Over 70s breast cancer management: A single institute experience (2018)

Type of publication:
Conference abstract

Author(s):
Dube M.; Talaat A.; *Rastall S.; *Przyczyna A.; *Usman T.

Citation:
European Journal of Surgical Oncology; Jun 2018; vol. 44 (no. 6); p. 898

Abstract:
Introduction: With increasing life expectancy, awareness and improved referral system more women over the age of 70 (70+) are diagnosed with breast cancer. NICE guidelines recommended standard treatment of breast cancer irrespective of age and decision rather based on co-morbidities and frailty. To review our compliance with NICE guidelines we audited management of breast cancer of 70+ women over a period of five years. Methods: Retrospective case note analysis of 833 70+ women with breast cancer diagnosed from April 2010 to March 2015. Breast MDT recommendations, reason for choice of treatment, co-morbidities and performance status recorded. Results: Out of 2729 breast cancer diagnosis 30% (833) were 70+. The median age was 78. Surgery was the treatment of choice in all five years and is represented by 60% in year one, four and five; 55% in year two; 45% in year three. Primary endocrine treatment was the next treatment of choice among 28% in year one, 23% in year two, 30% in year three, 20% in year four, and 25% in year five. Offer and acceptance adjuvant treatments have increased in year wise analysis. Conclusions: We have noticed a shift towards surgery from primary endocrine therapy in year wise analysis. There has been an increase of number of 70+ patients diagnosed with breast cancer. Inclusion of performance status had improved offer of adjuvant treatment in the last year of the study. More individualised and evidence based management recommended to offer appropriate treatment in this age group.

Breast reconstruction affects coping mechanisms in breast cancer survivors (2017)

Type of publication:
Journal article

Author(s):
*Lake, B., Fuller, H.R., *Rastall, S, *Usman, T

Citation:
Indian Journal of Surgery, December 2017

Abstract:
Coping strategies used by women with breast cancer are vital for adjustment to their disease. Whilst it is clear that factors such as age at diagnosis, social support and ethnicity can influence coping mechanisms, there is currently no information about whether breast reconstruction changes mechanisms of coping for such patients. The aims of this study, therefore, were to determine how women who have had immediate breast reconstruction and mastectomy cope, compared to those who have mastectomy alone, and whether there are differences in coping mechanisms due to breast reconstruction surgery. This was a retrospective cohort study, using a standardised questionnaire called the Brief Cope Scale. Inclusion criteria was the following: all women who had immediate breast reconstruction and mastectomy in Shropshire from 2003 to 2014 for ductal carcinoma in situ or node-negative invasive breast cancer. Each patient was matched for year of diagnosis, adjuvant therapy and age to one woman who had mastectomy alone. Two hundred thirty-four questionnaires were sent with a 58% response rate. Significantly more patients from the reconstruction cohort coped by active coping (T value 1.66, P value 0.04) compared to those in the mastectomy alone cohort. In contrast, significantly more patients in the mastectomy alone cohort coped by active venting compared to the reconstruction cohort (T value 1.71, P value 0.04). This study indicates for the first time that breast reconstruction may alter coping mechanisms in breast cancer survivors. Awareness of these coping mechanisms will enable clinicians to provide appropriate, individualised support.

The impact of age on the art of mammography and how to adapt accordingly (2017)

Type of publication:
Journal article

Author(s):
*Lake, B.; *Cielecki, L.; *Williams, S.; *Worrall, C.; *Metelko, M.

