Breast cancer in elderly women: a retrospective analysis of combined treatment with tamoxifen and once-weekly irradiation

Locoregional Ablative Radiation Therapy for Patients With Breast Cancer Unsuitable for Surgical Resection

PURPOSE

Patients with breast cancer who are unsuitable for surgical resection are typically managed with palliative systemic therapy alone. We report outcomes of 5-fraction ablative radiation therapy for nonresected breast cancers.

METHODS AND MATERIALS

This is a retrospective analysis of an institutional registry of patients with breast cancer who were unsuitable for resection and underwent 35 to 40 Gy/5 fractions to the primary breast tumor or regional lymph nodes from 2014 to 2021. Primary outcomes were cumulative incidence of local failure and grade ≥3 toxicity (Common Terminology Criteria for Adverse Events, version 5.0).

RESULTS

We reviewed 57 patients who received 61 treatment courses (median age of 81 years; range, 38-99). Unresectable tumor (10%), patient refusal (18%), medical inoperability (35%), and metastatic disease (37%) were the causes of not having surgery. Five patients (8%) had previously undergone adjuvant locoregional radiation therapy. Fifty-four percent (n = 33/61) of treatment courses targeted the breast only, 31% (n = 19/61) both the breast and lymph nodes, and 15% (n = 9/61) the lymph nodes only. Sixty-seven percent (n = 35/52) of the courses that targeted the breast were delivered with partial breast irradiation and 33% (n = 17/52) with whole breast radiation therapy (median dose of 25 Gy in 5 fractions) ± simultaneous integrated boost to the primary tumor. Most primary tumors (65%, n = 34/52) and target lymph nodes (61%, n = 17/28) were treated with a dose of 35 Gy in 5 fractions. Most treatments (52%) were delivered with intensity modulated radiation therapy (IMRT). Radiation therapy was delivered daily (20%), every other day (18%), twice weekly (36%), or weekly (26%). The 2-year cumulative incidence of local failure was 11.4% and grade≥3 toxicity was 15.1%. The grade ≥3 toxicity was 6.5% for IMRT treatments, versus 7.7% for non-IMRT treatments targeting partial breast or lymph nodes (hazard ratio, 1.13, P = .92), versus 38.9% for non-IMRT treatments targeting the entire breast (hazard ratio, 6.91, P = .023). All grade ≥3 toxicity cases were radiation dermatitis. No cases of brachial plexopathy were observed.

CONCLUSIONS

Thirty-five to 40 Gy in 5 fractions is a safe and effective breast stereotactic body radiation therapy (SBRT) regimen and may be an attractive option for patients who are not surgical candidates. Highly conformal techniques (ie, IMRT or partial breast irradiation) were associated with a reduced risk of toxicity and should be the preferred treatment approaches.

Locoregional control and toxicity following high-dose hypofractionated and accelerated palliative radiotherapy regimens in breast cancer

AIMS

For patients with locally advanced primary/recurrent breast cancer, radiotherapy is an effective treatment for locoregional control. 36 Gy in 6 Gy once-weekly fractions is a commonly used schedule, but there are no data comparing local control and toxicity between 36 Gy delivered once-weekly versus accelerated schedules of multiple 6 Gy fractions per week. This retrospective study compared local control rates and acute and late toxicity in patients undergoing 30-36 Gy in 6 Gy fractions over 6 weeks versus more accelerated schedules over 2-3 weeks for an unresected breast cancer.

MATERIALS AND METHODS

Patients who received 30-36 Gy in 6 Gy fractions to an unresected breast cancer ± involved lymph nodes between December 2011 and August 2020 were identified. Patients were grouped into once-weekly versus accelerated fractionation schedules. Response rates, local control and toxicity data were analysed.

RESULTS

In total, 109 patients were identified. The median follow-up duration was 46 months. Forty-seven patients (43%) received once-weekly fractions and 62 patients (57%) received accelerated fractionation schedules. There were no significant differences in baseline tumour characteristics between the groups. Eighty-seven per cent of patients had an objective (complete or partial) response (81% in the once-weekly group; 91% in the accelerated group). The median time to local progression was 23.5 months overall (95% confidence interval 17.8-29.2); 23.5 months (95% confidence interval 18.8-28.1) in the once-weekly group and 19.0 months (95% confidence interval 7.0-31.1) in the accelerated group (P = 0.99). Acute toxicity of any grade occurred in 75% of patients (76% in the once-weekly group; 74% in the accelerated group) and grade 3 toxicity occurred in 7% of patients (7% in the once-weekly group; 8% in the accelerated group). There were no associations between the groups and acute or late toxicity grade (P = 0.78 and P = 0.26, respectively), although one grade 4 late toxicity (skin radionecrosis) occurred in a patient who received five fractions a week and therefore this regimen is not recommended. Study limitations included a lack of statistical power analysis, the necessary grouping of all accelerated patients for analysis and a high rate of censored data.

