Disease-free survival advantage of weekly epirubicin plus tamoxifen versus tamoxifen alone as adjuvant treatment of operable, node-positive, elderly breast cancer patients: 6-year follow-up results of the French adjuvant study group 08 trial

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.

Outcome of adjuvant chemotherapy in elderly patients with early-stage, hormone receptor-positive, HER-2-negative breast cancer

The proportion of breast cancer cases among elderly (over 70 years old) patients is expected to rise from 24% to 35% by the next decade. However, elderly patients with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER-2)-negative, node-negative breast cancer were underrepresented in prior landmark prospective trials. Using a nationwide hospital cancer registry, our study of 12 004 elderly patients demonstrates that adjuvant chemotherapy was not associated with overall survival (hazards ratio [HR] 0.96, 95% confidence interval [CI] 0.77-1.20, P = .71). Given the toxicities associated with systemic treatment, cautious recommendation or the omission of chemotherapy may be considered in select elderly patients.

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.

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 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.

Approach and Management of Breast Cancer in the Elderly

Breast cancer is the mostly commonly diagnosed cancer in women both in the United States and worldwide. Although advanced age at diagnosis is associated with more favorable tumor biology, mortality rates are comparatively higher in older adults, possibly attributed to advanced stage at presentation. There are minimal specific treatment-based guidelines in elderly patients with cancer, mostly attributable to their limited inclusion on clinical trials. In addition to the existing evidence from clinical trials and retrospective studies, practitioners need to take into consideration functional status, social support, patient preference, presence of comorbidities, and life expectancy when selecting optimal treatment.

Early-Stage Breast Cancer in the Elderly: Confronting an Old Clinical Problem

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.

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.

Optimal management of breast cancer in the elderly patient: current perspectives

Breast cancer (BC) is the most common female malignancy in the world and almost one third of cases occur after 70 years of age. Optimal management of BC in the elderly is a real challenge and requires a multidisciplinary approach, mainly because the elderly population is heterogeneous. In this review, we describe the various possibilities of treatment for localized or metastatic BC in an aging population. We provide an overview of the comprehensive geriatric assessment, surgery, radiotherapy, and adjuvant therapy for early localized BC and of chemotherapy and targeted therapies for metastatic BC. Finally, we attempt to put into perspective the necessary balance between the expected benefits and risks, especially in the adjuvant setting.

Breast cancer in the elderly: which lessons have we learned?

Management of older breast cancer patients is challenging due to a lack of good quality evidence regarding the role of adjuvant chemotherapy. Older women can benefit as much from adjuvant chemotherapy as younger women, although they have an increased risk of toxicities. Decisions regarding adjuvant chemotherapy should be made based on tumor biology and biological age, rather than chronological age. Geriatrician assessment can detect subtle functional deficits that may impact on the ability of the patient to tolerate chemotherapy; however, implementation of comprehensive geriatric assessment in the oncology setting is challenging. Instead, numerous frailty screening tools are in development. Future advances should incorporate more accurate and efficient means for determining the biological age of elderly breast cancer patients, which will better define the risk:benefit ratio of adjuvant chemotherapy.

Breast cancer management in the elderly

The increase in life expectancy in the western world means that we are faced with patients diagnosed with breast cancer in old age with increasing frequency. The management of these cases is a challenge for the oncologist, who must take into account the conditions associated with advanced age and the lack of trials in this population. In this review, we addressed the incorporation of geriatric assessment methods that may be useful in making decisions, the particular biological characteristics of breast cancer in elderly patients and their treatment in both localized and advanced disease. Finally, we collected recommendations based on scientific evidence regarding the monitoring and life-style after finishing treatment.

