent and 36% of patients with MBC or FBC, respectively, received hormonal treatment as first course, but fewer MBC patients received chemotherapy and radiation. The mean follow up time was 754 days. As of December 2013, 355 (32%) MBC and 791 (15%) FBC patients died during the course of the study. Males had higher odds of death compared with that of females, but when adjusted for age, race, stage, and grade, survival was better among males.
Conclusions: To the authors’ knowledge, this is the largest series of MBC and FBC completed to date in the veteran population. The results suggested that males were older at presentation and had higher stage of breast cancer compared with that of FBC. The higher mortality rate in MBC may be due to higher stage and/or tumor biology.
Introduction: Male breast cancer (MBC) comprises < 1% of all cancers in men and continues to rise. Because of MBC rarity, there is paucity in the literature. Management of MBC is generalized from female breast cancer (FBC). The Veterans Affairs Central Cancer Registry (VACCR) provides a unique source for the study of MBC. The objective of this retrospective analysis was to compare and contrast the characteristics and outcomes of MBC with FBC in the VA population.
Methods: VACCR data from 153 VAMCs were used to analyze the database of VA patients who had breast cancer diagnosed between 1998 and 2013. Primary site codes were identified for breast cancer (50.0-50.9). Data were entered and analyzed using biostatistical software (SAS 9.3).
Results: In total, 6,443 patient records were reviewed, and 1,123 MBC patients were compared with 5,320 FBC patients. The mean age at diagnosis was 70 years for MBS and 57 years for FBC (P < .0001). In patients aged > 50 years, higher numbers of MBC diagnosis (95%) were made compared with FBC diagnosis (72%). Seventy-five percent of patients with breast cancer were white in both genders. More MBC patients (40% in men vs 24% in women) presented with higher disease stage (3 and 4) compared with FBC (21% had ductal carcinoma in situ and 53% stage 1). The dominant histology was ductal carcinoma. No difference in laterality was observed. Estrogen and progesterone receptor-positive tumors were more common in MBC compared with FBC. Forty-five percent and 36% of patients with MBC or FBC, respectively, received hormonal treatment as first course, but fewer MBC patients received chemotherapy and radiation. The mean follow up time was 754 days. As of December 2013, 355 (32%) MBC and 791 (15%) FBC patients died during the course of the study. Males had higher odds of death compared with that of females, but when adjusted for age, race, stage, and grade, survival was better among males.
Conclusions: To the authors’ knowledge, this is the largest series of MBC and FBC completed to date in the veteran population. The results suggested that males were older at presentation and had higher stage of breast cancer compared with that of FBC. The higher mortality rate in MBC may be due to higher stage and/or tumor biology.
Creation of a Quality Improvement Tool to Track Timeliness and Quality of Breast Cancer Care
Purpose: Development of a quality improvement (QI) tracking tool that allows staff to monitor care on an ongoing basis and make changes and modify system processes to improve outcomes for breast cancer care. The National Quality Forum (NQF) of the Commission on Cancer and National Consortium of Breast Centers Program (NQMBC) have collaborated and defined breast cancer quality measures. Timeliness and quality of breast cancer care will have a direct impact on quality of life and survivorship. The West Palm Beach VAMC did not have a process in place for data collection and ongoing performance improvement for breast cancer care.
Methods: The major aims of the project are to (1)Identify collaborative team members; (2) identify standardized benchmarks that track timeliness and quality of care; and (3) create a tracking tool to enter data that automatically measures timeliness and quality of care. A collaborative group of staff from the cancer registry, women’s health department, radiology, oncology, pathology, and applied systems engineers met biweekly/monthly over 9 months to add, define, and continuously retest data entry sets within the tool. Several timeliness measures have been identified by the NQMBC. The final measures for our facility were chosen by a multidisciplinary breast cancer committee and approved by the cancer committee. Timeliness measures included (1) time between diagnostic mammogram and open surgical biopsy/excision; (2) time between diagnostic mammogram and needle/core biopsy; (3) time between needle biopsy and initial breast cancer surgery; (4) time between initial breast biopsy (core/needle or incisional/excisional) and pathology results; (5) time between open (incisional/excisional) and pathology results; and (6) time between initial breast cancer surgery and pathology results. Quality measures from the NQF include (1) radiation therapy administration within 1 year of diagnosis; (2) combination chemotherapy considered or administered within 4 months (120 days) of diagnosis; and (3) tamoxifen or third-generation aromatase inhibitor (AI) considered or administered within 4 months (120 days) of diagnosis.
Results: Outcomes for baseline data for n = 30 patients demonstrated (1) time between diagnostic mammogram and open surgical biopsy/excision—52 days; (2) time between diagnostic mammogram and needle/core biopsy—50 days; (3) time between needle biopsy and initial breast cancer surgery—32 days; (4) time between initial breast biopsy (core/needle or incisional/excisional); and (5) pathology results—8 days. Quality measures from the NQF include (1) radiation therapy administration within 1 year of diagnosis—92%; (2) combination chemotherapy considered or administered within 4 months (120 days) of diagnosis—72%; and (3) tamoxifen or third-generation AI is considered or administered within 4 months (120 days) of diagnosis—72%.
Conclusions: Verification of tool data indicated the need for additional columns and definitions to accurately report timeliness measures. Patient refusal of care was included in data, although it skewed the data. Refusal of care will be individually analyzed to make sure patients were educated regarding disease process and scope of treatment options, which indicate informed consent. Facility goals for timeliness range from 2 to 30 days. Quality measure goal is 100%. As a continual evaluation process occurs, monitoring and adjustment of processes will advance our facility closer to meeting its goal of providing comprehensive quality breast care to our women veterans.
Purpose: Development of a quality improvement (QI) tracking tool that allows staff to monitor care on an ongoing basis and make changes and modify system processes to improve outcomes for breast cancer care. The National Quality Forum (NQF) of the Commission on Cancer and National Consortium of Breast Centers Program (NQMBC) have collaborated and defined breast cancer quality measures. Timeliness and quality of breast cancer care will have a direct impact on quality of life and survivorship. The West Palm Beach VAMC did not have a process in place for data collection and ongoing performance improvement for breast cancer care.
Methods: The major aims of the project are to (1)Identify collaborative team members; (2) identify standardized benchmarks that track timeliness and quality of care; and (3) create a tracking tool to enter data that automatically measures timeliness and quality of care. A collaborative group of staff from the cancer registry, women’s health department, radiology, oncology, pathology, and applied systems engineers met biweekly/monthly over 9 months to add, define, and continuously retest data entry sets within the tool. Several timeliness measures have been identified by the NQMBC. The final measures for our facility were chosen by a multidisciplinary breast cancer committee and approved by the cancer committee. Timeliness measures included (1) time between diagnostic mammogram and open surgical biopsy/excision; (2) time between diagnostic mammogram and needle/core biopsy; (3) time between needle biopsy and initial breast cancer surgery; (4) time between initial breast biopsy (core/needle or incisional/excisional) and pathology results; (5) time between open (incisional/excisional) and pathology results; and (6) time between initial breast cancer surgery and pathology results. Quality measures from the NQF include (1) radiation therapy administration within 1 year of diagnosis; (2) combination chemotherapy considered or administered within 4 months (120 days) of diagnosis; and (3) tamoxifen or third-generation aromatase inhibitor (AI) considered or administered within 4 months (120 days) of diagnosis.