Citation:
Radiography; Nov 2017; vol. 23 (no. 4) e120–e121

Abstract:
Introduction Breast cancer is increasingly a disease of the elderly, and combined with the NHS Breast Screening Extension means that more elderly patients are having mammography. Increasing age can make mammography more technically difficult. This is a technical note detailing the results of a local audit which may be of interest due to potential service implications. Method A retrospective audit of the first year of screening extension of The Shropshire Breast Screening Programme. Aims to collect data on patient demographics and describe the technical adaptations developed in Shropshire. Results Breast screening extension has increased by 2.5 times the number of women aged 70–74 screened, and doubled the overall numbers of women over 70 screened. Significantly more older patients are being screened to present technical challenges to a screening programme. Data was obtained from a month of screening showed that 29% of patients over 70 needed extra time for positioning. Reasons included 22% difficulty in obtaining adequate positioning and 15% needed a relative to aid with consent. Discussion In the Shropshire screening programme different technical adaptations have been developed and are key to ensuring adequate images. These include double appointments, two radiographers, thorough assessment, steeper angles, seated examinations, from-below imaging and pre-planning for subsequent screen. Conclusion Significantly more older women are having breast screening due to the increasing incidence of breast cancer and the Breast Screening Programme extension. Increasing age can significantly increase time taken for adequate imaging and present technical challenges. Development of technical adaptations to art of mammography is key to achieve adequate images.

Link to full-text

An audit of ‘real world’ systemic chemotherapy in breast cancer patients over the age of 70 in one U.K. Cancer Centre (2018)

Type of publication:
Conference abstract

Author(s):
*Choudhary Y.; *Pettit L.; *Khanduri S.

Citation:
European Journal of Surgical Oncology; Mar 2018; vol. 44

Abstract:
Background: Breast cancer incidence among the over 70’s is increasing. Trial data from this age group is not as extensive when compared with younger patients. Co-morbidities are common and may lead to poor tolerance of chemotherapy. Cytotoxic chemotherapy usage in patients over 70 was audited to record toxicity and tolerability.Method: Patients aged >70 years, diagnosed with invasive breast cancer between 01/01/2015 and 31/12/2015 treated with cytotoxic chemotherapy at the Shrewsbury and Telford Hospital NHS Trust were identified from the Somerset database. Clinical information was obtained from an electronic portal. Data collected: demographics, performance status, tumour characteristics, ER/PR and HER2 status, chemotherapy regimen, treatment intent, number of chemotherapy cycles planned, number given, toxicities, and hospital admissions. Data was collected on an excel database.Results: Thirty patients were identified, all female. 26 were between 71 and 75, 2 were between 76 and 80, 2 > 80 years. 20 patients (67%) ER/PR receptor positive. 15 (50%) HER2 positive. The majority 29 (97%) had a performance status of 0/1. Cardiovascular co-morbidities were the most common (57% pre-existing cardiovascular disease). 25 (83%) were treated with adjuvant intent. 15 (50%) were admitted to hospital, 6 (20%) with neutropenic sepsis. 12 (40%) had dose reductions. 21 (70%) completed their planned number of cycles. Chemotherapy was discontinued in 7 (23%) due to toxicity and 1 patient remains on treatment at the time of this audit. There were no patient deaths within 30 days of commencing chemotherapy.Conclusion: Chemotherapy usage in the >70’s was associated with higher risk breast cancer. Despite good baseline performance status, 50% of patients required hospital admission and 27% discontinued treatment due to toxicity. The decision to use chemotherapy must also account for potential toxicities and impact on quality of life. Increased contact with health professionals including tele-consults and increased specialist nurse support, will help to predict and manage toxicity and reduce admissions.

Partial breast radiotherapy after breast conservation: 5 year outcomes from the IMPORT LOW (CRUK/06/003) phase III trial (2017)

Type of publication:
Conference abstract

Author(s):
Coles C.; Griffin C.; Bhattacharya I.; Emson M.; Haviland J.; Hopwood P.; Kaggwa R.; Bliss J.; Kirby A.; Donovan E.; *Agrawal R.; Alhasso A.; Brunt A.M.; Ciurlionis L.; Chan H.; Harnett A.; Sawyer E.; Sybdikus I.; Tsang Y.; Wheatley D.; Wilcox M.; Yarnold J.; Jefford M.

