1
|
Martin C, Burton M, Wyld L. Caregiver experiences of making treatment decisions for older women with breast cancer and dementia. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e2058-e2068. [PMID: 34761449 DOI: 10.1111/hsc.13640] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 08/25/2021] [Accepted: 10/04/2021] [Indexed: 06/13/2023]
Abstract
Family caregivers are an important source of support for older people living with dementia, especially when faced with a new diagnosis of cancer. Little is currently known about the caregiver role in facilitating treatment discussions, and the factors that underpin breast cancer treatment decision-making in older patients. This study used a sequential explanatory mixed method approach to explore the role of family caregivers in making cancer treatment decisions for older women (aged over 70 years) with pre-existing dementia and primary operable breast cancer. Thirteen caregivers participated in the study (13 completed a postal questionnaire; eight questionnaire respondents participated in a semi-structured interview). Quantitative data were analysed descriptively, and the Framework Approach was used to analyse qualitative findings and identify themes. Three themes were generated: (a) Clinical interactions, information and support; (b) Treatment decision-making processes and (c) Influences on treatment choice. These findings highlight the complexities that caregivers face when navigating cancer treatment options and their role in facilitating treatment decisions.
Collapse
Affiliation(s)
- Charlene Martin
- Department of Oncology and Metabolism, The University of Sheffield, The Medical School, Sheffield, UK
| | - Maria Burton
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - Lynda Wyld
- Department of Oncology and Metabolism, The University of Sheffield, The Medical School, Sheffield, UK
| |
Collapse
|
2
|
Wyld L, Reed MWR, Collins K, Ward S, Holmes G, Morgan J, Bradburn M, Walters S, Burton M, Lifford K, Edwards A, Brain K, Ring A, Herbert E, Robinson TG, Martin C, Chater T, Pemberton K, Shrestha A, Nettleship A, Richards P, Brennan A, Cheung KL, Todd A, Harder H, Audisio R, Battisti NML, Wright J, Simcock R, Murray C, Thompson AM, Gosney M, Hatton M, Armitage F, Patnick J, Green T, Revill D, Gath J, Horgan K, Holcombe C, Winter M, Naik J, Parmeshwar R. Improving outcomes for women aged 70 years or above with early breast cancer: research programme including a cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/xzoe2552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
In breast cancer management, age-related practice variation is widespread, with older women having lower rates of surgery and chemotherapy than younger women, based on the premise of reduced treatment tolerance and benefit. This may contribute to inferior outcomes. There are currently no age- and fitness-stratified guidelines on which to base treatment recommendations.
Aim
We aimed to optimise treatment choice and outcomes for older women (aged ≥ 70 years) with operable breast cancer.
Objectives
Our objectives were to (1) determine the age, comorbidity, frailty, disease stage and biology thresholds for endocrine therapy alone versus surgery plus adjuvant endocrine therapy, or adjuvant chemotherapy versus no chemotherapy, for older women with breast cancer; (2) optimise survival outcomes for older women by improving the quality of treatment decision-making; (3) develop and evaluate a decision support intervention to enhance shared decision-making; and (4) determine the degree and causes of treatment variation between UK breast units.
Design
A prospective cohort study was used to determine age and fitness thresholds for treatment allocation. Mixed-methods research was used to determine the information needs of older women to develop a decision support intervention. A cluster-randomised trial was used to evaluate the impact of this decision support intervention on treatment choices and outcomes. Health economic analysis was used to evaluate the cost–benefit ratio of different treatment strategies according to age and fitness criteria. A mixed-methods study was used to determine the degree and causes of variation in treatment allocation.
Main outcome measures
The main outcome measures were enhanced age- and fitness-specific decision support leading to improved quality-of-life outcomes in older women (aged ≥ 70 years) with early breast cancer.
Results
(1) Cohort study: the study recruited 3416 UK women aged ≥ 70 years (median age 77 years). Follow-up was 52 months. (a) The surgery plus adjuvant endocrine therapy versus endocrine therapy alone comparison: 2854 out of 3416 (88%) women had oestrogen-receptor-positive breast cancer, 2354 of whom received surgery plus adjuvant endocrine therapy and 500 received endocrine therapy alone. Patients treated with endocrine therapy alone were older and frailer than patients treated with surgery plus adjuvant endocrine therapy. Unmatched overall survival and breast-cancer-specific survival were higher in the surgery plus adjuvant endocrine therapy group (overall survival: hazard ratio 0.27, 95% confidence interval 0.23 to 0.33; p < 0.001; breast-cancer-specific survival: hazard ratio 0.41, 95% confidence interval 0.29 to 0.58; p < 0.001) than in the endocrine therapy alone group. In matched analysis, surgery plus adjuvant endocrine therapy was still associated with better overall survival (hazard ratio 0.72, 95% confidence interval 0.53 to 0.98; p = 0.04) than endocrine therapy alone, but not with better breast-cancer-specific survival (hazard ratio 0.74, 95% confidence interval 0.40 to 1.37; p = 0.34) or progression-free-survival (hazard ratio 1.11, 95% confidence interval 0.55 to 2.26; p = 0.78). (b) The adjuvant chemotherapy versus no chemotherapy comparison: 2811 out of 3416 (82%) women received surgery plus adjuvant endocrine therapy, of whom 1520 (54%) had high-recurrence-risk breast cancer [grade 3, node positive, oestrogen receptor negative or human epidermal growth factor receptor-2 positive, or a high Oncotype DX® (Genomic Health, Inc., Redwood City, CA, USA) score of > 25]. In this high-risk population, there were no differences according to adjuvant chemotherapy use in overall survival or breast-cancer-specific survival after propensity matching. Adjuvant chemotherapy was associated with a lower risk of metastatic recurrence than no chemotherapy in the unmatched (adjusted hazard ratio 0.36, 95% confidence interval 0.19 to 0.68; p = 0.002) and propensity-matched patients (adjusted hazard ratio 0.43, 95% confidence interval 0.20 to 0.92; p = 0.03). Adjuvant chemotherapy improved the overall survival and breast-cancer-specific survival of patients with oestrogen-receptor-negative disease. (2) Mixed-methods research to develop a decision support intervention: an iterative process was used to develop two decision support interventions (each comprising a brief decision aid, a booklet and an online tool) specifically for older women facing treatment choices (endocrine therapy alone or surgery plus adjuvant endocrine therapy, and adjuvant chemotherapy or no chemotherapy) using several evidence sources (expert opinion, literature and patient interviews). The online tool was based on models developed using registry data from 23,842 patients and validated on an external data set of 14,526 patients. Mortality rates at 2 and 5 years differed by < 1% between predicted and observed values. (3) Cluster-randomised clinical trial of decision support tools: 46 UK breast units were randomised (intervention, n = 21; usual care, n = 25), recruiting 1339 women (intervention, n = 670; usual care, n = 669). There was no significant difference in global quality of life at 6 months post baseline (difference –0.20, 95% confidence interval –2.7 to 2.3; p = 0.90). In women offered a choice of endocrine therapy alone or surgery plus adjuvant endocrine therapy, knowledge about treatments was greater in the intervention arm than the usual care arm (94% vs. 74%; p = 0.003). Treatment choice was altered, with higher rates of endocrine therapy alone than of surgery in the intervention arm. Similarly, chemotherapy rates were lower in the intervention arm (endocrine therapy alone rate: intervention sites 21% vs. usual-care sites 15%, difference 5.5%, 95% confidence interval 1.1% to 10.0%; p = 0.02; adjuvant chemotherapy rate: intervention sites 10% vs. usual-care site 15%, difference 4.5%, 95% confidence interval 0.0% to 8.0%; p = 0.013). Survival was similar in both arms. (4) Health economic analysis: a probabilistic economic model was developed using registry and cohort study data. For most health and fitness strata, surgery plus adjuvant endocrine therapy had lower costs and returned more quality-adjusted life-years than endocrine therapy alone. However, for some women aged > 90 years, surgery plus adjuvant endocrine therapy was no longer cost-effective and generated fewer quality-adjusted life-years than endocrine therapy alone. The incremental benefit of surgery plus adjuvant endocrine therapy reduced with age and comorbidities. (5) Variation in practice: analysis of rates of surgery plus adjuvant endocrine therapy or endocrine therapy alone between the 56 breast units in the cohort study demonstrated significant variation in rates of endocrine therapy alone that persisted after adjustment for age, fitness and stage. Clinician preference was an important determinant of treatment choice.
Conclusions
This study demonstrates that, for older women with oestrogen-receptor-positive breast cancer, there is a cohort of women with a life expectancy of < 4 years for whom surgery plus adjuvant endocrine therapy may offer little benefit and simply have a negative impact on quality of life. The Age Gap decision tool may help make this shared decision. Similarly, although adjuvant chemotherapy offers little benefit and has a negative impact on quality of life for the majority of older women with oestrogen-receptor-positive breast cancer, for women with oestrogen-receptor-negative breast cancer, adjuvant chemotherapy is beneficial. The negative impacts of adjuvant chemotherapy on quality of life, although significant, are transient. This implies that, for the majority of fitter women aged ≥ 70 years, standard care should be offered.
Limitations
As with any observational study, despite detailed propensity score matching, residual bias cannot be excluded. Follow-up was at median 52 months for the cohort analysis. Longer-term follow-up will be required to validate these findings owing to the slow time course of oestrogen-receptor-positive breast cancer.
Future work
The online algorithm is now available (URL: https://agegap.shef.ac.uk/; accessed May 2022). There are plans to validate the tool and incorprate quality-of-life and 10-year survival outcomes.
Trial registration
This trial is registered as ISRCTN46099296.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 6. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Karen Collins
- Faculty of Health and Wellbeing, Department of Allied Health Professions, Collegiate Cresent Campus, Sheffield Hallam University, Sheffield, UK
| | - Sue Ward
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Geoff Holmes
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jenna Morgan
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Mike Bradburn
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Stephen Walters
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Maria Burton
- Faculty of Health and Wellbeing, Department of Allied Health Professions, Collegiate Cresent Campus, Sheffield Hallam University, Sheffield, UK
| | - Kate Lifford
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Kate Brain
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Esther Herbert
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Cardiovascular Research Centre, Glenfield General Hospital, Leicester, UK
| | - Charlene Martin
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Tim Chater
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Kirsty Pemberton
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Anne Shrestha
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Paul Richards
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alan Brennan
- Department of Health and Social Care Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Annaliza Todd
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
- Jasmine Breast Centre, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | | | - Riccardo Audisio
- Sahlgrenska Universitetssjukhuset, University of Gothenburg, Göteborg, Sweden
| | | | | | | | | | | | - Margot Gosney
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | | | | | - Julietta Patnick
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tracy Green
- Yorkshire and Humber Research Network Consumer Research Panel, Sheffield, UK
| | - Deirdre Revill
- Yorkshire and Humber Research Network Consumer Research Panel, Sheffield, UK
| | - Jacqui Gath
- Yorkshire and Humber Research Network Consumer Research Panel, Sheffield, UK
| | | | - Chris Holcombe
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Matt Winter
- Breast Unit, Weston Park Hospital, Sheffield, UK
| | - Jay Naik
- Breast Unit, Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Rishi Parmeshwar
- Breast Unit, Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, UK
| |
Collapse
|
3
|
Parks RM, Holmes HM, Cheung KL. Current Challenges Faced by Cancer Clinical Trials in Addressing the Problem of Under-Representation of Older Adults: A Narrative Review. Oncol Ther 2021; 9:55-67. [PMID: 33481206 PMCID: PMC7820837 DOI: 10.1007/s40487-021-00140-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/09/2021] [Indexed: 12/11/2022] Open
Abstract
The number of older adults living with cancer is increasing. There is a clear lack of representation of older adults in clinical trials, including cancer trials. Reasons for this are multifactorial and complex and include protocol, patient and sponsor factors. Potential solutions to overcome issues with trial design include varied methods of recruitment with flexible inclusion criteria. Possible alternatives to randomised trials include prospective cohort studies, pragmatic trials and the use of national population-based data sets. Patient factors may be addressed by integration of geriatric assessment, so patients can be randomised or treated based on their individual needs. Additionally, standard protocols for including older adults with cognitive impairment should be developed, rather than automatic exclusion. Increased effort is needed from sponsors and governing health care bodies to make recruitment of older adults to clinical trials standard.