Results: Outcomes for baseline data for n = 30 patients demonstrated (1) time between diagnostic mammogram and open surgical biopsy/excision—52 days; (2) time between diagnostic mammogram and needle/core biopsy—50 days; (3) time between needle biopsy and initial breast cancer surgery—32 days; (4) time between initial breast biopsy (core/needle or incisional/excisional); and (5) pathology results—8 days. Quality measures from the NQF include (1) radiation therapy administration within 1 year of diagnosis—92%; (2) combination chemotherapy considered or administered within 4 months (120 days) of diagnosis—72%; and (3) tamoxifen or third-generation AI is considered or administered within 4 months (120 days) of diagnosis—72%.
Conclusions: Verification of tool data indicated the need for additional columns and definitions to accurately report timeliness measures. Patient refusal of care was included in data, although it skewed the data. Refusal of care will be individually analyzed to make sure patients were educated regarding disease process and scope of treatment options, which indicate informed consent. Facility goals for timeliness range from 2 to 30 days. Quality measure goal is 100%. As a continual evaluation process occurs, monitoring and adjustment of processes will advance our facility closer to meeting its goal of providing comprehensive quality breast care to our women veterans.
Purpose: Development of a quality improvement (QI) tracking tool that allows staff to monitor care on an ongoing basis and make changes and modify system processes to improve outcomes for breast cancer care. The National Quality Forum (NQF) of the Commission on Cancer and National Consortium of Breast Centers Program (NQMBC) have collaborated and defined breast cancer quality measures. Timeliness and quality of breast cancer care will have a direct impact on quality of life and survivorship. The West Palm Beach VAMC did not have a process in place for data collection and ongoing performance improvement for breast cancer care.
Methods: The major aims of the project are to (1)Identify collaborative team members; (2) identify standardized benchmarks that track timeliness and quality of care; and (3) create a tracking tool to enter data that automatically measures timeliness and quality of care. A collaborative group of staff from the cancer registry, women’s health department, radiology, oncology, pathology, and applied systems engineers met biweekly/monthly over 9 months to add, define, and continuously retest data entry sets within the tool. Several timeliness measures have been identified by the NQMBC. The final measures for our facility were chosen by a multidisciplinary breast cancer committee and approved by the cancer committee. Timeliness measures included (1) time between diagnostic mammogram and open surgical biopsy/excision; (2) time between diagnostic mammogram and needle/core biopsy; (3) time between needle biopsy and initial breast cancer surgery; (4) time between initial breast biopsy (core/needle or incisional/excisional) and pathology results; (5) time between open (incisional/excisional) and pathology results; and (6) time between initial breast cancer surgery and pathology results. Quality measures from the NQF include (1) radiation therapy administration within 1 year of diagnosis; (2) combination chemotherapy considered or administered within 4 months (120 days) of diagnosis; and (3) tamoxifen or third-generation aromatase inhibitor (AI) considered or administered within 4 months (120 days) of diagnosis.
Results: Outcomes for baseline data for n = 30 patients demonstrated (1) time between diagnostic mammogram and open surgical biopsy/excision—52 days; (2) time between diagnostic mammogram and needle/core biopsy—50 days; (3) time between needle biopsy and initial breast cancer surgery—32 days; (4) time between initial breast biopsy (core/needle or incisional/excisional); and (5) pathology results—8 days. Quality measures from the NQF include (1) radiation therapy administration within 1 year of diagnosis—92%; (2) combination chemotherapy considered or administered within 4 months (120 days) of diagnosis—72%; and (3) tamoxifen or third-generation AI is considered or administered within 4 months (120 days) of diagnosis—72%.
Conclusions: Verification of tool data indicated the need for additional columns and definitions to accurately report timeliness measures. Patient refusal of care was included in data, although it skewed the data. Refusal of care will be individually analyzed to make sure patients were educated regarding disease process and scope of treatment options, which indicate informed consent. Facility goals for timeliness range from 2 to 30 days. Quality measure goal is 100%. As a continual evaluation process occurs, monitoring and adjustment of processes will advance our facility closer to meeting its goal of providing comprehensive quality breast care to our women veterans.
Geographic Distribution of Rural-Urban Status of Women With Breast Cancer in Veterans Health Administration, Using 2 Plans: Rural Urban Continuum and Rural Urban Commuting Areas
Purpose: Women with breast cancer (BC) are increasingly diagnosed and treated within the VHA. Breast cancer requires specialized care in tertiary settings such as VAMCs, typically located in urban settings, placing BC patients in rural areas at a disadvantage. Assigning rural-urban status is complicated by the presence of multiple classification plans. In this report, we compare rural-urban status of BC patients in the VHA and its association with distance to nearest VAMC, using 2 plans: USDA Economic Research Service (ERS) Rural Urban Continuum (RUC) and University of Washington’s Rural Urban Commuting Areas 2.0 (RUCA).
Methods: Between 2000 and 2012, 3,622 women were diagnosed with and/or treated for BC within the VHA and recorded in the VA Central Cancer Registry (VA CCR). The patient’s zip code of residence at the time of diagnosis and rural-urban status according to USDA ERS RUC were obtained from the VA CCR. Rural urban commuting status was aggregated into 3 categories: metropolitan, large nonmetropolitan, and rural. Using zip code of residence, rural-urban status of all but 63 women was determined using the University of Washington’s (RUCA) plan and aggregated into 3 categories: urban (metropolitan), large rural or micropolitan, and small rural/isolated small rural. The VHA is organized into 21 regional administrative service networks, or VISNs. The geographic distribution of BC in VHA was determined using the RUC and RUCA scheme, then reported by VISN Census Bureau geographic region: Northeast, Midwest, South, and West. The two plans were compared, using Cohen’s Kappa statistic. The distance between zip code of residence and the nearest within-VISN VAMC was obtained from the VA Planning Systems Support Group database. The association between rural-urban status according to RUC and RUCA and the distance to the nearest VAMC was determined using analysis of variance (ANOVA).
Results: Rural-urban status according to RUC and RUCA were strongly associated (Cohen’s Kappa 0.74, P < .001). About 80% of women with BC in VHA resided in metropolitan areas; the remaining women were split evenly between large nonmetropolitan/micropolitan and rural/small, isolated rural. The Midwest had the highest percentages of both large rural (14%) and small/isolated rural patients (17%), whereas patients in the Northeast had the smallest percentages of large rural (8%) and small/isolated rural patients (7%). Patients living in the Northeast had the shortest travel distances to the nearest within-VISN VAMC, whereas patients in the West had the longest distances. In the Northeast, the average distance to nearest VAMC increased from 11 miles for patients living in metropolitan areas, to 44 miles in small/isolated rural areas. In the West, patients living in metropolitan areas were on average, 37 miles from nearest VAMC. This increased to 124 miles for patients in small/isolated rural areas in the West. Both classifications were significantly associated with increased distance to nearest VAMC (P < .001). On multivariate analysis, rural residence remained significantly associated with increased distance to nearest VAMC (P = .01) even after adjusting for RUCA.
Conclusions: Women with BC living in rural areas must travel longer distances to their VHA facility to receive specialized cancer care. Various plans define rural-urban status, using different methodologies. The rural-urban status of women with BC in VHA was similar using either RUC or RUCA. Rural residence defined by RUC was significantly associated with longer distances to VAMC even after adjusting for RUCA. This suggests that the 2 methodologies are not identical but are highly related when being compared with distance from tertiary care. The choice of rural classification methodology should be considered carefully when researching rural status and cancer outcomes.
