Adjuvant chemotherapy in elderly patients with HER2-negative early breast cancer: A systematic review and meta-analysis

Evidence from randomized trials regarding adjuvant chemotherapy and its impact on survival in older patients with resected breast cancer is limited. This study evaluates the current evidence on the use of adjuvant chemotherapy and its effects on overall mortality and breast cancer-specific mortality in older patients. A systematic review and meta-analysis were conducted on the impact of adjuvant chemotherapy in elderly patients with HER2-negative breast cancer. Searches in PubMed, Embase, and The Cochrane Library up to May 2024 included terms such as "breast cancer," "adjuvant," "chemotherapy," "elderly," and "HER2-negative." Eligible studies involved women aged 65 years or older with HER2-negative breast cancer, comparing those receiving adjuvant chemotherapy versus those who did not. Excluded were studies on neoadjuvant therapy, HER2-positive disease, or non-English publications. The primary outcome was overall mortality. Among 2345 articles, 35 studies met the inclusion criteria, comprising 376,900 patients. Adjuvant chemotherapy significantly reduced overall mortality (hazard ratio [HR] = 0.73; 95% CI: 0.68-0.78) and breast cancer-specific mortality (HR = 0.81; 95% CI: 0.73-0.9), with the most pronounced benefit in triple-negative breast cancer (HR = 0.63; 95% CI: 0.60-0.67). Adjuvant chemotherapy reduces overall mortality and breast cancer-specific mortality in older patients, particularly those with triple-negative breast cancer. However, the evidence is predominantly based on retrospective or observational studies, highlighting inherent limitations. Comprehensive geriatric evaluations are crucial for patient selection, and dedicated clinical trials focused on older populations are urgently needed.

Chemotherapy in older patients with early breast cancer

The incidence of breast cancer increases with age. Particularly in ageing societies, breast cancer has a significant impact on both the older patient and the healthcare system. In older patients with early breast cancer, there is a complex interplay between (i) tumor biology, (ii) risk of recurrence, (iii) comorbidities, (iv) frailty, (v) life expectancy and (vi) patient expectations and preferences. Our treatment guidelines are often based on large meta-analyses that have shown that (neo)adjuvant chemotherapy improves the survival rate in early breast cancer in general. This is particularly important in triple-negative and HER2-positive breast cancer, but hormone receptor (HR)-positive, HER2-negative patients with a higher risk of recurrence also benefit from chemotherapy. However, most studies included younger and carefully selected patients. Since there is a positive correlation between age and estrogen receptor status, as well as between age and the number of concomitant diseases and the tolerability of chemotherapy, it is of great importance to evaluate the effects of additional (neo)adjuvant chemotherapy, especially in older patients with early-stage breast cancer. There are only a few studies in which only older patients with early breast cancer were included. On the whole, they show that older patients with HR-positive, HER2-negative tumors hardly benefit from chemotherapy in addition to endocrine therapy. In these patients, additional chemotherapy should be considered critically when weighing up the potential benefits and harms. However, this critical evaluation should not be confused with abandoning standard chemotherapy when it is feasible and clinically indicated based on geriatric assessment, risk assessment, and patient preference. The aim of our narrative review is to provide a concise overview of the evidence on chemotherapy in older women with breast cancer and place it in the context of geriatric assessment and risk evaluation in older HR-positive, HER2-negative patients with early breast cancer. This in turn should help to critically weigh up the risks and benefits of chemotherapy for the individual older patient with early-stage breast cancer, which should ultimately lead to more individualized and at the same time more evidence-based treatment recommendations that take into account the complex interplay of different and sometimes contradictory patient- and tumor-specific factors.

Unfavorable Prognostic Impact of HER2 2+/FISH-Negativity in Older Patients with HER2-Negative and High-Risk Breast Cancer

Purpose

Human epidermal growth factor receptor 2 (HER2)-low breast cancer, consisted of carcinomas with HER2 protein 1+ or 2+ without gene amplification, has been considered a biologically heterogeneous disease. Limited research separately investigated the prognostic significance of HER2 2+ without gene amplification, and no evidence can be identified in older patients. In this dedicated cohort of older patients with HER2-negative and high-risk breast cancer, we analyzed the real-world prognosis after standard adjuvant chemotherapy, and investigated the associations of survival with HER2 2+ without gene amplification.

Patients and Methods

From January 2016 to December 2021, older patients (≥65 years) with breast cancer were reviewed, and HER2-negative/high-risk disease receiving standard adjuvant chemotherapy was included. HER2-negativity was defined as immunohistochemistry (IHC) score 0, 1+ or 2+ without gene amplification by fluorescent in situ hybridization (FISH). Cox proportional hazards regression analyses were performed to assess the associations of HER2 2+/FISH-negativity with disease-free survival (DFS), which was estimated by the Kaplan-Meier method and compared by the Log rank test.

Results

This cohort consisted of 121 consecutive older patients. With a median follow-up of 46 months, 12 patients had a DFS event. By univariate and multivariate analyses, HER2 2+/FISH-negativity was the only independent predictor for worse DFS (hazard ratio 5.56; P=0.046). Patients with HER2 2+/FISH-negativity had significantly poorer DFS compared with those with HER2 0 or 1+ (Log rank test, P=0.029). In both hormone receptor (HR)-positive (Log rank test, P=0.052) and HR-negative (Log rank test, P=0.125) subgroups, HER2 2+/FISH-negativity showed a marginally significant adverse influence on DFS.

Conclusion

In older patients with HER2-negative/high-risk breast cancer undergoing standard adjuvant chemotherapy, our findings suggest that HER2 2+/FISH-negativity has an independent negative impact on prognosis.

Racial and Ethnic Disparities in European Breast Cancer Clinical Trials

Breast cancer is the most prevalent female cancer worldwide with known correlations between the race and tumor characteristics of the patients and prognosis. International and US-based studies, however, have reported a disproportionate representation of Black and Hispanic patients in clinical trials. This is the first study assessing race and ethnicity reporting trends and inclusion in European breast cancer trials. The PubMed and ClinicalTrials.gov databases were systematically searched for trials on breast cancer treatment conducted exclusively in Europe between 2010 and 2022. Of the 97 identified trials, race was reported in 10.31%. Multinational participation, but not the study size or trial phase, was significantly associated with higher race reporting trends. These 10 trials featured a White-predominant population, with 1.08% Asian and 0.88% Black patients included. The acquisition of the race and ethnicity data of patients in European trials is lower compared to the U.S. or worldwide studies and does not permit extensive analysis of minority participation. In a limited analysis, the low rates of minority participation are concerning, based on population-based data on minorities in select European countries. These observations should encourage race reporting practices in European breast cancer trials and adequate minority participation to support the generalizability of the results of the studies and promote healthcare equity.

