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Heidenreich A, Fuchshofen R, Elsner S, Gieseler F, Katalinic A, Hübner J. Contributing and limiting factors to guideline-adherent therapy in senior and elderly breast cancer patients: a questionnaire-based cross-sectional study using clinical and cancer registry data in Germany. J Cancer Res Clin Oncol 2023; 149:17297-17306. [PMID: 37815663 PMCID: PMC10657281 DOI: 10.1007/s00432-023-05446-y] [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: 08/24/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE Elderly cancer patients are less likely to be treated in accordance with evidence-based guideline recommendations. This study examines patient-related factors associated with deviations from guideline recommendations. METHODS Using medical documentation and cancer registry data, we investigated the treatment courses of female breast cancer patients aged 50 and older in Germany regarding compliance with German guidelines. Participants completed a questionnaire querying factors hypothesized to be associated with guideline adherence. We conducted univariate analyses to explore the data and select variables for multivariate logistic regression to estimate adjusted odds ratios. RESULTS Of 1150 participants, 206 (17.9%) were treated in deviation from guideline recommendations. Patients 70 years and older were more likely to be treated deviating from guideline recommendations than patients 50-69 years old (OR: 2.07; 95% CI: 1.52-2.80). Patients aged 50-69 years who reported that quality of life guided their treatment decision were more likely to be treated in deviation from guideline recommendations (AOR: 2.08; 95% CI: 1.11-3.92) than the elderly. In older patients, higher age was associated with an increased chance of receiving guideline-discordant care (AOR: 1.06; 95% CI: 1.01-1.11), as was depression diagnosed prior to cancer (AOR: 1.84; 95% CI: 1.00-3.40). CONCLUSION Reasons for deviations from guideline recommendations in breast cancer patients differ by age. In decision-making concerning elderly patients, particular attention should be paid to those with pre-existing depressive disorders. Adequately addressing their needs and concerns could prevent inappropriate deviations from guideline recommendations.
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Affiliation(s)
- Andreas Heidenreich
- Institute of Social Medicine and Epidemiology, University of Luebeck, Ratzeburger Allee 160, 23560, Luebeck, Germany.
| | - Rabea Fuchshofen
- Institute of Social Medicine and Epidemiology, University of Luebeck, Ratzeburger Allee 160, 23560, Luebeck, Germany
| | - Susanne Elsner
- Institute of Social Medicine and Epidemiology, University of Luebeck, Ratzeburger Allee 160, 23560, Luebeck, Germany
| | - Frank Gieseler
- Clinic for Hematology and Oncology, University Hospital Schleswig-Holstein (UKSH), Luebeck, Germany
| | - Alexander Katalinic
- Institute of Social Medicine and Epidemiology, University of Luebeck, Ratzeburger Allee 160, 23560, Luebeck, Germany
| | - Joachim Hübner
- Agency for Clinical Cancer Data of Lower Saxony, Oldenburg, Germany
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2
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Yang R, Wu Y, Qi Y, Liu W, Huang Y, Zhao X, Chen R, He T, Zhong X, Li Q, Zhou L, Chen J. A nomogram for predicting breast cancer specific survival in elderly patients with breast cancer: a SEER population-based analysis. BMC Geriatr 2023; 23:594. [PMID: 37749538 PMCID: PMC10518930 DOI: 10.1186/s12877-023-04280-8] [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: 10/07/2022] [Accepted: 09/05/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND The number of elderly patients diagnosed with breast cancer is increasing worldwide. However, treatment decisions for these patients are highly variable. Although researchers have identified the effects of surgery, radiotherapy, endocrine therapy, and chemotherapy in elderly patients with breast cancer, clinicians still struggle to make appropriate decisions for these patients. METHODS We identified 75,525 female breast cancer patients aged ≥ 70 years in the Surveillance, Epidemiology, and End Results (SEER) database treated between January 1, 2010, and December 31, 2016. The patients were further divided into training and testing cohorts. The cumulative occurrence of breast cancer-specific deaths (BCSDs) and other cause-specific deaths (OCSD) was calculated using the cumulative incidence function. In the univariate analysis, risk factors were screened using the Fine-Gray model. In the multivariate analysis for competing risks, the sub-distribution hazard ratio with a 95% confidence interval for each independent predictor associated with BCSD was calculated for the construction of nomograms. Based on the above analyses, a competing risk nomogram was constructed to predict the probability of BCSD in the 1st, 3rd, and 5th years after treatment. During validation, the concordance index (C-index) was selected to quantify the predictive ability of the competing risk model. RESULTS A total of 33,118 patients were included in this study, with 24,838 in the training group and 8,280 in the testing group. Age, race, marital status, cancer grade, tumor stage, node stage, estrogen receptor status, progesterone receptor status, human epidermal growth factor receptor--2 status, and treatment including surgery, radiation, and chemotherapy were used to establish a nomogram. The C-index of 0.852 (0.842-0.862) in the training cohort and 0.876 (0.868-0.892) in the testing cohort indicated satisfactory discriminative ability of the nomogram. Calibration plots showed favorable consistency between the nomogram predictions and actual observations in both the training and validation cohorts. CONCLUSIONS Our study identified independent predictors of BCSD in elderly patients with breast cancer. A prognostic nomogram was developed and validated to aid clinical decision-making.
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Affiliation(s)
- Ruoning Yang
- Division of Breast Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yunhao Wu
- Division of Breast Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yana Qi
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
- Departments of Obstetrics & Gynecology and Pediatrics, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Center of Growth, Metabolism and Aging, Sichuan University, Chengdu, Sichuan, 610041, China
- Departments of Obstetrics & Gynecology and Pediatrics, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, State Key Laboratory of Biotherapy and Collaborative Innovation Center of Biotherapy, Sichuan University, Chengdu, 610041, China
| | - Weijing Liu
- Division of Breast Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ya Huang
- Division of Breast Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Zhao
- Division of Breast Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ruixian Chen
- Division of Breast Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Tao He
- Division of Breast Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaorong Zhong
- Breast Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qintong Li
- Departments of Obstetrics & Gynecology and Pediatrics, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Development and Related Diseases of Women and Children Key Laboratory of Sichuan Province, Center of Growth, Metabolism and Aging, Sichuan University, Chengdu, Sichuan, 610041, China
- Departments of Obstetrics & Gynecology and Pediatrics, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, State Key Laboratory of Biotherapy and Collaborative Innovation Center of Biotherapy, Sichuan University, Chengdu, 610041, China
| | - Li Zhou
- Public Experimental Technology Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Chen
- Division of Breast Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China.
