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Variation in type of adjuvant chemotherapy received among patients with stage I breast cancer: a multi-institutional Portuguese cohort study

Publication . Ferreira, Arlindo; Palha, Ana; Correia, Lurdes; Filipe, Pedro; Rodrigues, Vasco; Costa, Luis; Miranda, Ana; André, Rosário; Fernandes, João; Gouveia, Joaquim; Passos-Coelho, José Luís; Moreira, António; Brito, Margarida; Ribeiro, Joana; Metzger-Filho, Otto; U. Lin, Nancy; Vaz-Luís, Inês

Background: A contemporary US study showed an increase in the use of chemotherapy in the last decade for some patients with stage-I breast cancer; with a rise in more intensive regimens, and declining use of anthracyclines. Nevertheless, there is still uncertainty on the absolute benefit of chemotherapy for these patients and the optimal regimen. In this study we compare those findings with the patterns of care among a Portuguese cohort of stage-I breast cancers. Methods: Retrospective cohort study of patients with stage-I breast cancer diagnosed from 2006 to 2008 at four Portuguese institutions. The use and type of chemotherapy was evaluated. Results: Among patients with stage I-III breast cancer 39.4% (n = 682) had stage I disease. Of the 595 eligible patients, 22.4% were treated with chemotherapy, 33.9% aged <55 years vs. 12.7% aged >65 years (p < 0.001). Thirteen percent of patients with hormone receptor (HR)+/HER2- tumors, 52.7% of patients with HER2+ and 66.0% of patients with HR-/HER2- received chemotherapy (p < 0.001). In addition, we found inter-institutional variability, with the use of chemotherapy ranging from 0.0% to 43.4% (p < 0.001). Eighty-five percent of patients treated with chemotherapy received less-intensive regimens with anthracycline-based regimens, such as doxorubicin and cyclophosphamide, being the most frequently used, while docetaxel and cyclophosphamide was only used in 1.5% of cases. Conclusions: Overall, almost one-quarter of patients received chemotherapy with institutional variability. When treated, mostly less-intensive associations including anthracyclines were used, which contrasts with contemporary US practice. This study highlights the need for health-services research to understand local practices and tailor quality improvement interventions.

2016Journal article

Restricted access

Padrões de tratamento e outcomes em doentes com cancro da mama T1 N0

Publication . Luis, Inês Maria Vaz Duarte; Costa, Luís Marques da; Lin, Nancy Uan-Tsin

Treatment decisions in Stage I breast cancer patients are challenging. To better inform these decisions, we used quantitative research methods to 1) study survival outcomes among patients with the smallest Stage I breast cancers (tumours with less than 1 cm [T1a, b N0]), 2) examine treatment time trends among patients with Stage I breast cancers, and 3) interrogate patients regarding the minimum survival benefit needed in order to accept adjuvant chemotherapy. Using an US contemporary cohort of ~4.000 patients, we found that, there are women with T1a,b tumors who have an excellent prognosis without chemotherapy, but size and tumor subtype may identify patients in whom the rate of recurrence justifies considering chemotherapy. Expanding the analyses to all stage I breast cancer tumors (~10.000 patients), we also found out that, particularly for subtypes such as human epidermal growth factor 2 (HER2) + and hormone receptor (HR)-HER2- breast cancers, there was an increase of use of chemotherapy over the last decade, and when treated there was an increase in use of intensive chemotherapy with substantial institutional and costs variations. In this same cohort, aggressive surgical strategies were in rise, with an increasing proportion of women with unilateral cancer treated with bilateral mastectomy. In contrast, in a Portuguese cohort of ~500 patients, mostly less-intensive associations of chemotherapy were used, also with substantial institutional variations. Finally, among ~500 patients who received contemporary adjuvant chemotherapy in a randomized controlled trial, we found substantial variation in preferences regarding benefit worth undergoing chemotherapy (57% of patients would consider 6 months of chemotherapy for 2 months of benefit, whereas there was a small minority [2%] of patients that would say no to 6 months of chemotherapy for 24 months of benefit). Differences between patient and physician choices were also apparent. This study identifies subgroups of Stage I breast cancer patients to whom we can safely avoid chemotherapy and subgroups of patients to whom chemotherapy can be considered. It also highlights that in an area, which treatments may be questionable, there is substantial institutional and regional variability calling into questioning the challenges around treatment options and highlighting that these patients represent an optimal group to evaluate less toxic adjuvant regimens to maintain efficacy while minimizing short- and long term risks. Finally, it shows that eliciting preferences regarding risks and benefits of adjuvant chemotherapy is critical.

2017Doctoral thesis

Open access