CONCLUSION

There were no apparent differences in response rate, time to local progression or toxicity between patients who received 30-36 Gy in 6 Gy fractions once-weekly compared with twice-weekly as palliative treatment for locally advanced breast cancer. This regimen appears to be a safe alternative and may be preferred by patients.

Ultra-hypofractionated whole breast adjuvant radiotherapy in the real-world setting: single experience with 271 elderly/frail patients treated with 3D and IMRT technique

PURPOSE

The purpose of the study was to evaluate the toxicity, local control, overall and disease-free survival of elderly breast cancer (BC) patients treated with adjuvant once-weekly ultra-hypofractionated radiotherapy (RT) either with intensity-modulated RT (IMRT) or 3D conformal RT (3DCRT).

METHODS

From July 2011 to July 2018, BC patients receiving 5.7 Gy once a week for 5 weeks to the whole breast after breast-conserving surgery were considered for the study. Inclusion criteria were: T1-T3 invasive BC, no or limited axillary involvement, age ≥ 65 years or women with commuting difficulties or disabling diseases.

RESULTS

A total of 271 patients were included in the study. Median age was 76 (46-86) years. Most of BC were T1 (77%), while the remaining were T2 (22.2%) and T3 (0.4%). Axillary status was negative in 68.3% of the patients. The only severe acute toxicity (G3) at the end of RT was erythema (0.4%), registered in the 3DCRT group; no G3 edema or epitheliolysis was recorded. With 18 months of median follow-up, severe early-late toxicity (G3) was reported in terms of fibrosis and breast retraction, both with an incidence of 1.4%, mostly in the 3DCRT group. Oncological outcomes at a median follow-up of 2.9 years reported 249/271 (91.9%) patients alive and free from any event and 5 (1.8%) isolated locoregional recurrences. At 3 years, disease-free survival and overall survival were 94.9% and 97.8%, respectively. Breast volume > 500 cm³ was reported as predictive for moderate-severe (≥ G2) acute toxicity.

CONCLUSIONS

Weekly ultra-hypofractionated whole breast RT seems feasible and effective. Toxicity was mild, local control was acceptable, and overall survival was 97.8% at 3 years. Rates of severe toxicity were reduced with the IMRT technique.

Evaluation of overall survival and barriers to surgery for patients with breast cancer treated without surgery: a National Cancer Database analysis

Surgery remains the foundation of curative therapy for non-metastatic breast cancer, but many patients do not undergo surgery. Evidence is limited regarding this population. We sought to assess factors associated with lack of surgery and overall survival (OS) in patients not receiving breast cancer surgery. Retrospective cohort study of patients in the US National Cancer Database treated in 2004-2016. The dataset comprised 2,696,734 patients; excluding patients with unknown surgical status or stage IV, cT0, cTx, or pIS, metastatic or recurrent disease resulted in 1,192,294 patients for analysis. Chi-square and Wilcoxon rank-sum tests were used to assess differences between groups. OS was analyzed using the Kaplan-Meier method with a Cox proportional hazards model performed to assess associated factors. In total 50,626 (4.3%) did not undergo surgery. Black race, age >50 years, lower income, uninsured or public insurance, and lower education were more prevalent in the non-surgical cohort; this group was also more likely to have more comorbidities, higher disease stage, and more aggressive disease biology. Only 3,689 non-surgical patients (7.3%) received radiation therapy (RT). Median OS time for the non-surgical patients was 58 months (3-year and 5-year OS rates 63% and 49%). Median OS times were longer for patients who received chemotherapy (80 vs 50 (no-chemo) months) and RT (85 vs 56 (no-RT) months). On multivariate analysis, age, race, income, insurance status, comorbidity score, disease stage, tumor subtype, treatment facility type and location, and receipt of RT were associated with OS. On subgroup analysis, receipt of chemotherapy improved OS for patients with triple negative (HR 0.66, 95% CI 0.59-0.75, P < 0.001) and HER2+ (HR 0.74, 95% CI 0.65-0.84, P < 0.001) subgroups while RT improved OS for ER+ (HR 0.72, 95% CI 0.64-0.82, P < 0.001) and favorable-disease (ER+, early-stage, age >60) (HR 0.61, 95% CI 0.45-0.83, P = 0.002) subgroups. Approximately 4% of women with breast cancer do not undergo surgery, particularly those with more aggressive disease and lower socioeconomic status. Despite its benefits, RT was underutilized. This study provides a benchmark of survival outcomes for patients who do not undergo surgery and highlights a potential role for use of RT.

