Huge decreases in the risk of breast cancer relapse over the last three decades

Introduction The aim of this study was to evaluate local and systemic breast cancer control by comparing the risk of relapse in breast cancer patients in 2003–2004 with that in 1972–1979 and in 1980–1986. Methods About 8,570 women diagnosed with invasive breast cancer in 2003–2004 were selected from the population-based Netherlands Cancer Registry and compared with 133 patients treated in 1972–1979 and 174 in 1980–1986. Five-year risk of relapse was calculated by the Kaplan–Meier method. Cox-proportional hazard models were applied to adjust for tumour size, nodal status and age at diagnosis. Results Patients diagnosed in 2003–2004 had smaller tumours and a less advanced nodal stage than patients diagnosed in 1972–1986. In 1972–1979, 1980–1986 and 2003–2004, treatment included mastectomy in 94%, 72% and 47%; postmastectomy radiotherapy in 75%, 70% and 30%; chemotherapy in 9%, 14% and 37% and hormonal therapy in 3%, 3% and 42% of patients, respectively. Five-year risk of locoregional and distant recurrence decreased from 37% and 34% to 15%, respectively. The 5-year risk of second primary breast cancer did not differ and was 1%, 4% and 2%, respectively. The improved relapse-free survival in patients diagnosed in 2003–2004 as compared with 1972–1979 hardly changed after adjustment (HR = 0.38, 95% CI = 0.28–0.52). Conclusion Over the last decades, local breast cancer therapies have become less rigorous, whereas systemic therapy use has increased. Simultaneously, the risk of breast cancer relapse has tremendously decreased. Future novel therapies may lead to such small additional decreases in relapse rates, while the long-term side effects in breast cancer survivors will increas

Cost-effectiveness of shifting breast cancer surveillance from a hospital setting to a community-based national screening programme setting

Background: In the Netherlands, breast cancer surveillance after breast conserving surgery (BCS) takes place in a hospital setting for at least five years to detect possible recurrences in early stage. As breast cancer incidence rises and mortality decreases, surveillance expenses increase. This study explores the effectiveness and cost-effectiveness of BCS surveillance as delivered in a hospital setting versus providing BCS surveillance as part of the community-based National Breast Cancer Screening Program (NBCSP). We hypothesise that the NBCSP-based strategy leads to lower costs and a lower proportion of true test results (TTR) compared to the hospital-based strategy and determine to what extent potential lower effectiveness may be balanced with expected cost savings. Materials and Methods: Both strategies are compared on effectiveness and cost-effectiveness in a decision tree from a healthcare perspective over a 5-year time horizon. Women aged 50–75 without distant metastases that underwent BCS in the years 2003–2006 with complete 5 year follow-up were selected from the Netherlands Cancer Registry (n = 14,093). Key input variables were mammography sensitivity and specificity, risk of loco regional recurrence (LRR), and direct healthcare costs. The primary outcome measure was the overall predictive value (measured in true test results). Secondary effectiveness measures were the positive predictive value (PPV) (LRRs detected or true positive test results) and the negative predictive value (NPV) (true negative test results) detected within five years post-treatment. Results are presented for low and high risk patients separately and expressed in incremental cost-effectiveness ratios (ICERs). Results: For low risk patients (with grade 1 tumours, no node involvement, and hormonal treatment), the PPV and NPV for the NBCSP strategy were 3.31% and 99.88%, and 2.74% and 99.95% for the hospital strategy respectively. For high risk patients (grade 3 tumours, over three nodes involved, without hormonal treatment), the PPV and NPV for the NBCSP strategy were 64.1% and 98.9%; and 51.0% and 99.7% for the hospital strategy respectively. For low risk patients the NBCSP saves €202 per patient leading to an ICER of €109/accurate test result. For high risk patients the cost savings are €72 per patient, leading to an ICER of €43/accurate test result. Conclusion: Although the NBCSP-based strategy is cheaper, it cannot replace the hospital-based strategy, since it leads to only half of the accurate test results compared to hospital-based strategy. This contradicts the goal of early detection of LRRs and improving outcomes

Survival after Locoregional Recurrence or Second Primary Breast Cancer: Impact of the Disease-Free Interval

