Early primary breast cancer in the elderly – Pattern of presentation and treatment

Refusal of treatment among HER2-positive breast cancer patients in China: a retrospective analysis

Background

There is a need to update the understanding of treatment refusal among cancer patients in China, taking into account recent developments. This study investigated how public insurance coverage of the first breast cancer targeted therapy contributed to the changes in treatment refusal among HER2-positive breast cancer patients in China. And it intensively examined and discussed additional barriers affecting patient utilization of innovative anticancer medicines based on the types and reasons for treatment refusal.

Methods

This retrospective study included female breast cancer patients diagnosed as HER2-positive who received treatment at a provincial oncology center in southern China between 2014 and 2020. Multivariable analysis was conducted using a binary logistic regression model. Subgroup analysis was performed with the same regression model.

Results

Among the 1,322 HER2-positive breast cancer patients who received treatment at the study hospital between 2014 and 2020, 327 (24.55%) had ever refused treatment. Economic reasons were reported as the primary cause by 142 patients (43.43%). Patients diagnosed after September 2017, when the first breast cancer targeted therapy was included in the public health insurance, were less likely to refuse treatment (OR = 0.64, 95% CI:0.45 ~ 0.91, p = 0.01) compared to those diagnosed before September 2017. Patients enrolled in the resident health insurance were more likely to refuse treatment (OR = 2.43, 95% CI:1.77 ~ 3.35, p < 0.001) than those enrolled in the employee health insurance.

Conclusion

This study reveals a high rate of treatment refusal among HER2-positive breast cancer patients, primarily attributed to financial factors. The disparity in public health insurance benefits resulted in a heavier economic burden for patients with less comprehensive benefits. Furthermore, the study identified challenges faced by patients seeking quality-assured cancer care in underdeveloped regions in China. By addressing economic barriers, promoting accurate health information, and improving cancer care capacity across the country can reduce the rate of treatment refusal.

The occurence of cancer in ageing populations at global and regional levels, 1990 to 2019

BACKGROUND

population ageing contributes to increased cancer cases and deaths and has profound implications for global healthcare systems. We estimated the trends of cancer cases and deaths in ageing populations at global and regional levels.

METHODS

using data from the Global Burden of Disease Study 2019, we analysed the change in cancer cases and deaths associated with population ageing, population growth and epidemiological factors from 1990 to 2019 using decomposition analysis. Additionally, we estimated the proportions of people aged 65 years and over accounting for total cases and deaths, and investigated relationships between the proportions and the Sociodemographic Index (SDI) using the Pearson correlation coefficient.

RESULTS

from 1990 to 2019, there was an increase of 128.9% for total cases and 74.8% for total deaths in all cancers combined; the percentages of older people increased from 48.6% to 56.4% for cases and from 52.0% to 61.9% for deaths. Population ageing contributed to the largest increase in global cancer occurrence, with 56.5% for cases and 63.3% for deaths. However, the changes attributed to epidemiological factors was 5.2% for cancer cases and -33.4% for cancer deaths. The proportions of total cases and deaths of older adults were positively correlated with socioeconomic development of the country.

CONCLUSION

our findings revealed that the main contributor to increased cancer cases and deaths has changed from comprehensive epidemiological factors to demographic shifts. To respond to the rapidly growing occurrence of cancer in ageing populations, the global health priority should focus on meeting the rising demand for cancer diagnosis, treatment and care services for older people.

Phenomapping of Patients with Primary Breast Cancer Using Machine Learning-Based Unsupervised Cluster Analysis

Primary breast cancer (PBC) is a heterogeneous disease at the clinical, histopathological, and molecular levels. The improved classification of PBC might be important to identify subgroups of the disease, relevant to patient management. Machine learning algorithms may allow a better understanding of the relationships within heterogeneous clinical syndromes. This work aims to show the potential of unsupervised learning techniques for improving classification in PBC. A dataset of 712 women with PBC is used as a motivating example. A set of variables containing biological prognostic parameters is considered to define groups of individuals. Four different clustering methods are used: K-means, self-organising maps, hierarchical agglomerative (HAC), and Gaussian mixture models clustering. HAC outperforms the other clustering methods. With an optimal partitioning parameter, the methods identify two clusters with different clinical profiles. Patients in the first cluster are younger and have lower values of the oestrogen receptor (ER) and progesterone receptor (PgR) than patients in the second cluster. Moreover, cathepsin D values are lower in the first cluster. The three most important variables identified by the HAC are: age, ER, and PgR. Unsupervised learning seems a suitable alternative for the analysis of PBC data, opening up new perspectives in the particularly active domain of dissecting clinical heterogeneity.

