Breast Cancer

CHICAGO – Compared with single-agent chemotherapy of the oncologist’s choice, the PARP inhibitor olaparib reduced the risk of progression or death by 42% in women with BRCA-related HER2-negative metastatic breast cancer, the OlympiAD trialists reported in a plenary session at the annual meeting of the American Society of Clinical Oncology.

Lead author Mark E. Robson, MD, of Memorial Sloan Kettering Cancer Center, New York, discussed findings of the randomized phase III trial, as well as strategies for building on the trial’s success and what the future holds for this class of agents in breast cancer.

Dr. Robson disclosed that he has a consulting or advisory role with McKesson and AstraZeneca; receives travel, accommodations, and/or expenses from AstraZeneca; receives honoraria from AstraZeneca; and receives research funding (institutional) from AstraZeneca, Abbvie, Myriad Genetics, Biomarin, Medivation, and Tesaro. The trial was funded by AstraZeneca.

CHICAGO – Compared with single-agent chemotherapy of the oncologist’s choice, the PARP inhibitor olaparib reduced the risk of progression or death by 42% in women with BRCA-related HER2-negative metastatic breast cancer, the OlympiAD trialists reported in a plenary session at the annual meeting of the American Society of Clinical Oncology.

Lead author Mark E. Robson, MD, of Memorial Sloan Kettering Cancer Center, New York, discussed findings of the randomized phase III trial, as well as strategies for building on the trial’s success and what the future holds for this class of agents in breast cancer.

Dr. Robson disclosed that he has a consulting or advisory role with McKesson and AstraZeneca; receives travel, accommodations, and/or expenses from AstraZeneca; receives honoraria from AstraZeneca; and receives research funding (institutional) from AstraZeneca, Abbvie, Myriad Genetics, Biomarin, Medivation, and Tesaro. The trial was funded by AstraZeneca.

CHICAGO – Compared with single-agent chemotherapy of the oncologist’s choice, the PARP inhibitor olaparib reduced the risk of progression or death by 42% in women with BRCA-related HER2-negative metastatic breast cancer, the OlympiAD trialists reported in a plenary session at the annual meeting of the American Society of Clinical Oncology.

Lead author Mark E. Robson, MD, of Memorial Sloan Kettering Cancer Center, New York, discussed findings of the randomized phase III trial, as well as strategies for building on the trial’s success and what the future holds for this class of agents in breast cancer.

Dr. Robson disclosed that he has a consulting or advisory role with McKesson and AstraZeneca; receives travel, accommodations, and/or expenses from AstraZeneca; receives honoraria from AstraZeneca; and receives research funding (institutional) from AstraZeneca, Abbvie, Myriad Genetics, Biomarin, Medivation, and Tesaro. The trial was funded by AstraZeneca.

CHICAGO – An integrated analysis of three trials has shown that larotrectinib, an oral selective inhibitor of tropomyosin receptor kinase (TRK), has durable efficacy across diverse adult and pediatric cancers harboring TRK fusions, netting an impressive 76% overall response rate.

Lead study author David Hyman, MD, chief of early drug development at Memorial Sloan Kettering Cancer Center in New York, discussed highlights of the analysis, larotrectinib’s regulatory status, and implications for TRK fusion testing in clinical care at the annual meeting of the American Society of Clinical Oncology.

Dr. Hyman disclosed that he has a consulting or advisory role with Atara Biotherapeutics, Chugai Pharma, and CytomX Therapeutics, and that he receives research funding from AstraZeneca and Puma Biotechnology. The study was funded by Loxo Oncology.

CHICAGO – An integrated analysis of three trials has shown that larotrectinib, an oral selective inhibitor of tropomyosin receptor kinase (TRK), has durable efficacy across diverse adult and pediatric cancers harboring TRK fusions, netting an impressive 76% overall response rate.

Lead study author David Hyman, MD, chief of early drug development at Memorial Sloan Kettering Cancer Center in New York, discussed highlights of the analysis, larotrectinib’s regulatory status, and implications for TRK fusion testing in clinical care at the annual meeting of the American Society of Clinical Oncology.

Dr. Hyman disclosed that he has a consulting or advisory role with Atara Biotherapeutics, Chugai Pharma, and CytomX Therapeutics, and that he receives research funding from AstraZeneca and Puma Biotechnology. The study was funded by Loxo Oncology.

CHICAGO – An integrated analysis of three trials has shown that larotrectinib, an oral selective inhibitor of tropomyosin receptor kinase (TRK), has durable efficacy across diverse adult and pediatric cancers harboring TRK fusions, netting an impressive 76% overall response rate.

Lead study author David Hyman, MD, chief of early drug development at Memorial Sloan Kettering Cancer Center in New York, discussed highlights of the analysis, larotrectinib’s regulatory status, and implications for TRK fusion testing in clinical care at the annual meeting of the American Society of Clinical Oncology.

Dr. Hyman disclosed that he has a consulting or advisory role with Atara Biotherapeutics, Chugai Pharma, and CytomX Therapeutics, and that he receives research funding from AstraZeneca and Puma Biotechnology. The study was funded by Loxo Oncology.

CHICAGO – Oncologists are highly skilled at minimizing side effects associated with toxic but curative therapies, but are less adept at helping patients cope with the distress, anxiety, fear, and other emotions associated with cancer.

Three studies presented at the annual meeting of the American Society of Clinical Oncology detail randomized, controlled trials of psychological interventions aimed at helping patients cope with a new cancer diagnosis, reduce fears of a recurrence, and come to grips with the realities of advanced disease, including fears of death or disability.

Don S. Dizon, MD, from the Massachusetts General Hospital Cancer Center, Boston, discusses the social and financial barriers that cancer patients face when they experience distress, and the difficulties that providers face with limited time and financial resources to help patients cope in this video interview.

Dr. Dizon reported having no relevant disclosures.

CHICAGO – Oncologists are highly skilled at minimizing side effects associated with toxic but curative therapies, but are less adept at helping patients cope with the distress, anxiety, fear, and other emotions associated with cancer.

Three studies presented at the annual meeting of the American Society of Clinical Oncology detail randomized, controlled trials of psychological interventions aimed at helping patients cope with a new cancer diagnosis, reduce fears of a recurrence, and come to grips with the realities of advanced disease, including fears of death or disability.

Don S. Dizon, MD, from the Massachusetts General Hospital Cancer Center, Boston, discusses the social and financial barriers that cancer patients face when they experience distress, and the difficulties that providers face with limited time and financial resources to help patients cope in this video interview.