Citation:
Radiotherapy and Oncology; May 2017; vol. 123

Abstract:
Background: Local cancer relapse rates after breast conservation surgery followed by radiotherapy have fallen sharply in many countries with risk influenced by patient age and clinico-pathological factors. In women at lower than average risk of local relapse, partial breast radiotherapy restricted to the vicinity of the original tumour is hypothesised to improve the balance of beneficial versus adverse effects compared with whole breast radiotherapy. Methods: The IMPORT LOW trial (ISRCTN12852634) recruited women aged >=50 years after breast conserving surgery for invasive ductal adenocarcinoma pT<=3cm, pN0- 3, G1-3 and >=2mm resection margins. Using 15 daily treatments, patients were randomly allocated (1:1:1) to 40 Gy whole breast radiotherapy (control), 36 Gy whole breast plus 40 Gy to partial breast (reduced dose) or 40 Gy partial breast only (partial breast). Primary endpoint was ipsilateral local relapse rate (80% power to exclude a +2.5% noninferiority margin at 5 years for each test group). Findings: Between May 2007 and October 2010, 2018 women were recruited (control n=675, reduced dose: n=674, partial breast: n=669). With a 72.2 month median followup (IQR 61.7-83.2), 5-year local relapse rates were 1.1% (95%CI 0.5-2.3), 0.2% (0.02-1.2) and 0.5% (0.2-1.4) in control, reduced dose and partial breast groups. Absolute differences in local relapse rate compared with the control group were -0.73% (-0.99, 0.22) for the reduced dose and -0.38% (-0.84, 0.90) for the partial breast groups, demonstrating non-inferiority for both test groups. Photographs, patients and clinicians reported similar or lower levels of adverse effects after reduced dose or partial breast radiotherapy compared with whole breast radiotherapy (see Table 1). (Table presented) Interpretation: At 5 years, partial breast and reduced
dose radiotherapy showed local relapse rates non-inferior to that observed following whole breast radiotherapy and produced equivalent or milder late normal tissue side effects. This simple radiotherapy technique is implementable in radiotherapy centres worldwide.

Osteonecrosis of the jaw and oral health-related quality of life after adjuvant zoledronic acid: An adjuvant zoledronic acid to reduce recurrence trial subprotocol (BIG01/04) (2017)

Type of publication:
Journal article

Author(s):
Rathbone E.J.; Brown J.E.; Coleman R.E.; Marshall H.C.; Collinson M.; Liversedge V.; Murden G.A.; Cameron D.; Spensley S.; *Agrawal R.; Jyothirmayi R.; Chakraborti P.; Yuille F.; Bell R.

Citation:
Journal of Clinical Oncology; Jul 2013; vol. 31 (no. 21); p. 2685-2691

Abstract:
Purpose: In patients with early breast cancer, adjuvant zoledronic acid (zoledronate) may reduce recurrence and improve survival. However, zoledronate is associated with the occasional development of osteonecrosis of the jaw (ONJ). We report on the frequency of ONJ and investigate oral health-related quality of life (Oral-QoL) in a large randomized trial (Adjuvant Zoledronic Acid to Reduce Recurrence [AZURE]). Patients and Methods: Three thousand three hundred sixty women with stage II or III breast cancer were randomly assigned to receive standard adjuvant systemic therapy alone or with zoledronate administered at a dose of 4 mg for 19 doses over 5 years. All potential occurrences of ONJ were reported as serious adverse events and centrally reviewed. Additionally, we invited 486 study participants to complete the Oral Health Impact Profile-14 (OHIP-14) to assess Oral-QoL around the time the patients completed 5 years on study. Multivariable linear regression was used to calculate mean scores and 95% CIs in addition to identifying independent prognostic factors. Results: With a median follow-up time of 73.9 months (interquartile range, 60.7 to 84.2 months), 33 possible cases of ONJ were reported, all in the zoledronate-treated patients. Twenty-six cases were confirmed as being consistent with a diagnosis of ONJ, representing a cumulative incidence of 2.1% (95% CI, 0.9% to 3.3%) in the zoledronate arm. Three hundred sixty-two patients (74%) returned the OHIP-14 questionnaire. Neither the prevalence nor severity of impacts on Oral-QoL differed significantly between zoledronate patients and control patients. Conclusion: Adjuvant zoledronate used in the intensive schedule studied in the AZURE trial is associated with a low incidence of ONJ but does not seem to adversely affect Oral-QoL.

