Risk of Synchronous Distant Recurrence at Time of Locoregional Recurrence in Patients With Stage II and III Breast Cancer (AFT-01).

Purpose National Comprehensive Cancer Network guidelines recommend systemic staging imaging at the time of locoregional breast cancer recurrence. Limited data support this recommendation. We determined the rate of synchronous distant recurrence at the time of locoregional recurrence in high-risk patients and identified clinical factors associated with an increased risk of synchronous metastases. Methods A stage-stratified random sample of 11,046 patients with stage II to III breast cancer in 2006 to 2007 was selected from the National Cancer Database for participation in a Commission on Cancer special study. From medical record abstraction of imaging and recurrence data, we identified patients who experienced locoregional recurrence within 5 years of diagnosis. Synchronous distant metastases (within 30 days of locoregional recurrence) were determined. We used multivariable logistic regression to identify factors associated with synchronous metastases. Results Four percent experienced locoregional recurrence (n = 445). Synchronous distant metastases were identified in 27% (n = 120). Initial presenting stage ( P = .03), locoregional recurrence type ( P = .01), and insurance status ( P = .03) were associated with synchronous distant metastases. The proportion of synchronous metastases was highest for women with lymph node (35%), postmastectomy chest wall (30%), and in-breast (15%) recurrence; 54% received systemic staging imaging within 30 days of a locoregional recurrence. Conclusion These findings support current recommendations for systemic imaging in the setting of locoregional recurrence, particularly for patients with lymph node or chest wall recurrences. Because most patients with isolated locoregional recurrence will be recommended locoregional treatment, early identification of distant metastases through routine systemic imaging may spare them treatments unlikely to extend their survival.

Current Trends in the Management of Phyllodes Tumors of the Breast.

INTRODUCTION: National Comprehensive Cancer Network (NCCN) guidelines recommend wide excision without axillary staging to treat phyllodes tumors of the breast. Without prospective trials to guide management, NCCN also recommends consideration of radiation therapy (XRT). We describe current patterns of care for the multidisciplinary management of phyllodes tumors. METHODS: Using Surveillance, Epidemiology, and End Results Program (SEER) data, we identified women diagnosed with phyllodes tumors between 2000 and 2012 who underwent surgical therapy. Trends in breast-conserving surgery (BCS), nodal sampling, and XRT were assessed using the Cochrane-Armitage test. Multivariable logistic regression was used to identify factors associated with treatment. RESULTS: Of 1238 patients, 56.9 % underwent BCS and 23.6 % underwent nodal sampling (10.5 % after BCS vs. 40.9 % after mastectomy). After surgery, 15.4 % received adjuvant XRT (BCS 12.9 %, and mastectomy 18.8 %). XRT utilization increased significantly over the study period (BCS, p = < 0.0001; mastectomy, p = 0.0003), while nodal sampling did not change significantly. Women were more likely to receive mastectomy if they were older or had larger tumors. Nodal sampling was also associated with older age, larger tumor size, and receipt of mastectomy. Receipt of XRT was associated with later year of diagnosis, larger tumors, and nodal assessment. CONCLUSION: Over time, an increasing number of women received XRT after surgical management of phyllodes tumor, and one in four women underwent nodal sampling. While some of this practice can be attributed to concern about more advanced disease in the absence of strong data, there may be an educational gap regarding current guidelines and appropriate management.

Temporal Trends in Postmastectomy Radiation Therapy and Breast Reconstruction Associated With Changes in National Comprehensive Cancer Network Guidelines.

IMPORTANCE: Evolving data on the effectiveness of postmastectomy radiation therapy (PMRT) have led to changes in National Comprehensive Cancer Network (NCCN) recommendations, counseling clinicians to "strongly consider" PMRT for patients with breast cancer with tumors 5 cm or smaller and 1 to 3 positive nodes; however, anticipation of PMRT may lead to delay or omission of reconstruction, which can have cosmetic, quality-of-life, and complication implications for patients. OBJECTIVE: To determine whether revised guidelines have increased PMRT and affected receipt of breast reconstruction. We hypothesized that (1) PMRT rates would increase for women affected by the revised guidelines while remaining stable in other cohorts and (2) receipt of breast reconstruction would decrease in these women while increasing in other groups. DESIGN, SETTING, AND PARTICIPANTS: Retrospective, population-based cohort study of Surveillance, Epidemiology, and End Results (SEER) data on women with stage I to III breast cancer undergoing mastectomy from 2000 through 2011. Our analytic sample (N = 62,442) was divided into cohorts on the basis of current NCCN radiotherapy recommendations: "radiotherapy recommended" (tumors > 5 cm or ≥ 4 positive lymph nodes), "strongly consider radiotherapy" (tumor ≤ 5 cm, 1-3 positive nodes), and "radiotherapy not recommended" (tumors ≤ 5 cm, no positive nodes). MAIN OUTCOMES AND MEASURES: We used Joinpoint regression analysis to evaluate temporal trends in receipt of PMRT and breast reconstruction. RESULTS: The 3 cohorts comprised 15,999 in the "radiotherapy recommended" group, 15,006 in the "strongly consider radiotherapy" group, and 31,837 in the "radiotherapy not recommended" group. [corrected]. Rates of PMRT were unchanged in the radiotherapy recommended (29.9%) and radiotherapy not recommended (7.4%) cohorts over the study period. Receipt of PMRT for the strongly consider radiotherapy cohort was unchanged at 26.9% until 2007. At that time, a significant change in the APC was observed (P = .01) with an increase in APC from 2.1% to 9.0% (P = .02) through the end of the study period, for a final rate of 40.5%. Breast reconstruction increased across all cohorts. Despite increasing receipt of PMRT, the strongly consider radiotherapy cohort maintained a consistent increase in reconstruction (annual percentage change, 7.4%) throughout the study period. This is similar to the increase in reconstruction observed for the radiotherapy recommended (10.7%) and radiotherapy not recommended (8.4%) cohorts. CONCLUSIONS AND RELEVANCE: Changes in NCCN guidelines have been associated with an increase in PMRT among patients with tumors 5 cm or smaller and 1 to 3 positive nodes without an associated decrease in receipt of reconstruction. This may represent increasing clinician comfort with irradiating a new breast reconstruction and may have cosmetic and quality-of-life implications for patients.

