Treatment strategies and survival outcomes in older women with breast cancer: A comparative study between the FOCUS cohort and Nottingham cohort

Frequency of use and characterization of frailty assessments in observational studies on older women with breast cancer: a systematic review

BACKGROUND

Breast cancer and frailty frequently co-occur in older women, and frailty status has been shown to predict negative health outcomes. However, the extent to which frailty assessments are utilized in observational research for the older breast cancer population is uncertain. Therefore, the aim of this review was to determine the frequency of use of frailty assessments in studies investigating survival or mortality, and characterize them, concentrating on literature from the past 5 years (2017-2022).

METHODS

MEDLINE, EMBASE and Cochrane Library were systematically queried to identify observational studies (case-control, cohort, cross-sectional) published from 2017-2022 that focus on older females (≥ 65 years) diagnosed with breast cancer, and which evaluate survival or mortality outcomes. Independent reviewers assessed the studies for eligibility using Covidence software. Extracted data included characteristics of each study as well as information on study design, study population, frailty assessments, and related health status assessments. Risk of bias was evaluated using the appropriate JBI tool. Information was cleaned, classified, and tabulated into review level summaries.

RESULTS

In total, 9823 studies were screened for inclusion. One-hundred and thirty studies were included in the final synthesis. Only 11 (8.5%) of these studies made use of a frailty assessment, of which 4 (3.1%) quantified frailty levels in their study population, at baseline. Characterization of frailty assessments demonstrated that there is a large variation in terms of frailty definitions and resulting patient classification (i.e., fit, pre-frail, frail). In the four studies that quantified frailty, the percentage of individuals classified as pre-frail and frail ranged from 18% to 29% and 0.7% to 21%, respectively. Identified frailty assessments included the Balducci score, the Geriatric 8 tool, the Adapted Searle Deficits Accumulation Frailty index, the Faurot Frailty index, and the Mian Deficits of Accumulation Frailty Index, among others. The Charlson Comorbidity Index was the most used alternative health status assessment, employed in 56.9% of all 130 studies. Surprisingly, 31.5% of all studies did not make use of any health status assessments.

CONCLUSION

Few observational studies examining mortality or survival outcomes in older women with breast cancer incorporate frailty assessments. Additionally, there is significant variation in definitions of frailty and classification of patients. While comorbidity assessments were more frequently included, the pivotal role of frailty for patient-centered decision-making in clinical practice, especially regarding treatment effectiveness and tolerance, necessitates more deliberate attention. Addressing this oversight more explicitly could enhance our ability to interpret observational research in older cancer patients.

Exercise in older women with breast cancer during systemic therapy: study protocol of a randomised controlled trial (BREACE)

INTRODUCTION

Exercise interventions have been widely investigated in patients with cancer and demonstrate beneficial effects. However, intervention studies that include older women with breast cancer exercising during medical treatment are scarce. Hence, the aim of this study is to investigate the effect of a 12-week exercise-based intervention in older women (≥65 years) with breast cancer receiving (neo)adjuvant or first-line or second-line systemic therapy.

METHODS AND ANALYSIS

This is a single-centre, two-armed randomised controlled trial. We anticipate including 100 patients, who will be randomised 1:1 to exercise-based intervention or control stratified by treatment setting ((neo)adjuvant or metastatic) and treatment (chemotherapy or endocrine therapy + cyclin-dependent kinase (CDK) 4/6 inhibitors). The intervention group will receive standard oncological treatment and a 12-week supervised exercise-based intervention comprising a progressive resistance exercise programme two times per week, a protein supplement after exercise and a home-based walking programme based on daily step counts. The control group will receive standard oncological treatment. Assessments will be performed at baseline and 6, 12 and 24 weeks after start of the intervention. Primary outcome is physical function, measured by the 30-second Chair Stand Test. Secondary outcomes are feasibility (compliance and adherence to intervention), objective and patient-reported functional measures (6-meter and 10-meter gait speed; 6-min Walk Test; Handgrip Strength; Stair Climb Test; Physical Activity Questionnaire), symptom burden and well-being (MD Anderson Symptom Inventory; Hospital Anxiety and Depression Scale), quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 and B23), body composition (dual-energy X-ray absorptiometry scan), side effects, inflammatory biomarkers, hospitalisation and survival.

ETHICS AND DISSEMINATION

The protocol was reviewed and accepted by the Scientific Ethics Review Committee of the Capital Region of Denmark, 17 June 2018 (VEK ref.: H-18021013). Trial results will be submitted for publication in a peer-reviewed journal and presented on conferences, in oncology wards, exercise centres in municipalities and patient organisations, ensuring dissemination to relevant stakeholders.

TRIAL REGISTRATION NUMBER

https://clinicaltrials.gov/ on 3 September 2018. Identifier: NCT03656731.

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.

Hospitalization by cytotoxic chemotherapy regimen among older women with stage IV breast cancer

BACKGROUND

Older patients with cancer are at risk for increased side effects of treatment. Our goal was to inform treatment for older patients by analyzing the relationship between chemotherapy regimen and hospitalization among older women receiving palliative cytotoxic chemotherapy for breast cancer.

METHOD

We identified women aged 66-99 years with stage IV de novo breast cancer diagnosed between 2010 and 2013 who received any of the 10 most common cytotoxic chemotherapy-containing regimens in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The primary outcome was hospitalization or death within 30 days of starting a new line of chemotherapy. Generalized linear mixed effects models with patient-specific random effects were used for multivariable analysis of the association between chemotherapy regimen and this outcome. Additional covariates included number of prior lines of therapy; time since diagnosis; hormone receptor and HER2 status; sites of metastatic disease; and age, race, and marital status. The unit of analysis was each new line of chemotherapy.

RESULTS

Of 972 lines of chemotherapy initiated among 693 patients, 188 (19%) were followed by hospitalization or death within 30 days. After adjustment, there was significant variation in this outcome by chemotherapy regimen (P = .03); compared with capecitabine, hospitalization/death rates were higher with cyclophosphamide + docetaxel (odds ratio [OR], 2.71; 95% confidence interval [CI], 1.31-5.59), cyclophosphamide + doxorubicin (OR, 2.45; 95% CI, 1.19-5.03), docetaxel (OR, 2.49; 95% CI, 1.19-5.21), and gemcitabine (OR, 3.51; 95% CI, 1.72-7.19).

CONCLUSION

Treatment regimen was associated with significant variation in 30-day hospitalization or death among older women receiving cytotoxic chemotherapy for stage IV de novo breast cancer.