Dr. Dizon reported having no relevant disclosures.

CHICAGO – Oncologists are highly skilled at minimizing side effects associated with toxic but curative therapies, but are less adept at helping patients cope with the distress, anxiety, fear, and other emotions associated with cancer.

Three studies presented at the annual meeting of the American Society of Clinical Oncology detail randomized, controlled trials of psychological interventions aimed at helping patients cope with a new cancer diagnosis, reduce fears of a recurrence, and come to grips with the realities of advanced disease, including fears of death or disability.

Don S. Dizon, MD, from the Massachusetts General Hospital Cancer Center, Boston, discusses the social and financial barriers that cancer patients face when they experience distress, and the difficulties that providers face with limited time and financial resources to help patients cope in this video interview.

Dr. Dizon reported having no relevant disclosures.

Members of the Food and Drug Administration’s Oncologic Drugs Advisory Committee voted 12-4 in support of approval of neratinib for single-agent extended adjuvant treatment of adults with early-stage HER2-positive breast cancer who received prior adjuvant trastuzumab-based therapy.

Members voting during the May 24 meeting expressed concern about the broadness of the indication proposed by the drug’s maker, Puma Biotechnology, but the majority said the risk-benefit profile of the drug is sufficient to support approval, particularly given the unmet need for such an agent. Those voting against approval argued that more data are needed to identify subpopulations of patients who would be most likely to benefit from treatment in order to narrow the indication.

sworcester@frontlinemedcom.com

Members of the Food and Drug Administration’s Oncologic Drugs Advisory Committee voted 12-4 in support of approval of neratinib for single-agent extended adjuvant treatment of adults with early-stage HER2-positive breast cancer who received prior adjuvant trastuzumab-based therapy.

Members voting during the May 24 meeting expressed concern about the broadness of the indication proposed by the drug’s maker, Puma Biotechnology, but the majority said the risk-benefit profile of the drug is sufficient to support approval, particularly given the unmet need for such an agent. Those voting against approval argued that more data are needed to identify subpopulations of patients who would be most likely to benefit from treatment in order to narrow the indication.

sworcester@frontlinemedcom.com

Members of the Food and Drug Administration’s Oncologic Drugs Advisory Committee voted 12-4 in support of approval of neratinib for single-agent extended adjuvant treatment of adults with early-stage HER2-positive breast cancer who received prior adjuvant trastuzumab-based therapy.

Members voting during the May 24 meeting expressed concern about the broadness of the indication proposed by the drug’s maker, Puma Biotechnology, but the majority said the risk-benefit profile of the drug is sufficient to support approval, particularly given the unmet need for such an agent. Those voting against approval argued that more data are needed to identify subpopulations of patients who would be most likely to benefit from treatment in order to narrow the indication.

sworcester@frontlinemedcom.com

“MORE THAN ONE-THIRD OF TUMORS FOUND ON BREAST CANCER SCREENING REPRESENT OVERDIAGNOSIS”

ANDREW M. KAUNITZ, MD (MARCH 2017)

Refutes concept of overdiagnosis of breast cancer

I read with interest and serious concern the commentary and conclusions of “overdiagnosed” breast cancer. Let us revisit a few time-honored principles. Are we throwing away the valued concept of the early diagnosis of node-negative breast cancer? Is it still true that 5-year and long-term survivals are markedly better for stage I and II disease as opposed to stage III and IV disease? Is it still true that treatments designed for cure are substantially less involved, more successful, and more likely to conserve the breast and require less chemotherapy in early stage disease? Is it still true that the majority of women diagnosed with breast cancer are in the lowest risk category, ie, no family history and negative for the BRCA gene? If so, then who can explain the statement that “an invasive breast cancer detected by any means is overdiagnosis”? Would this imply that screening and the biopsy required to make the diagnosis was time poorly spent, the breast cancer should not be treated, and/or we should simply wait for a lump to be found by the patient deep in a large breast most likely at that point representing advanced disease?

The last paragraph notes the current US Preventive Services Task Force (USPSTF) guidance: wait until 50 years of age to start biennial screening. If so, what do we say to women in their 40s who, through screening with mammography and/or ultrasound, were diagnosed with early node-negative invasive breast cancer? That all of that was unnecessary and would not have led to symptoms? Would extreme morbidity from advanced or recurrent disease and the horrors of treatment just to extend a few months of life qualify as a symptom to these investigators? Lax protocols are not for me, my colleagues, or patients that I know. One of the most common reasons for a lawsuit to be brought against a primary care or ObGyn provider is failure to diagnose breast cancer!

John T. Armstrong, MD
Napa, California

Dr. Kaunitz responds

I thank Dr. Armstrong for his interest in my commentary on screening mammography and overdiagnosis. As I indicated in my commentary, I continue to recommend screening mammography for my patients, encouraging average-risk women to begin biennial screens at age 50 (consistent with USPSTF guidance), when the likelihood that tumors found with mammograms representing overdiagnosis is lower. I also indicated that I recognize that some patients prefer to begin screening at a younger age and to be screened more frequently. Dr. Armstrong’s letter refers to the “horrors of treatment” of breast cancer. From my perspective, the most “horrible” treatment is that which is administered to a woman diagnosed with a tumor destined to not cause clinical problems during her lifetime (overdiagnosis). You also refer to a statement, “an invasive breast cancer detected by any means is overdiagnosis.” That statement does not appear in my commentary.

My commentary’s point is that overdiagnosis is common among tumors diagnosed by screening mammography, and likely explains why, in contrast with cervical cancer screening, screening mammography has failed to reduce the incidence of breast cancers presenting as advanced (metastatic) disease. Although this represents a confusing and disquieting reality for our patients, and for us their clinicians, I agree with Dr. Otis Brawley, Chief Medical and Scientific Officer of the American Cancer Society, that we must acknowledge to our patients that overdiagnosis is common, the benefits of screening have been overstated, and that some patients considered as “cured” from breast cancer have in fact been harmed by unneeded treatment.¹

Share your thoughts!  Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

“MORE THAN ONE-THIRD OF TUMORS FOUND ON BREAST CANCER SCREENING REPRESENT OVERDIAGNOSIS”

ANDREW M. KAUNITZ, MD (MARCH 2017)

Refutes concept of overdiagnosis of breast cancer

I read with interest and serious concern the commentary and conclusions of “overdiagnosed” breast cancer. Let us revisit a few time-honored principles. Are we throwing away the valued concept of the early diagnosis of node-negative breast cancer? Is it still true that 5-year and long-term survivals are markedly better for stage I and II disease as opposed to stage III and IV disease? Is it still true that treatments designed for cure are substantially less involved, more successful, and more likely to conserve the breast and require less chemotherapy in early stage disease? Is it still true that the majority of women diagnosed with breast cancer are in the lowest risk category, ie, no family history and negative for the BRCA gene? If so, then who can explain the statement that “an invasive breast cancer detected by any means is overdiagnosis”? Would this imply that screening and the biopsy required to make the diagnosis was time poorly spent, the breast cancer should not be treated, and/or we should simply wait for a lump to be found by the patient deep in a large breast most likely at that point representing advanced disease?

