Variation in type of adjuvant chemotherapy received among patients with stage I breast cancer: A multi-institutional study

Abstract

Background: Among patients with stage I breast cancer, there is significant uncertainty concerning the optimal threshold at which to consider chemotherapy, and when considered, there is controversy regarding whether to consider non-intensive versus intensive regimens. The authors examined the types and costs of adjuvant chemotherapy received among patients with stage I breast cancer.

Methods: The current study was a prospective cohort study including patients with stage I breast cancer who were treated at a National Comprehensive Cancer Network center from 2000 through 2009. Stage was defined according to the version of the American Joint Committee on Cancer Staging Manual applicable at the time of diagnosis. Stratifying by human epidermal growth factor receptor 2 (HER2), the authors examined the percentage of patients receiving intensive versus non-intensive chemotherapy regimens and the factors associated with type of chemotherapy administered using multivariable logistic regression. Costs of the most common regimens were estimated.

Results: Of 8907 patients, 33% received adjuvant chemotherapy. Among those individuals, there was an increase in the use of intensive chemotherapy within the last decade, from 31% in 2000 through 2005 to 63% in 2008 through 2009 (including an increase in the use of the combination of docetaxel, carboplatin, and trastuzumab) among patients with HER2-positive disease and from 15% in 2000 through 2005 to 41% in 2008 through 2009 among patients with HER2-negative disease (32% of patients with hormone receptor-positive and 59% of patients with triple-negative disease). Among patients treated with non-intensive regimens, there was an increase in the use of the combination of docetaxel and cyclophosphamide noted, with a decrease in the use of the doxorubicin and cyclophosphamide combination. The choice of regimen varied significantly by institution. The major drivers of cost variation were the incorporation of biologics (eg, trastuzumab) and growth factors, with significant variation even within non-intensive and intensive regimens.

Conclusions: Over time, there was an increase in use of intensive regimens among Stage I breast cancer, with striking institutional and cost variations.

Keywords: breast cancer; chemotherapy; cost; institutional variation; stage I.

Figure 1

Flow diagram of patient population. Note that patients treated with trastuzumab only were included in the non chemotherapy group (14 patients). HER2 indicates human epidermal growth factor receptor 2; HR, hormone receptor; NCCN, National Comprehensive Cancer Network.

Figure 2

Chemotherapy with or without trastuzumab received between 2000 and 2009 (A) the percentage of patients with human epidermal growth factor receptor 2 (HER2)-positive disease receiving chemotherapy and (B) patients with HER2-negative disease, subdivided into (B1) the percentage of patients with HER2-negative, hormone receptor (HR)-positive disease receiving chemotherapy and (B2) the percentage of patients with HER2-negative/HR-negative disease receiving chemotherapy.

Figure 3

Type of chemotherapy with or without trastuzumab received between 2000 and 2009 among (A) patients with human epidermal growth factor receptor 2 (HER2)-positive disease, with the percentage of all patients receiving each chemotherapy (722 patients) and (B) patients with HER2-negative disease, subdivided into (B1) the percentage of all patients receiving each chemotherapy regimen (2201 patients), (B2) the percentage of patients with HER2-negative/hormone receptor (HR)-positive disease receiving each chemotherapy regimen (1425 patients), and (B3) the percentage of patients with HER2-negative/HR-negative disease receiving each chemotherapy regimen (749 patients).

Figure 4

Type of chemotherapy with or without trastuzumab received between 2000 and 2009 among (A) patients with human epidermal growth factor receptor 2 (HER2)-positive disease, with the percentage of patients receiving each chemotherapy, subdivided into (A1) the percentage of patients receiving each chemotherapy off trial (596 patients) and (A2) the percentage of patients receiving each chemotherapy on trial (126 patients) and (B) among patients with HER2-negative disease, subdivided into (B1) the percentage of patients receiving each chemotherapy regimen off trial (1921 patients) and (B2) the percentage of patients receiving each chemotherapy regimen on trial (280 patients).

Figure 5

Cost of chemotherapy regimens (including chemotherapy, trastuzumab, and growth factor support) in 2006, 2009 and 2014 for (A) trastuzumab-based regimens and (B) non–trastuzumab-based regimens. AC indicates doxorubicin and cyclophosphamide; ACTH, doxorubicin, cyclophosphamide, paclitaxel, and trastuzumab; TAC, docetaxel, doxorubicin, and cyclophosphamide; TC, docetaxel and cyclophosphamide; TCH, docetaxel, carboplatin, and trastuzumab.

Figure 5

Cost of chemotherapy regimens (including chemotherapy, trastuzumab, and growth factor support) in 2006, 2009 and 2014 for (A) trastuzumab-based regimens and (B) non–trastuzumab-based regimens. AC indicates doxorubicin and cyclophosphamide; ACTH, doxorubicin, cyclophosphamide, paclitaxel, and trastuzumab; TAC, docetaxel, doxorubicin, and cyclophosphamide; TC, docetaxel and cyclophosphamide; TCH, docetaxel, carboplatin, and trastuzumab.