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Chemotherapy refusal and subsequent survival in healthy older women with high genomic risk estrogen receptor-positive breast cancer

  • Epidemiology
  • Published:
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Abstract

Background

Patients with estrogen receptor (ER)-positive, HER2-negative breast cancer (BC), and high-risk 21-gene recurrence score (RS) results benefit from chemotherapy. We evaluated chemotherapy refusal and survival in healthy older women with high-RS, ER-positive BC.

Methods

Retrospective review of the National Cancer Database (2010–2017) identified women ≥ 65 years of age, with ER-positive, HER2-negative, high-RS (≥ 26) BC. Patients with Charlson Comorbidity Index ≥ 1, stage III/IV disease, or incomplete data were excluded. Women were compared by chemotherapy receipt or refusal using the Cochrane–Armitage test, multivariable logistical regression modeling, the Kaplan–Meier method, and Cox’s proportional hazards modeling.

Results

6827 women met study criteria: 5449 (80%) received chemotherapy and 1378 (20%) refused. Compared to women who received chemotherapy, women who refused were older (71 vs 69 years), were diagnosed more recently (2014–2017, 67% vs 61%), and received radiation less frequently (67% vs 71%) (p ≤ 0.05). Refusal was associated with decreased 5-year OS for women 65–74 (92% vs 95%) and 75–79 (85% vs 92%) (p ≤ 0.05), but not for women ≥ 80 years old (84% vs 91%; p = 0.07). On multivariable analysis, hazard of death increased with refusal overall (HR 1.12, 95% CI 1.04–1.2); but, when stratified by age, was not increased for women ≥ 80 years (HR 1.10, 95% CI 0.80–1.51).

Conclusions

Among healthy women with high-RS, ER-positive BC, chemotherapy refusal was associated with decreased OS for women ages 65–79, but did not impact the OS of women ≥ 80 years old. Genomic testing may have limited utility in this population, warranting prudent shared decision-making and further study.

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Data availability

The datasets generated during and/or analyzed during the current study are not publicly available due to the data use agreement with the National Cancer Database, which restricts access to the dataset to hospitals that contribute to the NCDB. Data are available from the corresponding author on reasonable request.

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Acknowledgements

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The authors declare that no funds, grants, or other supports were received during the preparation of this manuscript.

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Authors and Affiliations

  1. Department of Surgery, University of Minnesota Medical School, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA

    McKenzie J. White, Saranya Prathibha, Jacob S. Ankeny, Christopher J. LaRocca, Eric H. Jensen, Todd M. Tuttle, Jane Y. C. Hui & Schelomo Marmor

  2. University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA

    Madison Kolbow & Corinne Praska

  3. School of Medicine and Public Health, Department of Surgery, Clinical Science Center, University of Wisconsin, 600 Highland Ave, Madison, WI, 53792, USA

    Corinne Praska

  4. Masonic Cancer Center, University of Minnesota, 420 Delaware St SE, MMC 806, Minneapolis, MN, 55455, USA

    Jacob S. Ankeny, Christopher J. LaRocca, Eric H. Jensen, Todd M. Tuttle, Jane Y. C. Hui & Schelomo Marmor

  5. Center for Clinical Quality & Outcomes Discovery & Evaluation (C-QODE), University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis, MN, 55455, USA

    Schelomo Marmor

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Contributions

MJW participated in the conceptualization, methodology, investigation, writing of the original draft, and writing, reviewing, & editing of the manuscript. MK participated in the conceptualization, methodology, writing of the original draft, and writing, reviewing, & editing of the manuscript. SP participated in the conceptualization, methodology, and writing, reviewing, & editing of the manuscript. CP participated in the conceptualization, methodology, and writing, reviewing, & editing of the manuscript. JSA participated in the conceptualization, methodology, and writing, reviewing, & editing of the manuscript. CJL participated in the conceptualization, methodology, and writing, reviewing, & editing of the manuscript. EHJ participated in the conceptualization, methodology, and writing, reviewing, & editing of the manuscript. TMT participated in the conceptualization, methodology, and writing, reviewing, & editing of the manuscript. JYCH participated in the conceptualization, methodology, and writing, reviewing, & editing of the manuscript. SM participated in the conceptualization, methodology, software, formal analysis, investigation, data curation, writing, reviewing, & editing of the manuscript, and supervision.

Corresponding author

Correspondence to Schelomo Marmor.

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The authors declare they have no relevant financial or non-financial competing interests to report.

Ethical approval

This is an observational study using de-identified data from the National Cancer Database. The University of Minnesota Institutional Research Board has confirmed that no ethical approval is required.

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The University of Minnesota Institutional Review Board has determined that evaluation of outcomes using the National Cancer Database does not constitute human subjects research and is therefore exempt from the consent process.

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White, M.J., Kolbow, M., Prathibha, S. et al. Chemotherapy refusal and subsequent survival in healthy older women with high genomic risk estrogen receptor-positive breast cancer. Breast Cancer Res Treat 198, 309–319 (2023). https://doi.org/10.1007/s10549-023-06862-x

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