Non-pegylated liposomal doxorubicin in older adjuvant early breast cancer patients: cardiac safety analysis and final results of the COLTONE study

AIMS

To explore the cardiac safety of adjuvant Non-Pegylated Liposomal Doxorubicin (NPL-DOX) plus Cyclophosphamide (CTX) followed by weekly Paclitaxel, in elderly women (≥ 65 years) with high-risk breast cancer. Previously, we described no symptomatic cardiac events within the first 12 months from starting treatment. We now reported the updated results after a median follow-up 76 months.

METHODS

The cardiac activity was evaluated with left ventricular ejection fraction (LVEF) echocardiograms assessments, before starting chemotherapy and every 6 months, until 30 months from baseline, then yearly for at least 5 years.

RESULTS

Forty-seven women were recruited by two Units of Medical Oncology (Ethics Committee authorization CESM-AOUP, 3203/2011; EudraCT identification number: 2010-024067-41, for Pisa and Pontedera Hospitals). An episode of grade 3 CHF (NCI-CTCAE, version 3.0) occurred after 18 months the beginning of chemotherapy. The echocardiograms assessments were performed comparing the LVEF values of each patient evaluated at fixed period of time, compared to baseline. We observed a slight changed in terms of mean values at 48, 60, 72 and 84 months. At these time points, a statistically significant reduction of - 3.2%, - 4.6%, - 6.4% and - 7.1%, respectively, was observed. However, LVEF remained above 50% without translation in any relevant clinical signs. No other cardiac significant episodes were reported. To this analysis, in 13 patients (28%) occurred disease relapse and,  of them, 11 (23%) died due to metastatic disease. Eight patients died of cancer-unrelated causes.

CONCLUSIONS

The combination including NPL-DOX in elderly patients revealed low rate of cardiac toxic effects. Comparative trials are encouraged.

A nomogram for individually predicting overall survival for elderly patients with early breast cancer: a consecutive cohort study

Background

Elderly patients with breast cancer are highly heterogeneous, and tumor load and comorbidities affect patient prognosis. Prediction models can help clinicians to implement tailored treatment plans for elderly patients with breast cancer. This study aimed to establish a prediction model for breast cancer, including comorbidities and tumor characteristics, in elderly patients with breast cancer.

Methods

All patients were ≥65 years old and admitted to the Peking Union Medical College Hospital. The clinical and pathological characteristics, recurrence, and death were observed. Overall survival (OS) was analyzed using the Kaplan-Meier curve and a prediction model was constructed using Cox proportional hazards model regression. The discriminative ability and calibration of the nomograms for predicting OS were tested using concordance (C)-statistics and calibration plots. Clinical utility was demonstrated using decision curve analysis (DCA).

Results

Based on 2,231 patients, the 5- and 10-year OS was 91.3% and 78.4%, respectively. We constructed an OS prediction nomogram for elderly patients with early breast cancer (PEEBC). The C-index for OS in PEEBC in the training and validation cohorts was 0.798 and 0.793, respectively. Calibration of the nomogram revealed a good predictive capability, as indicated by the calibration plot. DCA demonstrated that our model is clinically useful.

Conclusion

The nomogram accurately predicted the 3-year, 5-year, and 10-year OS in elderly patients with early breast cancer.

Systemic Therapy in Older Patients With High-Risk Disease

Adjuvant systemic treatments for older patients with breast cancer require constant dose or schedule adjustments of standards established for younger ones. This is mainly due to frailty that increases according to age (40%-50% of signals in all comers after age 70 years) and remains difficult to spot or diagnose accurately and therefore is often overlooked. Older patients are at higher risk to develop side effects whether under chemotherapy, optimized endocrine treatment, or targeted therapies. Pharmacokinetic reflects poorly functional reserves that reduce with aging and is therefore misleading. The demonstration of significant long-term benefits provided by adjuvant treatments is challenged by life expectancy, driven by multimorbidity status that increases with age, competing with cancer outcome. When geriatric assessment is incorporated into the multidisciplinary team, treatment decision process shows 30%-50% changes, de-escalating initial age-agnostic treatment choices in two of three cases. Finally, expectations from treatment vary over the years: In older ones, although not being exclusive, there is a general shift of preference for protecting functionality, cognitive functions, and independence, as summarized in quality of life that many systemic adjuvant treatment may jeopardize. These provocative considerations show importance to pay more attention to expectations expressed by older patients to limit gaps between what is thought by health care professionals as right, often on the basis of dose intensity models strongly engrained in oncology and that older patients may assess counterintuitively differently. The most achieved molecular testing to identify high-risk luminal tumors should be combined with determinant geriatric factors to bring relevant global information in the adjuvant setting for older patients.

Pitfalls in Oncogeriatrics

An oncogeriatric interdisciplinary activity exists only in a minority of high-income countries, and it is almost absent in those with lower incomes. Considering topics, sessions, and tracks in the main meetings and conferences of the major Oncological Societies in Europe and worldwide, the USA excluded, little attention has thus far been paid to the problem of cancer in the elderly. Again, with the exception of the USA, the major cooperative groups, for example, the EORTC in Europe, have only dedicated marginal attention to the research of cancer in the elderly. Despite major shortcomings, professionals interested in geriatric oncology have taken a number of important initiatives to highlight the benefits of this particular activity, including the organization of an international society (Société Internationale de Oncogeriatrie, or SIOG). In spite of these efforts, the authors believe that the management of cancer in the older population is still encountering several important and generalized pitfalls. The main obstacle is the grossly inadequate number of geriatricians and clinical oncologists necessary to an integrated care of the ever-expanding aging population, but other hurdles have been reported. Additionally, the prejudice of ageism can lead to missing potential resources for the development of a generalized oncogeriatric approach.