Dosimetric comparison between three- and four-dimensional computerised tomography radiotherapy for breast cancer

At present, methods of radiotherapy simulation for breast cancer based on four-dimensional computerised tomography (4D-CT) or three-dimensional CT (3D-CT) simulation remain controversial. In the present study, 7 patients with residual breast tissue received whole breast radiotherapy based on 3D-CT and 4D-CT simulation. For the 4D-CT plan, four types of CT images were produced, including images of the end of inspiration and the end of expiration, and images acquired by the maximal intensity projection (MIP) and average intensity projection (AIP). In the 3D-CT plan, the clinical target volume (CTV) and plan target volume (PTV) were marginally higher compared with the 4D-CT plan. In addition, the minimum point dose of the target volume (D_min), the maximum point dose of the target volume (D_max) and the mean point dose of the target volume (D_mean) of the CTV and PTV in the MIP and AIP plans were marginally higher compared with the 3D-CT plan. For the contralateral breast (C-B), volumes of the 4D-CT plan were markedly lower compared with the 3D-CT plan. Furthermore, D_min, D_max and D_mean of the 3D-CT plan were higher compared with the AIP and MIP plans. For the ipsilateral lungs (I-L), volumes of the 3D-CT and AIP plans were higher compared with the MIP plan. Furthermore, when breast lesions were on the left side, for the heart, the volume receiving no less than 40% of the prescription dose (V₄₀) and the volume receiving no less than 30% of the prescription dose (V₃₀) of the MIP and AIP plans were slightly lower compared with those of the 3D plan. In conclusion, 4D-CT radiotherapy based on the MIP and AIP plans provides a slightly smaller radiation area and slightly higher radiotherapy dosage of the CTV and PTV compared with 3D-CT radiotherapy for breast radiotherapy. Therefore, the MIP and AIP plans prevent C-B radiation exposure and improve sparing of the heart and I-L.

Once-Weekly Hypofractionated Radiotherapy for Breast Cancer in Elderly Patients: Efficacy and Tolerance in 486 Patients

Purpose

Radiation therapy is a key treatment of breast cancer. Elderly patients with associated diseases that modify their performance status do not tolerate long periods of daily irradiation. The objective of this study is to analyze the results of weekly hypofractionated treatment in these patients.

Material and Methods

Between 1992 and 2016, we included 486 elderly patients presenting concomitant pathology or sociofamilial problems in which it was not feasible to propose conventional treatment. They were treated with conservative surgery or mastectomy and then adjuvant hypofractionated irradiation, administering 5 Gy or 6.25 Gy in 6 fractions, once a week (total dose 30–37.5 Gy) over 6 weeks.

Results

Breast cancer overall survival according to the Kaplan-Meier method at 5 years was 74.2% ± 2.3%; breast cancer disease-free survival was 90% ± 1.6%; local relapse-free survival was 96.5% ± 1% showing that patients die more from other causes and not from their neoplasia. Acute dermatitis was mild (75.6% of the patients grades I–III) and 30.6% had moderate chronic fibrosis.

Conclusions

The once-weekly hypofractionated radiotherapy is a feasible and convenient option for elderly patients with breast cancer. It is a safe treatment modality with similar survival and local control results compared to standard fractionation, while the side effects are acceptable.

[Hypofractionated whole breast irradiation (WBRT): Results and indications]

Breast irradiation after breast-conserving surgery is essential for maximizing local control and overall survival. The increase of breast cancer (BC) incidence, constraints of classical five weeks (w) radiation regimens and scarcity of radiotherapy units have led to test short hypofractionated WBRT schemes. One pilot study and three prospective randomized trials have tested various hypofractionated regimens of WBRT. About 7000 patients were included and follow-up ranged from 5 to 12 years. The conclusion of these trials is similar, showing local control and toxicity equivalent to these of the standard regimens. Three schemes are now clearly validated: 42.5Gy/16fr/3w, 40Gy/15fr/3w, or 42Gy/13fr/5w. However, the majority of included patients had favorable prognostic factors, were treated to the breast only and the boost dose, when indicated, was delivered with a standard fractionation. Therefore, we recommend the regimens preferentially in patients treated to the breast only, and without nodal involvement. These studies did not evaluate the addition of a boost dose with a hypofractionated scheme. If a boost is to be given, a standard fractionation should be used. Particular care should be taken to avoid heterogeneities leading to high fraction doses to organs at risk (lung and heart).

