Bridging the age gap in breast cancer. Impacts of omission of breast cancer surgery in older women with oestrogen receptor positive early breast cancer. A risk stratified analysis of survival outcomes and quality of life.
Adjuvant endocrine therapy
Breast cancer
Older women
Patient-centred outcomes
Primary endocrine therapy
Propensity score matching
Quality of life
Surgery
Survival
Journal
European journal of cancer (Oxford, England : 1990)
ISSN: 1879-0852
Titre abrégé: Eur J Cancer
Pays: England
ID NLM: 9005373
Informations de publication
Date de publication:
01 2021
01 2021
Historique:
received:
18
06
2020
revised:
14
09
2020
accepted:
06
10
2020
pubmed:
22
11
2020
medline:
24
4
2021
entrez:
21
11
2020
Statut:
ppublish
Résumé
Age-related breast cancer treatment variance is widespread with many older women having primary endocrine therapy (PET), which may contribute to inferior survival and local control. This propensity-matched study determined if a subgroup of older women may safely be offered PET. Multicentre, prospective, UK, observational cohort study with propensity-matched analysis to determine optimal allocation of surgery plus ET (S+ET) or PET in women aged ≥70 with breast cancer. Data on fitness, frailty, cancer stage, grade, biotype, treatment and quality of life were collected. Propensity-matching (based on age, health status and cancer stage) adjusted for allocation bias when comparing S+ET with PET. A total of 3416 women (median age 77, range 69-102) were recruited from 56 breast units-2854 (88%) had ER+ breast cancer: 2354 had S+ET and 500 PET. Median follow-up was 52 months. Patients treated with PET were older and frailer than patients treated with S+ET. Unmatched overall survival was inferior in the PET group (hazard ratio, (HR) 0.27, 95% confidence interval (CI) 0.23-0.33, P < 0.001). Unmatched breast cancer-specific survival (BCSS) was also inferior in patients treated with PET (HR: 0.41, CI: 0.29-0.58, P < 0.001 for BCSS). In the matched analysis, PET was still associated with an inferior overall survival (HR = 0.72, 95% CI: 0.53-0.98, P = 0.04) but not BCSS (HR = 0.74, 95% CI: 0.40-1.37, P = 0.34) although at 4-5 years subtle divergence of the curves commenced in favor of surgery. Global health status diverged at certain time points between groups but over 24 months was similar when adjusted for baseline variance. For the majority of older women with early ER+ breast cancer, surgery is oncologically superior to PET. In less fit, older women, with characteristics similar to the matched cohort of this study (median age 81 with higher comorbidity and functional impairment burdens, the BCSS survival differential disappears at least out to 4-5 year follow-up, suggesting that for those with less than 5-year predicted life-expectancy (>90 years or >85 with comorbidities or frailty) individualised decision making regarding PET versus S+ET may be appropriate and safe to offer. The Age Gap online decision tool may support this decision-making process (https://agegap.shef.ac.uk/). ISRCTN: 46099296.
Sections du résumé
BACKGROUND
Age-related breast cancer treatment variance is widespread with many older women having primary endocrine therapy (PET), which may contribute to inferior survival and local control. This propensity-matched study determined if a subgroup of older women may safely be offered PET.
METHODS
Multicentre, prospective, UK, observational cohort study with propensity-matched analysis to determine optimal allocation of surgery plus ET (S+ET) or PET in women aged ≥70 with breast cancer. Data on fitness, frailty, cancer stage, grade, biotype, treatment and quality of life were collected. Propensity-matching (based on age, health status and cancer stage) adjusted for allocation bias when comparing S+ET with PET.
