Worse Outcomes for Breast Cancer Patients with Other Illnesses

Older breast cancer patients who have additional medical conditions have worse survival than patients without other illnesses.? These findings were recently published in the Journal of the National Cancer Institute.?

According to results from previous studies, illness in addition to breast cancer may shorten survival and increase death rates among older women with breast cancer. Studies to date have assessed the association between other illness as a whole and breast cancer death but have not evaluated specific illnesses independently.??

To better understand how medical conditions in addition to breast cancer may affect survival among older women, researches selected 13 medical conditions to evaluate; these included stroke, chronic obstructive pulmonary disease, chronic renal failure, congestive heart failure, dementia, diabetes, liver disease, heart attack, paralysis, peripheral vascular disease, previous cancer, rheumatoid arthritis, and ulcers. A total of 64,034 breast cancer patients were included in the study. Patients were 66 years old and older and had been diagnosed with breast cancer between 1992 and 2000.??

42% of patients had a history of one or more of the selected illness. ?Patients with selected illnesses experienced shorter overall survival times and increased overall deaths from breast cancer and other conditions compared with patients without another illness.?When patients between 66 and 74 years of age were further analyzed according to age and type of illness other than breast cancer, overall survival was worse or similar among patients with Stage I breast cancer and another illness compared with patients with Stage II breast cancer and no other illness.??

It appears that certain illnesses in addition to breast cancer may decrease overall survival and increase death among older women with breast cancer. These findings may help doctors more accurately predict survival among breast cancer patients. As well, they underscore the importance of balancing treatment for breast cancer with treatment for other conditions.?

Reference: Patnaik JL, Byers T, DiGuiseppi C, et al. The influence of comorbidities on overall survival among older women diagnosed with breast cancer. Journal of the National Cancer Institute [online publication]. June 30, 2011.?

Posted July 21, 2011

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Study Evaluates Predictors of DCIS Outcomes

Choice of treatment, choice of surgeon, and surgical margin (a measure of whether the cancer was completely removed) all appear to affect the risk of disease recurrence among women with ductal carcinoma in situ (DCIS) of the breast.? These findings were reported in the Journal of the National Cancer Institute.

Ductal carcinoma in situ refers to a condition in which abnormal cells are found within a breast duct but have not spread outside of the duct to other tissues in the breast. It is most commonly detected by screening mammography. If not treated, some cases of DCIS may progress to invasive breast cancer.

Treatment for DCIS tends to vary. Options include lumpectomy with or without radiation therapy or mastectomy. Data comparing outcomes of different treatment options, as well as how individual outcomes vary by surgeon, have previously been limited.

To compare outcomes of different treatments for DCIS, researchers reviewed the medical records of 994 women who had been diagnosed with DCIS between 1985 and 2000. They evaluated treatment (surgery and radiation therapy), margin status, and the role of surgeons and how these factors affect outcomes. The margin refers to the edges of the tissue that is removed surgically. If cancer cells are found at or near the margin (positive margin), it’s possible that the cancer was not completely removed.

Type of treatment had a significant impact on recurrence risk at five years. Mastectomy was associated with the lowest risk of recurrence, followed by breast-conserving surgery with radiation therapy. Women who received breast-conserving surgery without radiation therapy had the highest risk of recurrence. Margin status was also significantly associated with disease-free survival, with negative margins linked with improved disease-free survival.Disease-free survival also varied by surgeon. Choice of surgeon appeared to account for 15-30% of the variability in outcome.

These findings indicate that treatment type, margin status, and choice of surgeon are important predictors of long-term disease-free survival in DCIS. Recurrence risk is lowest for women with negative surgical margins and for women who are treated with mastectomy or the combination of breast-conserving surgery and radiation therapy.

Reference: Dick AW, Sorbero MS, Ahrendt GM, et al. Comparative effectiveness of ductal carcinoma in situ management and the roles of margins and surgeons. Journal of the National Cancer Institute [early online publication]. January 3, 2011.

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Additional Evidence That Post-Lumpectomy Radiation Improves Breast Cancer Outcomes

?In addition to reducing the risk of breast cancer recurrence, post-lumpectomy radiation therapy improves survival among women with early breast cancer. These results—from a combined analysis of 17 previous studies—were published in The Lancet.?????