Management of operable primary breast cancer in older women

A considerable number of breast cancer diagnoses are made in older women. Differing physiological needs of older patients and biology of tumors compared with younger patients may alter treatment options between surgery and nonsurgical primary approaches. Adjuvant therapies may benefit these patients; however, concerns about toxicity and physical demands of treatment may affect patient choice regarding treatment. Furthermore, quality of life may be more important to the older individual than curative treatment alone. Growing evidence is emerging for employing Comprehensive Geriatric Assessment to determine other factors that may contribute to treatment decision-making in the older population. The way geriatric oncology is delivered varies, bringing the importance of the multidisciplinary team to the forefront of care delivery in this age group. Future research in this area should include combined consideration of tumor biology and geriatric needs.

[Exclusive radiotherapy and concurrent endocrine therapy for the management of elderly breast cancer patients: case study and review of hypofractionated schemes]

Normofractionated radiotherapy is standard for adjuvant management of patients treated with breast conservative surgery for breast cancer. However, many elderly patients are not eligible to such strategy, either because of concurrent diseases, or because the tumor is inoperable. Several protocols of exclusive radiotherapy have been reported in the literature, frequently using hypofractionated radiotherapy and endocrine therapy. We report a case of a patient treated with exclusive endocrine and radiotherapy and address the state of the art on hypofractionated schemes for the management of elderly breast cancer patients. While hypofractionated radiotherapy does not compromise the oncologic or cosmetic outcome, there is no prospective data that assesses the place of radiotherapy for the exclusive treatment of elderly patients. This strategy should be further assessed in clinical randomized trial.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Breast cancer in the elderly

Breast cancer is the most commonly diagnosed cancer in women and most breast cancers are not attributable to risk factors other than female gender and increased age. However, despite its increasing prevalence in the geriatric population, prospective clinical trials for older cancer patients do not exist and most data come from retrospective studies or subanalyses from general population studies. As a result physician's, patient's and family members' fear predominates and elderly patients do not receive the appropriate treatment when compared with younger ones. Treatment is offered according to biological age alone and life expectancy, comorbidity and functional status are not considered when deciding treatment strategy. Surgery is often denied to patients older than 70 years of age, radiotherapy and chemotherapy are omitted due to the fear of toxicity and hormonal therapy, even though it represents a great tool as adjuvant therapy, it is associated with significant morbidity when chosen as primary treatment. Palliation of symptoms remains the main goal for metastatic disease but for the rest of the patients improving disease-free survival in the early stages should guide therapy no matter chronological age.

Breast-conserving treatment in the elderly: long-term results of adjuvant hypofractionated and normofractionated radiotherapy

PURPOSE

To evaluate the long-term cause-specific survival (CSS), locoregional recurrence-free survival (LRFS), and metastases-free survival (MFS) in elderly breast cancer patients receiving adjuvant normofractionated (NF) or hypofractionated (HF) radiotherapy (RT).

METHODS AND MATERIALS

Between 1995 and 1999, 367 women aged >or=70 years with nonmetastatic Stage T1 or T2 tumors were treated by breast-conserving surgery and adjuvant RT at the Institut Curie. They underwent wide tumor excision with or without lymph node dissection followed by RT. They received either a NF-RT schedule, which delivered a total dose of 50 Gy (25 fractions, 5 fractions weekly) to the whole breast, followed by a boost to the tumor bed when indicated, or a HF-RT schedule, which delivered a total dose of 32.5 Gy (five fractions of 6.5 Gy, once weekly) with no subsequent boost. The HF-RT schedule was indicated for the more elderly patients.

RESULTS

A total of 317 patients were in the NF-RT group, with 50 in the HF-RT group. The median follow-up was 93 months (range, 9-140). The 5- and 7-year CSS, LRFS, and MFS rates were similar in both groups. The 5-year NF-RT and HF-RT rate was 96% and 95% for CSS, 95% and 94% for LRFS, and 94% and 95% for MFS, respectively. The 7-year NF-RT and HF-RT rate was 93% and 87% for CSS, 93% and 91% for LRFS, and 92% and 93% for MFS, respectively.

CONCLUSION

According to the findings from this retrospective study, the HF-RT schedule is an acceptable alternative to NF-RT for elderly patients. However, large-scale prospective randomized trials are needed to confirm these results.

Long-term results of hypofractionated radiotherapy and hormonal therapy without surgery for breast cancer in elderly patients

BACKGROUND AND PURPOSE

To evaluate early and late reactions, local control, disease-free survival, cause-specific survival, and overall survival of elderly breast cancer patients treated with definitive once-a-week hypofractionated radiotherapy together with hormonal therapy.