Adjuvant Chemotherapy in Older Women With Early Breast Cancer

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.The clinical discussion on the adjuvant chemotherapy in older patients with breast cancer (BC) should routinely include comprehensive considerations of the health implications of competitive comorbidities, the safety of the treatment itself, and the likelihood that an appropriate dose intensity will be received (ie, relative dose intensity > 85%). All these factors have prognostic implications, as recently confirmed in the secondary analysis of the Hurria Older PatiEnts clinical trial. Full-informed, shared decision making is essential to provide best care. Our clinical approach for women with BC age ≥ 65 years is based on a standardized screening for frailty, triggering comprehensive geriatric assessment, as appropriate. We only recommend evidence-based regimens that have showed to reduce the risk of cancer recurrence and potentially increase overall survival. We frequently prefer docetaxel-cyclophosphamide, for hormone receptor-positive BC, on the basis of the subgroup analysis of the USOR-9735 study in older population. We avoid single agents (eg, capecitabine or weekly docetaxel), as showed to be inferior treatments in the CALGB-49907 and ELDA trials, and modified nonstandard regimens, for the lack of strong evidence in support.

Dysgeusia in Patients with Breast Cancer Treated with Chemotherapy-A Narrative Review

Breast cancer (BC) is the most common cancer worldwide. Chemotherapy (CT) is essential for the treatment of BC, but is often accompanied by several side effects, including taste alterations, due to different mechanisms. Although dysgeusia is usually underestimated by clinicians, it is considered very worrying and disturbing by cancer patients undergoing CT, because it induces changes in dietary choices and social habits, affecting their physical and psychological health, with a profound impact on their quality of life. Several strategies and therapies have been proposed to prevent or alleviate CT-induced dysgeusia. This review aimed to evaluate the available evidence on prevalence, pathophysiological mechanisms, clinical consequences, and strategies for managing dysgeusia in BC patients receiving CT. We queried the National Library of Medicine, the Cochrane Library, Excerpta Medica dataBASE, and the Cumulative Index to Nursing and Allied Health Literature database, performing a search strategy using database-specific keywords. We found that the literature on this topic is scarce, methodologically limited, and highly heterogeneous in terms of study design and criteria for patient inclusion, making it difficult to obtain definitive results and make recommendations for clinical practice.

Breast Cancer in Geriatric Patients: Current Landscape and Future Prospects

Breast cancer is the most common cancer diagnosed among women worldwide and more than half are diagnosed above the age of 60 years. Life expectancy is increasing and the number of breast cancer cases diagnosed among older women are expected to increase. Undertreatment, mostly due to unjustifiable fears of advanced-age and associated comorbidities, is commonly practiced in this group of patients who are under-represented in clinical trials and their management is not properly addressed in clinical practice guidelines. With modern surgery and anesthesia, breast surgeries are considered safe and is usually associated with very low complication rates, regardless of extent of surgery. However, oncoplastic surgery and management of the axilla can be tailored based on patients'- and disease-related factors. Most of chemotherapeutic agents, along with targeted therapy and anti-Human epidermal growth factor receptor-2 (HER2) drugs can be safely given for older patients, however, dose adjustment and close monitoring of potential adverse events might be needed. The recently introduced cyclin-D kinase (CDK) 4/6-inhibitors in combination with aromatase inhibitors (AI) or fulvestrant, which changed the landscape of breast cancer therapy, are both safe and effective in older patients and had substituted more aggressive and potentially toxic interventions. Despite its proven efficacy, adjusting or even omitting adjuvant radiation therapy, at least in low-risk older patients, is safe and frequently practiced. In this paper, we review existing data related to breast cancer management among older patients across the continuum; from resection of the primary tumor through adjuvant chemotherapy, radiation and endocrine therapy up to the management of recurrent and advanced-stage disease.

Chemotherapy and gene expression profiling in older early luminal breast cancer patients: An International Society of Geriatric Oncology systematic review

BACKGROUND

The benefit of chemotherapy for older patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative early breast cancer (EBC) is a key area of debate. Gene expression profiling (GEP) may identify patients deriving benefit, but their predictive role has not been established for older adults. We summarise evidence on efficacy, safety, and quality-of-life impacts of chemotherapy and on GEP use and impact in older HR-positive, HER2-negative EBC patients.

METHODS

We conducted a literature search of PubMed and Embase on publications describing prospective studies evaluating chemotherapy in older adults with HR-positive, HER2-negative EBC and on publications describing retrospective and prospective studies evaluating GEP in older adults.

RESULTS

Eight publications on chemotherapy use, including 2,035 older patients with EBC were selected. Only one trial evaluated chemotherapy survival benefits in older adults, showing no benefit. Of four studies comparing different regimens, only one showed the superiority of taxanes versus anthracyclines alone. Those investigating alternative regimens did not show improvements over standard regimens despite significant limitations. Five publications on GEP, including 445,323 older patients, were included and investigated Oncotype DX. Limited evidence shows that GEP aids treatment decisions in this population. GEP was offered less frequently to older versus younger patients. Higher Recurrence Score was prognostic for distant recurrence, but chemotherapy did not improve prognosis.

CONCLUSIONS

In older patients with HR-positive, HER2-negative, chemotherapy survival benefits EBC are unclear and GEP is less used. Although its prognostic role is well established, its predictive role remains unknown.

