Breast cancer in elderly women and altered clinico-pathological characteristics: a systematic review

Modulation of tumor plasticity by senescent cells: Deciphering basic mechanisms and survival pathways to unravel therapeutic options

Senescence is a cellular state in which the cell loses its proliferative capacity, often irreversibly. Physiologically, it occurs due to a limited capacity of cell division associated with telomere shortening, the so-called replicative senescence. It can also be induced early due to DNA damage, oncogenic activation, oxidative stress, or damage to other cellular components (collectively named induced senescence). Tumor cells acquire the ability to bypass replicative senescence, thus ensuring the replicative immortality, a hallmark of cancer. Many anti-cancer therapies, however, can lead tumor cells to induced senescence. Initially, this response leads to a slowdown in tumor growth. However, the longstanding accumulation of senescent cells (SnCs) in tumors can promote neoplastic progression due to the enrichment of numerous molecules and extracellular vesicles that constitutes the senescence-associated secretory phenotype (SASP). Among other effects, SASP can potentiate or unlock the tumor plasticity and phenotypic transitions, another hallmark of cancer. This review discusses how SnCs can fuel mechanisms that underlie cancer plasticity, like cell differentiation, stemness, reprogramming, and epithelial-mesenchymal transition. We also discuss the main molecular mechanisms that make SnCs resistant to cell death, and potential strategies to target SnCs. At the end, we raise open questions and clinically relevant perspectives in the field.

Nomograms predict survival in elderly women with triple-negative breast cancer: A SEER population-based study

BACKGROUND

The effective treatment of breast cancer in elderly patients remains a major challenge.

OBJECTIVE

To construct a nomogram affecting the overall survival of triple-negative breast cancer (TNBC) and establish a survival risk prediction model.

METHODS

A total of 5317 TPBC patients with negative expression of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) who were diagnosed and received systematic treatment from 2010 to 2015 were collected from the American Cancer Surveillance, Epidemiology and End Results (SEER) database. They were randomly divided into training set (n= 3721) and validation set (n= 1596). Univariate and multivariate Cox regression analysis were used to identify prognostic features, and a nomogram was established to predict the probability of 1-year, 3-year and 5-year OS and BCSS. We used consistency index (C-index), calibration curve, area under the curve (AUC) and decision curve analysis (DCA) to evaluate the predictive performance and clinical utility of the nomogram.

RESULTS

The C-indices of the nomograms for OS and BCSS in the training cohort were 0.797 and 0.825, respectively, whereas those in the validation cohort were 0.795 and 0.818, respectively. The receiver operating characteristic (ROC) curves had higher sensitivity at all specificity values as compared with the Tumor Node Metastasis (TNM) system. The calibration plot revealed a satisfactory relationship between survival rates and predicted outcomes in both the training and validation cohorts. DCA demonstrated that the nomogram had clinical utility when compared with the TNM staging system.

CONCLUSION

This study provides information on population-based clinical characteristics and prognostic factors for patients with triple-negative breast cancer, and constructs a reliable and accurate prognostic nomogram.

Global Stage Distribution of Breast Cancer at Diagnosis: A Systematic Review and Meta-Analysis

Importance

Stage at diagnosis is a key prognostic factor for cancer survival.

Objective

To assess the global distribution of breast cancer stage by country, age group, calendar period, and socioeconomic status using population-based data.

Data Sources

A systematic search of MEDLINE and Web of Science databases and registry websites and gray literature was conducted for articles or reports published between January 1, 2000, and June 20, 2022.

Study Selection

Reports on stage at diagnosis for individuals with primary breast cancer (C50) from a population-based cancer registry were included.

Data Extraction and Synthesis

Study characteristics and results of eligible studies were independently extracted by 2 pairs of reviewers (J.D.B.F., A.D.A., A.M., R.S., and F.G.). Stage-specific proportions were extracted and cancer registry data quality and risk of bias were assessed. National pooled estimates were calculated for subnational or annual data sets using a hierarchical rule of the most relevant and high-quality data to avoid duplicates.

Main Outcomes and Measures

The proportion of women with breast cancer by (TNM Classification of Malignant Tumors or the Surveillance, Epidemiology, and End Results Program [SEER]) stage group.

Results

Data were available for 2.4 million women with breast cancer from 81 countries. Globally, the proportion of cases with distant metastatic breast cancer at diagnosis was high in sub-Saharan Africa, ranging from 5.6% to 30.6% and low in North America ranging from 0.0% to 6.0%. The proportion of patients diagnosed with distant metastatic disease decreased over the past 2 decades from around 3.8% to 35.8% (early 2000s) to 3.2% to 11.6% (2015 onwards), yet stabilization or slight increases were also observed. Older age and lower socioeconomic status had the largest proportion of cases diagnosed with distant metastatic stage ranging from 2.0% to 15.7% among the younger to 4.1% to 33.9% among the oldest age group, and from 1.7% to 8.3% in the least disadvantaged groups to 2.8% to 11.4% in the most disadvantaged groups.

Conclusions and Relevance

Effective policy and interventions have resulted in decreased proportions of women diagnosed with metastatic breast cancer at diagnosis in high-income countries, yet inequality persists, which needs to be addressed through increased awareness of breast cancer symptoms and early detection. Improving global coverage and quality of population-based cancer registries, including the collection of standardized stage data, is key to monitoring progress.

Triple-negative and Her2-positive breast cancer in women aged 70 and over: prognostic impact of age according to treatment

Background

Elderly breast cancer (BC) patients have been underrepresented in clinical trials whereas ~60% of deaths from BC occur in women aged 70 years and older. Only limited data are available on the prognostic impact of age according to treatment, especially in the triple-negative (TN) and Her2-positive because of the lower frequency of these subtypes in elderly patients. We report herein the results of a multicenter retrospective study analyzing the prognostic impact of age according to treatment delivered in TN and Her2-positive BC patients of 70 years or older, including comparison by age groups.

Methods

The medical records of 31,473 patients treated from January 1991 to December 2018 were retrieved from 13 French cancer centers for retrospective analysis. Our study population included all ≥70 patients with TN or Her2-positive BC treated by upfront surgery. Three age categories were determined: 70-74, 75-80, and > 80 years.

Results

Of 528 patients included, 243 patients were 70-74 years old (46%), 172 were 75-80 years (32.6%) and 113 were >80 years (21.4%). Half the population (51.9%, 274 patients) were TN, 30.1% (159) Her2-positive/hormone receptors (HR)-positive, and, 18% (95) Her2-positive/endocrine receptors (ER)-negative BC. Advanced tumor stage was associated with older age but no other prognostic factors (tumor subtype, tumor grade, LVI). Adjuvant chemotherapy delivery was inversely proportional to age. With 49 months median follow-up, all patient outcomes (overall survival (OS), disease-free survival (DFS), breast cancer-specific survival (BCSS), and recurrence-free survival (RFS)) significantly decreased as age increased. In multivariate analysis, age >80, pT2-3 sizes, axillary macrometastases, lymphovascular involvement, and HR-negativity tumor negatively affected DFS and OS. Comparison between age >80 and <=80 years old showed worse RFS in patients aged > 80 (HR=1.771, p=0.031).

Conclusion

TN and Her2-positive subtypes occur at similar frequency in elderly patients. Older age is associated with more advanced tumor stage presentation. Chemotherapy use decreases with older age without worse other pejorative prognostic factors. Age >80, but not ≤80, independently affected DFS and OS.

