Survival and breast relapse in 3834 patients with T1-T2 breast cancer after conserving surgery and adjuvant treatment

doi:10.1016/j.radonc.2006.11.009

Radiotherapy and Oncology

Volume 82, Issue 3, March 2007, Pages 287-293

https://doi.org/10.1016/j.radonc.2006.11.009 Get rights and content

Abstract

Purpose

The aim of the present analysis is to determine the long-term results in terms of breast relapse and specific survival in patients treated with conserving surgery and adjuvant treatment for early breast cancer.

Methods

From January 1980 to December 2001, 3834 patients with pT1-T2 breast cancer were treated consecutively at the University of Florence. The median age of the patient population was 55 years (range 30–80). All patients were followed for a median of 7.4 years (range 0.6 year to 22.5 years). The crude probability of survival (or local recurrence) was estimated by using Kaplan–Meier method, and survival (or local recurrence) comparisons were carried out using Cox proportional hazard regression models.

Results

The Cox regression model by stepwise selection showed some parameters, such as chemotherapy (HR 1.53; CI 1.19–1.95), pT status (HR 1.62, CI 1.31–2.01), positive axillary lymph nodes (HR 1.92, CI 1.66–2.22), and local recurrence (HR 4.58; CI 3.66–5.73), as independent prognostic factors for breast cancer death.

Moreover, we found lower rate survival among patients treated before 1991 in comparison to women treated after 1991 (p = 0.0001) probably due to inadequate treatment. For local disease free survival, age at presentation (HR 0.47; CI 0.35–0.63), use of tamoxifen (HR 0.42; CI 0.25–0.71), surgical margins (HR 2.00; CI 1.21–3.30), and chemotherapy (HR 0.53; CI 0.31–0.91) emerged by multivariate analyses as significant breast relapse predictors.

Conclusion

In our experience breast conserving surgery followed by adjuvant radiotherapy treatment gives high rates of local control in women with early breast cancer. The use of routinely adjuvant chemotherapy and hormone therapy lowered the local recurrence and probably the modification of therapeutic approach in the last decades also improved the specific survival.

Section snippets

Methods and materials

From January 1980 to December 2001, 3834 patients with pT1-T2 breast cancer underwent radiotherapy treatment at the University of Florence. In the current analysis we included patients without clinical and radiographic evidence of local or distant recurrence after surgery at the time of the first evaluation in the radiotherapy unit. All 3834 patients had no prior malignant disease. The median age of the patient population was 55 years (range 30–80). All patients were followed for a median of

Statistical analysis

Information collected for each patient during the hospital’s admission was retrieved and checked before linkage to vital status information. For the survival analysis we considered patients with at least one year of follow-up (89.6%). The date of surgery was used as the start of observation. Survival time was calculated from the date of surgery to the date of last follow-up or data of death. Only the deaths for breast cancer disease were considered as events in our analyses, while the subjects

Results

According to the survival analysis, 13.9% of patients (477/3435) died of breast cancer Fig. 1.

Univariate regression analysis for cause specific survival is summarized in Table 2. Several individual characteristics, such as pT and pN status, surgical margins, histological type, hormonal receptor status, chemotherapy and local relapse, emerged as significant prognostic factors for overall specific survival (p < 0.05).

Over such a long period of time management was not homogeneous due to different

Discussion

In our Institution, after conserving surgery we irradiate patients with tangential beams to the whole breast only, independently from the numbers of positive axillary lymph nodes. The survival rates in the present study are comparable to the long-term outcomes reported in other series [9], [10], [11].

Our study developed in a long period of time. For this reason the management was not homogeneous due to different treatment standards in different periods. We noted that patients treated before

Conclusion

The current study represents a large and relatively uniform cohort of women treated at a single institution with RT comparable to contemporary practices. The long-median follow-up of analyzed women provides valuable information regarding long-term survival, patterns of failure, and risk factors for recurrence. In our experience breast conserving approach followed by adjuvant radiotherapy treatment gives high rates in terms of local control in women with early breast cancer. We noted also that

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Cited by (34)

