Journal Article
. 2017 Dec; 110(5):493-500.
doi: 10.1093/jnci/djx239.

Recent Trends in Chemotherapy Use and Oncologists' Treatment Recommendations for Early-Stage Breast Cancer

Allison W Kurian 1 Irina Bondarenko 2 Reshma Jagsi 3 Christopher R Friese 4 M Chandler McLeod 2 Sarah T Hawley 5 Ann S Hamilton 6 Kevin C Ward 7 Timothy P Hofer 8 Steven J Katz 5 
Affiliations
  • PMID: 29237009
  •     28 References
  •     21 citations

Abstract

Background: There is growing concern about overtreatment of breast cancer as outcomes have improved over time. However, little is known about how chemotherapy use and oncologists' recommendations have changed in recent years.

Methods: We surveyed 5080 women (70% response rate) diagnosed with breast cancer between 2013 and 2015 and accrued through two Surveillance, Epidemiology, and End Results registries (Georgia and Los Angeles) about chemotherapy receipt and their oncologists' chemotherapy recommendations. We surveyed 504 attending oncologists (60.3% response rate ) about chemotherapy recommendations in node-negative and node-positive case scenarios. We conducted descriptive statistics of chemotherapy use and patients' report of oncologists' recommendations and used a generalized linear mixed model of chemotherapy use according to time and clinical factors. All statistical tests were two-sided.

Results: The analytic sample was 2926 patients with stage I-II, estrogen receptor-positive, human epidermal growth factor receptor 2-negative breast cancer. From 2013 to 2015, keeping other factors constant, chemotherapy use was estimated to decline from 34.5% (95% confidence interval [CI] = 30.8% to 38.3%) to 21.3% (95% CI = 19.0% to 23.7%, P < .001). Estimated decline in chemotherapy use was from 26.6% (95% CI = 23.0% to 30.7%) to 14.1% (95% CI = 12.0% to 16.3%) for node-negative/micrometastasis patients and from 81.1% (95% CI = 76.6% to 85.0%) to 64.2% (95% CI = 58.6% to 69.6%) for node-positive patients. Use of the 21-gene recurrence score (RS) did not change among node-negative/micrometastasis patients, and increasing RS use in node-positive patients accounted for one-third of the chemotherapy decline. Patients' report of oncologists' recommendations for chemotherapy declined from 44.9% (95% CI = 40.2% to 49.7%) to 31.6% (95% CI = 25.9% to 37.9%), controlling for other factors. Oncologists were much more likely to order RS if patient preferences were discordant with their recommendations (67.4%, 95% CI = 61.7% to 73.0%, vs 17.5%, 95% CI = 13.1% to 22.0%, concordant), and they adjusted recommendations based on patient preferences and RS results.

Conclusions: For both node-negative/micrometastasis and node-positive patients, chemotherapy receipt and oncologists' recommendations for chemotherapy declined markedly over time, without substantial change in practice guidelines. Results of ongoing trials will be essential to confirm the quality of this approach to breast cancer care.