Purpose: Women with breast cancer (BC) are increasingly diagnosed and treated within the VHA. Breast cancer requires specialized care in tertiary settings such as VAMCs, typically located in urban settings, placing BC patients in rural areas at a disadvantage. Assigning rural-urban status is complicated by the presence of multiple classification plans. In this report, we compare rural-urban status of BC patients in the VHA and its association with distance to nearest VAMC, using 2 plans: USDA Economic Research Service (ERS) Rural Urban Continuum (RUC) and University of Washington’s Rural Urban Commuting Areas 2.0 (RUCA).
Methods: Between 2000 and 2012, 3,622 women were diagnosed with and/or treated for BC within the VHA and recorded in the VA Central Cancer Registry (VA CCR). The patient’s zip code of residence at the time of diagnosis and rural-urban status according to USDA ERS RUC were obtained from the VA CCR. Rural urban commuting status was aggregated into 3 categories: metropolitan, large nonmetropolitan, and rural. Using zip code of residence, rural-urban status of all but 63 women was determined using the University of Washington’s (RUCA) plan and aggregated into 3 categories: urban (metropolitan), large rural or micropolitan, and small rural/isolated small rural. The VHA is organized into 21 regional administrative service networks, or VISNs. The geographic distribution of BC in VHA was determined using the RUC and RUCA scheme, then reported by VISN Census Bureau geographic region: Northeast, Midwest, South, and West. The two plans were compared, using Cohen’s Kappa statistic. The distance between zip code of residence and the nearest within-VISN VAMC was obtained from the VA Planning Systems Support Group database. The association between rural-urban status according to RUC and RUCA and the distance to the nearest VAMC was determined using analysis of variance (ANOVA).
Results: Rural-urban status according to RUC and RUCA were strongly associated (Cohen’s Kappa 0.74, P < .001). About 80% of women with BC in VHA resided in metropolitan areas; the remaining women were split evenly between large nonmetropolitan/micropolitan and rural/small, isolated rural. The Midwest had the highest percentages of both large rural (14%) and small/isolated rural patients (17%), whereas patients in the Northeast had the smallest percentages of large rural (8%) and small/isolated rural patients (7%). Patients living in the Northeast had the shortest travel distances to the nearest within-VISN VAMC, whereas patients in the West had the longest distances. In the Northeast, the average distance to nearest VAMC increased from 11 miles for patients living in metropolitan areas, to 44 miles in small/isolated rural areas. In the West, patients living in metropolitan areas were on average, 37 miles from nearest VAMC. This increased to 124 miles for patients in small/isolated rural areas in the West. Both classifications were significantly associated with increased distance to nearest VAMC (P < .001). On multivariate analysis, rural residence remained significantly associated with increased distance to nearest VAMC (P = .01) even after adjusting for RUCA.
Conclusions: Women with BC living in rural areas must travel longer distances to their VHA facility to receive specialized cancer care. Various plans define rural-urban status, using different methodologies. The rural-urban status of women with BC in VHA was similar using either RUC or RUCA. Rural residence defined by RUC was significantly associated with longer distances to VAMC even after adjusting for RUCA. This suggests that the 2 methodologies are not identical but are highly related when being compared with distance from tertiary care. The choice of rural classification methodology should be considered carefully when researching rural status and cancer outcomes.
Purpose: Women with breast cancer (BC) are increasingly diagnosed and treated within the VHA. Breast cancer requires specialized care in tertiary settings such as VAMCs, typically located in urban settings, placing BC patients in rural areas at a disadvantage. Assigning rural-urban status is complicated by the presence of multiple classification plans. In this report, we compare rural-urban status of BC patients in the VHA and its association with distance to nearest VAMC, using 2 plans: USDA Economic Research Service (ERS) Rural Urban Continuum (RUC) and University of Washington’s Rural Urban Commuting Areas 2.0 (RUCA).
Methods: Between 2000 and 2012, 3,622 women were diagnosed with and/or treated for BC within the VHA and recorded in the VA Central Cancer Registry (VA CCR). The patient’s zip code of residence at the time of diagnosis and rural-urban status according to USDA ERS RUC were obtained from the VA CCR. Rural urban commuting status was aggregated into 3 categories: metropolitan, large nonmetropolitan, and rural. Using zip code of residence, rural-urban status of all but 63 women was determined using the University of Washington’s (RUCA) plan and aggregated into 3 categories: urban (metropolitan), large rural or micropolitan, and small rural/isolated small rural. The VHA is organized into 21 regional administrative service networks, or VISNs. The geographic distribution of BC in VHA was determined using the RUC and RUCA scheme, then reported by VISN Census Bureau geographic region: Northeast, Midwest, South, and West. The two plans were compared, using Cohen’s Kappa statistic. The distance between zip code of residence and the nearest within-VISN VAMC was obtained from the VA Planning Systems Support Group database. The association between rural-urban status according to RUC and RUCA and the distance to the nearest VAMC was determined using analysis of variance (ANOVA).
Results: Rural-urban status according to RUC and RUCA were strongly associated (Cohen’s Kappa 0.74, P < .001). About 80% of women with BC in VHA resided in metropolitan areas; the remaining women were split evenly between large nonmetropolitan/micropolitan and rural/small, isolated rural. The Midwest had the highest percentages of both large rural (14%) and small/isolated rural patients (17%), whereas patients in the Northeast had the smallest percentages of large rural (8%) and small/isolated rural patients (7%). Patients living in the Northeast had the shortest travel distances to the nearest within-VISN VAMC, whereas patients in the West had the longest distances. In the Northeast, the average distance to nearest VAMC increased from 11 miles for patients living in metropolitan areas, to 44 miles in small/isolated rural areas. In the West, patients living in metropolitan areas were on average, 37 miles from nearest VAMC. This increased to 124 miles for patients in small/isolated rural areas in the West. Both classifications were significantly associated with increased distance to nearest VAMC (P < .001). On multivariate analysis, rural residence remained significantly associated with increased distance to nearest VAMC (P = .01) even after adjusting for RUCA.
Conclusions: Women with BC living in rural areas must travel longer distances to their VHA facility to receive specialized cancer care. Various plans define rural-urban status, using different methodologies. The rural-urban status of women with BC in VHA was similar using either RUC or RUCA. Rural residence defined by RUC was significantly associated with longer distances to VAMC even after adjusting for RUCA. This suggests that the 2 methodologies are not identical but are highly related when being compared with distance from tertiary care. The choice of rural classification methodology should be considered carefully when researching rural status and cancer outcomes.
Locoregional recurrence of breast cancer less likely after neoadjuvant complete response
Patients with residual disease after neoadjuvant chemotherapy and surgery for breast cancer had a 60%-280% increased risk for locoregional recurrence, compared with patients with a pathologic complete response, an analysis of data from 12 large clinical trials found.
Investigators analyzed data on 11,955 patients with stage I-III breast cancer who underwent neoadjuvant chemotherapy in studies with long-term follow-up and information on complete pathologic response (no residual cancer in the breast and no cancer in the axillary lymph nodes after surgery). They included 5,252 patients in a multivariate analysis of predictors of locoregional recurrence a median of 5 years after treatment.
