The management of elderly patients with T1–T2 breast cancer treated with or without radiotherapy

External radiotherapy for breast cancer in the elderly

BACKGROUND

Breast cancer is the most common malignancy amongst elderly women and the main cause of mortality. A specific management for elderly woman is not clear because clinical trials are usually not customized for this subset of patients.

AIMS

The aim of this paper is to provide an overview of the available information on the main issues in the field of breast cancer radiotherapy in the elderly population.

MATERIALS AND METHODS

Authors discuss on different radiation treatments for breast cancer in the elderly, based on the data of the literature with a focus on new strategy: hypo-fractionation, accelerated partial breast irradiation, and the utility of a dose boost.

DISCUSSION

The treatment of breast cancer is not standardized in the elderly. The optimal management in this population often requires complex multidisciplinary supportive care due to multiple comorbidities to optimize their cancer care.

CONCLUSIONS

New options such as APBI or HyRT regimens should be taken into consideration and offered as a breach of duty to the elderly population. Furthermore, they should be extensively investigated through randomized clinical trials.

Optimal management of breast cancer in the elderly patient: current perspectives

Breast cancer (BC) is the most common female malignancy in the world and almost one third of cases occur after 70 years of age. Optimal management of BC in the elderly is a real challenge and requires a multidisciplinary approach, mainly because the elderly population is heterogeneous. In this review, we describe the various possibilities of treatment for localized or metastatic BC in an aging population. We provide an overview of the comprehensive geriatric assessment, surgery, radiotherapy, and adjuvant therapy for early localized BC and of chemotherapy and targeted therapies for metastatic BC. Finally, we attempt to put into perspective the necessary balance between the expected benefits and risks, especially in the adjuvant setting.

Treatment options for older woman with early breast cancer

Breast cancer is the most common cancer in women and its incidence increases with age. Older women are not often offered optimal treatment compared with younger women for any particular stage. This is due to various reasons, including the lack of evidence for older women from well-conducted clinical trials. In this paper, the currently available evidences from clinical trials are reviewed and the various treatment options for older women with early breast cancer are discussed.

[Radiotherapy for breast cancer: which strategy in 2012?]

Postoperative radiotherapy remains essential in breast cancer in 2012. After conserving surgery, it reduces local recurrence risks from 50 to 70%, both for ductal carcinoma in situ and invasive cancers. This was confirmed in several randomized trials and three meta-analyses. The boost increases local control in invasive cancers, but its role should be better defined in ductal carcinoma in situ. Among the latter, there is no clearly identified subgroup for which radiotherapy could be avoided. Local recurrence risk factors are now well-identified both for ductal carcinoma in situ and invasive cancers, with an inclusion, for the latter, of new molecular subgroups. After mastectomy, radiotherapy reduces local recurrence rates from 60 to 70%, especially among patients with axillary nodal involvement, with, in parallel, a 7 to 9% increased survival rate. In order to reduce the waiting list and to avoid under treatment, especially in the elderly, several hypofractionated radiotherapy schemes have been developed for several years. Three randomized trials confirmed similar results to classical radiotherapy. For ten years, several techniques of partial breast irradiation have been developed, with various doses and treated volumes. The optimal indications should be defined according to the new international guidelines.

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.

Treatment of breast cancer in older women

BACKGROUND

Breast carcinoma management in the elderly often differs from the management in younger women and there is considerable controversy about what constitutes appropriate cancer care for older women. This controversy is reflected in the persistence of age-dependent variations in care over time, with older women being less likely to receive definitive care for breast cancer. There has been a significant increase in the last years in the number of studies conducted in older patients with breast cancer. Although available age-specific clinical trials data demonstrate that treatment efficacy is not modified by age, this evidence is limited by the lack of inclusion of substantial numbers of older women, particularly those of advanced age and those with comorbidities.

METHOD

The literature-based evidence of the last 10 years was extensively reviewed on the main issues concerning the treatment of breast cancer in older women.

RESULTS

Surgical treatment in older patients has evolved from avoidance to mastectomy to breast-conserving surgery, similarly to younger patients. Given its negative effect on the quality of life, in the last few years the role of adjuvant radiotherapy has been questioned in elderly patients with breast cancer. Adjuvant chemotherapy benefit in older patients applies mainly to Estrogen-receptor-negative patients, while in Estrogen-receptor-positive patients a major role is played by endocrine treatment. New "elderly-friendly" drugs, that can help clinicians to reduce toxicity, are now available for breast cancer.

Older female cancer patients: importance, causes, and consequences of undertreatment

Despite increased interest in treatment of senior cancer patients, older patients are much too often undertreated. This review aims to present data on treatment practices of older women with breast and gynecologic cancers and on the consequences of undertreatment on patient outcome. We also discuss the reasons and validity of suboptimal care in older patients. Numerous studies have reported suboptimal treatment in older breast and gynecologic cancer patients. Undertreatment displays multiple aspects: from lowered doses of adjuvant chemotherapy to total therapeutic abstention. Undertreatment also concerns palliative care, treatment of pain, and reconstruction. Only few studies have evaluated the consequences of nonstandard approaches on cancer-specific mortality, taking into account other prognostic factors and comorbidities. These studies clearly showed that undertreatment increased disease-specific mortality for breast and ovarian cancers. For other gynecological cancers, data were insufficient to draw conclusions. Objective reasons at the origin of undertreatment were, notably, higher prevalence of comorbidity, lowered life expectancy, absence of data on treatment efficacy in clinical trials, and increased adverse effects of treatment. More subjective reasons were putative lowered benefits of treatment, less aggressive cancers, social marginalization, and physician's beliefs. Undertreatment in older cancer patients is a well-documented phenomenon responsible for preventable cancer deaths. Treatments are still influenced by unclear standards and have to be adapted to the older patient's general health status, but should also offer the best chance of cure.

Insight into the treatment of cancer in older patients: Developments in the last decade

In the last decades there has been an increased interest in the treatment of elderly cancer patients and a change in attitude of both clinicians and their patients has occurred. Drugs are now available that might be considered "elderly-friendly" and the enormous advances in surgical procedures and supportive treatments over the recent years have enabled adverse effects to be minimized. A Geriatric Assessment is increasingly used as a tool to define those patients who are more suitable for aggressive chemotherapy or, on the contrary, palliative treatment. For almost all cancers, older patients are better treated today than they were in the past, even though we are still far from optimal management. Despite the perceived barriers to including elderly patients in clinical trials, there are few data to support excluding them. We must not permit increased age in cancer patients to continue to be an important and independent risk factor for receiving inadequate care.