Breast cancer treatment in the elderly: Do treatment plans that do not conform to NCCN recommendations lead to worse outcomes?

BACKGROUND

Aging remains one of the greatest risk factors for development of new breast cancer with more than 30% of breast cancers occurring after the age of 75. Elderly women have been found to not conform with all aspects of treatment recommendations. Our study compared outcomes of elderly breast cancer patients whose treatment did or did not conform to NCCN guidelines.

METHODS

A retrospective review was conducted of breast cancer patients over the age of 70. Comparisons were made between patients whose treatment did or did not conform to NCCN guidelines for recurrence, metastatic disease, and breast cancer related deaths.

RESULTS

Patients whose treatment did not conform to NCCN guidelines were older (80.5 vs. 77.7 years, P = 0.001). No significant difference was seen between groups for tumor size, breast cancer type, or nodal status; however, more nonconforming women were ER/PR positive (90.3% vs. 76.6%, P = 0.020). There was no significant difference in local recurrence, metastatic disease, or breast cancer related deaths.

CONCLUSIONS

Women whose treatment did not conform to NCCN guidelines were not associated with worse outcomes.

Experience with age discrimination and attitudes toward ageism in older patients with cancer and their caregivers: A nationwide Korean survey

OBJECTIVE

It is not clear whether age-related differences in treatment and treatment decision-making are the result of age discrimination or just a reflection of older patients' elevated risk and their own preferences. Therefore, it is critical to understand older patients' own views toward their care in regard to its relationship to age.

MATERIAL AND METHODS

439 older patients with cancer (age ≥ 60) and 358 family members from eleven cancer centers participated in this cross-sectional survey.

RESULTS

Almost all patients (91.2%) and caregivers (92.7%) thought that older patients should be treated equal to younger patients, across all questionnaire items. The proportions of patients who reported having experienced age discrimination according to each item were: disease information (12.3%), treatment information (11.0%), participation in treatment decision (10.7%), attention from healthcare professionals (6.2%), supportive care (5.2%), and treatment (3.2%). Increasing age was the only demographic characteristic that was associated with greater ageism experience (p < .001). Patients' ageism attitudes, as well as caregivers' ageism attitudes, were negatively associated with ageism experience. Ageism experience was associated with a higher depression score, as well as a lower quality of life.

CONCLUSION

Discrimination in treatment and the treatment decision process based on age was not justified. Interventions that address ageist attitudes in older patients, family caregivers, and healthcare professionals are needed to reduce age discrimination, and thereby improve the quality of life of older patients with cancer.

[Refusal of treatments by an adult cancer patient]

INTRODUCTION

Refusal of treatment questions the treatment's adequacy as well as the quality of the care relationship. A rigorous analysis of these situations is necessary in order to respect the patient's fundamental right to decide for him/herself while preventing a potential loss of chance. This paper proposes practical guidelines for assessment and management of the refusal of treatment by adult cancer patients.

METHODS

The French Association for Supportive Care in Cancer and the French Society for Psycho-Oncology formed a task force that applied a consensus methodology to draft guidelines.

RESULTS

We propose five guidelines: (1) be informed of the conditions most often associated with refusal of treatment so as to reinforce adequate support measures; (2) understand the complexity of the process of refusal and accurately identify what is precisely refused; (3) apply an approach of systematic analysis to refusal, to try and increase the possibilities of finding an agreement while reinforcing the respect of the patient's position; (4) establish a legal procedure to address refusal of treatment that safeguards the stakeholders when no accord can be found; and (5) know the indications for ethical collective decision-making.

CONCLUSION

A systematic assessment procedure of treatment refusal is necessary in order to ensure that all the physical, psychological and contextual aspects of it are taken into account, and to provide patients with the best treatment possible. The setting of good care relationship, the improvement of communication skills training and of comprehensive multidisciplinary care are all crucial elements in the prevention of these situations.

Clinical practice guidelines of the French Association for Supportive Care in Cancer and the French Society for Psycho-oncology: refusal of treatment by adults afflicted with cancer

PURPOSE

The study's purpose was to develop practical guidelines for assessment and management of refusal of treatment by adults afflicted with cancer.

METHODS

The French Association for Supportive Care in Cancer and the French Society for Psycho-oncology gathered a task force that applied a consensus methodology to draft guidelines studied predisposing situations, the diagnosis, regulatory aspects, and the management of refusal of treatment by adults afflicted with cancer.

