Radiation After Lumpectomy in Women ≥70 Still Common

Fran Lowry

February 11, 2016

Despite evidence that use of adjuvant radiation therapy (RT) after lumpectomy yields no survival benefit for elderly women (aged 70 years and older) with small, estrogen-receptor-positive (ER+) breast cancer ― a fact that has been incorporated into guidelines recommending against it ― adjuvant RT continues to to be used in this setting.

In 2004, the Cancer and Leukemia Group B (CALGB) 9343 trial concluded that adjuvant RT can be safely omitted in such women, and the National Comprehensive Cancer Network (NCCN) subsequently released its national practice guidelines supporting the CALGB's position.

But the use of RT in these women has declined by only 3% since that time, researchers report in a study published in the Journal of the American College of Surgeons

The finding demonstrates either a "surprising" lack of compliance with the guidelines or a lack of awareness of the recommended treatment for many women with breast cancer, lead author Quyen D. Chu, MD, professor of surgery at Louisiana State University Health Sciences Center, in Shreveport, told Medscape Medical News.

Dr Quyen Chu

The CALGB 9343 researchers advised that it is safe to omit RT in cases involving the following characteristics:

  • patient aged 70 years or older

  • stage I breast cancer ≤2 cm in size, localized to the breast, with no spread to the lymph nodes

  • estrogen-receptor-positive tumor

  • surgical removal of the tumor with lumpectomy with negative surgical margins

  • subsequent long-term hormonal therapy (tamoxifen)

Dr Chu said he was prompted to compare the use of postlumpectomy RT before and after 2004 after noticing that some of his radiologist colleagues continued to favor its use.

"It made me wonder, if they were pushing for radiation, even though the literature suggests otherwise, what was the rest of the nation doing?" he said.

Dr Chu and his group evaluated data from a cohort of 205,860 women aged 70 years or older with stage I, ER+/PR+ breast cancer with lumpectomy who were diagnosed between 1998 and 2012. The data were taken from the National Cancer Data Base.

Approximately 50% of the women received their cancer diagnosis before the CALGB criteria were published (between 1998 and 2004); the other half, after publication (2005 to 2012).

They found that use of RT declined by 2.95% after publication of CALGB (68.71% before vs 65.76% after; P < .0001).

The greatest decline in RT use was seen in octagenarians (P < .0001). Despite such a decline, more than 56% of patients aged 80 to 84 years and 30% of patients aged 85 years or older continued to receive RT after the CALGB criteria were published.

The greatest decline in RT use occurred in academic research programs and comprehensive community cancer centers (3.6% and 3.12%, respectively; P < .0001 for both). Community cancer programs showed no statistically significant reduction (P = .076).

Dr Chu would like to see an increase in awareness of the CALGB recommendations among physicians and patients.

"I've had people in my institution come up to me and say their mother or grandmother did not realize that omitting radiation was an option. They were very surprised at this study because traditionally, whatever their doctors recommend is what they will go for. If the radiation oncologist says they need radiation, they will get it, but I think this study will empower patients as well as physicians to know about the recommendation and then ask if they really need radiation and what are the risks and benefits," Dr Chu said.

There is also a cost to society, he added.

The money that was been spent on radiotherapy, which does not affect overall survival, could have been spent on another treatment, he commented.

Some 70-Year-Olds Are Younger Than Others

For Bruce G. Haffty, MD, professor and chairman of radiation oncology at the Rutgers Cancer Institute of New Jersey, in New Brunswick, every patient is an individual.

Dr Bruce Haffty

"Our approach is to look at the patient's actual physical age, as well as her physiological age. There are 75-year-olds who are very young and fit, and there are 75-year-olds who are every bit their age and have a short life expectancy. That has to go into the decision-making of whether you offer them radiation or not," Dr Haffty told Medscape Medical News.

Omitting radiation is an option, but so is RT, because it lowers the chances of local recurrence, he said.

"If someone is elderly, has a short life expectancy and other multiple health problems, there is no reason why we should put them through a course of radiation, because there's no significant benefit. But if a very healthy 72-year-old woman who is likely going to live for another 10 or maybe 20 years wants radiation, she should not be denied that, because it will lower her local recurrence," Dr Haffty said.

Radiation can also be an option for the older woman who does not want to receive hormonal therapy, he added.

"I think they should go on hormonal therapy, but there may be reasons why they do not, and in those cases, we might push them a little bit more to have radiation to give them more protection against local recurrence. The main thing is that we continue to discuss the issue with our patients," Dr Haffty said.

CALGB Provided Good Evidence for RT Omission

Amber Orman, MD, from the Moffitt Cancer Center, Tampa, Florida, agrees that a discussion of the pros and cons with each patient is important.

Dr Amber Orman

"I have a balanced discussion with each patient who fits into this category. Many things factor into the joint decision-making process, including comorbidities, patient comfort level with a slgithly increased rate of locoregional recurrence, length of treatment, and toxicities," Dr Orman told Medscape Medical News.

"The patients in my practice who receive radiotherapy are physiologically younger than their actual age. They also have elected to forgo antihormonal therapy and are often uncomfortable with the slightly increased risk of local recurrence. I typically treat this small proportion of patients with some sort of accelerated partial breast technique or hypofractionated whole-breast radiation," she said.

"The CALGB 9343 trial provides good evidence for radiation omission in a subset of favorable patients receiving antihormonal therapy after partial mastectomy, allowing us to more effectively utilize resources," Dr Orman said.

The study was supported by the Charles D. Knight Sr. Endowed Professorship of Surgery. Dr Chu, Dr Haffty, and Dr Orman report no relevant financial relationships.

J Am Coll Surg. Published online January 27, 2016. Abstract

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