Use of trastuzumab in Australia and New Zealand: Results from the National Breast Cancer Audit

Background:  Trastuzumab increases disease-free and overall survival in HER-2-positive, early breast cancer. In 2007, the National Breast and Ovarian Cancer Centre recommended that patients with HER-2 positive cancers (node positive or node negative tumours >1 cm) be offered adjuvant trastuzumab with chemotherapy. The aim of this study was to evaluate recent trends in trastuzumab therapy in Australia and New Zealand. Methods:  Following data were obtained from the National Breast Cancer Audit for patients treated between 2006 and 2008: tumour size, number of cases recorded per surgeon per year, location of hospital, HER-2 receptor status, age, lymph node status, chemotherapy and trastuzumab treatment. Results:  Data were available from 23 290 patients. During the study period, the percentage of breast cancers tested for HER-2 rose from 77% to 91%. Patients over 70 had fewer HER-2 tests than their younger counterparts. Fourteen percent of tumours were HER-2 positive; the proportion treated with trastuzumab in 2006, 2007 and 2008 was 50%, 66% and 74%, respectively. Significantly more node-positive patients (77%) were given trastuzumab than node-negative patients (52%). All the patients prescribed trastuzumab also received chemotherapy. Patients under 70 years, patients treated in Australia and patients treated by higher caseload surgeons were more likely to be prescribed trastuzumab than those over 70, patients in New Zealand and patients treated by lower caseload surgeons. Conclusions:  Trastuzumab-prescribing trends conform to the published guidelines. However, older patients and those with HER-2 positive, node-negative tumours >1 cm may be undertreated in some cases.Robert Whitfield, James Kollias, Primali De Silva, Helen Zorbas and Guy Madder

Trends in surgical treatment of younger patients with breast cancer in Australia and New Zealand

Journal compilation © 2008 Royal Australasian College of SurgeonsBackground: The optimal surgical treatment of early breast cancer in young women is not fully determined, while past reports indicate a trend to the increased use of breast-conserving surgery (BCS). This study aims to assess the trend in Australia and New Zealand of BCS use between 1999 and 2006 and to determine pathological factors associated with it. Methods: Data on cancer characteristics and surgical procedures in younger patients with early breast cancer reported to the National Breast Cancer Audit have been analysed. Results: There was little change in the rate of BCS over the last 7 years with an overall rate of 53%. The main factors associated with the use of BCS are low histological grade, absence of extensive intraductal carcinoma (EIC), negative lymph node involvement, unifocal tumour and small tumour size. Conclusion: Between 1999 and 2006, the use of BCS for early breast cancer treatment in younger women was stable. These results show that surgeons contributing data to the National Breast Cancer Audit appear to use pathological factors that are known to increase the risk of local recurrence after BCS, in selecting mastectomy for younger women

Treatment and survival from breast cancer: The experience of patients at South Australian teaching hospitals between 1977 and 2003

Rationale: Treatment guidelines recommend a more conservative surgical approach than mastectomy for early stage breast cancer and a stronger emphasis on adjuvant therapy. Registry data at South Australian teaching hospitals have been used to monitor survivals and treatment in relation to these guidelines. Aims and objectives: To use registry data to: (1) investigate trends in survival and treatment; and (2) compare treatment with guidelines. Methods: Registry data from three teaching hospitals were used to analyse trends in primary courses of treatment of breast cancers during 1977–2003 (n = 4671), using univariate analyses and multiple logistic regression. Disease-specific survivals were analysed using Kaplan–Meier product limit estimates and multivariable Cox proportional hazards regression. Results: The 5-year survival was 79.9%, but with a secular increase, reaching 83.6% in 1997–2003. The relative risk of death (95% confidence limits) was 0.74 (0.62, 0.88) for 1997–2003, compared with previous diagnoses, after adjusting for tumour node metastasis stage, grade, age and place of residence. Treatment changes included an increase in conservative surgery (as opposed to mastectomy) from 51.7% in 1977–1990 to 76.8% in 1997–2003 for stage I (P < 0.001) and from 31.1% to 52.2% across these periods for stage II (P < 0.001). Adjuvant radiotherapy also became more common (P < 0.001), with 20.6% of patients receiving this treatment in 1977–1990 compared with 60.7% in 1997–2003. Radiotherapy generally was more prevalent when conservative surgery was provided, although also relatively common in mastectomy patients when tumour diameters exceeded 50 mm or when there were four or more involved nodes. The proportion of patients receiving chemotherapy increased (P < 0.001), from 19.6% in 1977–1990 to 36.9% in 1997–2003, and the proportion having hormone therapy also increased (P < 0.001), from 34.3% to 59.4% between these periods. Conclusions: Survivals appear to be increasing and treatment trends are broadly consistent with guideline directions, and the earlier research on which these recommendations were based.Colin Luke, Grantley Gill, Stephen Birrell, Vlad Humeniuk, Martin Borg, Christos Karapetis, Bogda Koczwara, Ian Olver, Michael Penniment, Ken Pittman, Tim Price, David Walsh, Eng Kiat (Eric) Yeoh and David Rode

