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Identification of Patients at Very Low Risk of Local Recurrence After Breast-Conserving Surgery

      Purpose

      To identify clinical and pathological factors that identify groups of women with stage I breast cancer with a 5-year risk of local recurrence (LR) ≤1.5% after breast-conserving therapy (BCS) plus whole-breast radiation therapy (RT).

      Methods and Materials

      Study subjects were 5974 patients ≥50 years of age whose cancer was diagnosed between 1989 and 2006, and were referred with pT1 pN0 invasive breast cancer treated with BCS and RT. Cases of 5- and 10-year LR were examined using Kaplan-Meier methods. Recursive partitioning analysis was performed in patients treated with and without endocrine therapy to identify combinations of factors associated with a 5-year LR risk ≤1.5%.

      Results

      The median follow-up was 8.61 years. Median age was 63 years of age (range, 50 to 91). Overall 5-year LR was 1.5% (95% confidence interval [CI], 1.2%-1.9%) and 10-year LR was 3.4% (95% CI, 2.8%-4.0%). Of 2830 patients treated with endocrine therapy, patient subsets identified with 5-year LR ≤1.5% included patients with grade 1 histology (n=1038; LR, 0.2%; 95% CI, 0%-0.5%) or grade 2 histology plus ≥60 years of age (n=843; LR, 0.5%; 95% CI, 0%-1.0%). Ten-year LR for these groups were 0.8% (95% CI, 0.1%-1.6%) and 0.9% (95% CI, 0.2%-1.6%), respectively. Of 3144 patients treated without endocrine therapy, patients with grade 1 histology plus clear margins had 5-year LR ≤1.5% (n=821; LR, 0.6%; 95% CI, 0.1%-1.2%). Ten-year LR for this group was 2.2% (95% CI, 1.0%-3.4%).

      Conclusions

      Histologic grade, age, margin status, and use of endocrine therapy identified 45% of a population-based cohort of female patients over age 50 with stage I breast cancer with a 5-year LR risk ≤1.5% after BCS plus RT. Prospective study is needed to evaluate the safety of omitting RT in patients with such a low risk of LR.
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      References

        • Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer
        Clinical practice guidelines for the care and treatment of breast cancer.
        CMAJ. 1998; 158: S71-S81
        • Blamey R.W.
        • Bates T.
        • Chetty U.
        • et al.
        Radiotherapy or Tamoxifen after conserving surgery for breast cancer of excellent prognosis: British Association of Surgical Oncology (BASO) II trial.
        Eur J Cancer. 2013; 49: 2292-2304
        • Fisher B.
        • Bryant J.
        • Dignam D.
        • et al.
        Tamoxifen, radiation therapy, or both for prevention of ipsilateral breast tumor recurrence after lumpectomy in women with invasive breast cancers of one centimeter of less.
        J Clin Oncol. 2002; 20: 4141-4149
        • Hughes K.S.
        • Schnaper L.A.
        • Berry D.
        • et al.
        Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer.
        N Engl J Med. 2004; 351: 971-977
        • Hughes K.S.
        • Schnaper L.A.
        • Cirincione C.
        • et al.
        Lumpectomy plus tamoxifen with or without irradiation in women age 70 or older with early breast cancer: Long-term follow-up of CALGB 9343.
        J Clin Oncol. 2013; 31: 2382-2387
        • Fyles A.W.
        • McCready D.R.
        • Manchul L.A.
        • et al.
        Tamoxifen with or without breast irradiation in women 50 years of age or older with early breast cancer.
        N Engl J Med. 2004; 351: 963-970
        • Fyles A.
        • McCready D.
        • Olivotto I.
        • et al.
        Mature results of a randomized trial of tamoxifen with or without breast radiation in women over 50 years of age with T1/2 N0 breast cancer.
        Eur J Ca Suppl. 2010; 8: 125-126
        • Potter R.
        • Gnant M.
        • Werner K.
        • et al.
        Lumpectomy plus tamoxifen or anastrozole with or without whole breast irradiation in women with favorable early breast cancer.
        Int J Radiat Biol Phys. 2007; 68: 334-340
        • Holli K.
        • Saaristo R.
        • Isola J.
        • et al.
        Lumpectomy with or without postoperative radiation therapy for breast cancer with favourable prognostic features: Results of a randomized study.
        Br J Cancer. 2001; 84: 164-169
        • Early Breast Cancer Trialists' Collaborative Group
        Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on LR and 15-year survival: An overview of the randomized trials.
        Lancet. 2005; 366: 2087-2106
        • Darby S.
        • McGale P.
        • Correa C.
        • et al.
        • Early Breast Cancer Trialists' Collaborative Group (EBCTCG)
        Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials.
        Lancet. 2011; 378: 1707-1716
      1. Therneau T. A package for survival analysis in S. R package version 2. 36–14. 2012.