The association between the disease-free interval (DFI) and survival after a locoregional recurrence (LRR) or second primary (SP) breast cancer remains uncertain. The objective of this study is to clarify this association to obtain more information on expected prognosis. Women first diagnosed with early breast cancer between 2003–2006 were selected from the Netherlands Cancer Registry. LRRs and SP tumours within five years of first diagnosis were examined. The five-year period was subsequently divided into three equal intervals. Prognostic significance of the DFI on survival after a LRR or SP tumour was determined using Kaplan-Meier estimates and multivariable Cox regression analysis. Follow-up was complete until January 1, 2014. A total of 37,278 women was included in the analysis. LRRs or SP tumours were diagnosed in 890 (2,4%) and 897 (2,4%) respectively. Longer DFI was strongly and independently related to an improved survival after a LRR (long versus short: HR 0.65, 95% CI 0.48–0.88; medium versus short HR 0.81, 95% CI 0.65–1.01). Other factors related to improved survival after LRR were younger age (<70 years) and surgical removal of the recurrence. No significant association was found between DFI and survival after SP tumours. This is the first study to explore the association between the DFI and survival after recurrence in a nationwide population-based cancer registry. The DFI before a LRR is an independent prognostic factor for survival, with a longer DFI predicting better prognosi

Use of neoadjuvant chemotherapy in locally advanced breast cancer in the Netherlands

Use of neoadjuvant chemotherapy in locally advanced breast cancer in the Netherlands P.E.R. Spronk1, A.C.M. Van Bommel1, S. Siesling2,3, M.J.T. Baas- Vrancken Peeters4, C.H. Smorenburg5. 1Leiden University Medical Centre, Surgery, Leiden, Netherlands; 2Comprehensive Cancer Centre the Netherlands IKNL, Epidemiology, Utrecht, Netherlands; 3University of Twente, MIRA Biomedical science and Technical Medicine, Twente, Netherlands; 4Netherlands Cancer Institute/Antoni van Leeuwenhoek, Surgery, Amsterdam, Netherlands; 5Netherlands Cancer Institute/Antoni van Leeuwenhoek, Medical Oncology, Amsterdam, Netherlands Background: Neoadjuvant chemotherapy (NAC) is the treatment of choice for patients with locally advanced breast cancer (LABC). The aim of this study is to examine the use of NAC for LABC in all Dutch hospitals participating in breast cancer care and to assess what patient, tumour and hospital characteristics influence its use. Material and Methods: Data were derived from the national multidisciplinary NABON Breast Cancer Audit (NBCA), regarding all women aged >18 years and newly diagnosed with LABC from January 2011 to September 2013. Multivariable logistic regression was used to assess the association between the use of NAC and patient, tumour and hospital related factors. Results: Of 1419 woman diagnosed with LABC, 70% were treated with NAC. This percentage varied from 12.5% to 90% between hospitals and did not increase over time. Factors associated with the use of NAC included young age, large tumour size, more advanced nodal disease and triple negative or hormone-receptor negative tumours. Also patients treated in hospitals with a multidisciplinary preoperative work-up and participation in neoadjuvant studies were more likely to receive NAC. However, considerable variation between hospitals remained after casemix correction. Table 1. Multivariable odds ratios (ORs) for receipt of NAC among 1419 stage III patients 2011 through 2013 OR 95% CI P-value Age 0.000 5 cm 5.68 2.34−13.79 Clinical nodal status 0.000 cNx/N0 ref. cN1 1.32 0.86−2.04 cN2 2.93 1.18−7.29 cN3 10.28 4.18−25.25 Receptor status 0.000 Triple negative 2.35 1.40−3.93 HR−, Her2+ 3.37 1.67−6.78 HR+, Her2+ 0.91 0.51−1.60 HR+, Her2− ref. Type of surgery 0.026 Breast conservation therapy 2.05 1.09−3.84 Mastectomy ref. Multidisciplinary team 0.021 Yes 1.98 1.11−3.53 No ref. Type of hospital 0.569 General 1.20 0.73−1.98 Top clinical ref. Academic 1.50 0.64−3.47 Hospital surgical volume 0.729 200 1.27 0.70−2.31 Study participation 0.005 Yes 1.80 1.20−2.70 No ref. Conclusions: There is considerable variation in the use of NAC for LABC in the Netherlands. Although various patient, tumor and institutional factors are associated with the use of NAC in LABC, these can only explain part of the observed variation in treatment patterns between hospitals