Management of early breast cancer in the elderly

Age-Related Biology of Early-Stage Operable Breast Cancer and Its Impact on Clinical Outcome

Simple Summary

Breast cancer incidence not only increases with advancing age but also changes its biology. This study was conducted to understand aging related change in the biological characteristics of breast cancer. The results highlighted that the change occurs in a gradual fashion, where 40 years and 70 years become the milestones for significant difference. Breast cancer in patients <40 years showed aggressive characteristics while at 70 years and above they are more indolent. The molecular pattern between 40 years and 70 years appears to be a transition from aggressive to less aggressive phenotypes. This change in the biology of the breast cancer significantly influences clinical outcome.

Abstract

As age advances, breast cancer (BC) tends to change its biological characteristics. This study aimed to explore the natural progression of such changes. The study included 2383 women with clinically T0-2N0-1M0 BC, managed by primary surgery and optimal adjuvant therapy in a dedicated BC facility. Tissue micro-arrays were constructed from their surgical specimens and indirect immunohistochemistry was used for analysis of a large panel (n = 16) of relevant biomarkers. There were significant changes in the pattern of expression of biomarkers related to luminal (oestrogen receptor (ER), progesterone receptors (PgR), human epidermal growth factor receptor (HER-2), E-cadherin, MUC1, bcl2 CK7/8, CK18 and bcl2) and basal (CK5/6, CK14, p53 and Ki67) phenotypes, lymph node stage, histological grade and pathological size when decade-wise comparison was made (p < 0.05). The ages of 40 years and 70 years appeared to be the milestones marking a change of the pattern. There were significantly higher metastasis free and breast cancer specific survival rates among older women with ER positive tumours while there was no significant difference in the ER negative group according to age. Biological characteristics of BC show a pattern of change with advancing age, where 40 years and 70 years appear as important milestones. The pattern suggests <40 years as the phase with aggressive phenotypes, >70 years as the less aggressive phase and 40–70 years being the transitional phase.

Liver Kinase B1-A Potential Therapeutic Target in Hormone-Sensitive Breast Cancer in Older Women

Background: The role of liver kinase B1 (LKB1), a serine/threonine kinase, has been described in the development of PeutzJagher’s syndrome, where a proportion (~45%) of patients have developed breast cancer in their lifetime. Cell line studies have linked LKB1 with oestrogen receptors (ER) and with the Adenosine monophosphate-activated protein kinase (AMPK) pathway for energy metabolism. However, limited studies have investigated protein expression of LKB1 in tumour tissues and its intracellular relationships. This study aimed to investigate the intracellular molecular relationships of LKB1 in older women with early operable primary breast cancer and its correlation with long-term clinical outcome. Methods: Between 1973 and 2010, a consecutive series of 1758 older (≥70 years) women with T0-2N0-1M0 breast carcinoma were managed in a dedicated facility. Of these, 813 patients underwent primary surgery, and 575 had good quality tumour samples available for tissue microarray construction. LKB1 was assessed in 407 cases by indirect immunohistochemistry (IHC). Tumours with 30% or more of cells with cytoplasmic LKB1 expression were considered positive. LKB1 expression was compared with tumour size, histological grade, axillary lymph node stage, ER, PgR, EGFR, HER2, HER3, HER4, BRCA1&2, p53, Ki67, Bcl2, Muc1, E-Cadherin, CD44, basal (CK5, CK5/6, CK14 and CK17) and luminal (CK7/8, CK18 and CK19) cytokeratins, MDM2 and MDM4, and correlated with long-term clinical outcome. Results: Positive LKB1 expression was seen in 318 (78.1%) patients, and was significantly associated with high tumour grade, high Ki67, over-expression of HER2, VEGF, HER4, BRCA2, MDM2 and negative expression of CD44 (p < 0.05). There was no significant correlation with tumour size, axillary lymph node status, ER, PgR, p53, basal or luminal cytokeratins, Bcl2, Muc1, EGFR, HER3, MDM4, E-cadherin and BRCA1. LKB1 did not show any significant influence on survival in the overall population; however, in those patients receiving adjuvant endocrine therapy for ER positive tumours, those with positive LKB1 had significantly better 5-year breast cancer specific survival when compared to those without such expression (93% versus 74%, p = 0.03). Conclusion: LKB1 expression has shown association with poor prognostic factors in older women with breast cancer. However, LKB1 expression appears to be associated with better survival outcome among those patients receiving adjuvant endocrine therapy. Further research is required to explore its potential role as a therapeutic target.