The last paragraph notes the current US Preventive Services Task Force (USPSTF) guidance: wait until 50 years of age to start biennial screening. If so, what do we say to women in their 40s who, through screening with mammography and/or ultrasound, were diagnosed with early node-negative invasive breast cancer? That all of that was unnecessary and would not have led to symptoms? Would extreme morbidity from advanced or recurrent disease and the horrors of treatment just to extend a few months of life qualify as a symptom to these investigators? Lax protocols are not for me, my colleagues, or patients that I know. One of the most common reasons for a lawsuit to be brought against a primary care or ObGyn provider is failure to diagnose breast cancer!

John T. Armstrong, MD
Napa, California

Dr. Kaunitz responds

I thank Dr. Armstrong for his interest in my commentary on screening mammography and overdiagnosis. As I indicated in my commentary, I continue to recommend screening mammography for my patients, encouraging average-risk women to begin biennial screens at age 50 (consistent with USPSTF guidance), when the likelihood that tumors found with mammograms representing overdiagnosis is lower. I also indicated that I recognize that some patients prefer to begin screening at a younger age and to be screened more frequently. Dr. Armstrong’s letter refers to the “horrors of treatment” of breast cancer. From my perspective, the most “horrible” treatment is that which is administered to a woman diagnosed with a tumor destined to not cause clinical problems during her lifetime (overdiagnosis). You also refer to a statement, “an invasive breast cancer detected by any means is overdiagnosis.” That statement does not appear in my commentary.

My commentary’s point is that overdiagnosis is common among tumors diagnosed by screening mammography, and likely explains why, in contrast with cervical cancer screening, screening mammography has failed to reduce the incidence of breast cancers presenting as advanced (metastatic) disease. Although this represents a confusing and disquieting reality for our patients, and for us their clinicians, I agree with Dr. Otis Brawley, Chief Medical and Scientific Officer of the American Cancer Society, that we must acknowledge to our patients that overdiagnosis is common, the benefits of screening have been overstated, and that some patients considered as “cured” from breast cancer have in fact been harmed by unneeded treatment.¹

Share your thoughts!  Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

“MORE THAN ONE-THIRD OF TUMORS FOUND ON BREAST CANCER SCREENING REPRESENT OVERDIAGNOSIS”

ANDREW M. KAUNITZ, MD (MARCH 2017)

Refutes concept of overdiagnosis of breast cancer

I read with interest and serious concern the commentary and conclusions of “overdiagnosed” breast cancer. Let us revisit a few time-honored principles. Are we throwing away the valued concept of the early diagnosis of node-negative breast cancer? Is it still true that 5-year and long-term survivals are markedly better for stage I and II disease as opposed to stage III and IV disease? Is it still true that treatments designed for cure are substantially less involved, more successful, and more likely to conserve the breast and require less chemotherapy in early stage disease? Is it still true that the majority of women diagnosed with breast cancer are in the lowest risk category, ie, no family history and negative for the BRCA gene? If so, then who can explain the statement that “an invasive breast cancer detected by any means is overdiagnosis”? Would this imply that screening and the biopsy required to make the diagnosis was time poorly spent, the breast cancer should not be treated, and/or we should simply wait for a lump to be found by the patient deep in a large breast most likely at that point representing advanced disease?

The last paragraph notes the current US Preventive Services Task Force (USPSTF) guidance: wait until 50 years of age to start biennial screening. If so, what do we say to women in their 40s who, through screening with mammography and/or ultrasound, were diagnosed with early node-negative invasive breast cancer? That all of that was unnecessary and would not have led to symptoms? Would extreme morbidity from advanced or recurrent disease and the horrors of treatment just to extend a few months of life qualify as a symptom to these investigators? Lax protocols are not for me, my colleagues, or patients that I know. One of the most common reasons for a lawsuit to be brought against a primary care or ObGyn provider is failure to diagnose breast cancer!

John T. Armstrong, MD
Napa, California

Dr. Kaunitz responds

I thank Dr. Armstrong for his interest in my commentary on screening mammography and overdiagnosis. As I indicated in my commentary, I continue to recommend screening mammography for my patients, encouraging average-risk women to begin biennial screens at age 50 (consistent with USPSTF guidance), when the likelihood that tumors found with mammograms representing overdiagnosis is lower. I also indicated that I recognize that some patients prefer to begin screening at a younger age and to be screened more frequently. Dr. Armstrong’s letter refers to the “horrors of treatment” of breast cancer. From my perspective, the most “horrible” treatment is that which is administered to a woman diagnosed with a tumor destined to not cause clinical problems during her lifetime (overdiagnosis). You also refer to a statement, “an invasive breast cancer detected by any means is overdiagnosis.” That statement does not appear in my commentary.

My commentary’s point is that overdiagnosis is common among tumors diagnosed by screening mammography, and likely explains why, in contrast with cervical cancer screening, screening mammography has failed to reduce the incidence of breast cancers presenting as advanced (metastatic) disease. Although this represents a confusing and disquieting reality for our patients, and for us their clinicians, I agree with Dr. Otis Brawley, Chief Medical and Scientific Officer of the American Cancer Society, that we must acknowledge to our patients that overdiagnosis is common, the benefits of screening have been overstated, and that some patients considered as “cured” from breast cancer have in fact been harmed by unneeded treatment.¹

Share your thoughts!  Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

LAS VEGAS – Although circulating tumor cells are prognostic in breast cancer, they aren’t likely to become a part of routine practice until they’ve been shown to improve outcomes, and that hasn’t happened yet, according to Anthony Lucci, MD, professor of breast surgical oncology at MD Anderson Cancer Center, Houston.