The challenges of individualized care for older patients with localized breast cancer

Individualized care is achieved when the appropriate screening and/or evaluative tests are used, the treatment plan is driven by evidence-based data and the patient's functional ability, physical and mental health, preference and social situation are incorporated into treatment decisions. Breast cancer is a disease of aging; yet, the management of breast cancer in older women in most cases lacks evidence from prospective randomized clinical trials (i.e., level 1 evidence) to support treatment recommendations. Older women are underrepresented in therapeutic clinical studies, even though studies show that selected fit older women enrolled on clinical trials derive similar benefits as younger women. Very few studies have focused on the distribution and biological behavior of different molecular subtypes of breast cancer in older women making it difficult to conclude whether old age adds extra biological complexity. A comprehensive geriatric assessment that includes a multidimensional process designed to assess functional ability, physical health, cognitive and mental health, social issues and environmental situation of elderly person should be an integral part of individualized care for older patients with breast cancer. However, incorporation of this tool into standard oncology practice is very slow despite the expected steep increase in older individuals with cancer projected over the next 25 years. All of the factors mentioned above hinder progress in delivering individualized care to older patients with breast cancer. This article provides an overview on progress and challenges of individualized and personalized health care in older women with breast cancer.

Treatment of breast cancer in the elderly: a prospective, population-based Swiss study

OBJECTIVES

The primary objective of this population-based study is to describe the patterns of care of elderly patients with breast cancer (BC), and evaluate potential causative factors for the decrease in BC-specific survival (BCSS) in the elderly.

PATIENTS AND METHODS

We included all or representative samples of patients with newly diagnosed BC from seven Swiss cancer registries between 2003 and 2005 (n=4820). Surgical and non-surgical BC treatment was analyzed over 5 age groups (<65, 65 to <70, 70 to <75, 75 to <80 and ≥80years), and the predictive impact of patient age on specific treatments was calculated using multivariate logistic regression analysis.

RESULTS

The proportion of locally advanced, metastatic and incompletely staged BC increased with age. The odds ratio for performing breast-conserving surgery (BCS) in stages I-II BC (0.37), sentinel lymph node dissection (SLND) in patients with no palpable adenopathy (0.58), post-BCS radiotherapy (0.04) and adjuvant endocrine treatment (0.23) were all in disfavor of patients ≥80years of age compared to their younger peers. Only 36% of patients ≥80years of age with no palpable adenopathy underwent SLND. In the adjusted model, higher age was a significant risk factor for omitting post-BCS radiotherapy, SLND and adjuvant endocrine treatment.

CONCLUSIONS

This study found an increase in incomplete diagnostic assessment, and a substantial underuse of BCS, post-BCS radiotherapy, SLND and adjuvant endocrine treatment in elderly patients with BC. There is a need for improved management of early BC in the elderly even in a system with universal access to health care services.

Early breast cancer in the older woman

Care of the older woman with early breast cancer is of particular importance to both the oncologist and geriatrician because of both the prevalence of the disease in this population as well as the subtleties necessary in individualizing treatment decisions. In general, older women are able to tolerate many of the same modalities of treatment for early breast cancer as younger women, but special consideration must be given to future life expectancy, comorbidities, and other elements that might be identified using a CGA. Both short-term and long-term side effects of cancer therapies can be clinically important in the older woman, and appropriate screening and support for these toxicities are necessary.

Adjuvant chemotherapy for breast cancer in older women: emerging evidence to aid in decision making

To prevent breast cancer-related recurrence and death, adjuvant therapy, including chemotherapy, is given. The decision to deliver chemotherapy requires careful weighing of the risk of toxicity versus the estimated benefit. The risk and benefit are based on information from clinical trials, statistical models, and past clinical experience . Compared to younger patients, it is perceived that older patients have cancers that are lower risk, gain less benefit from chemotherapy, and are at higher risk of toxicity. There is now strong evidence that healthy older women tolerate treatment and stand to gain the same benefits from treatment as do younger women. Numeric age alone, therefore, does not justify withholding adjuvant chemotherapy. New tools to aid in the decision are needed. Fortunately, the expected great increase in the size of the geriatric population spawned the field of geriatric oncology and the development of brief, practical versions of the Comprehensive Geriatric Assessment (CGA) for use in busy oncology clinics are in sight. It is time for us to incorporate elements of the CGA into practice, to systematically identify older patients at substantial risk of toxicity. For frail older women with breast cancer, no therapy or less toxic therapies can be considered, some of which are suggested herein. In addition, as always in oncology, physicians and patients should look for and participate in clinical trials that will define how to treat cancer, especially in older patients, in the future.

Adjuvant therapy for women over age 65 with breast cancer

BACKGROUND

Women over age 65 with breast cancer are often not treated in accordance with current guidelines as far as adjuvant therapy is concerned, because of the lack of adequate scientific evidence.