Chemotherapy Decision-Making and Survival Outcomes in Older Women With Early Triple-Negative Breast Cancer: Evidence From Real-World Practice

Data regarding chemotherapy options and benefits in older women with early triple-negative breast cancer (TNBC) are limited. Our study aimed to assess the effects of adjuvant chemotherapy on recurrence-free survival (RFS), breast cancer-specific survival (BCSS), and overall survival (OS) rates in elderly TNBC patients. Patients aged ≥65 years diagnosed with stage I-III TNBC (except T1aN0) between 2010 and 2016 were retrospectively included. Multivariate Cox regression was performed to minimize bias. A total of 177 patients were included with a median age of 69 years (range, 65-86), almost all had a Charlson Comorbidity Index of 0-2, and 127 (71.8%) received chemotherapy. Patients who received chemotherapy were younger, had more advanced-stage disease and had better ECOG performance status (P<0.05). Among the 127 patients who were administered chemotherapy, 45 (35%) received taxane plus carboplatin, 36 (28%) received anthracycline-and-taxane-based regimens, and 23 (18%) received taxane-based regimens. The regimen options differed based on patient age and tumour stage (P<0.05). Nearly 80% of the patients completed ≥6 cycles of chemotherapy, and half had their dosage decreased. After adjustment for confounding factors, patients who received ≥6 cycles of chemotherapy were found to have improved RFS rates (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.09-0.87; P=0.027), and receipt of chemotherapy (≥1 cycle) was associated with better BCSS (HR, 0.19; 95% CI, 0.04-0.97; P=0.046) and OS (HR, 0.26; 95% CI, 0.08-0.87; P=0.029) rates. These results support the considering the risk for recurrence and performing individualized assessments when determining the appropriate chemotherapy approach for older women with early TNBC.

Adjuvant Treatment of Elderly Breast Cancer Patients: Offer the Best Chances of Cure

Background

Breast cancer remains the most common cancer in women and a leading cause of death. Elderly people have a higher incidence of breast cancer since it increases with age. Furthermore, the extended life expectancy and advances in imaging techniques have led to an increased number of cases. Guidelines concerning the management of this specific age group are rare, mainly due to underrepresentation of seniors in clinical trials. Moreover, increased frailty, comorbidities, and a poor performance status make it complex to determine the best therapeutic approach.

Summary

In this review, we attempt to summarize the current literature and aim to provide specific approaches and recommendations for prompt diagnosis, treatment, and management of breast cancer in the elderly.

Key Messages

The establishment of applicable protocols is imperative and efforts are being made in this direction. A careful geriatric assessment and adequate consultation should be the standard of care and patient's preferences should always be considered.

Systemic therapy for older patients with early breast cancer

Over a third of breast cancers are diagnosed in patients ≥70 years. With the ageing of the population, the number of older breast cancer patients will continue to rise. Older patients are under-represented in clinical studies underpinning breast cancer therapy, and frequently do not receive guideline-concordant care. This review outlines the evidence on the efficacy and the safety of systemic treatment options for the management of early-stage breast cancer (EBC) in older adults and identifies where critical data gaps exist. Chemotherapy is beneficial for older patients with oestrogen receptor (ER)-negative EBC, whilst the benefit for those with ER-positive disease is less certain. Careful consideration should be given to the side-effect profile of the treatment regimen chosen, owing to the risks of myelosuppression and cardiac damage, as well as toxicities, such as neuropathy, that may impact independence. The impact of chemotherapy on quality of life (QOL) outcomes appears significant but reversible in this population. Gene expression profiling, benefit and chemotherapy toxicity prediction tools integrating global health considerations hold promise to better inform chemotherapy decisions in this population. Benefits on targeted anti-human epidermal growth factor receptor 2 (HER2) agents is maintained in older EBC patients with a favourable safety profile. Endocrine therapy including aromatase inhibitors is the standard of care in this population, and extended treatment decisions should consider effects on bone health and life expectancy. More trials recruiting older adults with pragmatic designs and meaningful endpoints for this population are warranted to better inform systemic treatment decisions and discussion with patients.

Systemic therapy for early breast cancer in older adults: current status and prospects

PURPOSE OF REVIEW

In this review, we describe the evidence on the efficacy and the safety of systemic treatments for the management of early breast cancer (EBC) in older individuals.

RECENT FINDINGS

Chemotherapy has a temporary impact on quality of life (QoL) for older EBC patients and improves survival outcomes for those with oestrogen receptor (ER)-negative disease. Benefits were seen also in the context of comorbidities, although these may be influenced by selection bias. The Cancer and Aging Research Group-Breast Cancer tool can predict the risk of severe toxicities on chemotherapy in older patients. Gene expression profiling is less frequently used in older adults although it holds promise to better inform patient selection also in this age group.Postneoadjuvant systemic therapy and novel agents remain poorly described in older patients with EBC. No disease-free survival benefits were seen in older patients receiving abemaciclib plus adjuvant endocrine therapy.

SUMMARY

Chemotherapy is beneficial for selected older patients with high-risk, ER-negative EBC. Although its impact on QoL is temporary, preferences, higher risk of toxicity and competing risks need to be carefully considered. Open questions remain on novel therapeutic approaches and gene expression profile in older EBC patients and more real-world evidence is warranted.

Updated recommendations regarding the management of older patients with breast cancer: a joint paper from the European Society of Breast Cancer Specialists (EUSOMA) and the International Society of Geriatric Oncology (SIOG)

Breast cancer is increasingly prevalent in older adults and is a substantial part of routine oncology practice. However, management of breast cancer in this population is challenging because the disease is highly heterogeneous and there is insufficient evidence specific to older adults. Decision making should not be driven by age alone but should involve geriatric assessments plus careful consideration of life expectancy, competing risks of mortality, and patient preferences. A multidisciplinary taskforce, including members of the European Society of Breast Cancer Specialists and International Society of Geriatric Oncology, gathered to expand and update the previous 2012 evidence-based recommendations for the management of breast cancer in older individuals with the endorsement of the European Cancer Organisation. These guidelines were expanded to include chemotherapy toxicity prediction calculators, cultural and social considerations, surveillance imaging, genetic screening, gene expression profiles, neoadjuvant systemic treatment options, bone-modifying drugs, targeted therapies, and supportive care. Recommendations on geriatric assessment, ductal carcinoma in situ, screening, primary endocrine therapy, surgery, radiotherapy, adjuvant systemic therapy, and secondary breast cancer were updated.

Simulation of Chemotherapy Effects in Older Breast Cancer Patients With High Recurrence Scores

BACKGROUND

Tumor genomic expression profile data are used to guide chemotherapy choice, but there are gaps in evidence for women aged 65 years and older. We estimate chemotherapy effects by age and comorbidity level among women with early-stage, hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancers and Oncotype DX scores of 26 or higher.