Oestrogen receptor negative early operable primary breast cancer in older women-Biological characteristics and long-term clinical outcome

Background

Older women are at the greatest risk of breast cancer development and a considerable number present with comorbidities. Although the majority of breast cancers in this age group express oestrogen receptor (ER), which makes endocrine therapy (primary or adjuvant) feasible, given the huge size of the elderly population, there remains a significant number of patients, in absolute term, whose tumours do not express ER and their management is challenging.

Methods

Of a consecutive series of 1,758 older (≥70 years) women with early operable primary breast cancer managed in a dedicated service from 1973–2010, 252(14.3%) had ER-negative (histochemical (H) score ≤50) tumours. Their clinical outcome was retrospectively reviewed and tumour samples collected from diagnostic core biopsies were analysed for progesterone receptor (PgR), HER2 and Ki67 using immunohistochemistry.

Results

The commonest primary treatment was surgery (N = 194, 77%) followed by primary endocrine therapy (14.3%), primary radiotherapy (5.6%) and supportive treatment only (3.1%). Among the patients undergoing surgery, most of them had grade 3 (78.1%) and node-negative disease (62.2%). Some of them (21.1%) received postoperative radiotherapy. At a median follow-up of 37.5 months, 117 patients had died, out of which 48.6% were due to breast cancer. For those who underwent surgery, the regional and local recurrence rates were 2% and 1.1% per annum respectively. For those who received primary endocrine therapy, 38% progressed at 6 months, however all patients who had primary radiotherapy achieved clinical benefit at 6 months. Regardless of treatment given, the 5-year breast cancer specific and overall survival rates were 70% and 50% respectively. Biological analysis based on good quality needle core biopsy specimensfrom181 patients showed that 26.8% (N = 49), 16.9% (N = 31) and 70.7% (N = 70)expressed positivity for PgR, HER2 and Ki67 respectively. No correlation between these biomarkers and breast cancer specific survival was demonstrated.

Conclusion

Oestrogen receptor negative early operable primary breast cancer in older women is associated with poor prognostic features in terms of biology and clinical outcome. Surgery appears to produce the best outcome as a primary treatment, however for those where neither surgery nor chemotherapy is appropriate, primary radiotherapy can be beneficial.

Distinct postsurgical management in young and elderly breast cancer patients results in equal survival rates

BACKGROUND

Although breast cancer (BC) is one of the most common malignant diseases in women, the majority of the studies describing the characteristics of BC in elderly patients have been limited to survival assessments or tumor features, without using younger BC patients as a reference group. The aim of our study was to describe and compare tumor characteristics and management patterns in elderly versus younger breast cancer patients in Turkey.

MATERIALS AND METHODS

We retrospectively analyzed 152 patients with invasive breast cancer who underwent surgery in our institution between 2002 and 2012. Patients were divided into 2 groups according to age at the time of diagnosis.

RESULTS

There were 62 patients in the elderly group (≥65 years) and 90 patients in the younger group (<65 years). Compared to the younger group, tumors in the elderly group were more likely to be larger (p=0.018), of lower grade (p=0.005), and hormone receptor-positive (p>0.001). There were no significant differences regarding histology, localization, lymph node involvement, or types of surgical procedures between the 2 groups. Comorbidities were more common in elderly patients (p<0.001). In addition, elderly patients were more likely to receive hormonal therapy (p<0.001) and less likely to receive radiotherapy (p=0.08) and chemotherapy (p=0.003). There was no difference in survival and locoregional recurrence rates between the groups.

CONCLUSIONS

The results of this study demonstrate that breast cancer in elderly patients has more favorable tumor features, warranting less aggressive treatment regimens after surgery.

