Survival Comparisons between Breast Conservation Surgery and Mastectomy Followed by Postoperative Radiotherapy in Stage I-III Breast Cancer Patients: Analysis of the Surveillance, Epidemiology, and End Results (Seer) Program Database

Abstract

Background: This study aims to evaluate the overall and breast cancer-specific survival (BCSS) after breast-conserving surgery (BCS) plus radiotherapy (RT) compared with mastectomy plus RT in resectable breast cancer. Moreover, the aim is to also identify the subgroups who benefit from BCS plus RT and establish a predictive nomogram for stage II patients. Methods: Stage I−III breast cancer patients were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 1990 and 2016. Patients with available clinical information were split into two groups: BCS plus RT and mastectomy plus RT. Kaplan−Meier survival analysis, univariate and multivariate regression analysis, and propensity score matching were used in the study. Hazard ratio (HR) was calculated based on stratified Cox univariate regression analyses. A prognostic nomogram by multivariable Cox regression model was developed for stage II patients, and consistency index (C-index) and calibration curve were used to evaluate the accuracy of the nomogram in the training and validation set. Results: A total of 24,590 eligible patients were enrolled. The difference in overall survival (OS) and BCSS remained significant in stage II patients both before and after PSM (after PSM: OS: HR = 0.8536, p = 0.0115; BCSS: HR = 0.7803, p = 0.0013). In stage II patients, the survival advantage effect of BCS plus RT on OS and BCSS was observed in the following subgroups: any age, smaller tumor size (<1 cm), stage IIA (T2N0, T0−1N1), ER (+), and any PR status. Secondly, the C-indexes for BCSS prediction was 0.714 (95% CI 0.694−0.734). The calibration curves showed perfect agreement in both the training and validation sets. Conclusions: BCS plus RT significantly improved the survival rates for patients of stage IIA (T2N0, T0−1N1), ER (+). For stage II patients, the nomogram was a good predictor of 5-, 10-, and 15-year BCSS. Our study may help guide treatment decisions and prolong the survival of stage II breast cancer patients.

Keywords: SEER; breast cancer; breast-conserving surgery plus radiotherapy; mastectomy plus radiotherapy; prognostic nomogram.

Figure 1

Flow diagram of selecting eligible patients.

Figure 2

Survival analysis. (A) Meier survival curve of all breast cancer patients. (a) Meier survival curve on OS, (b) Meier survival curve on BCSS. (B) Survival curve of stage I, II, and III patients before PSM on OS and BCSS. (a) Meier survival curve of stage I breast patients before PSM for OS, p = 0.91. (b) Meier survival curve of stage II breast patients before PSM for OS, p = 0.0067. (c) Meier survival curve of stage III breast patients before PSM for OS, p = 0.0013. (d) Meier survival curve of stage I breast patients before PSM for BCSS, p = 0.12. (e) Meier survival curve of stage II breast patients before PSM for BCSS, p < 0.0001. (f) Meier survival curve of stage III breast patients before PSM for BCSS, p = 0.0017. (C) Survival curve of stage II and III breast patients after PSM on OS and BCSS. (a) Meier survival curve of stage II breast patients after PSM for OS, p = 0.011. (b) Meier survival curve of stage II breast patients after PSM for BCSS, p = 0.0013. (c) Meier survival curve of stage III breast patients after PSM for OS, p = 0.83. (d) Meier survival curve of stage III breast patients after PSM for BCSS, p = 0.36.

Figure 3

Subgroup analysis for OS and BCSS for stage II patients. (A) Forest map for OS (B) Forest map for BCSS.

Figure 4

Prediction and validation of the nomogram in stage II patients. (A) The nomogram for the 5-, 10-, and 15-year BCSS prediction of stage II patients. (B) ROC curves verified the predictive value of the nomogram. (a) 5-year ROC curves. (b) 10-year ROC curves. (c) 15-year ROC curves. (C) Calibration of curves of 5, 10, and 15 years in the training set. (a) 5-year BCSS in the training set. (b) 10-year BCSS in the training set. (c) 15-year BCSS in the training set. (d) 5-year BCSS in the test set. (e) 10-year BCSS in the test set. (f) 15-year BCSS in the test set.