Accelerated versus standard epirubicin followed by cyclophosphamide, methotrexate, and fluorouracil or capecitabine as adjuvant therapy for breast cancer in the randomised UK TACT2 trial (CRUK/05/19): a multicentre, phase 3, open-label, randomised, controlled trial (2017)

Type of publication:
Randomised controlled trial

Author(s):
David Cameron, James P Morden, Peter Canney, Galina Velikova, Robert Coleman, John Bartlett, *Rajiv Agrawal, Jane Banerji, Gianfilippo Bertelli, David Bloomfield, A Murray Brunt, Helena Earl, Paul Ellis, Claire Gaunt, Alexa Gillman, Nicholas Hearfield, Robert Laing, Nicholas Murray, Niki Couper, Robert C Stein, Mark Verrill, Andrew Wardley, Peter Barrett-Lee, Judith M Bliss, on behalf of the TACT2 Investigators

Citation:
Lancet Oncology; Jul 2017; vol. 18 (no. 7); p. 929-945

Abstract:
Adjuvant chemotherapy for early breast cancer has improved outcomes but causes toxicity. The UK TACT2 trial used a 2 × 2 factorial design to test two hypotheses: whether use of accelerated epirubicin would improve time to tumour recurrence (TTR); and whether use of oral capecitabine instead of cyclophosphamide would be non-inferior in terms of patients’ outcomes and would improve toxicity, quality of life, or both.

Link to full-text [Open access]

Altmetric Attention Score

Partial-breast radiotherapy after breast conservation surgery for patients with early breast cancer (UK IMPORT LOW trial): 5-year results from a multicentre, randomised, controlled, phase 3, non-inferiority trial (2017)

Type of publication:
Randomised controlled trial

Author(s):
Charlotte E Coles, Clare L Griffin, Anna M Kirby, Jenny Titley, *Rajiv K Agrawal, Abdulla Alhasso, Indrani S Bhattacharya, Adrian M Brunt, Laura Ciurlionis, Charlie Chan, Ellen M Donovan, Marie A Emson, Adrian N Harnett, Joanne S Haviland, Penelope Hopwood, Monica L Jefford, Ronald Kaggwa, Elinor J Sawyer, Isabel Syndikus, Yat M Tsang, Duncan A Wheatley, Maggie Wilcox, John R Yarnold, Judith M Bliss, on behalf of the IMPORT Trialists

Citation:
Lancet, Sep 2017; vol. 390 (no. 10099); p. 1048-1060

Abstract:
Local cancer relapse risk after breast conservation surgery followed by radiotherapy has fallen sharply in many countries, and is influenced by patient age and clinicopathological factors. We hypothesise that partial-breast radiotherapy restricted to the vicinity of the original tumour in women at lower than average risk of local relapse will improve the balance of beneficial versus adverse effects compared with whole-breast radiotherapy.

Link to full-text [Open access]

Breast cancer surgery without suction drainage and impact of mastectomy flap fixation in reducing seroma formation (2017)

Type of publication:
Conference abstract

Author(s):
*Zaidi S.; *Hinton C.

