Breast and ovarian cancer in the older woman

Management of older women with early-stage breast cancer

Breast cancer is a disease of aging. The average age at diagnosis is 61, and the majority of deaths occur after age 65. Caring for older women with breast cancer is a major challenge, as many have coexisting illness that can preclude optimal breast cancer treatment and which frequently have greater effect than the breast cancer itself. Older patients with cancer should be screened or have a brief geriatric assessment to detect potentially remediable problems not usually assessed by oncologists (e.g., self-care, falls, social support, nutrition). Older women with early-stage breast cancer should be treated initially with surgery unless they have an exceedingly short life expectancy. Primary endocrine therapy should be considered for patients who have hormone receptor-positive tumors and a very short life expectancy, an acute illness that delays surgery, or tumors that need to be downstaged to be resectable. Sentinel node biopsy should be considered for patients in whom it might affect treatment decisions. Breast irradiation after breast-conserving surgery may be omitted for selected older women, especially for those with hormone receptor-positive early-stage breast cancer that are compliant with adjuvant endocrine therapy. The majority of older women with stage I and II breast cancer have hormone receptor-positive, HER2-negative tumors, and endocrine therapy provides them with optimal systemic treatment. If these patients have life expectancies exceeding at least 5 years, they should be considered for genetic assays to determine the potential value of chemotherapy. Partnering care with geriatricians or primary care physicians trained in geriatrics should be considered for all vulnerable and frail older patients.

Update of the Phase III trial 'GRETA' of surgery and tamoxifen versus tamoxifen alone for early breast cancer in elderly women

BACKGROUND

In the Phase III 'GRETA' trial 474 women aged ≥70 years with early breast cancer were randomly assigned to surgery plus tamoxifen for 5 years or tamoxifen alone for 5 years. This is a long-term update.

PATIENTS & METHODS

Focusing on patients still alive in 2003, outcome end points has been recalculated.

RESULTS

Median distant metastases disease-free survival is longer with tamoxifen alone for 5 years; (48.8 vs 37.9 months; p = 0.009). No difference was found in distant metastases rate, disease-free survival, breast cancer and overall survival.

CONCLUSION

Primary endocrine treatment until the the best response, followed by minimal surgery and prosecution endocrine treatment for 5-10 years is a suitable option for elderly breast cancer patients. Delayed surgery does not prejudice overall survival.

Comparison of toxicity experienced by older versus younger patients enrolled in breast cancer clinical trials

BACKGROUND

Elderly patients form a large proportion of patients with breast cancer but are underrepresented in clinical trials. We examined whether elderly patients experience more toxicity than younger patients within breast cancer clinical trials.

MATERIALS AND METHODS

All breast cancer trials open from 1999 to 2012 at BCCA, Vancouver Center, were reviewed. The primary endpoint was meaningful toxicity (MTOX), defined as any grade 3 or 4 adverse event (AE), any AE leading to dose delay or reduction, or premature discontinuation of therapy.

RESULTS

In the 46 trials enrolling 799 patients, the therapy given was chemotherapy to 18% of the patients, hormonal therapy to 40%, skeletal therapy to 14%, and targeted therapy and a combination of chemotherapy and targeted therapy to 14%. Elderly patients were more likely to enroll in hormonal and skeletal therapy trials, and younger patients were evenly distributed among the therapy types. Toxicity data were available for 778 patients (97%). Elderly patients and younger patients experienced a similar number and frequency of MTOX. The therapy type was the strongest predictor of toxicity on multivariate analysis. In non-chemotherapy-containing trials, elderly and younger patients had a similar frequency and number of toxicities. Few elderly patients were enrolled in cytotoxic chemotherapy trials, but they experienced no more toxicity than did the younger patients.

CONCLUSION

The appropriate selection of elderly patients using eligibility criteria, self selection, and/or clinician assessment will allow safe participation of elderly patients in breast cancer trials.