Outcomes After Sentinel Lymph Node Biopsy and Radiotherapy in Older Women With Early-Stage, Estrogen Receptor–Positive Breast Cancer

Abstract

IMPORTANCE Overtreatment of early-stage breast cancer with favorable tumor biology in older patients may be harmful without affecting recurrence and survival. Guidelines that recommend deimplementation of sentinel lymph node biopsy (SLNB) (Choosing Wisely) and radiotherapy (RT) (National Comprehensive Cancer Network) have been published. OBJECTIVE To describe the use rates and association with disease recurrence of SLNB and RT in older women with breast cancer. DESIGN, SETTING, AND PARTICIPANTS This cohort study obtained patient and clinical data from an integrated cancer registry and electronic health record of a single health care system in Pennsylvania. The cohort was composed of consecutive female patients 70 years or older who were diagnosed with early-stage, estrogen receptor-positive, ERBB2 (formerly HER2)-negative, clinically node-negative breast cancer from January 1, 2010, to December 31, 2018, who were treated at 15 community and academic hospitals within the health system. EXPOSURES Sentinel lymph node biopsy and adjuvant RT. MAIN OUTCOMES AND MEASURES Primary outcomes were 5-year locoregional recurrence-free survival (LRFS) rate and disease-free survival (DFS) rate after SLNB and after RT. Secondary outcomes included recurrence rate, subgroups that may benefit from SLNB or RT, and use rate of SLNB and RT over time. Propensity scores were used to create 2 cohorts to separately evaluate the association of SLNB and RT with recurrence outcomes. Cox proportional hazards regression model was used to estimate hazard ratios (HRs). RESULTS From 2010 to 2018, a total of 3361 women 70 years or older (median [interquartile range {IQR}] age, 77.0 [73.0-82.0] years) with estrogen receptor-positive, ERBB2-negative, clinically nodenegative breast cancer were included in the study. Of these women, 2195 (65.3%) received SLNB and 1828 (54.4%) received adjuvant RT. Rates of SLNB steadily increased (1.0% per year), a trend that persisted after the 2016 adoption of the Choosing Wisely guideline. Rates of RT decreased slightly (3.4% per year). To examine patient outcomes and maximize follow-up time, the analysis was limited to cases from 2010 to 2014, identifying 2109 patients with a median (IQR) follow-up time of 4.1 (2.5-5.7) years. In the propensity score-matched cohorts, no association was found between

Personalising therapy for early-stage oestrogen receptor-positive breast cancer in older women

“…23 A large cohort study of more than 3000 older women, aged 70 years and older, at a single health-care system revealed that performing SLNB in this subgroup provided no outcome advantages with respect to locoregional recurrence or breast cancer-specific survival. 10 Some recommendations, such as those from EUSOMA–SIOG, state that SLNB should only be omitted for frail patients with low-volume, luminal A-like tumours. 24 However, emerging evidence posits that SLNB omission can be extended to many more patients: even omitting SLNB in the setting of higher-grade or higher-stage disease did not affect disease-free or locoregional recurrence-free survival.…”

“…Even in the absence of a randomised trial, omission of SLNB from routine care is possible as: (1) there is limited diagnostic utility from the procedure; (2) with a clinically node-negative axilla, only some of these patients will actually have a pathologically positive node; and (3) in older women with early-stage disease, omitting SLNB will have a small absolute increase in recurrences without a detriment to their disease-free survival. 10 …”

“… 49 However, high rates of radiation therapy use are still observed, although there is high variability according to geographical region. 10 , 75 Results from the Bridging the Age Gap group show that radiation therapy use in the adjuvant setting is largely determined by patient age and the clinician’s observed risk of recurrence and, interestingly, less driven by geriatric assessment. 75 Overall, radiation therapy was well tolerated by older women, with only a transient decrease in quality of life.…”

“…Even with tolerability, adjuvant radiation therapy can safely be de-escalated in older women in this setting; higher-grade or higher-stage tumours in the setting of cN0 disease do not increase the risk of recurrence. 10 …”

“…Older patients typically have a greater degree of multimorbidity and polypharmacy burden than their younger counterparts ( figure 1 ). 10 As the International Society of Geriatric Oncology (SIOG) suggests, these patients are a heterogenous population, which warrants clinical use of validated comprehensive geriatric assessments. These assessments might reveal additional functional impairments, cognitive problems, nutritional issues, psychological distress, insufficient social support or engagement, and the presence of geriatric syndromes ( figure 2 ).…”