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One-third of patients do not receive recommended post-mastectomy radiation
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Only 65% of women with breast cancer whose disease spread to four or more nearby lymph nodes underwent recommended radiation therapy after mastectomy, according to study results.
“My colleagues and I were quite startled by the finding that a third of patients with N2/N3 disease did not receive post-mastectomy radiation therapy, which is the standard of care,” Quyen D. Chu, MD, MBA, FACS, professor of surgery at Louisiana State University Health Sciences Center, said in a press release. “From this study, we could not tease out whether patients refuse treatment or there is a lack of awareness among women and physicians about the need for radiation therapy after mastectomy for locally advanced breast cancer. If women with N2/N3 breast cancer who plan a mastectomy are not offered post-mastectomy radiation therapy, they should ask their physician why.”
Quyen D. Chu
Chu and colleagues used the National Cancer Data Base to identify 56,990 women diagnosed with N2/N3 breast cancer between 1998 and 2011. The median age of the population was 57 years (range, 19-90). The majority of women were non-Hispanic white (80.9%), had health insurance (96.1%) and had no comorbidities (83.1%). Most women in the study population were underwent treatment at a comprehensive community cancer program (59%) and resided in an urban community (97.8%).
After undergoing mastectomy, 82.1% of women received chemotherapy, 64.8% received radiation therapy and 51.3% received hormonal therapy.
The receipt of post-mastectomy radiation therapy was not significantly associated with facility type or location, race/ethnicity, insurance status, income and education levels, population density, comorbidities, histology, N-stage, T-stage, lymphovascular invasion, surgical margin status, or curative vs. palliative surgical intent.
Results of multiple logistic regression analyses indicated post-mastectomy radiation therapy was only significantly associated with the receipt of chemotherapy (OR = 4.55; 95% CI, 4.26-4.85), hospital readmission within 30 days of surgical discharge (OR = 1.14; 95% CI, 1.03-1.27) and being alive 30 days after surgery (OR = 1.55; 95 CI, 1.02-2.36).
“This study highlights that despite landmark randomized, controlled trials demonstrating the importance of post-mastectomy radiation therapy for patients with N2/N3 disease, [more than] a third of patients failed to adhere to these recommended evidence-based guidelines,” Chu and colleagues wrote. “From a public policy perspective, understanding the reasons behind the lack of compliance will not only increase the compliance rate, but can also potentially improve outcomes for these high-risk patients.” – by Alexandra Todak
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Katharine A. Yao, MD
It is disappointing that the utilization rates for post-mastectomy radiation therapy are so low, but these findings are similar to other studies on the topic (Shirvani SM, et al. Cancer. 2011;doi:10.1002/cncr.26081). Guidelines explicitly recommend radiation for patients with N2/N3 disease. Although the utilization rates were a bit higher in data from Chu and colleagues than in some other studies, these other studies predominantly examined older patients, which some would consider a relative contraindication to post-mastectomy chest wall radiation.Underreporting of radiation is definitely an issue here and can explain some of the low utilization numbers. Because post-mastectomy chest wall radiation occurs after chemotherapy and many months after the diagnosis, its use may be missed in data collection. There are likely multiple other good reasons why some patients do not undergo radiation — such as elderly age, health issues, side effects of adjuvant chemotherapy, etc — that the National Cancer Data Base is not able to discriminate well.
Nonetheless, we cannot expect radiation rates to reach 100%, but they should probably be higher than 65%. I expect that if we were able to examine these “noncompliant” cases more closely, we would see higher utilization rates, but there are probably at least 10% to 15% of cases that cannot be reasonably explained and we do need to research ways to increase compliance in these groups. It is interesting to note that those patients who do not undergo adjuvant chemotherapy are also the patients who forgo post-mastectomy chest wall radiation. This finding indicates that factors that exclude a patient from chemotherapy — such as medical issues, age, etc — are also excluding them from post-mastectomy chest wall radiation. Further, this may be an issue of patients not wanting to undergo these types of treatments because of toxicities or long-term effects.
There are many limitations with this study, such as underreporting of radiation, which is an issue with any large convenience dataset. Additionally, it is unclear if the authors excluded patients who underwent neoadjuvant therapy, where the use of post-mastectomy chest wall radiation — particularly in patients who have a good response to neoadjuvant therapy — is controversial. We also have to remember that many of the socioeconomic factors (income, education, urban/rural) are census-based variables and reflect the census region, and thus may not discriminate individual-level characteristics. There are also many missing values, mainly because some of the data points were not collected over all years of the study.
It also would have been interesting to see if the trend in post-mastectomy chest wall radiation has increased over time. This study only included data until 2011, so hopefully rates have continued to increase since then. Although utilization rates appear low now, there has likely been a significant increase over time, which would be encouraging to see. So much research has focused on characteristics of patients who undergo post-mastectomy chest wall radiation, whereas perhaps we should focus on patient, tumor and facility characteristics of those patients who do not undergo radiation and explore reasons why these patients are not undergoing radiation. Is it related to distance from the hospital? Receipt of treatment at multiple institutions? Delays in undergoing adjuvant chemotherapy? Tumor factors? Many of these questions remain to be elucidated.
Post-mastectomy chest wall radiation has been endorsed by the National Quality Forum and is part of the standards of the Commission on Cancer and the National Accreditation Program for Breast Centers. These programs will hopefully lead to more accountability and transparency from cancer programs and translate into higher chest wall radiation rates.
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