Overall, the likelihood of locoregional recurrence was low – less than 10%. Locoregional recurrence was seen in 5.5% of patients with a complete pathologic response to neoadjuvant chemotherapy and in 7.1% of patients without a complete response, a significant 60% increase in risk without a complete response, Dr. Eleftherios Mamounas reported in a press briefing held in advance of the breast cancer symposium sponsored by the American Society of Clinical Oncology.
Patients with residual cancer in the breast after surgery had a 60% higher risk for locoregional recurrence, and patients with residual cancer in the axillary lymph nodes had a 280% increased risk for locoregional recurrence, compared with patients who had a complete pathologic response, reported Dr. Mamounas, professor of surgery at the University of Central Florida, and medical director of the comprehensive breast program at the University of Florida Health Cancer Center, both in Orlando.
Breast cancer subtypes remained independent predictors of locoregional recurrence, regardless of whether patients had a pathologic complete response or not. The cancer recurred locally or regionally in 4% of patients with hormone receptor–positive, human epidermal growth factor receptor 2–negative (HR+/HER2–) grade 1 or 2 cancer, 9% of patients with HR+/HER2– grade 3 cancer, 15% of patients with HR–/HER2+ cancer, 10% of patients with HR+/HER2+ cancer, and 12% of patients with HR–/HER2– cancer (also known as hormone receptor–negative or triple-negative breast cancer).
Those rates would be different today because of more effective treatments for HER2+ breast cancer, he noted.
"For all breast cancer subtypes except for HR+/HER2– grade 1 and 2, there was a progressive increase in the locoregional recurrence rates with decreasing rates of pathologic complete response," he said. In other words, recurrence rates went from highest to lowest in patients "having positive nodes, versus having residual disease in the breast with negative nodes, versus having complete pathologic response," he explained.
Among patients with triple-negative cancer, for example, locoregional recurrence rates went from 6.2% in those with a complete response to 11.9% in patients with residual cancer in the breast but not lymph nodes and 22.1% in those who had positive nodes after treatment.
A pathologic complete response predicted lower locoregional recurrence rates with the various cancer subtypes, regardless of whether the patient underwent lumpectomy or mastectomy, he said.
Based on these results and previously published studies, "we have a lot of evidence that pathologic complete response is predictive of outcome, both in terms of systemic recurrence and also in terms of local recurrence," Dr. Mamounas commented. A previous meta-analysis that reported conflicting results for systemic recurrence "did not quite confirm that an incremental increase in pathologic complete response will improve overall survival, but there are a lot of technical issues if you look at the different studies that were included in the meta-analysis. The bar was very high to prove that concept."
Recurrence is less likely after a pathologic complete response in patients with HER2+ breast cancer, triple-negative cancer, or highly proliferative estrogen receptor–positive breast cancer, he said. That may not be the case for patients with estrogen receptor–positive, HER2– grade 1 disease, who do very well regardless, he added.
"Our findings have clinical implications relative to further tailoring the use of adjuvant radiation therapy after neoadjuvant chemotherapy and support the conduct of ongoing clinical trials attempting to tailor locoregional therapy in this setting," Dr. Mamounas said.
Dr. Mamounas reported financial associations with Genomic Health, GE Healthcare, Celgene, Pfizer, Eisai, and Genentech/Roche. Some of his coinvestigators reported associations with multiple companies.
On Twitter @sherryboschert
This is a group of women who have higher-than-average risk, such that they are being offered up-front chemotherapy to shrink cancers even before they would go for breast surgery.
We’ve known for a long time that this clinical endpoint of complete pathologic response – that is, when you do the breast surgery, there is no evidence of residual cancer – is a powerful predictor of the cancer not recurring somewhere else in the body. These data from Dr. Mamounas show that complete pathologic response also is a predictor for not having the cancer recur within the chest wall or the breast itself. That’s very important information for the clinical team.
|
|
Dr. Mamounas’s data also point to the idea that the breast cancer subtype is very important for predicting the outcomes. In the modern era, so much of what we are thinking about in the way of managing breast cancer is driven by our understanding of these major clinical subtypes, the so-called HER2-positive breast cancers, the so-called triple-negative breast cancers (which lack estrogen receptor, progesterone receptor, and HER2), and finally the spectrum of so-called estrogen receptor–positive, HER2-negative (sometimes called luminal) cancers.
What Dr. Mamounas’s data speak to is a very complicated matrix that helps us understand the risk of local recurrence in a woman who has a greater-than-average risk of breast cancer by factoring in the type of breast cancer, the response that you see with the up-front chemotherapy, and the age of the patient. These multiplex kinds of information set the stage for a variety of trials that are looking at trying to tailor additional therapy for women who are at higher risk and, conversely, sparing women who are at lower risk the need for extra treatment – in this case, possibly the need for radiation therapy.
These are data that really resonate with radiation oncologists, surgeons, and medical oncologists, who are into the nitty-gritty of caring for women with breast cancer and need to determine who is going to need more therapy and who can be spared additional treatment.
Dr. Harold J. Burstein is associate professor of medicine at Harvard Medical School and the Dana-Farber Cancer Institute, both in Boston. He reported having no relevant financial disclosures.
This is a group of women who have higher-than-average risk, such that they are being offered up-front chemotherapy to shrink cancers even before they would go for breast surgery.
We’ve known for a long time that this clinical endpoint of complete pathologic response – that is, when you do the breast surgery, there is no evidence of residual cancer – is a powerful predictor of the cancer not recurring somewhere else in the body. These data from Dr. Mamounas show that complete pathologic response also is a predictor for not having the cancer recur within the chest wall or the breast itself. That’s very important information for the clinical team.
|
|
|
Dr. Mamounas’s data also point to the idea that the breast cancer subtype is very important for predicting the outcomes. In the modern era, so much of what we are thinking about in the way of managing breast cancer is driven by our understanding of these major clinical subtypes, the so-called HER2-positive breast cancers, the so-called triple-negative breast cancers (which lack estrogen receptor, progesterone receptor, and HER2), and finally the spectrum of so-called estrogen receptor–positive, HER2-negative (sometimes called luminal) cancers.
What Dr. Mamounas’s data speak to is a very complicated matrix that helps us understand the risk of local recurrence in a woman who has a greater-than-average risk of breast cancer by factoring in the type of breast cancer, the response that you see with the up-front chemotherapy, and the age of the patient. These multiplex kinds of information set the stage for a variety of trials that are looking at trying to tailor additional therapy for women who are at higher risk and, conversely, sparing women who are at lower risk the need for extra treatment – in this case, possibly the need for radiation therapy.
These are data that really resonate with radiation oncologists, surgeons, and medical oncologists, who are into the nitty-gritty of caring for women with breast cancer and need to determine who is going to need more therapy and who can be spared additional treatment.
Dr. Harold J. Burstein is associate professor of medicine at Harvard Medical School and the Dana-Farber Cancer Institute, both in Boston. He reported having no relevant financial disclosures.
This is a group of women who have higher-than-average risk, such that they are being offered up-front chemotherapy to shrink cancers even before they would go for breast surgery.