Survival Outcome and Predictors of Survival in Elderly Breast Cancer Patients following Curative Treatment

Anoop TMObjectives  The lack of data on management of elderly breast cancer patients' population makes most oncologists reluctant to treat them with the standard treatment protocols as advised for the younger patients. This study was done to identify the survival outcome and predictors of survival in elderly breast cancer patients treated with curative intent. Materials and Methods  Newly diagnosed patients with breast cancer aged more than 65 years who received treatment with curative intent were included. Disease-free survival (DFS) and overall survival were estimated using the Kaplan-Meier method. Survival curves were compared using log-rank test. Cox regression analysis was done to find out the predictors of DFS. Results  This study included 112 elderly breast cancer patients. In our patient population, 79 (70.5%) were less than or equal to 70 years of age and 33 (29.5%) were more than or equal to 70 years. Median age was 68 years. Charlson comorbidity index score was six and above in 31 (28.1) patients. Median DFS in our study was 46 months. Median DFS was not reached in patients less than or equal to 70 years of age, whereas it was 50 months (47-53) among patients more than or equal to 70 years of age, p -value-0.009. In univariate analysis, age more than or equal to 70 years and locally advanced breast cancer were the predictors of DFS with hazard ratio (HR) of 2.8 (1.2-6.69), p -value 0.013 and 2.9 (1.12-7.6), and 0.027, respectively. In multivariate analysis, age more than or equal to 70 years was the only significant predictors of DFS with HR of 2.8 (1.2-6.5) and p -value of 0.015. Conclusion  Standard curative intent treatment was well tolerable among elderly patents. Elderly age more than 70 years was a unique predictor of DFS. We need to incorporate tools to assess life expectancy and functional status that will help us predict toxicity of treatment and survival advantage more precisely.

Prognostic Tools for Older Women with Breast Cancer: A Systematic Review

Background: Breast cancer is the most common cancer in women, and older patients comprise an increasing proportion of patients with this disease. The older breast cancer population is heterogenous with unique factors affecting clinical decision making. While many models have been developed and tested for breast cancer patients of all ages, tools specifically developed for older patients with breast cancer have not been recently reviewed. We systematically reviewed prognostic models developed and/or validated for older patients with breast cancer. Methods: We conducted a systematic search in 3 electronic databases. We identified original studies that were published prior to 8 November 2022 and presented the development and/or validation of models based mainly on clinico-pathological factors to predict response to treatment, recurrence, and/or mortality in older patients with breast cancer. The PROBAST was used to assess the ROB and applicability of each included tool. Results: We screened titles and abstracts of 7316 records. This generated 126 studies for a full text review. We identified 17 eligible articles, all of which presented tool development. The models were developed between 1996 and 2022, mostly using national registry data. The prognostic models were mainly developed in the United States (n = 7; 41%). For the derivation cohorts, the median sample size was 213 (interquartile range, 81-845). For the 17 included modes, the median number of predictive factors was 7 (4.5-10). Conclusions: There have been several studies focused on developing prognostic tools specifically for older patients with breast cancer, and the predictions made by these tools vary widely to include response to treatment, recurrence, and mortality. While external validation was rare, we found that it was typically concordant with interval validation results. Studies that were not validated or only internally validated still require external validation. However, most of the models presented in this review represent promising tools for clinical application in the care of older patients with breast cancer.

Development and validation of competitive risk model for older women with metaplastic breast cancer

BACKGROUND

Metaplastic breast cancer (MpBC) is a rare histological subtype of breast cancer. This study aims to establish a competitive risk model for older women with MpBC to predict patients' survival accurately.

METHODS

Data on patients diagnosed with MpBC from 2010 to 2019 are from the Surveillance, Epidemiology and End Results (SEER) program in the United States. All patients were randomly assigned to the training set and validation set. The proportional sub-distribution risk model was used in the training set to analyze the risk factors affecting patient death. Based on the risk factors for cancer-specific mortality (CSM) in patients, we constructed a competitive risk model to predict patients' 1-, 3-, and 5-year cancer-specific survival. Then we used the concordance index (C-index), the calibration curve and the area under the receiver operating characteristic curve (AUC) to validate the discrimination and accuracy of the model.

RESULTS

One thousand, four hundred twelve older women with MpBC were included in this study. Age, T stage, N stage, M stage, tumor size, surgery and radiotherapy were risk factors for CSM. We established a competitive risk model to predict 1-, 3-, and 5-year cancer-specific survival in older women with MpBC. The C-index of the model was 0.792 in the training set and 0.744 in the validation set. The calibration curves in the training and validation sets showed that the model's predicted values were almost consistent with the actual observed values. The AUC results show that the prediction model has good accuracy.

CONCLUSION

We developed a competitive risk model based on these risk factors to predict cancer-specific survival in older women with MpBC. The validation results of the model show that it is a very effective and reliable prediction tool. This predictive tool allows doctors and patients to make individualized clinical decisions.

Breast cancer survival in Mexico between 2007 and 2016 in women without social security: a retrospective cohort study

Background

Essential indicators of health system performance for breast cancer are lacking in Mexico. We estimated survival and clinical stage distribution for women without social insurance who were treated under a health financing scheme that covered 60% of the Mexican population.

Methods

We conducted a retrospective cohort study cross-linking reimbursement claims for 56,847 women treated for breast cancer between 2007 and 2016 to a mortality registry. We estimated overall- and clinical stage-specific survival and breast cancer survival according to patient age, state of residence, marginalization, type of treatment facility, and patient volume of the treatment facility. We also explored the distribution of clinical stage according to age, year of treatment initiation, and state where the woman was treated. We used log-rank tests and estimated 95% CIs to compare differences between patient groups.

Findings

Median age was 52 years (interquartile range [IQR] 45, 61) (Sixty five percent patients (36,731/56,847) had advanced disease at treatment initiation. Five-year overall survival was 72.2% (95% CI 71.7, 72.6). For early disease (excluding stage 0), 5-year overall survival was 89.0% (95% CI 88.4, 89.5), for locally advanced disease 69.9% (95% CI 69.0, 70.2) and for metastatic 36.9% (95% CI 35.4, 38.4). Clinical stage at treatment initiation and breast cancer survival remained unchanged in the period analyzed. Clinical stage and survival differed across age groups, state of residence, and type of facility where women received treatment.

Interpretation

In the absence of population-based cancer registries, medical claims data may be efficiently leveraged to estimate essential cancer-related performance indicators.

Funding

The authors received no financial support for this research.

Changes in the mammary gland during aging and its links with breast diseases

The functional capacity of organisms declines in the process of aging. In the case of breast tissue, abnormal mammary gland development can lead to dysfunction in milk secretion, a primary function, as well as the onset of various diseases, such as breast cancer. In the process of aging, the terminal duct lobular units (TDLUs) within the breast undergo gradual degeneration, while the proportion of adipose tissue in the breast continues to increase and hormonal levels in the breast change accordingly. Here, we review changes in morphology, internal structure, and cellular composition that occur in the mammary gland during aging. We also explore the emerging mechanisms of breast aging and the relationship between changes during aging and breast-related diseases, as well as potential interventions for delaying mammary gland aging and preventing breast disease.

Long-term outcomes and prognostic factors in elderly patients with breast cancer: single-institutional experience

Introduction

Despite advances in treatment, there is rising mortality in elderly patients with breast cancer. We aimed to conduct an audit of non-metastatic elderly breast cancer patients to understand the predictors of outcome.

Methods

Data collection was done from electronic medical records. All time-to-event outcomes were analysed using Kaplan-Meier method and compared using log-rank test. Univariate and multi-variate analysis of known prognostic factors was also done. Any p-value ≤0.05 was considered statistically significant.

Results

A total of 385 elderly (>70 years) breast cancer patients (range 70-95 years) were treated at our hospital from January 2013 to December 2016. The hormone receptor was positive in 284 (73.8%) patients; 69 (17.9%) patients had over-expression of HER2-neu, while 70 (18.2%) patients had triple-negative breast cancer. A large majority of women (N = 328, 85.9%) underwent mastectomy while only 54 (14.1%) had breast conservation surgery. Out of 134 patients who received chemotherapy, 111 patients received adjuvant, while the remaining 23 patients received neoadjuvant chemotherapy. Only 15 (21.7%) patients of the 69 HER2-neu receptor-positive patients received adjuvant trastuzumab. Adjuvant radiation was given to 194 (50.3%) women based on the type of surgery and disease stage. Adjuvant hormone therapy was planned using letrozole in 158 (55.6%) patients, while tamoxifen was prescribed in 126 (44.4%). At the median follow up of 71.7 months, the 5-year overall survival, relapse-free survival, locoregional relapse-free survival, distant disease-free survival, breast cancer-specific survival were 75.3%, 74.2%, 84.8%, 76.1% and 84.5%. Age, tumour size, presence of lymphovascular invasion (LVSI) and molecular subtype emerged as independent predictors of survival on multi-variate analysis.