METHODS

This article is based on a selective review of pertinent literature retrieved by a PubMed search, as well as on the German S3 guidelines for the diagnosis, treatment, and follow-up care of breast cancer, the treatment recommendations of the German Working Group on Gynecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie, AGO) and the German Society of Radiation Oncology (Deutsche Gesellschaft für Radioonkologie), US National Comprehensive Cancer Network, and the Cochrane database.

RESULTS

Women over age 65 are underrepresented in randomized trials of treatments for breast cancer. Geriatric assessment is essential for therapeutic decision-making. Endocrine treatment is feasible for nearly all patients with hormone-sensitive tumors. In selected patients over age 65, chemotherapy significantly improves overall survival. The best evidence regarding toxicity is available for anthracycline monotherapy and for combined therapy with doxorubicin/cyclophosphamide or taxane/doxorubicin. Women without cardiac disease can be given trastuzumab, which may lead to reversible cardiotoxicity. Adjuvant radiotherapy significantly improves local tumor control and survival. Adjuvant radiotherapy that is carried out with modern treatment planning, as recommended by the current guidelines, is no more toxic to older patients than to younger ones; thus, it should always be given, unless there is a special reason not to.

CONCLUSION

Women with breast cancer over age 65 whose life expectancy is greater than 5 years, and who are not otherwise too ill, should be given chemotherapy, trastuzumab, and radiotherapy as standard adjuvant treatment. Adjuvant therapy can be reduced or omitted in frail patients. Patients over age 65 should be given the opportunity to enroll in clinical trials.

Quality-of-life considerations in the treatment of early-stage breast cancer in the elderly

Breast cancer is a common tumour in the elderly population and management of early disease in particular is a major challenge for oncologists and geriatricians alike. An important aspect is a differentiated knowledge about the short-term effects and long-term perspectives regarding levels of functioning and subjective well-being associated with different treatment strategies. The article focuses on available quality-of-life (QOL) measurement instruments in elderly patients with early breast cancer and the impact of various local or systemic treatments on QOL scores. A selective literature search was carried out in the PubMed database from January 2000 to May 2010 using the terms 'early breast cancer', 'elderly' and 'quality of life'. Contributions to international congresses on breast cancer in 2009 were also included. Of the 80 articles retrieved, 46 publications were excluded from further consideration due to failure to fulfil inclusion criteria (e.g. not restricted to the elderly, inclusion of patients with metastatic disease, no adjuvant treatment). Sixteen papers focusing on complementary treatment were also rejected. The remaining 18 articles were extensively reviewed. The selection of described QOL measurements was very heterogeneous in these 18 studies. Commonly used QOL instruments were the European Organization for Research and Treatment of Cancer QOL questionnaires (EORTC QLQ-C30, EORTC QLQ-BR23) and the Functional Assessment of Cancer Therapy questionnaires (FACT-G, FACT-B) and its subscales. Additionally, the Medical Outcomes Study 36-Item Short-Form Health Survey (MOS-SF-36), the Hospital Anxiety and Depression Scale (HADS) and the International Breast Cancer Study Group (IBCSG) approach were used by various study groups. The general limitations of QOL assessment in the elderly population are discussed in the review. Surgery, when considered from a technical point of view, does not differ significantly with patient age. Furthermore, age in itself should not be a contraindication to breast-conserving surgery (BCS) because QOL appears somewhat better after conservative surgical treatment. Avoiding axillary surgery and undergoing sentinel lymph node dissection in elderly patients are both associated with better short-term QOL. However, conventional axillary surgery has little effect on long-term QOL in older women. The advent of innovative radiotherapy techniques has resulted in marked improvements in short-term tolerability together with reductions in the incidence and severity of late normal tissue damage. A potential alternative to conventional postoperative radiotherapy after BCS in the future is the intraoperative radiotherapy technique. Chemotherapy has considerable effects on QOL in breast cancer patients. Most studies found that overall QOL was maintained or improved in patients receiving either aromatase inhibitors or tamoxifen but patients reported different adverse effects. For the majority of older breast cancer survivors, cancer-specific well-being and general emotional health do not change substantially after a breast cancer diagnosis. In summary, issues related to baseline co-morbidities in frail elderly, the adverse effects of novel chemotherapeutic agents (e.g. nanoparticle albumin-bound paclitaxel) or target drugs (biologicals) and compliance in the elderly population should receive more attention in evaluations of QOL in elderly breast cancer patients. Future studies that include QOL measurements should also provide details on the data collection and quality control methodologies used.