PATIENTS AND METHODS

Between 1987 and 1999, 115 patients with a median age of 83 presenting with 124 non-metastatic breast carcinoma were treated with definitive once weekly hypofractionated radiotherapy associated with hormonal therapy. The main reasons for adopting this schedule were patient refusal of surgery, very old age, locally advanced case, and/or comorbid disease. Radiation was delivered as once-a-week, 6.5 Gy for a total breast dose of 32.5 Gy in five fractions, followed with 1-3 fractions of 6.5 Gy to the tumour site. The median follow-up was 41 months.

RESULTS

Neoadjuvant hormonal therapy led to 56% reduction of the tumour volume. Late reactions occurred in 46 patients; they were mild to moderate in 87% of these patients. The Kaplan-Meier rate was 52% of patients, with 6% experiencing grade 3 reactions. The 5-year local progression-free rate was 78%. The corresponding cause-specific survival was 71%, and was influenced by T classification, nodal status, oestrogen receptors and the total dose. The first three factors retained an independent prognostic impact on multivariate analysis. The 5-year overall survival was 38%. It was affected by the T classification, lymph node involvement and the performance status (PS). Using a multivariate analysis, only T classification and PS were identified as independent factors regarding overall survival.

CONCLUSIONS

Definitive hypofractionated radiotherapy allows a good local control, with acceptable toxicity. This schedule associated with hormonal therapy is a good alternative to surgery in non-operable old patients and in case of patient refusal to surgery and to standard fractionation.

Long-term results of adjuvant hypofractionated radiotherapy for breast cancer in elderly patients

PURPOSE

To evaluate early and late reactions, local control, disease-free survival, cause-specific survival, and overall survival of elderly breast cancer patients treated with adjuvant once-weekly hypofractionated radiotherapy (RT).

METHODS AND MATERIALS

Between 1987 and 1999, 150 patients (median age, 78 years) who presented with 151 nonmetastatic breast tumors were treated with surgery and then adjuvant hypofractionated RT. The clinical stage distribution was as follows: T1 in 47.7%, T2 in 43.2%, T3 in 6.1%, and T4 in 3.0%. Axillary lymph nodes were positive in 33.8% of cases. Estrogen receptors were present in 89.9%, and progesterone receptors in 77.3%. Conservative breast surgery was performed in 71.5% and total mastectomy in 28.5%. RT was delivered once weekly in five fractions of 6.5 Gy to a total dose of 32.5 Gy. A boost was delivered to the tumor bed in 33.1%. Adjuvant hormonal therapy was given in 76.2% of patients. The median follow-up was 65 months.

RESULTS

The Kaplan-Meier rate of all grades of early skin reactions was 26.5%, and the rate of all late reactions was 45.5%, mainly Grades 1 and 2. Early and late reactions were greater in those who underwent boost RT. The long-term local recurrence rate was 2.3%. The 5-year and 10-year disease-free survival rate was 80% and 71.5%, respectively. The corresponding rates for cause-specific survival were 89.1% and 77.6%. The 5-year and 10-year overall survival rate was 71.6% and 46.5%, respectively. These endpoints were influenced by tumor size, lymph node status, and hormone receptor status to varying degrees; however, tumor size appeared to be a major determinant on multivariate analysis.

CONCLUSIONS

This hypofractionated RT scheme resulted in mild early reactions and acceptable late toxicity, in addition to providing excellent long-term local control. It can be proposed to patients who would have difficulties sustaining daily treatment because of old age or disabling associated disease.

Breast cancer in the elderly: the role of adjuvant radiation therapy

PURPOSE

To evaluate available data on breast conserving surgery (BCS) with or without radiation therapy (RT), and alternative options (e.g. Tamoxifen alone) (Tam), focusing specifically on the older patients.

METHODS AND MATERIALS

The MEDLINE was searched for the terms elderly, BCS, adjuvant/postoperative RT, Tamoxifen, and randomized trials from 1992 to 2002.

RESULTS

Authors reviewed papers of general interest on the elderly and breast cancer (BC), meta-analysis, randomized trials on BCS+/-RT and Tam+/-surgery without RT, retrospective non-randomized trials, and reported on prognostic factors for local recurrence in BCS alone, including biomarkers, attempts made to define a low-risk group, and methods of modification of the current, protracted standard adjuvant RT course.

CONCLUSIONS

Postoperative RT after BCS has a firm rationale; in current clinical practice, if the BCS+RT is medically appropriate and the patient shares the choice, after a full information of the available options and their implications, it is clinically sound to propose this approach. However, there is controversy whether a subgroup of elderly patients could be safely spared: in this setting a randomized trial is clearly warranted.