METHODS

A discrete-time stochastic state transition simulation model synthesized data from population studies and clinical trials to estimate outcomes over a 25-year horizon for subgroups based on age (65-69, 70-74, 75-79, and 80-89 years) and comorbidity levels (no or low, moderate, severe). Outcomes were discounted at 3%, and included quality-adjusted life-years (QALYs), life-years, and breast cancer and other-cause mortality with chemoendocrine vs endocrine therapy. Sensitivity analysis tested the effect of varying uncertain parameters.

RESULTS

Women aged 65-69 years with no or low comorbidity gained 0.16 QALYs with chemo-endocrine and reduced breast cancer mortality from 34.8% to 29.7%, for an absolute difference of 5.1%; this benefit was associated with a 12.8% rate of grade 3-4 toxicity. Women aged 65-69 years with no or low or moderate comorbidity levels, and women aged 70-74 years with no or low comorbidity had small chemotherapy benefits. All women aged 75 years and older experienced net losses in QALYs with chemo-endocrine therapy. The results were robust in sensitivity analyses. Chemotherapy had greater benefits as treatment effectiveness increased, but toxicity reduced the QALYs gained.

CONCLUSION

Among women aged 65-89 years whose tumors indicate a high recurrence risk, only those aged 65-74 years with no or low or moderate comorbidity have small benefits from adding chemotherapy to endocrine therapy. Genomic expression profile testing (and chemotherapy use) should be reserved for women aged younger than 75 years without severe comorbidity.

Systemic Therapy of Common Tumours in Older Patients: Challenges and Opportunities. A Young International Society of Geriatric Oncology Review Paper

PURPOSE OF REVIEW

Decision-making for systemic treatments in older patients with cancer is difficult because of concerns for decreased organ function, risk of toxicity, limited life expectancy due to comorbidities and the lack of evidence available to guide its management in this population. Here, we review the data on the role of systemic agents for the treatment of common malignancies in this age group.

RECENT FINDINGS

Evidence on the use of systemic treatments for older patients with cancer is increasing, especially for newer options including immune checkpoint inhibitors and targeted agents that provide comparable benefit in older and younger patients. Nonetheless, the risks for short- and long-term toxicities need to be considered. More research is warranted and represents a unique opportunity to increase the knowledge on cancer treatment for older adults. Healthy, older individuals should be considered for standard systemic treatment options, whereas those at risk based on geriatric assessments require adjusted plans. Geriatric assessments are key for decision-making.

Age-related disparities in older women with breast cancer

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.

Prevalence of comorbidity in cancer patients scheduled for systemic anticancer treatment in Austria

The purpose of this observational study was to determine the prevalence of comorbid conditions in cancer patients with solid tumours selected for specific treatment at 12 divisions of medical oncology in Austria. Data from 1137 patients were collected using a standardized questionnaire; of these, 1036 datasets were evaluable for further analysis. Data were prospectively collected from patients during an in- or outpatient hospital visit over a 4-month period in 2011. Of these patients 42% had gastrointestinal cancer, 31% had breast cancer, 9% lung cancer and the remaining had urogenital cancer, sarcoma or other types of rare cancers. Around two-thirds of patients had metastatic disease (59%), confined to a single organ site in 55% of patients. A high proportion of patients had a good performance status (Eastern Cooperative Oncology Group [ECOG] 0, 1: 82%). Comorbid conditions were classified according to the Charlson scheme score and were present in 86% of patients with a median age of 64 years. The predominant conditions were cardiovascular diseases (57%), metabolic diseases (44%), endocrinological diseases (30%), gastrointestinal diseases (26%), neurological (23%) and respiratory diseases (23%). As has been reported by others we found a clear association between number of comorbid conditions and age. While 60% of the whole population had at least 2 comorbidities, most patients of the elderly population (89%) had more than three comorbidities. The high proportion of patients with comorbidities and accompanying medication represents a substantial challenge for medical oncologists in selecting the optimal cancer-specific treatment especially in the era of novel targeted and immunotherapies. Comorbid conditions and accompanying comedications require special precautions concerning potential interactions and unexpected adverse reactions from prescribed tumour-specific treatment.

Taxanes for adjuvant treatment of early breast cancer

BACKGROUND

Adjuvant chemotherapy improves survival in premenopausal and postmenopausal women with early breast cancer. Taxanes are highly active chemotherapy agents used in metastatic breast cancer. Review authors examined their role in early breast cancer. This review is an update of a Cochrane Review first published in 2007.

OBJECTIVES

To assess the effects of taxane-containing adjuvant chemotherapy regimens for treatment of women with operable early breast cancer.

SEARCH METHODS

For this review update, we searched the Specialised Register of the Cochrane Breast Cancer Group, MEDLINE, Embase, CENTRAL (2018, Issue 6), the WHO International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov on 16 July 2018, using key words such as 'early breast cancer' and 'taxanes'. We screened reference lists of other related literature reviews and articles, contacted trial authors, and applied no language restrictions.

SELECTION CRITERIA

Randomised trials comparing taxane-containing regimens versus non-taxane-containing regimens in women with operable breast cancer were included. Studies of women receiving neoadjuvant chemotherapy were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias and quality of the evidence using the GRADE approach. Hazard ratios (HRs) were derived for time-to-event outcomes, and meta-analysis was performed using a fixed-effect model. The primary outcome measure was overall survival (OS); disease-free survival (DFS) was a secondary outcome measure. Toxicity was represented as odds ratios (ORs), and quality of life (QoL) data were extracted when present.

