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Impact of omission of surgery on survival of older patients with breast cancer. BJS 2014; 101: 1397-1404.

Published: 4th August 2014

Authors: N. A. de Glas, J. M. Jonker, E. Bastiaannet, A. J. M. de Craen, C. J. H. van de Velde, S. Siesling et al.

Background

Older patients with breast cancer are often not treated in accordance with guidelines. With the emergence of endocrine therapy, omission of surgery can be considered in some patients. The aim of this population‐based study was to investigate time trends in surgical treatment between 1995 and 2011, and to evaluate the effects of omitting surgery on overall and relative survival in older patients with resectable breast cancer.

Method

Patients aged 75 years and older with stage I–III breast cancer diagnosed between 1995 and 2011 were selected from the Netherlands Cancer Registry. Time trends of all treatment modalities were evaluated using linear regression models. Changes in overall survival were calculated by Cox regression. Relative survival was calculated using the Ederer II method.

Results

Overall, 26 292 patients were included. The proportion of patients receiving surgical treatment decreased significantly, from 90·8 per cent in 1995 to 69·9 per cent in 2011 (P < 0·001). Multivariable analysis showed that overall survival did not change over time (hazard ratio 1·00 (95 per cent confidence interval (c.i.) 0·99 to 1·00) per year); nor did relative survival (relative excess risk 1·00 (0·98 to 1·02) per year).

Conclusion

Omission of surgery has become more common in older patients with breast cancer during the past 15 years in the Netherlands, but this has not altered overall or relative survival.

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Your comments

2 Comments

Kirsty McFarlane

3 years ago

Dear Sir,

The authors (1) concluded that the proportions of elderly breast cancer patients receiving surgical treatment have decreased over time without a concomitant decrease in survival. However, overall survival is not the only criteria to assess the impact of change in the standard treatment modality. Poor loco-regional control may prove to be a major cause of suffering to the patients. It must be reiterated that ‘quality of life’ issues cannot take a back seat and must be quantified. Frequently surgical resection provides good palliation of loco-regional symptoms yet it may not alter survival. With the current advancement in surgical and anaesthetic techniques, mastectomy or breast conservation surgery has minimal postoperative morbidity. Individualization of the treatment is the cornerstone of proving the best care to the patients. In the present study, 2794 of 11633 (24.0%) hormone (ER) sensitive breast cancer patients had only endocrine therapy compared to 183 of 1870 (9.7%) of hormone (ER) refractory breast cancer patients. Most oncologists would prescribe only endocrine therapy to elderly patients with hormone sensitive breast cancer if they have co-morbidities making them high risk for surgery. Using treatment across the board irrespective of stage and patient characteristics casts doubt on the viability and place of the surgical option in the elderly patients with breast cancer as is an over simplification.

Pankaj Kumar Garg
Department of Surgery
University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, India
Dilshad Garden
Delhi 110095
India
dr.pankajgarg@gmail.com

References:
1. de Glas NA, Jonker JM, Bastiaannet E, de Craen AJ, van de Velde CJ, SieslingS, Liefers GJ, Portielje JE, Hamaker ME. Impact of omission of surgery on survival of older patients with breast cancer. Br J Surg 2014 Aug 4. doi:10.1002/bjs.9616.

Kirsty McFarlane

3 years ago

Dear Editor,

We fully agree with Dr Garg that overall survival is not the only endpoint of interest when treatment modalities change over time. As discussed in our manuscript (1), the previously performed randomized clinical trials that assessed omission of surgical treatment in older patients with breast cancer concluded that omission of surgery resulted in poor locoregional control (2). However, it must be noted that 19.4% of all breast cancer patients who do receive surgery suffer from postoperative complications (3). It remains unclear if the possible benefits of surgical treatment in terms of locoregional control outweigh the risks of surgical treatment, as no previous studies assessed outcomes such as functional status or quality of life in relation to surgical treatment of older patients. Furthermore, current clinical trials that are being performed rarely include these endpoints (4). Therefore, we are currently performing a prospective, observational study in which these important endpoints are studied.

Secondly, Dr Garg mentions the large percentage of patients with HR-negative tumours who did receive endocrine treatment. We do agree that this may be inappropriate. It must be noted, however, that the percentage of patients with an HR-negative tumour who did receive endocrine treatment strongly decreased from 33.3% in 1997 to 5.2% in 2011. We therefore believe that this way of treating older patients is waning and is currently infrequently used in medical practice.

NA de Glas
JEA Portielje
ME Hamaker

Department of Geriatric Medicine
Diakonessenhuis Utrecht/Zeist/Doorn
Professor Lorentzlaan 76
3707 HL Zeist
The Netherlands
mhamaker@diakhuis.nl 

References:
1. de Glas NA, Jonker JM, Bastiaannet E et al. Impact of omission of surgery on survival of older patients with breast cancer. Br J Surg 2014; 101: 1397-1404.
2. Hind D, Wyld L, Reed MW. Surgery, with or without tamoxifen, vs tamoxifen alone for older women with operable breast cancer: cochrane review. Br J Cancer 2007; 96: 1025-1029.
3. de Glas NA, Kiderlen M, Bastiaannet E et al. Postoperative complications and survival of elderly breast cancer patients: a FOCUS study analysis. Breast Cancer Res Treat 2013; 138: 561-569.
4. de Glas NA, Hamaker ME, Kiderlen M et al. Choosing relevant endpoints for older breast cancer patients in clinical trials: an overview of all current clinical trials on breast cancer treatment. Breast Cancer Res Treat 2014; 146: 591-597.