        • Schemper M.
        • Smith T.L.
        A note on quantifying follow-up in studies of failure time.
        Control Clin Trials. 1996; 17: 343-346
        • Soulos P.R.
        • Yu J.B.
        • Roberts K.B.
        • et al.
        Assessing the impact of a cooperative group trial on breast cancer in the Medicare population.
        J Clin Oncol. 2012; 30: 1601-1607
      2. Chan EK, Speers C, Smith S et al. Provincial changes in the use of adjuvant breast radiotherapy and tamoxifen in elderly women after the publication of the CALGB C9343 Trial. Radiotherapy and Oncology Vol 108 Supplement 1, S43 2013

        • Sorlie T.
        • Perou C.M.
        • Tibshirani R.
        • et al.
        Gene expression patterns of breast carcinomas distinguish tumor subclasses with clinical implications.
        Proc Natl Acad Sci U S A. 2001; 98: 10869-10874
        • Millar E.K.
        • Graham P.H.
        • O'Toole S.A.
        • et al.
        Prediction of local recurrence, distant metastases, and death after breast-conserving therapy in early-stage invasive breast cancer using a five-biomarker panel.
        J Clin Oncol. 2009; 27: 4701-4708
        • Nguyen P.L.
        • Taghian A.G.
        • Katz M.S.
        • et al.
        Breast cancer subtype approximated by estrogen receptor, progesterone receptor, and HER-2 is associated with local and distant recurrence after breast-conserving therapy.
        J Clin Oncol. 2008; 26: 2373-2378
        • Sanpaolo P.
        • Barbieri V.
        • Genovesi D.
        Prognostic value of breast cancer subtypes on breast cancer specific survival, distant metastases and local relapse rates in conservatively managed early stage breast cancer: a retrospective clinical study.
        Eur J Surg Oncol. 2011; 37: 876-882
        • Lowery A.J.
        • Kell M.R.
        • Glynn R.W.
        • et al.
        Locoregional recurrence after breast cancer surgery: A systematic review by receptor phenotype.
        Breast Cancer Res Treat. 2012; 133: 831-844
        • Arvold N.D.
        • Taghian A.G.
        • Niemierko A.
        • et al.
        Age, breast cancer subtype approximation, and local recurrence after breast-conserving therapy.
        J Clin Oncol. 2011; 29: 3885-3891
        • Cancello G.
        • Maisonneuve P.
        • Rotmensz N.
        • et al.
        Prognosis in women with small (T1mic, T1a, T1b) node-negative operable breast cancer by immunohistochemically selected subtypes.
        Br Cancer Res Treat. 2011; 127: 713-720
        • Voduc K.D.
        • Cheang M.C.
        • Tyldesley S.
        • et al.
        Breast cancer subtypes and the risk of local and regional relapse.
        J Clin Oncol. 2010; 28: 1684-1691
        • Albert J.M.
        • Gonzalez-Angulo A.M.
        • Guray M.
        • et al.
        Estrogen/progesterone receptor negativity and HER2 positivity predict locoregional recurrence in patients with T1a, N0 breast cancer.
        Int J Radiat Oncol Biol Phys. 2010; 77: 1296-1302
        • Gabos Z.
        • Thoms J.
        • Ghosh S.
        • et al.
        The association between biological subtype and locoregional recurrence in newly diagnosed breast cancer.
        Breast Cancer Res Treat. 2010; 124: 187-194
        • Rao R.
        • Euhus D.
        • Mayo H.G.
        • Balch C.
        Axillary node interventions in breast cancer: A systematic review.
        JAMA. 2013; 310: 1385-1394
        • Shaitelman S.F.
        • Kim L.H.
        Accelerated partial-breast irradiation: The current state of our knowledge.
        Oncology (Williston Park). 2013; 27: 329-342
        • Murphy C.C.
        • Bartholomew L.K.
        • Carpentier M.Y.
        • et al.
        Adherence to adjuvant hormonal therapy among breast cancer survivors in clinical practice: A systematic review.
        Breast Cancer Res Treat. 2012; 134: 459-478
        • Chan A.
        • Speers C.
        • Woods R.
        • et al.
        Adherence of adjuvant hormonal therapies in post-menopausal hormone receptor positive early stage breast cancer: A population based study from British Columbia [abstract 36].
        Cancer Res. 2009; 69
        • Lim M.
        • Bellon J.R.
        • Gelman R.
        • et al.
        A prospective study of conservative surgery without radiation therapy in select patients with stage I breast cancer.
        Int J Radiat Oncol Biol Phys. 2006; 65: 1149-1154
        • Canavan J.
        • Truong P.T.
        • Smith S.L.
        • et al.
        Local recurrence in women with stage I breast cancer: declining rates over time in a large, population-based cohort.
        Int J Radiat Oncol Biol Phys. 2014; 88: 80-86
        • Pass H.
        • Vicini F.A.
        • Kestin L.L.
        • et al.
        Changes in management techniques and patterns of disease recurrence over time in patients with breast carcinoma treated with breast-conserving therapy at a single institution.
        Cancer. 2004; 101: 713-720
        • Cabioglu N.
        • Hunt K.K.
        • Buchholz T.A.
        • et al.
        Improving local control with breast-conserving therapy: A 27 year single-institution experience.
        Cancer. 2005; 104: 20-29
      3. A prospective cohort study evaluating risk of local recurrence following breast-conserving surgery and endocrine therapy in low risk luminal A breast cancer (LUMINA). Principal investigators Whelan T. and Smith S. Available at: http://clinicaltrials.gov/show/NCT01791829. Accessed May 1, 2014.

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