Clinical response to primary letrozole therapy in elderly patients with early breast cancer: possible role for p53 as a biomarker

Primary tamoxifen therapy has been widely used to treat elderly women with ER-positive breast cancer in the past. Aromatase inhibitors may be more beneficial than tamoxifen when used as primary endocrine therapy in elderly patients. We aimed to retrospectively evaluate a series of elderly women with ER-positive breast cancer treated with primary letrozole therapy as sole therapy with a minimum of 5 years follow up. To identify possible predictive biomarkers a pilot immunohistochemical analysis was performed to assess the expression of PR, HER2, EGFR, BCL2 and p53. A total of 45 women, aged more than 70 years with a diagnosis of ER-positive breast cancer that was treated with primary letrozole therapy were identified. A case note review was undertaken to obtain clinical information. Formalin fixed paraffin embedded tumour tissue from diagnostic core biopsies was available for all patients. Immunohistochemical analysis was performed to establish the protein expression status of p53, PR, HER2, EGFR and BCL2. The mean age of the 45 patients was 87 years (range 70-101). Clinical benefit was seen in 60% of the patients. Median progression free survival was 53 months (95% CI - 34-72) and the median time to progression was 43 months (95% CI - 22-64). BCL2 was expressed in 45/45 (100%); PR in 38/45 (84%); EGFR in 13/45 (28%); HER2 in 9/45 (20%) and p53 in 5/45 (11%) of tissue samples. Positive expression of p53 was associated with poor progression free survival (p = 0.03) in this pilot study. This study demonstrates that letrozole as sole treatment appears to be a suitable treatment option for elderly patients with ER-positive breast cancer who are not fit for, or decline, surgery. The analysis of p53 in a larger study is warranted in order to assess its role as a biomarker in this patient group.

Clinicopathological features and treatment sensitivity of elderly Chinese breast cancer patients

This study aimed to determine the clinicopathological features and treatment sensitivity of elderly breast cancer patients in China. The clinical data of 594 elderly breast cancer patients of 70 or more years of age were collected and compared to those of 657 patients of less than 70 years of age to analyze whether breast cancer in the elderly is different and whether the difference affected outcome. The median age was 75.2 years in the elderly patients and 49.8 years in the young patients. Age of menarche, parous status and body mass index were similar in the two groups. A higher frequency of steroid receptor-positive rate, a lower expression of HER-2 and p53, less axillary node-positive rate and earlier tumor stage were found in patients of 70 years or older. The 5-year relapse-free survival (RFS) and overall survival (OS) was 77 and 82% in the elderly and 86 and 93% in the young patients, respectively. Patients with estrogen receptor (ER)-positive or lymph node (LN)-negative cancers showed a more favorable outcome in the elderly patients. RFS and OS were increased in elderly patients who underwent endocrine therapy or omitted chemotherapy. Breast cancer in the elderly had more favorable tumor features, using estrogen receptor and lymph node status as prognostic factors. It was therefore concluded that adjuvant endocrine therapy may benefit elderly patients, while chemotherapy may not.

Management of operable invasive breast cancer in women over the age of 70: long-term results of a large-scale single-institution experience

BACKGROUND

The treatment of choice for elderly women with breast cancer remains controversial. This retrospective analysis of a cohort from a single institution was designed to evaluate whether such patients are really undertreated because of their age and to reappraise their usual management.

METHODS

The characteristics of 538 patients aged > or = 70 years with operable breast cancer, treated between 1995 and 1999, were retrospectively analyzed comparing patients aged 70 to 75 years (group I, n = 288), 75 to 80 years (group II, n = 156), and > or = 80 years (group III, n = 94). Cause-specific survival, distant recurrence-free interval, and local control were estimated by the Kaplan-Meier method and compared by log rank test. Multivariate analysis used Cox regression.

RESULTS

In group III, tumors were more frequently T2 than T1 (P < 0.0001) and estrogen receptor negative (P = 0.045) than in groups I and II. Surgery was performed in 94.6% of patients, breast-conserving in 72.1% (62% in group III; P = 0.0015) with axillary dissection in 89.2% (77% in group III; P = 0.0015); 100% received radiotherapy after lumpectomy (hypofractionated in 63% of group III; P < 0.0001). Adjuvant hormone therapy and chemotherapy were administered to 57 and 3.7% of patients, respectively. At 7 years, no difference in the three groups was observed for cause-specific survival (91% for group I, 89% for group II, 86% for group III) distant recurrence-free interval, and local control (>90%).

