Background: Despite the paucity of evidence supporting chemotherapy in the treatment of node-negative, HER2-positive breast cancer measuring <2 cm, use of trastuzumab-based chemotherapy has increased over the past decade. Therefore, we used the National Cancer Database to evaluate the use and impact of chemotherapy on survival in this population. Methods: We identified female patients aged 18 to 70 years with node-negative, HER2-positive breast cancer measuring <2 cm. A propensity-matched cohort model was used to control for risk factors known to influence survival. Primary end points assessed were receipt of chemotherapy and overall survival (OS). Results: In our propensity-matched cohort model (n=8,222), adjuvant chemotherapy (ACT) was associated with a lower 5-year OS rate in T1mi breast cancer (n=626; 89.1% [95% CI, 81.8%–93.5%] vs 99.1% [96.6%–99.8%]), no significant effect in T1a disease (n=2,901; 95.4% [93.2%–96.9%] vs 96.9% [94.1%–98.3%]), and improved 5-year OS in T1b (n=2,340; 97.1% [95.1%–98.4%] vs 92.3% [88.5%–94.9%]) and T1c tumors (n=2,355; 95.9% [93.5%–97.5%] vs 91.5% [88.4%–93.9%]). In the entire cohort of 21,148 patients who met the inclusion criteria, ACT was associated with lower 5-year OS in T1mi (89.6% [83.7%–93.4%] vs 98.1% [96.6%–98.9%]) and T1a tumors (94.9% [92.9%–96.3%] vs 96.5% [94.6%–97.7%]), and improved 5-year OS in T1b (96.8% [95.6%–97.7%] vs 92.3% [88.7%–94.8%]) and T1c tumors (95.8% [94.9%–96.5%] vs 91.6% [88.5%–93.9%]). Increased use of ACT was observed over the study period. From 2010 to 2013, annual treatment rates were 71.5%, 72.4%, 73.3%, and 74.4%, respectively (trend test, P<.0001). Conclusions: Our data support the use of ACT for HER2-positive, node-negative T1b and T1c breast cancer, whereas no benefit was observed for ACT in T1mi and T1a HER2-positive, node-negative breast cancer. Although use of ACT is increasing in node-negative, HER2-positive breast cancer <2 cm, our findings caution against its use in the smallest of these tumors (T1mi and T1a) due to lack of survival benefit.
Benjamin M. Parsons, Dipesh Uprety, Angela L. Smith, Andrew J. Borgert, and Leah L. Dietrich
Titilayo O. Adegboyega, Jeffrey Landercasper, Jared H. Linebarger, Jeanne M. Johnson, Jeremiah J. Andersen, Leah L. Dietrich, Collin D. Driscoll, Meghana Raghavendra, Anusha R. Madadi, Mohammed Al-Hamadani, Choua A. Vang, Kristen A. Marcou, Jane Hudak, and Ronald S. Go
Background: Variations exist in compliance with NCCN Guidelines. Prior reports of adherence to NCCN Guidelines contain limitations because of lack of contemporary review and incomplete listing of reasons for noncompliance. Purpose: To assess institutional compliance and assist national quality improvement strategies through identifying valid reasons for noncompliance. Methods: Compliance with NCCN Guidelines was recorded prospectively using electronic synoptic templates for patients with newly diagnosed breast cancer treated at a single institution between January 2010 and December 2011. Compliance with NCCN Guidelines was recorded. The accuracy of real-time synoptic auditing methods compared with retrospective chart review and reasons for noncompliance was assessed. SAS 9.3 software was used for data analysis. Results: Compliance with NCCN Guidelines among 395 patients was 94% for initial staging evaluation, 97% for surgery, 91% for chemotherapy, 89% for hormone therapy, 91% for radiation therapy, 85% for follow-up, and 100% for determination of estrogen receptor/progesterone receptor and HER2 status. Age, comorbidities, and stage influenced guideline compliance. The most common reasons for noncompliance were patient refusal, patient choice after shared decision-making, and overuse of testing. Synoptic templated reporting was accurate in 97% patients. Conclusions: High compliance with NCCN Guidelines was demonstrated. Reasons for noncompliance were identifiable. Compliance and nonadherence can be evaluated quickly with electronic synoptic reporting. This allows real-time action plans to address quality concerns and aids national risk adjustment for comparison and benchmarking.