Surgery for early-stage breast cancer may consist of mastectomy or lumpectomy. A?mastectomy?involves removal of the entire breast, whereas a?lumpectomy?involves removal of the cancer and some surrounding tissue. A lumpectomy is usually followed by radiation therapy in order to reduce the risk of cancer recurrence in or near the breast. The combination of lumpectomy and radiation therapy is referred to as breast-conserving therapy.???

Several previous studies have reported giving radiation therapy after lumpectomy results in a lower risk of breast cancer recurrence than lumpectomy alone. To further evaluate the benefits of post-lumpectomy radiation therapy, researchers conducted a combined analysis of 17 previous studies. These studies included more than 10,000 women with early-stage breast cancer.???

Post-lumpectomy radiation therapy reduced the 10-year risk of breast cancer recurrence from 35% to 19%. ?The 15-year risk of death from breast cancer was 25% among women who did not receive post-lumpectomy radiation therapy and 21% among women who did receive radiation therapy. ?For every four breast cancer recurrences that were prevented by radiation therapy by year 10, one breast cancer death was prevented by year 15.?Benefits of radiation therapy were seen in women with node-negative breast cancer as well as women with node-positive breast cancer.?

These results provide additional evidence that giving radiation therapy after a lumpectomy substantially reduces the risk of cancer recurrence and also reduces the risk of death from breast cancer.?????

Reference: Early Breast Cancer Trialists’ Collaborative Group. 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. Early online publication October 20, 2011.?

Posted October 27, 2011?

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Social Support May Improve Breast Cancer Outcomes

Social well-being during the first year after a breast cancer diagnosis may have a beneficial effect on cancer outcomes. These results were published in the Journal of Clinical Oncology.

A diagnosis of breast cancer often affects a woman’s quality of life, but it’s been less clear whether quality of life affects breast cancer outcomes. Quality of life has physical, psychological, social, and material aspects, and any one these (or a combination) may affect health.?

To explore the relationship between post-diagnosis quality of life and breast cancer outcomes, researchers evaluated information from the Shanghai Breast Cancer Study. The study enrolled more than 2,000 women. Information about quality of life was collected six and 36 months after diagnosis.

Women were followed for close to five years after their initial quality-of-life assessment.???

Social well-being at six months after diagnosis was linked with both survival and risk of recurrence. Women with the highest level of social well-being had a 38% reduction in risk of death and a 48% reduction in risk of recurrence. The aspects of social well-being that appeared to provide the most benefit were marriage and family, social support, and interpersonal relationships.The other measures of quality of life (physical, psychological, and material) at six months after diagnosis did not significantly cancer outcomes, although there was a suggestion that psychological well-being may be important.By 36 months after diagnosis, none of the quality of life measures were strongly linked with cancer outcomes.

The researchers conclude “Social well-being in the first year after cancer diagnosis is a significant prognostic factor for breast cancer recurrence or mortality, suggesting a possible avenue of intervention by maintaining or enhancing social support for women soon after their breast cancer diagnosis to improve disease outcomes.”

Reference: Epplein M, Zheng Y, Zheng W et al. Quality of life after breast cancer diagnosis and survival. Journal of Clinical Oncology. Early online publication December 20, 2010.

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Outcomes in Older Women with Breast Cancer

Among postmenopausal women with hormone receptor-positive breast cancer, the likelihood of dying from breast cancer increases with age. These results were published in the Journal of the American Medical Association. ?

Of the more than 200,000 cases of breast cancer diagnosed each year in the United States, roughly 40 percent occur in women over the age of 65. Research that explores how breast cancer outcomes change as women age has the potential to improve care for this large group of women.?

To evaluate breast cancer outcomes by age, researchers analyzed information from a clinical trial known as TEAM (Tamoxifen, Exemestane, Adjuvant, Multinational). The study enrolled more than 9,700 postmenopausal women with non-metastatic, hormone receptor-positive breast cancer. All women were treated with surgery and hormonal therapy. Decisions about chemotherapy and/or radiation therapy were left to the treating physician.?

Women were followed for just over five years.?