Conclusion

The audit highlights the underutilisation of breast-conserving therapy and systemic therapy in the elderly. Increasing age and tumour size, presence of LVSI and molecular subtype were found to be strong predictors of outcome. The findings from this study will help to improve the current gaps in the management of breast cancer among the elderly.

Evaluation of outcome of chemotherapy for breast cancer patients older than 70 years: A SEER-based study

Background

With the aging of the population, the number of elderly breast cancer cases has increased. However, there is a lack of effective randomized clinical trial data to support whether elderly patients should receive chemotherapy. Our goal was to observe the relationship between chemotherapy and breast cancer-specific survival (BCSS) in elderly breast cancer patients and to identify those who could benefit from chemotherapy.

Methods

We collected the data of patients who were diagnosed with invasive ductal carcinoma and older than 70 years in the SEER database from 1995 to 2016. The independent predictors of BCSS were identified by Cox regression analysis. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were performed to eliminate confounding factors.

Results

A total of 142,537 patients were collected, including 21,782 patients in the chemotherapy group and 120,755 patients in the non-chemotherapy group. We identified the same potential predictors of BCSS after PSM and IPTW, such as age, race, grade, stage, therapy, subtype. A nomogram for predicting 3-year, 5-year and 10-year BCSS was constructed. The 3-year, 5-year and 10-year AUCs of the nomogram were 0.842, 0.819, and 0.788. According to the risk stratification of model predictive scores, patients in the high-risk group achieved the greatest improvement in BCSS after receiving chemotherapy.

Conclusions

Our study suggests that women older than 70 years with larger tumors, higher grade, positive nodes, negative hormone receptor and inactive local therapy gain prognostic benefits from chemotherapy, but for those with low- and median-risk, conventional chemotherapy should be administered cautiously.

Quality Indicators Compliance and Survival Outcomes in Breast Cancer according to Age in a Certified Center

Age as a breast cancer (BC) prognostic factor remains debatable. Several studies have investigated clinicopathological features at different ages, but few make an age group direct comparison. The European Society of Breast Cancer Specialists quality indicators (EUSOMA-QIs) allow a standardized quality assurance of BC diagnosis, treatment, and follow-up. Our objective was to compare clinicopathological features, compliance to EUSOMA-QIs and BC outcomes in three age groups (≤45 years, 46-69 years, and ≥70 years). Data from 1580 patients with staged 0-IV BC from 2015 to 2019 were analyzed. The minimum standard and desirable target on 19 mandatory and 7 recommended QIs were studied. The 5-year relapse rate, overall survival (OS), and BC-specific survival (BCSS) were also evaluated. No meaningful differences in TNM staging and molecular subtyping classification between age groups were found. On the contrary, disparities in QIs compliance were observed: 73.1% in ≤45 years and 46-69 years women vs. 54% in older patients. No differences in loco-regional or distant progression were observed between age groups. Nevertheless, lower OS was found in older patients due to concurrent non-oncological causes. After survival curves adjustment, we underscored evidence of undertreatment impacting BCSS in ≥70 years women. Despite a unique exception-more invasive G3 tumors in younger patients-no age-specific differences in BC biology impacting outcome were found. Although increased noncompliance in older women, no outcome correlation was observed with QIs noncompliance in any age group. Clinicopathological features and differences in multimodal treatment (not the chronological age) are predictors of lower BCSS.

Impact of age on indication for chemotherapy in early breast cancer patients: results from 104 German institutions from 2008 to 2017

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.

Characteristics and chronologically changing patterns of late-onset breast cancer in Korean women of age ≥ 70 years: A hospital based-registry study

BACKGROUND

Women from Asian and western countries have vastly different ages of onset of breast cancer, with the disease tending to occur at an older age in the West. Through an investigation of the patterns of old-onset breast cancer (OBC) in Korean women, we aimed to identify the characteristics of Korean OBC and evaluate whether these patterns are changing in relation to increasing westernization.

METHODS

This study retrospectively evaluated 102,379 patients who underwent surgical treatment of primary breast cancer between January 1, 2000 and December 31, 2013 in Korea. We used hospital -based breast cancer registry and analyzed data from these patients using multiple linear regression analysis to compare the characteristics and chronologically changing patterns between OBC (70 years of age or older) and non-OBC (40-69 years of age) patients in Korea.

RESULTS

A total of 6% of the 102,379 patients had OBC. Overall, OBC had more favorable biological features, such as a higher incidence of luminal A subtype, than did non-OBC, except for a higher incidence rate of triple-negative breast cancer (TNBC). However, OBC also presented with a higher overall disease stage, including higher T and M stages. Although the incidence rates of both OBC and non-OBC have increased overtime, the relative proportion of OBC patients has slightly increased, whereas that of non-OBC has slightly decreased. The increase in the incidence of both OBC and non-OBC was primarily due to the luminal A subtype.

CONCLUSIONS

Based on a hospital-based registry, overall, Korean OBC had favorable biological features but showed a higher rate of TNBC and advanced cancer stages. The incidence trend of breast cancer in Korea is slowly shifting toward an older age at onset, largely due to the luminal A subtype. Our results may provide novel insights into OBC in Asia, and aid in the development of optimal management of the disease in Asia.

TRIAL REGISTRATION

Retrospectively registered.

[Epidemiology, diagnosis and extension]

Breast cancer is the most common cancer in women. The elderly, whose numbers have been increasing, constitute a population in their own right, because of the many co-morbidities they suffer from. The epidemiology of breast cancer, particularly in elderly women, is described here, as well as the diagnosis and the assessment of extension, which do not differ from the rest of the population.

Guideline-Consistent Treatment for Inflammatory Breast Cancer Provides Associated Survival Benefit Independent of Age

BACKGROUND

Guideline-consistent treatment (GCT) for inflammatory breast cancer (IBC) includes neoadjuvant chemotherapy (NAC), modified radical mastectomy (MRM), and radiation. We hypothesized that younger patients more frequently receive GCT, resulting in survival differences.

METHODS

Using the National Cancer Database (2004-2018), female patients with unilateral IBC (by histology code and clinical stage T4d) were stratified by age (< 50, 50-65, > 65 years). Factors associated with NAC, MRM, radiation, and "GCT" (defined as all three treatments) were identified using multivariable logistic regression. Multivariable Cox proportional hazards regression identified predictors of overall survival.

RESULTS

Of 3278 IBC patients, 30% were younger than 50 years, 44% were 50-65 years of age, and 26% were older than 65 years. The youngest group comprised the greatest proportion of non-White patients ([35%] vs. [29%] age 50-65 years and [23%] age > 65 years, p < 0.001) and was most often treated at academic facilities ([33%] vs. [28%] age 50-65 years; and [23%] age > 65, p < 0.001). Patients older than 65 years received NAC, MRM, and radiation less frequently, and only 35% underwent GCT (vs. [57%] age 50-65 years and [52%] age < 50 years; p < 0.001). On multivariable logistic regression, age older than 65 years independently predicted omission of NAC (odds ratio [OR], 0.36), MRM (OR, 0.56), and radiation (OR, 0.56) (all p < 0.001), and patients older than 65 years also were less likely to undergo GCT than patients 50-65 years of age (OR, 0.65; p = 0.001). GCT was associated with superior overall survival in all three age groups ([hazard ratio {HR}, 0.61] age < 50 years, [HR, 0.62] age 50-65 years, [HR, 0.53] age > 65 years; all p < 0.001).

CONCLUSION

Advanced age alone should not limit receipt of GCT for IBC. Multimodal care should be performed for IBC patients of all ages to improve oncologic outcomes for this aggressive breast cancer subtype.

Age disparities in triple-negative breast cancer treatment and outcomes: An NCDB analysis

BACKGROUND

Race, access to care, and molecular features result in outcome disparities in triple-negative breast cancer (TNBC). We sought to determine the role of age in TNBC disparity by hypothesizing that younger patients receive more comprehensive treatment, resulting in survival differences.