RESULTS

We propose five guidelines: (1) be aware of the conditions/profiles of patients most often associated with refusal of treatment so as to adequately underpin the care and support measures; (2) understand the complexity of the process of refusal and knowing how to accurately identify the type and the modalities of the refused treatments; (3) apply a way to systematically analyze refusal, thereby promoting progression from a situation of disaccord toward a consensual decision; (4) devise procedures, according to the legal context, to address refusal of treatment that safeguards the stakeholders in situations of sustained disaccord; and (5) know the indications for ethical collective decision-making.

CONCLUSION

The quality of the relationship between patients and health professionals, and the communication between them are essential components involved in reaching a point of consent or refusal of treatment. A process of systematic analysis of refusal is recommended as the only way to ensure that all of the physiological, psychological, and contextual elements that are potentially involved are taken into account.

Adjuvant chemotherapy in elderly patients with breast cancer: key challenges

Elderly women with early breast cancer (BC) form a heterogeneous and large subgroup (41.8% of women with BC are over 65). Decision making in this subgroup is made more difficult by lack of familiarity with their physical, cognitive and social issues. Adequate management depends on biological factors and accurate clinical evaluation through comprehensive geriatric assessment (CGA). CGA can help to better select and determine potential risks factors for patients who are candidates for adjuvant chemotherapy. It is still recently introduced in geriatric oncology and there is a lack of awareness of its importance. Available data on adjuvant chemotherapy for BC is limited but suggests it can be of benefit for well selected patients, though the risk of short and long-term toxicity is significant. Here we provide a discussion of the key practical issues in decision making in the setting of adjuvant chemotherapy for elderly BC patients.

Distinct postsurgical management in young and elderly breast cancer patients results in equal survival rates

BACKGROUND

Although breast cancer (BC) is one of the most common malignant diseases in women, the majority of the studies describing the characteristics of BC in elderly patients have been limited to survival assessments or tumor features, without using younger BC patients as a reference group. The aim of our study was to describe and compare tumor characteristics and management patterns in elderly versus younger breast cancer patients in Turkey.

MATERIALS AND METHODS

We retrospectively analyzed 152 patients with invasive breast cancer who underwent surgery in our institution between 2002 and 2012. Patients were divided into 2 groups according to age at the time of diagnosis.

RESULTS

There were 62 patients in the elderly group (≥65 years) and 90 patients in the younger group (<65 years). Compared to the younger group, tumors in the elderly group were more likely to be larger (p=0.018), of lower grade (p=0.005), and hormone receptor-positive (p>0.001). There were no significant differences regarding histology, localization, lymph node involvement, or types of surgical procedures between the 2 groups. Comorbidities were more common in elderly patients (p<0.001). In addition, elderly patients were more likely to receive hormonal therapy (p<0.001) and less likely to receive radiotherapy (p=0.08) and chemotherapy (p=0.003). There was no difference in survival and locoregional recurrence rates between the groups.

CONCLUSIONS

The results of this study demonstrate that breast cancer in elderly patients has more favorable tumor features, warranting less aggressive treatment regimens after surgery.

The role of primary endocrine therapy in older women with operable breast cancer

ABSTRACT 

A Cochrane review of randomized trials shows no difference in overall survival between surgery and primary endocrine therapy (PET) in older women with operable primary breast cancer. Most of these trials were small and unselected for estrogen receptor (ER) status. Evidence exists showing a significant correlation between the degree of ER-positivity and response and outcome in patients receiving PET. Although surgery remains the treatment of choice, patients with ER-rich tumors tend to do equally well on PET. When deciding optimal therapies, co-morbidities and frailty (which impact on the likelihood of death due to competing causes), patient choice, agent of choice (notably the third-generation aromatase inhibitors) and biology (more than just being ER-positive) should all be taken into account.

A systematic review of factors influencing older adults' decision to accept or decline cancer treatment

BACKGROUND

Cancer is a disease that affects mostly older adults. Older adults often have other chronic health conditions in addition to cancer and may have different health priorities, both of which can impact cancer treatment decision-making. However, no systematic review of factors that influence an older cancer patient's decision to accept or decline cancer treatment has been conducted.

MATERIALS AND METHODS

Systematic review of the literature published between inception of the databases and February 2013. Dutch, English, French or German articles reporting on qualitative studies, cross-sectional, longitudinal observational or intervention studies describing factors why older adults accepted or declined cancer treatment examining actual treatment decisions were included. Ten databases were used. Two independent reviewers reviewed manuscripts and performed data abstraction using a standardized form and the quality of studies was assessed with the Mixed Methods Appraisal Tool.