Integrating comparative effectiveness design elements and endpoints into a phase III, randomized clinical trial (SWOG S1007) evaluating oncotypeDX-guided management for women with breast cancer involving lymph nodes.
Scott D Ramsey, William E Barlow, +6 authors, Gabriel N Hortobagyi.
Contemp Clin Trials, 2012 Sep 25; 34(1). PMID: 23000081    Free PMC article.
Review.
21-Gene recurrence score decreases receipt of chemotherapy in ER+ early-stage breast cancer: an analysis of the NCDB 2010-2013.
Benjamin M Parsons, Jeffrey Landercasper, +3 authors, Leah L Dietrich.
Breast Cancer Res Treat, 2016 Aug 11; 159(2). PMID: 27507245    Free PMC article.
Chemotherapy use for hormone receptor-positive, lymph node-negative breast cancer.
Michael J Hassett, Melissa E Hughes, +7 authors, Jane C Weeks.
J Clin Oncol, 2008 Oct 29; 26(34). PMID: 18955448    Free PMC article.
Adoption of gene expression profile testing and association with use of chemotherapy among women with breast cancer.
Michael J Hassett, Samuel M Silver, +12 authors, Jane C Weeks.
J Clin Oncol, 2012 May 16; 30(18). PMID: 22585699    Free PMC article.
Initial Trends in the Use of the 21-Gene Recurrence Score Assay for Patients With Breast Cancer in the Medicare Population, 2005-2009.
Michaela A Dinan, Xiaojuan Mi, +3 authors, Lesley H Curtis.
JAMA Oncol, 2015 Jul 17; 1(2). PMID: 26181015
Genetic Testing and Counseling Among Patients With Newly Diagnosed Breast Cancer .
Allison W Kurian, Kent A Griffith, +4 authors, Reshma Jagsi.
JAMA, 2017 Feb 09; 317(5). PMID: 28170472    Free PMC article.
Highly Cited.
Use of Gene Expression Profiling and Chemotherapy in Early-Stage Breast Cancer: A Study of Linked Electronic Medical Records, Cancer Registry Data, and Genomic Data Across Two Health Care Systems.
Anosheh Afghahi, Maya Mathur, +14 authors, Allison W Kurian.
J Oncol Pract, 2016 May 26; 12(6). PMID: 27221993    Free PMC article.
Chemotherapy decisions and patient experience with the recurrence score assay for early-stage breast cancer.
Christopher R Friese, Yun Li, +6 authors, Steven J Katz.
Cancer, 2016 Oct 25; 123(1). PMID: 27775837    Free PMC article.
Assessment of risks by predicting counterfactuals.
G Y Zou.
Stat Med, 2009 Oct 27; 28(30). PMID: 19856279
Molecular portraits of human breast tumours.
C M Perou, T Sørlie, +15 authors, D Botstein.
Nature, 2000 Aug 30; 406(6797). PMID: 10963602
Highly Cited.
Invasive Breast Cancer Version 1.2016, NCCN Clinical Practice Guidelines in Oncology.
William J Gradishar, Benjamin O Anderson, +28 authors, Rashmi Kumar.
J Natl Compr Canc Netw, 2016 Mar 10; 14(3). PMID: 26957618
Highly Cited.
Population-based study of the effect of gene expression profiling on adjuvant chemotherapy use in breast cancer patients under the age of 65 years.
Arnold L Potosky, Suzanne C O'Neill, +8 authors, Marc D Schwartz.
Cancer, 2015 Aug 21; 121(22). PMID: 26291519    Free PMC article.
Social and Clinical Determinants of Contralateral Prophylactic Mastectomy.
Sarah T Hawley, Reshma Jagsi, +4 authors, Steven J Katz.
JAMA Surg, 2014 May 23; 149(6). PMID: 24849045    Free PMC article.
Concerns about cancer risk and experiences with genetic testing in a diverse population of patients with breast cancer.
Reshma Jagsi, Kent A Griffith, +5 authors, Sarah T Hawley.
J Clin Oncol, 2015 Apr 08; 33(14). PMID: 25847940    Free PMC article.
Treatment-associated toxicities reported by patients with early-stage invasive breast cancer.
Christopher R Friese, Jordan M Harrison, +8 authors, Timothy P Hofer.
Cancer, 2017 Jan 25; 123(11). PMID: 28117882    Free PMC article.
The influence of 21-gene recurrence score assay on chemotherapy use in a population-based sample of breast cancer patients.
Yun Li, Allison W Kurian, +6 authors, Timothy P Hofer.
Breast Cancer Res Treat, 2016 Dec 25; 161(3). PMID: 28012085    Free PMC article.
Association Between Use of the 21-Gene Recurrence Score Assay and Receipt of Chemotherapy Among Medicare Beneficiaries With Early-Stage Breast Cancer, 2005-2009.
