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Treatment of stage I breast cancer has intensified over time
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The use of intense, taxane-based regimens in patients with stage I breast cancer has increased over the last decade, according to study results.
However, the choice of regimen and its cost tended to vary according to the treating institution, results showed.
“Stage I breast cancers represent nearly one-half of early breast cancer diagnoses and generally have an excellent prognosis,” Nancy U. Lin, MD, of the department of medical oncology at Dana-Farber Cancer Institute, and colleagues wrote. “However, some patients have a significant risk of disease recurrence to drive a recommendation for adjuvant chemotherapy … To our knowledge, patients with stage I disease have generally been excluded or underrepresented in [phase 3] trials and, therefore, there is uncertainty regarding the preferred chemotherapy for these individuals.”
Lin and colleagues evaluated data from 8,907patients with stage I breast cancer who underwent treatment at a National Comprehensive Cancer Network center between 2000 and 2009.
One-third of the patients (33%; n = 2,923) received adjuvant chemotherapy. The use of adjuvant chemotherapy was more common among patients with HER-2–positive disease (66%) and triple-negative breast cancer (74%) compared with patients with HER-2–negative, hormone receptor-positive disease (21%).
Researchers then compared the use of intensive vs. non-intensive chemotherapy regimens. Intensive regimens tended to contain a taxane, whereas non-intensive regimens did not.
Among patients with HER-2–positive disease who received adjuvant chemotherapy, the percentage of those who received an intensive regimen increased from 31% in 2000-2005 to 63% in 2008-2009. Sixty-one percent of these patients received trastuzumab (Herceptin, Genentech).
Among patients with HER-2–negative breast cancer who received adjuvant chemotherapy, the percentage of those who received an intensive regimen increased from 15% in 2000-2005 to 41% in 2008-2009.
Among HER-2–positive patients, the use of intensive chemotherapy was greater over time (OR = 1.43 per year of diagnosis; 95% CI, 1.06-1.92) and in patients with larger tumors (OR = 2.03 per cm; 95% CI, 1.04-3.96). However, the use of intensive chemotherapy varied according to institution, where the ORs ranged from .05 to 1.1 (P ˂ .001).
The use of docetaxel, carboplatin and trastuzumab increased over time in women with HER-2–positive disease (OR =1.83 per year of diagnosis; 95% CI, 1.34-2.51); however, unadjusted analyses indicated the use of this regimen varied from 25% to 53% across institutions.
Women with HER-2–negative breast cancer displayed the same significant predictors of intensive chemotherapy as the HER-2–positive cohort, with the addition of age, hormone receptor status, grade and lymphovascular invasion. The use of docetaxel and cyclophosphamide increased over time in women with HER-2–negative disease (OR = 3.53 per year of diagnosis; 95% CI, 2.71-4.59); however, its use also varied according to institution (18%-79%).
Researchers also noted significant variability in drug cost, particularly with regard to the use of trastuzumab. In 2006, 1 year of trastuzumab treatment exceeded $45,000. Non-intensive regimens such as paclitaxel with trastuzumab cost $46,178, whereas intensive therapy with docetaxel, carboplatin and trastuzumab cost $58,115 and doxorubicin and cyclophosphamide followed by paclitaxel and trastuzumab cost $47,062.
Non-intensive chemotherapy costs were much lower, ranging from $346 to $17,383 for four cycles.
Prices of chemotherapy regimens — regardless of whether they contained trastuzumab —leveled in 2009 with the availability of generic docetaxel. Price differences at this time were primarily influenced by the use of growth factor support, the researchers wrote.
“In the United States alone, over 100,000 women are diagnosed with stage I breast cancer a year,” Lin and colleagues concluded. “In an era of increasing scrutiny of the cost-effectiveness of therapy and attention to toxicity and quality of life, the current study data point to large gaps of knowledge with which to guide the care of patients with stage I breast cancer. These results highlight the need for dedicated studies among the growing number of patients with small lymph node-negative breast cancer.” – by Cameron Kelsall
Disclosures: Vaz-Luis reports no relevant financial disclosures. Other researchers report grants from Array BioPharma, Genentech, GlaxoSmithKline and Novartis.
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