- Breast Center, West China Hospital, Sichuan University, Chengdu, China.
- Department of Breast Surgery, West China Hospital, Sichuan University, Guoxue Street 37#, Chengdu, 610041, China.
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3
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Corbaux P, Terret C, Cropet C, Chabaud S, Russo C, Faure C, Tredan O, Bachelot T, Heudel PE. Association of chemotherapy and comorbidities with overall survival in elderly patients with early breast cancer: a French population-based propensity score-matched analysis. Int J Clin Oncol 2023; 28:371-381. [PMID: 36645534 DOI: 10.1007/s10147-023-02296-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/09/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND Additional systemic treatment for early breast cancer in elderly is challenged by increasing comorbidities with age. We aimed to examine the effect of additional chemotherapy on overall survival in patients aged 70 years or older and the impact of comorbidities on chemotherapy benefit. METHODS This retrospective monocentric cohort study includes data from all patients aged 70 years and older who underwent surgery for an early breast cancer from 1997 to 2016. A propensity score analysis allowed adjustment for chemotherapy prescription preferences based on tumour characteristics. RESULTS Of 15,599 patients who had surgery for an early breast cancer, 1743 (11.2%) over 70 years old were included, of whom 269 (15.4%) had received additional chemotherapy. Median follow-up was 5.3 years. Multivariate analyses on the propensity-score weighted cohort (n = 1 354) identified improved overall survival in patients with chemotherapy versus without (HR 0.54, 95% CI 0.31-0.92). Chronic obstructive pulmonary disease (HR, 2.16, 95% CI 1.40-3.34) and polypharmacy (HR 1.40, 95%CI 1.07-1.84) were associated with worse overall survival. No statistically significant interactions were identified between these comorbidities and chemotherapy prescription. CONCLUSION Additional chemotherapy in elderly with early breast cancer is feasible and associated with overall survival benefit, supporting the importance of chemotherapy considerations in this population, and of avoiding undertreatment based on chronological age considerations alone.
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Affiliation(s)
- Pauline Corbaux
- Department of Medical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
| | - Catherine Terret
- Department of Medical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
| | - Claire Cropet
- Biostatistics Unit, Centre Léon Bérard, DRCI, Lyon, France
| | - Sylvie Chabaud
- Biostatistics Unit, Centre Léon Bérard, DRCI, Lyon, France
| | - Chiara Russo
- Department of Medical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
| | | | - Olivier Tredan
- Department of Medical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
| | - Thomas Bachelot
- Department of Medical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France
| | - Pierre-Etienne Heudel
- Department of Medical Oncology, Centre Léon Bérard, 28 Rue Laennec, 69008, Lyon, France.
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4
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Hoffmann AS, Hennigs A, Feisst M, Moderow M, Heublein S, Deutsch TM, Togawa R, Schäfgen B, Wallwiener M, Golatta M, Heil J, Riedel F. Impact of age on indication for chemotherapy in early breast cancer patients: results from 104 German institutions from 2008 to 2017. Arch Gynecol Obstet 2023; 308:219-229. [PMID: 36604331 DOI: 10.1007/s00404-022-06902-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 12/18/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Today, the decision to treat patients with chemotherapy for early breast cancer (EBC) is made based on the patient's individual risk stratification and tumor biology. In cases with chemotherapy indication, the neoadjuvant application (NACT) is the preferred option in comparison with primary surgery and adjuvant chemotherapy (ACT). Age remains a relevant factor in the decision-making process. The aim of the present study was to illustrate the impact of age on the use of systemic therapy in clinical routine. METHODS The study separately analyzed chemotherapy use among six age cohorts of EBC patients who had been treated at 104 German breast units between January 2008 and December 2017. RESULTS In total, 124,084 patients were included, 46,279 (37.3%) of whom had received chemotherapy. For 44,765 of these cases, detailed information on treatment was available. Within this cohort, chemotherapy was administered as NACT to 14,783 patients (33.0%) and as ACT to 29,982 (67.0%) patients. Due to the higher prevalence of unfavorable tumor subtypes, younger patients had a higher rate of chemotherapy (≤ 29y: 74.2%; 30-39y: 71.3%) and a higher proportion of NACT administration ( ≤ 29y: 66.9%; 30-39y: 56.0%) in comparison with elderly patients, who had lower rates for overall chemotherapy (60-69y: 37.5%; ≥ 70y: 17.6%) and NACT (60-69y: 25.5%; ≥ 70y: 22.8%). Pathologic complete response was higher in younger than in older patients (≤ 29y: 30.4% vs. ≥ 70y: 16.7%), especially for HER2- subtypes. CONCLUSION The data from the nationwide German cohort reveal relevant age-dependent discrepancies concerning the use of chemotherapy for EBC.
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Affiliation(s)
- Ann Sophie Hoffmann
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - André Hennigs
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Sabine Heublein
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
- National Center for Tumor Diseases, Heidelberg, Germany
| | - Thomas Maximilian Deutsch
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Riku Togawa
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Benedikt Schäfgen
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Markus Wallwiener
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Michael Golatta
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
- Heidelberg Breast Center at the St. Elisabeth Clinic, Heidelberg, Germany
| | - Jörg Heil
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
- Heidelberg Breast Center at the St. Elisabeth Clinic, Heidelberg, Germany
| | - Fabian Riedel
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
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5
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Akezaki Y, Nakata E, Kikuuchi M, Tominaga R, Kurokawa H, Okamoto M, Ozaki T, Aogi K, Ohsumi S, Sugihara S. Characteristics of Postoperative Patients with Breast Cancer Aged 65 Years and Older. Curr Oncol 2023; 30:673-680. [PMID: 36661701 PMCID: PMC9858311 DOI: 10.3390/curroncol30010052] [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: 11/04/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
Objective: This study aimed to compare postoperative patients with breast cancer aged ≥65 years with those aged <65 years and clarify the characteristics of postoperative patients with breast cancer aged ≥65. Methods: In total, 376 patients in whom we were able to evaluate survey items one month after surgery were included in the study. Comorbidity, including diabetes mellitus and hypertension, shoulder range of motion (ROM), upper-limb function, and psychological problems, was evaluated. Results: Hypertension and diabetes mellitus were significantly higher in patients aged ≥65 years (the elderly group) than in those aged <65 years (the non-elderly group) (p < 0.05). Preoperative shoulder flexion ROM was significantly restricted in the elderly group compared with the non-elderly group (p < 0.05). Preoperative shoulder abduction ROM was significantly restricted in the elderly group compared with the non-elderly group (p < 0.05). At one month after surgery, upper-limb function was more impaired in the non-elderly group than in the elderly group (p < 0.05). In both groups, both ROM and upper-limb function were significantly impaired one month after surgery compared with before surgery (p < 0.05). Conclusions: Postoperative patients with breast cancer aged ≥65 years should be careful about risk management and intervention during rehabilitation. Preoperative evaluation of shoulder ROM should be performed because patients aged ≥65 years have limited ROM before surgery.
