Change of paradigm in treating elderly with breast cancer: are we undertreating elderly patients?

The Use of Cyclin-Dependent Kinase 4/6 Inhibitors in Elderly Breast Cancer Patients: What Do We Know?

BACKGROUND

Breast cancer (BC) incidence increases with age, particularly in HR-positive/HER2-negative subtypes. Cyclin-dependent kinase 4 and 6 inhibitors (CDK 4/6is) alongside endocrine therapy (ET) have emerged as promising treatments for HR-positive/HER2-negative advanced and early BC. However, their efficacy, safety, and impact on quality of life (QoL) in older and frail patients remain underexplored.

METHODS

This position paper assesses the existing literature from 2015 to 2024, focusing on CDK4/6is use in patients aged 65 years and older with HR-positive/HER2-negative BC.

RESULTS

Our analysis methodically addresses critical questions regarding the utilization of CDK4/6is in the elderly BC patient population, organizing findings from the metastatic and adjuvant settings. In the metastatic setting, CDK4/6is significantly improve progression-free survival (PFS), paralleling benefits observed in younger patients, and suggest potential overall survival (OS) benefits, warranting further investigation. Despite an increased incidence of grade ≥ 3 adverse events (AEs), such as neutropenia and asthenia, CDK4/6is present a markedly lower toxicity profile compared to traditional chemotherapy, with manageable side effects. QoL analysis indicates that integrating CDK4/6is into treatment regimens does not significantly impact elderly BC patients' daily life and symptom management. Special attention is given to frail subgroups, and personalized approaches are recommended to balance efficacy and adverse effects, such as starting with ET alone and introducing CDK4/6is upon progression in patients with a low disease burden. Transitioning to the adjuvant setting, early results, particularly with abemaciclib, indicate positive effects on disease-free survival (DFS), emphasizing the need for continued analysis to validate these findings and assess long-term implications. However, data on older patients are insufficient to conclude whether they truly benefit from this treatment.

CONCLUSION

Overall, CDK4/6is present a favorable benefit-risk profile in older BC patients, at least in advanced BC; however, further research is warranted to optimize treatment strategies and improve outcomes in this population.

Have the recent advancements in cancer therapy and survival benefitted patients of all age groups across the Nordic countries? NORDCAN survival analyses 2002-2021

BACKGROUND

Since the early 2000s, overall and site-specific cancer survival have improved substantially in the Nordic countries. We evaluated whether the improvements have been similar across countries, major cancer types, and age groups.

MATERIAL AND METHODS

Using population-based data from the five Nordic cancer registries recorded in the NORDCAN database, we included a cohort of 1,525,854 men and 1,378,470 women diagnosed with cancer (except non-melanoma skin cancer) during 2002-2021, and followed for death until 2021. We estimated 5-year relative survival (RS) in 5-year calendar periods, and percentage points (pp) differences in 5-year RS from 2002-2006 until 2017-2021. Separate analyses were performed for eight cancer sites (i.e. colorectum, pancreas, lung, breast, cervix uteri, kidney, prostate, and melanoma of skin).

RESULTS

Five-year RS improved across nearly all cancer sites in all countries (except Iceland), with absolute differences across age groups ranging from 1 to 21 pp (all cancer sites), 2 to 20 pp (colorectum), -1 to 36 pp (pancreas), 2 to 28 pp (lung), 0 to 9 pp (breast), -11 to 26 pp (cervix uteri), 2 to 44 pp (kidney), -2 to 23 pp (prostate) and -3 to 30 pp (skin melanoma). The oldest patients (80-89 years) exhibited lower survival across all countries and sites, although with varying improvements over time.

INTERPRETATION

Nordic cancer patients have generally experienced substantial improvements in cancer survival during the last two decades, including major cancer sites and age groups. Although survival has improved over time, older patients remain at a lower cancer survival compared to younger patients.

Access to cancer clinical trials for racialised older adults: an equity-focused rapid scoping review protocol

BACKGROUND

The intersection of race and older age compounds existing health disparities experienced by historically marginalised communities. Therefore, racialised older adults with cancer are more disadvantaged in their access to cancer clinical trials compared with age-matched counterparts. To determine what has already been published in this area, the rapid scoping review question are: what are the barriers, facilitators and potential solutions for enhancing access to cancer clinical trials among racialised older adults?

