Breast conservation versus mastectomy for patients with T3 primary tumors (>5 cm): A review of 5685 medicare patients

Abstract

BACKGROUND Although breast conservation therapy (BCT) is standard for breast cancer treatment, patients with tumors measuring >5 cm have been excluded from clinical trials. Nevertheless, only a few small retrospective series to date have compared BCT with mastectomy for tumors measuring >5 cm. The current study was performed to determine whether survival is equivalent for BCT versus mastectomy using a large national data set. METHODS Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked cases were identified for patients aged ≥66 years undergoing breast conservation for invasive, noninflammatory, nonmetastatic breast cancer between 1992 and 2009. Propensity score-based adjustment was used to account for demographics and tumor and treatment factors. RESULTS A total of 5685 patients with tumors measuring >5.0 cm underwent breast surgery, with 15.6% receiving BCT. Mean ages of the patients and tumor sizes were similar. Predictors of BCT included neoadjuvant chemotherapy and postoperative radiotherapy use, higher income, breast cancer as a first malignancy, and a higher Charlson Comorbidity Index. Predictors of mastectomy included younger age, nonductal histology, higher grade, numbers of lymph nodes examined and found to be positive, American Joint Committee on Cancer stage III disease, postoperative chemotherapy use, and residential region of the country. Adjusted overall and breast cancer-specific survival were not different between patients treated with BCT and mastectomy (hazard ratio, 0.934; 95% confidence interval, 0.791-1.103 [P =.419] for overall survival; and subdistribution hazard ratio, 1.042; 95% confidence interval, 0.793-1.369 [P =.769] for breast cancer-specific survival), with each improving over time. The median follow-up was 7.0 years. CONCLUSIONS For Medicare patients with tumors measuring >5 cm, survival is similar between those treated with BCT and mastectomy as for patients with smaller primary tumors. Despite exclusion from randomized trials, BCT may remain an option for patients with larger tumors when deemed clinically and cosmetically amenable to surgical resection. Cancer 2016;122:42-49. Breast conservation trials to date have excluded patients whose tumors measure >5 cm, and therefore the data supporting breast conservation for such tumors are limited. The current study reviews the Surveillance, Epidemiology, and End Results-Medicare data set and finds that overall and disease-specific survival are equivalent between patients treated with breast conservation compared with mastectomy for tumors measuring >5 cm.