We’ve known for a long time that this clinical endpoint of complete pathologic response – that is, when you do the breast surgery, there is no evidence of residual cancer – is a powerful predictor of the cancer not recurring somewhere else in the body. These data from Dr. Mamounas show that complete pathologic response also is a predictor for not having the cancer recur within the chest wall or the breast itself. That’s very important information for the clinical team.
|
|
|
Dr. Mamounas’s data also point to the idea that the breast cancer subtype is very important for predicting the outcomes. In the modern era, so much of what we are thinking about in the way of managing breast cancer is driven by our understanding of these major clinical subtypes, the so-called HER2-positive breast cancers, the so-called triple-negative breast cancers (which lack estrogen receptor, progesterone receptor, and HER2), and finally the spectrum of so-called estrogen receptor–positive, HER2-negative (sometimes called luminal) cancers.
What Dr. Mamounas’s data speak to is a very complicated matrix that helps us understand the risk of local recurrence in a woman who has a greater-than-average risk of breast cancer by factoring in the type of breast cancer, the response that you see with the up-front chemotherapy, and the age of the patient. These multiplex kinds of information set the stage for a variety of trials that are looking at trying to tailor additional therapy for women who are at higher risk and, conversely, sparing women who are at lower risk the need for extra treatment – in this case, possibly the need for radiation therapy.
These are data that really resonate with radiation oncologists, surgeons, and medical oncologists, who are into the nitty-gritty of caring for women with breast cancer and need to determine who is going to need more therapy and who can be spared additional treatment.
Dr. Harold J. Burstein is associate professor of medicine at Harvard Medical School and the Dana-Farber Cancer Institute, both in Boston. He reported having no relevant financial disclosures.
Patients with residual disease after neoadjuvant chemotherapy and surgery for breast cancer had a 60%-280% increased risk for locoregional recurrence, compared with patients with a pathologic complete response, an analysis of data from 12 large clinical trials found.
Investigators analyzed data on 11,955 patients with stage I-III breast cancer who underwent neoadjuvant chemotherapy in studies with long-term follow-up and information on complete pathologic response (no residual cancer in the breast and no cancer in the axillary lymph nodes after surgery). They included 5,252 patients in a multivariate analysis of predictors of locoregional recurrence a median of 5 years after treatment.
Overall, the likelihood of locoregional recurrence was low – less than 10%. Locoregional recurrence was seen in 5.5% of patients with a complete pathologic response to neoadjuvant chemotherapy and in 7.1% of patients without a complete response, a significant 60% increase in risk without a complete response, Dr. Eleftherios Mamounas reported in a press briefing held in advance of the breast cancer symposium sponsored by the American Society of Clinical Oncology.
Patients with residual cancer in the breast after surgery had a 60% higher risk for locoregional recurrence, and patients with residual cancer in the axillary lymph nodes had a 280% increased risk for locoregional recurrence, compared with patients who had a complete pathologic response, reported Dr. Mamounas, professor of surgery at the University of Central Florida, and medical director of the comprehensive breast program at the University of Florida Health Cancer Center, both in Orlando.
Breast cancer subtypes remained independent predictors of locoregional recurrence, regardless of whether patients had a pathologic complete response or not. The cancer recurred locally or regionally in 4% of patients with hormone receptor–positive, human epidermal growth factor receptor 2–negative (HR+/HER2–) grade 1 or 2 cancer, 9% of patients with HR+/HER2– grade 3 cancer, 15% of patients with HR–/HER2+ cancer, 10% of patients with HR+/HER2+ cancer, and 12% of patients with HR–/HER2– cancer (also known as hormone receptor–negative or triple-negative breast cancer).
Those rates would be different today because of more effective treatments for HER2+ breast cancer, he noted.
"For all breast cancer subtypes except for HR+/HER2– grade 1 and 2, there was a progressive increase in the locoregional recurrence rates with decreasing rates of pathologic complete response," he said. In other words, recurrence rates went from highest to lowest in patients "having positive nodes, versus having residual disease in the breast with negative nodes, versus having complete pathologic response," he explained.
Among patients with triple-negative cancer, for example, locoregional recurrence rates went from 6.2% in those with a complete response to 11.9% in patients with residual cancer in the breast but not lymph nodes and 22.1% in those who had positive nodes after treatment.
A pathologic complete response predicted lower locoregional recurrence rates with the various cancer subtypes, regardless of whether the patient underwent lumpectomy or mastectomy, he said.
Based on these results and previously published studies, "we have a lot of evidence that pathologic complete response is predictive of outcome, both in terms of systemic recurrence and also in terms of local recurrence," Dr. Mamounas commented. A previous meta-analysis that reported conflicting results for systemic recurrence "did not quite confirm that an incremental increase in pathologic complete response will improve overall survival, but there are a lot of technical issues if you look at the different studies that were included in the meta-analysis. The bar was very high to prove that concept."
Recurrence is less likely after a pathologic complete response in patients with HER2+ breast cancer, triple-negative cancer, or highly proliferative estrogen receptor–positive breast cancer, he said. That may not be the case for patients with estrogen receptor–positive, HER2– grade 1 disease, who do very well regardless, he added.
"Our findings have clinical implications relative to further tailoring the use of adjuvant radiation therapy after neoadjuvant chemotherapy and support the conduct of ongoing clinical trials attempting to tailor locoregional therapy in this setting," Dr. Mamounas said.
Dr. Mamounas reported financial associations with Genomic Health, GE Healthcare, Celgene, Pfizer, Eisai, and Genentech/Roche. Some of his coinvestigators reported associations with multiple companies.
On Twitter @sherryboschert
Patients with residual disease after neoadjuvant chemotherapy and surgery for breast cancer had a 60%-280% increased risk for locoregional recurrence, compared with patients with a pathologic complete response, an analysis of data from 12 large clinical trials found.
Investigators analyzed data on 11,955 patients with stage I-III breast cancer who underwent neoadjuvant chemotherapy in studies with long-term follow-up and information on complete pathologic response (no residual cancer in the breast and no cancer in the axillary lymph nodes after surgery). They included 5,252 patients in a multivariate analysis of predictors of locoregional recurrence a median of 5 years after treatment.
Overall, the likelihood of locoregional recurrence was low – less than 10%. Locoregional recurrence was seen in 5.5% of patients with a complete pathologic response to neoadjuvant chemotherapy and in 7.1% of patients without a complete response, a significant 60% increase in risk without a complete response, Dr. Eleftherios Mamounas reported in a press briefing held in advance of the breast cancer symposium sponsored by the American Society of Clinical Oncology.
Patients with residual cancer in the breast after surgery had a 60% higher risk for locoregional recurrence, and patients with residual cancer in the axillary lymph nodes had a 280% increased risk for locoregional recurrence, compared with patients who had a complete pathologic response, reported Dr. Mamounas, professor of surgery at the University of Central Florida, and medical director of the comprehensive breast program at the University of Florida Health Cancer Center, both in Orlando.
Breast cancer subtypes remained independent predictors of locoregional recurrence, regardless of whether patients had a pathologic complete response or not. The cancer recurred locally or regionally in 4% of patients with hormone receptor–positive, human epidermal growth factor receptor 2–negative (HR+/HER2–) grade 1 or 2 cancer, 9% of patients with HR+/HER2– grade 3 cancer, 15% of patients with HR–/HER2+ cancer, 10% of patients with HR+/HER2+ cancer, and 12% of patients with HR–/HER2– cancer (also known as hormone receptor–negative or triple-negative breast cancer).
Those rates would be different today because of more effective treatments for HER2+ breast cancer, he noted.
"For all breast cancer subtypes except for HR+/HER2– grade 1 and 2, there was a progressive increase in the locoregional recurrence rates with decreasing rates of pathologic complete response," he said. In other words, recurrence rates went from highest to lowest in patients "having positive nodes, versus having residual disease in the breast with negative nodes, versus having complete pathologic response," he explained.