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Affiliation(s)
- Yoshiteru Akezaki
- Division of Physical Therapy, Kochi Professional University of Rehabilitation, Kochi 781-1102, Japan
| | - Eiji Nakata
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama 700-8558, Japan
| | - Masato Kikuuchi
- Department of Rehabilitation Medicine, National Hospital Organization Shikoku Cancer Center, Ehime 791-0280, Japan
| | - Ritsuko Tominaga
- Department of Rehabilitation Medicine, National Hospital Organization Shikoku Cancer Center, Ehime 791-0280, Japan
| | - Hideaki Kurokawa
- Department of Rehabilitation Medicine, National Hospital Organization Shikoku Cancer Center, Ehime 791-0280, Japan
| | - Masaki Okamoto
- Department of Rehabilitation Medicine, National Hospital Organization Shikoku Cancer Center, Ehime 791-0280, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Hospital, Okayama 700-8558, Japan
| | - Kenjiro Aogi
- Department of Breast Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama 791-0280, Japan
| | - Shozo Ohsumi
- Department of Breast Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama 791-0280, Japan
| | - Shinsuke Sugihara
- Department of Rehabilitation Medicine, National Hospital Organization Shikoku Cancer Center, Ehime 791-0280, Japan
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6
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Sang Y, Yang B, Mo M, Liu S, Zhou X, Chen J, Hao S, Huang X, Liu G, Shao Z, Wu J. Treatment and survival outcomes in older women with primary breast cancer: A retrospective propensity score-matched analysis. Breast 2022; 66:24-30. [PMID: 36096070 PMCID: PMC9471966 DOI: 10.1016/j.breast.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Changes in biological features and functional status make management decisions in older women with primary breast cancer complicated. We aimed to provide an overview of the clinicopathological characteristics and survival outcomes of older breast cancer patients based on the current treatment strategies. METHODS Female patients diagnosed with primary invasive breast cancer at Fudan University Shanghai Cancer Centre from 2008 to 2016 were included. Patients were divided into a younger group (<65 years) and older group (≥65 years). Propensity score matching was utilised to generate balanced cohorts. RESULTS A total of 13,707 patients met the study criteria. Compared with younger patients, older patients had a higher Charlson Comorbidity Index (p < 0.001), less lymph node metastasis (p = 0.009), more advanced tumour stage (p = 0.038), and a larger proportion of estrogen receptor-positive (p < 0.001) and epidermal growth factor receptor 2-negative (p < 0.001) tumours. Older patients were likely to receive mastectomy and axillary lymph node dissection in addition to a lower proportion of adjuvant chemotherapy. Adjuvant chemotherapy (HR [hazard ratio] 0.69, p = 0.039) was independently correlated with better overall survival in the older patients. This survival benefit (HR 0.58, p = 0.041) was confirmed in matched cohorts. Among the older patients with larger tumours (HR 0.48, p = 0.038) and more lymph node involvement (HR 0.44, p = 0.040), adjuvant chemotherapy was associated with a significant survival benefit. CONCLUSION Older breast cancer patients showed less aggressive biological characteristics, intensive surgical and moderate medical preferences. The addition of adjuvant chemotherapy should be considered for older patients, especially for patients with large tumours and more lymph node involvement.
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Affiliation(s)
- Yuting Sang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China
| | - Benlong Yang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Miao Mo
- Department of Cancer Prevention, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Shiyang Liu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China
| | - Xujie Zhou
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China
| | - Jiajian Chen
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Shuang Hao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Xiaoyan Huang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Guangyu Liu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China
| | - Zhimin Shao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China
| | - Jiong Wu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China,Department of Oncology, Fudan University Shanghai Medical College, Shanghai, 200032, China,Corresponding author. Department of Breast Surgery, Breast Cancer Institute, Shanghai Cancer Center, Fudan University, Shanghai, 200032, China.
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7
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Xiu M, Zhang P, Li Q, Yuan P, Wang J, Luo Y, Ma F, Cai R, Fan Y, Li Q, Xu B. Chemotherapy Decision-Making and Survival Outcomes in Older Women With Early Triple-Negative Breast Cancer: Evidence From Real-World Practice. Front Oncol 2022; 12:867583. [PMID: 35574419 PMCID: PMC9097590 DOI: 10.3389/fonc.2022.867583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/30/2022] [Indexed: 11/22/2022] Open
Abstract
Data regarding chemotherapy options and benefits in older women with early triple-negative breast cancer (TNBC) are limited. Our study aimed to assess the effects of adjuvant chemotherapy on recurrence-free survival (RFS), breast cancer-specific survival (BCSS), and overall survival (OS) rates in elderly TNBC patients. Patients aged ≥65 years diagnosed with stage I-III TNBC (except T1aN0) between 2010 and 2016 were retrospectively included. Multivariate Cox regression was performed to minimize bias. A total of 177 patients were included with a median age of 69 years (range, 65-86), almost all had a Charlson Comorbidity Index of 0-2, and 127 (71.8%) received chemotherapy. Patients who received chemotherapy were younger, had more advanced-stage disease and had better ECOG performance status (P<0.05). Among the 127 patients who were administered chemotherapy, 45 (35%) received taxane plus carboplatin, 36 (28%) received anthracycline-and-taxane-based regimens, and 23 (18%) received taxane-based regimens. The regimen options differed based on patient age and tumour stage (P<0.05). Nearly 80% of the patients completed ≥6 cycles of chemotherapy, and half had their dosage decreased. After adjustment for confounding factors, patients who received ≥6 cycles of chemotherapy were found to have improved RFS rates (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.09-0.87; P=0.027), and receipt of chemotherapy (≥1 cycle) was associated with better BCSS (HR, 0.19; 95% CI, 0.04-0.97; P=0.046) and OS (HR, 0.26; 95% CI, 0.08-0.87; P=0.029) rates. These results support the considering the risk for recurrence and performing individualized assessments when determining the appropriate chemotherapy approach for older women with early TNBC.
