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Chen YA, Lai HW, Su HC, Loh EW, Huang TW, Tam KW. Efficacy and safety of adjuvant therapies in older patients with breast cancer: a systematic review and meta-analysis of real-world data. Breast Cancer 2024; 31:739-753. [PMID: 39085679 DOI: 10.1007/s12282-024-01622-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 07/29/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Insufficient data available for older patients with breast cancer complicates decision-making regarding optimal treatment. A systematic review that uses real-world data is required for assessing the effectiveness and potential adverse effects of various therapies for this age group of patients. METHODS Databases of PubMed, Embase, and Cochrane Library were searched. We included clinical studies that evaluated various treatments for geriatric breast cancer, including adjuvant radiation therapy, hypofractionated radiation therapy (hypo-RT) and accelerated and partial breast irradiation (APBI), endocrine therapy, chemotherapy, and targeted therapy. RESULTS A total of 71 studies were retrieved. Adjuvant radiation therapy significantly improved overall survival (OS) compared with no radiation [hazard ratio (HR) = 0.60, 95% confidence interval (CI) 0.54-0.67]. The pooled estimates of OS for hypo-RT and APBI demonstrated no inferiority compared with conventional radiation. Both endocrine treatment (HR = 0.63, 95% CI 0.43-0.92) and chemotherapy (HR = 0.76, 95% CI 0.65-0.88) significantly increased OS compared with no treatment. Trastuzumab monotherapy significantly enhanced OS compared with no trastuzumab use (HR = 0.23, 95% CI 0.07-0.73). CONCLUSION Despite concerns about potential complications during treatment in older patients, proactive therapies significantly increase their survival rates. For patients who are frailer, hypo-RT and APBI offer survival rates comparable to traditional modalities. Additionally, targeted therapy as a monotherapy holds promise as a viable option for patients with HER2-positive breast cancer who cannot undergo chemotherapy. Therefore, by conducting thorough general assessments and clinical evaluations, the side effects of postoperative treatments can be effectively managed.
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Affiliation(s)
- Yu-An Chen
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsuan-Wen Lai
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hui-Chen Su
- Department of Pharmacy, Chi Mei Medical Center, Tainan City, Taiwan
| | - El-Wui Loh
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Medical Imaging, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Tsai-Wei Huang
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Ka-Wai Tam
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
- Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan.
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Sanchez DN, Derks MGM, Verstijnen JA, Menges D, Portielje JEA, Van den Bos F, Bastiaannet E. Frequency of use and characterization of frailty assessments in observational studies on older women with breast cancer: a systematic review. BMC Geriatr 2024; 24:563. [PMID: 38937703 PMCID: PMC11212278 DOI: 10.1186/s12877-024-05152-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 06/14/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Breast cancer and frailty frequently co-occur in older women, and frailty status has been shown to predict negative health outcomes. However, the extent to which frailty assessments are utilized in observational research for the older breast cancer population is uncertain. Therefore, the aim of this review was to determine the frequency of use of frailty assessments in studies investigating survival or mortality, and characterize them, concentrating on literature from the past 5 years (2017-2022). METHODS MEDLINE, EMBASE and Cochrane Library were systematically queried to identify observational studies (case-control, cohort, cross-sectional) published from 2017-2022 that focus on older females (≥ 65 years) diagnosed with breast cancer, and which evaluate survival or mortality outcomes. Independent reviewers assessed the studies for eligibility using Covidence software. Extracted data included characteristics of each study as well as information on study design, study population, frailty assessments, and related health status assessments. Risk of bias was evaluated using the appropriate JBI tool. Information was cleaned, classified, and tabulated into review level summaries. RESULTS In total, 9823 studies were screened for inclusion. One-hundred and thirty studies were included in the final synthesis. Only 11 (8.5%) of these studies made use of a frailty assessment, of which 4 (3.1%) quantified frailty levels in their study population, at baseline. Characterization of frailty assessments demonstrated that there is a large variation in terms of frailty definitions and resulting patient classification (i.e., fit, pre-frail, frail). In the four studies that quantified frailty, the percentage of individuals classified as pre-frail and frail ranged from 18% to 29% and 0.7% to 21%, respectively. Identified frailty assessments included the Balducci score, the Geriatric 8 tool, the Adapted Searle Deficits Accumulation Frailty index, the Faurot Frailty index, and the Mian Deficits of Accumulation Frailty Index, among others. The Charlson Comorbidity Index was the most used alternative health status assessment, employed in 56.9% of all 130 studies. Surprisingly, 31.5% of all studies did not make use of any health status assessments. CONCLUSION Few observational studies examining mortality or survival outcomes in older women with breast cancer incorporate frailty assessments. Additionally, there is significant variation in definitions of frailty and classification of patients. While comorbidity assessments were more frequently included, the pivotal role of frailty for patient-centered decision-making in clinical practice, especially regarding treatment effectiveness and tolerance, necessitates more deliberate attention. Addressing this oversight more explicitly could enhance our ability to interpret observational research in older cancer patients.