Impact of liposomal doxorubicin-based adjuvant chemotherapy on autonomy in women over 70 with hormone-receptor-negative breast carcinoma: A French Geriatric Oncology Group (GERICO) phase II multicentre trial

RATIONALE

Breast cancer is a disease of ageing. Functional independence in elderly patients, measured with the Katz activities of daily living (ADL) scale, predicts overall survival and the need for welfare support. Few prospective studies have examined the feasibility of adjuvant chemotherapy and its impact on autonomy in women over 70 years of age with high-risk breast cancer. This multicentre phase II trial was designed to assess the impact of adjuvant anthracycline-based chemotherapy on these patients' autonomy.

DESIGN AND METHODS

In a two-stage Fleming design, women aged ≥70 years with histologically proven hormone-receptor-negative early breast cancer and a significant risk of recurrence (pN+ or "high risk" pN0) received 4 cycles of nonpegylated liposomal doxorubicin 60 mg/m(2) and cyclophosphamide 600 mg/m(2) every 3 weeks postoperatively, on an outpatient basis. The primary endpoint was the change in the ADL score during chemotherapy. Secondary endpoints include comprehensive geriatric, quality-of-life and acceptability assessments, tolerability, and long-term outcome. The results for the primary endpoint and other scales at completion of adjuvant chemotherapy are reported here, while long-term follow-up is not yet complete.

RESULTS

Forty patients (median age 75 [70-82]) were enrolled between February 2006 and November 2007. Chemotherapy had no deleterious impact on ADL, cognition, mental status, or the frequency of comorbidities. In contrast, the number of patients at risk of malnutrition, based on the Mini Nutritional Assessment, more than doubled between baseline and the end of chemotherapy, rising from 15% to 38%. Quality-of-life deteriorated in terms of social and role functioning, likely owing to fatigue, loss of appetite, nausea and vomiting. Treatment acceptability was good. The main adverse effect was neutropenia, 15% of the patients experiencing febrile neutropenia. No cardiac toxicity or toxic deaths occurred.

CONCLUSION

This study demonstrates the feasibility of an adjuvant chemotherapy regimen combining nonpegylated liposomal doxorubicin and cyclophosphamide in fit elderly women <85 years with breast cancer. Although chemotherapy had an impact on social and role functioning, autonomy was not impaired and toxicity was acceptable. Special attention should be paid to nutritional status before and after treatment.

Oncologists' recommendations for adjuvant therapy in hormone receptor-positive breast cancer patients of varying age and health status

BACKGROUND

Currently, evidence supports the use of adjuvant endocrine therapy with aromatase inhibitors in post-menopausal patients with hormone receptor (HR)-positive breast cancer. The goal of the current study is to understand the effect of patient age and health status on oncologists' decision to recommend adjuvant treatment (endocrine therapy and chemotherapy) in older women with HR-positive breast cancer.

PATIENTS AND METHODS

An online survey was conducted, with questions related to a hypothetical patient of varying age and health status with a T2 N2 HR-positive, HER2-negative breast cancer. Treatment options included chemotherapy and endocrine therapy, endocrine therapy alone, or no therapy. Respondents (n = 151) were further asked to specify use of either tamoxifen or aromatase inhibitors. A generalized linear mixed-effects model was used to determine the effect of age and health status on recommendations.

RESULTS

As the hypothetical patient's age increased or health status deteriorated, oncologists (n = 151) were less likely to recommend a combination of chemotherapy and endocrine therapy (P < .0001 for both). In contrast, oncologists were more likely to recommend endocrine therapy alone with advanced age and deteriorating health status (P < .0001 for both). Oncologists were more likely to choose treatment with aromatase inhibitors as opposed to tamoxifen (P < .01), irrespective of age or health status.

CONCLUSION

With increasing age and declining health status, oncologists were more likely to recommend endocrine therapy alone as opposed to chemotherapy with endocrine therapy. Oncologists were most likely to recommend aromatase inhibitors, irrespective of age or health status.

