Patterns of Axillary Management in Stages 2 and 3 Hormone Receptor-Positive Breast Cancer by Initial Treatment Approach

Weiss, Anna; Wong, Stéphanie; Golshan, Mehra; Freedman, Rachel A.; Metzger, Otto; Bellon, Jennifer R.; Mittendorf, Elizabeth A.; King, Tari A.

doi:10.1245/s10434-019-07785-y

Cited by 33 publications

(23 citation statements)

References 31 publications

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“…15 In our study, we found that the success of NET is less frequently reported in the literature and that nodal response is not looked at as a main outcome, as it has in most studies evaluating the effect of NAC in the axilla. [7][8][9][10][16][17][18] In both our literature review and in our NCDB data analysis, we found that there is a significant underutilization of NET despite having an acceptable pCR compared with those patients who undergo NAC for N ? disease: 14.5% in NET versus 20.95% in NAC.…”

Section: Discussionmentioning

confidence: 70%

“…, HER2-IBC, and found a 13.3% rate of pCR in the axilla after NET. 8 The median duration of NET was 152 days (interquartile range 97-205 days). Two studies looked specifically at invasive lobular carcinoma (ILC).…”

Section: Resultsmentioning

confidence: 99%

“… 7 This was similar to the findings in a National Cancer Database (NCDB) review from 2012 to 2015, which included clinical stage 2 or 3 (T1-4 and/or N0-1) HR + , HER2-IBC, and found a 13.3% rate of pCR in the axilla after NET. 8 The median duration of NET was 152 days (interquartile range 97–205 days). Two studies looked specifically at invasive lobular carcinoma (ILC).…”

Section: Resultsmentioning

confidence: 99%

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Axillary Response in Patients Undergoing Neoadjuvant Endocrine Treatment for Node-Positive Breast Cancer: Systematic Literature Review and NCDB Analysis

et al. 2020

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Background. Several studies have proven that neoadjuvant endocrine therapy (NET) has a similar beneficial therapeutic effect in estrogen-positive (ER ?) breast cancer (BC) with improved breast conservation rate in patients undergoing NET versus neoadjuvant chemotherapy (NAC). The impact of axillary complete pathologic response (pCR) is less clear. We evaluate the impact of NET on axillary downstaging and surgical management. Methods. Using the National Cancer Database (NCDB), we identified all patients with node positive (N ?), ER ? , HER 2-BC undergoing NET and performed a systemic review of literature using PRISMA guidelines. Results. The literature review identified 1479 clinically N ? patients in four studies, 148 of whom had axillary pCR (10.0%). In the two studies of patients with invasive lobular carcinoma (ILC), 7.8% (69/883) of clinically N ? patients had axillary pCR. The NCDB query identified 4580 female patients with clinically N ? ER ? HER 2-BC who underwent NET from 2010 to 2016 with mean age of 61.4 years. Patients who achieved a pCR were more likely to have N1 disease (p 0.008), moderately differentiated tumors (p 0.003), and ductal histology (p 0.04). There was no statistically significant difference in race, comorbidity score, education, income, hospital setting, or clinical tumor stage. Of the 4580 total patients, 663 (14.48%) had an axillary pCR (pN0) after NET, and 3917 (85.52%) remained pN?. Conclusions. We found that patients who underwent NET for N ? disease had a higher axillary pCR than previously reported (10%) in smaller studies. Although NET is not a common treatment option for women with N ? ER ? HER 2-BC, it may be a suitable option for axillary downstaging, which is currently underutilized. In 2019, approximately 268,600 new cases of invasive breast cancer (IBC) and 48,100 cases of ductal carcinoma in situ (DCIS) were diagnosed among U.S. women, and more than 80% of breast cancers (BC) were diagnosed among women aged C 50 years. 1 Hormone receptor-positive (HR ?)/human epidermal growth factor receptor 2 (HER2)-negative BC is by far the most common subtype. 1 In patients with HR ? breast cancer, the innate exposure to endogenous estrogen results in dimerization of the estrogen receptor (ER) promoting estrogen gene transcription. 2 Multiple endocrine therapies have been developed for adjuvant use, such as selective ER downregulators, aromatase inhibitors (AIs), and luteinizing hormone releasing agonists. 3 The role of neoadjuvant endocrine therapy (NET) in the setting of HR ? breast cancer in the US is underutilized, typically being reserved for elderly patients,