Michaela A Dinan, Xiaojuan Mi, +2 authors, Lesley H Curtis.
JAMA Oncol, 2015 Aug 28; 1(8). PMID: 26313372
70-Gene Signature as an Aid to Treatment Decisions in Early-Stage Breast Cancer.
Fatima Cardoso, Laura J van't Veer, +32 authors, MINDACT Investigators.
N Engl J Med, 2016 Aug 25; 375(8). PMID: 27557300
Highly Cited.
Second Opinions From Medical Oncologists for Early-Stage Breast Cancer: Prevalence, Correlates, and Consequences.
Allison W Kurian, Christopher R Friese, +5 authors, Steven J Katz.
JAMA Oncol, 2016 Dec 30; 3(3). PMID: 28033448    Free PMC article.
Latinas and breast cancer outcomes: population-based sampling, ethnic identity, and acculturation assessment.
Ann S Hamilton, Timothy P Hofer, +5 authors, Steven J Katz.
Cancer Epidemiol Biomarkers Prev, 2009 Jun 25; 18(7). PMID: 19549806    Free PMC article.
Gene expression and benefit of chemotherapy in women with node-negative, estrogen receptor-positive breast cancer.
Soonmyung Paik, Gong Tang, +11 authors, Norman Wolmark.
J Clin Oncol, 2006 May 25; 24(23). PMID: 16720680
Highly Cited.
A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer.
Soonmyung Paik, Steven Shak, +12 authors, Norman Wolmark.
N Engl J Med, 2004 Dec 14; 351(27). PMID: 15591335
Highly Cited.
Optimizing the Use of Gene Expression Profiling in Early-Stage Breast Cancer.
Hyun-Seok Kim, Christopher B Umbricht, +22 authors, Leslie Cope.
J Clin Oncol, 2016 Dec 22; 34(36). PMID: 27998227    Free PMC article.
NCCN Guidelines Insights: Breast Cancer, Version 1.2017.
William J Gradishar, Benjamin O Anderson, +30 authors, Rashmi Kumar.
J Natl Compr Canc Netw, 2017 Apr 14; 15(4). PMID: 28404755
Highly Cited.
St. Gallen/Vienna 2015: A Brief Summary of the Consensus Discussion.
Michael Gnant, Christoph Thomssen, Nadia Harbeck.
Breast Care (Basel), 2015 Jul 22; 10(2). PMID: 26195941    Free PMC article.
Review.
Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.
E Senkus, S Kyriakides, +6 authors, ESMO Guidelines Committee.
Ann Oncol, 2015 Sep 01; 26 Suppl 5. PMID: 26314782
Highly Cited.
Prognostic and predictive value of the 21-gene recurrence score assay in postmenopausal women with node-positive, oestrogen-receptor-positive breast cancer on chemotherapy: a retrospective analysis of a randomised trial.
Kathy S Albain, William E Barlow, +20 authors, Breast Cancer Intergroup of North America.
Lancet Oncol, 2009 Dec 17; 11(1). PMID: 20005174    Free PMC article.
Highly Cited.
Prospective Validation of a 21-Gene Expression Assay in Breast Cancer.
Joseph A Sparano, Robert J Gray, +28 authors, George W Sledge.
N Engl J Med, 2015 Sep 29; 373(21). PMID: 26412349    Free PMC article.
Highly Cited.
Uptake, Results, and Outcomes of Germline Multiple-Gene Sequencing After Diagnosis of Breast Cancer.
Allison W Kurian, Kevin C Ward, +8 authors, Steven J Katz.
JAMA Oncol, 2018 May 26; 4(8). PMID: 29801090    Free PMC article.
Adjuvant Chemotherapy Guided by a 21-Gene Expression Assay in Breast Cancer.
Joseph A Sparano, Robert J Gray, +27 authors, George W Sledge.
N Engl J Med, 2018 Jun 05; 379(2). PMID: 29860917    Free PMC article.
Highly Cited.
Lymph Node Status in Breast Cancer Does Not Predict Tumor Biology.
Danielle M Bello, Christy Russell, +2 authors, Monica Morrow.
Ann Surg Oncol, 2018 Jul 04; 25(10). PMID: 29968028    Free PMC article.
Association of Attending Surgeon With Variation in the Receipt of Genetic Testing After Diagnosis of Breast Cancer.
Steven J Katz, Irina Bondarenko, +4 authors, Timothy P Hofer.
JAMA Surg, 2018 Jul 05; 153(10). PMID: 29971344    Free PMC article.
Breast Cancers of Special Histologic Subtypes Are Biologically Diverse.
Audree B Tadros, Hannah Y Wen, Monica Morrow.
Ann Surg Oncol, 2018 Aug 11; 25(11). PMID: 30094484    Free PMC article.
Can precision medicine help achieve the goal of reducing care when the risks exceed the benefits?