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Affiliation(s)
- Dafne N Sanchez
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zürich, Hirschengraben 82, Zurich, CH-8001, Switzerland
| | - Marloes G M Derks
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jose A Verstijnen
- Department of Medical Oncology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Dominik Menges
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zürich, Hirschengraben 82, Zurich, CH-8001, Switzerland
| | | | - Frederiek Van den Bos
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther Bastiaannet
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zürich, Hirschengraben 82, Zurich, CH-8001, Switzerland.
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Tallet A, Rey D, Casanova C, Lecourtois D, Bergeaud M, Bendiane MK, Mancini J. Physicians’ Opinion on Intraoperative Radiotherapy as a Therapeutic De-Escalation Option in Older Women with Early Breast Cancer. Curr Oncol 2023; 30:2812-2824. [PMID: 36975427 PMCID: PMC10047225 DOI: 10.3390/curroncol30030214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
Background: Intraoperative radiotherapy (IORT) is a therapeutic de-escalation option in older women with low-risk early breast cancer (EBC). A qualitative study was implemented to describe EBC physicians’ points of view on IORT as a de-escalation option. Methods: Recorded face-to-face and telephone semi-structured interviews were conducted among diverse physicians from seven French comprehensive cancer centers. Interview transcripts were grouped as corpus to construct a typology. Thematic analysis was performed. Results: Positions toward IORT were contrasted between the 16 participating physicians. Five fully supported IORT as a de-escalation option, four were not in favor, and seven had a more reserved or neutral opinion. Points of divergence concerned treatment efficacy, treatment duration, side effects and sequelae, psychological impact, compliance with adjuvant endocrine therapy, logistical constraints, financial cost, and availability of other techniques of partial breast irradiation. Physicians in favor of IORT emphasized direct benefits for the patient, and those against pointed the lack of specific guidelines, risk of lost opportunity in older women with long life expectancy, and challenges of shared decision making. Conclusions: Despite national policies to preserve cancer patients’ quality of life and increase their participation in medical decision making, therapeutic de-escalation using IORT is not consensual among physicians. Further efforts are needed to promote patient-centered care.
