Trends in Locoregional Therapy in Older Women with Early-Stage Hormone Receptor-Positive Breast Cancer by Frailty and Life Expectancy

Minami, Christina A.; Jin, Ginger; Freedman, Rachel A.; Schonberg, Mara A.; King, Tari A.; Mittendorf, Elizabeth A.

doi:10.1245/s10434-023-14446-8

Cited by 4 publications

(3 citation statements)

References 47 publications

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“…Although radiotherapy is often no longer generally used for patients who receive a diagnosis of breast cancer after 65 years of age, approximately half of all breast cancers are diagnosed before 63 years of age. [17][18][19][20] The risk of secondary angiosarcoma provides further impetus to not irradiate most people older than 65 years, given the lack of clinical benefit. There is also evidence that radiotherapy can be omitted for younger postmenopausal women at low risk for recurrence, 21,22 and additional trials are ongoing to further evaluate the possibility of de-escalation of breast radiotherapy.…”

Section: Discussionmentioning

confidence: 99%

“…The incidence of breast cancer during this period remained stable, so we can say that the increase in the incidence of angiosarcoma was not due solely to the increase in breast cancer incidence rates over that time period. Although radiotherapy is often no longer generally used for patients who receive a diagnosis of breast cancer after 65 years of age, approximately half of all breast cancers are diagnosed before 63 years of age . The risk of secondary angiosarcoma provides further impetus to not irradiate most people older than 65 years, given the lack of clinical benefit.…”

Section: Discussionmentioning

confidence: 99%

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Incidence and Presenting Characteristics of Angiosarcoma in the US, 2001-2020

Wagner,

Ravi,

Schaub

et al. 2024

JAMA Netw Open

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ImportanceAngiosarcoma is an aggressive vascular malignant neoplasm presenting either as a primary or secondary cancer, often arising after radiotherapy or in the context of preexisting lymphedema. Comprehensive data describing its incidence and presentation patterns are needed.ObjectiveTo describe the incidence, presenting characteristics, and change over time of angiosarcoma in the US.Design, Setting, and ParticipantsThis retrospective cross-sectional study used data from the US Cancer Statistics (USCS) National Program of Cancer Registries–Surveillance, Epidemiology, and End Results Combined Database, which captures more than 99% of newly diagnosed cancers in the US. The study included all 19 289 patients in the US with a new diagnosis of angiosarcoma between 2001 and 2020 captured in the USCS database. Statistical analysis was performed from June to September 2023.Main Outcomes and MeasuresIncidence of angiosarcoma, demographics of patients with angiosarcoma, and extent of disease at presentation.ResultsThe study included 19 289 patients (median age, 71 years [IQR, 59-80 years]; 10 506 women [54.5%]) with a new diagnosis of angiosarcoma. The US incidence of angiosarcoma doubled between 2001 (657 cases) and 2019 (1312 cases), reflecting both an increase in the adjusted incidence rate of 1.6% per year (P = .001), to 3.3 cases per 1 000 000 person-years (95% CI, 3.1-3.5 cases per 1 000 000 person-years), and an increase in the population at risk. In 2020, the reported incidence rate (3.0 cases per 1 000 000 person-years) and cases of angiosarcoma (n = 1159) were modestly lower than in 2019. Overall, 72.3% of cases of angiosarcoma (n = 13 955) were cutaneous, subcutaneous, or breast angiosarcomas; 24.4% were visceral (n = 4701); and 3.3% were located in unknown or rare primary sites (n = 633). Secondary breast and chest wall angiosarcomas among women represented the largest contribution to increasing incidence. Among breast angiosarcomas, 99.2% (2684 of 2705) were in women and 71.9% (1944 of 2705) were secondary. A total of 80.4% of chest wall or thorax cases among women (1861 of 2316) were secondary vs 26.5% among men (112 of 422), and 63.9% of upper extremity cases among women (205 of 321) were secondary vs 26.8% (56 of 209) among men (P = .001). Rates of secondary angiosarcoma in the abdomen and lower extremities were similar between men and women. The incidence rate of visceral angiosarcoma was also found to be increasing (1.5% per year; P = .001).Conclusions and RelevanceThis cross-sectional study describes angiosarcoma presentation patterns and incidence rates in the US over a 20-year period and shows that the number of cases in men and women increased, with the greatest increase among women with secondary angiosarcoma of the chest, breast, and upper extremity. These data increase awareness of a rare but highly morbid disease and highlight the need for improved early detection of angiosarcoma among patients at high risk, such as women with a history of breast cancer.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Incidence and Presenting Characteristics of Angiosarcoma in the US, 2001-2020

