A systematic review of generic and breast cancer specific life expectancy models in the elderly

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.

Why do Older Women Avoid Breast Cancer Surgery? A Qualitative Analysis of Decision-making Factors

BACKGROUND

Few studies have explored why older women (≥70 years old) avoid breast cancer surgery. This study aimed to identify physician- and patient-perceived attitudes that influence the decision to avoid surgery among older women with invasive breast cancer.

METHODS

Semi-structured in-depth interviews were conducted with multidisciplinary breast cancer specialists and older women (≥70 years old) with breast cancer who declined surgery. Transcripts were iteratively coded using a theoretical framework to guide identification of common themes. Thematic comparison was performed between patients and physicians.

RESULTS

Ten breast cancer specialists and eleven patients participated. Physicians believed older women declined surgery because they did not perceive breast cancer as a life-threatening ailment compared to other medical comorbidities. Physicians did not discuss breast reconstruction, as it was perceived to be unimportant. Treatment side effects, length of treatment, impact on quality of life, and minimal survival benefit strongly influenced patients' decision to decline surgery. Patients valued independence and quality of life over quantity of life. Patients felt empowered to participate in the decision-making process but appreciated having support. Both phyisicians and patients had congruent beliefs with respect to age impacting treatment decision, cosmesis playing a minor factor in treatment decisions, and importance of quality of life; however, they were discordant in their perceptions about the amount of support that patients have from their families.

CONCLUSIONS

The decision to avoid surgery in older women stems from a variety of individual beliefs. Acknowledging patient values early in treatment planning may facilitate a patient-centered approach to the decision-making process.

The G8 frailty screening tool and the decision-making process in older breast cancer patients

OBJECTIVE

To assess the decision-making process in fit and frail older breast cancer patients.

METHODS

Breast cancer patients aged ≥70 years who completed the G8 frailty screening tool (G8) were included in this retrospective study. Socio-demographic and clinical characteristics were collected, as well as information from geriatric assessment (GA). Treatment decisions were compared with national guidelines.

RESULTS

Of 177 patients, 85 patients were considered fit by the G8 (G8-fit) and 92 patients frail (G8-frail). All G8-fit and 53 G8-frail were proposed for surgery. GA was performed in 34 patients (9 G8-fit; 25 G8-frail) of whom 16 (2 G8-fit;14 G8-frail) were considered frail (GA-frail). 28 out of these 34 patients were considered fit for surgery (including 11 GA-frail); their impairments were unlikely to interfere with surgery or life expectancy. Reasons for adjusting treatment were physical/cognitive condition and patient preference. Ultimately, 123 patients underwent surgery in accordance with guidelines (81 G8-fit;42 G8-frail, p < 0.001). Survival was reduced in G8-frail compared to G8-fit (p = 0.001), but G8 lost its association with mortality in multivariable survival analysis. Among patients undergoing surgery, no difference in mortality was seen between G8-fit and G8-frail (p = 0.996).

CONCLUSION

The G8 is associated with treatment decisions and did not affect survival in patients undergoing surgery. In the decision-making process, the G8 may help and estimates the need for adaptive care.

Early stage breast cancer treatment and outcome of older patients treated in an oncogeriatric care and a standard care setting: an international comparison

Introduction

Since older patients with breast cancer are underrepresented in clinical trials, an oncogeriatric approach is advocated to guide treatment decisions. However, the effect on outcomes is unclear. The aim of this study was to compare treatments and outcomes between patients treated in an oncogeriatric and a standard care setting.

Methods

Patients aged ≥ 70 years with early stage breast cancer were included. The oncogeriatric cohort comprised unselected patients from the Moffitt Cancer Center, and the standard cohort patients from a Dutch population-based cohort. Cox models were used to characterize the influence of care setting on recurrence risk and overall mortality.

Results

Overall, 268 patients were included in the oncogeriatric and 1932 patients in the standard cohort. Patients in the oncogeriatric cohort were slightly younger, had more comorbidity, and received more adjuvant endocrine therapy and chemotherapy. Oncogeriatric care was associated with a lower risk of recurrence, which remained significant after adjustment for patient and tumour characteristics [hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.44–0.99]. Oncogeriatric care was also associated with a lower overall mortality, which also remained significant after adjustment for patient and tumour characteristics (HR 0.69, 95% CI 0.55–0.87).