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Affiliation(s)
- Agnès Tallet
- UNICANCER, Institut Paoli-Calmettes, Department of Radiation Oncology, 13009 Marseille, France
| | - Dominique Rey
- Aix-Marseille Univ, INSERM, IRD, ISSPAM, SESSTIM, Cancer, Biomedicine & Society Group, Ligue 2019 Accredited Team, 13009 Marseille, France
| | - Clémence Casanova
- Aix-Marseille Univ, INSERM, IRD, ISSPAM, SESSTIM, Cancer, Biomedicine & Society Group, Ligue 2019 Accredited Team, 13009 Marseille, France
| | - Delphine Lecourtois
- Aix-Marseille Univ, INSERM, IRD, ISSPAM, SESSTIM, Cancer, Biomedicine & Society Group, Ligue 2019 Accredited Team, 13009 Marseille, France
| | | | - Marc-Karim Bendiane
- Aix-Marseille Univ, INSERM, IRD, ISSPAM, SESSTIM, Cancer, Biomedicine & Society Group, Ligue 2019 Accredited Team, 13009 Marseille, France
| | - Julien Mancini
- Aix-Marseille Univ, INSERM, IRD, ISSPAM, SESSTIM, Cancer, Biomedicine & Society Group, Ligue 2019 Accredited Team, 13009 Marseille, France
- APHM, BIOSTIC, Hop Timone, 13005 Marseille, France
- Correspondence: ; Tel.: +33-4-91-22-34-87
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Ali AA, Tawk R, Xiao H, Semykina A, Montero AJ, Moussa RK, Popoola O, Diaby V. Comparative cost-effectiveness of radiotherapy among older women with hormone receptor positive early-stage breast cancer. Expert Rev Pharmacoecon Outcomes Res 2022; 22:735-741. [PMID: 35189767 PMCID: PMC10791147 DOI: 10.1080/14737167.2022.2044309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 02/16/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The aim was to examine the real-world cost-effectiveness of breast-conserving surgery (BCS) plus hormonal therapy with radiotherapy, compared to hormonal therapy alone among women 66 and older with hormone receptor positive early-stage breast cancer in the United States (US). METHODS This study was conducted from a U.S. Centers for Medicare and Medicaid Services perspective and an eight-year time horizon. Both costs (2020 US$) and health utilities (quality-adjusted life years, QALYs) were obtained from retrospective studies using the SEER linked with Medicare and Medicare Health Outcomes Survey, respectively. The incremental cost-effectiveness ratio (ICER) of the addition of radiotherapy to hormonal therapy versus hormonal therapy alone after BCS was estimated by an unbiased doubly robust estimator. Sensitivity analyses were conducted through bootstrapping to estimate credible intervals. RESULTS The addition of radiotherapy to hormonal therapy after BCS yielded the highest clinical benefits (2.66 QALYs) and costs ($19,424.27) compared to its hormonal therapy alone after BCS (0.77 QALYS; $2,028.58). The ICER was estimated to be $9,174.94/QALY. Sensitivity analyses did not change the direction of the findings. CONCLUSIONS The results implicated that the combination of radiotherapy and hormonal therapy is cost-effective in the US.
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Affiliation(s)
- Askal Ayalew Ali
- Economic, Social & Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Florida A&m University, Tallahassee, FL, USA
| | - Rima Tawk
- Institute of Public Health, College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Florida A&m University, Tallahassee, FL, USA
| | - Hong Xiao
- Solid tumor, Bristol Myers Squibb, Lawrenceville, NJ USA
| | | | - Alberto J. Montero
- Breast Cancer Program, Uh Seidman Cancer Center, CWRU School of Medicine
| | - Richard K. Moussa
- Ecole Nationale Supérieure de Statistiques Et d’Economie Appliquée (ENSEA), Côte d’Ivoire, Abidjan, Côte d’Ivoire
| | - Olayiwola Popoola
- Social & Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Florida A&m University, Tallahassee, FL, USA
| | - Vakaramoko Diaby
- Pharmaceutical Outcomes & Policy (POP), College of Pharmacy, Hpnp 3337, University of Florida, Gainesville, FL, USA
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Effectiveness of radiotherapy after breast-conserving surgery in older patients with T1-2N0 breast cancer. Breast Cancer Res Treat 2019; 178:637-645. [PMID: 31451977 PMCID: PMC6817758 DOI: 10.1007/s10549-019-05412-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/19/2019] [Indexed: 11/30/2022]
Abstract
Purpose In the Netherlands, radiotherapy after breast-conserving surgery (BCS) is omitted in up to 30% of patients aged ≥ 75 years. Although omission of radiotherapy is considered an option for older women treated with endocrine treatment, the majority of these patients do not receive systemic treatment following Dutch treatment guidelines. Therefore, the aim of this study was to evaluate the effect of omission of radiotherapy on locoregional recurrence risk in this patient population. Methods Patients aged ≥ 75 years undergone BCS for T1-2N0 breast cancer diagnosed between 2003 and 2009 were selected from the Netherlands Cancer Registry. To minimize confounding by indication, hospital variation was used to assess the impact of radiotherapy-use on locoregional recurrence risk using cox proportional hazards regression. Hazards ratios with 95% confidence interval (CI) were estimated. Results Overall, 2390 patients were included. Of the patients with hormone receptor-positive breast cancer, 39.3% received endocrine treatment. Five-year incidences of locoregional recurrence were 1.9%, 2.8%, and 3.0% in patients treated at hospitals with higher (average radiotherapy-use 96.0%), moderate (88.0%), and lower radiotherapy-use (72.2%) respectively, and nine-year incidences were 2.2%, 3.1%, and 3.2% respectively. Adjusted hazard ratios were 1.46 (95% CI 0.77–2.78) and 1.50 (95% CI 0.79–2.85) for patients treated at hospitals with moderate and lower radiotherapy-use, compared to patient treated at hospitals with higher radiotherapy-use. Conclusions Despite endocrine treatment in only 39.3%, locoregional recurrence risk was low, even in patients treated at hospitals with lower radiotherapy-use. This provides reasonable grounds to consider omission of radiotherapy in patients aged ≥ 75 years with T1-2N0 breast cancer. Electronic supplementary material The online version of this article (10.1007/s10549-019-05412-8) contains supplementary material, which is available to authorized users.