Breast-conserving therapy for stage I-II breast cancer in elderly women

PURPOSE

To assess breast-conserving therapy results in elderly patients with early-stage breast cancer (clinical Stage I-II).

METHODS AND MATERIALS

Between 1979 and 1998, 196 women (200 treated breasts) aged > or =70 years (median age, 72.5 years) were treated with breast-conserving therapy (lumpectomy or quadrantectomy with axillary lymph node dissection and radiotherapy). Pathologic axillary node involvement was found in 51 patients (28%). Two-thirds of patients received tamoxifen, and 16% received chemotherapy.

RESULTS

At a median follow-up of 59 months, 3 patients (1.5%) had developed local recurrence and 20 (10.2%) distant metastases. The overall survival rate was 81% and 62% at 5 and 10 years, respectively. The corresponding disease-specific survival rates were 92% and 88%. Axillary nodal involvement was the only statistically significant risk factor for the development of metastases (p = 0.0035). Arm mobility impairment and arm lymphedema each occurred in 5 patients. In another 5 patients, a thromboembolic event occurred during tamoxifen treatment.

CONCLUSION

Elderly women tolerate breast-conserving therapy, including radiotherapy, well and have excellent rates of locoregional control and disease-specific survival.

[Partial irradiation of the breast: why, how?]

Radiation therapy represents a very important part of breast conservative treatment. The classic schedule consists in delivering a total dose of 50 Gy in 25 fractions on 5 weeks, sometimes associated with a 10 to 16 Gy boost. For elderly women with difficulties to move or for younger women having professional activity or with young children in charge, a 5 to 6 weeks radiation therapy with long and frequent transportations is sometimes difficult to achieve. The aim of partial breast irradiation (PBI) is to prevent, in a short period (5 to 8 days) and less transportations, the risk of local recurrence into the tumor bed. Different techniques have been described, using either interstitial brachytherapy (low or high dose rate) or intra-operative radiation therapy (IORT photons or electrons) or external beam radiation therapy. Phase II PBI trials using interstitial brachytherapy showed a local control rate of 0 to 4% with a follow-up of 20 to 75 months. The rate of good/excellent cosmetic results is 67 to 100%. Results analysis of trials using very new PBI techniques (MammoSite), IORT) remains more difficult. If phase III randomized trials could confirm that PBI achieved, for selected patients, local controls equivalent to those obtain with whole breast irradiation, PBI could improve quality of life during radiation therapy, and maybe contribute to have a cost effective breast cancer conservative treatment.

Short course radiation therapy for elderly cancer patients. Evidences from the literature review

The choice of the appropriate treatment strategy for elderly cancer patients may be a difficult challenge. Radiation therapy is commonly offered to these patients, but treatment duration may represent a limiting factor, as many patients cannot tolerate a conventional course of radiotherapy (RT) due to age-related medical or logistic problems. Hypofractionated RT may represent a very convenient choice, but it entails an increased risk of late toxicity occurrence. We made a literature review to define the possible role of hypofractionated RT for elderly cancer patients. As expected, we found out that short irradiation schedules are more commonly employed for treatments with palliative aims but a more widespread use of these regimes is still controversial. The lack of prospective trials tailored for these patients makes even more difficult to tailor the choice of treatment on standardised treatment guidelines. Nevertheless our review highlights that for several tumour types RT can be scheduled conveniently and effectively in order to achieve local disease control and/or symptom relief with the least discomfort and treatment-related morbidity for elderly patients.

Differences in Breast Cancer Treatment and Survival Between Older and Younger Women

The study aim was to compare breast cancer treatment and survival between older and younger women treated at the University of Texas M. D. Anderson Cancer Center over a 30-year period, 1958-1987. Data were obtained from the Medical Informatics Tumor Registry and were examined by 15-year time periods. Treatments were stratified by no surgery, surgery alone, or surgery and additional treatment. Mantel-Haenszel chi-square statistics and actuarial life tables were used for comparisons. Among 3,382 women treated for breast cancer, treatment differed by age groups (p < 0.01). The most consistent finding by disease stage was that older women were less likely to receive treatment in addition to surgery compared to younger women (p < 0.01-0.05). Among women with local or regional involvement who received surgery and additional treatment, 5-year survival was similar regardless of age group. However, among women with distant disease who received surgery and additional treatment, 5-year survival differed significantly by age group (p = 0.03); women in the 65- to 74-year age group experienced the best survival. In this hospital population, older women with breast cancer who received surgery and additional treatment experienced similar, sometimes better, 5-year survival compared with younger women, which suggests that older women, in some cases, may benefit from combined modality treatment for breast cancer.