Citation:
European Journal of Surgical Oncology; May 2017; vol. 43 (no. 5)

Abstract:
Background: One of the most invalidating complications after breast cancer surgery is seroma formation. The incidence of seroma formation after breast surgery varies from 3% to 85%. Seroma formation and inadequate drainage of seroma may lead to infections, pain, hospitalization and delay in treatment. Methods employed to prevent seromata include suction drainage, shoulder immobilization, quilting sutures, fibrin sealants. Aim: To determine the effect of a ‘no drains’ policy on seroma formation and other complications in women undergoing breast cancer surgery and to evaluate the effect of obliteration of dead space by suture fixation of the mastectomy flaps to the underlying chest wall, on the amount and duration of postoperative fluid drainage and incidence of seroma formation after breast surgery. Materials and methods: A retrospective analysis was performed on a consecutive series of patients that had been treated with mastectomy with or without axillary surgery for breast cancer for the last 1 year. Patients divided into Group 1 the wound was closed in the conventional method at the edges and closed suction drains are used. Group 2; after completing the mastectomy procedure, using absorbable sutures (vicryl), continuous stitches 3 cm apart were taken, in rows, between the subcutaneous tissues of the skin flaps and the underlying muscles. Special attention is taken to the obliteration of the largest potential dead space, the empty axillary apex. Closed suction drains are used. Group 3 similar procedure but no drain used. The patient characteristics collected were: age, type of surgery, side of the affected breast, neoadjuvant chemotherapy, diabetes, body mass index (BMI), smoking, anticoagulants usage and length of hospital stay. Definitions: Postoperative haematoma: clear postoperative haematoma formation in the area of the operation, for which intervention is necessary. Wound infection: clinical signs of infection (pain, swelling, erythema, fever, exudate, delayed wound healing or breakdown), purulent discharge or a positive microbiological culture. Seroma production: palpable fluid collection, with serous consistency, produced subcutaneous in the area of operation or axilla Results: 113 women were included in the study. Women underwent modified radical mastectomy (MRM) and ALND , MRM +/- sentinel lymph node biopsy (SLNB) /axillary node sampling (ANS) and simple Mx. There was no significant difference between the studied groups concerning the age, type of surgery, side of the affected breast, neoadjuvant chemotherapy, diabetes, body mass index (BMI), smoking, anticoagulants usage. There were six patients with evacuation of haematoma postoperatively and belong to group 1 and 2 with drains. The number (and percentage) of women with wound infection was none in the group 1, 8 in gp 2 and 2 among gp 3 patients. Seroma formation was 10 in gp 1, 9 in gp 2 and 4 in gp 3. The length of hospital stays (days) was 2.7 in gp 1, 2.6 in gp 2 and 1.3 days in gp 3 patients with no drains (ND). Conclusion: This study investigated that wound drainage following mastectomy could be avoided by suturing flaps to the underlying chest wall, thereby facilitating early discharge with no associated increase in surgical morbidity. This study suggests that MRM +/- ALND/SLNB/ANS can be performed without the use of suction drains without increasing seroma formation and other complication rates. Adopting a ‘nodrains’ policy may also contribute to earlier hospital discharge.

Link to full-text: http://www.ejso.com/article/S0748-7983(17)30225-1/abstract

Addition of gemcitabine to paclitaxel, epirubicin, and cyclophosphamide adjuvant chemotherapy for women with early-stage breast cancer (tAnGo): final 10-year follow-up of an open-label, randomised, phase 3 trial (2017)

Type of publication:
Randomised controlled trial

Author(s):
Earl, Helena M; Hiller, Louise; Howard, Helen C; Dunn, Janet A; Young, Jennie; Bowden, Sarah J; McDermaid, Michelle; Waterhouse, Anna K; Wilson, Gregory; *Agrawal, Rajiv; O’Reilly, Susan; Bowman, Angela; Ritchie, Diana M; Goodman, Andrew; Hickish, Tamas; McAdam, Karen; Cameron, David; Dodwell, David; Rea, Daniel W; Caldas, Carlos; Provenzano, Elena; Abraham, Jean E; Canney, Peter; Crown, John P; Kennedy, M John; Coleman, Robert; Leonard, Robert C; Carmichael, James A; Wardley, Andrew M; Poole, Christopher J; tAnGo trial collaborators