Geriatric oncology: an overview of progresses and challenges

Thanks to the global improvement of health care and living conditions, the world population is aging. Already, in developed countries half of the cancers occur in patients aged 70 and older. In booming Asian nations, such as South Korea, the aging trend is particularly striking, and therefore geriatric oncology is rapidly coming at the foreground of oncology practice. As older patients have a very variable health status, the need for proper integration of an oncologic and a geriatric approach has become increasingly clear. The last two decades have seen the development of geriatric oncology programs and research, which we review here. An increasing amount of data is making clear that a geriatric assessment identifies many problems in older people with cancer, adds prognostic information, and might improve the outcomes of these patients. The near future will likely deliver the following: Operationalization of geriatric assessment into assessment and decision tools, as well as multidisciplinary interventions, in oncology; cooperation of aging and cancer research in the understanding of cancer biology, aging physiology, pharmacology of anticancer drugs; improved clinical study designs; development of geriatric oncology programs, and screening tools accessible to the private practitioner.

Benefit of adjuvant chemotherapy in elderly ER-negative breast cancer patients: benefits and pitfalls

Approximately 50% of breast cancer (BC) cases occur in women aged 65 and older, and more than 30% occur in those aged over 70, yet very old (older than 70) patients are under-represented in clinical trials. In the Oxford meta-analysis, the hazard ratios for recurrence and BC mortality in women aged over 70 were 0.88 and 0.87, respectively, suggesting a benefit from chemotherapy in this group of patients as well; however, the large confidence intervals surrounding reductions in this subgroup reflect the small number of older patients recruited in randomized trials in Early Breast Cancer Trialists' Collaborative Group meta-analyses. If we consider the tumor biology of BC in older adults, we will see that they are more likely to develop a tumor with high estrogen receptor (ER)- and/or progesterone receptor-positive status and a lower proliferative index. However, the biology of these tumors appears to change according to chronological age into aggressive forms diagnosed in these patients as well. This subgroup analysis for the benefit of adjuvant chemotherapy in elderly patients (at least 65 years) is reported in a few studies, even though a limited statistical significance has been revealed. Retrospective evidences suggest that even more aggressive treatments such as taxanes and dose-dense schedule appear feasible (but probably more toxic) in the elderly. Age is no longer considered the only criterion for choosing the right treatment for patients with BC; in fact, functional status and comorbidity have to be taken into consideration as well. Fit elderly patients with more aggressive forms (node-positive and ER-poor disease) seem to obtain the same benefits as younger patients, and thus have to be treated in the same manner.

Adjuvant Chemotherapy for Older Adults with Breast Cancer: Making the Standard a Standard

Muss HB, Berry DA, Cirrincione CT et al.: Adjuvant chemotherapy in older women with early-stage breast cancer. N. Engl. J. Med. 360, 2055–2065 (2009). To date, only two prospective trials evaluating adjuvant therapy for breast cancer in older adults have been published. The second and more recent trial, Cancer and Leukemia Group B (CALGB) 49907, provides substantial evidence supporting the use of standard adjuvant chemotherapy regimens (doxorubicin-cyclophosphamide or cyclophosphamide-methotrexate-5-fluorouracil) as opposed to simplified oral regimens (capecitabine). In this trial, both the risk of relapse (hazard ratio: 2.09; 95% CI: 1.38–3.17; p < 0.001) and the risk of death (hazard ratio: 1.85; 95% CI: 1.11–3.08; p = 0.02) were significantly higher with capecitabine compared with standard chemotherapy. The current review explores both the implications and potential caveats of this innovative trial. CALGB 49907 represents a paradigm for further studies of adjuvant cancer therapy in older adults.