METHODS

The National Cancer Database was used to identify women with unilateral TNBC treated from 2005 through 2017. Patients were stratified by age (≤40, 41-70, >70); demographics, clinical characteristics, and treatment factors were compared. Logistic regression determined factors associated with treatment received. Survival outcomes were analyzed using a stratified log-rank test.

RESULTS

Of the 168,715 patients, 16,287 (9.6%) were ≤40 years. Patients ≤40 were significantly more likely to present at higher clinical stage (P < .001) and receive neoadjuvant chemotherapy (NAC, P < .001). Bilateral mastectomy was the most common surgery for patients ≤40 (37%), whereas partial mastectomy was most often used in patients 41 to 70 years old (48%) and those >70 (49%) (P < .001). Patients ≤40 years were significantly more likely to undergo both NAC and mastectomy than those >40 (odds ratio 1.5, both P < .05) despite a greater in-breast tumor response in the youngest patients. Patients treated with mastectomy and axillary lymph node dissection had inferior survival outcomes compared to those treated with partial mastectomy and sentinel lymph node biopsy across all 3 age groups (P < .001).

CONCLUSION

The clinical characteristics of TNBC differ significantly at the extremes of age, likely driving treatment decisions. Although patients ≤40 present with a more advanced disease and appropriately receive NAC, they also undergo more extensive surgery that does not yield a survival benefit. Further research is needed to determine if age disparity is due to oncologic factors or patient and provider preferences.

Cellular and molecular mechanisms of breast cancer susceptibility

There is a plethora of recognized risk factors for breast cancer (BC) with poorly understood or speculative biological mechanisms. The lack of prevention options highlights the importance of understanding the mechanistic basis of cancer susceptibility and finding new targets for breast cancer prevention. Until now, we have understood risk and cancer susceptibility primarily through the application of epidemiology and assessing outcomes in large human cohorts. Relative risks are assigned to various human behaviors and conditions, but in general the associations are weak and there is little understanding of mechanism. Aging is by far the greatest risk factor for BC, and there are specific forms of inherited genetic risk that are well-understood to cause BC. We propose that bringing focus to the biology underlying these forms of risk will illuminate biological mechanisms of BC susceptibility.

Clinicopathological characteristics in women with breast cancer in extreme ages in Greece: A single centre experience

Introduction

Breast cancer is the most common malignancy in Greek women. The highest incidence occurs in patients aged 40–70 years. However, the emergence of the disease in women under 40 and over 80 years old is a significant problem in everyday practice, because of the diagnostic and therapeutic challenges for these age groups. The objective of this study is to investigate clinicopathological characteristics of Greek women under 40 and over 80 diagnosed with breast cancer during 2019–2020 in a specialized Breast Cancer Surgical Centre, as well as the pathological characteristics of their disease and the therapeutic measures applied to these women.

Aim of the study

The aim of this study is to compare clinical and pathological characteristics of breast cancer in a group of Greek premenopausal women younger than 40 years of age with a group of elderly women older than 80 years old, who were treated in a surgical breast centre in Greece during the last two years.

Patients and Methods

During the last 2 years, 21 women under 40 and 22 women older than 80 were diagnosed with breast cancer in our Centre.

Results

Invasive ductal adenocarcinoma was the most frequent histological type for both Groups: Most younger women underwent surgery followed by chemotherapy, while the majority of older patients received hormonal therapy after surgery.

Conclusions

There were no statistically significant differences between women under 40 and women over 80 in the study sample regarding their clinicopathological characteristics. However, younger women underwent more therapeutic modalities (i.e.adjuvant treatments in addition to surgery) than older ones.

Low RUFY3 expression level is associated with lymph node metastasis in older women with invasive breast cancer

PURPOSE

Sentinel lymph node biopsy is omitted in older women (≥ 70 years old) with clinical lymph node (LN)-negative hormone receptor-positive breast cancer as it does not influence adjuvant treatment decision-making. However, older women are heterogeneous in frailty while the chance of recurrence increase with improving longevity. Therefore, a biomarker that identifies LN metastasis may facilitate treatment decision-making. RUFY3 is associated with cancer progression. We evaluated RUFY3 expression level as a biomarker for LN-positive breast cancer in older women.

METHODS

Clinical and transcriptomic data of breast cancer patients were obtained from the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC, n = 1903) and The Cancer Genome Atlas (TCGA, n = 1046) Pan-cancer study cohorts.

RESULTS

A total of 510 (METABRIC) and 211 (TCGA) older women were identified. LN-positive breast cancer, which represented 51.4% (METABRIC) and 48.4% (TCGA), demonstrated worse disease-free, disease-specific, and overall survival. RUFY3 levels were significantly lower in LN-positive tumors regardless of age. The area under the curve for the receiver operator characteristic (AUC-ROC) curves showed RUFY3-predicted LN metastasis. Low RUFY3 enriched oxidative phosphorylation, DNA repair, MYC targets, unfolded protein response, and mtorc1 signaling gene sets, was associated with T helper type 1 cell infiltration, and with intratumor heterogeneity and fraction altered. Low RUFY3 expression was associated with LN-positive breast cancer and with worse disease-specific survival among older women.

CONCLUSION

Older women with breast cancers who had low expression level of RUFY3 were more frequently diagnosed with LN-positive tumors, which translated into worse prognosis.

Invasive Breast Cancer Treatment Patterns in Women Age 80 and Over: A Report from the National Cancer Database

BACKGROUND

There are no established treatment guidelines for women with breast cancer aged ≥80 despite increasing representation in the US population. Here we identify national treatment patterns and survival outcomes in women with stage I-III invasive breast cancer.

PATIENTS AND METHODS

Women age ≥80 diagnosed with stage I-III invasive breast cancer (IBC) were identified from 2005-2014 in the National Cancer Database. χ², Fisher's exact test, and logistic regression models were used to identify factors influencing receipt of breast surgery, and Cox proportional hazard models were used to evaluate overall survival (OS).

RESULTS

A total of 62,575 women with IBC met inclusion criteria, of which the majority received surgery (94%). Receipt of surgery was associated with White race, age <90, lower stage, and fewer comorbidities. OS was higher for those who received surgery compared to those who did not (HR 3.3 [3.18-3.46] P < .001). Molecular subtype analysis demonstrated improved survival with receipt of surgery or radiation for all subtypes, as well as improved survival with chemotherapy for those with triple negative breast cancer.

CONCLUSION

The vast majority of breast cancer patients aged ≥80 in the National Cancer Database with IBC received primary surgical management, which was associated with a significant OS benefit. Due to this finding, surgical resection should be considered for all patients ≥80 who are suitable operative candidates.

Survival outcomes in elderly Taiwanese women according to breast cancer subtype and lymph node status: A single-center retrospective study

This study aimed to determine the rates of overall survival and recurrence-free survival among elderly Taiwanese women (>65 years old) according to breast cancer subtype and lymph node status. We identified 554 eligible patients who were >65 years old and had been treated based on international recommendations at our center between June 2005 and June 2015. Patients with the luminal A subtype had the highest rates of overall survival (90.6%) and recurrence-free survival (97.0%), while the lowest overall survival rate was observed in those with the triple-negative subtype (81.3%) and the lowest recurrence-free survival rate was observed in those with the luminal B subtype (84.0%). Multivariate Cox proportional hazard analysis, using the luminal A subtype as the reference, revealed significant differences in recurrence-free survival among luminal B patients according to lymph node status. Among elderly Taiwanese women with breast cancer, the breast cancer subtype might help predict survival outcomes. The luminal B subtype was associated with poor recurrence-free survival, and lymph node status was useful for predicting recurrence-free survival in this subset of patients.

Nomograms predict survival of patients with lymph node-positive, luminal a breast cancer

Background

To develop nomograms for the prediction of the 1-, 3-, and 5-year overall survival (OS) and breast cancer-specific survival (BCSS) for patients with lymph node positive, luminal A breast cancer.