MAIN RESULTS

This review included 29 studies (27 full-text publications and 2 abstracts or online theses). The updated analysis included 41,911 randomised women; the original review included 21,191 women. Taxane-containing regimens improved OS (HR 0.87, 95% confidence interval (CI) 0.83 to 0.92; high-certainty evidence; 27 studies; 39,180 women; 6501 deaths) and DFS (HR, 0.88, 95% CI 0.85 to 0.92; high-certainty evidence; 29 studies; 41,909 women; 10,271 reported events) compared to chemotherapy without a taxane. There was moderate to substantial heterogeneity across studies for OS and DFS (respectively).When a taxane-containing regimen was compared with the same regimen without a taxane, the beneficial effects of taxanes persisted for OS (HR 0.84, 95% CI 0.77 to 0.92; P < 0.001; 7 studies; 10,842 women) and for DFS (HR 0.84, 95% CI 0.78 to 0.90; P < 0.001; 7 studies; 10,842 women). When a taxane-containing regimen was compared with the same regimen with another drug or drugs that were substituted for the taxane, a beneficial effect was observed for OS and DFS with the taxane-containing regimen (OS: HR 0.80, 95% CI 0.74 to 0.86; P < 0.001; 13 studies; 16,196 women; DFS: HR 0.83, 95% CI 0.78 to 0.88; P < 0.001; 14 studies; 16,823 women). Preliminary subgroup analysis by lymph node status showed a survival benefit with taxane-containing regimens in studies of women with lymph node-positive disease only (HR 0.83, 95% CI 0.78 to 0.88; P < 0.001; 17 studies; 22,055 women) but less benefit in studies of women both with and without lymph node metastases or with no lymph node metastases. Taxane-containing regimens also improved DFS in women with lymph node-positive disease (HR 0.84, 95% CI 0.80 to 0.88; P < 0.001; 17 studies; 22,055 women), although the benefit was marginal in studies of women both with and without lymph node-positive disease (HR 0.95, 95% CI 0.88 to 1.02; 9 studies; 12,998 women) and was not apparent in studies of women with lymph node-negative disease (HR 0.99, 95% CI 0.86 to 1.14; 3 studies; 6856 women).Taxanes probably result in a small increase in risk of febrile neutropenia (odds ratio (OR) 1.55, 95% CI 0.96 to 2.49; moderate-certainty evidence; 24 studies; 33,763 women) and likely lead to a large increase in grade 3/4 neuropathy (OR 6.89, 95% CI 3.23 to 14.71; P < 0.001; moderate-certainty evidence; 22 studies; 31,033 women). Taxanes probably cause little or no difference in cardiotoxicity compared to regimens without a taxane (OR 0.87, 95% CI 0.56 to 1.33; moderate-certainty evidence; 23 studies; 32,894 women). Seven studies reported low-quality evidence for QoL; overall, taxanes may make little or no difference in QoL compared to chemotherapy without a taxane during the follow-up period; however, the duration of follow-up differed across studies. Only one study, which was conducted in Europe, provided cost-effectiveness data.

AUTHORS' CONCLUSIONS

This review of studies supports the use of taxane-containing adjuvant chemotherapy regimens, with improvement in overall survival and disease-free survival for women with operable early breast cancer. This benefit persisted when analyses strictly compared a taxane-containing regimen versus the same regimen without a taxane or the same regimen with another drug that was substituted for the taxane. Preliminary evidence suggests that taxanes are more effective for women with lymph node-positive disease than for those with lymph node-negative disease. Considerable heterogeneity across studies probably reflects the varying efficacy of the chemotherapy backbones of the comparator regimens used in these studies. This review update reports results that are remarkably consistent with those of the original review, and it is highly unlikely that this review will be updated, as new trials are assessing treatments based on more detailed breast cancer biology.

Randomized Trial of Standard Adjuvant Chemotherapy Regimens Versus Capecitabine in Older Women With Early Breast Cancer: 10-Year Update of the CALGB 49907 Trial

PURPOSE

Older women with breast cancer remain under-represented in clinical trials. The Cancer and Leukemia Group B 49907 trial focused on women age 65 years and older. We previously reported the primary analysis after a median follow-up of 2.4 years. Standard adjuvant chemotherapy showed significant improvements in recurrence-free survival (RFS) and overall survival compared with capecitabine. We now update results at a median follow-up of 11.4 years.

PATIENTS AND METHODS

Patients age 65 years or older with early breast cancer were randomly assigned to either standard adjuvant chemotherapy (physician's choice of either cyclophosphamide, methotrexate, and fluorouracil or cyclophosphamide and doxorubicin) or capecitabine. An adaptive Bayesian design was used to determine sample size and test noninferiority of capecitabine. The primary end point was RFS.

RESULTS

The design stopped accrual with 633 patients at its first sample size assessment. RFS remains significantly longer for patients treated with standard chemotherapy. At 10 years, in patients treated with standard chemotherapy versus capecitabine, the RFS rates were 56% and 50%, respectively (hazard ratio [HR], 0.80; P = .03); breast cancer-specific survival rates were 88% and 82%, respectively (HR, 0.62; P = .03); and overall survival rates were 62% and 56%, respectively (HR, 0.84; P = .16). With longer follow-up, standard chemotherapy remains superior to capecitabine among hormone receptor-negative patients (HR, 0.66; P = .02), but not among hormone receptor-positive patients (HR, 0.89; P = .43). Overall, 43.9% of patients have died (13.1% from breast cancer, 16.4% from causes other than breast cancer, and 14.1% from unknown causes). Second nonbreast cancers occurred in 14.1% of patients.

CONCLUSION

With longer follow-up, RFS remains superior for standard adjuvant chemotherapy versus capecitabine, especially in patients with hormone receptor-negative disease. Competing risks in this older population dilute overall survival benefits.

Functional status in a geriatric oncology setting: A review

BACKGROUND

Comprehensive Geriatric Assessment (CGA), is used in older patients with cancer to identify frailties, which can interfere with specialized treatment, and to help with therapeutic care. Functional Status (FS) is a domain of CGA in which Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) are evaluation tools.

OBJECTIVE

Our study reviewed the data available on the most frequently used tools to assess ADL and IADL in a geriatric oncology setting and their predictive values on overall survival (OS), toxicity, treatment feasibility or decision and postoperative complications.

DESIGN

This review was based on a systematic search of the MEDLINE® database for articles published in English and French between January 1, 2010, and December 31, 2017. In the final analysis, 40 out of 4061 studies were included.

RESULTS

The most common ADL and IADL scales used are the Katz ADL (KL-ADL) in 25 studies and the Lawton IADL (IADL₈) in 22 studies. FS is predictive of OS in 11 out of 24 studies, chemotoxicity in 2 out of 7 studies, treatment feasibility in 2 out of 5 studies, treatment decisions in 2 out of 3 studies, and postoperative complications in 4 out of 6 studies.

CONCLUSION

FS is of prognostic value in a geriatric oncology setting despite heterogeneous methodology and inclusion criteria, in the studies included. Additional research is needed to explore more precisely the prognostic value of FS in overall survival, toxicity, treatment feasibility or decision and postoperative complications, in older cancer patients.