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Affiliation(s)
- Meng Xiu
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pin Zhang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Li
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peng Yuan
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiayu Wang
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Luo
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Ma
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ruigang Cai
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Fan
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiao Li
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Binghe Xu
- Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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8
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Lorentsen MK, Vohra S, Muss HB, Damone E, Deal AM, Brenizer AT, Nyrop KA. Age and competing concerns in treatment selection for women with non-metastatic HR+ and HER2- breast cancer: Current clinical practice. J Geriatr Oncol 2022; 13:839-843. [PMID: 35459585 DOI: 10.1016/j.jgo.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 01/30/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Newer adjuvant treatment options for non-metastatic breast cancer have increased survival. There is a need to investigate whether demographic and clinical characteristics of women with hormone receptor-positive, human epidermal growth receptor 2-negative non-metastatic breast cancer (stages I-III) differentially influence treatment decisions in older (age 65 or older) versus younger patients (under age 65). METHODS In a retrospective electronic medical record review, prevalence ratio with 95% confidence interval for treatment decisions in older vs younger patients was calculated using log binomial regression adjusted for race, stage, and total number of comorbidities. RESULTS In a sample of 537 patients, 66% were age < 65 and 34% age ≥ 65. Older patients included a higher proportion of White women (85% vs 75%, P = .02), higher number of comorbidities (P ≤0.0001), and lower stage tumors (P = .0004). In multivariable analysis, age ≥ 65 was independently associated with fewer mastectomies (95% CI 0.65-0.96, P = .02), more lumpectomies (95% CI 1.05-1.42, P = .01), and less receipt of radiation treatment (95% CI 0.78-0.97, P = .01) and/or chemotherapy (95% CI 0.73-0.95, P = .006). In multivariate analysis, stage was independently significant for all treatment modalities, except endocrine therapy, and race was not. CONCLUSIONS This study suggests that age, in addition to breast cancer stage, is a predictor of treatment modality, independent of race and number of comorbidities. Treatment modality reflects a combination of patient preference and clinician assessment of fitness for current standard of care.
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Affiliation(s)
- Michael K Lorentsen
- The University of North Carolina at Chapel Hill, USA; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA.
| | - Sanah Vohra
- The University of North Carolina at Chapel Hill, USA
| | - Hyman B Muss
- The University of North Carolina at Chapel Hill, USA; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Emily Damone
- The University of North Carolina at Chapel Hill, USA
| | - Allison M Deal
- The University of North Carolina at Chapel Hill, USA; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | | | - Kirsten A Nyrop
- The University of North Carolina at Chapel Hill, USA; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
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9
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Marinopoulos S, Dimitrakakis C, Kalampalikis A, Zagouri F, Andrikopoulou A, Rodolakis A. Adjuvant Treatment of Elderly Breast Cancer Patients: Offer the Best Chances of Cure. Breast Care (Basel) 2022; 17:71-80. [PMID: 35355693 PMCID: PMC8914240 DOI: 10.1159/000513708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 12/11/2020] [Indexed: 02/03/2023] Open
Abstract
Background Breast cancer remains the most common cancer in women and a leading cause of death. Elderly people have a higher incidence of breast cancer since it increases with age. Furthermore, the extended life expectancy and advances in imaging techniques have led to an increased number of cases. Guidelines concerning the management of this specific age group are rare, mainly due to underrepresentation of seniors in clinical trials. Moreover, increased frailty, comorbidities, and a poor performance status make it complex to determine the best therapeutic approach. Summary In this review, we attempt to summarize the current literature and aim to provide specific approaches and recommendations for prompt diagnosis, treatment, and management of breast cancer in the elderly. Key Messages The establishment of applicable protocols is imperative and efforts are being made in this direction. A careful geriatric assessment and adequate consultation should be the standard of care and patient's preferences should always be considered.
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Affiliation(s)
- Spyridon Marinopoulos
- Breast Unit, 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece,*Spyridon Marinopoulos, 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, 80 V. Sofias Ave., GR–11528 Athens (Greece),
| | - Constantine Dimitrakakis
- Breast Unit, 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Andreas Kalampalikis
- Breast Unit, 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Flora Zagouri
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Angeliki Andrikopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Alexandros Rodolakis
- Breast Unit, 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
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10
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Rocque GB, Caston NE, Franks JA, Williams CP, Aswani MS, Azuero A, Gidwani R. Clinical trial representativeness and treatment intensity in a real-world sample of women with early stage breast cancer. Breast Cancer Res Treat 2021; 190:531-540. [PMID: 34585334 DOI: 10.1007/s10549-021-06381-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/06/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE The extent to which evidence-based treatments are applied to populations not well represented in early stage breast cancer (EBC) trials remains unknown. This study evaluated treatment intensity for patients traditionally well represented, underrepresented, and unrepresented in clinical trials. METHODS This retrospective cohort study used real-world data to evaluate the intensity (high or low) of EBC chemotherapy by patient characteristics (age, race and ethnicity, presence of comorbidity) denoting clinical trial representation status (well represented, underrepresented, unrepresented) for patients diagnosed from 2011 to 2020. Odds ratios (OR) from a logistic regression model was used to evaluate the association between receipt of high-intensity chemotherapy and clinical trial representation status characteristics adjusting for cancer stage and subtype. RESULTS Of 970 patients with EBC, 41% were characterized as well represented, 45% as underrepresented, and 13% as unrepresented in clinical trials. In adjusted models, patients aged ≥ 70 versus 45-69 had lower odds of receiving a high-intensity treatment (OR 0.40, 95% CI 0.26-0.60), while those aged < 45 versus 45-69 had higher odds of receiving high-intensity treatment (OR 1.82, 95% CI 1.10-3.01). In predicted estimates, the proportion of patients receiving a high-intensity treatment was 87% for patients aged < 45, 79% for patients aged 45-69, and 60% for patients aged ≥ 70. CONCLUSION 59% of the EBC population is not well represented in clinical trials. Age was associated with differential treatment intensity. Widening clinical trial eligibility criteria should be considered to better understand survival outcomes, toxicity effects, and ultimately make evidence-based treatment decisions using a more diverse sample.
