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When are breast cancer patients old enough for the quitclaim of local control?

Stellungnahme der Deutschen Gesellschaft für Radioonkologie (DEGRO): Wird bei Brustkrebs im Alter das Lokalrezidiv zumutbar?

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Abstract

Background

Although postoperative radiotherapy (RT) after breast-conserving surgery (BCS) halves the 10-year recurrence rate in breast cancer patients through all age groups, the question of whether RT may be omitted and replaced by endocrine therapy for women aged 70 years and older with low-risk factors has recently become an issue of debate.

Methods

Survey of the relevant recent literature (Medline) and international guidelines.

Results

Three randomized studies investigating the effect of RT in older women revealed significantly increased local recurrence rates when RT was omitted, and a negative impact on disease-free survival was observed in two of these trials. Despite these findings, in one of the studies omission of RT in women over 70 is recommended, leading to a respective amendment in the guidelines of the American National Comprehensive Cancer Network. Several large retrospective cohort studies analyzing the outcome of patients over 65 years with and without RT have since been published and showed a significantly improved local control in all subgroups of advanced age and stage, which predominantly translated into improved disease-free and overall survival.

Conclusion

No subgroup of elderly patients has yet been identified that did not profit from RT in terms of local control. Therefore, chronological age alone is not an appropriate criterion for deciding against or in favor of adjuvant RT. The DEGRO breast cancer expert panel explicitly discourages determination of a certain age for the omission of postoperative RT in healthy elderly women with low-risk breast cancer. For frail elderly women, treatment decisions should be individually decided on the basis of standardized geriatric assessment.

Zusammenfassung

Hintergrund

Nach brusterhaltender Operation wird die 10-Jahres-Rezidivrate bei Brustkrebspatientinnen sämtlicher Altersgruppen durch eine postoperative Radiotherapie (RT) halbiert. Dennoch ist neuerdings eine Kontroverse darüber entbrannt, ob bei Frauen über 70 Jahre mit niedrigem Risikoprofil auf die RT verzichtet und stattdessen eine endokrine Therapie erfolgen solle.

Methoden

Literaturrecherche der kürzlich zu diesem Thema publizierten Studien (Medline) und internationaler Leitlinien.

Resultate

In drei randomisierten Studien wurde die Effektivität der RT bei älteren Frauen untersucht und zeigte eine signifikant höhere Lokalrezidivrate bei Nichtbestrahlten sowie in zwei dieser Studien einen negativen Einfluss auf das krankheitsfreie Überleben. Dennoch wurde in einer Publikation der Verzicht auf eine RT bei >70-Jährigen empfohlen, was als Ergänzung in die aktuellen amerikanischen National-Comprehensive-Cancer-Network-Leitline übernommen wurde. Seitdem wurde in mehreren umfangreichen Kohortenstudien der Verlauf von Patientinnen >65 Jahre mit und ohne RT ausgewertet, wobei sich in sämtlichen Alterssubgruppen und Tumorstadien der >65-Jährigen eine signifikant verbesserte lokale Tumorkontrolle nach RT zeigte, die überwiegend auch zu einem verlängerten rezidivfreien und Gesamtüberleben führte.

Schussfolgerung

Bislang wurde keine Subgruppe älterer Patientinnen identifiziert, die nicht durch Senkung der Lokalrezidivrate von einer RT profitierten. Die DEGRO-Expertengruppe Mammakarzinom sieht deshalb das kalendarische Alter allein nicht als hinreichendes Entscheidungskriterium gegen eine RT, diese sollte deshalb älteren Patientinnen in gutem Allgemeinzustand nicht vorenthalten werden. Bei gebrechlichen Älteren ist eine individuelle Entscheidung anhand eines standardisierten geriatrischen Assessments zu treffen.

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Conflict of interest

On behalf of all authors, the corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Klinik für Radioonkologie und Strahlentherapie, Städtisches Klinikum Karlsruhe, Moltkestr. 90, 76133, Karlsruhe, Germany

    M.L. Sautter-Bihl

  2. LKH Salzburg, Paracelsus Medical University Hospital, Salzburg, Austria

    F. Sedlmayer

  3. University Hospital Duesseldorf, Duesseldorf, Germany

    W. Budach

  4. University Hospital Schleswig-Holstein, Luebeck, Germany

    J. Dunst

  5. Klinikum Neukoelln, Berlin, Germany

    P. Feyer

  6. University Hospital Erlangen, Erlangen, Germany

    R. Fietkau

  7. formerly St.-Vincentius-Kliniken, Karlsruhe, Germany

    W. Haase

  8. St. Clara Hospital, Basel, Switzerland

    W. Harms

  9. University Hospital Frankfurt/Main, Frankfurt/Main, Germany

    C. Rödel

  10. University Hospital Tübingen, Tübingen, Germany

    R. Souchon

  11. University Hospital Mannheim, Mannheim, Germany

    F. Wenz

  12. University Hospital Erlangen, Erlangen, Germany

    R. Sauer

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  1. M.L. Sautter-Bihl
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  2. F. Sedlmayer
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Correspondence to M.L. Sautter-Bihl.

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Sautter-Bihl, M., Sedlmayer, F., Budach, W. et al. When are breast cancer patients old enough for the quitclaim of local control?. Strahlenther Onkol 188, 1069–1073 (2012). https://doi.org/10.1007/s00066-012-0253-6

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  • DOI: https://doi.org/10.1007/s00066-012-0253-6

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