MD Anderson and other institutions have established that in breast cancer, from baseline through treatment follow-up, the presence of circulating tumor cells (CTCs) in the blood predicts worse outcomes in both metastatic and local disease, even among women who have a pathologic complete response to treatment.

aotto@frontlinemedcom.com

LAS VEGAS – Although circulating tumor cells are prognostic in breast cancer, they aren’t likely to become a part of routine practice until they’ve been shown to improve outcomes, and that hasn’t happened yet, according to Anthony Lucci, MD, professor of breast surgical oncology at MD Anderson Cancer Center, Houston.

MD Anderson and other institutions have established that in breast cancer, from baseline through treatment follow-up, the presence of circulating tumor cells (CTCs) in the blood predicts worse outcomes in both metastatic and local disease, even among women who have a pathologic complete response to treatment.

aotto@frontlinemedcom.com

LAS VEGAS – Although circulating tumor cells are prognostic in breast cancer, they aren’t likely to become a part of routine practice until they’ve been shown to improve outcomes, and that hasn’t happened yet, according to Anthony Lucci, MD, professor of breast surgical oncology at MD Anderson Cancer Center, Houston.

MD Anderson and other institutions have established that in breast cancer, from baseline through treatment follow-up, the presence of circulating tumor cells (CTCs) in the blood predicts worse outcomes in both metastatic and local disease, even among women who have a pathologic complete response to treatment.

aotto@frontlinemedcom.com

Nearly 155,000 women in the United States are living with metastatic breast cancer (MBC), three-fourths of whom were initially diagnosed with lower-stage disease that progressed to stage IV, based on estimated prevalence data.

The estimates, derived from national breast cancer mortality and survival data, also show positive trends in breast cancer care, especially a doubling of 5-year survival rates among younger women diagnosed with de novo metastatic disease from the 1990s to the 2000s, reported Angela B. Mariotto, PhD, of the National Cancer Institute and her colleagues.

“Despite the progressive and incurable nature of almost all MBC, median survival after diagnosis with metastatic disease has been increasing, resulting in a growing number of women living with MBC in the United States. The increased survival is especially noted for women diagnosed at younger ages,” they wrote in Cancer Epidemiology, Biomarkers, & Prevention (2017 May 18. doi: 10.1158/1055-9965.epi-16-088).

Patients with advanced breast cancer require extensive care and intensive use of medical and other resources, but, until this study, there were no reliable estimates of the number of women actually living with metastatic disease in the United States, the authors said.

To get a clearer picture of the prevalence of advanced breast cancer in the United States, they worked backward from Surveillance, Epidemiology, and End Results data on breast cancer deaths and survival, working on the assumption that each observed breast cancer death is the result of metastatic disease, either in women whose initial diagnosis was stage IV disease (de novo metastatic disease) or disease recurrence with metastases.

They estimated that, in 2013, the most recent year for which there were observed data, the prevalence of metastatic breast cancer was 138,622, and that 38,897 (28%) of survivors were diagnosed with metastatic disease. The remaining 99,725 survivors (72%) were women who were initially diagnosed with stage I-III disease that either recurred or metastasized.

The authors calculated that 50,344 women were diagnosed with de novo metastatic disease in 2013, 12,966 of whom (26%) had de novo metastatic breast cancer and 37,378 of whom had recurrent disease. They projected that, as of Jan. 1, 2017, there are 154,794 women living with metastatic breast cancer in the United States.

They also estimated changes over time in survival and found that, for women diagnosed from the ages of 15 to 49 during the 1992-1994 surveillance period, median survival time was 22.3 months, which improved to 38.7 months during the 2005-2012 surveillance period. The respective survival times for women 50-64 years were 19.1 months and 29.7 months.

For women 15-49 years who were diagnosed with de novo metastatic breast cancer, the 5-year relative survival rates doubled from 18% during 1992-1994 to 36% during 2005-2012.

“Despite a poor prognosis, there is a small but meaningful percentage of these cases who survive 10 years or more. More than 11% of women diagnosed between 2000-2004 under the age of 64 years survived 10 years or more. Younger women diagnosed with de novo MBC have higher survival than women diagnosed at older ages,” Dr. Mariotto and her colleagues wrote.

The investigators pointed to the population size, population-based data, long follow-up, and use of consistent staging definitions over time as study strengths but acknowledged that the study was limited by the absence of population-based estimates of survival following recurrence of metastatic breast cancer.

“To our knowledge, this is the first time that the number of women living with MBC in the United States has been estimated. These estimates provide a new perspective on the population burden of breast cancer and have great potential significance to the research and advocacy community working on behalf of patients with MBC and their families,” the authors wrote.

The study was supported by the National Cancer Institute. The authors reported no relevant financial disclosures.

This article was updated June 5, 2017.

Nearly 155,000 women in the United States are living with metastatic breast cancer (MBC), three-fourths of whom were initially diagnosed with lower-stage disease that progressed to stage IV, based on estimated prevalence data.

The estimates, derived from national breast cancer mortality and survival data, also show positive trends in breast cancer care, especially a doubling of 5-year survival rates among younger women diagnosed with de novo metastatic disease from the 1990s to the 2000s, reported Angela B. Mariotto, PhD, of the National Cancer Institute and her colleagues.

“Despite the progressive and incurable nature of almost all MBC, median survival after diagnosis with metastatic disease has been increasing, resulting in a growing number of women living with MBC in the United States. The increased survival is especially noted for women diagnosed at younger ages,” they wrote in Cancer Epidemiology, Biomarkers, & Prevention (2017 May 18. doi: 10.1158/1055-9965.epi-16-088).

Patients with advanced breast cancer require extensive care and intensive use of medical and other resources, but, until this study, there were no reliable estimates of the number of women actually living with metastatic disease in the United States, the authors said.

To get a clearer picture of the prevalence of advanced breast cancer in the United States, they worked backward from Surveillance, Epidemiology, and End Results data on breast cancer deaths and survival, working on the assumption that each observed breast cancer death is the result of metastatic disease, either in women whose initial diagnosis was stage IV disease (de novo metastatic disease) or disease recurrence with metastases.

They estimated that, in 2013, the most recent year for which there were observed data, the prevalence of metastatic breast cancer was 138,622, and that 38,897 (28%) of survivors were diagnosed with metastatic disease. The remaining 99,725 survivors (72%) were women who were initially diagnosed with stage I-III disease that either recurred or metastasized.

The authors calculated that 50,344 women were diagnosed with de novo metastatic disease in 2013, 12,966 of whom (26%) had de novo metastatic breast cancer and 37,378 of whom had recurrent disease. They projected that, as of Jan. 1, 2017, there are 154,794 women living with metastatic breast cancer in the United States.