Among patients with triple-negative cancer, for example, locoregional recurrence rates went from 6.2% in those with a complete response to 11.9% in patients with residual cancer in the breast but not lymph nodes and 22.1% in those who had positive nodes after treatment.
A pathologic complete response predicted lower locoregional recurrence rates with the various cancer subtypes, regardless of whether the patient underwent lumpectomy or mastectomy, he said.
Based on these results and previously published studies, "we have a lot of evidence that pathologic complete response is predictive of outcome, both in terms of systemic recurrence and also in terms of local recurrence," Dr. Mamounas commented. A previous meta-analysis that reported conflicting results for systemic recurrence "did not quite confirm that an incremental increase in pathologic complete response will improve overall survival, but there are a lot of technical issues if you look at the different studies that were included in the meta-analysis. The bar was very high to prove that concept."
Recurrence is less likely after a pathologic complete response in patients with HER2+ breast cancer, triple-negative cancer, or highly proliferative estrogen receptor–positive breast cancer, he said. That may not be the case for patients with estrogen receptor–positive, HER2– grade 1 disease, who do very well regardless, he added.
"Our findings have clinical implications relative to further tailoring the use of adjuvant radiation therapy after neoadjuvant chemotherapy and support the conduct of ongoing clinical trials attempting to tailor locoregional therapy in this setting," Dr. Mamounas said.
Dr. Mamounas reported financial associations with Genomic Health, GE Healthcare, Celgene, Pfizer, Eisai, and Genentech/Roche. Some of his coinvestigators reported associations with multiple companies.
On Twitter @sherryboschert
FROM THE ASCO BREAST CANCER SYMPOSIUM
Key clinical point: Response to neoadjuvant chemotherapy for breast cancer predicts the locoregional recurrence risk.
Major finding: Risk for locoregional recurrence was 60%-280% higher in patients without a pathologic complete response.
Data source: A pooled analysis of data on 11,955 patients who got neoadjuvant therapy and surgery for stage I-III breast cancer.
Disclosures: Dr. Mamounas reported financial associations with Genomic Health, GE Healthcare, Celgene, Pfizer, Eisai, and Genentech/Roche. Some of his coinvestigators reported associations with multiple companies.
Extending Therapy for Breast Cancer
Laronna Colbert, MD, discusses how recent breast cancer studies "have the potential to change current practice standards" for breast cancer.
"This is really a dynamic field of study," Colbert said during her 2013 AVAHO Meeting presentation. "Hopefully, we can continue to make advancements for these patients."
Laronna Colbert, MD, discusses how recent breast cancer studies "have the potential to change current practice standards" for breast cancer.
"This is really a dynamic field of study," Colbert said during her 2013 AVAHO Meeting presentation. "Hopefully, we can continue to make advancements for these patients."
Laronna Colbert, MD, discusses how recent breast cancer studies "have the potential to change current practice standards" for breast cancer.
"This is really a dynamic field of study," Colbert said during her 2013 AVAHO Meeting presentation. "Hopefully, we can continue to make advancements for these patients."
No mortality benefit from bilateral mastectomy, vs. breast-conserving surgery with radiation
The use of bilateral mastectomy has increased significantly in California, but the results from an observational cohort study show it achieves similar mortality reductions to breast-conserving surgery plus radiation, while unilateral mastectomy is associated with higher mortality.
In an analysis of data from nearly 190,000 patients in the population-based California Cancer Registry, no significant differences were found in all-cause mortality between patients who underwent bilateral mastectomy and those who had breast-conserving surgery with radiation (HR, 1.02 [95%CI, 0.94-1.11]); however, unilateral mastectomy was linked to 35% higher all-cause mortality than was breast-conserving surgery with radiation (HR, 1.35 [95% CI, 1.32-1.39]).
Dr. Allison W. Kurian of Stanford (Calif.)University and colleagues also found the rate of bilateral mastectomy had increased 14.3% each year, from 2% of all patients in 1998 to 12.3% in 2011, with it more commonly used among non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute–designated cancer center, according to a paper published Sept. 2 in JAMA [doi:10.1001/jama.2014.10707].
"In a time of increasing concern over treatment, the risk-benefit ratio of bilateral mastectomy warrants careful consideration and raises the larger question of how physicians and society should respond to a patient’s preference for a morbid, costly intervention of dubious effectiveness," the authors wrote.
In an accompanying editorial, Dr. Lisa A. Newman of the comprehensive cancer center, University of Michigan, Ann Arbor, said the findings refute patient assumptions that bilateral mastectomy represents their best chance for a cure, and for eliminating the perceived cancer threat to the unaffected breast, and advocated a more calm and considered approach to treatment decision making (JAMA 2014 Sept. 2 [doi:10.1001/jama.2014.11308]).
"Physicians should not permit excessive treatment delays to compromise outcomes, but the initial few weeks surrounding the diagnosis are more effectively utilized by time invested in patient education and procedures that contribute to comprehensive treatment planning as opposed to hastily coordinating impulsive, irreversible surgical plans," Dr. Newman wrote.
The study was supported by the Jan Weimer Junior Faculty Chair in Breast Oncology, the Suzanne Pride Bryan Fund for Breast Cancer Research at Stanford Cancer Institute, and the National Cancer Institute. Two authors reported grants from Genentech for other work, but there were no other conflicts of interest disclosed.
The use of bilateral mastectomy has increased significantly in California, but the results from an observational cohort study show it achieves similar mortality reductions to breast-conserving surgery plus radiation, while unilateral mastectomy is associated with higher mortality.
In an analysis of data from nearly 190,000 patients in the population-based California Cancer Registry, no significant differences were found in all-cause mortality between patients who underwent bilateral mastectomy and those who had breast-conserving surgery with radiation (HR, 1.02 [95%CI, 0.94-1.11]); however, unilateral mastectomy was linked to 35% higher all-cause mortality than was breast-conserving surgery with radiation (HR, 1.35 [95% CI, 1.32-1.39]).
Dr. Allison W. Kurian of Stanford (Calif.)University and colleagues also found the rate of bilateral mastectomy had increased 14.3% each year, from 2% of all patients in 1998 to 12.3% in 2011, with it more commonly used among non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute–designated cancer center, according to a paper published Sept. 2 in JAMA [doi:10.1001/jama.2014.10707].
"In a time of increasing concern over treatment, the risk-benefit ratio of bilateral mastectomy warrants careful consideration and raises the larger question of how physicians and society should respond to a patient’s preference for a morbid, costly intervention of dubious effectiveness," the authors wrote.
In an accompanying editorial, Dr. Lisa A. Newman of the comprehensive cancer center, University of Michigan, Ann Arbor, said the findings refute patient assumptions that bilateral mastectomy represents their best chance for a cure, and for eliminating the perceived cancer threat to the unaffected breast, and advocated a more calm and considered approach to treatment decision making (JAMA 2014 Sept. 2 [doi:10.1001/jama.2014.11308]).
"Physicians should not permit excessive treatment delays to compromise outcomes, but the initial few weeks surrounding the diagnosis are more effectively utilized by time invested in patient education and procedures that contribute to comprehensive treatment planning as opposed to hastily coordinating impulsive, irreversible surgical plans," Dr. Newman wrote.