CONCLUSIONS

Elderly patients with operable breast cancer who are completely and correctly treated with realistic treatment options that are based on surgery and adjuvant radiotherapy have a similar chance of being cured as younger patients.

Patterns of surgical treatment for women with breast cancer in relation to age

Although treatment recommendations have been advocated for all women with early breast cancer regardless of age, it is generally accepted that different treatments are preferred based on the age of the patient. The aim of this study was to assess the pattern of breast cancer surgery after adjusting for other major prognostic factors in relation to patient age. Data on cancer characteristics and surgical procedures in 31,298 patients with early breast cancer reported to the National Breast Cancer Audit between 1999 and 2006 were used for the study. There was a close association between age and surgical treatment pattern after adjusting for other prognostic factors, including tumor size, histologic grade, number of tumors, lymph node positivity, lymphovascular invasion (LVI), and extensive intraduct component. Breast Conserving Surgery (BCS) was highest among women aged <or=40 years (OR = 1.140; 95% CI: 1.004-1.293) compared to women aged 51-70 years (reference group). BCS was lowest in women aged >70 years (OR = 0.498, 95% CI: 0.455-0.545). Significantly more women aged <or=50 years underwent more than one operation for breast conservation (20.4-24.8%) compared with women aged >50 years (11.4-17.0%). Women aged >70 years were more likely to receive no surgical treatment, 3.5% versus 1.0-1.3% in all other age groups (<or=40, 41-50 51-70 years). There is an association between patient age and the type of breast cancer surgery for women in Australia and New Zealand. Women age <or=40 years are more likely to undergo BCS despite having adverse histologic features and have more than one procedure to achieve breast conservation. Older women (>70 years) more commonly undergo mastectomy and are more likely to receive no surgical treatment.

Treating elderly patients with hormone sensitive breast cancer: what do the data show?

Elderly patients with breast cancer frequently present with one or more comorbid conditions in addition to their cancer, and this can complicate clinicians' treatment decisions. Declining estrogen levels increase the risk for conditions such as cardiovascular disease and osteoporosis in the elderly. Evidence from clinical trials suggests that the elderly are frequently underrepresented; this may be due to an inherent reluctance among physicians to prescribe the latest, most effective therapies and/or recommend elderly patients for participation in clinical trials. Nonetheless, there is evidence that breast cancer in the elderly is generally more indolent than in younger patients, with a low proliferative and invasive capacity and a high degree of hormone responsiveness, making elderly patients ideal candidates for adjuvant endocrine therapies. The aromatase inhibitors, including anastrozole, letrozole, and exemestane, have proven to be well tolerated and superior alternatives to tamoxifen for post-menopausal women with hormone-sensitive breast cancer, whether used upfront or sequentially with adjuvant tamoxifen. Although the elderly have also been underrepresented in clinical trials of the aromatase inhibitors, evidence from the major trials has not shown any decrement in efficacy or major safety concerns when these drugs are used in older populations. While recently published data from MA.17 and the Breast International Group 1-98 showed letrozole to be effective irrespective of age, clinicians should carefully consider underlying comorbidities when prescribing adjuvant endocrine treatments to elderly patients with breast cancer.

Breast cancer in elderly women. Optimizing the treatment

The elderly population is on the rise. Breast cancer is the most common cancer in western women and its incidence increases with age. Despite the epidemiological burden of this condition, there is a lack of knowledge regarding the management of older patients, as treatment planning is mainly based on personal preferences rather than hard data. Older women are often offered sub-optimal treatment when compared to their younger counterpart at any particular stage. This is due to various reasons, including the lack of scientific evidence from well-conducted clinical trials. Reluctance to prescribe systemic treatments may be explained by the complexity of cost-benefit evaluations in such patients. It is also an ethical dilemma to decide how aggressive one should be when it comes to treat cancer in the elderly in view of the higher rate of cognitive impairment and specific patients' expectations. This paper reviews the currently available evidence and attempts presenting and discussing chemoprevention of breast cancer, risk and benefit of hormone replacement therapy and the various treatment options for older women with breast cancer.