They also estimated changes over time in survival and found that, for women diagnosed from the ages of 15 to 49 during the 1992-1994 surveillance period, median survival time was 22.3 months, which improved to 38.7 months during the 2005-2012 surveillance period. The respective survival times for women 50-64 years were 19.1 months and 29.7 months.

For women 15-49 years who were diagnosed with de novo metastatic breast cancer, the 5-year relative survival rates doubled from 18% during 1992-1994 to 36% during 2005-2012.

“Despite a poor prognosis, there is a small but meaningful percentage of these cases who survive 10 years or more. More than 11% of women diagnosed between 2000-2004 under the age of 64 years survived 10 years or more. Younger women diagnosed with de novo MBC have higher survival than women diagnosed at older ages,” Dr. Mariotto and her colleagues wrote.

The investigators pointed to the population size, population-based data, long follow-up, and use of consistent staging definitions over time as study strengths but acknowledged that the study was limited by the absence of population-based estimates of survival following recurrence of metastatic breast cancer.

“To our knowledge, this is the first time that the number of women living with MBC in the United States has been estimated. These estimates provide a new perspective on the population burden of breast cancer and have great potential significance to the research and advocacy community working on behalf of patients with MBC and their families,” the authors wrote.

The study was supported by the National Cancer Institute. The authors reported no relevant financial disclosures.

This article was updated June 5, 2017.

Nearly 155,000 women in the United States are living with metastatic breast cancer (MBC), three-fourths of whom were initially diagnosed with lower-stage disease that progressed to stage IV, based on estimated prevalence data.

The estimates, derived from national breast cancer mortality and survival data, also show positive trends in breast cancer care, especially a doubling of 5-year survival rates among younger women diagnosed with de novo metastatic disease from the 1990s to the 2000s, reported Angela B. Mariotto, PhD, of the National Cancer Institute and her colleagues.

“Despite the progressive and incurable nature of almost all MBC, median survival after diagnosis with metastatic disease has been increasing, resulting in a growing number of women living with MBC in the United States. The increased survival is especially noted for women diagnosed at younger ages,” they wrote in Cancer Epidemiology, Biomarkers, & Prevention (2017 May 18. doi: 10.1158/1055-9965.epi-16-088).

Patients with advanced breast cancer require extensive care and intensive use of medical and other resources, but, until this study, there were no reliable estimates of the number of women actually living with metastatic disease in the United States, the authors said.

To get a clearer picture of the prevalence of advanced breast cancer in the United States, they worked backward from Surveillance, Epidemiology, and End Results data on breast cancer deaths and survival, working on the assumption that each observed breast cancer death is the result of metastatic disease, either in women whose initial diagnosis was stage IV disease (de novo metastatic disease) or disease recurrence with metastases.

They estimated that, in 2013, the most recent year for which there were observed data, the prevalence of metastatic breast cancer was 138,622, and that 38,897 (28%) of survivors were diagnosed with metastatic disease. The remaining 99,725 survivors (72%) were women who were initially diagnosed with stage I-III disease that either recurred or metastasized.

The authors calculated that 50,344 women were diagnosed with de novo metastatic disease in 2013, 12,966 of whom (26%) had de novo metastatic breast cancer and 37,378 of whom had recurrent disease. They projected that, as of Jan. 1, 2017, there are 154,794 women living with metastatic breast cancer in the United States.

They also estimated changes over time in survival and found that, for women diagnosed from the ages of 15 to 49 during the 1992-1994 surveillance period, median survival time was 22.3 months, which improved to 38.7 months during the 2005-2012 surveillance period. The respective survival times for women 50-64 years were 19.1 months and 29.7 months.

For women 15-49 years who were diagnosed with de novo metastatic breast cancer, the 5-year relative survival rates doubled from 18% during 1992-1994 to 36% during 2005-2012.

“Despite a poor prognosis, there is a small but meaningful percentage of these cases who survive 10 years or more. More than 11% of women diagnosed between 2000-2004 under the age of 64 years survived 10 years or more. Younger women diagnosed with de novo MBC have higher survival than women diagnosed at older ages,” Dr. Mariotto and her colleagues wrote.

The investigators pointed to the population size, population-based data, long follow-up, and use of consistent staging definitions over time as study strengths but acknowledged that the study was limited by the absence of population-based estimates of survival following recurrence of metastatic breast cancer.

“To our knowledge, this is the first time that the number of women living with MBC in the United States has been estimated. These estimates provide a new perspective on the population burden of breast cancer and have great potential significance to the research and advocacy community working on behalf of patients with MBC and their families,” the authors wrote.

The study was supported by the National Cancer Institute. The authors reported no relevant financial disclosures.

This article was updated June 5, 2017.

AT ACOG 2017

SAN DIEGO – Continuation of tamoxifen for an additional 5 years is a cost-effective strategy that does not increase all-cause mortality for premenopausal women with estrogen receptor–positive breast cancer, based on an analysis using sophisticated computational modeling techniques.

“For premenopausal women with an early estrogen receptor–positive breast cancer who have completed 5 years of tamoxifen as initial treatment, another 5 years of tamoxifen is preferable to ovarian ablation with an aromatase inhibitor as extended endocrine treatment,” Janice Kwon, MD, said at the annual meeting of the American College of Obstetricians and Gynecologists.

The researchers sought to answer a key clinical question: “What is the optimal endocrine strategy for premenopausal women who have completed 5 years of tamoxifen? Another 5 years of tamoxifen? An aromatase inhibitor preceded by ovarian ablation? Or no further treatment?”

Dr. Kwon and her coinvestigators used a Markov Monte Carlo simulation to project adverse events that would occur with each of the three treatments in a hypothetical cohort of 18,000 premenopausal women with estrogen receptor–positive breast cancer. They also conducted sensitivity analyses to ascertain the point at which a given treatment would become cost effective. The investigators used a time horizon of 40 years in the Monte Carlo simulation, which uses repeated random sampling of a large data set to model the probability of a variety of outcomes. The primary outcome measure used to compare the three treatment strategies was the incremental cost-effectiveness ratio (ICER).

For the no further treatment strategy, the average costs were $1,074, for an average life expectancy gain of 16.69 years. Compared with this strategy, 5 more years of tamoxifen would cost $3,550 for an average life expectancy gain of 17.31 years, yielding an ICER of $4,042. The strategy of performing a bilateral salpingo-oophorectomy (BSO), followed by 5 years of aromatase inhibitor therapy, was more costly at $14,312 and yielded a shorter life expectancy gain at an average of 17.06 years, eliminating it as a feasible strategy in the ICER analysis.