Interdisciplinary Screening, Diagnosis, Therapy and Follow-up of Breast Cancer. Guideline of the DGGG and the DKG (S3-Level, AWMF Registry Number 032/045OL, December 2017) - Part 2 with Recommendations for the Therapy of Primary, Recurrent and Advanced Breast Cancer

Purpose The aim of this official guideline coordinated and published by the German Society for Gynecology and Obstetrics (DGGG) and the German Cancer Society (DKG) was to optimize the screening, diagnosis, therapy and follow-up care of breast cancer. Method The process of updating the S3 guideline published in 2012 was based on the adaptation of identified source guidelines. They were combined with reviews of evidence compiled using PICO (Patients/Interventions/Control/Outcome) questions and with the results of a systematic search of literature databases followed by the selection and evaluation of the identified literature. The interdisciplinary working groups took the identified materials as their starting point and used them to develop suggestions for recommendations and statements, which were then modified and graded in a structured consensus process procedure. Recommendations Part 2 of this short version of the guideline presents recommendations for the therapy of primary, recurrent and metastatic breast cancer. Loco-regional therapies are de-escalated in the current guideline. In addition to reducing the safety margins for surgical procedures, the guideline also recommends reducing the radicality of axillary surgery. The choice and extent of systemic therapy depends on the respective tumor biology. New substances are becoming available, particularly to treat metastatic breast cancer.

Treatment Minimization in Older Patients With Early-Stage Breast Cancer

The management of early-stage breast cancer in older patients is complex and requires a careful balance of the risk of cancer death with the competing risks of comorbidities and treatment-related toxicity in women with largely favorable disease. As the US population continues to age, oncologists will increasingly encounter this clinical challenge. Several strategies involving each core component of breast cancer therapy have been investigated to minimize treatment in these patients while still maintaining acceptable outcomes. These include omission of primary tumor resection, surgical axillary evaluation, systemic chemotherapy, and/or radiotherapy, as well as reduction in radiotherapy treatment volume (partial breast irradiation) or total treatment time (hypofractionation). We review these strategies and the literature supporting their use, as well as future directions for treatment minimization.

Quality of life of elderly patients with solid tumours undergoing adjuvant cancer therapy: a systematic review

OBJECTIVES

The measurement of quality of life (QoL) in elderly cancer population is increasingly being recognised as an important element of clinical decision-making and the evaluation of treatment outcome. This systematic review aimed to summarise the evidence of QoL during and after adjuvant therapy in elderly patients with cancer.

METHODS

A systematic search was conducted of studies published in CINAHL plus, CENTRAL, PubMed, PsycINFO and Web of Science from the inception of these databases to December 2016. Eligible studies included RCTs and non-RCTs in which QoL was measured in elderly patients (aged 65 years or above) with stage I-III solid tumours who were undergoing adjuvant chemotherapy and/or radiotherapy. Because of the heterogeneity and the insufficient data among the included studies, the results were synthesised narratively.

RESULTS

We included 4 RCTs and 14 non-RCTs on 1785 participants. In all four RCTs, the risk of bias was low or unclear for most items but high for detection. Of the 14 non-RCTs, 5 studies were judged to have a low or moderate risk of bias for all domains, and the other 9 studies had a serious risk of bias in at least one domain. The bias was observed mainly in the confounding and in the selection of participants for the study. For most elderly patients with breast cancer, the non-significant negative change in the QoL was transient. A significant increase in the QoL during the course of temozolomide in elderly patients with glioblastoma but a decreasing trend in QoL after radiotherapy was shown. This review also shows a uniform trend of stable or improved QoL during adjuvant therapy and at follow-up evaluations across the studies with prostate, colon or cervical cancer population.

CONCLUSIONS

This review suggests that adjuvant chemotherapy and radiotherapy may not have detrimental effects on QoL in most elderly patients with solid tumours.

Controversial issues in the management of older adults with early breast cancer

It is well recognized that the incidence of breast cancer increases significantly with age. Despite this, older people remain under-represented in many clinical trials and their management relies on extrapolation of data from younger patients. Providing an aggressive intervention can be challenging, particularly in less fit older patients where a conservative approach is commonly perceived to be more appropriate. The optimal management of this population is unknown and treatment decision should be personalized. This review article will discuss several controversial issues in managing older adults with early breast cancer in a multidisciplinary setting, including the role of surgical treatment of the axilla in clinically node negative disease, radiotherapy after breast conservation surgery in low-risk tumours, personalizing adjuvant systemic therapy, and geriatric assessments in breast cancer treatment decisions.

Pharmacogenomics, Pharmacokinetics, and Pharmacodynamics in the Era of Targeted Therapies

The complex nature of the pharmacologic aspects of cancer therapeutics has become more apparent in the past several years with the arrival of a cascade of target-based agents and the difficult challenge of bringing individualized precision medicine to oncology. Interpatient variability in drug action, singularly in novel agents, is in part caused by pharmacogenomic (PG), pharmacokinetic, and pharmacodynamic (PD) factors, and drug selection and dosing should take this into consideration to optimize the benefit for our patients in terms of antitumor activity and treatment tolerance. In this regard, somatic genetic evaluation of tumors is useful in not only predicting response to initial targeted therapies but also in anticipating and guiding therapy after the development of acquired resistance; therapeutic drug monitoring of novel small molecules and monoclonal antibodies must be incorporated in our day-to-day practice to minimize the negative effect on clinical outcome of interindividual variability on pharmacokinetic processes of these drugs for all patients, but especially for fragile patient populations and those with organ dysfunction or comorbidities. For these populations, incorporating frailty assessment tools into trials of newer agents and validating frailty-based dose adjustment should be an important part of further drug development.

Cardiac safety of adjuvant non-pegylated liposomal doxorubicin combined with cyclophosphamide and followed by paclitaxel in older breast cancer patients

PURPOSE

To investigate the cardiac safety of adjuvant Non-Pegylated Liposomal Doxorubicin (NPL-DOX) combined to Cyclophosphamide (CTX) and followed by weekly Paclitaxel, in older patients (≥65 years) with diagnosis of high risk breast cancer. The main end point of this prospective study was the detection of early episodes of symptomatic congestive heart failure (CHF).