RESULTS

Of 17,343 abstracts reviewed, a total of 38 studies were included. The majority focused on breast and prostate cancer treatment decisions and most studies used a qualitative design. Important factors for accepting treatment were convenience and success rate of treatment, seeing necessity of treatment, trust in the physician and following the physician's recommendation. Factors important for declining cancer treatment included concerns about the discomfort of the treatments, fear of side effects and transportation difficulties.

CONCLUSION

Although the reasons why older adults with cancer accepted or declined treatment varied considerably, the most consistent determinant was physician recommendation. Further studies using large, representative samples and exploring decision-making incorporating health literacy and comorbidity are needed.

A population based study of variations in operation rates for breast cancer, of comorbidity and prognosis at diagnosis: failure to operate for early breast cancer in older women

BACKGROUND

Older women are less likely to have surgery for operable breast cancer. This population-based study examines operation rates by age and identifies groups which present with early or late disease.

METHODS

37 000 cancer registrations for 2007 were combined with Hospital Episode Statistics comorbidity data for England. Operation rates were examined by age, ethnicity, deprivation, comorbidity, screen-detection, tumour size, grade and nodal status. Early and late presentation were correlated with Nottingham Prognostic Index (NPI) groups and tumour size.

RESULTS

The proportion of women not having surgery increased from 7-10% at ages 35-69 to 82% from age 90. From age 70, the proportion not having surgery rose by an average of 3.1% per year of age. Women with a Charlson Comorbidity Index score of ≥1 (which increased with age), with tumours >50 mm or who were node positive, were less likely to have surgery. Although women aged 70-79 were more likely to have larger tumours, their tumours were also more likely to have an excellent or good NPI (p < 0.001). Good prognosis tumours were more likely to be screen-detected, and less likely in women aged 0-39, the deprived and certain ethnic groups (p < 0.02).

CONCLUSIONS

From age 70 there is an increasing failure to operate for breast cancer. Younger women and certain ethnic groups presented with more advanced tumours. Older women had larger tumours which were otherwise of good prognosis, and this would not account for the failure to operate which may in part be related to comorbidity in this age group.

Is lack of surgery for older breast cancer patients in the UK explained by patient choice or poor health? A prospective cohort study

BACKGROUND

Older women have lower breast cancer surgery rates than younger women. UK policy states that differences in cancer treatment by age can only be justified by patient choice or poor health.

METHODS

We investigate whether lack of surgery for older patients is explained by patient choice/poor health in a prospective cohort study of 800 women aged ≥70 years diagnosed with operable (stage 1-3a) breast cancer at 22 English breast cancer units in 2010-2013.

DATA COLLECTION

interviews and case note review.

OUTCOME MEASURE

surgery for operable (stage 1-3a) breast cancer <90 days of diagnosis. Logistic regression adjusts for age, health measures, tumour characteristics, socio-demographics and patient's/surgeon's perceived responsibility for treatment decisions.

RESULTS

In the univariable analyses, increasing age predicts not undergoing surgery from the age of 75 years, compared with 70-74-year-olds. Adjusting for health measures and choice, only women aged ≥85 years have reduced odds of surgery (OR 0.18, 95% CI: 0.07-0.44). Each point increase in Activities of Daily Living score (worsening functional status) reduced the odds of surgery by over a fifth (OR 0.23, 95% CI: 0.15-0.35). Patient's role in the treatment decisions made no difference to whether they received surgery or not; those who were active/collaborative were as likely to get surgery as those who were passive, that is, left the decision up to the surgeon.

CONCLUSION

Lower surgery rates, among older women with breast cancer, are unlikely to be due to patients actively opting out of having this treatment. However, poorer health explains the difference in surgery between 75-84-year-olds and younger women. Lack of surgery for women aged ≥85 years persists even when health and patient choice are adjusted for.

Locoregional Recurrence and Survival Rates after Breast-Conserving Surgery and Hormonal Therapy in 70-Year-Old or Older Patients with Stage I or IIA Breast Carcinoma

BACKGROUND

Data for treatment of elderly women (≥ 70 years) with estrogen receptor-positive early stage breast cancer are available. We have compared different treatment options to determine whether lumpectomy (LU) plus adjuvant hormonal therapy (HT) is as effective as combined LU, HT, and radiotherapy (RT).