Methods

Thirty-nine thousand fifty-one patients from The Surveillance, Epidemiology, and End Results (SEER) database were included in our study and were set into a training group (n = 19,526) and a validation group (n = 19,525). Univariate analysis and Cox proportional hazards analysis were used to select variables and set up nomogram models on the basis of the training group. Kaplan-Meier curves and the log-rank test were adopted in the survival analysis and curves plotting. C-index, calibration plots and ROC curves were used to performed internal and external validation on the training group and validation group.

Results

Following independent factors were included in our nomograms: Age, marital status, grade, ethnic group, T stage, positive lymph nodes numbers, Metastasis, surgery, radiotherapy, chemotherapy. In both the training group and testing group, the calibration plots show that the actual and nomogram-predicted survival probabilities are consistent greatly. The C-index values of the nomograms in the training and validation cohorts were 0.782 and 0.806 for OS and 0.783 and 0.804 for BCSS, respectively. The ROC curves show that our nomograms have good discrimination.

Conclusions

The nomograms may assist clinicians predict the 1-, 3-, and 5-year OS and BCSS of patients with lymph node positive, luminal A breast cancer.

Breast cancer in elderly Korean women: clinicopathological and biological features

BACKGROUND

With an aging society, Korean women ≥70 years of age are increasingly being diagnosed with breast cancer.

OBJECTIVE

To investigate the clinicopathological and biological characteristics of breast cancer in elderly Korean women and compare them with breast cancer in elderly (≥70 years) women globally and in Korean women of all ages.

METHODS

We retrospectively reviewed the clinicopathological and biological features of breast cancer in elderly Korean women (≥70 years; n = 87) who sought treatment during 2004-2014 from a single institution. These data were indirectly compared with data of Korean women of all ages (nationwide Korean Breast Cancer Registry) or elderly women globally (meta-analysis).

RESULTS

Compared to elderly women with breast cancer globally, Korean elderly women had a more symptomatic presentation, lower ER expression, and overexpression or amplification of human epidermal growth factor receptor 2. Compared to Korean women of all ages with breast cancer, elderly Korean women presented with advanced tumor stages, larger tumor size, more lymph node involvement, and more luminal B and basal-like subtypes.

CONCLUSIONS

Breast cancer had a more aggressive clinicopathological and biological characteristics in elderly Korean women than in Korean women of all ages or elderly women globally.

Breast cancer in women aged 75 years and older - tumour characteristics and treatment options

Introduction

An optimal approach to older women with breast cancer is still a major challenge. In this paper, we present a retrospective analysis of treatment in patients aged 75 years and older who were treated at the Holycross Cancer Centre in 2015–2019.

Material and methods

The analysed group consisted of 259 women. For estimation of the general status of patients, we used the Geriatric 8 questionnaire. For every patient, an individual treatment plan was established. Survival analysis was performed; disease-free survival (DFS), cancer-specific survival, and overall survival (OS) were calculated by the Kaplan-Meier method. For DFS and OS, the Cox proportional-hazard regression was applied.

Results

The mean age in the analysed group was 80 years. Stage I and II cancer accounted for over 80% of patients. Radical mastectomy was performed in 56% and breast-conserving surgery in over 34% of patients. Sentinel lymph node biopsy was used in 114 patients. Preoperative systemic treatment was applied in 34 and postoperative chemotherapy in 51 patients, respectively. Trastuzumab was used in 23 patients. Postoperative hormonal therapy was applied in 205 and radiotherapy in 178 patients. During the observation after the treatment 32 patients died, while 227 survived. In multivariate analysis for DFS hormonotherapy was statistically significant for OS clinical stage and hormonotherapy.

Conclusions

The treatment plan for older women consisted of surgery and radiation therapy, and systemic treatment should be always considered. The decision should be made by the breast cancer team.

Refining breast cancer prognosis by incorporating age at diagnosis into clinical prognostic staging: introduction of a novel online calculator

PURPOSE

American Joint Committee on Cancer (AJCC) clinical staging is used to estimate breast cancer prognosis, but individual patient survival within each stage varies considerably by age at diagnosis. We hypothesized that the addition of age at diagnosis to the staging schema will enable more refined risk stratification.

METHODS

We performed a retrospective population analysis of adult women diagnosed with invasive breast cancer between 2010 and 2015 registered in SEER. Multivariable Cox hazards models were used to evaluate the association of AJCC 8th edition clinical prognostic stage (CPS) and age with risk of overall mortality. Separate hierarchical models were fit to the data: Model 1: CPS alone; Model 2: CPS + age + age²; and Model 3: CPS + age + age² + CPS x age + CPS x age². Models were compared by the Akaike information criterion (AIC), the c-statistic for time-dependent receiver operator characteristic curves, and category-free net reclassification improvement (NRI). Internal validation was performed using bootstrapping samples.

RESULTS

Among 86,637 women, the median follow-up was 36 months and 3-year overall survival was 91.9% ± 0.1%. Age significantly modified the effect of CPS on survival (p < 0.0001). Model 3 was the most precise, with the lowest AIC (126,619.63), the highest c-statistic (0.8212, standard error 0.0187), and superior NRI indices.

CONCLUSION

Age at diagnosis is a highly prognostic variable that warrants consideration for inclusion in future editions of the AJCC Breast Cancer Staging Manual.

Real-world, single-centre prospective data of age at breast cancer onset: focus on survival and reproductive history

OBJECTIVES

Being either young or old at the time of breast cancer diagnosis has been suggested as an indicator of a poor prognosis. We studied the effect of age at breast cancer onset in relation to survival, focusing in particular on biological subtypes and reproductive anamnesis.

DESIGN, SETTING AND PARTICIPANTS

Patients with early breast cancer (n=594) treated in a Finnish University Hospital during 2003-2013 were prospectively collected and followed in median 102 months.

RESULTS

Patients with luminal A-like breast cancer were older than the patients with luminal B-like (HER2-positive) (p=0.045) or patients with the HER2-positive (non-luminal) subtype (p=0.029). Patients ≥70 years received substantially less adjuvant chemotherapy (p=1.5×10^-9) and radiotherapy (p=5.9×10^-7) than younger women. Nevertheless, the estimated 10-year breast cancer-specific rates of survival were 84.2%, 92.9% and 87.0% in age groups <41 years, 41-69 years and ≥70 years, respectively, with no statistical difference (p=0.115). Survival rates were also comparable between the three age groups when assessed separately in different biological subtypes, and for patients with metastatic breast cancer there was similarly no difference between the age groups. Later menarche (p=5.7×10^-8) and high parity (p=0.000078) correlated with increased age at breast cancer diagnosis, but, according to the patients' oestrogen receptor (ER) status, only among ER-positive patients.

CONCLUSIONS

Despite the suggested undertreatment of older patients, we report excellent long-term outcomes in all age groups in this prospective cohort. Later endogenous endocrine exposure may cause delay in breast cancer onset, but the exact biology behind this phenomenon is so far unclear.

A population-based study of treatment patterns, 10-year recurrence and breast cancer-specific mortality in a cohort of elderly patients with breast cancer

BACKGROUND

We compared disease characteristics, therapies offered and received, and outcomes between older (>75 years) and younger (60-75 years) women with breast cancer (BC) from a regional database in Ontario, Canada.

METHODS

BC surgical cases from 12 hospitals were included. Younger (60-75 years) and older (>75 years) groups were compared. Cox proportional hazards regression with competing risk analyses assessed the relationship between predictor variables, 10-year recurrence and BC-specific mortality.

RESULTS

Our sample comprised 774 women; 33.5% were older. Older women had larger tumours, were more likely to have positive nodes, had more comorbidities, were more likely to undergo mastectomy, had less nodal surgery, were less likely to receive adjuvant therapies, and experienced more recurrences and BC-specific deaths (p < 0.05). Significant predictors of recurrence were older age, higher grade and disease stage, and omission of nodal surgery. Older age, higher grade, and stage were predictors of BC-specific mortality.

CONCLUSION

Older BC patients (>75 years) received less treatment and experienced increased recurrence and BC-specific mortality.

Older women's experience with breast cancer treatment: A systematic review of qualitative literature

Background

The experience of older women during breast cancer treatment is insufficiently described by quantitative studies. This study aimed to systematically review qualitative data describing factors that influence older women’s (≥65 years old) experience with breast cancer treatment.