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Ali AA, Tawk R, Xiao H, Campbell E, Semykina A, Montero AJ, Mogos M, Diaby V. Comparative effectiveness of radiotherapy for early-stage hormone receptor-positive breast cancer in elderly women using real-world data. Cancer Med 2019; 8:117-127. [PMID: 30548840 PMCID: PMC6346228 DOI: 10.1002/cam4.1904] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/08/2018] [Accepted: 11/10/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Radiotherapy is the recommended treatment after breast-conserving surgery (BCS) for early-stage breast cancer (BC). However, there is no clear evidence whether radiotherapy after BCS improves the survival of elderly women diagnosed with early-stage hormone receptor-positive (HR+) BC. The aim of this study was to investigate the survival benefit associated with radiotherapy plus hormonal therapy vs hormonal therapy alone after BCS for early-stage HR+ BC patients. METHODS Using the Surveillance, Epidemiology, and End Results linked with Medicare data, we identified elderly (65 years and older) women diagnosed with early-stage HR+ BC (2006-2011) who received hormonal therapy with or without radiotherapy after BCS. A log-rank test, Cox proportional hazards models, and propensity score matching were used to estimate the overall survival (OS) benefit associated with radiotherapy after BCS. RESULTS Of the 5688 patients, there were 303 deaths from any cause. One hundred and eighty-five (61%) of these deaths occurred in the hormonal therapy group, and 118 (39%) deaths occurred in the radiotherapy plus hormonal therapy group. The mean survival time in the radiotherapy plus hormonal therapy group was 5.32 ± 1.86 years compared with 4.92 ± 1.86 years in the hormonal therapy group. Based on the adjusted and propensity score matching analysis, patients in the adjuvant radiotherapy group had a lower risk of death compared with those who did not receive radiotherapy. Radiotherapy plus hormonal therapy decreased the risk of death by 32%. The effect estimates were similar in the adjusted and matched cohorts. CONCLUSIONS Radiotherapy plus hormonal therapy resulted in a significant improvement in the OS of elderly women diagnosed with HR+ BC.
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Affiliation(s)
- Askal A. Ali
- Economic, Social & Administrative Pharmacy, College of Pharmacy and Pharmaceutical SciencesFlorida A&M UniversityTallahasseeFlorida
| | - Rima Tawk
- Institute of Public Health, College of Pharmacy and Pharmaceutical SciencesFlorida A&M UniversityTallahasseeFlorida
| | - Hong Xiao
- Pharmaceutical Outcomes & Policy (POP), College of PharmacyUniversity of FloridaGainesvilleFlorida
| | - Ellen Campbell
- Economic, Social & Administrative Pharmacy, College of Pharmacy and Pharmaceutical SciencesFlorida A&M UniversityTallahasseeFlorida
| | | | - Alberto J. Montero
- Cleveland ClinicDepartment of Solid Tumor OncologyTaussig Cancer InstituteClevelandOhio
| | - Muluberhan Mogos
- Department of Women, Children and Family Health ScienceUniversity of Illinois at ChicagoChicagoIllinois
| | - Vakaramoko Diaby
- Pharmaceutical Outcomes & Policy (POP), College of PharmacyUniversity of FloridaGainesvilleFlorida
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