Collapse
Affiliation(s)
- Ruth M Parks
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, University of Texas Health Science Center McGovern Medical School, Houston, USA
| | - Kwok-Leung Cheung
- Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Nottingham, UK.
| |
Collapse
|
4
|
Ring A, Battisti NML, Reed MWR, Herbert E, Morgan JL, Bradburn M, Walters SJ, Collins KA, Ward SE, Holmes GR, Burton M, Lifford K, Edwards A, Robinson TG, Martin C, Chater T, Pemberton KJ, Brennan A, Cheung KL, Todd A, Audisio RA, Wright J, Simcock R, Green T, Revell D, Gath J, Horgan K, Holcombe C, Winter MC, Naik J, Parmeshwar R, Gosney MA, Hatton MQ, Thompson AM, Wyld L. Bridging The Age Gap: observational cohort study of effects of chemotherapy and trastuzumab on recurrence, survival and quality of life in older women with early breast cancer. Br J Cancer 2021; 125:209-219. [PMID: 33972747 PMCID: PMC8292504 DOI: 10.1038/s41416-021-01388-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/20/2021] [Accepted: 03/31/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Chemotherapy improves outcomes for high risk early breast cancer (EBC) patients but is infrequently offered to older individuals. This study determined if there are fit older patients with high-risk disease who may benefit from chemotherapy. METHODS A multicentre, prospective, observational study was performed to determine chemotherapy (±trastuzumab) usage and survival and quality-of-life outcomes in EBC patients aged ≥70 years. Propensity score-matching adjusted for variation in baseline age, fitness and tumour stage. RESULTS Three thousands four hundred sixteen women were recruited from 56 UK centres between 2013 and 2018. Two thousands eight hundred eleven (82%) had surgery. 1520/2811 (54%) had high-risk EBC and 2059/2811 (73%) were fit. Chemotherapy was given to 306/1100 (27.8%) fit patients with high-risk EBC. Unmatched comparison of chemotherapy versus no chemotherapy demonstrated reduced metastatic recurrence risk in high-risk patients(hazard ratio [HR] 0.36 [95% CI 0.19-0.68]) and in 541 age, stage and fitness-matched patients(adjusted HR 0.43 [95% CI 0.20-0.92]) but no benefit to overall survival (OS) or breast cancer-specific survival (BCSS) in either group. Chemotherapy improved survival in women with oestrogen receptor (ER)-negative cancer (OS: HR 0.20 [95% CI 0.08-0.49];BCSS: HR 0.12 [95% CI 0.03-0.44]).Transient negative quality-of-life impacts were observed. CONCLUSIONS Chemotherapy was associated with reduced risk of metastatic recurrence, but survival benefits were only seen in patients with ER-negative cancer. Quality-of-life impacts were significant but transient. TRIAL REGISTRATION ISRCTN 46099296.
Collapse
Affiliation(s)
- Alistair Ring
- Department of Medicine, Breast Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK & Breast Cancer Research Division, The Institute of Cancer Research, London, UK
| | - Nicolò Matteo Luca Battisti
- Department of Medicine, Breast Unit, The Royal Marsden Hospital NHS Foundation Trust, London, UK & Breast Cancer Research Division, The Institute of Cancer Research, London, UK
| | | | - Esther Herbert
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jenna L Morgan
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - Michael Bradburn
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Stephen J Walters
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Karen A Collins
- College of Health, Wellbeing and Life Sciences, Department of Allied Health Professions, Sheffield Hallam University, Sheffield, UK
| | - Sue E Ward
- Department of Health Economics and Decision Science, School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Geoffrey R Holmes
- Department of Health Economics and Decision Science, School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Maria Burton
- College of Health, Wellbeing and Life Sciences, Department of Allied Health Professions, Sheffield Hallam University, Sheffield, UK
| | - Kate Lifford
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Biomedical Research Centre, University of Leicester, Cardiovascular Research Centre, Leicester, UK
| | - Charlene Martin
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - Tim Chater
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Kirsty J Pemberton
- Clinical Trials Research Unit, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Alan Brennan
- Department of Health Economics and Decision Science, School for Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Kwok Leung Cheung
- School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
| | - Annaliza Todd
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK
| | - Riccardo A Audisio
- University of Gothenberg, Sahlgrenska Universitetssjukhuset, Göteborg, Sweden
| | | | - Richard Simcock
- Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK
| | - Tracey Green
- Yorkshire and Humber Consumer Research Panel, Cottingham, UK
| | - Deirdre Revell
- Yorkshire and Humber Consumer Research Panel, Cottingham, UK
| | - Jacqui Gath
- Yorkshire and Humber Consumer Research Panel, Cottingham, UK
| | - Kieran Horgan
- Department of Breast Surgery, Bexley Cancer Centre, St James's University Hospital, Leeds, UK
| | - Chris Holcombe
- Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | | | - Jay Naik
- Pinderfields Hospital, Mid Yorkshire NHS Foundation Trust, Wakefield, UK
| | - Rishi Parmeshwar
- University Hospitals of Morecambe Bay, Royal Lancashire Infirmary, Lancaster, Lancashire, UK
| | | | | | | | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield Medical School, Sheffield, UK.
| | | |
Collapse
|
5
|
Gómez-Acebo I, Dierssen-Sotos T, Mirones M, Pérez-Gómez B, Guevara M, Amiano P, Sala M, Molina AJ, Alonso-Molero J, Moreno V, Suarez-Calleja C, Molina-Barceló A, Alguacil J, Marcos-Gragera R, Fernández-Ortiz M, Sanz-Guadarrama O, Castaño-Vinyals G, Gil-Majuelo L, Moreno-Iribas C, Aragonés N, Kogevinas M, Pollán M, Llorca J. Adequacy of early-stage breast cancer systemic adjuvant treatment to Saint Gallen-2013 statement: the MCC-Spain study. Sci Rep 2021; 11:5375. [PMID: 33686151 PMCID: PMC7970883 DOI: 10.1038/s41598-021-84825-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 01/20/2021] [Indexed: 11/27/2022] Open
Abstract
The St Gallen Conference endorsed in 2013 a series of recommendations on early breast cancer treatment. The main purpose of this article is to ascertain the clinical factors associated with St Gallen-2013 recommendations accomplishment. A cohort of 1152 breast cancer cases diagnosed with pathological stage < 3 in Spain between 2008 and 2013 was begun and then followed-up until 2017/2018. Data on patient and tumour characteristics were obtained from medical records, as well as their first line treatment. First line treatments were classified in three categories, according on whether they included the main St Gallen-2013 recommendations, more than those recommended or less than those recommended. Multinomial logistic regression models were carried out to identify factors associated with this classification and Weibull regression models were used to find out the relationship between this classification and survival. About half of the patients were treated according to St Gallen recommendations; 21% were treated over what was recommended and 33% received less treatment than recommended. Factors associated with treatment over the recommendations were stage II (relative risk ratio [RRR] = 4.2, 2.9-5.9), cancer positive to either progesterone (RRR = 8.1, 4.4-14.9) or oestrogen receptors (RRR = 5.7, 3.0-11.0). Instead, factors associated with lower probability of treatment over the recommendations were age (RRR = 0.7 each 10 years, 0.6-0.8), poor differentiation (RRR = 0.09, 0.04-0.19), HER2 positive (RRR = 0.46, 0.26-0.81) and triple negative cancer (RRR = 0.03, 0.01-0.11). Patients treated less than what was recommended in St Gallen had cancers in stage 0 (RRR = 21.6, 7.2-64.5), poorly differentiated (RRR = 1.9, 1.2-2.9), HER2 positive (RRR = 3.4, 2.4-4.9) and luminal B-like subtype (RRR = 3.6, 2.6-5.1). Women over 65 years old had a higher probability of being treated less than what was recommended if they had luminal B-like, HER2 or triple negative cancer. Treatment over St Gallen was associated with younger women and less severe cancers, while treatment under St Gallen was associated with older women, more severe cancers and cancers expressing HER2 receptors.
Collapse
Affiliation(s)
- Inés Gómez-Acebo
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
- Universidad de Cantabria, Santander, Spain.
- IDIVAL, Santander, Spain.
- Medicina Preventiva y Salud Pública, Facultad de Medicina, Avda. Herrera Oria s/n, 39011, Santander, Cantabria, Spain.