METHODS

We will use a rapid scoping review methodology in which we follow the six-step framework of Arksey and O'Malley, including a systematic search of the literature with abstract and full-text screening to be conducted by two independent reviewers, data abstraction by one reviewer and verification by a second reviewer using an Excel data abstraction sheet. Articles focusing on persons aged 18 and over who identify as a racialised person with cancer, that describe therapies/therapeutic interventions/prevention/outcomes related to barriers, facilitators and solutions to enhancing access to and equity in cancer clinical trials will be eligible for inclusion in this rapid scoping review.

ETHICS AND DISSEMINATION

All data will be extracted from published literature. Hence, ethical approval and patient informed consent are not required. The findings of the scoping review will be submitted for publication in a peer-reviewed journal and presentation at international conferences.

Predictive value for axillary lymph node metastases in early breast cancer: Based on contrast-enhanced ultrasound characteristics of the primary lesion and sentinel lymph node

OBJECTIVE

To evaluate the value of contrast-enhanced ultrasound (CEUS) characteristics based on primary lesion combined with lymphatic contrast-enhanced ultrasound (LCEUS) patterns of SLN in predicting axillary lymph node metastasis (ALNM) with T1-2N0 breast cancer.

METHODS

A retrospective study was conducted in 118 patients with clinically confirmed T1-2N0 breast cancer. Conventional ultrasound (CUS) and CEUS characteristics of the primary lesion and enhancement patterns of SLN were recorded. The risk factors associated with ALNM were selected by univariate and binary logistic regression analysis, and the receiver operating characteristic (ROC) curve was drawn for the evaluation of predictive ALNM metastasis performance.

RESULTS

Univariate analysis showed that age, HER-2 status, tumor size, nutrient vessels, extended range of enhancement lesion, and the enhancement patterns of SLN were significant predictive features of ALNM. Further binary logistic regression analysis indicated that the extended range of enhancement lesion (p <  0.001) and the enhancement patterns of SLN (p <  0.001) were independent risk factors for ALNM. ROC analysis showed that the AUC of the combination of these two indicators for predicting ALNM was 0.931 (95% CI: 0.887-0.976, sensitivity: 75.0%, specificity: 99.8%).

CONCLUSION

The CEUS characteristics of primary lesion combined with enhancement patterns of SLN are highly valuable in predicting ALNM and can guide clinical axillary surgery decision-making in early breast cancer.

Healthcare delivery to elderly and unfit patients with breast disease and comorbidities under an outpatient regime: A report of a personal surgical technique named "Cut&Sew"

Introduction

A growing need for proper geriatric assessment and short-stay surgical programs supported by the availability of less invasive approaches, even in ambulatory settings, is being recognized as a feasible option for breast cancer patients with comorbidities who are usually distressed after standard surgery with ordinary hospitalization. Few studies have been conducted in Italian breast centers with dedicated techniques and approach for frail patients with breast diseases due to a jeopardized approach to ambulatory surgery among institutions.

Methods

This study included 58 women diagnosed with breast disease and comorbidities between March 2019 and December 2022 at the Ambulatory of Senology of San Giacomo Hospital in Novi Ligure (AL, Italy) and Civil Hospital in Ovada (AL, Italy). The patients were evaluated by a multidisciplinary consensus according to the guidelines provided to limit sentinel lymph node biopsy (SLNB) in older women. This kind of ambulatory surgery technique has been designed for i) patients with advanced age and/or comorbidities, ii) frail patients who psychologically do not accept other kinds of surgery, iii) patients who do not require SLNB, and iv) patients who need a surgical biopsy for lesions classified as B3 or small lesions with dubious radiological imaging. With this technique, the quadrant and whole breast may be removed in an outpatient setting with local anesthesia to limit blood loss by immediately cutting and suturing small portions of the gland. Local anesthetic infiltration is sequential and occurs stepwise before providing short passages of approximately 2 cm during resection and immediately suturing the surgical wound. This overclock technique, named "Cut&Sew," requires no more than 20-25 min and allows for a 1-2 h patient discharge with no drainage. The follow-up period was set at 60 months during routine yearly visits.