Using the Monte Carlo simulation to assess treatment-related mortality, Dr. Kwon and her colleagues found that no further treatment would result in the most deaths from breast cancer, at 7,358. For this, and each of the other two strategies, the investigators also modeled deaths from other causes and from early BSO, using the Nurses’ Health Study hazard ratios. No further treatment would result in 5,878 deaths from other causes and none from early BSO, for a total of 13,236.

Another 5 years of tamoxifen, the model showed, would result in 6,227 deaths from breast cancer, 6,330 from other causes, and none from BSO, for a total of 12,557.

The BSO–aromatase inhibitor strategy was modeled to have the fewest deaths from breast cancer (5,504) and from other causes (5,834) but would result in an additional 1,897 deaths from the early BSO. The BSO–aromatase inhibitor strategy thus resulted in a virtually identical number of deaths over a 40-year period as no treatment at all, at 13,235.

An aromatase inhibitor is frequently considered as a treatment strategy for women with estrogen receptor–positive breast cancer. However, using an aromatase inhibitor is predicated on the patient being menopausal, so ovarian ablation is recommended for patients who have, or who may have, intact ovarian function.

Nearly 3 decades’ worth of data from the Nurses’ Health Study showed an overall hazard ratio of 1.41 for premenopausal oophorectomy without hormone therapy, said Dr. Kwon of the gynecologic oncology division at the University of British Columbia, Vancouver. Increased rates of osteoporosis, stroke, and coronary heart disease contributed to the increased risk, with 80% of the excess deaths occurring within 15 years of oophorectomy. The analysis yielded a number needed to harm for the procedure of eight.

The study’s results have also been substantiated by a recent meta-analysis, said Dr. Kwon, that also saw “fewer disease-free events but more deaths with aromatase inhibitor versus tamoxifen” (Breast Cancer Res Treat. 2017;161:185-90). However, she said, the long-term outcomes of breast cancer over many decades are unknown, and the analysis did not include costs for treatment of recurrent breast cancer.

No external funding sources were reported, and Dr. Kwon reported having no relevant financial disclosures.

koakes@frontlinemedcom.com

On Twitter @karioakes

AT ACOG 2017

SAN DIEGO – Continuation of tamoxifen for an additional 5 years is a cost-effective strategy that does not increase all-cause mortality for premenopausal women with estrogen receptor–positive breast cancer, based on an analysis using sophisticated computational modeling techniques.

“For premenopausal women with an early estrogen receptor–positive breast cancer who have completed 5 years of tamoxifen as initial treatment, another 5 years of tamoxifen is preferable to ovarian ablation with an aromatase inhibitor as extended endocrine treatment,” Janice Kwon, MD, said at the annual meeting of the American College of Obstetricians and Gynecologists.

The researchers sought to answer a key clinical question: “What is the optimal endocrine strategy for premenopausal women who have completed 5 years of tamoxifen? Another 5 years of tamoxifen? An aromatase inhibitor preceded by ovarian ablation? Or no further treatment?”

Dr. Kwon and her coinvestigators used a Markov Monte Carlo simulation to project adverse events that would occur with each of the three treatments in a hypothetical cohort of 18,000 premenopausal women with estrogen receptor–positive breast cancer. They also conducted sensitivity analyses to ascertain the point at which a given treatment would become cost effective. The investigators used a time horizon of 40 years in the Monte Carlo simulation, which uses repeated random sampling of a large data set to model the probability of a variety of outcomes. The primary outcome measure used to compare the three treatment strategies was the incremental cost-effectiveness ratio (ICER).

For the no further treatment strategy, the average costs were $1,074, for an average life expectancy gain of 16.69 years. Compared with this strategy, 5 more years of tamoxifen would cost $3,550 for an average life expectancy gain of 17.31 years, yielding an ICER of $4,042. The strategy of performing a bilateral salpingo-oophorectomy (BSO), followed by 5 years of aromatase inhibitor therapy, was more costly at $14,312 and yielded a shorter life expectancy gain at an average of 17.06 years, eliminating it as a feasible strategy in the ICER analysis.

Using the Monte Carlo simulation to assess treatment-related mortality, Dr. Kwon and her colleagues found that no further treatment would result in the most deaths from breast cancer, at 7,358. For this, and each of the other two strategies, the investigators also modeled deaths from other causes and from early BSO, using the Nurses’ Health Study hazard ratios. No further treatment would result in 5,878 deaths from other causes and none from early BSO, for a total of 13,236.

Another 5 years of tamoxifen, the model showed, would result in 6,227 deaths from breast cancer, 6,330 from other causes, and none from BSO, for a total of 12,557.

The BSO–aromatase inhibitor strategy was modeled to have the fewest deaths from breast cancer (5,504) and from other causes (5,834) but would result in an additional 1,897 deaths from the early BSO. The BSO–aromatase inhibitor strategy thus resulted in a virtually identical number of deaths over a 40-year period as no treatment at all, at 13,235.

An aromatase inhibitor is frequently considered as a treatment strategy for women with estrogen receptor–positive breast cancer. However, using an aromatase inhibitor is predicated on the patient being menopausal, so ovarian ablation is recommended for patients who have, or who may have, intact ovarian function.

Nearly 3 decades’ worth of data from the Nurses’ Health Study showed an overall hazard ratio of 1.41 for premenopausal oophorectomy without hormone therapy, said Dr. Kwon of the gynecologic oncology division at the University of British Columbia, Vancouver. Increased rates of osteoporosis, stroke, and coronary heart disease contributed to the increased risk, with 80% of the excess deaths occurring within 15 years of oophorectomy. The analysis yielded a number needed to harm for the procedure of eight.

The study’s results have also been substantiated by a recent meta-analysis, said Dr. Kwon, that also saw “fewer disease-free events but more deaths with aromatase inhibitor versus tamoxifen” (Breast Cancer Res Treat. 2017;161:185-90). However, she said, the long-term outcomes of breast cancer over many decades are unknown, and the analysis did not include costs for treatment of recurrent breast cancer.

No external funding sources were reported, and Dr. Kwon reported having no relevant financial disclosures.

koakes@frontlinemedcom.com

On Twitter @karioakes

AT ACOG 2017

SAN DIEGO – Continuation of tamoxifen for an additional 5 years is a cost-effective strategy that does not increase all-cause mortality for premenopausal women with estrogen receptor–positive breast cancer, based on an analysis using sophisticated computational modeling techniques.