Breast conservation therapy as a treatment option for the elderly. The M. D. Anderson experience

BACKGROUND

Although almost half of all incidents of breast carcinoma occur in women age > or = 65 years, not enough is known about appropriate care for patients in this age group. The objective of the current study was to evaluate the role of breast conservation therapy in the management of breast carcinoma in women age > or = 65 years.

METHODS

From 1970 to 1994, 1325 patients with carcinoma of the breast were treated with breast conservation therapy (segmental mastectomy and radiation therapy with or without axillary lymph node dissection) at The University of Texas M. D. Anderson Cancer Center. From this patient group, the authors identified 184 elderly women (> or = 65 years) with Stage 0-III disease at the time of diagnosis.

RESULTS

The median patient age was 70 years (range, 65-88 years). The distribution of disease by stage among the women was Stage 0 disease in 12 patients (7%), Stage I disease in 107 patients (58%), Stage II disease in 63 patients (34%), and Stage III disease in 2 patients (1%). Comorbid conditions that may have influenced treatment planning were reported in 91 patients (50%). An axillary lymph node dissection was performed in 135 patients (73%), with positive axillary lymph nodes found in 30 patients (22%). Adjuvant chemotherapy was given to 10 patients (5%), and tamoxifen therapy was given to 63 patients (34%). Complications from treatment were reported in 24 patients (13%). With a median follow-up of 7.3 years (range, 0.25-23.5 years), 9 patients developed locoregional disease recurrence (5%), 10 patients developed contralateral breast carcinoma (5%), and 21 patients developed distant metastasis (11%). At last follow-up, 113 patients (61%) were alive, 15 patients (8%) were dead of disease, and 56 patients (30%) were dead of other causes. The 5-year and 10-year disease specific survival rates were 96% and 91%, respectively.

CONCLUSIONS

Breast conservation therapy with segmental mastectomy and postoperative radiation therapy with or without axillary lymph node dissection provides excellent local control and disease free survival in elderly women with breast carcinoma. This treatment should be considered as the standard of care for elderly patients without severe comorbid disease.

[Cancer and the elderly. Management. Decision aspects]

INTRODUCTION

Age is the major risk factor for the majority of patients with cancer. More than 50% of cancers occurs after the age of 60. Cancer in the elderly is therefore a public health issue at stake. However, in daily clinical practice the elderly presenting cancer are not listened to with great interest and treatment is often not proper or suboptimal.

CURRENT KNOWLEDGE AND KEY POINTS

Diagnosis in the elderly is established at a more advanced stage of cancer than in younger people; diagnostic workup is reduced and suboptimal treatments are implemented. Therefore, barriers exist that prevent the elderly from accessing the healthcare system as easily as their younger counterpart. Misconceptions about cancer also lead them to delay their first visit. As well, although treatment with curative intent and without major side-effect is feasible, physicians have misconceptions regarding therapeutic possibilities. Due to the heterogeneity of the so-called "ageing population", difficulties are related to patients' selection.

FUTURE PROSPECTS AND PROJECTS

Decision in oncology for the elderly must walk a fine line in attempting to deliver the best treatment under the best conditions. Age per se must not be the only criterion for medical decision. Providing accurate information adapted to the elderly, with large circulation among healthcare professionals, should lead to the same quality of care as that in young people. Comprehensive multimodal geriatric assessments should help to further differentiate patients who may benefit from curative treatment from those for whom only palliative treatment is necessary.

Nd: YAG interstitial laser thermotherapy in the treatment of breast cancer

BACKGROUND AND OBJECTIVE

"Minimal treatment strategy" is desirable in certain breast cancer patients. The main objective of the present study is to examine the use of interstitial laser thermotherapy (laserthermia) for this purpose.

STUDY DESIGN/MATERIALS AND METHODS

Thirty-five patients with primary breast cancer were treated with laserthermia using the Nd:YAG (1,064 nm) pulse-wave laser. In 28 patients, laserthermia was performed before radical resection, and in seven patients it was the only invasive treatment.

RESULTS

One gaseous rupture of tumor occurred at 3 Watts. The diameter of single focus of laser-induced damage after 1-2 Watts was less than 1 cm, and after 2.5-6 Watts it reached 1.5-2.5 cm. Of seven patients treated without surgery, local tumor control was achieved in five, and in three stage I-III patients disease-free survival followed for 19-60 months. After laserthermia plus surgery, 3-year disease-free survival was 27% in premenopausal and 92% in menopausal patients.

CONCLUSIONS

It seems that laser destruction of relatively small primary breast cancer is possible. Provisionally, laserthermia should not be used in premenopausal patients.