Surgical management of early breast cancer
2018, The Breast: Comprehensive Management of Benign and Malignant Diseases
The advent of screening mammography and its widespread application has resulted in more patients being diagnosed with small invasive breast cancers. Most of these early breast cancer patients can be treated with breast conservation surgery and sentinel lymphadenectomy followed by radiotherapy. Preoperative planning includes a tissue diagnosis of cancer before proceeding to surgery and assessment of whether the patient can receive radiotherapy. Surgical incisions used in breast conservation surgery should be placed such as to maximize cosmesis but not compromise a mastectomy, if one is needed. Surgeons should play an active role in inking the margins and assessing margin status intraoperatively. Shaved margins aid in obtaining negative margins. Sentinel lymphadenectomy for axillary evaluation has become the primary tool in axillary evaluation in patients with early breast cancers. Percutaneous ablation has been shown to adequately treat primary and metastatic disease in multiple organs, including the liver, kidneys, lungs, brain, and prostate. Questions regarding its applicability to breast cancer treatment have arisen over the past 2 decades. Although no large, randomized trials have been performed to assess the feasibility of replacing lumpectomy with percutaneous ablation in breast conserving therapy for early-stage breast cancer, a growing body of literature supports the safety and efficacy of percutaneous ablation and stresses the importance of undertaking such a trial.
A single-institution analysis of the effect on local control of high-dose rate brachytherapy boost in a single 7 Gy fraction
2016, Revista de Senologia y Patologia Mamaria
Evaluar el impacto de la sobreimpresión con fracción única de braquiterapia de alta tasa en estadios iniciales del cáncer de mama en términos de control local, supervivencia global y toxicidad.
Tras un tratamiento conservador, 137 pacientes, con una edad media de 57 años, recibieron sobreimpresión con braquiterapia de alta tasa en fracción única de 7 Gy entre enero de 2002 y diciembre de 2012. Recibieron quimioterapia el 70% y hormonoterapia el 67%.
Con un seguimiento medio de casi 8 años, la supervivencia global a los 5 y 10 años fue de 89,5 y 87,7%, respectivamente, con una supervivencia libre de recaída local a los 5 años del 99,3%. Los factores favorecedores de recaída local fueron el tamaño tumoral, la presencia de carcinoma in situ, un margen próximo y un grado iii. La toxicidad aguda fue poco frecuente y de rápida resolución. La fibrosis moderada fue el efecto secundario tardío predominante.
La sobreimpresión con braquiterapia intersticial en fracción única de 7 Gy en estadios iniciales del cáncer de mama es una técnica bien tolerada, con toxicidades tardías aceptables, que permite un excelente control local tumoral acortando el tiempo de tratamiento.
To evaluate the impact of single fraction boost high-dose rate brachytherapy for breast cancer in early stages in terms of local control, overall survival and toxicity.
After conservative treatment 137 patients, mean age was 57 years, received high-dose rate brachytherapy boost in only fraction of 7 Gy between January 2002 and December 2012. Chemotherapy was used in 70% of the patients and hormone treatment in 67%.
At a mean follow-up 90 months, at 5 and 10 years the overall survival was 89.5 and 87.7%, respectively, and local recurrence free survival was 99.3% at 5 years. The risk factors for local recurrence were tumor size, carcinoma in situ, involved margins and grade iii. Acute toxicity was rare and rapid resolution. Moderate fibrosis was the most common late effect.
High-dose rate brachytherapy boost in only fraction of 7 Gy to the tumour bed in early stage breast cancer is well tolerated with long term aceptable toxicities and improved local tumor control with a short duration of treatment.
Lessons learned in breast-conserving therapy
2015, Breast Diseases
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
2011, European Journal of Surgical Oncology
Citation Excerpt :
Horiguchi et al.13 reported in their single institution experience that positive estrogen receptor status was a favorable prognostic factor for local control after breast conservative therapy. Similar results were published by other authors.14–17 On the other hand, Rutqvist et al. in the Stockholm trial reported a 7-years local recurrence rate of 5% for patients observed vs a 2% rate for patients treated with tamoxifen, but the difference was not statistically significant.
To ascertain if breast cancer subtypes had prognostic effect on breast cancer specific survival, distant metastases and local relapse rates in women affected by early stage breast cancer.
Data of 774 patients affected by early stage breast cancer and treated with breast-conserving therapy were reviewed. Patients were grouped, based on steroid receptor status and HER2 status as: Luminal A (ER+/PR+/HER2−), Luminal B (ER+/PR+/HER2+), Basal-like (ER−/PR−/HER2−) and HER2 (ER−/PR−/HER2+). Distribution of variables among subtypes was evaluated with Pearson’s test. Survival rates were calculated with life tables; Cox regression stepwise method was used to identify predictive variables of survival.
Median age was 55.0 years old (range 27–80) and median follow up time of 59.0 months (range 13.6–109.7). Breast cancer specific survival and distant metastases rates were different among breast cancer subtypes (both outcomes P = 0.00001) but there was no difference regarding local relapse rates (P = 0.07). Axillary nodes status (P = 0.00001), adjuvant therapy (P = 0.03) and breast cancer subtypes (P = 0.03) resulted prognostic factors of breast cancer specific survival; axillary node status (P = 0.00001) and breast cancer subtypes (P = 0.00001) had an impact on distant metastases. Age (P = 0.003), tumor size (P = 0.0001), positive or close surgical margin (P = 0.00001) and tumor grade 3 (P = 0.049) resulted prognostic factors of local relapse.