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Affiliation(s)
- Gabrielle B Rocque
- Division of Hematology and Oncology, University of Alabama at Birmingham (UAB), WTI 240E, Birmingham, AL, 35294, USA.
| | - Nicole E Caston
- Division of Hematology and Oncology, University of Alabama at Birmingham (UAB), WTI 240E, Birmingham, AL, 35294, USA
| | - Jeffrey A Franks
- Division of Hematology and Oncology, University of Alabama at Birmingham (UAB), WTI 240E, Birmingham, AL, 35294, USA
| | - Courtney P Williams
- Division of Hematology and Oncology, University of Alabama at Birmingham (UAB), WTI 240E, Birmingham, AL, 35294, USA
| | | | | | - Risha Gidwani
- Department of Health Management & Policy, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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11
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Scharl S, Sprötge T, Gerken M, Scharl A, Ignatov A, Inwald EC, Ortmann O, Kölbl O, Klinkhammer-Schalke M, Papathemelis T. Factors influencing treatment decision and guideline conformity in high-grade endometrial cancer patients: a population-based study. Arch Gynecol Obstet 2021; 305:203-213. [PMID: 34223974 DOI: 10.1007/s00404-021-06140-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Treatment according to guidelines has been demonstrated to improve survival in a number of different cancer entities. Deviations from guidelines depend on several factors, including the patient's preferences, age and comorbidities. The aim of this study was to assess the adherence to guideline recommendations concerning surgical and adjuvant treatment in endometrial cancer. Furthermore, we sought to evaluate the reasons for non-adherence to guidelines by further examining the influence of comorbidities and age. METHODS The influence of age, comorbidities, tumor stage and histological subtype on guideline adherence was evaluated by multivariable logistic regression in a cohort of 353 high-grade endometrial cancer patients. High-grade endometrial cancer was defined as carcinosarcoma, Type II (serous, clear cell, mixed cell carcinoma) and Type I G3 histology. RESULTS Extensive surgical procedures, particularly systematic LNE, were less frequently applied in patients with comorbidities (p = 0.015) or higher age (p < 0.01). Guideline adherence was not affected by comorbidities (p = 0.563), but was significantly reduced with higher age (p < 0.01). In a multivariable model, higher age (p < 0.01), obesity (p = 0.011), higher FIGO Stage (p < 0.01) and histologic subtype (p < 0.01) significantly decreased OS. Surgery (p < 0.001), chemotherapy (p < 0.01) and systematic LNE (p = 0.011) were associated with higher OS. CONCLUSION Age seems to be the strongest independent factor leading to guideline deviation. Comorbidities were associated with less aggressive treatment, but not with deviations from guidelines.
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Affiliation(s)
- Sophia Scharl
- Department of Radiation Oncology and Nuclear Medicine, Medizinisches Versorgungszentrum am Klinikum Rosenheim, Rosenheim, Germany.
| | - Tim Sprötge
- Tumor Center, Institute for Quality Management and Health Services Research, University of Regensburg, Regensburg, Germany
| | - Michael Gerken
- Tumor Center, Institute for Quality Management and Health Services Research, University of Regensburg, Regensburg, Germany
| | - Anton Scharl
- Department of Gynecology and Obstetrics, Klinikum St. Marien Amberg, Amberg, Germany
| | - Atanas Ignatov
- Department of Gynecology and Obstetrics, University Medical Center, Regensburg, Regensburg, Germany
| | - Elisabeth C Inwald
- Department of Gynecology and Obstetrics, University Medical Center, Regensburg, Regensburg, Germany
| | - Olaf Ortmann
- Department of Gynecology and Obstetrics, University Medical Center, Regensburg, Regensburg, Germany
| | - Oliver Kölbl
- Department of Radiation Oncology, University Medical Center, Regensburg, Regensburg, Germany
| | - Monika Klinkhammer-Schalke
- Tumor Center, Institute for Quality Management and Health Services Research, University of Regensburg, Regensburg, Germany
| | - Thomas Papathemelis
- Department of Gynecology and Obstetrics, Klinikum St. Marien Amberg, Amberg, Germany
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12
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Zhou P, Zhang WW, Bao Y, Wang J, Lian CL, He ZY, Wu SG. Chemotherapy and 21-gene recurrence score testing for older breast cancer patients: A competing-risks analysis. Breast 2020; 54:319-327. [PMID: 33278648 PMCID: PMC7718160 DOI: 10.1016/j.breast.2020.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/09/2020] [Accepted: 11/26/2020] [Indexed: 12/24/2022] Open
Abstract
PURPOSE To evaluate the effect of the 21-gene recurrence score (RS) assay in breast cancer-specific mortality (BCSM) and decision-making for chemotherapy in older (aged ≥65 years) breast cancer. METHODS We retrospectively included older patients with T1-2N0 and estrogen receptor-positive breast cancer in the Surveillance, Epidemiology, and End Results database. Cox regression model and competing-risks model were used for data analysis. RESULTS This study included 8524 patients, 1987 (23.3%) had low RS, 5059 (59.4%) had intermediate RS, and 1478 (17.3%) had high RS. Chemotherapy was administrated in 2.0%, 8.6%, and 51.2% for low, intermediate, and high RS cohorts, respectively (P < 0.001). A total of 597 deaths were recorded, including one-quarter of breast cancer-related deaths and three-quarters as competing causes of death. The 5-year BCSM was 5.4%, 4.7%, and 9.1% for low, intermediate, and high RS cohorts, respectively (P < 0.001), using the Cox regression model, and was 0.8%, 0.9%, and 5.2% for low, intermediate, and high RS cohorts using the competing-risks regression, respectively (P < 0.001). RS was independently correlated with BCSM in both prognostic models. The stratified analysis demonstrated that chemotherapy was not correlated with a lower risk of BCSM in intermediate and high RS cohorts in both prognostic models. Sensitivity analyses replicated similar findings after stratification by the year of diagnosis and patients' age. CONCLUSIONS The competing-risks model is useful in dealing with multiple end events for older breast cancer patients. 21-gene RS was independently associated with BCSM. However, chemotherapy did not significantly decrease the risk of BCSM in intermediate and high RS cohorts.
