Physician Study: Adjuvant systemic therapy practices in node negative (Except N1) hormone receptor positive HER-2 negative breast cancer during 2014-2015.
There is considerable ambiguity in treatment of early stage hormone receptor positive, HER-2 negative breast cancer. Most
patients with tumor size > 0.5 cm will benefit from adjuvant hormonal therapy but the selection criteria for patients who
would benefit from systemic chemotherapy is still under development. Guidelines are vague and several factors such as age,
pathological staging, multigene signature methods, size of the tumor, lymph node status, etc., can play a role in deciding
if patients would be candidates for hormone therapy plus chemotherapy or hormonal therapy alone or no systemic therapy.
We reviewed charts of hormone receptor positive, nonmetastatic, T1-T3, N0 - N1, treated in 2014 and 2015. We only included
hormone receptor positive patients who were negative for HER-2.
Included in the study were 172 patients with a median age of 62 years (range 25-91 years). Of those patients, 164 were alive
at the time of data entry. Pathological staging and grades were as follows:
- Stage 0 - 24 patients
- Stage I - 94 patients
- Stage II - 43 patients
- Stage III - 2 patients
- Unknown stage - 1 patient
- Low grade pathology - 79
- Intermediate grade pathology - 52
- High grade pathology - 24
- Stage III - 2 patients
- Unknown grade pathology - 17
Multigene assays were done in 20 patients, leaving multigene analysis unavailable for 152 patients. Of the patients who had
Oncotype DX(n=13), a low recurrence score was found in 4 patients, intermediate recurrence score in 2 patients, and a high
recurrence score in 6 patients. Results are not known for 1 patient.
Among patients who had the Mamma-print assay, 4 were low risk of recurrence and 1 was high risk of recurrence. In 2 patients,
the type of multigene assay was not available, but both were low risk of recurrence.
None of the 10 patients with low risk of recurrence (n=10) got chemotherapy. Hormone therapy was received by 8 of the 10
patients. Of the 7 patients with high risk of recurrence, 6 got chemotherapy. Among the 2 intermediate grade patients, 1
got hormone therapy and 1 did not get any systemic therapy.
Based on pathological grading, 84 patients had well-differentiated tumors. Out of those 84, 11 received chemotherapy, and 10
of those who received chemotherapy also got hormonal therapy afterward.
Of the 30 patients who had poorly differentiated pathology, 14 patients got chemotherapy and 11 of the 14 did get hormone
therapy afterwards. Out of all the poorly differentiated pathology, 18 got hormonal therapy. Out of all poorly
differentiated patients, 7 got only hormonal therapy without any chemotherapy.
Fifty-eight patients had moderately differentiated histopathology. Twenty-three of those patients got hormonal therapy. Twenty patients got
chemotherapy. Sixteen out of those did not get any systemic therapy or it is unknown.
Although our analysis is limited by several factors, including missing data and retrospective review, it’s evident that
significant heterogeneity exists in the use of systemic therapy in patients treated with local modality. Multigene
signature methods were either not used or the results were not available in most patients. Recent studies have shown that
multigene panels could help identify patients even in high risk pathology group who may not need chemotherapy. More
widespread use and reporting of multigene assays will be beneficial, as well as careful selections of patients who would
benefit from chemotherapy. Further steps need to be taken to standardize post local therapy treatment in early stage breast