In our study, breast cancer subtype seems a prognostic factor of breast cancer specific survival and distant metastases rates, but not of local relapse rate. Patients could be submitted to conservative surgery, if feasible, but considering the differences in survivals, patients with worse prognosis should receive more aggressive adjuvant treatments.
Three-dimensional conformal hypofractionated simultaneous integrated boost in breast conserving therapy: Results on local control and survival
2011, Radiotherapy and Oncology
Citation Excerpt :
Furthermore, the increased use of adjuvant systemic therapy, particularly in high risk node-negative patients might explain this lack of impact of age. In an overview of the randomized trials by the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), both single agent and polychemotherapy have been shown to improve LC and survival significantly, with the largest gain in the youngest age groups (i.e., patients <50 years) [17,18]. Finally, another factor might be the boost dose, which was given to all patients.
To report on local control and survival after breast conserving therapy (BCT) including three-dimensional conformal simultaneous integrated boost irradiation (3D-CRT-SIB) and on the influence of age on outcome.
For this study, 752 consecutive female breast cancer patients (stages I–III), treated with 3D-CRT-SIB at the University Medical Center Groningen from 2005 to 2008, were retrospectively identified. Median age was 58.4 (range 26–84) years. The SIB fractionation used was: 28 × 1.8 Gy (whole breast) and 28 × 2.3 Gy or 2.4 Gy (tumour bed). Next to outcome, we estimated the effect of age on the recurrence-free period (RFP) by multivariate Cox regression survival analysis.
Median follow-up was 41 (range 3–65) months. Local control was 99.6% at 3 years (6 ipsilateral recurrences). The 3-year locoregional control, RFP and overall survival (OS) rates were 99.2%, 95.5%, and 97.1%, respectively. In multivariate analysis, tumours >2 cm (hazard ratio (HR) 3.11; 95% confidence interval (CI) 1.57–6.17) and triple negativity (HR 3.03; 95% CI 1.37–6.67) and not age were associated with impaired RFP.
At 3 years, the 3D-CRT-SIB technique in BCT results in excellent local control and OS. Age was not a risk factor for any recurrence.
Benefit of Radiation Boost After Whole-Breast Radiotherapy
2009, International Journal of Radiation Oncology Biology Physics
Citation Excerpt :
Radiotherapy (RT) has an essential role in breast conserving therapy. Several randomized trials have demonstrated similar survival rates after mastectomy or breast-conserving surgery (BCS) in Stage I and II breast cancer (1–3). The meta-analysis of the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) revealed the need for RT after tumorectomy by showing that breast irradiation reduced the 5-year local recurrence (LR) rate from 26% to 7% (4).
To determine whether a boost to the tumor bed after breast-conserving surgery (BCS) and radiotherapy (RT) to the whole breast affects local control and disease-free survival.
A total of 1,138 patients with pT1 to pT2 breast cancer underwent adjuvant RT at the University of Florence. We analyzed only patients with a minimum follow-up of 1 year (range, 1–20 years), with negative surgical margins. The median age of the patient population was 52.0 years (±7.9 years). The breast cancer relapse incidence probability was estimated by the Kaplan-Meier method, and differences between patient subgroups were compared by the log rank test. Cox regression models were used to evaluate the risk of breast cancer relapse.
On univariate survival analysis, boost to the tumor bed reduced breast cancer recurrence (p < 0.0001). Age and tamoxifen also significantly reduced breast cancer relapse (p = 0.01 and p = 0.014, respectively). On multivariate analysis, the boost and the medium age (45–60 years) were found to be inversely related to breast cancer relapse (hazard ratio [HR], 0.27; 95% confidence interval [95% CI], 0.14–0.52, and HR 0.61; 95% CI, 0.37–0.99, respectively). The effect of the boost was more evident in younger patients (HR, 0.15 and 95% CI, 0.03–0.66 for patients <45 years of age; and HR, 0.31 and 95% CI, 0.13–0.71 for patients 45–60 years) on multivariate analyses stratified by age, although it was not a significant predictor in women older than 60 years.
Our results suggest that boost to the tumor bed reduces breast cancer relapse and is more effective in younger patients.

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Breast conserving treatmentSurvival and breast relapse in 3834 patients with T1-T2 breast cancer after conserving surgery and adjuvant treatment

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Methods and materials

Statistical analysis

Results

Discussion

Conclusion

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Am J Surg

Clin Breast Cancer

Twenty-years follow-up a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer

N Engl J Med

and lumpectomy plus irradiation for the treatment of invasive breast cancer

N Engl J Med

Cosmetic results following primary radiation therapy for early breast cancer

Cancer

Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 trial

J Natl Cancer Inst

Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data

J Clin Oncol

Conservative surgery with radiation therapy in clinical stage I and II breast cancer: results of a 20-year experience

Arch Surg

Negative margin status improves local control in conservatively managed breast cancer patients

Cancer J Sci Am

Breast conserving treatment
Survival and breast relapse in 3834 patients with T1-T2 breast cancer after conserving surgery and adjuvant treatment