| | - Trinidad Dierssen-Sotos
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Universidad de Cantabria, Santander, Spain
- IDIVAL, Santander, Spain
| | | | - Beatriz Pérez-Gómez
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- National Center for Epidemiology, Carlos III Institute of Health, Madrid, Spain
| | - Marcela Guevara
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Navarra Public Health Institute, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Pilar Amiano
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Public Health Division of Gipuzkoa, Biodonostia Health Research Institute, Ministry of Health of the Basque Government, San Sebastian, Spain
| | - Maria Sala
- Department of Epidemiology and Evaluation, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Research Network on Health Services in Chronic Diseases (REDISSEC), Barcelona, Spain
| | - Antonio J Molina
- Grupo de Investigación en Interacción Gen-Ambiente-Salud (GIIGAS), Instituto de Biomedicina (IBIOMED), Universidad de León, León, Spain
| | | | - Victor Moreno
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Oncology Data Analytics Program, Catalan Institute of Oncology (ICO), Hospitalet de Llobregat, Barcelona, Spain
- Colorectal Cancer Group, ONCOBELL Program, Bellvitge Biomedical Research Institute (IDIBELL), Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Claudia Suarez-Calleja
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias-ISPA, Oviedo, Spain
- IUOPA, Universidad de Oviedo, Oviedo, Spain
| | | | - Juan Alguacil
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Centro de Investigación en Recursos Naturales, Salud y Medio Ambiente (RENSMA), Universidad de Huelva, Huelva, Spain
| | - Rafael Marcos-Gragera
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health, Autonomous Government of Catalonia, Catalan Institute of Oncology, Girona, Spain
| | | | - Oscar Sanz-Guadarrama
- Servicio de Cirugía General, Unidad de Mama, Complejo Asistencial Universitario de León, León, Spain
| | - Gemma Castaño-Vinyals
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- ISGlobal, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Leire Gil-Majuelo
- Public Health Division of Gipuzkoa, Biodonostia Health Research Institute, Ministry of Health of the Basque Government, San Sebastian, Spain
| | - Conchi Moreno-Iribas
- Navarra Public Health Institute, Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Nuria Aragonés
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Epidemiology Section, Public Health Division, Department of Health, Madrid, Spain
| | - Manolis Kogevinas
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- ISGlobal, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Marina Pollán
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- National Center for Epidemiology, Carlos III Institute of Health, Madrid, Spain
| | - Javier Llorca
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Universidad de Cantabria, Santander, Spain
| |
Collapse
|
6
|
Chemotherapy Options beyond the First Line in HER-Negative Metastatic Breast Cancer. JOURNAL OF ONCOLOGY 2020; 2020:9645294. [PMID: 33312203 PMCID: PMC7719522 DOI: 10.1155/2020/9645294] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/05/2020] [Accepted: 11/11/2020] [Indexed: 12/24/2022]
Abstract
Despite the recent advances in the biological understanding of breast cancer (BC), chemotherapy still represents a key component in the armamentarium for this disease. Different agents are available as mono-chemotherapy options in patients with locally advanced or metastatic BC (MBC) who progress after a first- and second-line treatment with anthracyclines and taxanes. However, no clear indication exists on what the best option is in some populations, such as heavily pretreated, elderly patients, triple-negative BC (TNBC), and those who do not respond to the first-line therapy. In this article, we summarize available literature evidence on different chemotherapy agents used beyond the first-line, in locally advanced or MBC patients, including rechallenge with anthracyclines and taxanes, antimetabolite and antimicrotubule agents, such as vinorelbine, capecitabine, eribulin, ixabepilone, and the newest developed agents, such as vinflunine, irinotecan, and etirinotecan.
Collapse
|
7
|
Abstract
Improvements in breast cancer (BC) mortality rates have not been seen in the older adult community, and the fact that older adults are more likely to die from their cancer than younger women establishes a major health disparity. Studies have identified that despite typically presenting with more favorable histology, older women present with more advanced disease, which may be related in part to delayed diagnosis. This is supported by examination of screening practices in older adults. Older women have a worse prognosis than younger women in both early stage disease, and more advanced and metastatic disease. Focus on the treatment of older adults has often concentrated on avoiding overtreatment, but in fact undertreatment may be one reason for the age-related differences in outcomes, and treatments need to be individualized for every older adult, and take into account patient preferences and functional status and not chronologic age alone. Given the aging population in the US, identifying methods to improve early diagnosis in this population and identify additional factors will be important to reducing this age-related disparity.
Collapse
|
8
|
Fleurier C, De Wit A, Pilloy J, Boivin L, Jourdan ML, Arbion F, Body G, Ouldamer L. Outcome of patients with breast cancer in the oldest old (≥80 years). Eur J Obstet Gynecol Reprod Biol 2019; 244:66-70. [PMID: 31760264 DOI: 10.1016/j.ejogrb.2019.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE In the present study, we present a large institutional study to determine the influence of age≥ 80 years on breast cancer presentation and prognosis. METHODS The study is a retrospective analysis of our prospectively maintained breast cancer database study using data from of women managed from January 2007 through December 2013. Clinicopathologic characteristics were correlated with outcomes according to age (<80 years and ≥ 80 years). RESULTS During the study period, 2083 women with invasive breast cancer were included of which 160 women aged ≥ 80 years (7.7 %). Overall survival was lower in the oldest old than in younger counterparts (p < 0.0001) as was distant metastasis free survival (p = 0.004). Differences in management included more radical surgeries and less chemotherapy and radiotherapy in case of age≥ 80 years. By multivariate analysis, age ≥ 80 years was an independent predictive factor of poor overall survival. CONCLUSION In the present study, age ≥ 80 years was an independent predictive factor of poor overall survival.
Collapse
Affiliation(s)
- Claire Fleurier
- Gynecology Department, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François Rabelais University, Faculté de Médecine de Tours, 10 boulevard Tonnellé, 37044 Tours, France
| | - Adeline De Wit
- Gynecology Department, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François Rabelais University, Faculté de Médecine de Tours, 10 boulevard Tonnellé, 37044 Tours, France
| | - Joseph Pilloy
- Gynecology Department, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François Rabelais University, Faculté de Médecine de Tours, 10 boulevard Tonnellé, 37044 Tours, France
| | - Laura Boivin
- Gynecology Department, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François Rabelais University, Faculté de Médecine de Tours, 10 boulevard Tonnellé, 37044 Tours, France
| | - Marie-Lise Jourdan
- INSERM UMR1069, 10 boulevard Tonnellé, 37044 Tours, France; Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France
| | - Flavie Arbion
- Histology Department, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France
| | - Gilles Body
- Gynecology Department, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François Rabelais University, Faculté de Médecine de Tours, 10 boulevard Tonnellé, 37044 Tours, France; INSERM UMR1069, 10 boulevard Tonnellé, 37044 Tours, France
| | - Lobna Ouldamer
- Gynecology Department, Centre Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, 2 boulevard Tonnellé, 37044 Tours, France; François Rabelais University, Faculté de Médecine de Tours, 10 boulevard Tonnellé, 37044 Tours, France; INSERM UMR1069, 10 boulevard Tonnellé, 37044 Tours, France.
| |
Collapse
|
9
|
Findlay SG, Gill JH, Plummer R, DeSantis C, Plummer C. Chronic cardiovascular toxicity in the older oncology patient population. J Geriatr Oncol 2019; 10:685-689. [DOI: 10.1016/j.jgo.2019.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/21/2019] [Accepted: 01/24/2019] [Indexed: 12/28/2022]
|
10
|
Bundred N, Todd C, Morris J, Keeley V, Purushotham A, Bagust A, Foden P, Bramley M, Riches K. Individualising breast cancer treatment to improve survival and minimise complications in older women: a research programme including the PLACE RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2019. [DOI: 10.3310/pgfar07050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundOver 44,000 women are diagnosed with breast cancer annually in the UK. The research comprised three workstreams (WSs) focused on older women.Maximising survivalWS1 – to identify the role of older women’s and surgeons’ preferences in cancer treatment decisions and whether comorbidity or fitness for surgery has an impact on survival.Minimising complicationsWS2 – to assess multifrequency bioimpedance (BEA) compared with perometry in identifying women predisposed to develop lymphoedema after axillary node clearance (ANC) surgery. WS3 – to assess, in women at risk of lymphoedema, whether or not applying compression garments prevents the onset of lymphoedema.DesignWS1 – a prospective, consecutive cohort of surgical consultations with women aged ≥ 70 years with operable breast cancer. Interviews and questionnaire surveys of surgeons’ and women’s perceptions of responsibility for treatment decisions (Controlled Preference Score), effects related to survival and secondary outcomes. WS2 – women undergoing ANC for cancer in 21 UK centres underwent baseline and subsequent BEA, and perometer arm measurements and quality-of-life (QoL) assessments. WS3 – a randomised controlled trial testing standard versus applying graduated compression garments to the affected arm, for 1 year, in WS2 patients developing arm swelling.SettingBreast outpatient clinics in hospitals with specialist lymphoedema clinics.ParticipantsWS1 – patients aged ≥ 70 years with newly diagnosed, operable, invasive breast cancer. WS2 – women with node-positive cancer scheduled to undergo ANC. WS3 – WS2 participants developing a 4–9% increase in arm volume.InterventionsWS1 – observational study. WS2 – observational study. WS3 – application of graduated compression garments to affected arm, compared with standard management, for 1 year.OutcomesWS1 – self-report and clinically assessed health, QoL, complications and survival. WS2 – perometer and bioimpedance spectroscopy (BIS) measurements, QoL and health utility; and sensitivity and specificity of BIS for detecting lymphoedema compared with perometer arm measurements; in addition, a health economics assessment was performed. WS3 – time to the development of lymphoedema [≥ 10% relative arm-volume increase (RAVI)] from randomisation.ResultsWS1 – overall, 910 women were recruited, but numbers in the substudies differ depending on consent/eligibility. In a study of patient/surgeon choice, 83.0% [95% confidence interval (CI) 80.4% to 85.6%] had surgery. Adjusting for health and choice, only women aged > 85 years had reduced odds of surgery [odds ratio (OR) 0.18, 95%CI 0.07 to 0.44]. Patient role in treatment decisions made no difference to receipt of surgery. A qualitative study of women who did not have surgery identified three groups: ‘patient declined’, ‘patient considered’ and ‘surgeon decided’. In a survival substudy, adjusting for tumour stage, comorbidity and functional status, women undergoing surgery had one-third the hazard of dying from cancer. Serious complications from surgery were low and not predicted by older age. In a substudy of the effect of surgical decision-making on HRQoL, 59 (26%) received preferred treatment decision-making style. In multivariate analyses, change in HRQoL was associated neither with congruence (p = 0.133) nor with receipt of surgery (p = 0.841). In a substudy of receipt of chemotherapy in women aged ≥ 65 years, adjusting for tumour characteristics, health measures and choice, women aged ≥ 75 years had reduced odds of chemotherapy (OR 0.06, 95%CI 0.02 to 0.16). WS2 – lymphoedema by 24 months was detected in 21.4% of women by perometry (24.4% sleeve application) and in 39.4% by BIS. Perometer and BIS measurements correlated at 6 months (r = 0.61). Specificity for sleeve application was greater for perometry (94% CI 93% to 96%) at 24 months, as was a positive predictive value of 59% (95% CI 48% to 68%). Lymphoedema diagnosis reduced QoL scores. Sleeve application in the absence of RAVI of > 9% did not improve QoL or symptoms. A composite definition of lymphoedema was developed, comprising a 9% cut-off point for perometer and self-reported considerable swelling. Diagnostic accuracy was ≥ 94% at 6, 12 and 24 months. WS3 – the PLACE (Prevention of Lymphoedema After Clearance of External compression) trial recruited 143 patients, but recruitment was slow and closed early on the advice of the Independent Data Monitoring Committee. A qualitative substudy identified a number of barriers to recruitment.ConclusionsHalf of older patients felt that they influenced decisions about their treatment. No relationship between decision preference being fulfilled and HRQoL in elderly patients diagnosed with cancer occurred, and older age did not predict complications. Primary surgery reduced the hazard of dying of cancer by two-thirds, independent of age, health and tumour characteristics. Women aged ≥ 75 years have reduced odds of receiving chemotherapy. Lymphoedema (along with a BMI of > 30 kg/m2, cigarette smoking and chemotherapy) reduces QoL. Changes in arm volume of > 9% predicted lymphoedema requiring and benefiting from sleeve application. The PLACE trial qualitative work provides a number of insights into problems of recruitment that were specific to this trial (stigma of compression garments) but that are also generalisable to other RCTs.LimitationsBoth WS1 and WS2 were large, multicentre, UK cohort, observational studies. The WS3 PLACE trial has not reported yet but closed with approximately half of the patients originally planned.Future workResearch producing objective measures for sleeve prescription in the NHS is required.Trial registrationCurrent Controlled Trials ISRCTN48880939.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 7, No. 5. See the NIHR Journals Library website for further project information. Additional support for WS1 came from a Breast Cancer Campaign Grant and a NIHR Postdoctoral Fellowship. ImpediMed (Carslbad, CA, USA;www.impedimed.com) provided bioimpedance L-Dex®machines and electrodes for the study and Sigvaris provided the external compression garments free of charge for the (PLACE) trial.