Wagner,

Ravi,

Schaub

et al. 2024

JAMA Netw Open

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“…This intervention comes at a time of de-escalation in breast surgery across several indications, including for SLNB in older patients. Specifically in this patient population, evidence continues to accumulate for the low-value nature of axillary staging even years after the Society of Surgical Oncology’s adoption of the Choosing Wisely recommendations, building momentum for continued de-escalation. Additionally, there could be an element of conformity or social pressure as this intervention was deployed within a single division.…”

Section: Discussionmentioning

confidence: 99%

Electronic Health Record–Based Nudge Intervention and Axillary Surgery in Older Women With Breast Cancer

Carleton,

Radomski,

et al. 2024

JAMA Surg

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ImportanceChoosing Wisely recommendations advocate against routine use of axillary staging in older women with early-stage, clinically node-negative (cN0), hormone receptor–positive (HR+), and HER2-negative breast cancer. However, rates of sentinel lymph node biopsy (SLNB) in this population remain persistently high.ObjectiveTo evaluate whether an electronic health record (EHR)–based nudge intervention targeting surgeons in their first outpatient visit with patients meeting Choosing Wisely criteria decreases rates of SLNB.Design, Setting, and ParticipantsThis nonrandomized controlled trial was a hybrid type 1 effectiveness-implementation study with subsequent postintervention semistructured interviews and lasted from October 2021 to October 2023. Data came from EHRs at 8 outpatient clinics within an integrated health care system; participants included 7 breast surgical oncologists. Data were collected for female patients meeting Choosing Wisely criteria for omission of SLNB (aged ≥70 years with cT1 and cT2, cN0, HR+/HER2− breast cancer). The study included a 12-month preintervention control period; baseline surveys assessing perceived acceptability, appropriateness, and feasibility of the designed intervention; and a 12-month intervention period.InterventionA column nudge was embedded into the surgeon’s schedule in the EHR identifying patients meeting Choosing Wisely criteria for potential SLNB omission.Main Outcomes and MeasuresThe primary outcome was rate of SLNB following nudge deployment into the EHR.ResultsSimilar baseline demographic and tumor characteristics were observed before (control period, n = 194) and after (intervention period, n = 193) nudge deployment. Patients in both the control and intervention period had a median (IQR) age of 75 (72-79) years. Compared with the control period, unadjusted rates of SLNB decreased by 23.1 percentage points (46.9% SLNB rate prenudge to 23.8% after; 95% CI, −32.9 to −13.8) in the intervention period. An interrupted time series model showed a reduction in the rate of SLNB following nudge deployment (adjusted odds ratio, 0.26; 95% CI, 0.07 to 0.90; P = .03). The participating surgeons scored the intervention highly on acceptability, appropriateness, and feasibility. Dominant themes from semistructured interviews indicated that the intervention helped remind the surgeons of potential Choosing Wisely applicability without the need for additional clicks or actions on the day of the patient visit, which facilitated use.Conclusions and RelevanceThis study showed that a nudge intervention in the EHR significantly decreased low-value axillary surgery in older women with early-stage, cN0, HR+/HER2− breast cancer. This user-friendly and easily implementable EHR-based intervention could be a beneficial approach for decreasing low-value care in other practice settings or patient populations.Trial RegistrationClinicalTrials.gov Identifier: NCT06006910

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