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Trends in Locoregional Therapy in Older Women with Early-Stage Hormone Receptor-Positive Breast Cancer by Frailty and Life Expectancy

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

In women ≥ 70 years of age with T1N0 hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2−) breast cancer, breast surgery type and omission of axillary surgery or radiation therapy (RT) do not impact overall survival. Although frailty and life expectancy ideally factor into therapy decisions, their impact on therapy receipt is unclear. We sought to identify trends in and factors associated with locoregional therapy type by frailty and life expectancy.

Methods

Women ≥ 70 years of age with T1N0 HR+/HER2− breast cancer diagnosed in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database between 2010 and 2015 were stratified by validated claims-based frailty and life expectancy measures. Therapy trends over time by regimen intensity (‘high intensity’: lumpectomy + axillary surgery + RT, or mastectomy + axillary surgery; ‘moderate intensity’: lumpectomy + RT, lumpectomy + axillary surgery, or mastectomy only; or ‘low intensity’: lumpectomy only) were analyzed. Factors associated with therapy type were identified using generalized linear mixed models.

Results

Of 16,188 women, 21.8% were frail, 22.2% had a life expectancy < 5 years, and only 12.3% fulfilled both criteria. In frail women with a life expectancy < 5 years, high-intensity regimens decreased significantly (48.8–31.2%; p < 0.001) over the study period, although in 2015, 30% still received a high-intensity regimen. In adjusted analyses, frailty and life expectancy < 5 years were not associated with breast surgery type but were associated with a lower likelihood of axillary surgery (frailty: odds ratio [OR] 0.86, 95% confidence interval [CI] 0.76–0.96; life expectancy < 5 years: OR 0.22, 95% CI 0.20–0.25). Life expectancy < 5 years was also associated with a lower likelihood of RT receipt in breast-conserving surgery patients (OR 0.30, 95% CI 0.27–0.34).

Conclusions

Rates of high-intensity therapy are decreasing but overtreatment persists in this population. Continued efforts aimed at appropriate de-escalation of locoregional therapy are needed.

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Data Availability

These data will not be shared as this dataset is widely used/publicly available.

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Acknowledgment

This research was funded by the American Society of Clinical Oncology Conquer Cancer Foundation (Young Investigator Award in Geriatric Oncology). Mara A. Schonberg’s effort was supported by NIH/NIA K24 (5K24AG071906). Christina A. Minami reports research support (to the institution) from the American Society of Clinical Oncology Conquer Cancer Foundation (Young Investigator Award, 2020–2021), American College of Surgeons (Faculty Research Fellowship, 2020–2022), and a Grant for Early Medical/Surgical Specialists’ Transition to Aging Research (GEMSSTAR). Elizabeth A. Mittendorf acknowledges support as the Rob and Karen Hale Distinguished Chair in Surgical Oncology. This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the National Cancer Institute; Information Management Services (IMS), Inc.; and the SEER Program tumor registries in the creation of the SEER-Medicare database. This project included data from the California Cancer Registry. The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; Centers for Disease Control and Prevention’s (CDC’s) National Program of Cancer Registries, under cooperative agreement 1NU58DP007156; the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program under contract HHSN261201800032I awarded to the University of California, San Francisco, contract HHSN261201800015I awarded to the University of Southern California, and contract HHSN261201800009I awarded to the Public Health Institute. The ideas and opinions expressed herein are those of the authors and do not necessarily reflect the opinions of the State of California, Department of Public Health, the National Cancer Institute, and the CDC, or their contractors and subcontractors.

Funding

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Authors and Affiliations

  1. Division of Breast Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA, USA

    Christina A. Minami MD, MS, FACS, Tari A. King MD, FACS & Elizabeth A. Mittendorf MD, PhD, MHCM, FACS

  2. Breast Oncology Program, Dana-Farber/Brigham and Women’s Cancer Center, Boston, MA, USA

    Christina A. Minami MD, MS, FACS, Rachel A. Freedman MD, MPH, Tari A. King MD, FACS & Elizabeth A. Mittendorf MD, PhD, MHCM, FACS

  3. Harvard Medical School, Boston, MA, USA

    Christina A. Minami MD, MS, FACS, Rachel A. Freedman MD, MPH, Mara A. Schonberg MD, MPH, Tari A. King MD, FACS & Elizabeth A. Mittendorf MD, PhD, MHCM, FACS

  4. Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA

    Christina A. Minami MD, MS, FACS & Ginger Jin MS

  5. Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA

    Rachel A. Freedman MD, MPH

  6. Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Mara A. Schonberg MD, MPH

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  1. Christina A. Minami MD, MS, FACS
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Contributions

Conceptualization: CAM; Data curation: CAM, GJ; Formal analysis: CAM, GJ; Funding acquisition: CAM, EAM; Investigation: CAM, GJ, MAS, RAF, TAK, EAM; Methodology: CAM, GJ, MAS, RAF; Project administration: CAM; Resources: CAM; Software: GJ; Visualization: CAM; Writing—original draft: CAM; Writing—review and editing: CAM, GJ, MAS, RAF, TAK, EAM; Supervision: CAM, EAM, TAK; Validation: CAM, GJ; CAM had full access to all the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis.

Corresponding author

Correspondence to Christina A. Minami MD, MS, FACS.

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Disclosure

Tari A. King reports speaker honoraria and compensated service on the Scientific Advisory Board of Exact Sciences. Elizabeth A. Mittendorf reports compensated service on Scientific Advisory Boards for Astra Zeneca, BioNTech and Merck; uncompensated service on Steering Committees for Bristol Myers Squibb and Roche/Genentech; speakers honoraria and travel support from Merck Sharp & Dohme; and institutional research support from Roche/Genentech (via an SU2C grant) and Gilead. She also reports research funding from Susan Komen for the Cure for which she serves as a Scientific Advisor, and uncompensated participation as a member of the American Society of Clinical Oncology Board of Directors. Christina A. Minami, Ginger Jin, Rachel A. Freedman, and Mara A. Schonberg report no disclosures or conflicts of interest.

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Minami, C.A., Jin, G., Freedman, R.A. et al. Trends in Locoregional Therapy in Older Women with Early-Stage Hormone Receptor-Positive Breast Cancer by Frailty and Life Expectancy. Ann Surg Oncol 31, 920–930 (2024). https://doi.org/10.1245/s10434-023-14446-8

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