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Section: Discussionmentioning

confidence: 70%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Axillary Response in Patients Undergoing Neoadjuvant Endocrine Treatment for Node-Positive Breast Cancer: Systematic Literature Review and NCDB Analysis

et al. 2020

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“…For patients with early-stage ER+ breast cancer, NET is not currently widely used in the US. 20 , 21 Similar in-breast tumor response rates have been noted in patients undergoing NET compared with those undergoing neoadjuvant chemotherapy, 5 with 50% to 80% of women seeing partial or complete in-breast responses. 6 , 22 Although patients with cT1N0 disease were included in studies of primary endocrine therapy alone, which examined the difference in survival between older women undergoing primary endocrine therapy vs operation and endocrine therapy, 8 , 9 , 10 NET has primarily been explored in patients with stage II to III disease in whom the intent was to downstage the primary tumor.…”

Section: Discussionmentioning

confidence: 79%

Association Between Time to Operation and Pathologic Stage in Ductal Carcinoma in Situ and Early-Stage Hormone Receptor-Positive Breast Cancer

Minami

Kantor

Weiss

et al. 2020

Journal of the American College of Surgeons

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BACKGROUND: During the COVID-19 pandemic, surgical delays have been common for patients with ductal carcinoma in situ (DCIS) and early-stage estrogen receptor-positive (ERþ) breast cancer, often in favor of neoadjuvant endocrine therapy (NET). To understand possible ramifications of these delays, we examined the association between time to operation and pathologic staging and overall survival (OS). STUDY DESIGN: Patients with DCIS or ERþ cT1-2N0 breast cancer treated from 2010 through 2016 were identified in the National Cancer Database. Time to operation was recorded. Factors associated with pathologic upstaging were examined using logistic regression analyses. Cox proportional hazard models were used to analyze OS. Analyses were stratified by disease stage and initial treatment strategy. RESULTS: There were 378,839 patients identified. Among those undergoing primary surgical procedure, time to operation was within 120 days in > 98% in all groups. Among cT1-2N0 patients selected for NET, operations were performed within 120 days in 59.6% of cT1N0 and 30.9% of cT2N0 patients. Increased time to operation was associated with increased odds of pathologic upstaging in DCIS patients (ERþ: 60 to 120 days: odds ratio 1.15; 95% CI, 1.08 to 1.22; more than 120 days: odds ratio 1.44; 95% CI, 1.24 to 1.68; ERe: 60 to 120 days: NS; more than 120 days: odds ratio 1.36; 95% CI, 1.01 to 1.82; 60 days or less: reference), but not in patients with invasive cancer, irrespective of initial treatment strategy. No difference in OS was seen by time to operation in DCIS or NET patients. CONCLUSIONS: Increased time to operation was associated with a small increase in pathologic upstaging in DCIS patients, but did not impact OS. In patients with cT1-2N0 disease, NET use did not impact stage or OS, supporting the safety of delay strategies in ERþ breast cancer patients during the pandemic.

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“…Few studies have assessed the place of axillary lymph node surgery after NET and the few published results are derived from relatively old studies, at a time when initial axillary staging did not necessarily include ultrasound (US) +/− fine-needle aspiration or biopsy. It is noteworthy that patients treated by NET are less likely to undergo axillary lymph node dissection (ALND) than those receiving NCT [37]. Despite similar rates of axillary node involvement at diagnosis, patients treated by NET in the ACOSOG Z1031 B trial less frequently underwent ALND than those treated by NCT [14].…”

Section: Surgical Issuesmentioning

confidence: 99%

Neoadjuvant Endocrine Therapy in Breast Cancer Management: State of the Art

Lerebours

Cabel

Pierga

2021

Cancers

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Endocrine therapy is the mainstay of treatment in HR+/HER2- breast cancers, which represent about 70% of all breast cancers. Neoadjuvant therapy has been developed since the 1990s to address several issues, including breast-conserving surgery (BCS) and improvement of survival rates. For a long time, neoadjuvant endocrine therapy (NET) was confined to frail patients in order to improve surgery outcome. Since the 2000s, NET now plays a central role as a research tool for predictive endocrine sensitivity biomarkers and targeted therapies. One of the major issues in early HR+/HER2- breast cancer is to identify patients in whom chemotherapy can be safely withheld. In vivo assessment of response to NET might be the best treatment strategy to address this issue.

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Patterns of Axillary Management in Stages 2 and 3 Hormone Receptor-Positive Breast Cancer by Initial Treatment Approach

Cited by 33 publications

References 31 publications

Axillary Response in Patients Undergoing Neoadjuvant Endocrine Treatment for Node-Positive Breast Cancer: Systematic Literature Review and NCDB Analysis

Axillary Response in Patients Undergoing Neoadjuvant Endocrine Treatment for Node-Positive Breast Cancer: Systematic Literature Review and NCDB Analysis

Association Between Time to Operation and Pathologic Stage in Ductal Carcinoma in Situ and Early-Stage Hormone Receptor-Positive Breast Cancer

Neoadjuvant Endocrine Therapy in Breast Cancer Management: State of the Art

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