Conclusions

Patients treated in the oncogeriatric care setting had a lower risk of recurrence, which may be explained by more systemic treatment. Overall mortality was also lower, but other explanations besides care setting could not be ruled out as the cohorts had different patient profiles. Future studies need to clarify the impact of an oncogeriatric approach on outcomes.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05860-7) contains supplementary material, which is available to authorized users.

Effect of omission of surgery on survival in patients aged 80 years and older with early-stage hormone receptor-positive breast cancer

BACKGROUND

Surgery is increasingly being omitted in older patients with operable breast cancer in the Netherlands. Although omission of surgery can be considered in frail older patients, it may lead to inferior outcomes in non-frail patients. Therefore, the aim of this study was to evaluate the effect of omission of surgery on relative and overall survival in older patients with operable breast cancer.

METHODS

Patients aged 80 years or older diagnosed with stage I-II hormone receptor-positive breast cancer between 2003 and 2009 were selected from the Netherlands Cancer Registry. An instrumental variable approach was applied to minimize confounding, using hospital variation in rate of primary surgery. Relative and overall survival was compared between patients treated in hospitals with different rates of surgery.

RESULTS

Overall, 6464 patients were included. Relative survival was lower for patients treated in hospitals with lower compared with higher surgical rates (90·2 versus 92·4 per cent respectively after 5 years; 71·6 versus 88·2 per cent after 10 years). The relative excess risk for patients treated in hospitals with lower surgical rates was 2·00 (95 per cent c.i. 1·17 to 3·40). Overall survival rates were also lower among patients treated in hospitals with lower compared with higher surgical rates (48·3 versus 51·3 per cent after 5 years; 15·0 versus 19·7 per cent after 10 years respectively; adjusted hazard ratio 1·07, 95 per cent c.i. 1·00 to 1·14).

CONCLUSION

Omission of surgery is associated with worse relative and overall survival in patients aged 80 years or more with stage I-II hormone receptor-positive breast cancer. Future research should focus on the effect on quality of life and physical functioning.

Surgical treatment and prognosis of breast cancer in elderly - A population-based study

BACKGROUND

The aim of this study was to investigate outcome of treatment in patients over 80 years of age with early breast cancer at the time of the diagnosis with special interest in surgical treatment.

MATERIALS AND METHODS

Breast cancer patients older than 80 years of age, treated at the Breast Surgery Unit of Helsinki University Hospital in 2005-2010 were identified from electronic patient records. Patients were followed-up until the end of 2014. Patient and tumour characteristics, recurrences, co-morbidities and reasons for omission of surgery were collected from electronic patient records. Survival data was obtained from Finnish Cancer Registry.

RESULTS

446 patients were eligible for the study: 401 (90%) received surgery. The median follow-up time was 52 months. In the entire study population, local and regional recurrences/disease progression were diagnosed in 16 (3.6%) and 6 (1.3%) patients, respectively. The five-year overall survival was 50.6% in the surgical treatment and only 15.2% in non-surgical treatment group, p < 0.001. Also, the five-year breast cancer specific survival was significantly better in the patients with surgery, 82.0%, but 56.0% in the patients without surgery, p < 0.001. There was no mortality related to the surgery, but 122 (30%) patients died within three years from surgery.

CONCLUSION

Surgical treatment rate was high. OS and BCSS were better in surgically treated elderly patients. Local and regional disease control was excellent, probably due to high rate of surgical treatment. Surgical treatment also seemed safe in this elderly patient population. However, surgical overtreatment was obvious in some patients.

Systematic Predictive Analysis of Personalized Life Expectancy Using Smart Devices

With the emergence of technologies such as electronic health and mobile health (eHealth/mHealth), cloud computing, big data, and the Internet of Things (IoT), health related data are increasing and many applications such as smartphone apps and wearable devices that provide wellness and fitness tracking are entering the market. Some apps provide health related data such as sleep monitoring, heart rate measuring, and calorie expenditure collected and processed by the devices and servers in the cloud. These requirements can be extended to provide a personalized life expectancy (PLE) for the purpose of wellbeing and encouraging lifestyle improvement. No existing works provide this PLE information that is developed and customized for the individual. This article is based on the concurrent models and methodologies to calculate and predict life expectancy (LE) and proposes an idea of using multi-phased approaches to the solution as the project requires an immense and broad range of work to accomplish. As a result, the current prediction of LE, which was found to be up to a maximum of five years could potentially be extended to a lifetime prediction by utilizing generic health data. In this article, the novel idea of the solution proposing a PLE on an individual basis, which can be extended to lifetime is presented in addition to the existing works.