Komorbide brystkræftpatienter kan de tåle behandling? Et registerstudie baseret på Danish Breast Cancer Cooperative Group
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1 Komorbide brystkræftpatienter kan de tåle behandling? Et registerstudie baseret på Danish Breast Cancer Cooperative Group Lotte Holm Land MD, ph.d. Onkologisk Afd. R. OUH Kræft og komorbiditet - alle skal have del i de gode resultater 6. Marts
2 The impact of comorbidity on breast cancer specific mortality and other cause mortality. Comorbidity and its influence outcome after adjuvant treatment for early breast cancer The influence of specific comorbid conditions on breast cancer specific mortality and non-breast cancer mortality 2 Trine Lembrecht Jørgensen
3 Background Breast cancer is the most frequent malignant disease among women in Denmark. A total of 4,944 women diagnosed in
4 Epidemiology Incidens Dødelighed
5 Background The incidence of breast cancer as well as other chronic diseases increase with age 5
6 Prognostic factors Tumor size and grade Lymph node involvement Hormone receptor status Age at diagnosis Surgery Adjuvant treatment Year of diagnosis Comorbiditet? 6
7 Comorbidity Reasons that comorbidity could influence on prognosis in breast cancer patients Increased mortality due to the comorbid condition Delay of diagnosis Increased toxicity to treatment Suboptimal or no antineoplastic treatment Patients willingness and compliance to treatment Biological interaction 7
8 Comorbidity Guidelines for breast cancer treatment have been developed from randomized clinical trials (RCT) Older patients and patients with comorbidity are excluded from RCTs * Studies suggest that older patients without comorbidity have similar beneficial effect of guideline therapy as patients > 70 years** Majority of studies reported the influence of comorbidity on death from all causes Breast cancer deaths, reflects breast cancer treatment Death from other causes is more likely to be caused by comorbid condition * Bouchardy et al. JCO Muss et al. NEJM 2009 **Houterman et al. Br J Cancer
9 Methods Databases, Registries & Comorbidity index The Danish Breast Cancer Cooperative Group The Danish National patient Registry The Danish Civil Registration system The Danish Register of Causes of Death The Charlson Comorbidity Index 9
10 Study cohort 62,591 women diagnosed with early stage breast cancer in the period , with information on causes of death Median potential follow-up 8.2 years 36% died. (22,282). 16,316 (73%) died of breast cancer and 5,966 (27%) died of other causes. 10
11 Results 5- year OS (%) according to time periods and CCI score 5 year overall survival according to time periods (%) with 95% confidence intervals Charlson Comorbidity Score Diagnostic periods ( ) 55.8 ( ) 53.0 ( ) 42.0 ( ) ( ) 61.5 ( ) 56.9 ( ) 44.7 ( ) ( ) 68.0 ( ) 62.6 ( ) 43.5 ( ) 11
12 Results Multivariate analysis with Hazard Ratio and 95% Confidence Intervals Variable Adjusted HR 95 % CI Breast Cancer Specific Mortality CCI O CCI 1 CCI 2 CCI 3+ Reference Reference Non-Breast Cancer Mortality CCI 0 CCI 1 CCI 2 CCI 3+ Reference Reference All Cause Mortality CCI 0 CCI 1 CCI 2 CCI 3+ Reference Reference *all p-values > *Adjusted for; age, menopausal status, tumour size, nodal status, deep fascia invasion, vascular invasion, histological type and grade, hormone receptor status, year at diagnosis, type of surgery, and allocated adjuvant treatment. 12
13 Cohort with known adjuvant treatment 13
14 OS according to inclusion in DBCG treatment programme 14
15 Results Cumulative breast cancer specific mortality according to type of treatment and CCI score 15
16 Breast cancer specific mortality 16
17 Specific chronic conditions All women diagnosed with breast cancer in Denmark. N= 62,591 Patients with severe comorbidity (CCI = 3+) were excluded. N= 2,189 Charlson comorbidity score 0, 1, and 2. N= 60,402 Patients with no comorbidity (CCI=0). N=39,943 Patients with mild to moderate comorbidity (CCI= 1-2). N= 10,574 17
18 Distribution of comorbid conditions in % for each age category None DM 30 Chronic pulmonary disease 20 Cerebrovascular disease 10 Previous cancer 0 <40 years years years years years 80+ years Dementia 18
19 Distribution of treatment (%) according to specific comorbid conditions Comorbidity Treatment None Congestive heart failure Dementia Previous cancer Chronic pulmonary disease Connective tissue disease (-) Low risk 12,481 (25) 99 (13) 21 (7) 266 (16) 476 (22) 233 (21) Endocrine treatment (E) Chemotherapy +/- E 11,036 (22) 133 (17) 29 (10) 228 (14) 555 (26) 287 (26) 10,440 (21) 20 (3) 8 (3) 113 (7) 272 (13) 153 (14) Unknown 15,871 (32) 534 (68) 231 (80) 1,026 (63) 853 (40) 439 (39) Total 49, ,633 1,987 1,112 19
20 5-year Cumulative mortality in % for specific comorbid conditions 5-year Breast cancer specific mortality in % with 95% CI 5-year Other cause mortality in % with 95% CI None Chronic pulmonary disease Connective tissue disease Previous cancer DM Cerebrovascular disease Congestive heart failure Dementia
21 Results Breast cancer specific cumulative mortality (%) 21
22 Conclusions Patients with high comorbidity score had no improvement in 5 year overall survival over time Comorbidity had a prognostic impact on mortality in terms of breast cancer specific mortality, non-breast cancer mortality and all cause mortality. 22
23 Conclusions Patients enrolled in a DBCG treatment programme had an overall survival about twice that of patients not enrolled Patients with mild to moderate comorbidity (CCI 1-2) recieving chemotherapy had similar risk of breast cancer deaths compared to patients without comorbidity (CCI 0) 23
24 Conclusions Patients with Chronic pulmonary disease and Connective tissue disease, are more likely to have known adjuvant treatment, whereas patients with Congestive heart failure, Dementia and Any tumor are more likely to have treatment unknown. Comorbid conditions such as diabetes and congestive heart failure had an independent influence on breast cancer mortality, compared to other comorbid conditions. 24
25 Perspectives How do we provide optimal breast cancer treatment for the elderly with comorbidity? 25
26 Thanks for your attention! 26
27 27
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