Methods

A systematic review was performed in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA) principles. MEDLINE, CINAHL, PsycINFO, and EMBASE were searched (inception – 2020). Quality assessment of essential item reporting was performed using the Standards for Reporting Qualitative Research (SRQR) criteria. Common ideas were coded, thematically organized, and synthesized within a theoretical framework.

Results

Of 7,773 studies identified, twelve were included. The median SRQR score was 13.4 (range 11.3–15.9) (maximum score: 21). Data synthesis revealed that older women experienced breast cancer as a journey with challenges during each phase. During diagnosis, they delayed seeking medical help despite symptoms. Age and experience gave them perspective on the impact of their diagnosis. During decision-making, preconceptions and personal values determined choices. In the treatment phase, women experienced medical and social barriers to care. During the post-treatment phase, many experienced treatment adverse effects, but could move on or compartmentalize as coping mechanisms.

Conclusion

Older women with breast cancer have unique challenges specific to each phase of their treatment journey. Older women may benefit from proactive treatment discussions with health care providers to address their specific needs, individualize care, and assist with cancer care navigation.

•

Older women have challenges specific to each phase of their treatment journey.

•

Older women experience barriers to care and depended on their social network.

•

Older women could conceptually move on or compartmentalize as coping mechanisms.

•

Physicians should be aware of the unique features of each treatment phase.

Exposure to radiofrequency radiation increases the risk of breast cancer: A systematic review and meta-analysis

The present systematic review and meta-analysis investigated the association between exposure to radiofrequency radiation and the risk of breast cancer. The published studies that were available in PubMed, Embase, Cochrane Library, Ovid MEDLINE, CINAHL Plus, Web of Science, Airiti Library, Networked Digital Library of Theses and Dissertations and ProQuest until May 2020 were investigated. A total of eight studies (four case-control and four cohort studies) were eligible for quantitative analysis. A significant association between radiofrequency radiation exposure and breast cancer risk was detected [pooled relative risk (RR)=1.189; 95% confidence interval (CI), 1.056-1.339]. Subgroup analyses indicated that radiofrequency radiation exposure significantly increased the risk of breast cancer susceptibility among subjects aged ≥50 years (RR=2.179; 95% CI, 1.260-3.770). Pooled estimates revealed that the use of electrical appliances, which emit radiofrequency radiation, such as mobile phones and computers, significantly increased breast cancer development (RR=2.057; 95% CI, 1.272-3.327), while occupational radiofrequency exposure and transmitters did not increase breast cancer development (RR=1.274; 95% CI, 0.956-1.697; RR=1.133; 95% CI, 0.987-1.300, respectively). It was concluded that radiofrequency radiation exposure significantly increased the risk of breast cancer, especially in women aged ≥50 years and in individuals who used electric appliances, such as mobile phones and computers. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis, an evaluation protocol was prepared and registered with the PROSPERO database (registration no. CRD42018087283).

The Association Between Smartphone Use and Breast Cancer Risk Among Taiwanese Women: A Case-Control Study

Introduction

Breast cancer is a common malignancy worldwide. Smartphones have gradually become indispensable to our modern lives and have already changed lifestyles of human beings. To our best knowledge, no study has investigated the relationship between smartphone use and breast cancer. This case-control study purposely investigated the relationship between smartphone use and breast cancer risk.

Materials and Methods

This was a case-control study comprising 894 healthy controls and 211 patients with breast cancer. All participants were asked to respond to standard questionnaires to collect information on sleep quality, smartphone addiction, and smartphone use.

Results

Participants with smartphone addiction had a significantly higher 1.43-fold risk of breast cancer. Individuals with the habitual behavior of smartphone use >4.5 minutes before bedtime had a significantly increased 5.27-fold risk of breast cancer compared to those who used a smartphone for ≤4.5 minutes before bedtime. Additionally, a closer distance between the smartphone and the breasts when using the smartphone exhibited a significantly increased 1.59-fold risk. Participants who carried their smartphone near their chest or waist-abdomen area had significantly increased 5.03-fold and 4.06-fold risks of breast cancer, respectively, compared to those who carried the smartphone below the waist. Moreover, there was a synergistic effect of smartphone addiction and smartphone use of >4.5 minutes before bedtime which increased the breast cancer risk.

Conclusion

Excessive smartphone use significantly increased the risk of breast cancer, particularly for participants with smartphone addiction, a close distance between the breasts and smartphone, and the habit of smartphone use before bedtime.

The 8-Year Management of an Older Breast Cancer Patient by Non-surgical Primary Therapies and Minimized Surgery: A Case Report

A 74-year-old woman presented with a palpable lesion in her right breast. At the time of her visit, she was taking medications for diabetes, hypertension, tremors, tinnitus, and lumbago. She was also caring for her husband, who had dementia. Imaging studies revealed another lesion in addition to the palpable mass. A core biopsy of the palpable mass confirmed invasive ductal carcinoma. Surgery was recommended to remove both masses. However, the patient refused the operation due to her comorbidities and her husband's nursing needs. A modified treatment process, including non-surgical primary therapies, minimized surgery, and close follow-up, for 8 years proved successful. This report focuses on the points to consider in the treatment and management of older patients with breast cancer.

The prevalence of luminal B subtype is higher in older postmenopausal women with ER+/HER2- breast cancer and is associated with inferior outcomes

OBJECTIVES

To establish whether clinicopathologic and genomic characteristics may explain the poor prognosis associated with advanced age in ER+/HER2- breast cancer.

MATERIALS AND METHODS

The cohort included 271 consecutive post-menopausal patients with ER+/HER2- invasive breast cancer ages 55 years and older. Patients were categorized as "younger" (ages 55- < 75) and "older" (ages ≥75). The Kaplan-Meier method was used to estimate locoregional recurrence (LRR), recurrence-free interval (RFi), and overall survival (OS). Gene expression of tumor samples was assessed with Affymetrix Rosetta/Merck Human RSTA microarray platform. Differential gene expression analysis of tumor samples was performed using R package Limma.

RESULTS

271 breast cancer patients were identified, including 186 younger and 85 older patients. Older patients had higher rates of Luminal B subtype (53% vs 34%) and lower rates of Luminal A subtype (42% vs 58%, p = 0.02). Older patients were less likely to receive chemotherapy (9% vs 40%, p < 0.001) and hormone therapy (71% vs 89%, p < 0.001). For cases of grade 1-2 disease, older patients had a higher proportion of the luminal B subtype (49% vs. 30%, p = 0.014). Age ≥ 75 predicted for inferior OS (HR = 3.06, p < 0.001). The luminal B subtype predicted for inferior OS (HR = 2.12, p = 0.014), RFi (HR 5.02, p < 0.001), and LRR (HR = 3.12, p = 0.045). There were no significant differences in individual gene expression between the two groups.

CONCLUSION

Women with ER+/HER2- breast cancer ≥75 years old had higher rates of the more aggressive luminal B subtype and inferior outcomes. Genomic testing of these patients should be strongly considered, and treatment should be intensified when appropriate.

Prognostic validation and treatment decision making of the 8th edition of the American Joint Committee on Cancer pathological staging system for elderly women with early-stage breast cancer

Purpose: To determine the prognostication and treatment decision making of the American Joint Committee on Cancer (AJCC) 8^th pathological staging system in elderly women (aged ≥65 years) with T1-2N0M0 breast cancer (BC).

Results: We included 67699 patients, and patients were restaged into stage IA (84.9%), IB (8.9%), and IIA (6.2%) using the 8^th AJCC edition criteria. Overall, 69.4% and 30.6% of them underwent breast-conservation surgery (BCS) and mastectomy (MAST), respectively. In patients who received BCS, 30.3% of them underwent postoperative radiotherapy (RT). Patients with a higher pathological stage were more likely to receive MAST. The 5-year breast cancer-specific mortality rate was 2.2%, 6.5% and 13.7% in stage IA, IB, and IIA, respectively. Patients treated with BCS and RT had significantly lower risk of breast cancer-specific mortality compared to those treated with MAST or with BCS alone regardless of the pathological prognostic stages (P<0.001).