FINDINGS
A total of 3416 women (median age 77, range 69-102) were recruited from 56 breast units-2854 (88%) had ER+ breast cancer: 2354 had S+ET and 500 PET. Median follow-up was 52 months. Patients treated with PET were older and frailer than patients treated with S+ET. Unmatched overall survival was inferior in the PET group (hazard ratio, (HR) 0.27, 95% confidence interval (CI) 0.23-0.33, P < 0.001). Unmatched breast cancer-specific survival (BCSS) was also inferior in patients treated with PET (HR: 0.41, CI: 0.29-0.58, P < 0.001 for BCSS). In the matched analysis, PET was still associated with an inferior overall survival (HR = 0.72, 95% CI: 0.53-0.98, P = 0.04) but not BCSS (HR = 0.74, 95% CI: 0.40-1.37, P = 0.34) although at 4-5 years subtle divergence of the curves commenced in favor of surgery. Global health status diverged at certain time points between groups but over 24 months was similar when adjusted for baseline variance.
INTERPRETATION
For the majority of older women with early ER+ breast cancer, surgery is oncologically superior to PET. In less fit, older women, with characteristics similar to the matched cohort of this study (median age 81 with higher comorbidity and functional impairment burdens, the BCSS survival differential disappears at least out to 4-5 year follow-up, suggesting that for those with less than 5-year predicted life-expectancy (>90 years or >85 with comorbidities or frailty) individualised decision making regarding PET versus S+ET may be appropriate and safe to offer. The Age Gap online decision tool may support this decision-making process (https://agegap.shef.ac.uk/).
TRIAL REGISTRATION NUMBER
ISRCTN: 46099296.
Identifiants
pubmed: 33220653
pii: S0959-8049(20)31274-0
doi: 10.1016/j.ejca.2020.10.015
pmc: PMC7789991
pii:
doi:
Types de publication
Journal Article
Multicenter Study
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
48-62Subventions
Organisme : Department of Health
ID : RP-PG-1209-10071
Pays : United Kingdom
Informations de copyright
Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.
Déclaration de conflit d'intérêts
Conflict of interest statement None declared.
Références
Psychooncology. 2008 Apr;17(4):410-6
pubmed: 17847124
Br J Surg. 2015 Aug;102(9):1056-63
pubmed: 26095684
Ann Oncol. 2002;13 Suppl 4:127-9
pubmed: 12401678
Gerontologist. 1969 Autumn;9(3):179-86
pubmed: 5349366
J Natl Cancer Inst. 1993 Mar 3;85(5):365-76
pubmed: 8433390
JAMA Oncol. 2015 Nov;1(8):1051-9
pubmed: 26270597
Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004272
pubmed: 16437480
Br J Surg. 2020 Oct;107(11):1468-1479
pubmed: 32488911
Br J Cancer. 2011 Apr 26;104(9):1393-400
pubmed: 21448163
Clin Oncol (R Coll Radiol). 2009 Mar;21(2):99-102
pubmed: 19200920
Br J Surg. 2018 Oct;105(11):1454-1463
pubmed: 29790154
Patient Prefer Adherence. 2019 Jan 14;13:131-143
pubmed: 30679905
J Psychiatr Res. 1975 Nov;12(3):189-98
pubmed: 1202204
Am J Clin Oncol. 1982 Dec;5(6):649-55
pubmed: 7165009
Md State Med J. 1965 Feb;14:61-5
pubmed: 14258950
JAMA Surg. 2018 Dec 1;153(12):1090-1096
pubmed: 30167636
BMJ. 2007 Oct 20;335(7624):806-8
pubmed: 17947786
Eur J Surg Oncol. 2011 Sep;37(9):754-7
pubmed: 21764540
J Chronic Dis. 1987;40(5):373-83
pubmed: 3558716
J Natl Cancer Inst. 2000 Apr 5;92(7):550-6
pubmed: 10749910
Qual Life Res. 2011 Dec;20(10):1727-36
pubmed: 21479777
J Clin Oncol. 2001 Sep 15;19(18):3808-16
pubmed: 11559718
Psychooncology. 2019 Jul;28(7):1367-1380
pubmed: 30838697
Breast Cancer Res Treat. 1992;22(3):207-19
pubmed: 1391987
Psychooncology. 2015 Aug;24(8):878-84
pubmed: 25534045
Ann Oncol. 2012 Sep;23(9):2296-2300
pubmed: 22357257
Nutr Cancer. 2005;53(1):51-6
pubmed: 16351506