“For premenopausal women with an early estrogen receptor–positive breast cancer who have completed 5 years of tamoxifen as initial treatment, another 5 years of tamoxifen is preferable to ovarian ablation with an aromatase inhibitor as extended endocrine treatment,” Janice Kwon, MD, said at the annual meeting of the American College of Obstetricians and Gynecologists.

The researchers sought to answer a key clinical question: “What is the optimal endocrine strategy for premenopausal women who have completed 5 years of tamoxifen? Another 5 years of tamoxifen? An aromatase inhibitor preceded by ovarian ablation? Or no further treatment?”

Dr. Kwon and her coinvestigators used a Markov Monte Carlo simulation to project adverse events that would occur with each of the three treatments in a hypothetical cohort of 18,000 premenopausal women with estrogen receptor–positive breast cancer. They also conducted sensitivity analyses to ascertain the point at which a given treatment would become cost effective. The investigators used a time horizon of 40 years in the Monte Carlo simulation, which uses repeated random sampling of a large data set to model the probability of a variety of outcomes. The primary outcome measure used to compare the three treatment strategies was the incremental cost-effectiveness ratio (ICER).

For the no further treatment strategy, the average costs were $1,074, for an average life expectancy gain of 16.69 years. Compared with this strategy, 5 more years of tamoxifen would cost $3,550 for an average life expectancy gain of 17.31 years, yielding an ICER of $4,042. The strategy of performing a bilateral salpingo-oophorectomy (BSO), followed by 5 years of aromatase inhibitor therapy, was more costly at $14,312 and yielded a shorter life expectancy gain at an average of 17.06 years, eliminating it as a feasible strategy in the ICER analysis.

Using the Monte Carlo simulation to assess treatment-related mortality, Dr. Kwon and her colleagues found that no further treatment would result in the most deaths from breast cancer, at 7,358. For this, and each of the other two strategies, the investigators also modeled deaths from other causes and from early BSO, using the Nurses’ Health Study hazard ratios. No further treatment would result in 5,878 deaths from other causes and none from early BSO, for a total of 13,236.

Another 5 years of tamoxifen, the model showed, would result in 6,227 deaths from breast cancer, 6,330 from other causes, and none from BSO, for a total of 12,557.

The BSO–aromatase inhibitor strategy was modeled to have the fewest deaths from breast cancer (5,504) and from other causes (5,834) but would result in an additional 1,897 deaths from the early BSO. The BSO–aromatase inhibitor strategy thus resulted in a virtually identical number of deaths over a 40-year period as no treatment at all, at 13,235.

An aromatase inhibitor is frequently considered as a treatment strategy for women with estrogen receptor–positive breast cancer. However, using an aromatase inhibitor is predicated on the patient being menopausal, so ovarian ablation is recommended for patients who have, or who may have, intact ovarian function.

Nearly 3 decades’ worth of data from the Nurses’ Health Study showed an overall hazard ratio of 1.41 for premenopausal oophorectomy without hormone therapy, said Dr. Kwon of the gynecologic oncology division at the University of British Columbia, Vancouver. Increased rates of osteoporosis, stroke, and coronary heart disease contributed to the increased risk, with 80% of the excess deaths occurring within 15 years of oophorectomy. The analysis yielded a number needed to harm for the procedure of eight.

The study’s results have also been substantiated by a recent meta-analysis, said Dr. Kwon, that also saw “fewer disease-free events but more deaths with aromatase inhibitor versus tamoxifen” (Breast Cancer Res Treat. 2017;161:185-90). However, she said, the long-term outcomes of breast cancer over many decades are unknown, and the analysis did not include costs for treatment of recurrent breast cancer.

No external funding sources were reported, and Dr. Kwon reported having no relevant financial disclosures.

koakes@frontlinemedcom.com

On Twitter @karioakes

LAS VEGAS – Intraoperative radiation therapy (IORT) is effective in patients with ductal carcinoma in situ (DCIS), and bilateral digital mammography and breast MRI effectively predicted which patients would be most suited for the procedure, according to a nonrandomized study.

The TARGIT-A trial showed that IORT was noninferior to external beam radiation therapy in women with early-stage breast cancer (Lancet. 2014 Feb 15;383:603-13), but the technique hasn’t been tested in DCIS patients.

LAS VEGAS – Intraoperative radiation therapy (IORT) is effective in patients with ductal carcinoma in situ (DCIS), and bilateral digital mammography and breast MRI effectively predicted which patients would be most suited for the procedure, according to a nonrandomized study.

The TARGIT-A trial showed that IORT was noninferior to external beam radiation therapy in women with early-stage breast cancer (Lancet. 2014 Feb 15;383:603-13), but the technique hasn’t been tested in DCIS patients.

LAS VEGAS – Intraoperative radiation therapy (IORT) is effective in patients with ductal carcinoma in situ (DCIS), and bilateral digital mammography and breast MRI effectively predicted which patients would be most suited for the procedure, according to a nonrandomized study.

The TARGIT-A trial showed that IORT was noninferior to external beam radiation therapy in women with early-stage breast cancer (Lancet. 2014 Feb 15;383:603-13), but the technique hasn’t been tested in DCIS patients.

LAS VEGAS – In women aged 70 years or older with hormone receptor–positive invasive breast cancer, their tumor size, grade, and histology – but not human epidermal growth factor receptor–2 status – predicted nodal positivity, according to a retrospective analysis.

Investigators at the Mayo Clinic, Rochester, Minn., reviewed 52,532 women in the National Cancer Database from 2010 to 2013 who were at least 70 years old with hormone receptor–positive invasive breast cancer and clinically node negative disease, who had axillary surgery performed. Two-thirds of the cohort was used to identify risk factors, and the remaining third to validate them. About 16% in both groups had cancer in their axillary lymph nodes.

On multivariate analysis, higher clinical T stage, higher grade, and invasive lobular and invasive mammary histology were all associated with positive nodes. Although significant on univariate analysis, age (P = .57) and HER2 status (P = .32) fell out on multivariate analysis.

Nodal positivity was more than five times as likely with clinical T2 tumors, compared with T1a tumors, and far less likely for patients with invasive mucinous carcinoma than for those with invasive ductal carcinoma.

The team expects to release a nomogram for general use in clinical practice to predict the risk of positive nodes for various combinations of tumor size, grade, and histology in older women. When the model predicted a less than 10% chance of node positive disease, the actual rate in the validation set was around 5.5%. When it predicted a 30%-39% chance, the actual rate was 32.6%. The area under the receiver operating characteristic curve was 0.7 in both the development and validation sets, indicating good discrimination.

