Among accredited cancer centers in the United States, hospitals serving primarily minority patients are as likely as other hospitals to offer the standard of surgical care for early-stage breast cancer, according to results presented at the virtual American College of Surgeons Clinical Congress 2020 and published by Olga Kantor, MD, MS, and colleagues in the Journal of the American College of Surgeons.
Olga Kantor, MD, MS
T. Salewa Oseni, MD, FACS
“There are a lot of health disparities in cancer: in access to care, treatment, and outcomes,” said senior study investigator T. Salewa Oseni, MD, FACS, Assistant Professor of Surgery at Harvard Medical School. “In our study, we were pleasantly surprised there was no difference between the care that Black, Hispanic, and White women receive.”
The researchers examined hospitals’ management practices involving completion axillary lymph node dissection (ALND), which often results in lymphedema. “Five to 10 years ago, studies found that not every woman needs to have an axillary dissection after a positive sentinel lymph node biopsy,” explained Dr. Oseni. “The combination of radiation and chemotherapy in certain instances may be sufficient, with the same survival and fewer clinical complications.”
Recommendations from these study results are rapidly becoming the standard of care in breast cancer with up to two positive lymph nodes, said lead study investigator Dr. Kantor, an Associate Surgeon at Brigham and Women’s Hospital. When more than two sentinel lymph nodes are positive, the standard of care remains an ALND.
Analysis of Past Trials
Dr. Kantor and colleagues assessed whether disparities exist in the application of these evidence-based guidelines depending on whether a hospital serves predominantly minorities. The researchers defined minority-serving hospitals as those in the top 10% treating the largest proportion of Black and Hispanic patients.
Many patients at minority-serving hospitals lack health insurance and have decreased access to high-quality care, such as cancer specialists, said Dr. Kantor. Additionally, some studies have found lower adherence to cancer treatment guidelines among minority-serving hospitals, such as a 2016 report published by Rhoads et al in the Journal of Clinical Oncology.
Using data from the National Cancer Database, Dr. Kantor’s group included more than 21,000 patients with breast cancer treated in 2015 and 2016.
The researchers studied whether the cancer centers omitted ALND in appropriately selected patients, which they called uptake of results from three landmark clinical trials. These studies were the ACS Oncology Group (ACOSOG) Z0011 trial published in 2011 by Giuliano et al in JAMA; the ACOSOG Z1071 trial published in 2013 by Boughey et al in JAMA; and the After Mapping of the Axilla: Radiotherapy or Surgery (AMAROS) trial by the European Organisation of Research and Treatment of Cancer published in 2014 by Donker et al in The Lancet Oncology. The studies included patients with early-stage breast cancer and small tumors on examination or imaging (clinical T1 or cT2) who underwent breast conservation (lumpectomy) or, in the AMAROS trial, mastectomy.
There was no survival difference in patients with one or two positive sentinel lymph nodes between those who had ALND and those who did not in the ACOSOG Z0011 trial. Similarly, the AMAROS investigators found no survival difference between patients who had ALND and those who received axillary radiation therapy but no ALND. The Z1071 trial results showed it was possible to do sentinel lymph node biopsy alone after a response to neoadjuvant chemotherapy.
Dr. Kantor and her team divided patients into three groups by matching the cancer characteristics to the inclusion criteria for these clinical trials. Among the 7,167 patients who met the criteria for the ACOSOG Z0011 trial, there was a similar uptake of the recommendation to omit ALND between minority-serving hospitals and non–minority serving hospitals (74.6% vs 72.9%, respectively). Likewise, uptake of the ACOSOG Z1071 results was similar among the 4,546 patients meeting study criteria: 41.9% for minority-serving hospitals and 44.9% for non–minority serving hospitals.
In the 9,433 patients who matched criteria for the AMAROS trial, uptake was slightly lower at minority-serving hospitals—11.7%—compared with 14% at non–minority serving hospitals. However, after the researchers adjusted their statistical analyses for multiple factors, they found no difference in uptake by minority-serving hospital status, said Dr. Kantor.
“Minority-serving hospitals offer a strong level of evidence-based breast cancer care if accredited by the Commission on Cancer,” concluded Dr. Oseni.
Disclosure: For full disclosures of the study authors, visit journalacs.org.