Collapse
Affiliation(s)
- Nigel Bundred
- Department of Academic Surgery, Manchester University NHS Foundation Trust, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Chris Todd
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Julie Morris
- Department of Academic Surgery, Manchester University NHS Foundation Trust, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Clinical Trials Co-ordination Unit, The Christie NHS Foundation Trust, Manchester, UK
| | - Vaughan Keeley
- Department of Palliative Medicine, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | | | - Adrian Bagust
- Management School, University of Liverpool, Liverpool, UK
| | - Philip Foden
- Department of Academic Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Maria Bramley
- Oncology Research, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Katie Riches
- Department of Palliative Medicine, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| |
Collapse
|
11
|
Ayala ALM, Anjos JCD, Cassol GA, Höfelmann DA. [Survival rate of 10 years among women with breast cancer: a historic cohort from 2000-2014]. CIENCIA & SAUDE COLETIVA 2019; 24:1537-1550. [PMID: 31066855 DOI: 10.1590/1413-81232018244.16722017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 07/25/2017] [Indexed: 11/21/2022] Open
Abstract
Breast cancer is a public health problem due to its high incidence, morbidity and mortality. The analysis of survival for this disease contributes to the description of behavior and prognostic factors. The scope of this article is to investigate survival for 10 years after diagnosis and the prognostic factors of women with breast cancer admitted to the Unified Health System Mastology Service in Joinville, State of Santa Catarina, between 2000 and 2014. A historical cohort study with data from the medical records and death certificates of 1,321 women, of whom 471 were considered eligible under the minimum follow-up criteria of 10 years (n = 288), and/or death before this period (n = 183). Survival analysis using the Kaplan-Meier model, the Log-Rank test and the Cox regression model was conducted. Overall survival at 10 years was 41% (CI 95%, 36.1%-45.0%). The risk of 10-year mortality stratified by tumor staging was higher among women with lymphatic invasion and staging II, and staging III, at 60 years or older. The findings suggest that the presence of lymphatic invasion, advanced age and intermediate/advanced staging of the disease can be considered indicators of a worse prognosis for breast cancer.
Collapse
|
12
|
Minicozzi P, Van Eycken L, Molinie F, Innos K, Guevara M, Marcos-Gragera R, Castro C, Rapiti E, Katalinic A, Torrella A, Žagar T, Bielska-Lasota M, Giorgi Rossi P, Larrañaga N, Bastos J, Sánchez MJ, Sant M. Comorbidities, age and period of diagnosis influence treatment and outcomes in early breast cancer. Int J Cancer 2018; 144:2118-2127. [PMID: 30411340 DOI: 10.1002/ijc.31974] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/26/2018] [Accepted: 10/23/2018] [Indexed: 12/17/2022]
Abstract
Survival for breast cancer (BC) is lower in eastern than northern/central Europe, and in older than younger women. We analysed how comorbidities at diagnosis affected whether selected standard treatments (STs) were given, across Europe and over time, also assessing consequences for survival/relapse. We analysed 7581 stage I/IIA cases diagnosed in 9 European countries in 2009-2013, and 4 STs: surgery; breast-conserving surgery plus radiotherapy (BCS + RT); reconstruction after mastectomy; and prompt treatment (≤6 weeks after diagnosis). Covariate-adjusted models estimated odds of receiving STs and risks of death/relapse, according to comorbidities. Pearson's R assessed correlations between odds and risks. The z-test assessed the significance of time-trends. Most women received surgery: 72% BCS; 24% mastectomy. Mastectomied patients were older with more comorbidities than BCS patients (p < 0.001). Women given breast reconstruction (25% of mastectomies) were younger with fewer comorbidities than those without reconstruction (p < 0.001). Women treated promptly (45%) were younger than those treated later (p = 0.001), and more often without comorbidities (p < 0.001). Receiving surgery/BCS + RT correlated strongly (R = -0.9), but prompt treatment weakly (R = -0.01/-0.02), with reduced death/relapse risks. The proportion receiving BCS + RT increased significantly (p < 0.001) with time in most countries. This appears to be the first analysis of the influence of comorbidities on receiving STs, and of consequences for outcomes. Increase in BCS + RT with time is encouraging. Although women without comorbidities usually received STs, elderly patients often received non-standard less prompt treatments, irrespective of comorbidities, with increased risk of mortality/relapse. All women, particularly the elderly, should receive ST wherever possible to maximise the benefits of modern evidence-based treatments.
Collapse
Affiliation(s)
- Pamela Minicozzi
- Analytical Epidemiology and Health Impact Unit, Research Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | | | - Florence Molinie
- Loire-Atlantique/Vendée Cancer Registry, Nantes, France.,SIRIC-ILIAD, CHU Nantes, Nantes, France
| | - Kaire Innos
- Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
| | - Marcela Guevara
- Navarra Cancer Registry, Public Health Institute of Navarra, IDISNA, Pamplona, Spain.,Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Rafael Marcos-Gragera
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain.,Epidemiology Unit and Girona Cancer Registry, Department of Health, Catalan Institute of Oncology (ICO), Girona, Spain
| | - Clara Castro
- Department of Epidemiology, Portuguese Oncology Institute of Porto (IPO Porto), Porto, Portugal.,EpiUnit, Institute of Public Health, University of Porto, Porto, Portugal
| | - Elisabetta Rapiti
- Geneva Cancer Registry, Global Health Institute, University of Geneva, Geneva, Switzerland
| | - Alexander Katalinic
- University of Lübeck, Institute for Social Medicine and Epidemiology, Lübeck, Germany
| | - Ana Torrella
- Castellón Cancer Registry, Epidemiology Unit, Public Health Department, Castellón, Spain
| | - Tina Žagar
- Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Magdalena Bielska-Lasota
- Department of Health Promotion and Prevention of Chronic Diseases, National Institute of Public Health (NIH), Warsaw, Poland
| | - Paolo Giorgi Rossi
- Epidemiology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Nerea Larrañaga
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain.,Public Health Department of Gipuzkoa, Donostia, Spain
| | - Joana Bastos
- EpiUnit, Institute of Public Health, University of Porto, Porto, Portugal.,Portuguese Institute of Oncology Francisco Gentil (IPO Coimbra), Coimbra, Portugal
| | - Maria José Sánchez
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain.,Andalusian School of Public Health, Granada Cancer Registry, Granada, Spain.,Biomedical Research Institute of Granada (ibs. Granada), Granada, Spain
| | - Milena Sant
- Analytical Epidemiology and Health Impact Unit, Research Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | | |
Collapse
|
13
|
Tao J, Tan Z, Diao L, Ji Z, Zhu J, Chen W, Hu Y. Co-delivery of dihydroartemisinin and docetaxel in pH-sensitive nanoparticles for treating metastatic breast cancerviathe NF-κB/MMP-2 signal pathway. RSC Adv 2018; 8:21735-21744. [PMID: 35541720 PMCID: PMC9080987 DOI: 10.1039/c8ra02833h] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 05/28/2018] [Indexed: 01/01/2023] Open
Abstract
Metastasis is a major barrier in cancer chemotherapy. Prolonged circulation and rapid, specific intracellular drug release are two main goals in the development of nanoscale drug delivery systems to treat metastatic breast cancer. In this study, we investigated the anti-metastasis effect of docetaxel (DTX) in combination with dihydroartemisinin (DHA) in metastatic breast cancer 4T1 cells. We synthesized a pH-sensitive material 4-arm-PEG-DTX with a hydrazone bond and used it to construct nanoparticles that co-deliver DTX and DHA (D/D NPs). The D/D NPs had a mean size of 142.5 nm and approximately neutral zeta potential. The pH-sensitive nanoparticles allowed acid-triggered drug release at the tumor site, showing excellent cytotoxicity (IC50 = 7.0 μg mL−1), cell cycle arrest and suppression of cell migration and invasion. The mechanisms underlying the anti-metastasis effect of the D/D NPs involved downregulation of the expression of p-AKT, NF-κB and MMP-2. Therefore, D/D NPs represent a new nanoscale drug delivery system for treating metastatic breast cancer, responding to the acidic tumor microenvironment to release the chemotherapeutic drugs. Co-delivery DTX and DHA as acid-sensitive nanoparticles to exert synergistic effects for metastatic breast cancer therapy.![]()
Collapse
Affiliation(s)
- Jin Tao
- Zhejiang Pharmaceutical College
- Ningbo
- China
| | - Zeng Tan
- Zhejiang Pharmaceutical College
- Ningbo
- China
| | - Lu Diao
- Zhejiang Pharmaceutical College
- Ningbo
- China
- School of Pharmaceutical Sciences
- Wenzhou Medical University
| | | | | | - Wei Chen
- Zhejiang Pharmaceutical College
- Ningbo
- China
| | - Ying Hu
- Zhejiang Pharmaceutical College
- Ningbo
- China
- School of Pharmaceutical Sciences
- Wenzhou Medical University
| |
Collapse
|
14
|
Routine treatment and outcome of breast cancer in younger versus elderly patients: results from the SENORA project of the prospective German TMK cohort study. Breast Cancer Res Treat 2017; 167:567-578. [PMID: 29030786 PMCID: PMC5790852 DOI: 10.1007/s10549-017-4534-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 10/06/2017] [Indexed: 11/06/2022]
Abstract
Purpose There is an ongoing discussion about ‘undertreatment’ of breast cancer in elderly patients. Due to low accrual into clinical trials, level 1 evidence is scarce. We report prospective data of elderly patients with breast cancer treated by medical oncologists in Germany. Methods The SENORA project within the prospective cohort study TMK (Tumour Registry Breast Cancer) was conducted in 82 centres from 2007–2015. Among 2316 patients, half were enrolled with curative and half with palliative treatment intention. Overall, 478 patients (21%) were aged ≥ 70. Results In the adjuvant setting, elderly patients aged ≥ 70 had more advanced tumour stages at diagnosis and a higher prevalence of comorbidities than younger patients. Elderly patients received adjuvant chemotherapy less frequently, yet the 3-year disease-free survival was similar (86% vs. 88%). In the palliative setting, elderly patients more frequently received endocrine therapy and less frequently chemotherapy. Their median overall survival [24.9 months, 95% CI (confidence interval) 20.0–30.2] was significantly shorter than that of younger patients (39.7 months, 95% CI 34.9–44.2). A Cox proportional hazards model showed a significantly increased risk of mortality for: age ≥ 70 at start of therapy, negative HR- or HER2-status, higher number of metastatic sites, more comorbidities and high tumour grading at diagnosis. Conclusions Our results shed light on the routine treatment of elderly patients with breast cancer. A regression model demonstrated that age is but one of various prognostic factors determining the shorter overall survival of elderly patients.