The work grew out of an effort to implement the Society of Surgical Oncologists’ recommendation not to do routine sentinel node biopsies in clinically node negative, hormone receptor–positive invasive breast cancer in women over the age of 70 years, a recommendation the group made as part of its contribution to the Choosing Wisely campaign.

“After the guideline was released, we were sitting in the clinic thinking how to apply it to our patients,” lead investigator Jessemae Welsh, MD, a surgeon at the Mayo Clinic, said at the American Society of Breast Surgeons annual meeting.

The problem is that nodal positivity is important to know for other aspects of care, including regional nodal irradiation and duration of systemic hormone therapy, and axillary lymph node staging might still be indicated if older women are truly at high risk. “We [wanted] to develop a multivariate model that gives a precise estimate of nodal risk,” to help “patients and surgeons to decide together based on an individual risk” how best to proceed. Also, a prediction of low risk “can help reassure patients that they will do well without axillary surgery,” she said.

Mayo’s nomogram is unique in that it focuses specifically on women 70 years and older. Development of previous nomograms incorporated older women, but did not focus on them specifically, Dr. Welsh said.

Dr. Welsh said she had no relevant disclosures.

aotto@frontlinemedcom.com

LAS VEGAS – In women aged 70 years or older with hormone receptor–positive invasive breast cancer, their tumor size, grade, and histology – but not human epidermal growth factor receptor–2 status – predicted nodal positivity, according to a retrospective analysis.

Investigators at the Mayo Clinic, Rochester, Minn., reviewed 52,532 women in the National Cancer Database from 2010 to 2013 who were at least 70 years old with hormone receptor–positive invasive breast cancer and clinically node negative disease, who had axillary surgery performed. Two-thirds of the cohort was used to identify risk factors, and the remaining third to validate them. About 16% in both groups had cancer in their axillary lymph nodes.

On multivariate analysis, higher clinical T stage, higher grade, and invasive lobular and invasive mammary histology were all associated with positive nodes. Although significant on univariate analysis, age (P = .57) and HER2 status (P = .32) fell out on multivariate analysis.

Nodal positivity was more than five times as likely with clinical T2 tumors, compared with T1a tumors, and far less likely for patients with invasive mucinous carcinoma than for those with invasive ductal carcinoma.

The team expects to release a nomogram for general use in clinical practice to predict the risk of positive nodes for various combinations of tumor size, grade, and histology in older women. When the model predicted a less than 10% chance of node positive disease, the actual rate in the validation set was around 5.5%. When it predicted a 30%-39% chance, the actual rate was 32.6%. The area under the receiver operating characteristic curve was 0.7 in both the development and validation sets, indicating good discrimination.

The work grew out of an effort to implement the Society of Surgical Oncologists’ recommendation not to do routine sentinel node biopsies in clinically node negative, hormone receptor–positive invasive breast cancer in women over the age of 70 years, a recommendation the group made as part of its contribution to the Choosing Wisely campaign.

“After the guideline was released, we were sitting in the clinic thinking how to apply it to our patients,” lead investigator Jessemae Welsh, MD, a surgeon at the Mayo Clinic, said at the American Society of Breast Surgeons annual meeting.

The problem is that nodal positivity is important to know for other aspects of care, including regional nodal irradiation and duration of systemic hormone therapy, and axillary lymph node staging might still be indicated if older women are truly at high risk. “We [wanted] to develop a multivariate model that gives a precise estimate of nodal risk,” to help “patients and surgeons to decide together based on an individual risk” how best to proceed. Also, a prediction of low risk “can help reassure patients that they will do well without axillary surgery,” she said.

Mayo’s nomogram is unique in that it focuses specifically on women 70 years and older. Development of previous nomograms incorporated older women, but did not focus on them specifically, Dr. Welsh said.

Dr. Welsh said she had no relevant disclosures.

aotto@frontlinemedcom.com

LAS VEGAS – In women aged 70 years or older with hormone receptor–positive invasive breast cancer, their tumor size, grade, and histology – but not human epidermal growth factor receptor–2 status – predicted nodal positivity, according to a retrospective analysis.

Investigators at the Mayo Clinic, Rochester, Minn., reviewed 52,532 women in the National Cancer Database from 2010 to 2013 who were at least 70 years old with hormone receptor–positive invasive breast cancer and clinically node negative disease, who had axillary surgery performed. Two-thirds of the cohort was used to identify risk factors, and the remaining third to validate them. About 16% in both groups had cancer in their axillary lymph nodes.

On multivariate analysis, higher clinical T stage, higher grade, and invasive lobular and invasive mammary histology were all associated with positive nodes. Although significant on univariate analysis, age (P = .57) and HER2 status (P = .32) fell out on multivariate analysis.

Nodal positivity was more than five times as likely with clinical T2 tumors, compared with T1a tumors, and far less likely for patients with invasive mucinous carcinoma than for those with invasive ductal carcinoma.

The team expects to release a nomogram for general use in clinical practice to predict the risk of positive nodes for various combinations of tumor size, grade, and histology in older women. When the model predicted a less than 10% chance of node positive disease, the actual rate in the validation set was around 5.5%. When it predicted a 30%-39% chance, the actual rate was 32.6%. The area under the receiver operating characteristic curve was 0.7 in both the development and validation sets, indicating good discrimination.

The work grew out of an effort to implement the Society of Surgical Oncologists’ recommendation not to do routine sentinel node biopsies in clinically node negative, hormone receptor–positive invasive breast cancer in women over the age of 70 years, a recommendation the group made as part of its contribution to the Choosing Wisely campaign.

“After the guideline was released, we were sitting in the clinic thinking how to apply it to our patients,” lead investigator Jessemae Welsh, MD, a surgeon at the Mayo Clinic, said at the American Society of Breast Surgeons annual meeting.

The problem is that nodal positivity is important to know for other aspects of care, including regional nodal irradiation and duration of systemic hormone therapy, and axillary lymph node staging might still be indicated if older women are truly at high risk. “We [wanted] to develop a multivariate model that gives a precise estimate of nodal risk,” to help “patients and surgeons to decide together based on an individual risk” how best to proceed. Also, a prediction of low risk “can help reassure patients that they will do well without axillary surgery,” she said.

Mayo’s nomogram is unique in that it focuses specifically on women 70 years and older. Development of previous nomograms incorporated older women, but did not focus on them specifically, Dr. Welsh said.

Dr. Welsh said she had no relevant disclosures.

aotto@frontlinemedcom.com