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Affiliation(s)
- Ping Zhou
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, People's Republic of China
| | - Wen-Wen Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, People's Republic of China
| | - Yong Bao
- Department of Radiation Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, People's Republic of China
| | - Jun Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, People's Republic of China
| | - Chen-Lu Lian
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, People's Republic of China
| | - Zhen-Yu He
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, 510060, People's Republic of China.
| | - San-Gang Wu
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, People's Republic of China.
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13
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Tamirisa N, Lin H, Shen Y, Shaitelman SF, Sri Karuturi M, Giordano SH, Babiera G, Bedrosian I. Association of Chemotherapy With Survival in Elderly Patients With Multiple Comorbidities and Estrogen Receptor-Positive, Node-Positive Breast Cancer. JAMA Oncol 2020; 6:1548-1554. [PMID: 32672820 PMCID: PMC7366278 DOI: 10.1001/jamaoncol.2020.2388] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022]
Abstract
Importance Breast cancer risk and comorbidities increase with age. Data are lacking on the association of adjuvant chemotherapy with survival in elderly patients with multiple comorbidities and node-positive breast cancer. Objective To examine the association of chemotherapy with survival in elderly patients with multiple comorbidities and estrogen receptor-positive, node-positive breast cancer. Design, Setting, and Participants This retrospective cohort study included patients in the US National Cancer Database who were 70 years or older; had a Charlson/Deyo comorbidity score of 2 or 3; had estrogen receptor-positive, ERBB2 (formerly HER2 or HER2/neu)-negative breast cancer; and underwent surgery for pathologic node-positive breast cancer from January 1, 2010, to December 31, 2014. Propensity scores were used to match patients receiving adjuvant chemotherapy with those not receiving adjuvant chemotherapy based on age, comorbidity score, facility type, facility location, pathologic T and N stage, and receipt of adjuvant endocrine and radiation therapy. Data analysis was performed from December 13, 2018, to April 28, 2020. Exposures Chemotherapy. Main Outcomes and Measures The association of adjuvant chemotherapy with overall survival was estimated using a double robust Cox proportional hazards regression model. Results Of a total of 2 445 870 patients in the data set, 1592 patients (mean [SD] age, 77.5 [5.5] years; 1543 [96.9%] female) met the inclusion criteria and were included in the initial nonmatched analysis. Of these patients, 350 (22.0%) received chemotherapy and 1242 (78.0%) did not. Compared with patients who did not receive chemotherapy, patients who received chemotherapy were younger (mean age, 74 vs 78 years; P < .001), had larger primary tumors (pT3/T4 tumors: 72 [20.6%] vs 182 [14.7%]; P = .005), and had higher pathologic nodal burden (75 [21.4%] vs 81 [6.5%] with stage pN3 disease and 182 [52.0%] vs 936 [75.4%] with stage pN1 disease; P < .001). More patients who received chemotherapy also received other adjuvant treatments, including endocrine therapy (309 [88.3%] vs 1025 [82.5%]; P = .01) and radiation therapy (236 [67.4%] vs 540 [43.5%]; P < .001). In the matched cohort, with a median follow-up of 43.1 months (95% CI, 39.6-46.5 months), no statistically significant difference was found in median overall survival between the chemotherapy and no chemotherapy groups (78.9 months [95% CI, 78.9 months to not reached] vs 62.7 months [95% CI, 56.2 months to not reached]; P = .13). After adjustment for potential confounding factors, receipt of chemotherapy was associated with improved survival (hazard ratio, 0.67; 95% CI, 0.48-0.93; P = .02). Conclusions and Relevance This cohort study found that in node-positive, estrogen receptor-positive elderly patients with breast cancer and multiple comorbidities, receipt of chemotherapy was associated with improved overall survival. Despite attempts to adjust for selection bias, these findings suggest that physicians carefully selected patients likely to derive treatment benefit from adjuvant chemotherapy based on certain unmeasured variables. A standardized, multidisciplinary approach to care may be associated with long-term treatment outcomes in this subset of the population.
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Affiliation(s)
- Nina Tamirisa
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Heather Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Yu Shen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Simona F. Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Meghan Sri Karuturi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Sharon H. Giordano
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Gildy Babiera
- MD Anderson Physician Network, The University of Texas MD Anderson Cancer Center, Houston
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
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14
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DuMontier C, Loh KP, Bain PA, Silliman RA, Hshieh T, Abel GA, Djulbegovic B, Driver JA, Dale W. Defining Undertreatment and Overtreatment in Older Adults With Cancer: A Scoping Literature Review. J Clin Oncol 2020; 38:2558-2569. [PMID: 32250717 PMCID: PMC7392742 DOI: 10.1200/jco.19.02809] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The terms undertreatment and overtreatment are often used to describe inappropriate management of older adults with cancer. We conducted a comprehensive scoping review of the literature to clarify the meanings behind the use of the terms. METHODS We searched PubMed (National Center for Biotechnology Information), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms undertreatment or overtreatment with regard to older adults with cancer. We included all types of articles, cancer types, and treatments. Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived through qualitative analysis. Within a random subset of articles, C.D. and K.P.L. independently performed this analysis to determine final categories and then independently assigned these categories to assess inter-rater reliability. RESULTS Articles using the terms undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion in our review (n = 256). Only 14 articles (5.5%) explicitly provided formal definitions; for the remaining, we inferred the implicit definitions from the terms' surrounding context. There was substantial agreement (κ = 0.81) between C.D. and K.P.L. in independently assigning categories of definitions within a random subset of 50 articles. Undertreatment most commonly implied less than recommended therapy (148; 62.7%) or less than recommended therapy associated with worse outcomes (88; 37.3%). Overtreatment most commonly implied intensive treatment of an older adult in whom the harms of treatment outweigh the benefits (38; 53.5%) or intensive treatment of a cancer not expected to affect an older adult in his/her remaining lifetime (33; 46.5%). CONCLUSION Undertreatment and overtreatment of older adults with cancer are imprecisely defined concepts. We propose new, more rigorous definitions that account for both oncologic factors and geriatric domains.