Collapse
|
15
|
Abstract
Breast cancer is one of the three most common cancers worldwide. Early breast cancer is considered potentially curable. Therapy has progressed substantially over the past years with a reduction in therapy intensity, both for locoregional and systemic therapy; avoiding overtreatment but also undertreatment has become a major focus. Therapy concepts follow a curative intent and need to be decided in a multidisciplinary setting, taking molecular subtype and locoregional tumour load into account. Primary conventional surgery is not the optimal choice for all patients any more. In triple-negative and HER2-positive early breast cancer, neoadjuvant therapy has become a commonly used option. Depending on clinical tumour subtype, therapeutic backbones include endocrine therapy, anti-HER2 targeting, and chemotherapy. In metastatic breast cancer, therapy goals are prolongation of survival and maintaining quality of life. Advances in endocrine therapies and combinations, as well as targeting of HER2, and the promise of newer targeted therapies make the prospect of long-term disease control in metastatic breast cancer an increasing reality.
Collapse
Affiliation(s)
- Nadia Harbeck
- Breast Center, Department of Gynecology and Obstetrics, Comprehensive Cancer Center of the Ludwig-Maximilians-University, Munich, Germany.
| | - Michael Gnant
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
16
|
Dellapasqua S. Systemic Treatment for Specific Medical Situations. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
17
|
Spurrell E, Wilson P, Gallagher C, Slater S, Roylance R. Adjuvant Chemotherapy for Breast Cancer in Older Women. Clin Oncol (R Coll Radiol) 2016; 28:542. [DOI: 10.1016/j.clon.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 03/31/2016] [Indexed: 11/26/2022]
|
18
|
Königsberg R, Pfeiler G, Hammerschmid N, Holub O, Glössmann K, Larcher-Senn J, Dittrich C. Breast Cancer Subtypes in Patients Aged 70 Years and Older. Cancer Invest 2016; 34:197-204. [DOI: 10.1080/07357907.2016.1182184] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Robert Königsberg
- Ludwig Boltzmann Institute for Applied Cancer Research (LBI-ACR VIEnna)—LB Cluster Translational Oncology, 3rd Medical Department—Centre for Oncology and Haematology, Kaiser Franz Josef-Spital, Vienna, Austria
- Applied Cancer Research—Institution for Translational Research Vienna (ACR-ITR VIEnna)/CEADDP, Vienna, Austria
| | - Georg Pfeiler
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | - Nicole Hammerschmid
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | - Oliver Holub
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | - Kerstin Glössmann
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | - Julian Larcher-Senn
- Assign Data Management and Biostatistics GmbH, Assign Group, Innsbruck, Austria
| | - Christian Dittrich
- Ludwig Boltzmann Institute for Applied Cancer Research (LBI-ACR VIEnna)—LB Cluster Translational Oncology, 3rd Medical Department—Centre for Oncology and Haematology, Kaiser Franz Josef-Spital, Vienna, Austria
- Applied Cancer Research—Institution for Translational Research Vienna (ACR-ITR VIEnna)/CEADDP, Vienna, Austria
| |
Collapse
|
19
|
Balabram D, Turra CM, Gobbi H. Association between age and survival in a cohort of Brazilian patients with operable breast cancer. CAD SAUDE PUBLICA 2016; 31:1732-42. [PMID: 26375651 DOI: 10.1590/0102-311x00114214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Whether age is an independent prognostic factor in breast cancer is a matter of debate. This is a retrospective cohort study of 767 breast cancer patients, stages I-III, treated at the Hospital das Clínicas, Minas Gerais Federal University, Belo Horizonte, Minas Gerais State, Brazil, from 2001 to 2008, aiming to study the relationship between age and survival. We included variables related to patients, tumors, and types of treatment. Different sets of Cox models were used for survival analysis. Hazard ratios (HR) and 95%CI were calculated. The relationship between age and breast cancer survival did not change substantially in any of them. In the model that accounted for all variables, women aged 70 and older (HR = 1.51, 95%CI: 1.04-2.18), and 35 or younger (HR = 1.78, 95%CI: 1.05-3.01) had shorter cancer specific survival than patients aged between 36 and 69. In addition, older age, having at least one comorbidity, and being white were associated with a higher risk of dying from other causes. In conclusion, shorter breast cancer survival is expected among the youngest and oldest patients.
Collapse
Affiliation(s)
- Débora Balabram
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, BR
| | - Cassio M Turra
- Centro de Desenvolvimento e Planejamento Regional, Universidade Federal de Minas Gerais, Belo Horizonte, BR
| | - Helenice Gobbi
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, BR
| |
Collapse
|
20
|
Morgan JL, Richards P, Zaman O, Ward S, Collins K, Robinson T, Cheung KL, Audisio RA, Reed MW, Wyld L. The decision-making process for senior cancer patients: treatment allocation of older women with operable breast cancer in the UK. Cancer Biol Med 2016; 12:308-15. [PMID: 26779368 PMCID: PMC4706524 DOI: 10.7497/j.issn.2095-3941.2015.0080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective Up to 40% of women over 70 years with primary operable breast cancer in the UK are treated with primary endocrine therapy (PET) as an alternative to surgery. A variety of factors are important in determining treatment for older breast cancer patients. This study aimed to identify the patient and tumor factors associated with treatment allocation in this population. Methods Prospectively collected data on treatment received (surgery vs. PET) were analysed with multivariable logistic regression using the variables age, modified Charlson Comorbidity Index (CCI), activities of daily living (ADL) score, Mini-Mental State Examination (MMSE) score, HER2 status, tumour size, grade and nodal status. Results Data were available for 1,122 cancers in 1,098 patients recruited between February 2013 and June 2015 from 51 UK hospitals. About 78% of the population were treated surgically, with the remainder being treated with PET. Increasing patient age at diagnosis, increasing CCI score, large tumor size (5 cm or more) and dependence in one or more ADL categories were all strongly associated with non-surgical treatment (P<0.05). Conclusion Increasing comorbidity, large tumor size and reduced functional ability are associated with reduced likelihood of surgical treatment of breast cancer in older patients. However, age itself remains a significant factor for non-surgical treatment; reinforcing the need for evidence-based guidelines.
Collapse
Affiliation(s)
- Jenna L Morgan
- 1 Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield S10 2RX, UK ; 2 Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK ; 3 Center for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield S10 2BP, UK ; 4 Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK ; 5 School of Medicine, University of Nottingham, Royal Derby Hospital Center, Derby DE22 3DT, UK ; 6 Department of Surgery, University of Liverpool, St Helens Teaching Hospital, St Helens WA9 3DA, UK ; 7 Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | - Paul Richards
- 1 Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield S10 2RX, UK ; 2 Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK ; 3 Center for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield S10 2BP, UK ; 4 Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK ; 5 School of Medicine, University of Nottingham, Royal Derby Hospital Center, Derby DE22 3DT, UK ; 6 Department of Surgery, University of Liverpool, St Helens Teaching Hospital, St Helens WA9 3DA, UK ; 7 Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | - Osama Zaman
- 1 Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield S10 2RX, UK ; 2 Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK ; 3 Center for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield S10 2BP, UK ; 4 Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK ; 5 School of Medicine, University of Nottingham, Royal Derby Hospital Center, Derby DE22 3DT, UK ; 6 Department of Surgery, University of Liverpool, St Helens Teaching Hospital, St Helens WA9 3DA, UK ; 7 Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | - Sue Ward
- 1 Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield S10 2RX, UK ; 2 Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK ; 3 Center for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield S10 2BP, UK ; 4 Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK ; 5 School of Medicine, University of Nottingham, Royal Derby Hospital Center, Derby DE22 3DT, UK ; 6 Department of Surgery, University of Liverpool, St Helens Teaching Hospital, St Helens WA9 3DA, UK ; 7 Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | - Karen Collins
- 1 Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield S10 2RX, UK ; 2 Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK ; 3 Center for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield S10 2BP, UK ; 4 Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK ; 5 School of Medicine, University of Nottingham, Royal Derby Hospital Center, Derby DE22 3DT, UK ; 6 Department of Surgery, University of Liverpool, St Helens Teaching Hospital, St Helens WA9 3DA, UK ; 7 Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | - Thompson Robinson
- 1 Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield S10 2RX, UK ; 2 Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK ; 3 Center for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield S10 2BP, UK ; 4 Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK ; 5 School of Medicine, University of Nottingham, Royal Derby Hospital Center, Derby DE22 3DT, UK ; 6 Department of Surgery, University of Liverpool, St Helens Teaching Hospital, St Helens WA9 3DA, UK ; 7 Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | - Kwok-Leung Cheung
- 1 Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield S10 2RX, UK ; 2 Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK ; 3 Center for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield S10 2BP, UK ; 4 Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK ; 5 School of Medicine, University of Nottingham, Royal Derby Hospital Center, Derby DE22 3DT, UK ; 6 Department of Surgery, University of Liverpool, St Helens Teaching Hospital, St Helens WA9 3DA, UK ; 7 Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | - Riccardo A Audisio
- 1 Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield S10 2RX, UK ; 2 Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK ; 3 Center for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield S10 2BP, UK ; 4 Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK ; 5 School of Medicine, University of Nottingham, Royal Derby Hospital Center, Derby DE22 3DT, UK ; 6 Department of Surgery, University of Liverpool, St Helens Teaching Hospital, St Helens WA9 3DA, UK ; 7 Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | - Malcolm W Reed
- 1 Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield S10 2RX, UK ; 2 Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK ; 3 Center for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield S10 2BP, UK ; 4 Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK ; 5 School of Medicine, University of Nottingham, Royal Derby Hospital Center, Derby DE22 3DT, UK ; 6 Department of Surgery, University of Liverpool, St Helens Teaching Hospital, St Helens WA9 3DA, UK ; 7 Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | - Lynda Wyld
- 1 Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield S10 2RX, UK ; 2 Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK ; 3 Center for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield S10 2BP, UK ; 4 Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, UK ; 5 School of Medicine, University of Nottingham, Royal Derby Hospital Center, Derby DE22 3DT, UK ; 6 Department of Surgery, University of Liverpool, St Helens Teaching Hospital, St Helens WA9 3DA, UK ; 7 Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | | |
Collapse
|
21
|
Dimitrakopoulos FID, Kottorou A, Antonacopoulou AG, Makatsoris T, Kalofonos HP. Early-Stage Breast Cancer in the Elderly: Confronting an Old Clinical Problem. J Breast Cancer 2015; 18:207-17. [PMID: 26472970 PMCID: PMC4600684 DOI: 10.4048/jbc.2015.18.3.207] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 07/20/2015] [Indexed: 01/06/2023] Open
Abstract
Breast cancer generally develops in older women and its incidence is continuing to increase with increasing age of the population. The pathology and biology of breast cancer seem to be different in the elderly, often resulting in the undertreatment of elderly patients and thus in higher rates of recurrence and mortal-ity. The aim of this review is to describe the differences in the biology and treatment of early breast cancer in the elderly as well as the use of geriatric assessment methods that aid decision-making. Provided there are no contraindications, the cornerstone of treatment should be surgery, as the safety and efficacy of surgical resection in elderly women have been well documented. Because most breast cancers in the elderly are hormone responsive, hormonal therapy remains the mainstay of systemic treatment in the adjuvant setting. The role of chemotherapy is limited to patients who test negative for hormone receptors and demonstrate an aggressive tumor profile. Although the prognosis of breast cancer patients has generally improved during the last few decades, there is still a demand for evidence-based optimization of therapeutic interventions in older patients.
