RESUMEN
BACKGROUND: Recurrence score (RS) testing in early-stage, ER-positive breast cancer is used to predict the benefit of adjuvant chemotherapy for disease recurrence and overall survival. TAILORx results decreased the ambiguity of "intermediate risk" RS by creating a binary classification system. We aimed to determine how women ≥ 70 years with intermediate RS were redistributed post-TAILORx and to identify predictors of low RS. METHODS: Patients ≥ 70 years with early-stage, node-negative, ER-positive breast cancers in the National Cancer Database(2006-2014) were included. "Pre-TAILORx" RS were classified as low (0-17), intermediate (18-30), and high (> 30). "Post-TAILORx" RS were classified as low (0-25) and high (> 25). RESULTS: In total, 14,925 women were included. Average age was 74 years. 60% (n = 9009) had low pre-TAILORx RS, 31% (n = 4635) intermediate, and 9% (n = 1281) high. Of 4635 patients with intermediate RS, 72% (n = 3660) were reclassified to low RS. Only 12% (n = 1783) of patients received chemotherapy. Of patients with pre-TAILORx intermediate RS who received chemotherapy, 55% (n = 417) would have been spared chemotherapy by being reclassified with low RS post-TAILORx. The strongest predictor of post-TAILORx low RS was tumor grade; 95% of well-differentiated had low RS, compared with 56% of poorly/undifferentiated tumors (p < 0.001). Smaller tumor size also was associated with low RS. Age was not associated with RS. CONCLUSIONS: With post-TAILORx RS criteria, the vast majority of patients ≥ 70 years can be classified as low-risk and unlikely to benefit from chemotherapy. Given that the elderly have greater rates of chemotherapy-associated complications, reconsideration of routine RS testing in patients ≥ 70 years is warranted. Tumor grade and size also may inform the decision to omit RS testing.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Biomarcadores de Tumor/genética , Neoplasias de la Mama/patología , Recurrencia Local de Neoplasia/patología , Guías de Práctica Clínica como Asunto/normas , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/genética , Neoplasias de la Mama/metabolismo , Quimioterapia Adyuvante , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Perfilación de la Expresión Génica , Humanos , Recurrencia Local de Neoplasia/tratamiento farmacológico , Recurrencia Local de Neoplasia/genética , Recurrencia Local de Neoplasia/metabolismo , Pronóstico , Receptor ErbB-2/metabolismo , Receptores de Estrógenos/metabolismo , Receptores de Progesterona/metabolismoRESUMEN
The complex decision of breast reconstruction in the setting of postmastectomy radiotherapy (PMRT) involves an understanding of the indications of PMRT and weighing the risks and benefits of various reconstruction options suitable for each patient. Classic indications for PMRT include patients with at least T3 tumors, 4 or more positive lymph nodes, and/or positive surgical margins. The benefit of PMRT in patients with T1-T2 tumors with 1 to 3 positive lymph nodes, however, remains unclear. Breast reconstruction is known to improve quality of life in breast cancer patients. Reconstruction rates have continued to increase despite the lack of medical consensus in these patients with early cancers and limited nodal burden. A collaborative effort among providers is therefore of utmost importance in selecting an optimal approach of reconstruction in the setting of PMRT to minimize postoperative complications. In this review, we discuss the advantages and disadvantages of each reconstruction method with PMRT and highlight the practice patterns at different types of institutions, especially noting the disparities seen at safety net institutions. By refocusing on this important topic, we hope to encourage a multidisciplinary effort to reduce disparities and find innovative algorithms that can be applied to patients at diverse institutions.