Locally Advanced Breast Cancer Flashcards
What were the pt population, randomization, major results, and conclusions of the Danish 82b (Overgaard, 1997) for LABC?
- Pts:
– Pre-menopausal women
– High-risk breast cancer (size > 5 cm, LN+, or skin/pectoral fascia involvement) - Randomization
– mastectomy + CMF (cyclophosphamide, methotrexate, 5-FU) ± RT
– RT was given to the chest wall, axilla, supraclavicular, and internal mammary (IMN) LNs. - Results: RT vs. no RT (all findings below are SS)
– 10-yr LRF: 9% vs. 32%
– 10-yr DFS: 48% vs. 34%
– 10-yr OS: 54% vs. 45%
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82B → were still bleeding
What were the pt population, randomization, major results, and conclusions of the Danish 82c for LABC?
Pts:
– Post-menopausal women
– High-risk breast cancer (size > 5 cm, LN+, or skin/pectoral fascia involvement)
- Randomization:
– Mastectomy plus tamoxifen ± PMRT
– RT was given to the chest wall, supraclavicular lymph nodes, and IMNs - Results: +RT vs. -RT (all findings below are SS)
– 10-yr LRF: 8% vs. 35%
– 10-yr DFS: 36% vs. 24%
– 10-yr OS: 45% vs. 36%
What were the pt population, randomization, major results, and conclusions of the NSABP B-18 for LABC?
- Pts: 1,523 women with operable breast cancer (cT1-3N0-1)
- Randomization:
1. Neoadjuvant AC x 4CC
2. Adjuvant AC x 4C - Results: NACT ↑ tumor downstaging and ↑ ability to undergo BCC
What were the pt population, randomization, major results, and conclusions of the NSABP B-27 for LABC?
- Pts: 2,411 W w/ operable breast cancers
- Randomization:
1. Neoadj. AC x 4C → surgery
2. ACx 4C → T → surgery
3. AC x 4C → surgery → T x 4C - Findings: 1 vs. 2/3
- cCR: 40.1% vs. 63.6% (S)
- pCR: 13.7% vs. 26.1% (S)
- Gr 4 tox: 10.3%% vs. 23.4% (S)
- BCS rates: 61.6% vs. 63.7% (NS)
- DFS (~70%) and OS similar across all arms
- Conc: Docetaxol significantly improves the cCR and pCR rates but did not significantly impact disease-free survival or overall survival
What were the findings of the combined subgroup analysis of the Danish 92b and 82c for LABC w/ regards to # of LNs and the benefits of PMRT?
RT vs. No RT
- 1-3 LNs: RT
– 15-yr LRF: 4% vs. 27%, (SS)
– 15-yr OS: 57% vs. 48% (SS)
- ≥ 4 LNs
– 15-yr LRF: 10% vs. 51% (SS)
– 15-yr OS: 21% vs. 12% (SS)
What were the pt population, randomization, major results, and conclusions of the British Columbia trial for post-mastectomy LABC?
- Pts: LN+
- Randomization
– Mastectomy plus adjuvant CMF (cyclophosphamide, methotrexate, and 5-
FU) ± PMRT
– PMRT was given to 37.5 Gy in 16 fx w/ SCL and ALN were treated to 35 Gy in 15 x - Results: +RT vs. -RT, all findings below are SS
– 20-yr LRF = 10% vs. 26%
– 20-yr EFS = 38% vs. 25%
– 20-yr OS = 47% vs. 37%
What were the LRR noted on the NSABP B-18 and B-27 pooled analysis for LABC patients s/p NACT f/b mastectomy?
Mamounas et. al. JCO 2012
How are 10-yr outcomes improved in pts w/ stage III LABC w/ vs. w/o PMRT?
McGuire et al, MDACC, IJORBP 2007
What are the benefits of doing SLNBx before vs. after NACT?
Before:
1. Accurate assessment of the initial involvement of the axilla.
2. May help counsel the patient on the need for post-mastectomy RT or the need for regional irradiation.
3. May affect systemic therapy decisions.
After:
1. Only one procedure is done.
2. Provides an assessment of the response to chemotherapy.
3. If patients become node-negative, fewer patients may need an axillary dissection.
4. There is no delay in initiating chemotherapy.
What are the predictors or recurrence in mastectomy pts per the NSABP nomogram (combined analysis of B-18 and B-27)?
- Tumor size pre-CHT
- Nodal status pre-CHT
- Pathologic post-CHT
What are the predictors or recurrence in lumpectomy pts per the NSABP nomogram (combined analysis of B-18 and B-27)?
- Age
- Clinical nodal status (pre-CHT)
- Response to CHT
What were the rates of LRR post-NACT f/b mastectomy vs. lumpectomy + RT in the NSABP combined analysis (B-18 + B-27)?
- LRR
– NACT → Mastectomy: 12.3%
– NACT → BCS → RT: 10.3%
What were the oncologic outcomes of the Chinese trial (Wang et al, 2019) comparing
hypofractionated PMRT to conventionally fractionated PMRT?
- HF-PMRT was non-inferior to CF-PMRT
- Less Gr 3 tox in HF-PMRT
- No differences in other tox
How does the clinical/oncologic benefit of RT vary w/ pathologic LN status and # of LNs involved?
Takeaways:
- pN0 → 20-yr OS benefit, but no other benefit
- 1-3 LN+ → no OS benefit
What are the indicators for PMRT?
- Risk Factors:
1. Age ≤ 50
2. Tumor size > 2 cm
3. Close or positive margins
4. LVSI+
5. No systemic therapy - The 10-yr LRF based on the total number of factors are as follows:
– 0: 2%
– 1: 3.3%
– 2:5.8%
– 3 or 3+: 19.7% - Conclusions:
– ≥ 3 risk factors may benefit from adjuvant radiation therapy after mastectomy
– The majority of the failures (73%) were on the chest wall
How do tumor size and LN status pre and post-NACT impact 10-yr LRR in pts w/ LABC?