Collapse
Affiliation(s)
| | - Anastasia Kottorou
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
| | - Anna G Antonacopoulou
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
| | - Thomas Makatsoris
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
| | - Haralabos P Kalofonos
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
| |
Collapse
|
22
|
Sowerbutts AM, Griffiths J, Todd C, Lavelle K. Why are older women not having surgery for breast cancer? A qualitative study. Psychooncology 2015; 24:1036-42. [PMID: 25645068 PMCID: PMC4671254 DOI: 10.1002/pon.3764] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 12/19/2014] [Accepted: 01/02/2015] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Surgery is the mainstay of treatment for breast cancer. However, there is evidence that older women are not receiving this treatment. This study explores reasons why older women are not having surgery. METHODS Twenty eight in-depth interviews were conducted with women over 70 years old with operable breast cancer receiving primary endocrine therapy (PET) as their primary treatment. The interviews focused on their perceptions of why they were being treated with PET rather than surgery. Transcripts were analysed using the Framework method. RESULTS Based on reasons for PET, patients were divided into three groups: 'Patient Declined', 'Patient Considered' or 'Surgeon Decided'. The first group 'Patient Declined' absolutely ruled out surgery to treat their breast cancer. These patients were not interested in maximising their survival and rejected surgery citing their age or concerns about impact of treatment on their level of functioning. The second group 'Patient Considered' considered surgery but chose to have PET most specifying if PET failed then they could have the operation. Patients viewed this as offering them two options of treatment. The third group 'Surgeon Decided' was started by the surgeon on PET. These patients had comorbidities and in most cases the surgeon asserted that the comorbidities were incompatible with surgery. CONCLUSIONS Older women represent a diverse group and have multifaceted reasons for foregoing surgery. Discussions about breast cancer treatment should be patient centred and adapted to differing patient priorities.
Collapse
Affiliation(s)
- Anne Marie Sowerbutts
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
| | - Jane Griffiths
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
| | - Chris Todd
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
| | - Katrina Lavelle
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
| |
Collapse
|
23
|
Morgan J, Richards P, Ward S, Francis M, Lawrence G, Collins K, Reed M, Wyld L. Case-mix analysis and variation in rates of non-surgical treatment of older women with operable breast cancer. Br J Surg 2015; 102:1056-63. [PMID: 26095684 DOI: 10.1002/bjs.9842] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 11/26/2014] [Accepted: 04/01/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Non-surgical management of older women with oestrogen receptor (ER)-positive operable breast cancer is common in the UK, with up to 40 per cent of women aged over 70 years receiving primary endocrine therapy. Although this may be appropriate for frailer patients, for some it may result in treatment failure, contributing to the poor outcomes seen in this age group. Wide variation in the rates of non-operative management of breast cancer in older women exists across the UK. Case mix may explain some of this variation in practice. METHODS Data from two UK regional cancer registries were analysed to determine whether variation in treatment observed between 2002 and 2010 at hospital and clinician level persisted after adjustment for case mix. Expected case mix-adjusted surgery rates were derived by logistic regression using the variables age, proxy Charlson co-morbidity score, deprivation quintile, method of cancer detection, tumour size, stage, grade and node status. RESULTS Data on 17,129 women aged 70 years or more with ER-positive operable breast cancer were analysed. There was considerable variation in rates of surgery at both hospital and clinician level. Despite adjusting for case mix, this variation persisted at hospital level, although not at clinician level. CONCLUSION This study demonstrates variation in selection criteria for older women for operative treatment of early breast cancer, indicating that some older women may be undertreated or overtreated, and may partly explain the inferior disease outcomes in this age group. It emphasizes the urgent need for evidence-based guidelines for treatment selection criteria in older women with breast cancer.
Collapse
Affiliation(s)
- J Morgan
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield, UK
| | - P Richards
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - S Ward
- Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, UK
| | - M Francis
- Knowledge and Intelligence Team (West Midlands), Public Health England, Birmingham, UK
| | - G Lawrence
- Knowledge and Intelligence Team (West Midlands), Public Health England, Birmingham, UK
| | - K Collins
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - M Reed
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield, UK
| | - L Wyld
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Sheffield, UK
| |
Collapse
|
24
|
Morgan JL, Burton M, Collins K, Lifford KJ, Robinson TG, Cheung KL, Audisio R, Reed MW, Wyld L. The balance of clinician and patient input into treatment decision-making in older women with operable breast cancer. Psychooncology 2015; 24:1761-6. [PMID: 26043439 DOI: 10.1002/pon.3853] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/16/2015] [Accepted: 04/27/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Primary endocrine therapy (PET) is an alternative to surgery for oestrogen receptor positive operable breast cancer in some older women. However the decision to offer PET involves complex trade-offs and is influenced by both patient choice and healthcare professional (HCP) preference. This study aimed to compare the views of patients and HCPs about this decision and explore decision-making (DM) preferences and whether these are taken into account during consultations. METHODS This multicentre, UK, mixed methods study had three components: (a) questionnaires to older women undergoing counseling about breast cancer treatment options which assessed their DM preferences and realities; (b) qualitative interviews with older women with operable breast cancer offered a choice of either surgery or PET and (c) qualitative interviews with HCPs (both of which focused on DM preferences in this setting). RESULTS Thirty-three patients and 34 HCPs were interviewed. A range of opinions about patient involvement in DM were identified. Patients indicated varying preferences for DM involvement which were variably taken into account by HCPs. These qualitative findings were broadly supported by the questionnaire results. Most patients (536/729; 73.5%) achieved their preferred DM style; however, the remainder felt that their DM preferences had not been taken into consideration. CONCLUSIONS These results suggest that whilst many older women achieve their desired level of DM engagement, some do not, raising the possibility that they may be making choices which are not concordant with their treatment preferences.
Collapse
Affiliation(s)
- Jenna L Morgan
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
| | - Maria Burton
- Centre for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield, UK
| | - Karen Collins
- Centre for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield, UK
| | - Kate J Lifford
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Thompson G Robinson
- University of Leicester, Department of Cardiovascular Sciences, Robert Kilpatrick Clinical Sciences Building, Leicester, UK
| | - Kwok-Leung Cheung
- School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby, UK
| | - Riccardo Audisio
- Department of Surgery, University of Liverpool, St Helens Teaching Hospital, Marshalls Cross Road, St Helens, UK
| | - Malcolm W Reed
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
| | - Lynda Wyld
- Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, UK
| | | |
Collapse
|
25
|
Lavelle K, Sowerbutts AM, Bundred N, Pilling M, Todd C. Pretreatment health measures and complications after surgical management of elderly women with breast cancer. Br J Surg 2015; 102:653-67. [PMID: 25790147 DOI: 10.1002/bjs.9796] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/13/2014] [Accepted: 01/29/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Elderly patients with breast cancer are less likely to be offered surgery, partly owing to co-morbidities and reduced functional ability. However, there is little consensus on how best to assess surgical risk in this patient group. METHODS The ability of pretreatment health measures to predict complications was investigated in a prospective cohort study of a consecutive series of women aged at least 70 years undergoing surgery for operable (stage I-IIIa) breast cancer at 22 English breast units between 2010 and 2013. Data on treatment, surgical complications, health measures and tumour characteristics were collected by case-note review and/or patient interview. Outcome measures were all complications and serious complications within 30 days of surgery. RESULTS The study included 664 women. One or more complications were experienced by 41·0 per cent of the patients, predominantly seroma or primary/minor infections. Complications were serious in 6·5 per cent. More extensive surgery predicted a higher number of complications, but not serious complications. Older age did not predict complications. Several health measures were associated with complications in univariable analysis, and were included in multivariable analyses, adjusting for type/extent of surgery and tumour characteristics. In the final models, pain predicted a higher count of complications (incidence rate ratio 1·01, 95 per cent c.i. 1·00 to 1·01; P = 0·004). Fatigue (odds ratio (OR) 1·02, 95 per cent c.i. 1·01 to 1·03; P = 0·004), low platelet count (OR 4·19, 1·03 to 17·12: P = 0·046) and pulse rate (OR 0·96, 0·93 to 0·99; P = 0·010) predicted serious complications. CONCLUSION The risk of serious complications from breast surgery is low for older patients. Surgical decisions should be based on patient fitness rather than age. Health measures that predict surgical risk were identified in multivariable models, but the effects were weak, with 95 per cent c.i. close to unity.
Collapse
Affiliation(s)
- K Lavelle
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK; Manchester Academic Health Sciences Centre, Core Technology Facility, Manchester, UK
| | | | | | | | | |
Collapse
|
26
|
Panal M, Sánchez-Mendez JI, Revello R, Abehsera D, de Santiago J, Zapardiel I. Primary Hormonal Therapy for Elderly Breast Cancer Patients: Single Institution Experience. Gynecol Obstet Invest 2014; 80:10-4. [PMID: 25401708 DOI: 10.1159/000368229] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 09/08/2014] [Indexed: 11/19/2022]
Abstract
AIMS Breast cancer is the most frequently diagnosed cancer among women. Up to 50% of breast cancer cases occur in patients over the age of 65 years. Hormonal therapy as a single alternative treatment has been used in this population. The aim of this study was to analyze the oncological outcomes in breast cancer patients who received hormonal therapy alone as a primary treatment. METHODS We retrospectively reviewed our database to find all patients with breast cancer from 2006 to 2011 who were treated with hormonal therapy only at our center. The collected data included patients and tumor characteristics, type of drug administered, follow-up details and type of response obtained using RECIST criteria. RESULTS We included 44 breast cancer patients. The mean age was 83.5 ± 6.0 years. The majority of patients had tumors with less aggressive immunohistochemical characteristics and 100% of them presented positive estrogen receptors. The pharmacological treatment included exemestane, anastrozole, tamoxifen, letrozole and fulvestrant. The effectiveness rate was 60%, evaluated according to tumor reduction or no progression. CONCLUSION The efficacy of hormonal therapy in older patients is reasonably high to justify its use in selected patients. Therefore, it is a sensible alternative for patients who refuse or are unfit for surgery.