Results

The patients were older or super-older with most primary pT1/pT2 tumors and ductal type cancers, which were distributed in molecular subtypes Luminal A (37.1 %) and Luminal B (41.5 % Luminal B, with 11.2 % being HER2 positive). The tumour grade was mostly G2-G3. Mastectomy was performed in 10 patients, whereas quadrantectomy was performed in 48 patients, with the majority of tumors localized in Q1.While accompanied by a relative or a caregiver, all 58 patients acceded the "Cut&Sew" surgical technique in an ambulatory setting reporting negligible pain during the surgery and no pain within 10 days post-surgery. No post-operative complications or readmissions were recorded, and no discomfort or recurrence was detected during scheduled visits. Finally, the extent of satisfaction with the overall surgery was recorded immediately and corroborated by most patients during the follow-up period.

Conclusions

Although the small volume of cases collected does not allow for a controlled study necessary to evaluate the safety and efficacy of this technique for approaching frail and older women with comorbidities, through the "Cut&Sew" surgical technique, frail, older, and super older patients may benefit from a minimal psychological impact of surgery, while improving the patients' disease-free life so to corroborate the advised surgical de-escalation but avoiding undertreatment for this kind of patient category. Moreover, a stricter assessment of patient pain and overall satisfaction with the collection of a larger amount of reliable data could allow this technique to be extended to frail and/or older patients as a valuable and safe alternative to the more common hospitalization with general anesthesia. Other advantages include reduced hospitalization costs for sanitary structures.

A nomogram for predicting breast cancer specific survival in elderly patients with breast cancer: a SEER population-based analysis

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.

Impact of Medical Specialties on Diagnostic and Therapeutic Management of Elderly Cancer Patients

The management (diagnostic and therapeutic) of cancer in the geriatric population involves a number of complex difficulties. The aim of this study was to assess the impact of a medical specialty on the diagnostic and therapeutic management of elderly cancer patients. Four clinical scenarios of cancer in the geriatric population, with a dedicated survey to gather information regarding each clinical case's diagnostic and therapeutic approaches, as well as the different criteria influencing physicians' therapeutic decisions, were exposed to geriatricians, oncologists, and radiotherapists in Saint-Etienne. The surveys were filled out by 13 geriatricians, 11 oncologists, and 7 radiotherapists. There was a homogeneity of responses regarding the confirmation of cancer diagnostics in the elderly. There were strong disparities (inter- and intra-specialties) for several clinical situations regarding the therapeutic management of cancer. There were significant disparities in terms of surgical management, the implementation of a chemotherapy protocol, and the adaptation of the chemotherapy dosage. Contrary to oncologists, who primarily consider the G8 and the Karnofsky score, geriatric autonomy scores and frailty with cognitive assessment were the key factors determining diagnostic/therapeutic therapy for geriatricians. These results raise important ethical questions, requiring specific studies in geriatric populations to provide the homogenous management of elderly patients with cancer.

Age-specific survival trends and life-years lost in women with breast cancer 1990-2016: the NORDCAN survival studies

BACKGROUND

A recent overview of cancer survival trends 1990-2016 in the Nordic countries reported continued improvements in age-standardized breast cancer survival among women. The aim was to estimate age-specific survival trends over calendar time, including life-years lost, to evaluate if improvements have benefited patients across all ages in the Nordic countries.

METHODS

Data on breast cancers diagnosed 1990-2016 in Denmark, Finland, Iceland, Norway, and Sweden were obtained from the NORDCAN database. Age-standardized and age-specific relative survival (RS) was estimated using flexible parametric models, as was reference-adjusted crude probabilities of death and life-years lost.

RESULTS

Age-standardized period estimates of 5-year RS in women diagnosed with breast cancer ranged from 87% to 90% and 10-year RS from 74% to 85%. Ten-year RS increased with 15-18 percentage points from 1990 to 2016, except in Sweden (+9 percentage points) which had the highest survival in 1990. The largest improvements were observed in Denmark, where a previous survival disadvantage diminished. Most recent 5-year crude probabilities of cancer death ranged from 9% (Finland, Sweden) to 12% (Denmark, Iceland), and life-years lost from 3.3 years (Finland) to 4.6 years (Denmark). Although survival improvements were consistent across different ages, women aged ≥70 years had the lowest RS in all countries. Period estimates of 5-year RS were 94-95% in age 55 years and 84-89% in age 75 years, while 10-year RS were 88-91% in age 55 years and 69-84% in age 75 years. Women aged 40 years lost on average 11.0-13.8 years, while women lost 3.8-6.0 years if aged 55 and 1.9-3.5 years if aged 75 years.