Citation:
The Lancet. Oncology, Volume 18, No. 6, p755–769, June 2017

Abstract:
BACKGROUND The tAnGo trial was designed to investigate the potential role of gemcitabine when added to anthracycline and taxane-containing adjuvant chemotherapy for early breast cancer. When this study was developed, gemcitabine had shown significant activity in metastatic breast cancer, and there was evidence of a favourable interaction with paclitaxel. METHOD StAnGo was an international, open-label, randomised, phase 3 superiority trial that enrolled women aged 18 years or older with newly diagnosed, early-stage breast cancer who had a definite indication for chemotherapy, any nodal status, any hormone receptor status, Eastern Cooperative Oncology Group performance status of 0-1, and adequate bone marrow, hepatic, and renal function. Women were recruited from 127 clinical centres and hospitals in the UK and Ireland, and randomly assigned (1:1) to one of two treatment regimens: epirubicin, cyclophosphamide, and paclitaxel (four cycles of 90 mg/m2 intravenously administered epirubicin and 600 mg/m2 intravenously administered cyclophosphamide on day 1 every 3 weeks, followed by four cycles of 175 mg/m2 paclitaxel as a 3 h infusion on day 1 every 3 weeks) or epirubicin, cyclophosphamide, and paclitaxel plus gemcitabine (the same chemotherapy regimen as
the other group, with the addition of 1250 mg/m2 gemcitabine to the paclitaxel cycles, administered intravenously as a 0·5 h infusion on days 1 and 8 every 3 weeks). Patients were randomly assigned by a central computerised deterministic minimisation procedure, with stratification by country, age, radiotherapy intent, nodal status, and oestrogen receptor and HER-2 status. The primary endpoint was disease-free survival and the trial aimed to detect 5% differences in 5-year disease-free survival between the treatment groups. Recruitment completed in 2004 and this is the final, intention-to-treat analysis. This trial is registered with EudraCT (2004-002927-41), ISRCTN (51146252), and ClinicalTrials.gov (NCT00039546).FINDINGS Between Aug 22, 2001, and Nov 26, 2004, 3152 patients were enrolled and randomly assigned to epirubicin, cyclophosphamide, paclitaxel, and gemcitabine (gemcitabine group; n=1576) or to epirubicin, cyclophosphamide, and paclitaxel (control group; n=1576). 11 patients (six in the gemcitabine group and five in the control group) were ineligible because of pre-existing metastases and were therefore excluded from the analysis. At this protocol-specified final analysis (median follow-up 10 years [IQR 10-10]), 1087 disease-free survival events and 914 deaths had occurred. Disease-free survival did not differ significantly between the treatment groups at 10 years (65% [63-68] in the gemcitabine group vs 65% [62-67] in the control group), and median disease-free survival was not reached (adjusted hazard ratio 0·97 [95% CI 0·86-1·10], p=0·64). Toxicity, dose intensity, and a detailed safety substudy showed both regimens to be safe, deliverable, and tolerable. Grade 3 and 4 toxicities were reported at expected levels in both groups. The most common were neutropenia (527 [34%] of 1565 patients in the gemcitabine group vs 412 [26%] of 1567 in the control group), myalgia and arthralgia (207 [13%] vs 186 [12%]), fatigue (207 [13%] vs 152 [10%]), infection (202 [13%] vs 141 [9%]), vomiting (143 [9%] vs 108 [7%]), and nausea (132 [8%] vs 102 [7%]).INTERPRETATION The addition of gemcitabine to anthracycline and taxanebased adjuvant chemotherapy at this dose and schedule confers no therapeutic advantage in terms of disease free survival in early breast cancer, although it can cause increased toxicity. Therefore, gemcitabine has not been added to standard adjuvant chemotherapy in breast cancer for any subgroup.FUNDING Cancer Research UK core funding for Clinical Trials Unit at the University of Birmingham, Eli Lilly, Bristol-Myers Squibb, and Pfizer.

Altmetric Attention Score