Collapse
Affiliation(s)
- Mariana Panal
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
| | | | | | | | | | | |
Collapse
|
27
|
Adjogatse D, Thanopoulou E, Okines A, Thillai K, Tasker F, Johnston S, Harper-Wynne C, Torrisi E, Ring A. Febrile Neutropaenia and Chemotherapy Discontinuation in Women Aged 70 Years or Older Receiving Adjuvant Chemotherapy for Early Breast Cancer. Clin Oncol (R Coll Radiol) 2014; 26:692-6. [DOI: 10.1016/j.clon.2014.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 03/31/2014] [Accepted: 04/01/2014] [Indexed: 11/26/2022]
|
28
|
Portrait, treatment choices and management of breast cancer in nonagenarians: an ongoing challenge. Breast 2014; 23:221-5. [PMID: 24725451 DOI: 10.1016/j.breast.2014.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 03/04/2014] [Accepted: 03/17/2014] [Indexed: 11/22/2022] Open
Abstract
There are only scarce data on the management of nonagenarians with breast cancer, and more particularly on the place of radiation therapy (RT). We report a retrospective study on patients aged 90 years old or older, with breast cancer, receiving RT. Records from RT departments from five institutions were reviewed to identify patients 90 years old of age and older undergoing RT over past decade for breast cancer. Tumors' characteristics were examined, as well treatment specificities and treatment intent. 44 patients receiving RT courses were identified, mean age 92 years. Treatment was given with curative and palliative intent in 72.7% and 27.3% respectively. Factors associated with a curative treatment were performance status (PS), place of life, previous surgery, and tumor stage. Median total prescribed dose was 40 Gy (23-66). Hypo fractionation was used in 77%. Most toxicities were mild to moderate. RT could not be completed in 1 patient (2.3%). No long-term toxicity was reported. Among 31 patients analyzable for effectiveness, 24 patients (77.4%) had their diseased controlled until last follow-up, including 17 patients (54.8%) experiencing complete response. At last follow-up, 4 patients (12.9%) were deceased, cancer being cause of death for two of them. The study shows that breast/chest RT is feasible in nonagenarians. Although the definitive benefit of RT could not be addressed here, hypofractionated therapy allowed a good local control with acceptable side effects.
Collapse
|
29
|
Panjari M, Robinson PJ, Davis SR, Schwarz M, Bell RJ. A comparison of the characteristics, treatment and outcome after 5years, of Australian women aged 70+with those aged<70years at the time of diagnosis of breast cancer. J Geriatr Oncol 2014; 5:141-7. [DOI: 10.1016/j.jgo.2013.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 09/12/2013] [Accepted: 12/13/2013] [Indexed: 11/15/2022]
|
30
|
Muss H, Cortes J, Vahdat LT, Cardoso F, Twelves C, Wanders J, Dutcus CE, Yang J, Seegobin S, O'Shaughnessy J. Eribulin monotherapy in patients aged 70 years and older with metastatic breast cancer. Oncologist 2014; 19:318-27. [PMID: 24682463 DOI: 10.1634/theoncologist.2013-0282] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Following the demonstrated efficacy and safety of eribulin mesylate in heavily pretreated patients with metastatic breast cancer, an exploratory analysis was performed to investigate the effect of age in these patients. METHODS Data were pooled from two single-arm phase II studies and one open-label randomized phase III study in which patients received eribulin mesylate at 1.4 mg/m(2) as 2- to 5-minute intravenous infusions on days 1 and 8 of a 21-day cycle. The effect of age on median overall survival (OS), progression-free survival (PFS), overall response rate (ORR), clinical benefit rate (CBR), and incidence of adverse events (AEs) was calculated for four age groups (<50 years, 50-59 years, 60-69 years, ≥ 70 years). RESULTS. Overall, 827 patients were included in the analysis (<50 years, n = 253; 50-59 years, n = 289; 60-69 years, n = 206; ≥ 70 years, n = 79). Age had no significant impact on OS (11.8 months, 12.3 months, 11.7 months, and 12.5 months, respectively; p = .82), PFS (3.5 months, 2.9 months, 3.8 months, and 4.0 months, respectively; p = .42), ORR (12.7%, 12.5%, 6.3%, and 10.1%, respectively), or CBR (20.2%, 20.8%, 20.4%, and 21.5%, respectively). Although some AEs had higher incidence in either the youngest or the oldest subgroup, there was no overall effect of age on the incidence of AEs (including neuropathy, neutropenia, and leukopenia). CONCLUSION Eribulin monotherapy in these selected older patients with good baseline performance status led to OS, PFS, ORR, CBR, and tolerability similar to those of younger patients with metastatic breast cancer. The benefits and risks of eribulin appear to be similar across age groups.
Collapse
Affiliation(s)
- Hyman Muss
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA; Vall d'Hebron University Hospital and Vall d'Hebron Institute of Oncology, Barcelona, Spain; Weill Cornell Medical College, New York, New York, USA; Jules Bordet Institute, Brussels, Belgium; University of Leeds and St James's Institute of Oncology, Leeds, UK; Formerly of Eisai Ltd, Hatfield, UK; Eisai Inc., Woodcliff Lake, New Jersey, USA; NJS Associates Company, Somerset, New Jersey USA; Baylor-Charles A. Sammons Cancer Center, Texas Oncology, and US Oncology, Dallas, Texas, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Sinha R, Coyle C, Ring A. Breast cancer in older patients: national cancer registry data. Int J Clin Pract 2013; 67:698-700. [PMID: 23758449 DOI: 10.1111/ijcp.12117] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 12/27/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The population in developed countries is ageing. Cancer is a disease of ageing, and this is likely to lead to an increase in the number of older patients diagnosed with cancer with significant implications for resource allocation and research priorities. Breast Cancer in older women presents a number of challenges. AIMS This paper describes the trends in number of new breast cancer registrations in older patients over the last 38 years. MATERIALS AND METHODS Data were extracted from the Office for National Statistics describing new registrations of breast cancer for patients aged 65 or over, from 1971 to 2009. RESULTS The number of diagnoses of breast cancer across all age groups increased from 17,694 in 1971 to 40,260 in 2009. The proportion of diagnoses of breast cancer made in women aged 65 and over increased from 42% in 1971 to 45% in 2009. The proportion of diagnoses of breast cancer made in women aged 70 and over increased from 30% in 1971 to 33% in 2009. The number of cases of breast cancer registered in patients aged 65 and over has increased from 7376 in 1971 to 17,934 in 2009. DISCUSSION The reasons for the large increases in the number of older women diagnosed with breast cancer, and older women represent an increasing proportion of those diagnosed are multi-factorial. These include the ageing of the population, obesity, alcohol consumption, use of hormone replacement therapy and reproductive factors, improved breast cancer awareness and the UK National Screening Programme. Clinician attitudes and behaviours and also cancer registries striving to increase their levels are other causes. The effective management of these women will present constraints to service delivery and should therefore influence research priorities. CONCLUSION This short communication reports on the increasing registration of breast cancer in the older age group which will present a number of challenges for the future.
Collapse
Affiliation(s)
- R Sinha
- Brighton and Sussex Medical School, Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK
| | | | | |
Collapse
|
32
|
O'Connor T, Shinde A, Doan C, Katheria V, Hurria A. Managing breast cancer in the older patient. CLINICAL ADVANCES IN HEMATOLOGY & ONCOLOGY : H&O 2013; 11:341-347. [PMID: 24472802 PMCID: PMC3906632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Breast cancer is a disease that is associated with aging, with almost one-half of all new breast cancer cases diagnosed annually in the United States occurring in women ages 65 and older. Recent data suggest that although breast cancer outcomes in younger women have shown substantial improvement as a result of advances in treatment and screening, the benefits in older women have been less pronounced. Although older patients have been underrepresented in cancer clinical trials, there is an emerging body of literature to help guide treatment decisions. For early-stage breast cancer, the discussion regarding treatment options involves balancing the reduction in risk of recurrence gained by specific therapies with the potential for increased treatment-related toxicity, potentially exacerbated by physiological decline or comorbidities that often co-exist in the older population. A key component of care is the recognition that chronologic age alone cannot guide the management of an older patient with breast cancer. Rather, treatment decisions must also take into account a patient's functional status, estimated life expectancy, the risks and benefits of the therapy, potential barriers to treatment, and patient preference. This article reviews the available evidence for therapeutic management of early-stage breast cancer in older patients, and highlights data from the geriatric oncology literature that provide a basis on which to facilitate evidence-based treatment.
Collapse
|
33
|
Güth U, Myrick ME, Kandler C, Vetter M. The use of adjuvant endocrine breast cancer therapy in the oldest old. Breast 2013; 22:863-8. [PMID: 23541734 DOI: 10.1016/j.breast.2013.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 02/09/2013] [Accepted: 03/03/2013] [Indexed: 10/27/2022] Open
Abstract
In order to report specifically on the use of adjuvant endocrine therapy (ET) in the oldest old breast cancer (BC) patients, we compared treatment patterns including drug compliance and persistence in a cohort of patients who were ≥ 80 years at diagnosis (n = 79) with those of "younger elderly" patients who were 60-79 years old (n = 358). The geriatric cohort more commonly declined the recommended ET (non-compliance: 13.0% vs. 4.5%, p = 0.011). Of the patients who initiated ET, only a minority of the older patients completed the planned therapy duration of five years (39.6% vs. 71.3%, p < 0.001). However, when applying strict criteria for non-persistence, this was found in comparable frequency (17.0% vs. 12.0%, p = 0.370). In older patients, medication was more often discontinued by the physician due to serious medical reasons independent of BC (17.0% vs. 4.7%, p = 0.003). Older women were treated by a general practitioner more often and not by an oncologist (54.4% vs. 23.9%, p < 0.001). Studies on compliance/persistence on cancer therapy in the oldest old demand a detailed follow-up of the patients and the consideration of principles of geriatric medicine. Efforts should be made to make sure that all physicians, but above all general practitioners, who are predominantly involved in the treatment of elderly BC patients, are provided with current knowledge and skills, as to ensure optimal patient management.
Collapse
Affiliation(s)
- Uwe Güth
- University Hospital Basel (UHB), Department of Gynecology and Obstetrics, Spitalstrasse 21, CH-4031 Basel, Switzerland; Cantonal Hospital Winterthur (CHW), Department of Gynecology and Obstetrics, Brauerstrasse 15, CH-8401 Winterthur, Switzerland; Breast Center "SenoSuisse", Brauerstrasse 15, CH-8401 Winterthur, Switzerland.
| | | | | | | |
Collapse
|
34
|
Bartlett J, Canney P, Campbell A, Cameron D, Donovan J, Dunn J, Earl H, Francis A, Hall P, Harmer V, Higgins H, Hillier L, Hulme C, Hughes-Davies L, Makris A, Morgan A, McCabe C, Pinder S, Poole C, Rea D, Stallard N, Stein R. Selecting breast cancer patients for chemotherapy: the opening of the UK OPTIMA trial. Clin Oncol (R Coll Radiol) 2012; 25:109-16. [PMID: 23267818 DOI: 10.1016/j.clon.2012.10.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 09/19/2012] [Accepted: 10/19/2012] [Indexed: 11/26/2022]
Abstract
The mortality from breast cancer has improved steadily over the past two decades, in part because of the increased use of more effective adjuvant therapies. Thousands of women are routinely treated with intensive chemotherapy, which can be unpleasant, is expensive and is occasionally hazardous. Oncologists have long known that some of these women may not need treatment, either because they have a low risk of relapse or because they have tumour biology that makes them less sensitive to chemotherapy and more suitable for early adjuvant endocrine therapy. There is an urgent need to improve patient selection so that chemotherapy is restricted to those patients who will benefit from it. Here we review the emerging technologies that are available for improving patient selection for chemotherapy. We describe the OPTIMA trial, which has just opened to recruitment in the UK, is the latest addition to trials in this area, and is the first to focus on the relative cost-effectiveness of alternate predictive assays.