CONCLUSIONS

Survival for Nordic women with breast cancer improved from 1990 to 2016 in all age groups, albeit with larger country variation among older women where survival was also lower. Women over 70 years of age have not had the same survival improvement as women of younger age.

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.

Breast surgical oncology in elderly and unfit patients: a systematic review

INTRODUCTION

Breast cancer treatment in elderly women remains a complex issue due to pre-existing comorbidities, therapy-related toxicities, and the lack of evidence-based data in this population, leading to both overtreatment and undertreatment.

EVIDENCE ACQUISITION

The aim was to investigate the literature on breast surgical oncology in the older woman as a major therapeutic challenge: the 86 more consistent articles amongst 1440 potential citations according to PRISMA guidelines were retained.

EVIDENCE SYNTHESIS

Studies demonstrated that despite low-grade tumor types, lower incidence of axillary lymph node involvement, ER+ disease, and less aggressive tumor biology, elderly breast cancer patients often receive less than the standard-of-care when compared to their younger counterparts. The surgery omission in elderlies and the preference for the primary endocrine treatment is associated with worse survival, especially in patients aged 80 years or over - a cohort with no specific recommendations concerning breast and axillary surgical procedures. On the other hand, a higher mastectomy rate is still considered the standard treatment in older women with higher T2:T1 tumor ratio and greater difficulties to attend radiotherapy due to severe comorbidities. Surgical de-escalation procedures even in an-ambulatory setting are recognized as a feasible option in these patients to prevent or palliate breast or chest wall symptoms.

CONCLUSIONS

Benefits and disadvantages from surgery only or coupled with adjuvant therapies for elderly women were analyzed in literature, outlining a growing need for a proper geriatric assessment and short-stay surgical programs which are feasible today owing to the availability of less invasive approaches.

Modified Frailty Index (mFI) predicts 30-day complications after microsurgical breast reconstruction

Frailty lacks a universal definition. The modified Frailty Index (mFI) using patient comorbidities can be used to measure frailty. We hypothesized that mFI predicts 30-day complications after microsurgical breast reconstruction. American College of Surgeons' (ACS) National Surgical Quality Improvement Project (NSQIP) was investigated to identify patients undergoing microsurgical breast reconstruction between 2005-2014 using Current Procedure Terminology (CPT) code, 19364. We used mFI as a measure of frailty. The patients were assigned a frailty score based on the number of preoperative comorbid conditions as defined by the mFI. Other risk indices used include age, BMI, wound class, ASA class. Stratification was performed in ascending order for each. The outcome measure was aggregate 30-day complications. Regression analysis was performed followed by Receptor Operating Characteristic (ROC) curve to determine the accuracy of each risk index in predicting 30-day complications. Of the 3237 patients 24% experienced complications. Univariate logistic regression analysis found odds ratio of complications for frailty score 1 = 22.1 (CI = 17.9-27.3, p < 0.01), and 2 = 28 (CI = 18.3-43, p < 0.01) compared to frailty score = 0. ROC curve demonstrated mFI with the highest concordance score (c-score = 0.816). Multivariable logistic regression found frailty as the strongest independent predictor of 30-day aggregate complications adjusted OR = 22.24, CI = 17.77-27.82, p < 0.01 when compared to other risk indices. The modified Frailty Index is a simple, reliable, and objective tool that can be used to predict postoperative complications after microsurgical breast reconstruction. The application of this tool can help microsurgeons preoperatively identify patients who are at high risk.Abbreviations: ACS: American College of Surgeons; ASA: American Society of Anesthesiologists; BMI: body mass index; CHF: congestive heart failure; CPT: current procedural terminology; COPD: chronic obstructive pulmonary disease; CVA: cerebrovascular accident; DM: diabetes mellitus; IRB: institutional review board; mfi: modified frailty index; MI: myocardial infarction; NSQIP: national surgical quality improvement program; PVD: peripheral vascular disease; ROC: receptor operating characteristic; TIA: transient ischemic attach.

The role of family confidants and caregivers in the care of older cancer patients: Extending the concept of "shared decision-making"

BACKGROUND AND AIMS

Family caregivers play an important role in assisting their family members with cancer, but their influence on the treatment decision-making process has not yet been adequately investigated. This exploratory study approached this topic via reconstructive methodology, focusing on assessing patient-caregiver relationships.