Cancer surgery in the elderly

The incidence of most cancers increases with age. Although the risk for surgery increases in elderly patients who have comorbidities, evaluations of risk can allow interventions that may decrease morbidity and mortality. Appropriate treatments should be offered to the elderly until studies demonstrate the elderly can safely be managed differently from younger patients. The elderly should not be denied adequate treatment simply because of age.

Breast cancer and aging. Clinical interactions

The incidence and mortality rates of breast cancer increase with age. As the geriatric population grows, the number of breast cancer cases will reach epidemic proportions. The number of coexisting medical conditions also increases with advancing age. The presence and severity of comorbid conditions influences an individual's ability to tolerate procedures and treatments and must be considered in making disease-management decisions. Screening mammography can potentially save lives in older women. Women whose life expectancy exceeds 5 years should continue annual screening mammography. Choices for local definitive therapy, systemic adjuvant therapy, and treatment of metastatic disease should be based on patient preference and ability to tolerate the planned procedure. In general, otherwise healthy older women should be offered the same treatment options given to younger, postmenopausal women. Alternative, less aggressive, or nonstandard approaches are warranted in women whose life expectancy is limited or who are unable or unwilling to undergo standard management procedures.

Radiation therapy of the older patient

Radiotherapy has a major role in the multidisciplinary approach to cancer therapy. It is widely used for curative and palliative treatment of cancer involving various sites. Radiotherapy is of particular benefit to older and frail cancer patients as an alternative to surgery and to systemic therapy. The available data on the sensitivity of normal tissues to radiotherapy in elderly patients strongly suggest that older patients with good functional status tolerate radiotherapy as well as younger patients and have comparable tumor response and survival rates. Aggressive radiotherapy should not be withheld from older patients because of chronological age alone.

Radiotherapy in the elderly

Older patients with cancer are frequently victims of discriminatory treatment strategies according to parameters unrelated to the tumour itself. The general approach is influenced by the belief that good tolerance to radiotherapy might be compromised in older patients and that the course of cancer might be less aggressive in this age group. Substandard treatment is therefore often offered to older patients, although this attitude is supported neither by clinical nor by scientific evidence, but rather stems from a lack of specific knowledge of the actual cancer prognosis and the tolerance to radiotherapy in the elderly. In clinical practice advanced age may result in undertreatment, even though patients may have no other medical illness and no functional impairment. Some comorbid conditions which are more frequent in older patients may complicate the outcome of treatment. However, these impaired vital functions are not an intrinsic feature of the elderly. Overall, noncompliance in radiotherapy, related to comorbidity or technical condition, is rare. Short-term radiotherapy using a large daily fraction is often advocated in elderly patients; however, this should only be considered if a palliative treatment option has previously been selected due to the high risk of late side-effects. Acute side-effects often result in decreasing doses of radiotherapy. Data on acute tolerance of radiotherapy for different types of tumours did not demonstrate a radical difference in occurrence of toxicities. 'Reducing' radiotherapy is never a solution, unless the life expectancy of the patient is obviously so short that the tumour recurrence is unlikely to occur or at least to produce substantial morbidity before the patient has died from other causes.

Breast cancer in elderly women: presentation, survival, and treatment options

Recent data suggest that breast cancer in elderly women does not present as more advanced disease, nor is survival significantly inferior to that in younger women. Unfortunately, until recently, older women have been excluded from clinical trials that have determined survival benefit in both screening and treatment modalities. Unless co-morbid conditions adversely affect one's life expectancy or tolerance to therapy, older women should be treated with standard surgical procedures (including breast conservation, if so desired) for early-stage disease, as outcome is comparable to that in younger patients. Adjuvant tamoxifen therapy has proven survival benefit in women over 70 years of age with estrogen receptor-positive tumors and should be considered in all women with tumors greater than 1 cm in size. Older women may experience more chemotherapy-related toxicities. However, for those with a significant risk of recurrence due to tumor size or lymph node status, chemotherapy can be safely administered when factors such as age-related decline in creatinine clearance and co-morbid conditions are considered. Hormonal therapy (tamoxifen) is usually the first-line treatment option over chemotherapy for metastatic disease in the elderly unless the patient has an estrogen receptor-negative tumor, visceral-dominant disease, or significant disease-related symptoms. In the latter settings, chemotherapy can provide improved or more rapid response proportions but does not affect long-term survival.

Management of breast cancer in the elderly

This paper examines data which has been published on breast cancer in the elderly and concludes that, wherever possible, combined modality treatment should be offered to elderly breast cancer patients. It appears from an examination of the literature that single modality treatment in the form of hormone treatment often results in very high rates of loco-regional recurrence.