Abstract
Purpose
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.
Methods
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.
Results
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.
Conclusions
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.
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References
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.
Hughes KS, Schnaper LA, Berry D, et al. Lumpectomy plus Tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med. 2004;351(10):971–7. doi:10.1056/NEJMoa040587.
Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013;31(19):2382–7. doi:10.1200/JCO.2012.45.2615.
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.
NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed November 8, 2016.
Soulos PR, Yu JB, Roberts KB, et al. Assessing the impact of a Cooperative Group Trial on Breast Cancer Care in the medicare population. J Clin Oncol. 2012;30(14):1601–7. doi:10.1200/JCO.2011.39.4890.
Shirvani SM, Jiang J, Likhacheva A, et al. Trends in local therapy utilization and cost for early-stage breast cancer in older women: implications for payment and policy reform. Int J Radiat Oncol. 2016;95(2):605–16. doi:10.1016/j.ijrobp.2016.01.059.
Shen X, Anne PR, Keith SW, et al. Radiation therapy use and outcomes among older women with ER-positive and ER-negative stage I breast cancer. Am J Clin Oncol. 2014;37(3):241–7. doi:10.1097/COC.0b013e318271b326.
Rhieu B, Rajagopalan M. Patterns of care for omission of radiation therapy for elderly women with early-stage breast cancer receiving hormonal therapy. Pract Radiat Oncol 2015;5(4):e267–e273. doi:10.1016/j.prro.2014.12.003.
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).
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.
Mauceri S, Miller T. Strategies for Controlling Biases in Survey Data. Int J Soc Res Methodol. 2008;11(1):79–85. doi:10.1080/13645570701814564.
Jagsi R, Abrahamse P, Morrow M, et al. Patterns and correlates of adjuvant radiotherapy receipt after lumpectomy and after mastectomy for breast cancer. J Clin Oncol. 2010;28(14):2396–403. doi:10.1200/JCO.2009.26.8433.
Zhou J, Griffith KA, Hawley ST, et al. Surgeons’ knowledge and practices regarding the role of radiation therapy in breast cancer management. Int J Radiat Oncol Biol Phys. 2013;87(5):1022–9. doi:10.1016/j.ijrobp.2013.08.031.
Jagsi R, Smith BD, Sabel M, Pierce L. Individualized, patient-centered application of consensus guidelines to improve the quality of breast cancer care. Int J Radiat Oncol Biol Phys. 2014;88(3):535–6. doi:10.1016/j.ijrobp.2013.11.236.
Hughes KS, Schnaper LA. Can older women with early breast cancer avoid radiation? Lancet Oncol. 2015;16(3):235–7. doi:10.1016/S1470-2045(15)70014-8.
Williams GR, Jones E, Muss HB. Challenges in the treatment of older breast cancer patients. Hematol Oncol Clin North Am. 2013;27(4):785–804. doi:10.1016/j.hoc.2013.05.008.
Smith BD, Jiang J, McLaughlin SS, et al. Improvement in breast cancer outcomes over time: Are older women missing out? J Clin Oncol. 2011;29(35):4647–53. doi:10.1200/JCO.2011.35.8408.
Schonberg MA, Marcantonio ER, Ngo L, Li D, Silliman RA, McCarthy EP. Causes of death and relative survival of older women after a breast cancer diagnosis. J Clin Oncol. 2011;29(12):1570–7. doi:10.1200/JCO.2010.33.0472.
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.
Ring A, Sestak I, Baum M, et al. Influence of comorbidities and age on risk of death without recurrence: a retrospective analysis of the Arimidex, tamoxifen alone or in combination trial. J Clin Oncol. 2011;29(32):4266–72. doi:10.1200/JCO.2011.35.5545.
Smith BD, Buchholz TA, Cancer A. Radiation treatments after breast-conserving therapy for elderly patients. J Clin Oncol. 2013;31(19):2367–68. doi:10.1200/JCO.2012.48.0939.
Walter LC, Covinsky KE. Cancer screening in elderly patients: A framework for individualized decision making. Jama. 2001;285(21):2750–6. doi:10.1001/jama.285.21.2750.
Schonberg MA, Marcantonio ER, Ngo L, Silliman RA, McCarthy EP. Does life expectancy affect treatment of women aged 80 and older with early stage breast cancers? J Geriatr Oncol. 2012;3(1):8–16. doi:10.1016/j.jgo.2011.10.002.
Schonberg MA, Birdwell RL, Bychkovsky BL, et al. Older women’s experience with breast cancer treatment decisions. Breast Cancer Res Treat. 2014;145(1):211–23. doi:10.1007/s10549-014-2921-y.
Feinstein AJ, Soulos PR, Long JB, et al. Variation in receipt of radiation therapy after breast-conserving surgery: assessing the impact of physicians and geographic regions. Med Care. 2013;51(4):330–8. doi:10.1097/MLR.0b013e31827631b0.
Hawley ST, Hofer TP, Janz NK, et al. Correlates of between-surgeon variation in breast cancer treatments. Med Care. 2006;44(7):609–16. doi:10.1097/01.mlr.0000215893.01968.f1.
Mandelblatt JS, Faul LA, Luta G, et al. Patient and physician decision styles and breast cancer chemotherapy use in older women: Cancer and leukemia group B protocol 369901. J Clin Oncol. 2012;30(21):2609–14. doi:10.1200/JCO.2011.40.2909.
Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction: A prospective validation of 3 methods of measuring quality. Jama. 2000;283(13):1715–22.
Veloski J, Tai S, Evans AS, Nash DB. Clinical vignette-based surveys: a tool for assessing physician practice variation. Am J Med Qual. 2005;20(3):151–7. doi:10.1177/1062860605274520.
Walker GA, Kaidar-Person O, Kuten A, Morgan DAL. Radiotherapy as sole adjuvant treatment for older patients with low-risk breast cancer. Breast. 2012;21(5):629–34. doi:10.1016/j.breast.2012.06.008.
Acknowledgement
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).
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Shumway, D.A., Griffith, K.A., Sabel, M.S. et al. Surgeon and Radiation Oncologist Views on Omission of Adjuvant Radiotherapy for Older Women with Early-Stage Breast Cancer. Ann Surg Oncol 24, 3518–3526 (2017). https://doi.org/10.1245/s10434-017-6013-1
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DOI: https://doi.org/10.1245/s10434-017-6013-1