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Affiliation(s)
- Clark DuMontier
- Brigham and Women’s Hospital, Boston, MA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Kah Poh Loh
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | | | | | - Tammy Hshieh
- Brigham and Women’s Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Jane A. Driver
- Brigham and Women’s Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Veterans Affairs Boston Healthcare System, New England Geriatric Research Education and Clinical Center, Boston, MA
| | - William Dale
- City of Hope Comprehensive Cancer Center, Duarte, CA
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15
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Angeli E, Chouahnia K, Canoui-Poitrine F, Duchemann B, Aparicio T, Paillaud E, Zelek L, Bousquet G, Pamoukdjian F. Development, validation and clinical impact of a prediction model for 6-month mortality in older cancer patients: the GRADE. Aging (Albany NY) 2020; 12:4230-4246. [PMID: 32156833 PMCID: PMC7093177 DOI: 10.18632/aging.102876] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 02/20/2020] [Indexed: 01/16/2023]
Abstract
Background: To develop, validate, and assess the clinical impact of a clinical score to predict a 6-month mortality risk among older cancer patients. Results: The mean age was 81.2 ± 6.1 years (women: 54%, various cancers, metastatic cancer: 45%). The score, namely the GRADE, included two geriatric variables (unintentional weight loss, impaired mobility), two oncological variables (cancer site, cancer extension), and exclusively supportive care. Up to a 14% risk of early death, the decision curves suggest that cancer treatment should be instated. Conclusion: We have developed and validated a simple score, easy to implement in daily oncological practice, to predict early death among older cancer patients which could guide oncologists in their treatment decisions. Methods: 603 outpatients prospectively included in the Physical Frailty in Elderly Cancer patients cohort study. We created a multivariate prediction model by evaluating the strength of the individual components of the Geriatric Assessment regarding risk of death at 6 months. Each component was evaluated by univariate analysis and the significant variables (P ≤ 0.20) were carried on as covariates in the multivariate cox proportion hazard analysis. The beta coefficients from the model were used to build a point-based scoring system. Clinical impact was assessed using decision curves.
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Affiliation(s)
- Eurydice Angeli
- APHP, Avicenne Hospital, Department of Medical Oncology, Bobigny F-93000, France.,INSERM, U942, Paris F-75010, France
| | - Kader Chouahnia
- APHP, Avicenne Hospital, Department of Medical Oncology, Bobigny F-93000, France
| | - Florence Canoui-Poitrine
- APHP, Henri-Mondor Hospital, Public Health Department, Créteil F-94000, France.,Université Paris-Est, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology And Ageing Unit), Créteil F-94000, France
| | - Boris Duchemann
- APHP, Avicenne Hospital, Department of Medical Oncology, Bobigny F-93000, France.,Université Paris 13, Sorbonne Paris Cite, Villetaneuse F-93000, France
| | - Thomas Aparicio
- APHP, Avicenne Hospital, Department of Gastroenterology, Bobigny F-93000, France
| | - Elena Paillaud
- Université Paris-Est, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology And Ageing Unit), Créteil F-94000, France.,APHP, Georges Pompidou European Hospital, Geriatric Department, Paris F-75015, France
| | - Laurent Zelek
- APHP, Avicenne Hospital, Department of Medical Oncology, Bobigny F-93000, France.,Université Paris 13, Sorbonne Paris Cite, Villetaneuse F-93000, France
| | - Guilhem Bousquet
- APHP, Avicenne Hospital, Department of Medical Oncology, Bobigny F-93000, France.,INSERM, U942, Paris F-75010, France.,Université Paris 13, Sorbonne Paris Cite, Villetaneuse F-93000, France
| | - Frédéric Pamoukdjian
- Université Paris-Est, UPEC, DHU A-TVB, IMRB- EA 7376 CEpiA (Clinical Epidemiology And Ageing Unit), Créteil F-94000, France.,Université Paris 13, Sorbonne Paris Cite, Villetaneuse F-93000, France.,APHP, Avicenne Hospital, Geriatric department, Coordination Unit in Geriatric Oncology, Bobigny F-93000, France
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16
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LeMasters T, Madhavan SS, Sambamoorthi U, Hazard-Jenkins HW, Kelly KM, Long D. Receipt of Guideline-Concordant Care Among Older Women With Stage I-III Breast Cancer: A Population-Based Study. J Natl Compr Canc Netw 2019; 16:703-710. [PMID: 29891521 DOI: 10.6004/jnccn.2018.7004] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 01/03/2018] [Indexed: 11/17/2022]
Abstract
Background: This study examined receipt of guideline-concordant care (GCC) according to evidence-based treatment guidelines and quality measures and specific types of treatment among older women with breast cancer. Patients and Methods: A total of 142,433 patients aged ≥66 years diagnosed with stage I-III breast cancer between 2007 and 2011 were identified in the SEER-Medicare linked database. Algorithms considering cancer characteristics and the appropriate course of care as per guidelines versus actual care received determined receipt of GCC. Multivariable logistic regression estimated the likelihood of GCC and specific types of treatment for women aged ≥75 versus 66 to 74 years. Results: Overall, 39.7% of patients received GCC. Patients diagnosed at stage II or III, with certain preexisting conditions, and of nonwhite race were less likely to receive GCC. Patients with hormone-negative tumors, higher grade tumors, and greater access to oncology care resources were more likely to receive GCC. Patients aged ≥75 years were approximately 40% less likely to receive GCC or adjuvant endocrine therapy, 78% less likely to have any surgery, 61% less likely to have chemotherapy, and about half as likely to have radiation therapy than those aged 66 to 74 years. Conclusions: Fewer than half of older women with breast cancer received GCC, with the lowest rates observed among the oldest age groups, racial/ethnic minorities, and women with later-stage cancers. However, patients with more aggressive tumor characteristics and greater access to oncology resources were more likely to receive GCC. Considering that older women have the highest incidence of breast cancer and that many are diagnosed at stages requiring more aggressive treatment, efforts to increase rates of earlier stage diagnosis and the development of less toxic treatments could help improve GCC and survival while preserving quality of life.