METHODS

The cardiac function was evaluated by left ventricular ejection fraction (LVEF) measurements with repeated echocardiograms, performed 2 weeks before the beginning of chemotherapy and every 6 months, until 30 months after the study entry; then yearly for at least 5 years.

RESULTS

Forty-seven patients were enrolled from two Italian Divisions of Medical Oncology. Final results revealed no early episodes of symptomatic CHF within the first 12 months from the enrolment. Only two cardiac events were observed: an episode of atrial flutter after the first cycle of NPL-DOX and CTX, with a quick return to normal rhythm, and a grade 3 (scored to NCI-CTCAE, version 3.0) CHF episode, 18 months later chemotherapy start. No other relevant toxicities were reported.

CONCLUSIONS

This adjuvant combination including NPL-DOX in elderly patients, resulted in a low rate of cardiac toxic effects. Comparative trials should be encouraged to confirm these findings.

Adjuvant chemotherapy and HER-2-directed therapy for early-stage breast cancer in the elderly

There is a lack of sufficient evidence-based data defining the optimal adjuvant systemic therapies in older women. Recommendations are mainly based on retrospective studies, subgroup analyses within larger randomised trials and expert opinion. Treatment decisions should consider the functional fitness of the patient, co-morbidities, in addition to chronological age with the aim to balance risks and potential benefits from treatment(s). In this review, we discuss assessment tools to aid clinicians to select elderly patients who are ‘fit' for chemotherapy, and review the literature on the use of chemotherapy and of the anti-HER 2 antibody trastuzumab in this population. We will also review two commonly used prediction models to assess their accuracy in predicting survival outcomes in elderly patients. Ongoing clinical trials specifically focusing on older patients may help to clarify the absolute benefits and risks of adjuvant systemic therapy in this age group.

Adjuvant systemic therapy in older women with breast cancer

Breast cancer in the elderly is an increasing clinical problem. In addition, ~60% of deaths from breast cancer occur in women aged 65 years and older. Despite this, older women with breast cancer have been underrepresented in clinical trials, and this has led to less than optimal evidence to guide their therapy. The management of elderly women with early breast cancer is a complex process that requires careful evaluation of life expectancy, comorbidities, patient values, and risks and benefits of available treatment options. This review will focus on current adjuvant systemic therapy options for older women with breast cancer, discuss the principles in the decision-making process, and define the role of endocrine therapy, chemotherapy, and targeted agents.

Effect of age on drug metabolism in women with breast cancer

INTRODUCTION

The aging of the population will increase the number of breast cancer patients requiring treatment in both the adjuvant and metastatic setting. Hormones, chemotherapy and targeted drugs all have a role in treatment. Older patients have been underrepresented in clinical trials making evidence-based decisions difficult. The increase in comorbidity and aging, polypharmacy and changes in function make pharmacotherapy decisions more complicated. Knowledge of the issues is critical in the prescribing of effective and safe therapy. There are factors associated with advancing age that can result in pharmacokinetic and pharmacodynamic variations in processing of hormonal agents, chemotherapy and targeted drugs.

AREAS COVERED

A review of the literature pertaining to pharmacokinetic changes in aging in breast cancer was untaken. Studies are reviewed involving single agents and some combinations.

EXPERT OPINION

Older patients should be considered for standard therapies. Their specific problems need to be evaluated by geriatric-specific assessment including functional status, end organ dysfunction and polypharmacy. There are few instances for age-related changes in pharmacokinetics and when present are usually not clinically significant. When changes are present, they are often the result of comorbidity, drug interactions and drug scheduling issues. The older patients may be more sensitive to certain toxicities such as cardiac toxicity, neuropathy and myelosuppression.

Reactive Oxygen Species-Manipulated Drug Release from a Smart Envelope-Type Mesoporous Titanium Nanovehicle for Tumor Sonodynamic-Chemotherapy

Despite advances in drug delivery systems (DDSs), the stimuli-responsive controlled release DDSs with high spatial/temporal resolution are still the best choice. Herein, a novel type of envelope-type mesoporous titanium dioxide nanoparticle (MTN) was developed for one-demand drug delivery platform. Docetaxel (DTX) was loaded in the pores of MTN with a high drug loading efficiency (∼26%). Then β-cyclodextrin (β-CD, a bulky gatekeeper) was attached to the outer surface of MTN via a reactive oxygen species (ROS) sensitive linker to block the pores (MTN@DTX-CD). MTN@DTX-CD could entrap the DTX in the pores and allow the rapid release until a focused ultrasound (US) emerged. A large number of ROS were generated by MTN under US radiation, leading to the cleavage of the ROS-sensitive linker; thus, DTX could be released rapidly since the gatekeepers (β-CD) were detached. Besides, the generation of ROS could also be used for tumor-specific sonodynamic therapy (SDT). Studies have shown the feasibility of MTN@DTX-CD for US-triggered DTX release and sonodynamic-chemotherapy. In the in vitro and in vivo studies, by integrating SDT and chemotherapy into one system, MTN@DTX-CD showed excellent antitumor efficacy. More importantly, this novel DDS significantly decreased the side effects of DTX by avoiding the spleen and hematologic toxicity to tumor-bearing mice.

Adjuvant Systemic Therapy in Older Breast Cancer Women: Can We Optimize the Level of Care?

Defining optimal adjuvant treatment for older women with breast cancer is challenged by the lack of level-1 clinical evidence and the heterogeneity of the older population. Nevertheless, recommendations based on reviews of available evidence mainly from retrospective subgroup analyses and extrapolation of study results from younger patients, and expert opinions, may be useful to guide treatment decisions in fit patients. But how can we properly define a "fit" older patient? In clinical practice, age by itself and clinical impression generally drive treatment decision, although the appropriateness of this judgment is under-documented. Such an approach risks overtreatment or, more frequently, undertreatment. A geriatric assessment can be valuable in oncology practice to address this issue. In this review article, we will focus only on systemic treatment and will discuss "standard" adjuvant systemic treatment strategies for fit older breast cancer patients and the role of "personalized" systemic therapy in unfit patients. The concepts conveyed in this review cannot be extrapolated to locoregional therapy.