Characterization and treatment of local recurrence following breast conservation for ductal carcinoma in situ.

PURPOSE: The optimal treatment strategy for ductal carcinoma in situ (DCIS) continues to evolve and should consider the consequences of initial treatment on the likelihood, type, and treatment of recurrences. METHODS: We conducted a retrospective cohort study using two data sources of patients who experienced a recurrence (DCIS or invasive cancer) following breast-conserving surgery (BCS) for index DCIS: patients with an index DCIS diagnosed from 1997 to 2008 at the academic institutions of the National Comprehensive Cancer Network (NCCN; N = 88) and patients with an index DCIS diagnosed from 1990 to 2001 at community-based integrated healthcare delivery sites of the Health Maintenance Organization Cancer Research Network (CRN) (N = 182). RESULTS: Just under half of local recurrences in both cohorts were invasive cancer. While 40 % of patients in both cohorts underwent mastectomy alone at recurrence, treatment of the remaining patients varied. In the earlier CRN cohort, most other patients underwent repeat BCS (39 %) with only 18 % receiving mastectomy with reconstruction, whereas only 16 % had repeat BCS and 44 % had mastectomy with reconstruction in the NCCN cohort. Compared with patients not treated with radiation, those who received radiation for index DCIS were less likely to undergo repeat BCS (NCCN: 6.6 vs. 37 %, p = 0.001; CRN: 20 vs. 48 %, p = 0.0004) and more likely to experience surgical complications after treatment of recurrence (NCCN: 15 vs. 4 %, p = 0.17; CRN: 40 vs. 25 %, p = 0.09). CONCLUSION: We found that treatment of recurrences after BCS and subsequent complications may be affected by the use of radiotherapy for the index DCIS. Initial treatment of DCIS may have long-term implications that should be considered.

The role of National Cancer Institute-designated cancer center status: observed variation in surgical care depends on the level of evidence.

OBJECTIVE: We sought to evaluate differences in guideline concordance between National Cancer Institute (NCI)-designated and other centers and determine whether the level of available evidence influences the degree of variation in concordance. BACKGROUND: The National Cancer Institute recognizes centers of excellence in the advancement of cancer care. These NCI-designated cancer centers have been shown to have better outcomes for cancer surgery; however, little work has compared surgical process measures. METHODS: A retrospective cohort study was conducted using Surveillance, Epidemiology and End Results registry linked to Medicare claims data. Fee-for-service Medicare patients with a definitive surgical resection for breast, colon, gastric, rectal, or thyroid cancers diagnosed between 2000 and 2005 were identified. Claims data from 1999 to 2006 were used. Our main outcome measure was guideline concordance at NCI-designated centers compared to other institutions, stratified by level of evidence as graded by National Comprehensive Cancer Network guideline panels. RESULTS: All centers achieved at least 90%, and often 95%, concordance with guidelines based on level 1 evidence. Concordance rates for guidelines with lower-level evidence ranged from 30% to 97% and were higher at NCI-designated centers. The adjusted concordance ratios for category 1 guidelines were between 1.02 and 1.08, whereas concordance ratios for guidelines with lower-level evidence ranged from 0.97 to 2.19, primarily favoring NCI-designated centers. CONCLUSIONS: When strong evidence supports a guideline, there is little variation in practice between NCI-designated centers and other hospitals, suggesting that all are providing appropriate care. Variation in care may exist, however, for guidelines that are based on expert consensus rather than strong evidence. This suggests that future efforts to generate needed evidence on the optimal approach to care may also reduce institutional variation.