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

Patients' experiences with decisions on timing of chemotherapy for breast cancer

Introduction: Despite potential advantages, application of chemotherapy in the neo-adjuvant (NAC) instead of adjuvant (AC) setting for breast cancer (BC) patients varies among hospitals. The aim of this study was to gain insight in patients' experiences with decisions on the timing of chemotherapy for stage II and III BC. Materials and methods: A 35-item online questionnaire was distributed among female patients (age>18) treated with either NAC or AC for clinical stage II/III invasive BC in 2013–2014 in the Netherlands. Outcome measures were the experienced exchange of information on the possible choice between both options and patients' involvement in the final decision on chemotherapy timing. Chemotherapy treatment experience was measured with the Cancer Therapy Satisfaction Questionnaire (CTSQ). Results: Of 805 invited patients, 49% responded (179 NAC, 215 AC). NAC-treated patients were younger and more often treated in teaching/academic hospitals and high-volume hospitals. Information on the possibility of NAC was given to a minority of AC-treated patients (AC, stage II:14%, stage III: 31%). Information on pros and cons of both NAC and AC was rated sufficient in about three fourth of respondents. Respondents not always felt having a choice in the timing of chemotherapy (stage II: 54% NAC vs 36% AC; stage III: 26% NAC, 54% AC). Conclusion: The need to make a treatment decision on NAC was found to be made explicit in only a small number of adjuvant treated patients, in particular in BC stage II. Less than half of the respondents felt they had a real choice

Current decisions on neoadjuvant chemotherapy for early breast cancer: Experts’ experiences in the Netherlands

Purpose: To evaluate the opinion of surgical and medical oncologists on neoadjuvant chemotherapy (NAC) for early breast cancer. Methods: Surgical and medical oncologists (N = 292) participating in breast cancer care in the Netherlands were invited for a 20-question survey on the influence of patient, disease, and management related factors on their decisions towards NAC. Results: A total of 138 surgical and medical oncologists from 64 out of 89 different Dutch hospitals completed the survey. NAC was recommended for locally advanced breast cancer (94%) and for downstaging to enable breast conserving surgery (BCS) (75%). Despite willingness to downstage, 64% of clinicians routinely recommended NAC when systemic therapy was indicated preoperatively. Reported reasons to refrain from NAC are comorbidities (68%), age >70 years (52%), and WHO-performance status ≥2 (93%). Opinions on NAC and surgical management were inconclusive; while 75% recommends NAC to enable BCS, some stated that BCS after NAC increases the risk of a non-radical resection (21%), surgical complications (9%) and recurrence of disease (5%). Conclusion: This article emphasizes the need for more consensus among specialists on the indications for NAC in early BC patients. Unambiguous and evidence-based treatment information could improve doctor-patient communication, supporting the patient in chemotherapy timing decision-making

Hospital transfer after a breast cancer diagnosis: A population-based study in the Netherlands of the extent, predictive characteristics and its impact on time to treatment

Purpose: Patients may transfer of hospital for clinical reasons but this may delay time to treatment. The purpose of this study is to provide insight in the extent of hospital transfer in breast cancer care; which type of patients transfer and what is the impact on time to treatment.Methods: We included 41,413 breast cancer patients registered in the Netherlands Cancer Registry between 2014 and 2016. We investigated transfer of hospital between diagnosis and first treatment being surgery or neoadjuvant chemotherapy (NAC). Co-variate adjusted characteristics predictive for hospital transfer were determined. To adjust for possible treatment by indication bias we used propensity score matching (PSM). Time to treatment in patients with and without hospital transfer was compared.Results: Among 41,413 patients, 8.5% of all patients transferred to another hospital between diagnosis and first treatment; 4.9% before primary surgery and 24.8% before NAC. Especially young (aged <40 years) patients and those who underwent a mastectomy with immediate breast reconstruction (IBR) were more likely to transfer. The association of mastectomy with IBR with hospital transfer remained when using PSM. Hospital transfer after diagnosis significantly prolonged time to treatment; breast conserving surgery by 5 days, mastectomy by 7 days, mastectomy with IBR by 9 days and NAC by 1 day.Conclusions: While almost 5% of Dutch patients treated with primary surgery transfer hospital after diagnosis and up to 25% for patients treated with NAC, our findings suggest that especially those treated with primary surgery are at risk for additional treatment delay by hospital transfer. (C) 2018 Published by Elsevier Ltd.Analysis and support of clinical decision makin