Abstract
Purpose
According to German S3 guidelines, radiotherapy (RT) is indicated in patients with invasive breast cancer after breast-conserving therapy (BCT). The aim of this analysis was to assess adherence to guidelines, long-term survival, recurrence rates, and recurrence-free survival after adjuvant RT in patients with BCT in daily clinical practice.
Methods
This retrospective cohort study comprised data from the population-based clinical cancer registry of the Tumor Centre Regensburg (Bavaria, Germany). 6370 patients with non-metastatic invasive breast cancer and UICC tumor stages I, II, and III who were treated in certified breast cancer centers by BCT and diagnosed between 2003 and 2013 were included in the study.
Results
6184 (97.1%) breast cancer patients received guideline concordant RT and showed a 3-year overall survival (OAS) of 96.8% in contrast to 90.9% in patients without RT (5-year OAS of 93.1% vs. 79.0%, p < 0.001). In multivariable Cox regression models, better overall survival was confirmed for the RT group (HR 0.64, 95% CI 0.46–0.88, p = 0.007). The 5-year local recurrence-free survival rate (RFS) in the irradiated patients was 92.1% vs. 62.0% in the comparison group (p < 0.001). The 10-year RFS was 80.5% vs. 36.0% (p < 0.001). This difference persisted after adjusting in multivariable analysis (HR 0.20, 95% CI 0.16–0.26, p < 0.001).
Conclusions
This population-based analysis showed that the implementation of German guidelines in clinical routine was successful and guideline concordant adjuvant radiotherapy after BCT leads to better overall and recurrence-free survival and lower local recurrence rates.
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Abbreviations
- RT:
-
Radiotherapy
- BCT:
-
Breast-conserving therapy
- OAS:
-
Overall survival
- HR:
-
Hazard ratio
- APBI:
-
Accelerated partial breast irradiation
- SD:
-
Standard deviation
- CI:
-
Confidence interval
- RFS:
-
Recurrence-free survival
- DKG:
-
German Cancer Society, “Deutsche Krebsgesellschaft”
- ER:
-
Estrogen receptor
References
Kaatsch P, Spix C, Katalinic A, Hentschel S, Luttmann S, Stegmaier C, Waldeyer-Sauerland M, Waldmann A, Caspritz S, Christ M, Ernst A, Folkerts J, Hansmann J, Klein S, Kranzhöfer K, Kunz B, Manegold K, Penzkofer A, Treml K, Weg-Remers S, Wittenberg K, Barnes B, Bertz J, Buttmann-Schweiger N, Dahm S, Fiebig J, Haberland J, Kraywinkel K, Wienecke A, Wolf U (2017) Krebs in Deutschland für 2013/2014, 11. Ausgabe Robert Koch-Institut, Berlin. https://www.krebsdaten.de/Krebs/DE/Content/Publikationen/Krebs_in_Deutschland/kid_2017/krebs_in_deutschland_2017.pdf?__blob=publicationFile. Accessed 24 Dec 2018
Kreienberg R, Kopp I, Lorenz W, Budach W, Dunst J, Lebeau A, Lück HJ, v. Minckwitz G, Possinger K, Sauerbrei W, Sauerland S, Souchon R, Thomssen C, Untch M, Volm T, Weis J, Schmitt-Reißer B, Koller M, Heilmann V (2004) Diagnostik, Therapie und Nachsorge des Mammakarzinoms der Frau. Interdisziplinäre Leitlinie der Deutschen Krebsgesellschaft und der beteiligten Fachgesellschaften. Version Juni 2004. Frankfurt. http://leitlinien.net/. Accessed 24 Dec 2018
Leitlinienprogramm Onkologie (2017) Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF. S3-Leitlinie Früherkennung, Diagnose, Therapie und Nachsorge des Mammakarzinoms, Version 4.0, 2017 AWMF Registernummer: 032-045OL. http://www.leitlinienprogramm-onkologie.de/leitlinien/mammakarzinom/. Accessed 18 July 2018
Cao JQ, Olson RA, Tyldesley SK (2013) Comparison of recurrence and survival rates after breast-conserving therapy and mastectomy in young women with breast cancer. Curr Oncol 20(6):593–601. https://doi.org/10.3747/co.20.1543
Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, Jeong JH, Wolmark N (2002) Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1233–1241
De Los Santos JF, Hayes DF, Wazer DE, Vora SR (2018) Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer. https://www.uptodate.com/contents/adjuvant-radiation-therapy-for-women-with-newly-diagnosed-non-metastatic-breast-cancer. Accessed 15 Aug 2018
Shah C, Tendulkar R, Smile T, Nanavati A, Manyam B, Balagamwala E et al (2016) Adjuvant radiotherapy in early-stage breast cancer: evidence-based options. Ann Surg Oncol 23(12):3880–3890. https://doi.org/10.1245/s10434-016-5503-x
Buchholz TA (2009) Radiation therapy for early-stage breast cancer after breast-conserving surgery. N Engl J Med 360:63–70. https://doi.org/10.1056/NEJMct0803525
Offersen BV, Boersma LJ, Kirkove C, Hol S, Aznar MC, Sola AB et al (2016) ESTRO consensus guideline on target volume delineation for elective radiation therapy of early stage breast cancer, version 1.1. Radiother Oncol 118:205–208. https://doi.org/10.1016/j.radonc.2014.11.030
Hogeveen SE, Han D, Trudeau-Tavara S et al (2012) Comparison of international breast cancer guidelines: are we globally consistent? Cancer Guideline AGREEment. Curr Oncol 19(3):184–190. https://doi.org/10.3747/co.19.930
Deutsche Krebsgesellschaft e.V., Deutsche Gesellschaft für Senologie e.V. (2017) Zertifizierungskommission Brustkrebszentren Jens-Uwe Blohmer, Sprecher Zertifizierungskommission Anton Scharl, Sprecher Zertifizierungskommission Simone Wesselmann, Deutsche Krebsgesellschaft e.V. Christoph Kowalski, Deutsche Krebsgesellschaft e.V., Julia Ferencz, OnkoZert GmbH. Arbeitsgemeinschaft Bildgebung in der Onkologie (ABO). „JahresberichtBrust2017 (Auditjahr2016/Kennzahlenjahr 2015)“. Version e-A1-de