Death from breast cancer occurred in 5.7 percent of women under the age of 65, 6.3 percent of women between the ages of 65 and 74, and 8.3 percent of women age 75 or older.?Older women continued to be more likely to die from breast cancer even after the researchers accounted for tumor characteristics and other factors known to affect outcomes.??

One of the possible explanations for the worse breast cancer outcomes among older women involves treatment. Studies have suggested that older women are less likely than younger women to received standard breast cancer treatments, possibly due to concern that about the ability of older women to tolerate these treatments. In the current study, for example, 48 percent of the oldest women had breast cancer that had spread to the lymph nodes, but only 5 percent received chemotherapy. Older women were also less likely than younger women to receive radiation therapy after a lumpectomy.?

Although older women in this study were more likely to die of breast cancer than younger women, it should be noted that most women—regardless of their age—did not die of breast cancer. It should also be noted that all of the women in this study were postmenopausal. This study did not address cancer outcomes in premenopausal women.?

Reference: van de Water W, Markopoulos C, van de Velde CJH et al. Association between age at diagnosis and disease-specific mortality among postmenopausal women with hormone receptor-positive breast cancer. JAMA. 2012;307:590-597.?

Posted February 10, 2012

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Improved Breast Cancer Outcomes Among Women Using Beta-Blockers

Women who take beta-blockers for high blood pressure and are diagnosed with breast cancer may have better outcomes than women who do not take beta-blockers, according to findings from two recent studies. Results from both studies were recently published in the Journal of Clinical Oncology.?

Beta-blockers are a class of drugs used to treat heart conditions and high blood pressure. Studies have indicated that beta-blockers may help control growth and spread of breast cancer, possibly due to their ability to control stress hormones. Two current studies have further investigated this association.

One study, conducted by researchers from M.D. Anderson Cancer Center, reviewed 1,413 patients with breast cancer who had been treated with neoadjuvant chemotherapy (chemotherapy prior to surgery) between 1995 and 2007. Outcomes including complete response, relapse-free survival, and overall survival of those taking beta-blockers were compared with outcomes of those not taking beta-blockers.

Of the participants, 102 used beta-blockers. Rates of complete response among those using beta-blockers were not significantly different from complete response rates among non beta-blocker users. Beta-blockers use, however, was associated with significantly better relapse-free survival when the researchers accounted for age, race, disease stage and grade, receptor status, lymph node involvement, and other factors affecting disease outcome. Overall survival was not significantly improved among beta-blocker users. Patients diagnosed with triple-negative breast cancer who took beta-blockers had improved relapse-free survival but, like other patients, not significantly improved overall survival.

Another study of beta-blockers and breast cancer survival was conducted by researchers from Ireland.? Women diagnosed with Stage I to IV breast cancer between 2001 and 2006 were identified in a national cancer registry. Women who took beta-blockers in the year before they were diagnosed were matched and compared with women not taking beta-blockers. Two types of beta-blockers with different mechanisms were evaluated, propranolol and atenolol. The researchers assessed risk of tumor progression and spread and time to death from cancer.

Patients who used the beta-blocker propranolol had a significantly lower rate of death from breast cancer than their counterparts who didn’t used beta-blockers (9% versus 22%, respectively). Atenolol, however, was not associated with any improved outcomes.

These two studies suggest that beta-blockers could possibly improve outcomes among women with breast cancer, including those with difficult-to-treat triple-negative disease. However, it is far too early and beta blocker use should not be administered to women with breast cancer at this time until further research is done.

References:

Melhem-Bertrandt A, Chavez-MacGregor M, Lei X, et al. Beta-blocker use is associated with improved relapse-free survival in patients with triple-negative breast cancer. Journal of Clinical Oncology [early online publication]. May 31, 2011.
Barron TI, Connolly RM, Sharp L, et al. Beta blockers and breast cancer mortality: a population-based study. Journal of Clinical Oncology [early online publication]. May 31, 2011.

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Pregnancy Doesn’t Appear to Worsen Breast Cancer Outcomes

According to the results of a study conducted at the M. D. Anderson Cancer Center, women who are diagnosed with breast cancer and treated with chemotherapy while pregnant have a better disease-free survival (survival without a cancer recurrence or a new cancer) than women who are not pregnant at the time of diagnosis. Overall survival was similar in the two groups of patients. These results were presented at the 2010 Breast Cancer Symposium.