METHOD

Medical records of elderly patients over 69 years of age who had been treated for T1N0M0 (stage I) and T2N0M0 (stage IIA) at 2 different medical centers between March 2004 and January 2011 were assessed, and 35 patients were included in this study. 21 of these patients underwent only breast-conserving surgery (BCS) and HT (Group 1: T1N0M0-Group 1a, n = 16; T2N0M0-Group 1b, n = 5) and the others either BCS, HT and RT (Group 2, n = 4) or BCS, chemotherapy (CT), HT and RT (Group 3, n = 10). Adjuvant HT for all the patients comprised aromatase inhibitors.

RESULTS

The mean follow-up period for Groups 1, 2 and 3 were 32.2, 31.3 and 20.4 months, respectively. No locoregional recurrence or cancer-specific mortality occurred in any of these patients; 1 patient from Group 1 died of a different cause.

DISCUSSION

The BCS+HT regimen seems to be an efficient treatment option for early stage breast cancer in selected 70-year-old and older patient groups.

Clinical and Biological Significance of Cathepsin D Levels in Breast Cancer Cytosol in Women Over 70 years

Objective

To study cytosolic cathepsin D behavior and possible relationship with other clinical and biological parameters in women affected by breast invasive ductal carcinomas and older than 70 years (range: 71–88).

Material and methods

cytosolic levels of cathepsin D were determined by an Immunoradiometric Assay (IRMA-CIS France). Clinical and biological factors analyzed were: size, axillary lymph node involvement, distant metastasis, histological grade, ploidy, S phase cell, cytosolic estrogen receptor, progesterone receptor and pS2, and concentrations of epidermal growth factor receptor (EGFR) in cell membranes.

Results

Cathepsin D concentrations ranged between 13 and 1228 pmol/mg prot.. Median value of 41 was considered as threshold of positivity. Cathepsin D positive tumors showed higher S-phase values (P = 0.046) and were most often histological grade III (P = 0.047). However, the most important finding was the existence of a positive correlation (r = 0.51786) and statistically significant (P < 0.05) between S-phase values and cathepsin D in the overall group of tumors, and those ER+, but not in ER−. We determined cathepsin D concentrations in 131 women with invasive ductal breast carcinomas, but aged between 50 and 70 years (median 61) and we did not find differences based on those values in women >70 years. In addition, we found no correlation between S-phase values and Cathepsin D, both overall and in relation with hormone dependence (ER).

Conclusions

Those results led us to the following conclusions: (1) cytosolic concentrations of cathepsin D in invasive infiltrating breast carcinomas in women over 70 are similar to those seen in women with the same type of tumor, but aged 50 to 70 years and are associated with increased cell proliferation measured by S phase, and histological grade III; (2) in women older than 70 years, cathepsin D concentrations are statistically significantly correlated with phase synthesis values in hormone-dependent tumors, but not in hormone-independent, fact not observed in infiltrating ductal breast carcinomas of women aged between 50 and 70. This could reflect a different mitogenic role of the aspartyl protease enzyme linked to hormone dependence as age function parameter.

Long-term clinical outcome of oestrogen receptor-positive operable primary breast cancer in older women: a large series from a single centre

INTRODUCTION

A Cochrane review of seven randomised trials (N=1571) comparing surgery and primary endocrine therapy (PET) (oestrogen receptor (ER) unselected) shows no difference in overall survival (OS). We report outcome of a large series with ER-positive (ER+) early invasive primary breast cancer.

METHODS

Between 1973 and 2009, 1065 older (≥ 70 years) women (median age 78 years (70-99)) had either surgery (N=449) or PET (N=616) as initial treatment.

RESULTS

At 49-month median follow-up (longest 230 months), the 5-year breast cancer-specific survival (BCSS) and OS were 90 and 62%, respectively. Majority (74.2%) died from causes other than breast cancer. The rates (per annum) of local/regional recurrence (<1%) (following surgery), contralateral tumour (<1%) and metastases (<3%) were low. For patients on PET, 97.9% achieved clinical benefit (CB) at 6 months, with median time to progression of 49 months (longest 132 months) and significantly longer BCSS when compared with those who progressed (P<0.001). All patients with strongly ER+ (H-score >250) tumours achieved CB and had better BCSS (P<0.01). Patients with tumours having an H-score >250 were found to have equivalent BCSS regardless of treatment (surgery or PET; P=0.175), whereas for those with H-score ≤ 250, surgery produced better outcome (P<0.001).

CONCLUSION

Older women with ER+ breast cancer appear to have excellent long-term outcome regardless of initial treatment. Majority also die from non-breast cancer causes. Although surgery remains the treatment of choice, patients with ER-rich (H-score >250) tumours tend to do equally well when treated by PET. This should be taken into account when therapies are considered.