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17
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Dumontier C, Clough-Gorr KM, Silliman RA, Stuck AE, Moser A. Motivation and mortality in older women with early stage breast cancer: A longitudinal study with ten years of follow-up. J Geriatr Oncol 2017; 8:133-139. [PMID: 27986501 PMCID: PMC5373974 DOI: 10.1016/j.jgo.2016.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/11/2016] [Accepted: 12/01/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The Getting Out of Bed Scale (GOB) was validated as a health-related quality of life (HRQoL) variable in older women with early stage breast cancer, suggesting its potential as a concise yet powerful measure of motivation. The aim of our project was to assess the association between GOB and mortality over 10years of follow-up. MATERIALS AND METHODS We studied 660 women ≥65-years old diagnosed with stage I-IIIA primary breast cancer. Data were collected over 10years of follow-up from interviews, medical records, and death indexes. RESULTS Compared to women with lower GOB scores, women with higher GOB had an unadjusted hazard ratio (HR) of all-cause mortality of 0.78 at 5years, 95% confidence interval (CI) (0.52, 1.19) and 0.77 at 10years, 95%CI (0.59, 1.00). These associations diminished after adjusting for age and stage of breast cancer, and further after adjusting for other HRQoL variables including physical function, mental health, emotional health, psychosocial function, and social support. Unadjusted HRs of breast cancer-specific mortality were 0.92, 95%CI (0.49, 1.74), at 5years, and 0.82, 95%CI (0.52, 1.32), at 10years. These associations also decreased in adjusted models. CONCLUSION Women with higher GOB scores had a lower hazard of all-cause mortality in unadjusted analysis. This effect diminished after adjusting for confounding clinical and HRQoL variables. GOB is a measure of motivation that may not be independently associated with cancer mortality, but reflects other HRQoL variables making it a potential outcome to monitor in older patients with cancer.
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Affiliation(s)
- Clark Dumontier
- Internal Medicine Residency Program, Boston Medical Center, 72 East Concord Street, Evans 124, Boston, MA 02118, USA
| | - Kerri M Clough-Gorr
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, CH 3012 Bern, Switzerland
| | - Rebecca A Silliman
- Section of Geriatrics, Boston Medical Center/Boston University School of Medicine, 88 East Newton Street, Robinson Building, Boston, MA 02118, USA.
| | - Andreas E Stuck
- Department of Geriatrics, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - André Moser
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Finkenhubelweg 11, CH 3012 Bern, Switzerland; Department of Geriatrics, Inselspital, Bern University Hospital, and University of Bern, Switzerland
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18
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Vallet-Regí M, Manzano M, Rodriguez-Mañas L, Checa López M, Aapro M, Balducci L. Management of Cancer in the Older Age Person: An Approach to Complex Medical Decisions. Oncologist 2017; 22:335-342. [PMID: 28220025 DOI: 10.1634/theoncologist.2016-0276] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 11/12/2016] [Indexed: 01/21/2023] Open
Abstract
The management of cancer in older aged people is becoming a common problem due to the aging of the population. There are many variables determining the complex situation that are interconnected. Some of them can be assessed, such as risk of mortality and risk of treatment complications, but many others are still unknown, such as the course of disease, the host-related factors that influence cancer aggressiveness, and the phenotype heralding risk of permanent treatment-related damage.This article presents a dynamic and personalized approach to older people with cancer based on our experience on aging, cancer, and their biological interactions. Also, novel treatments and management approaches to older individuals, based on their functional age and their social and emotional needs, are thoughtfully explored here. The Oncologist 2017;22:335-342 IMPLICATIONS FOR PRACTICE: The goal of this article is to suggest a practical approach to complexity, a clinical situation becoming increasingly common with the aging of the population. Beginning with the analysis of two clinical cases, the authors offer an algorithm for approaching cancer in the older person that involves the assessment of life expectancy without cancer, the risk that cancer might compromise a patient's survival, function, or quality of life, and the potential benefits and risks of the treatments based on a clinical evaluation. The authors then review possible laboratory assessment of functional age and the importance of rapid-learning databases in the study of cancer and age.
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Affiliation(s)
- María Vallet-Regí
- Departamento de Química Inorgánica y Bioinorgánica, Facultad de Farmacia, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital, 12 de Octubre i+12, Madrid, Spain
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - Miguel Manzano
- Departamento de Química Inorgánica y Bioinorgánica, Facultad de Farmacia, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital, 12 de Octubre i+12, Madrid, Spain
- Networking Research Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | | | - Marta Checa López
- Fundación para la Investigación Biomédica, Hospital Universitario de Getafe, Madrid, Spain
| | - Matti Aapro
- Breast Center, IMO Clinique de Genolier, Genolier, Switzerland
| | - Lodovico Balducci
- University of South Florida, College of Medicine, H. Lee Moffitt Cancer Center & Research Institute, Senior Adult Oncology Program, Tampa, Florida, USA
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Screening-relevant age threshold of 70 years and older is a stronger determinant for the choice of adjuvant treatment in breast cancer patients than tumor biology. Breast Cancer Res Treat 2017; 163:119-130. [PMID: 28205042 PMCID: PMC5387012 DOI: 10.1007/s10549-017-4151-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/07/2017] [Indexed: 12/21/2022]
Abstract
Purpose The 70-year threshold determines whether patients are eligible or not for the breast cancer screening program in Germany. It is not known whether this age threshold also influences the choice of adjuvant treatment and ultimate outcome. Methods 3463 patients were analyzed from the clinical cancer registry Regensburg (Germany) with primary, non-metastatic invasive breast cancer diagnosed between 2000 and 2012. The distribution of tumor biological subtypes was evaluated in breast cancer patients both in those eligible for screening (ESG, 50–69 years) and those not eligible for screening (NESG, ≥70 years). Local and systemic therapies in different subtypes as well as overall survival (OS) were analyzed. Results 2171 patients (62.7%) pertained to the ESG and 1292 patients (37.3%) referred to the NESG. The distribution of the common subtypes Luminal A, Luminal B, HER2-like, and Basal-like was comparable in both groups. Treatment varied considerably with less systemic therapies in all subtypes in patients in the NESG. Regarding local therapies, patients in the NESG also received less surgery and less radiotherapy. As to Luminal A patients, best OS was seen in patients receiving endocrine therapy (ET) (7-year OS of 95.6%) and CHT plus ET (7-year OS of 93.1%) in the ESG. In the NESG, best OS was seen in patients receiving CHT plus ET (7-year OS of 95.2%), whereas patients receiving only ET had a 7-year OS of 73.9%. Conclusions Despite similar tumor biology, elderly patients are undertreated regarding both systemic and local therapies compared to younger patients, leading to reduced OS.
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