Surgeon and Radiation Oncologist Views on Omission of Adjuvant Radiotherapy for Older Women with Early-Stage Breast Cancer
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Although clinical trials have shown no survival advantage and only a modest improvement in local control from adjuvant radiotherapy after lumpectomy in older women with stage I, estrogen receptor-positive (ER+) breast cancer, radiotherapy is commonly administered, raising concerns about overtreatment. Therefore, we sought to evaluate physician views on omission of radiotherapy in older women with favorable prognosis breast cancer.
We surveyed a national sample of 713 radiation oncologists and 879 surgeons. Of these, 1504 were eligible and 825 responded (55%). We assessed responses to clinical scenarios, knowledge of pertinent risk information, and correlates of views on radiotherapy omission.
Omission of radiotherapy in patients age ≥70 years with stage I, ER+ breast cancer, treated with lumpectomy and endocrine therapy, was felt to be unreasonable by 40% of surgeons and 20% of radiation oncologists. Many surgeons (29%) and radiation oncologists (10%) erroneously associated radiotherapy in older women with improvement in survival. Similarly, 32% of surgeons and 19% of radiation oncologists tended to substantially overestimate the risk of locoregional recurrence in older women with omission of RT. In a scenario with an 81-year-old with multiple comorbidities, 31% of surgeons and 35% of radiation oncologists would still recommend radiotherapy.
Many radiation oncologists and surgeons continue to consider omission of radiotherapy as substandard therapy and overestimate the benefits of radiotherapy. Surgeons, in addition to radiation oncologists, may have an opportunity to play a pivotal role in reducing overuse of aggressive care in this setting.
This work was supported by a grant from the Conquer Cancer Foundation, the Breast Cancer Research Foundation, and intramural pilot project funding from the Cancer Surveillance and Outcomes Research Team (CanSORT) to D.S, and by the National Cancer Institute of the National Institutes of Health (P01CA163233). We thank Steven Katz, MD, MPH, Sarah Hawley, PhD, MPH, and Rose Juhasz, PhD for the scientific and administrative leadership of CanSORT and P01 elements that supported this work, and Research Management Team members Rebecca Morrison, MPH, Stefanie Goodell, BS, Alex Jeanpierre, MPH, and Rachel Tocco, MA, for their efforts in supporting this project. Study data were collected and managed using REDCap electronic data capture tools hosted at University of Michigan (Michigan Institute for Clinical & Health Research grant support CTSA: UL1TR000433).
The authors have no conflicts of interest to disclose.
- 1.Darby S, McGale P, Correa C, et al. 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. 2011;378(9804):1707–16. doi: 10.1016/S0140-6736(11)61629-2.CrossRefPubMedGoogle Scholar
- 4.Kunkler IH, Williams LJ, Jack WJL, Cameron DA, Dixon JM. Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial. Lancet Oncol. 2015;16(3):266–73. doi: 10.1016/S1470-2045(14)71221-5.CrossRefPubMedGoogle Scholar
- 5.NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed November 8, 2016.
- 10.Dillman DA, Smyth JD, Christian LM, ebrary I. Internet, phone, mail, and mixed-mode surveys the tailored design method. 2014:1 online resource (530 pages).Google Scholar
- 11.Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. doi: 10.1016/j.jbi.2008.08.010.CrossRefPubMedGoogle Scholar
- 20.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. doi: 10.1001/jama.2012.84.