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Many older patients with early-stage breast cancer receive radiation despite limited effectiveness
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About two-thirds of elderly women with early-stage breast cancers undergo radiation, even though clinical trial data support omission of that treatment modality, according to study results.
“It’s important to improve patient and doctor communication to ensure that the right patients are getting the right treatment at the right time,” Rachel Blitzblau, MD, PhD, assistant professor of radiation oncology at Duke Cancer Institute, told HemOnc Today. “As we work toward more efficient and evidence-based medical practice in all medical specialties, we will need to understand what processes may be needed to spur change.”
Results from a large randomized trial — conducted by the Cancer and Leukemia Group B (CALGB) and published in 2004 — showed the addition of radiation to lumpectomy and adjuvant tamoxifen failed to extend survival among elderly women with early-stage hormone receptor-positive breast cancer.
Those who underwent radiation demonstrated lower rates of 5-year recurrence (1% vs. 4%), but the researchers in that study suggested the absolute difference of 3% was small enough to warrant consideration of lumpectomy and tamoxifen alone in this patient population.
Despite those findings, many doctors administer radiation to this patient population, but the extent to which this occurs had not been established, according to background information in the study.
Blitzblau and colleagues used the SEER database to identify 40,583 women aged ≥70 years who underwent lumpectomy between 2000 and 2009. All women in the cohort had stage I ER-positive and/or PR-positive breast cancer.
Results showed that 68.6% of patients treated between 2000 and 2004 — prior to publication of the CALGB study results — received some type of radiation therapy. Between 2005 and 2009, the percentage declined to 61.7% (P<.001). During the latter time period, fewer patients underwent standard whole breast radiation and more underwent a short course of focused radiation.
Researchers reported significant reductions in frequency of radiotherapy delivery over time among subsets of patients grouped by age, tumor grade and tumor size (P<.001 for all).
However, the fact three out of five women in this population continue to undergo some type of radiation treatment shows publication of the [CALGB] trial results had only a very small impact on practice, the researchers wrote.
“The onus is on physicians to critically analyze data to shape our treatment recommendations for patients, weighing the potential toxicities of treatment against clinical benefit,” Blitzblau and colleagues wrote. –by Anthony SanFilippo
Rachel Blitzblau, MD, PhD, can be reached at Department of Radiation Oncology, Duke University, DUMC 3085, Durham, NC 27710.
Disclosure: The researchers report no relevant financial disclosures.
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Reshma Jagsi, MD, DPhil
Palta and colleagues report on the use of adjuvant radiotherapy, as recorded in the SEER database, for a cohort of women aged 70 years and older treated with breast-conserving surgery for clinical stage I, hormone receptor-positive breast cancer from 2000-2009. Consistent with prior studies using linked SEER–Medicare claims data, they observed a decrease in adjuvant radiotherapy use after the publication of data from the CALGB 9343 randomized trial, which established omission of radiotherapy as a reasonable option for such women if they plan to receive tamoxifen. The authors note, however, that the majority of women (62% of those treated from 2005-2009) still received radiotherapy. In fact, because the SEER database is known to under-ascertain radiotherapy receipt, the rates observed likely represent an underestimate of radiotherapy use during the years studied.When interpreting these observations, it is important to note that many practitioners — and patients included in this study — may have been awaiting longer-term results from CALGB 9343 before widely applying its findings. Although the 5-year results of the trial — published in 2004 — revealed a low rate of local recurrence in both groups (1% with radiotherapy vs. 4% without), radiotherapy did provide a clear benefit with regard to reduction of local recurrence. This effect of radiotherapy ultimately was even more pronounced in the long-term analysis (2% vs. 10%), an analysis published after the timing of the current study of practice patterns.
Some patients may consider such a benefit to be small in absolute magnitude and, therefore, elect to for go radiotherapy. Others still may reasonably choose to receive radiotherapy in order to minimize risks of recurrence, particularly if their life expectancy exceeds that of the women included in the CALGB trial. Moreover, not all patients with hormone receptor-positive disease decide to pursue endocrine therapy; omission of radiotherapy in that situation is not established. Therefore, although interesting, the results of the current study must be taken in context. Further studies of more current cohorts are needed to more firmly evaluate the impact of the CALGB trial on practice today.
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