METHODS

We conducted semi-structured interviews with 37 mostly elderly cancer patients (median age: 74 years) about the context of their diagnosis, treatment decision, and family support. Additionally, we interviewed 34 caregivers of cancer patients. Of these, 25 were related to patients interviewed. We analyzed the interviews via a multi-step coding method informed by Grounded Theory methodology toward characterizing patient-caregiver relationships, the treatment decision-making process, and the caregivers' role therein.

RESULTS

In the majority of cases (86%), patients were being supported by caregivers. We categorized patient-caregiver relationships in regards to the caregivers' involvement in the therapy decision-making process. We found patient-caregiver interaction patterns that indicate the potential of caregivers to decidedly influence the therapy decision-making process. Yet, only in 38% of cases, a caregiver attended relevant patient-physician-consultations.

CONCLUSION

Depending on the nature of the patient-caregiver relationship, the traditional concept of shared decision-making, which assumes a dyadic relationship, needs to be extended toward a more dynamic concept in which caregivers should be involved more frequently. This could enable physicians to better understand a patient's reasons for or against a therapy proposal and ensure that the patient's wishes are communicated and considered. On the other hand, strong caregiver-involvement bears risks of over-stepping elderly patients' wishes, thus violating patient autonomy.

Prevelance of upper extremity lymphedema and risk factors in patients with mastectomy: Single-center, observational, cross-sectional study

Objective:

Upper extremity complaints are frequently encountered in breast cancer. It was aimed to investigate the pain, extremity pain, and limitation of motion, lymphedema prevalence, severity, risk factors and quality of life in patients with breast cancer followed by mastectomy in our center.

Materials and Methods:

The study included 67 patients with mastectomy. The presence of lymphedema, lymphedema duration, and grade of lymphedema were recorded. Grip strength was measured on both hands using a dynamometer; arm, shoulder and hand problems were evaluated using the disabilities of the arm, shoulder, and hand. Quality of life was assessed using the World Health Organization Quality of Life scale-short form.

Results:

The presence of lymphedema was 23.9%; the most common was international society of lymphology grade 1 (76.1%); the median lymphedema duration was 12 (range, 3-72) months. Radical/modified radical mastectomy (58.2%) was the most common type of surgery. Median pain score in the affected extremity according to the visual analogue scale was 2 (minimum: 0/maximum: 7); the presence of shoulder pain was 40.3%; shoulder movement limitation was 7.5%.

Conclusion:

It was found that lymphedema had a negative effect on quality of life by affecting shoulder, arm, and hand functions even in the early stages. The recognition of risk factors and signs of upper extremity complications in breast cancer survivors will contribute to rehabilitation success.

Outcomes of primary endocrine therapy in elderly women with stage I-III breast cancer: a SEER database analysis

BACKGROUND

Frail elderly women with nonmetastatic hormone receptor-positive breast cancer often receive primary endocrine therapy. Limited data are available on the outcomes associated with this population and treatment approach.

METHODS

We selected patients with an initial primary diagnosis of stage I-III ER-positive breast cancer from 2001 to 2015 in Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Patients were excluded if they received surgery, radiation, chemotherapy, or other targeted drug treatment including anti-HER2 agents. Two Cox proportional-hazards models were constructed to determine the predictors of breast cancer-specific survival and overall survival after a cancer diagnosis.

RESULTS

A total of 552 patients were identified, with 82.1% of the patients being 80 years or older and 81.7% of patients being non-Hispanic White. PR positive (OR 1.77; 95% CI 1.09-2.85; p = 0.025) and tumor size larger than 50 mm (OR 1.99; 95% CI 1.05-3.75; p = 0.035) were associated with higher adherence to endocrine therapy. In the multivariable Cox analyses, patients who were adherent of endocrine therapy had significantly worse survival (HR 1.40; 95% CI 1.17-1.69; p < 0.001). The other two factors associated with worse survival were larger tumor size and more comorbidities. The competing risk model demonstrated no statistically significant difference between patients who were adherent to endocrine therapy and those who were not in terms of risk of dying from breast cancer.

CONCLUSION

In elderly women with localized ER-positive breast cancer, there were no statistically significant differences in breast cancer-specific or overall mortality between those who were adherent to endocrine therapy and those who were not.