Underuse of Trimodality Treatment for Patients With Inflammatory Breast Cancer Negatively Impacts Survival

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Analysis of data for 10,197 women treated for nonmetastatic inflammatory breast cancer treated over a 12-year-period found that the use of trimodality treatment (chemotherapy, surgery, and radiation therapy) fluctuated annually between 58.4% and 73%. “Underutilization of trimodality therapy negatively impacted survival for patients with [inflammatory breast cancer],” Natasha M. Rueth, MD, and colleagues from The University of Texas MD Anderson Cancer Center, Houston, concluded in the study report published in the Journal of Clinical Oncology.

Unsurprising Findings

“Not surprising, 5- and 10-year survival rates were highest among patients receiving trimodality treatment (55.4% and 37.3%, respectively) compared with any other treatment group,” the researchers wrote. Survival rates for patients who received the combination of surgery plus chemotherapy were 42.9% at 5 years and 28.5% at 10 years, and for those receiving surgery plus radiation therapy, 40.7% at 5 years and 23.5% at 10 years. The 10-year survival rate for patients receiving surgery alone was 16.5%.

“Current [inflammatory breast cancer] treatment guidelines published by the National Comprehensive Cancer Network recommend anthracycline-based neoadjuvant chemotherapy followed by modified radical mastectomy and postmastectomy radiation therapy to the chest wall and draining lymphatics (trimodality treatment),” the investigators noted. Over the course of the study, they found that the use of trimodality treatment “increased steadily until it reached a maximum of 73.4% in 2004. In the years that followed, use varied; by 2010, only 65.9% of patients received trimodality treatment for [inflammatory breast cancer].”

Patients diagnosed earlier in the study period were significantly less likely to receive trimodality therapy, as were those who were older, lived in regions of the country outside of the Midwest, had lower incomes or public insurance, and had a higher comorbid score (all P < .05). “After adjusting for potential confounding variables, use of trimodality therapy remained a significant independent predictor of survival,” the authors noted.

The majority of the patients, identified through the National Cancer Data Base, were white, insured, and had a low comorbidity score. Almost all women (93.4%) had unilateral or bilateral mastectomy, and the remainder had segmental mastectomy of an unknown or unreported breast operation.

Surprising Findings

The authors noted that they were “surprised to find that 5.3% of women in the study were treated with substandard segmental mastectomy rather than total mastectomy, a surgical option associated with poor cosmetic outcomes and unacceptably high positive margin and local recurrence rates. We also found it notable that nearly one third of women did not have pathologic lymph node status reported, despite the knowledge that [inflammatory breast cancer] is associated with axillary lymph node involvement in 55% to 85% of cases and is a predictor of patient survival.”

Although 93.5% of patients received chemotherapy in addition to surgery, 26.8% of those patients did not receive radiotherapy also, which had a significant detrimental impact on overall survival. “By focusing our study on the surgical population, we have created a cohort of women who had access to medical care; despite this, patients with lower incomes or public insurance were less likely to receive complete trimodality treatment than those with higher incomes or private insurance,” the researchers wrote.

“Although it is quite likely that the reasons for noncompliance of treatment are multifactorial, clinicians must consider the individual impact of each patient’s social setting, recognizing that unique financial challenges including travel, childcare, and days away from work may influence a woman’s ability to fully adhere to her cancer treatment plan,” the authors advised.

“Given that recurrence rates in [inflammatory breast cancer] are relatively high and take place within a shorter time period than in other forms of breast cancer, adherence to [radiotherapy] may play a greater role in locoregional control,” they continued. “The ongoing nationwide trends in underutilization of [radiotherapy] warrant further investigation into the specific patient and physician factors that preclude comprehensive cancer care.” ■

Rueth NM, et al: J Clin Oncol. June 2, 2014 (early release online).