The Effect of Less Than Definitive Care on Breast Carcinoma: Recurrence and Mortality
The Effect of Less Than Definitive Care on Breast Carcinoma: Recurrence and Mortality
ABSTRACT & COMMENTARY
Synopsis: The care for patients with localized carcinoma of the breast is relatively standardized. Lash and colleagues have evaluated the outcomes of patients with localized carcinoma of the breast with respect to diagnostic and treatment parameters. Those patients who underwent less than definitive prognostic evaluations or treatment had significantly higher rates of breast cancer mortality.
Source: Lash TL, et al. Cancer 2000;89:1739-1747.
Diagnostic evaluation and therapy in primary therapy for patients with early stage breast carcinoma have been recently well characterized.1 In this study, a standard definitive diagnostic/prognostic evaluation was considered to include an axillary dissection and evaluation of estrogen receptor status. Definitive primary therapy was defined as either a mastectomy or breast conserving surgery plus radiation therapy starting within five months of surgery. Definitive therapy for women with regional disease also included systemic adjuvant chemotherapy (with either CMF or cyclophosphamide and doxorubicin) and/or hormonal therapy with tamoxifen administered for five years. Women receiving definitive diagnostic/prognostic evaluation and definitive therapy were considered as a reference group (i.e. those women who received "definitive care"). The analyses were adjusted for the age of the patient at the time of diagnosis, the extent of disease, and the number or comorbid diseases.
Four hundred ninety-four female breast cancer patients were diagnosed at eight Rhode Island hospitals between July 1984 and February 1986. Re-identification of patients for outcome was performed through a cancer registry and 431 (87%) of these patients were identified. Of the 431 patients, 390 had local or regional disease and formed the basis of this report. Ninety-seven percent of the patients studied were white. One hundred sixty-four (68%) of the patients received definitive treatment for their local disease, and 130 (89%) patients received definitive therapy for regional disease. Patients with less than definitive prognostic evaluation for primary disease included patients who did not have an estrogen receptor evaluation (16%), an axillary dissection (12%), or neither (3%). For patients with regional disease, 6% did not have estrogen receptor evaluation and 5% did not have an axillary dissection. From a therapeutic standpoint, 60% of the women were considered to have had definitive therapy for their disease. The major causes for less than definitive therapy was the failure to implement systemic adjuvant therapy for regional disease (69 patients, 18% of the total) and the use of breast-conserving surgery without radiation (25 patients, 6% of the total). Women whose prognostic evaluation was less than definitive had a greater risk for breast cancer recurrence (hazard ratio 1.7, 95% confidence interval [CI], 1.0-2.7) and breast caner mortality (hazard ratio 2.2, 95% CI, 1.2-3.9) for events that occurred during the first five years of follow-up. Patients with less than definitive therapy had respective hazard ratios for these parameters of 1.6 (95% CI, 1.0-2.6) and 1.7 (CI, 1.0-2.8). Interestingly, events that occurred after more than five years of follow-up were not significantly different for the two groups.
COMMENT BY MICHAEL J. HAWKINS, MD
This is an interesting report that evaluates breast cancer recurrence and mortality with respect to adherence to well-accepted standards of medical care. While the reasons that women may not have received what was defined as definitive diagnostic or therapeutic care may vary, the differences identified in this study are striking. In addition, the analyses were not affected by age at diagnosis, stage of disease, or the presence of comorbid conditions. With greater access to nonreviewed literature via the internet, the number of patients who resist receiving treatment according to standard, evidence-based practice guidelines is increasing. These patients should be cautioned that deviations from standard care may be associated with a significantly increased (approximately 2-fold) risk for tumor recurrence and death from breast cancer.
Reference
1. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. CMAJ 1998;158(Suppl 3):S1-83.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.