Conclusions: The 8^th AJCC pathological prognostic staging system provides accurate risk stratification and impacts the treatment decision making for elderly women with early-stage BC.

Methods: We identified stage T1-2N0M0 BC patients using the Surveillance, Epidemiology, and End Results database. Statistical analyses were used binomial logistic regression, and multivariable competing risk models in the Cox model framework.

Independent risk factors for axillary lymph node metastasis in breast cancer patients with one or two positive sentinel lymph nodes

Background

The benefit of axillary lymph node dissection (ALND) in breast cancer patients with one or two positive sentinel lymph nodes (SLNs) remains inconclusive. The purpose of this study was to identify risk factors independently associated with axillary lymph node (ALN) metastasis.

Methods

We retrospectively analyzed data from 389 Chinese breast cancer patients with one or two positive SLNs who underwent ALND. Univariate and multivariate logistic regression analyses were performed to identify ALN metastasis-associated risk factors.

Results

Among the 389 patients, 174 (44.7%) had ALN metastasis, while 215 (55.3%) showed no evidence of ALN metastasis. Univariate analysis revealed significant differences in age (< 60 or ≥ 60 years), human epidermal growth factor receptor-2 (Her-2) status, and the ratio of positive to total SLNs between the ALN metastasis and non-metastasis groups (P < 0.05). The multivariate analysis indicated that age, the ratio of positive to total SLNs, and occupations were significantly different between the two groups. Lastly, younger age (< 60 years), a higher ratio of positive to total SLNs, and manual labor jobs were independently associated with ALN metastasis (P < 0.05).

Conclusions

The risk of ALN metastasis in breast cancer patients with one or two positive SLNs can be further increased by younger age, manual labor jobs, and a high ratio of positive to total SLNs. Our findings may also aid in identifying which patients with one or two positive SLNs may not require ALND.

What predicts better prognosis in elderly breast cancer patients?

Purpose

As we enter an aging society, the number of elderly patients with breast cancer is increasing. We assessed the prognostic factors for breast cancer recurrence or metastasis in patients over the age of 65 years by analyzing tumor characteristics and long-term clinical outcomes.

Methods

In this retrospective study, the data of 286 breast cancer patients aged 65 years and older, who underwent treatment at the Pusan National University Hospital and Pusan National University Yangsan Hospital from 2008 to 2014, were analyzed. The patients were divided into two groups: those with recurrence or metastasis and those without. Cox-regression model was used to analyze the risk factors for recurrence or metastasis. Kaplan-Meier method was used to analyze survival rates by the log-rank test.

Results

Among the 286 patients with invasive breast cancer, 43 patients (15.0%) had recurrence or distant metastasis during a median follow-up period of 61 months. Advanced stages of breast cancer and patients who are not adapted to endocrine therapy were associated with poor prognosis.

Conclusion

In this study, advanced stages of breast cancer and endocrine therapy were the prognostic factors for breast cancer recurrences or metastases. Early detection of elderly breast cancer generally increases the possibility of diagnosis at an earlier stage, which can lead to a better prognosis. Moreover, endocrine therapy should be administered to elderly patients who manifest favorable intrinsic subtypes of breast cancer.

Microbial Alterations and Risk Factors of Breast Cancer: Connections and Mechanistic Insights

Breast cancer-related mortality remains high worldwide, despite tremendous advances in diagnostics and therapeutics; hence, the quest for better strategies for disease management, as well as the identification of modifiable risk factors, continues. With recent leaps in genomic technologies, microbiota have emerged as major players in most cancers, including breast cancer. Interestingly, microbial alterations have been observed with some of the established risk factors of breast cancer, such as obesity, aging and periodontal disease. Higher levels of estrogen, a risk factor for breast cancer that cross-talks with other risk factors such as alcohol intake, obesity, parity, breastfeeding, early menarche and late menopause, are also modulated by microbial dysbiosis. In this review, we discuss the association between known breast cancer risk factors and altered microbiota. An important question related to microbial dysbiosis and cancer is the underlying mechanisms by which alterations in microbiota can support cancer progression. To this end, we review the involvement of microbial metabolites as effector molecules, the modulation of the metabolism of xenobiotics, the induction of systemic immune modulation, and altered responses to therapy owing to microbial dysbiosis. Given the association of breast cancer risk factors with microbial dysbiosis and the multitude of mechanisms altered by dysbiotic microbiota, an impaired microbiome is, in itself, an important risk factor.

Nomograms predicting survival for all four subtypes of breast cancer: a SEER-based population study

Background

The prognosis of female breast cancer (BC) patients is determined by many clinicopathological factors. In this study, we aimed to identify prognostic factors for BC and develop reliable nomograms to predict the 1-, 3-, and 5-year overall survival (OS) and breast cancer-specific survival (BCSS).

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was used to screen 227,989 eligible patients as the study cohort. The whole cohort was randomly divided into a training cohort (n=113,996) and a testing cohort (n=113,993). The log-rank test and Cox proportional hazards analysis were applied to select variables and build nomogram models based on the training cohort. Internal and external validation were performed to evaluate the performance of the models by calculating the C-index and generating calibration plots in the training cohort and testing cohort.

Results

The following factors were included in both the OS and BCSS nomograms: subtypes of BC, metastasis (bone, liver, lung, and brain), age at diagnosis, race, tumor size, grade, number of positive lymph nodes, and marital status. The calibration plots presented excellent consistency between the actual and nomogram-predicted survival probabilities in both the training cohort and testing cohort. The C-index values of the nomograms were 0.796 and 0.793 for OS and 0.856 and 0.853 for BCSS in the training and testing cohorts, respectively.

Conclusions

The established nomograms provide a visualization of the risk of each prognostic factor and can assist clinicians in predicting the 1-, 3-, and 5-year OS and BCSS for all 4 subtypes of BC.

The intra-tumoural stroma in patients with breast cancer increases with age

PURPOSE

The tumour microenvironment in older patients is subject to changes. The tumour-stroma ratio (TSR) was evaluated in order to estimate the amount of intra-tumoural stroma and to evaluate the prognostic value of the TSR in older patients with breast cancer (≥ 70 years).

METHODS

Two retrospective cohorts, the FOCUS study (N = 619) and the Nottingham Breast Cancer series (N = 1793), were used for assessment of the TSR on haematoxylin and eosin stained tissue slides.

RESULTS

The intra-tumoural stroma increases with age in the FOCUS study and the Nottingham Breast Cancer series (B 0.031, 95% CI 0.006-0.057, p = 0.016 and B 0.034, 95% CI 0.015-0.054, p < 0.001, respectively). Fifty-one per cent of the patients from the Nottingham Breast Cancer series < 40 years had a stroma-high tumour compared to 73% of the patients of ≥ 90 years from the FOCUS study. The TSR did not validate as an independent prognostic parameter in patients ≥ 70 years.

CONCLUSIONS

The intra-tumoural stroma increases with age. This might be the result of an activated tumour microenvironment. The TSR did not validate as an independent prognostic parameter in patients ≥ 70 years in contrast to young women with breast cancer as published previously.

The Influence of Age on the Histopathology and Prognosis of Atypical Breast Lesions

BACKGROUND

Although several prognostic variables and risk factors for breast cancer are age-related, the association between age and risk of cancer with breast atypia is controversial. This study aimed to compare the type of breast atypia and risk of underlying or subsequent breast cancer by age.

METHODS

Adult women with breast atypia (atypical ductal hyperplasia, atypical lobular hyperplasia, and lobular carcinoma in situ) at a single institution from 2008 to 2017 were stratified by age at initial diagnosis: <50 y, 50-70 y, and >70 y. Regression modeling was used to estimate the association of age with risk of underlying carcinoma or subsequent cancer diagnosis.

RESULTS

A total of 530 patients with atypia were identified: 31.1% < 50 y (n = 165), 58.1% 50-70 y (n = 308), and 10.8% > 70 y (n = 57). The proportion of women with atypical ductal hyperplasia steadily increased with age, compared with atypical lobular proliferations (P = 0.04). Of those with atypia on needle biopsy, the overall rate of underlying carcinoma was 17.5%. After adjustment, older age was associated with a greater risk of underlying carcinoma (odds ratio: 1.028, 95% confidence interval: 1.003-1.053; P = 0.03). Of those confirmed to have atypia on surgical excision, the overall rate of a subsequent cancer diagnosis was 15.7%. Age was not associated with a long-term risk for breast cancer (P = 0.48) or the time to a subsequent diagnosis of carcinoma (log-rank P = 0.41).