The study was supported by the Jan Weimer Junior Faculty Chair in Breast Oncology, the Suzanne Pride Bryan Fund for Breast Cancer Research at Stanford Cancer Institute, and the National Cancer Institute. Two authors reported grants from Genentech for other work, but there were no other conflicts of interest disclosed.
The use of bilateral mastectomy has increased significantly in California, but the results from an observational cohort study show it achieves similar mortality reductions to breast-conserving surgery plus radiation, while unilateral mastectomy is associated with higher mortality.
In an analysis of data from nearly 190,000 patients in the population-based California Cancer Registry, no significant differences were found in all-cause mortality between patients who underwent bilateral mastectomy and those who had breast-conserving surgery with radiation (HR, 1.02 [95%CI, 0.94-1.11]); however, unilateral mastectomy was linked to 35% higher all-cause mortality than was breast-conserving surgery with radiation (HR, 1.35 [95% CI, 1.32-1.39]).
Dr. Allison W. Kurian of Stanford (Calif.)University and colleagues also found the rate of bilateral mastectomy had increased 14.3% each year, from 2% of all patients in 1998 to 12.3% in 2011, with it more commonly used among non-Hispanic white women, those with private insurance, and those who received care at a National Cancer Institute–designated cancer center, according to a paper published Sept. 2 in JAMA [doi:10.1001/jama.2014.10707].
"In a time of increasing concern over treatment, the risk-benefit ratio of bilateral mastectomy warrants careful consideration and raises the larger question of how physicians and society should respond to a patient’s preference for a morbid, costly intervention of dubious effectiveness," the authors wrote.
In an accompanying editorial, Dr. Lisa A. Newman of the comprehensive cancer center, University of Michigan, Ann Arbor, said the findings refute patient assumptions that bilateral mastectomy represents their best chance for a cure, and for eliminating the perceived cancer threat to the unaffected breast, and advocated a more calm and considered approach to treatment decision making (JAMA 2014 Sept. 2 [doi:10.1001/jama.2014.11308]).
"Physicians should not permit excessive treatment delays to compromise outcomes, but the initial few weeks surrounding the diagnosis are more effectively utilized by time invested in patient education and procedures that contribute to comprehensive treatment planning as opposed to hastily coordinating impulsive, irreversible surgical plans," Dr. Newman wrote.
The study was supported by the Jan Weimer Junior Faculty Chair in Breast Oncology, the Suzanne Pride Bryan Fund for Breast Cancer Research at Stanford Cancer Institute, and the National Cancer Institute. Two authors reported grants from Genentech for other work, but there were no other conflicts of interest disclosed.
FROM JAMA
Key clinical point: There is no mortality benefit associated with bilateral mastectomy, compared with breast-conserving surgery, and a higher mortality associated uniquely with unilateral mastectomy.
Major finding: Compared with breast-conserving surgery with radiation, bilateral mastectomy was not associated with a mortality difference (HR, 1.02 [95%CI, 0.94-1.11]), whereas unilateral mastectomy was associated with higher mortality (HR, 1.35 [95% CI, 1.32-1.39]).
Data source: An observational cohort study using data from 189,734 patients in the population-based California Cancer Registry.
Disclosures: The study was supported by the Jan Weimer Junior Faculty Chair in Breast Oncology, the Suzanne Pride Bryan Fund for Breast Cancer Research at Stanford Cancer Institute, and the National Cancer Institute. Two authors reported grants from Genentech for other work, but there were no other conflicts of interest disclosed.
For advanced HER2-negative breast cancer, no best treatment
A new evidence-based practice guideline from the American Society of Clinical Oncology on treating women with advanced breast cancer that is negative for human epidermal growth factor receptor 2 emphasizes that "optimal" chemotherapy regimens may vary considerably between patients.
When choosing treatment for an individual with HER2-negative breast cancer, consider not only the potential efficacy of a therapy but also the potential toxicity, the patient’s performance status and comorbid conditions, history of prior therapy, whether the cancer is indolent or immediately life threatening, and the patient’s preferences and schedule, the guideline states.
That said, the guideline on "Chemotherapy and Targeted Therapy for Women with Human Epidermal Growth Factor Receptor 2-Negative (or unknown) Advanced Breast Cancer" offers some specific recommendations (J. Clin. Oncol. 2014 Sept. 2 [doi:10.1200/JCO.2014.56.7479]).
First-line treatment should be endocrine therapy if the patient has metastatic HER2-negative breast cancer that’s also estrogen receptor positive, unless the disease is immediately life threatening or there is concern about potential resistance to hormone therapy.
Treating with single chemotherapy drugs (in sequential trials, if needed) is preferable to combination chemotherapy for HER2-negative breast cancer in order to limit side effects and help preserve the patient’s quality of life, the guideline states. Although a longer duration of chemotherapy can improve survival, this must be balanced against the treatment’s toxicity.
Use of targeted therapy with bevacizumab, a monoclonal antibody, remains controversial and should only be considered with single-agent chemotherapy for patients with immediately life-threatening disease or severe symptoms, the guideline suggests. Bevacizumab is not approved in the United States to treat breast cancer.
Other targeted therapies have not been shown to improve outcomes in women with advanced HER2-negative breast cancer and should not be used with or instead of chemotherapy in these patients.
Offer palliative care early and throughout the continuum of care, the guideline recommends.
"Although no clear chemotherapy winner emerged, the guideline will help doctors and patients choose the best therapy based on what treatment would be most tolerable and convenient for the patient," Dr. Ann H. Partridge said in an American Society of Clinical Oncology statement. Dr. Partridge cochaired the expert panel that developed the guideline and is director of the Adult Survivorship Program and the Program for Young Women with Breast Cancer at the Dana-Farber Cancer Institute, Boston.
Some of the many treatments available for HER2-negative breast cancer are "unnecessarily toxic," expert panel cochair Dr. Ian E. Smith said in the ASCO statement. "Breast cancer can often be controlled with less intensive approaches that offer a better quality of life," said Dr. Smith, a professor of cancer medicine at Royal Marsden Hospital, London.
ASCO’s consensus-driven expert panel reviewed randomized studies in the medical literature from 1993 through May 2013 and used the 2009 systematic review by the National Collaborating Centre for Cancer in England as a starting point for what’s known. The panel considered 79 studies, including 20 systematic reviews or meta-analyses, 30 trials of first-line treatments, and 29 trials of second-line or subsequent treatments.
A majority of patients with advanced breast cancer have HER2-negative disease, for which development of targeted therapies is in the early stages. The current speed of research progress in cancer genomics and potential targets of drug therapy is likely to produce new targeted therapies soon to enhance or replace chemotherapy, the guideline authors predicted.
Even then, collaboration between physician and patient to find the optimal approach will remain key. "Given the heterogeneity of breast cancer, even when restricted to HER2-negative disease, it is also possible that ‘one size will never fit all’ and that there is no best treatment for most patients," they wrote.
Dr. Partridge and Dr. Smith reported having no financial disclosures. Disclosures for several of their coauthors who reported having associations with pharmaceutical companies are available with the article online.
On Twitter @sherryboschert
A new evidence-based practice guideline from the American Society of Clinical Oncology on treating women with advanced breast cancer that is negative for human epidermal growth factor receptor 2 emphasizes that "optimal" chemotherapy regimens may vary considerably between patients.
