Patterns of Care: High-Risk (Locally Advanced) Breast Cancer

Lack of treatment compliance and/or failure to provide standard-of-care treatment in high-risk breast cancer can lead to a higher incidence of metastatic cancer and mortality. The benefits of adjuvant treatment for highrisk patients in disease-free survival at ten years in the clinical literature can now easily be estimated by patients and health care providers through an online computer program, known as Adjuvant!, that offers the latest clinical trials information concerning the impact of various forms of treatment on ten-year disease free survival and mortality. Developed by Dr. Peter Ravdin and colleagues at the University of Texas in San Antonio in 2001, this calculator can be found online.63 This tool is “not intended for use by patients in the absence of health professional input,” however. According to the authors, this caveat is necessary due to both the potential emotional impact on a newly diagnosed patient of reading prognostic data and the difficulty of including all the relevant factors which oncologists factor into treatment recommendations. Nevertheless, for our purposes here, Adjuvant! provides a useful way of estimating potential risk and benefit from adjuvant treatment, and illustrating the potential impact inferior adjuvant care can have on outcome.

In general it is true that statistically, the greater the risk of recurrence, the greater the actual benefit of optimal adjuvant therapy to the patient, so that the benefit for patients with high-risk primary breast cancer is proportionally more than for those with early-stage disease. This means that provision of standard-of-care treatments is crucial to obtain the best chance at survival.

Without adjuvant chemotherapy, a 38-year-old black woman with a 3.5 centimeter, ER-negative, grade 2 tumor with four involved lymph nodes faces only a 26 percent chance of being alive and cancer-free ten years later. The standard four cycles of Adriamycin and Cytoxan (CA) can improve her absolute odds of not having recurrence by over 20 percent, but the addition of four cycles of Taxol to the CA can increase her chances of disease-free survival by an additional 8 percent, in absolute terms. With optimal chemotherapy, then, this hypothetical high-risk patient's chances of disease-free survival at ten years are doubled by aggressive chemotherapy, from 26 percent to 54 percent. If she has more than nine involved lymph nodes at diagnosis, the disease-free survival benefit to her of optimal chemotherapy is actually tripled.

We know that certain patient groups are at greater risk for getting less than optimal care, notably those who are elderly, obese, poor, and those of some minority populations. Questions have also been raised about the relative treatment given at NCI-Designated Comprehensive Cancer Center and teaching hospitals, community cancer centers and private oncology practices. Are there differences in the kind of care that is offered to patients, according to medical setting? Does where breast cancer is treated affect outcome? These are important questions to examine.

We need to understand whether certain patient groups, such as those with inflammatory breast cancer, for whom the usual delays in diagnosis and treatment can be deadly, are receiving optimal care, and whether this care differs by age, racial/ethnic group, and socio-economic status. We need to know if issues of familial predisposition and genetic testing are being adequately addressed in the various communities.