Kreienberg R, Albert US, Follmann M, Kopp IB, Kühn T, Wöckel A (2013) Interdisciplinary GoR level III guidelines for the diagnosis, therapy and follow-up care of breast cancer: short version - AWMF registry no.: 032-045OL AWMF-Register-Nummer: 032-045OL - Kurzversion 3.0, Juli 2012. Geburtshilfe Frauenheilkd 73(6):556–583
Eisemann N, Waldmann A, Katalinic A (2013) Epidemiology of breast cancer—current figures and trends. Geburtshilfe Frauenheilkde 73(2):130–135. https://doi.org/10.1055/s-0032-1328075
Benson JR, Teo KA (2012) Breast cancer local therapy: what is its effect on mortality? World J Surg 36(7):1460–1474. https://doi.org/10.1007/s00268-012-1468-5
Veronesi U, Marubini E, Del Vecchio M et al (1995) Local recurrences and distant metastases after conservative breast cancer treatments: partly independent events. J Natl Cancer Inst 87:19–27
Corradini S, Niyazi M, Niemoeller OM, Li M, Roeder F, Eckel R, Schubert-Fritschle G, Scheithauer HR, Harbeck N, Engel J, Belka C (2015) Adjuvant radiotherapy after breast conserving surgery—a comparative effectiveness research study. Radiother Oncol 114(1):28–34. https://doi.org/10.1016/j.radonc.2014.08.027
Darby S, McGale P, Correa C, Taylor C, Arriagada R, Clarke M et al (2011) 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 378:1707–1716
Kunkler IH, Williams L, Prescott R, King C (2005) Effects of radiotherapy and surgery for early breast cancer. Lancet 367:1653–1654
Morigi C (2017) Highlights from the 15th St Gallen International Breast Cancer Conference 15–18 March, 2017, Vienna: tailored treatments for patients with early breast cancer. ecancermedicalscience 11:732
Tinterri C, Gatzemeier W, Costa A et al (2014) Breast-conservative surgery with and without radiotherapy in patients aged 55–75 years with early-stage breast cancer: a prospective, randomized, multicenter trial analysis after 108 months of median follow-up. Ann Surg Oncol. https://doi.org/10.1245/s10434-013-3233-x
Hughes KS, Schnaper LA, Bellon JR, Cirrincione CT, Berry DA, McCormick B et al (2013) Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB9343. J Clin Oncol 31:2382–2387
Fisher B, Bryant J, Dignam JJ, Wickerham DL, Mamounas EP, Fisher ER et al (2002) National Surgical Adjuvant Breast and Bowel Project. Tamoxifen, radiation therapy, or both for prevention of ipsilateral breast tumor recurrence after lumpectomy in women with invasive breast cancers of one centimeter or less. J Clin Oncol 20:4141–4149
Blamey RW, Bates T, Chetty U, Duffy SW, Ellis IO, George D et al (2013) Radiotherapy or tamoxifen after conserving surgery for breast cancers of excellent prognosis: British Association of Surgical Oncology (BASO) II trial. Eur J Cancer 49:2294–2302
Kunkler IH, Williams LJ, Jack WJ, Cameron DA, Dixon JM (2015) PRIME II investigators. Breast conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomized controlled trial. Lancet Oncol 16:266–273
Murphy CC, Bartholomew LK, Carpentier MY, Bluethmann SM, Vernon SW (2012) Adherence to adjuvant hormonal therapy among breast cancer survivors in clinical practice: a systematic review. Breast Cancer Res Treat 134:459–478
Poortmans PMP, Arenas M, Livi L (2016) Over-irradiation. Breast 31:295–302. https://doi.org/10.1016/j.breast.2016.07.022
Fitzal F et al (2015) The genomic expression test EndoPredict is a prognostic tool for identifying risk of local recurrence in postmenopausal endocrine receptor-positive, her2neu-negative breast cancer patients randomised within the prospective ABCSG 8 trial. Br J Cancer 112(8):1405–1410
Huber KE, Carey LA, Wazer DE (2009) Breast cancer molecular subtypes in patients with locally advanced disease: impact on prognosis, patterns of recurrence, and response to therapy. Semin Radiat Oncol 19:204–210
Langlands FE, Horgan K, Dodwell DD, Smith L (2013) Breast cancer subtypes: response to radiotherapy and potential radiosensitisation. Br J Radiol 86:20120601. https://doi.org/10.1259/bjr.20120601
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TW: project development, data collection, data analysis, and manuscript writing. OO: project development and manuscript editing. MG: project development, data collection, data analysis, and manuscript editing. MK: project development and manuscript editing. OK: manuscript editing. ECI: project development and manuscript editing.
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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this retrospective type of study formal consent is not required.
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This article is a retrospective study and does not contain any studies with human participants or animals performed by any of the authors.
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Wimmer, T., Ortmann, O., Gerken, M. et al. Adherence to guidelines and benefit of adjuvant radiotherapy in patients with invasive breast cancer: results from a large population-based cohort study of a cancer registry. Arch Gynecol Obstet 299, 1131–1140 (2019). https://doi.org/10.1007/s00404-018-5030-z
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DOI: https://doi.org/10.1007/s00404-018-5030-z