Adjuvant therapy, not mammographic screening, accounts for most of the observed breast cancer specific mortality reductions in Australian women since the national screening program began in 1991

There has been a 28% reduction in age-standardised breast cancer mortality in Australia since 1991 when the free national mammographic program (BreastScreen) began. Therefore, a comparative study between BreastScreen participation and breast cancer age specific mortality trends in Australia was undertaken for two time periods between 1991 and 2007, where women aged 50&ndash;59 and 60&ndash;69 years, who were invited to screen, were compared to women aged 40&ndash;49 and 70&ndash;79 years who were not invited, but who did have access to the program. There were mortality reductions in all four age groups between 1991&ndash;1992 and 2007, resulting in 5,849 (95% CI 4,979 to 6,718) fewer women dying of breast cancer than would have otherwise been the case. Women aged 40&ndash;49 years, who had the lowest BreastScreen participation (approximately 20%), had the largest mortality reduction: 44% (95% CI 34.8&ndash;51.2). Women aged 60&ndash;69 years, who had the highest BreastScreen participation (approximately 60%), had the smallest mortality reduction: 19% (95% CI 10.5&ndash;26.9). As BreastScreen participation by invited women aged 50&ndash;69 years only reached a maximum of about 55&ndash;60% in 1998&ndash;1999, a decline in mortality in Australian women cannot be attributed to BreastScreen prior to this time. Thus, almost 60% of the Australian decline in breast cancer mortality since 1991 cannot be attributed to BreastScreen. Therefore, mammographic screening cannot account for most of the reductions in breast cancer mortality that have occurred in Australian women since 1991 and may have contributed to over-diagnosis. Most, if not all, of the reductions can be attributed to the adjuvant hormonal and chemotherapy, which Australian women have increasingly received since 1986

A prospective examination of perceived stress as a mediator of the relationship between life-events and QOL following breast cancer

Objectives: This study prospectively investigated the relationship between life-events, perceived stress, and quality of life (QOL) following breast cancer diagnosis, using the bio-behavioural model of cancer stress as a framework. Design: A longitudinal, self-report design was used. Methods: Three waves of data from 10,543 mid-aged Australian women (aged 45-50 at Survey 1) were collected over 5 years as part of a population-based survey. From this group a subsample (N=140) were identified who did not have breast cancer at Survey 1, but who subsequently developed breast cancer. Random regression growth curve analyses were used to investigate whether perceived stress mediated the relationship between initial life-events and change in QOL functioning overtime. Results: Prospective evidence was generated for each of the three criteria for testing mediation. As the number of life-events before breast cancer increased, women were significantly more likely to experience corresponding increases in perceived stress over the 5-year period. As the level of perceived stress before breast cancer increased, women were more likely to experience deteriorations overtime in role emotional, role physical, vitality, bodily pain, physical functioning, and social functioning. As the number of life-events before breast cancer increased, women were at significant risk of experiencing deteriorations overtime in bodily pain, social functioning, role emotional, and vitality. Mediational analyses revealed that perceived stress fully mediated the relationship between initial life-events and two QOL domains; role-emotional and social functioning. Conclusion: Results partially supported the bio-behavioural model of cancer stress, but the model does not appear to fit the data as well as predicted, and may require revision