Collapse
Affiliation(s)
- J Bartlett
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
van de Water W, Seynaeve C, Bastiaannet E, Markopoulos C, Jones SE, Rea D, Hasenburg A, Putter H, Hille ETM, Paridaens R, de Craen AJM, Westendorp RGJ, van de Velde CJH, Liefers GJ. Elderly postmenopausal patients with breast cancer are at increased risk for distant recurrence: a tamoxifen exemestane adjuvant multinational study analysis. Oncologist 2012; 18:8-13. [PMID: 23263290 DOI: 10.1634/theoncologist.2012-0315] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION For postmenopausal patients with hormone-sensitive breast cancer, outcome is worse with increasing age at diagnosis. The aim of this study was to assess the incidence of breast cancer recurrence (locoregional and distant), and contralateral breast cancer by age at diagnosis. METHODS Patients enrolled in the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial were included. Primary endpoints were locoregional recurrence, distant recurrence, and contralateral breast cancer. Age at diagnosis was categorized as younger than 65 years, 65-74 years, and 75 years or older. RESULTS Overall, 9,766 patients were included, of which 5,349 were younger than 65 years (reference group), 3,060 were 65-74 years, and 1,357 were 75 years or older. With increasing age, a decreased administration of radiotherapy after breast conserving surgery (94%, 92%, and 88%, respectively) and adjuvant chemotherapy (51%, 23%, and 5%, respectively) was observed. Risk of distant recurrence increased with age at diagnosis; multivariable hazard ratio for patients aged 65-74 years was 1.20 (95% confidence interval [CI]: 1.00-1.44), hazard ratio for patients aged 75 years or older was 1.39 (95% CI: 1.08-1.79). Risks of locoregional recurrence and contralateral breast cancer were not significantly different across age groups. CONCLUSION Elderly patients with breast cancer were at increased risk for distant recurrence. Other studies have shown that the risk of distant recurrence is mainly affected by adjuvant systemic therapy. All TEAM patients received adjuvant endocrine treatment; however, chemotherapy was administered less often in elderly patients. These findings are suggestive for consideration of chemotherapy in relatively fit elderly breast cancer patients with hormone-sensitive disease.
Collapse
Affiliation(s)
- Willemien van de Water
- Department of Surgical Oncology, Leiden University Medical Center, Albinusdreef 2, P.O. 9600, 2300 RC Leiden, The Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Markopoulos C, van de Water W. Older patients with breast cancer: is there bias in the treatment they receive? Ther Adv Med Oncol 2012; 4:321-7. [PMID: 23118807 DOI: 10.1177/1758834012455684] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Breast cancer is the most frequent malignant tumor in women worldwide and as breast cancer incidence increases with increasing age, over 40% of new cases are diagnosed in women older than 65 years of age. However, older patients are not treated to the same extent as younger patients and increasing age at diagnosis predicts deviation from guidelines for all treatment modalities. Evidence-based medicine in older patients is lacking as they are usually excluded from clinical trials often because of existing comorbidities and limited life expectancy. Accordingly, there is a higher competing risk of death from other causes than breast cancer compared with younger patients and this may have led to the false interpretation that prognosis of breast cancer in older patients is relatively good. However, every treatment modality should be evaluated during treatment decision making. Multimodal therapy should not be routinely withheld as data show that disease-specific mortality increases with age, probably due to undertreatment. Prognostic markers, fitness and comorbidities rather than chronological age should determine optimal, individualized therapy. It is recommended that treatment decisions should be discussed in a multidisciplinary setting, ideally in combination with any form of geriatric assessment, to improve breast cancer outcome in the older population.
Collapse
Affiliation(s)
- Christos Markopoulos
- Athens University Medical School and Department of Surgery - Breast Unit, 8 Lassiou Street, 11521 iassiou, Athens, Greece
| | | |
Collapse
|
37
|
Khan AJ, Haffty BG. Issues in the Curative Therapy of Breast Cancer in Elderly Women. Semin Radiat Oncol 2012; 22:295-303. [DOI: 10.1016/j.semradonc.2012.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
38
|
Lavelle K, Downing A, Thomas J, Lawrence G, Forman D, Oliver SE. Are lower rates of surgery amongst older women with breast cancer in the UK explained by co-morbidity? Br J Cancer 2012; 107:1175-80. [PMID: 22878370 PMCID: PMC3461147 DOI: 10.1038/bjc.2012.192] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 04/12/2012] [Accepted: 04/14/2012] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Around 60% of women ≥ 80 years old, in the UK do not have surgery for their breast cancer (vs<10% of younger age groups). The extent to which this difference can be accounted for by co-morbidity has not been established. METHODS A Cancer Registry/Hospital Episode Statistics-linked data set identified women aged ≥ 65 years diagnosed with invasive breast cancer (between 1 April 1997 and 31 March 2005) in two regions of the UK (n=23038). Receipt of surgery by age was investigated using logistic regression, adjusting for co-morbidity and other patient, tumour and treatment factors. RESULTS Overall, 72% of older women received surgery, varying from 86% of 65-69-year olds to 34% of women aged ≥ 85 years. The proportion receiving surgery fell with increasing co-morbidity (Charlson score 0=73%, score 1=66%, score 2+=49%). However, after adjustment for co-morbidity, older age still predicts lack of surgery. Compared with 65-69-year olds, the odds of surgery decreased from 0.74 (95% CI: 0.66-0.83) for 70-74-year olds to 0.13 (95% CI: 0.11-0.14) for women aged ≥ 85 years. CONCLUSION Although co-morbidity is associated with a reduced likelihood of surgery, it does not explain the shortfall in surgery amongst older women in the UK. Routine data on co-morbidity enables fairer comparison of treatment across population groups but needs to be more complete.
Collapse
Affiliation(s)
- K Lavelle
- School of Nursing, Midwifery and Social Work, The University of Manchester, 5.332 Jean McFarlane Building, Oxford Road, Manchester M13 9PL, UK.
| | | | | | | | | | | |
Collapse
|
39
|
Feliu J, González-Montalvo JI. [Controversies in the management of breast cancer in women of advanced age]. Rev Esp Geriatr Gerontol 2012; 47:191-192. [PMID: 22954901 DOI: 10.1016/j.regg.2012.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Accepted: 04/25/2012] [Indexed: 06/01/2023]
|
40
|
Königsberg R, Pfeiler G, Klement T, Hammerschmid N, Brunner A, Zeillinger R, Singer C, Dittrich C. Tumor characteristics and recurrence patterns in triple negative breast cancer: a comparison between younger (<65) and elderly (≥65) patients. Eur J Cancer 2012; 48:2962-8. [PMID: 22647688 DOI: 10.1016/j.ejca.2012.04.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Revised: 03/31/2012] [Accepted: 04/28/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND In an aging population an increasing number of breast cancers is diagnosed in elderly women. Tumor characteristics and patterns of metastasation have been extensively elucidated in younger triple negative breast cancer (TNBC) patients, but data regarding TNBC in elderly women are missing. The goal of this investigation was to compare clinical pathological characteristics of younger and elderly TNBC patients in order to assess their relevance for TNBC in an aging population. METHODS Data of TNBC patients diagnosed between 1998 and 2004 were retrospectively analyzed by computer based chart information. Baseline tumor characteristics, patient demographics and patterns of metastasation were compared between younger (<65 years) and elderly (≥65 years) TNBC patients. RESULTS Out of 254 TNBC patients 75.6% were <65 years and 24.4% were ≥65 years. Mean tumor size, tumor grade and number of positive lymph nodes did not differ significantly (p=0.865, 0.115 and 0.442, respectively) between both age groups. Distant visceral metastases occurred significantly more often than bone metastases in both age groups (p<0.001). Local recurrences, bone and secondary lymph node metastases were observed at significantly higher numbers in younger patients (p=0.035, 0.025 and 0.041, respectively). Elderly TNBC patients received significantly less chemotherapy than younger patients (p<0.001). CONCLUSIONS TNBC of elderly patients is an aggressive breast cancer subtype claiming as much attention as TNBC in younger patients, thus warranting chemotherapeutic intervention irrespectively of age.
Collapse
Affiliation(s)
- Robert Königsberg
- Applied Cancer Research - Institution for Translational Research Vienna, Bernardgasse 24, A-1070 Vienna, Austria.
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Predictors of re-operation due to post-surgical bleeding in breast cancer patients: A Danish population-based cohort study. Eur J Surg Oncol 2012; 38:407-12. [DOI: 10.1016/j.ejso.2012.02.184] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 02/06/2012] [Accepted: 02/27/2012] [Indexed: 11/23/2022] Open
|
42
|
Wang H, Singh AP, Luce SAS, Go AR. Breast cancer treatment practices in elderly women in a community hospital. Int J Breast Cancer 2011; 2011:467906. [PMID: 22295225 PMCID: PMC3262575 DOI: 10.4061/2011/467906] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 09/20/2011] [Indexed: 11/20/2022] Open
Abstract
Background. Elderly women with breast cancer are considered underdiagnosed and undertreated, and this adversely affects their overall survival. Methods. A total of 393 female breast cancer patients aged 70 years and older, diagnosed within the years 1989-1999, were identified from the tumor registry of The Brooklyn Hospital Center. Comparisons between the 3 different subgroups 70-74, 75-79, and 80 years and older were made using the Pearson Chi Square test. Results. Lumpectomy was performed in 42% of all patients, while mastectomy was done in 46% of patients. Adjuvant therapy such as chemotherapy, radiation therapy, and hormonal therapy were done in 12%, 25%, and 38%, respectively. Forty-seven percent of patients with positive lymph nodes received chemotherapy. Eighty-six percent of patients who were estrogen receptor-positive received adjuvant hormonal therapy. Overall five-year survival was only 14% for the ≥80 age group, compared to that of 32% and 35% for the 70-74 and the 75-79 age groups, respectively. Conclusions. Surgery was performed in majority of these patients, about half received lumpectomy, the other half mastectomy. Adjuvant therapies were frequently excluded, with only hormonal therapy being the most commonly used. Overall five-year survival is significantly worse in patients ≥80 years with breast cancer.
Collapse
Affiliation(s)
| | | | | | - Alan R. Go
- Department of Surgery, The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA
| |
Collapse
|
43
|
Vallejo AN. Immune aging and challenges for immune protection of the graying population. Aging Dis 2011; 2:339-345. [PMID: 22396886 PMCID: PMC3295083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 10/20/2011] [Accepted: 10/22/2011] [Indexed: 05/31/2023] Open
Affiliation(s)
- Abbe N. Vallejo
- Correspondence should be addressed to: Dr. Abbe N. de Vallejo, Children’s Hospital of Pittsburgh Rangos Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA.
| |
Collapse
|