When choosing treatment for an individual with HER2-negative breast cancer, consider not only the potential efficacy of a therapy but also the potential toxicity, the patient’s performance status and comorbid conditions, history of prior therapy, whether the cancer is indolent or immediately life threatening, and the patient’s preferences and schedule, the guideline states.
That said, the guideline on "Chemotherapy and Targeted Therapy for Women with Human Epidermal Growth Factor Receptor 2-Negative (or unknown) Advanced Breast Cancer" offers some specific recommendations (J. Clin. Oncol. 2014 Sept. 2 [doi:10.1200/JCO.2014.56.7479]).
First-line treatment should be endocrine therapy if the patient has metastatic HER2-negative breast cancer that’s also estrogen receptor positive, unless the disease is immediately life threatening or there is concern about potential resistance to hormone therapy.
Treating with single chemotherapy drugs (in sequential trials, if needed) is preferable to combination chemotherapy for HER2-negative breast cancer in order to limit side effects and help preserve the patient’s quality of life, the guideline states. Although a longer duration of chemotherapy can improve survival, this must be balanced against the treatment’s toxicity.
Use of targeted therapy with bevacizumab, a monoclonal antibody, remains controversial and should only be considered with single-agent chemotherapy for patients with immediately life-threatening disease or severe symptoms, the guideline suggests. Bevacizumab is not approved in the United States to treat breast cancer.
Other targeted therapies have not been shown to improve outcomes in women with advanced HER2-negative breast cancer and should not be used with or instead of chemotherapy in these patients.
Offer palliative care early and throughout the continuum of care, the guideline recommends.
"Although no clear chemotherapy winner emerged, the guideline will help doctors and patients choose the best therapy based on what treatment would be most tolerable and convenient for the patient," Dr. Ann H. Partridge said in an American Society of Clinical Oncology statement. Dr. Partridge cochaired the expert panel that developed the guideline and is director of the Adult Survivorship Program and the Program for Young Women with Breast Cancer at the Dana-Farber Cancer Institute, Boston.
Some of the many treatments available for HER2-negative breast cancer are "unnecessarily toxic," expert panel cochair Dr. Ian E. Smith said in the ASCO statement. "Breast cancer can often be controlled with less intensive approaches that offer a better quality of life," said Dr. Smith, a professor of cancer medicine at Royal Marsden Hospital, London.
ASCO’s consensus-driven expert panel reviewed randomized studies in the medical literature from 1993 through May 2013 and used the 2009 systematic review by the National Collaborating Centre for Cancer in England as a starting point for what’s known. The panel considered 79 studies, including 20 systematic reviews or meta-analyses, 30 trials of first-line treatments, and 29 trials of second-line or subsequent treatments.
A majority of patients with advanced breast cancer have HER2-negative disease, for which development of targeted therapies is in the early stages. The current speed of research progress in cancer genomics and potential targets of drug therapy is likely to produce new targeted therapies soon to enhance or replace chemotherapy, the guideline authors predicted.
Even then, collaboration between physician and patient to find the optimal approach will remain key. "Given the heterogeneity of breast cancer, even when restricted to HER2-negative disease, it is also possible that ‘one size will never fit all’ and that there is no best treatment for most patients," they wrote.
Dr. Partridge and Dr. Smith reported having no financial disclosures. Disclosures for several of their coauthors who reported having associations with pharmaceutical companies are available with the article online.
On Twitter @sherryboschert
A new evidence-based practice guideline from the American Society of Clinical Oncology on treating women with advanced breast cancer that is negative for human epidermal growth factor receptor 2 emphasizes that "optimal" chemotherapy regimens may vary considerably between patients.
When choosing treatment for an individual with HER2-negative breast cancer, consider not only the potential efficacy of a therapy but also the potential toxicity, the patient’s performance status and comorbid conditions, history of prior therapy, whether the cancer is indolent or immediately life threatening, and the patient’s preferences and schedule, the guideline states.
That said, the guideline on "Chemotherapy and Targeted Therapy for Women with Human Epidermal Growth Factor Receptor 2-Negative (or unknown) Advanced Breast Cancer" offers some specific recommendations (J. Clin. Oncol. 2014 Sept. 2 [doi:10.1200/JCO.2014.56.7479]).
First-line treatment should be endocrine therapy if the patient has metastatic HER2-negative breast cancer that’s also estrogen receptor positive, unless the disease is immediately life threatening or there is concern about potential resistance to hormone therapy.
Treating with single chemotherapy drugs (in sequential trials, if needed) is preferable to combination chemotherapy for HER2-negative breast cancer in order to limit side effects and help preserve the patient’s quality of life, the guideline states. Although a longer duration of chemotherapy can improve survival, this must be balanced against the treatment’s toxicity.
Use of targeted therapy with bevacizumab, a monoclonal antibody, remains controversial and should only be considered with single-agent chemotherapy for patients with immediately life-threatening disease or severe symptoms, the guideline suggests. Bevacizumab is not approved in the United States to treat breast cancer.
Other targeted therapies have not been shown to improve outcomes in women with advanced HER2-negative breast cancer and should not be used with or instead of chemotherapy in these patients.
Offer palliative care early and throughout the continuum of care, the guideline recommends.
"Although no clear chemotherapy winner emerged, the guideline will help doctors and patients choose the best therapy based on what treatment would be most tolerable and convenient for the patient," Dr. Ann H. Partridge said in an American Society of Clinical Oncology statement. Dr. Partridge cochaired the expert panel that developed the guideline and is director of the Adult Survivorship Program and the Program for Young Women with Breast Cancer at the Dana-Farber Cancer Institute, Boston.
Some of the many treatments available for HER2-negative breast cancer are "unnecessarily toxic," expert panel cochair Dr. Ian E. Smith said in the ASCO statement. "Breast cancer can often be controlled with less intensive approaches that offer a better quality of life," said Dr. Smith, a professor of cancer medicine at Royal Marsden Hospital, London.
ASCO’s consensus-driven expert panel reviewed randomized studies in the medical literature from 1993 through May 2013 and used the 2009 systematic review by the National Collaborating Centre for Cancer in England as a starting point for what’s known. The panel considered 79 studies, including 20 systematic reviews or meta-analyses, 30 trials of first-line treatments, and 29 trials of second-line or subsequent treatments.
A majority of patients with advanced breast cancer have HER2-negative disease, for which development of targeted therapies is in the early stages. The current speed of research progress in cancer genomics and potential targets of drug therapy is likely to produce new targeted therapies soon to enhance or replace chemotherapy, the guideline authors predicted.
Even then, collaboration between physician and patient to find the optimal approach will remain key. "Given the heterogeneity of breast cancer, even when restricted to HER2-negative disease, it is also possible that ‘one size will never fit all’ and that there is no best treatment for most patients," they wrote.
Dr. Partridge and Dr. Smith reported having no financial disclosures. Disclosures for several of their coauthors who reported having associations with pharmaceutical companies are available with the article online.
On Twitter @sherryboschert
FROM JOURNAL OF CLINICAL ONCOLOGY
Moving beyond the one-size-fits-all formula for breast cancer treatments
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Click on the PDF icon at the top of this introduction to read the full article.
Click on the PDF icon at the top of this introduction to read the full article.
Breast cancer in male veteran population: an analysis from VA cancer registry
Click on the PDF icon at the top of this introduction to read the full article.
Click on the PDF icon at the top of this introduction to read the full article.
Click on the PDF icon at the top of this introduction to read the full article.