CONCLUSIONS

Although atypia diagnosed on needle biopsy may be sufficient to warrant surgical excision, older women may be at a greater risk for an underlying carcinoma, albeit the long-term risk for malignancy associated with atypia does not appear to be affected by age.

Lumpectomy Plus Hormone or Radiation Therapy Alone for Women Aged 70 Years or Older With Hormone Receptor-Positive Early Stage Breast Cancer in the Modern Era: An Analysis of the National Cancer Database

PURPOSE

Deintensification of adjuvant therapy is being considered for older women with early-stage, biologically favorable breast cancer. Although radiation therapy (RT) can be omitted in some cases, toxicity from hormone therapy (HT) is not trivial, and adherence rates vary. We hypothesized that adjuvant RT alone would produce survival outcomes comparable to those with adjuvant HT alone among elderly patients treated with lumpectomy.

METHODS AND MATERIALS

We searched the National Cancer Database (2010-2014) for healthy women (aged ≥70 years, Charlson/Deyo [CD] score 0-1) with T1N0 hormone-receptor-positive, HER-2-negative breast cancer treated with lumpectomy and adjuvant HT or RT. Propensity scores were used to match patients for analysis.

RESULTS

We identified 2995 patients (median age, 78 years), most (81%) with a CD score of 0, clinical stage IA (77%), of whom 65% received HT alone and 35% received RT only after lumpectomy. On multivariate analysis of the matched cohort, older age (hazard ratio [HR] 1.10; 95% confidence interval [CI] 1.07-1.13; P < .001), CD score 1 (HR 1.92; 95% CI 1.37-2.70; P = .0002), and living in a metropolitan (vs urban) area (HR 3.09; 95% CI 1.43-6.67; P = .004) were associated with inferior overall survival (OS), whereas treatment with HT (vs RT) was not (HR 1.13; 95% CI 0.85-1.49; P = .406). At a median follow-up of 45 months, no difference was found in OS between HT versus RT cohorts (85% and 86%, respectively; P = .44).

CONCLUSIONS

For healthy, older women with biologically favorable breast cancer treated with lumpectomy, adjuvant RT or HT is associated with equivalent 5-year OS rates. A randomized controlled trial is warranted to explore these adjuvant monotherapy options in elderly patients with hormone receptor-positive breast cancer.

Surgery in the Older Patient with Breast Cancer

PURPOSE OF REVIEW

Breast cancer incidence and mortality increase with age. Older patients (≥ 70) are often excluded from studies. Due to multiple factors, it is unclear whether this population is best-treated using standard guidelines. Here, we review surgical management in older women with breast cancer.

RECENT FINDINGS

Geriatric assessments can guide treatment recommendations and aid in predicting survival and quality of life. Surgery remains a principal component of breast cancer treatment in older patients, though differences exist compared with younger women, including higher mastectomy rates and evidence-based support of omission of post-lumpectomy radiation or axillary dissection in subsets of patients. In those forgoing surgical management, there is increased use of endocrine therapy. Hospice is also a valuable element of end-of-life care. Physicians should utilize geriatric assessment to make treatment recommendations for older breast cancer patients, including omission of radiation therapy, alterations to standard surgeries, or enrollment in hospice care.

Artificial neural network models to predict nodal status in clinically node-negative breast cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) is standard staging procedure for nodal status in breast cancer, but lacks therapeutic benefit for patients with benign sentinel nodes. For patients with positive sentinel nodes, individualized surgical strategies are applied depending on the extent of nodal involvement. Preoperative prediction of nodal status is thus important for individualizing axillary surgery avoiding unnecessary surgery. We aimed to predict nodal status in clinically node-negative breast cancer and identify candidates for SLNB omission by including patient-related and pathological characteristics into artificial neural network (ANN) models.

METHODS

Patients with primary breast cancer were consecutively included between January 1, 2009 and December 31, 2012 in a prospectively maintained pathology database. Clinical- and radiological data were extracted from patient's files and only clinically node-negative patients constituted the final study cohort. ANN-based models for nodal prediction were constructed including 15 risk variables for nodal status. Area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow goodness-of-fit test (HL) were used to assess performance and calibration of three predictive ANN-based models for no lymph node metastasis (N0), metastases in 1-3 lymph nodes (N1) and metastases in ≥ 4 lymph nodes (N2). Linear regression models for nodal prediction were calculated for comparison.

RESULTS

Eight hundred patients (N0, n = 514; N1, n = 232; N2, n = 54) were included. Internally validated AUCs for N0 versus N+ was 0.740 (95% CI = 0.723-0.758); median HL was 9.869 (P = 0.274), for N1 versus N0, 0.705 (95% CI = 0.686-0.724; median HL: 7.421; P = 0.492) and for N2 versus N0 and N1, 0.747 (95% CI = 0.728-0.765; median HL: 9.220; P = 0.324). Tumor size and vascular invasion were top-ranked predictors of all three end-points, followed by estrogen receptor status and lobular cancer for prediction of N2. For each end-point, ANN models showed better discriminatory performance than multivariable logistic regression models. Accepting a false negative rate (FNR) of 10% for predicting N0 by the ANN model, SLNB could have been abstained in 27.25% of patients with clinically node-negative axilla.

CONCLUSIONS

In this retrospective study, ANN showed promising result as decision-supporting tools for estimating nodal disease. If prospectively validated, patients least likely to have nodal metastasis could be spared SLNB using predictive models.

TRIAL REGISTRATION

Registered in the ISRCTN registry with study ID ISRCTN14341750 . Date of registration 23/11/2018. Retrospectively registered.

SIRT1: a potential tumour biomarker and therapeutic target

SIRT1, which is highly homologous to yeast silent information regulator 2, has recently garnered tremendous attention because of its various regulatory effects in several pathological conditions. Numerous studies have found that SIRT1 is highly expressed in a broad range of tumours compared with the paracancerous tissue. However, the role of SIRT1 in malignancies has yet to be systematically elucidated, and its use as a promising biomarker or therapeutic target for tumours has not been well-reported. Herein, we focus on the roles of SIRT1 in cancers and summarise the potential use of SIRT1 as a promising tumour biomarker or therapeutic target.

Patient-reported factors influencing the treatment decision-making process of older women with non-metastatic breast cancer: a systematic review of qualitative evidence

PURPOSE

Older women (≥ 70 years old) with breast cancer undergo different treatments than young women. Studies have examined factors that influence this disparity, but synthesized patient-reported data are lacking in the literature. This study aims to identify, appraise, and synthesize the existing qualitative evidence on patient-reported factors influencing older women's decision to accept or decline breast cancer treatment.

METHODS

A systematic review was performed in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA) principles. Medline, Embase, CINAHL, and PsycINFO were searched for qualitative studies describing patient-reported factors influencing the decision-making process of older women (≥ 70 years old) with non-metastatic invasive breast cancer. Quality was assessed using the Standards for Reporting Qualitative Research (SRQR) criteria. Common ideas were coded, thematically organized, and synthesized within a theoretical framework.

RESULTS

Of 5998 studies identified, 10 met eligibility criteria. The median SRQR total score was 13.04 (IQR 12.84-13.81). The studies represented a range of cancer treatments; most of the studies focused on surgery and primary endocrine therapy. Our data show that the most common patient-reported factors in the decision-making process included treatment characteristics, personal goals/beliefs, patient characteristics, physician's recommendation, and personal/family experience. These factors led the patient to either accept or decline treatment, and were not consistent across all studies included. Studies used different interview guides, which may have affected these results.

CONCLUSIONS

This systematic review highlights the complexity of factors that influence an older woman's treatment decision-making process. Acknowledging and addressing these factors may improve discussions about treatment choices between older women and their health care providers, and encourage maximization of a patient-centered approach.