Previous reports have suggested that being pregnant at the time of diagnosis worsens breast cancer outcomes. This may have been due to older approaches to cancer treatment, in which pregnant women received less effective cancer treatment than non-pregnant women or delayed cancer treatment until after the birth of the baby.

A recent study compared breast cancer outcomes between pregnant and non-pregnant women who were treated with 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC).[1] In pregnant women, treatment with FAC was administered after the first trimester of pregnancy. When additional therapies—such as hormonal therapy—were warranted, these were started after the woman gave birth. Each of the 54 pregnant breast cancer patients treated was matched with two non-pregnant patients based on age and stage of cancer.

Overall survival between pregnant and non-pregnant women was similar. In fact, pregnant women appeared to have a slightly better overall five-year survival (77%) than their non-pregnant counterparts (72%). ??????????? This difference, however, was not statistically significant and may be the result of chance alone.

For five-year disease-free survival, results were significantly better for pregnant women: 74% versus 56% for non-pregnant women.

These results suggest that with current approaches to treatment, pregnancy does not worsen breast cancer outcomes. In a prepared statement, one of the authors of the study stated “Now, when we are counseling breast cancer patients who are pregnant, we can say that they should have every expectation that they will do as well as our non-pregnant patients, and that they should start their treatment in the second or third trimester without delay.”[2]

References:

[1] Litton JK, Warneke CL, Hahn K, et al. Case-control analysis of patients (pts) treated with chemotherapy during pregnancy for breast cancer (BC). Presented at the Breast Cancer Symposium, Washington, DC, October 1-3, 2010. Abstract 105.

[2] MD Anderson News Release. UT MD Anderson Study Finds Women Treated for Breast Cancer While Pregnant Have Improved Survival. 09/29/10.

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Hidden Lymph Node Metastases Have Small Effect on Breast Cancer Outcomes

Among women with early breast cancer and a sentinel lymph node that appears to be cancer-free on routine evaluation, more extensive lymph node evaluation identifies small areas of cancer in approximately 16% of women. These small, hidden areas of cancer appear to have only a small effect on cancer outcomes, suggesting that current approaches to lymph node evaluation are adequate. These results were published in the New England Journal of Medicine.

For women with early breast cancer, determining whether the cancer has spread to the axillary (under the arm) lymph nodes is an important part of cancer staging. Evaluation of the axillary nodes may involve either an axillary lymph node dissection (ALND), in which many lymph nodes are surgically removed and evaluated, or a less extensive procedure known as a sentinel lymph node biopsy.

Sometimes, very small areas of cancer may be missed on routine lymph node evaluation. These areas of cancer are referred to as “occult” (hidden) metastases. Some previous studies have found that breast cancer patients with occult lymph node metastases have worse outcomes than patients with lymph nodes that are truly cancer-free.

To further evaluate the importance of occult lymph node metastases, researchers evaluated information from the NSABP-B32 study. The primary objective of the study was to evaluate the safety and effectiveness of sentinel lymph node biopsy, but researchers have also been able to explore other questions, including the impact of occult metastases.

The current analysis focused on 3,887 women with sentinel lymph nodes that were negative (cancer-free) on routine evaluation. These lymph nodes underwent further evaluation in an effort to detect occult metastases.

Occult metastases were detected in 16% of patients.The presence of occult metastases was linked with a higher rate of recurrence and worse survival, but these effects were small. Five-year overall survival, for example, was 94.6% among women with occult metastases and 95.8% among women without occult metastases.

The researchers conclude that although occult metastases appear to influence breast cancer outcomes, the magnitude of the effect is very small. Efforts to detect occult metastases appear unlikely to provide much benefit. The researchers note that continued follow-up is warranted, and it remains possible that these results will change as more information becomes available. ?

Reference: Weaver DL, Ashikaga T, Krag KN et al. Effect of occult metastases on survival in node-negative breast cancer. New England Journal of Medicine. Early online publication January 19, 2011.

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