Kathryn A Phillips, Deborah A Marshall, Allison W Kurian.
Per Med, 2019 Sep 26; 16(5). PMID: 31552799    Free PMC article.
Impact of deviation from guideline recommended treatment on breast cancer survival in Asia.
Peh Joo Ho, Samuel Guan Wei Ow, +12 authors, Mikael Hartman.
Sci Rep, 2020 Jan 30; 10(1). PMID: 31992769    Free PMC article.
Prognostic Impact of the 21-Gene Recurrence Score Assay Among Young Women With Node-Negative and Node-Positive ER-Positive/HER2-Negative Breast Cancer.
Philip D Poorvu, Shari I Gelber, +12 authors, Ann H Partridge.
J Clin Oncol, 2019 Dec 07; 38(7). PMID: 31809240    Free PMC article.
21-Gene Recurrence Score and Adjuvant Chemotherapy Decision for Breast Cancer Patients with Positive Lymph Nodes.
Yiwei Tong, Jiayi Wu, +6 authors, Kunwei Shen.
Sci Rep, 2019 Sep 13; 9(1). PMID: 31511599    Free PMC article.
Racial/ethnic differences in the utilization of chemotherapy among stage I-III breast cancer patients, stratified by subtype: Findings from ten National Program of Cancer Registries states.
Lu Zhang, Jessica King, +7 authors, Tekeda Ferguson.
Cancer Epidemiol, 2018 Nov 12; 58. PMID: 30415099    Free PMC article.
Association of Germline Genetic Testing Results With Locoregional and Systemic Therapy in Patients With Breast Cancer.
Allison W Kurian, Kevin C Ward, +5 authors, Steven J Katz.
JAMA Oncol, 2020 Feb 07; 6(4). PMID: 32027353    Free PMC article.
Association of Germline Genetic Test Type and Results With Patient Cancer Worry After Diagnosis of Breast Cancer.
Steven J Katz, Kevin C Ward, +3 authors, Allison W Kurian.
JCO Precis Oncol, 2019 Jan 19; 2018. PMID: 30656245    Free PMC article.
Gene Expression Profiling Tests for Early-Stage Invasive Breast Cancer: A Health Technology Assessment.
Ontario Health (Quality).
Ont Health Technol Assess Ser, 2020 Apr 15; 20(10). PMID: 32284770    Free PMC article.
Strategies to Improve Recruitment to a De-escalation Trial: A Mixed-Methods Study of the OPTIMA Prelim Trial in Early Breast Cancer.
C Conefrey, J L Donovan, +18 authors, OPTIMA Prelim Study Group.
Clin Oncol (R Coll Radiol), 2020 Feb 25; 32(6). PMID: 32089356    Free PMC article.
Patients' perceptions of 70-gene signature testing: commonly changing the initial inclination to undergo or forego chemotherapy and reducing decisional conflict.
Julia E C van Steenhoven, Bianca M den Dekker, +6 authors, Thijs van Dalen.
Breast Cancer Res Treat, 2020 May 21; 182(1). PMID: 32430679    Free PMC article.
The 21-Gene Recurrence Score Assay and Prediction of Chemotherapy Benefit: A Propensity Score-Matched Analysis of the SEER Database.
In Sil Choi, Jiwoong Jung, +5 authors, Ki-Tae Hwang.
Cancers (Basel), 2020 Jul 12; 12(7). PMID: 32650374    Free PMC article.
Use of Mastectomy for Overdiagnosed Breast Cancer in the United States: Analysis of the SEER 9 Cancer Registries.
C Harding, F Pompei, D Burmistrov, R Wilson.
J Cancer Epidemiol, 2019 Feb 26; 2019. PMID: 30804999    Free PMC article.
Update Breast Cancer 2019 Part 3 - Current Developments in Early Breast Cancer: Review and Critical Assessment by an International Expert Panel.
Hans-Christian Kolberg, Andreas Schneeweiss, +18 authors, Sara Y Brucker.
Geburtshilfe Frauenheilkd, 2019 Jun 01; 79(5). PMID: 31148847    Free PMC article.
The Changing Role of Gene-Expression Profiling in the Era of De-escalating Adjuvant Chemotherapy in Early-Stage Breast Cancer.
J E C van Steenhoven, A Kuijer, +5 authors, T van Dalen.
Ann Surg Oncol, 2019 Jun 19; 26(11). PMID: 31209664    Free PMC article.
Executable cancer models: successes and challenges.
Matthew A Clarke, Jasmin Fisher.
Nat Rev Cancer, 2020 Apr 29; 20(6). PMID: 32341552
Review.
Adjuvant Chemotherapy for Low-Clinical-Risk Breast Cancer Defined by Modified Version of Adjuvant! Online: A Propensity Score Matched SEER Analysis.
Jiefeng Huang, Zhiyong Wu, +3 authors, Guosheng Ren.
Breast Care (Basel), 2021 May 21; 16(2). PMID: 34012370    Free PMC article.