Adjuvant systemic therapy for older adults with early-stage breast cancer

There is a relative paucity of evidence to guide the adjuvant therapy of breast cancer in older adults. Herein, we review data from relevant clinical trials and retrospective analyses that assess systemic therapies in older adults. Chemotherapy, endocrine therapy, HER2-directed agents and bisphosphonates in the adjuvant setting are discussed. Meta-analyses, such as the Oxford overview, suggest a decreasing benefit of chemotherapy with age. However, prospective trials do support a benefit from the addition of chemotherapy to endocrine therapy in older adults. In contrast to chemotherapy, the value of endocrine therapy appears to increase with age. In addition, available subset analyses suggest that the benefit from aromatase inhibitors relative to tamoxifen is independent of age. The use of HER2-directed therapy in older adults is challenged by the relatively low enrollment of this subset in prospective clinical trials. Nonetheless, the extent of enrollment may be proportional to the frequency of HER2 overexpression in this population. Finally, there are little data to support the use of adjuvant bisphosphonate therapy in older adults--ongoing prospective trials may address this issue. Each of the aforementioned therapeutic strategies will be augmented by efforts to personalize therapy for older adults. Clinical tools such as the geriatric assessment and biologic assays, such as the 21-gene recurrence score, may ultimately play a role in treatment algorithms for this unique demographic.

Expression of ER-{alpha}36, a novel variant of estrogen receptor {alpha}, and resistance to tamoxifen treatment in breast cancer

PURPOSE Recently, a 36-kDa variant of estrogen receptor alpha (ER-alpha66), ER-alpha36, has been identified and cloned. ER-alpha36 predominantly localizes on the plasma membrane and in the cytoplasm and mediates a membrane-initiated "nongenomic" signaling pathway. Here, we investigate the association between ER-alpha36 expression and tamoxifen resistance in patients with breast cancer. PATIENTS AND METHODS ER-alpha36 protein expression in tumors from 896 women (two independent cohorts, 1 and 2) with operable primary breast cancer was assessed using an immunohistochemistry assay. Results In the first cohort of 710 consecutive patients, overexpression of ER-alpha36 was associated with poorer disease-free survival (DFS) and disease-specific survival (DSS) in patients with ER-alpha66-positive tumors who received tamoxifen treatment (chemotherapy plus tamoxifen or tamoxifen alone, n = 307). In contrast, ER-alpha36 was not associated with survival in patients with ER-alpha66-positive tumors who did not receive tamoxifen (chemotherapy alone, n = 129) and in patients with ER-alpha66-negative tumors whether they received tamoxifen (n = 73) or not (n = 149). In the second cohort of 186 patients who only received tamoxifen as adjuvant therapy, overexpression of ER-alpha36 was significantly associated with poorer DFS and DSS in 156 ER-alpha66-positive patients from this cohort, and ER-alpha36 remained an independent unfavorable factor for both DFS and DSS in these 156 patients by a multivariate analysis (DFS: hazard ratio [HR] = 5.47; 95% CI, 1.81 to 16.51; P =. 003; DSS: HR = 13.97; 95% CI, 1.58 to 123.53; P = .018). CONCLUSION Women with ER-alpha66-positive tumors that also express high levels of ER-alpha36 are less likely to benefit from tamoxifen treatment.

Adjuvant chemotherapy in older women with early-stage breast cancer

BACKGROUND

Older women with breast cancer are underrepresented in clinical trials, and data on the effects of adjuvant chemotherapy in such patients are scant. We tested for the noninferiority of capecitabine as compared with standard chemotherapy in women with breast cancer who were 65 years of age or older.

METHODS

We randomly assigned patients with stage I, II, IIIA, or IIIB breast cancer to standard chemotherapy (either cyclophosphamide, methotrexate, and fluorouracil or cyclophosphamide plus doxorubicin) or capecitabine. Endocrine therapy was recommended after chemotherapy in patients with hormone-receptor-positive tumors. A Bayesian statistical design was used with a range in sample size from 600 to 1800 patients. The primary end point was relapse-free survival.

RESULTS

When the 600th patient was enrolled, the probability that, with longer follow-up, capecitabine therapy was highly likely to be inferior to standard chemotherapy met a prescribed level, and enrollment was discontinued. After an additional year of follow-up, the hazard ratio for disease recurrence or death in the capecitabine group was 2.09 (95% confidence interval, 1.38 to 3.17; P<0.001). Patients who were randomly assigned to capecitabine were twice as likely to have a relapse and almost twice as likely to die as patients who were randomly assigned to standard chemotherapy (P=0.02). At 3 years, the rate of relapse-free survival was 68% in the capecitabine group versus 85% in the standard-chemotherapy group, and the overall survival rate was 86% versus 91%. Two patients in the capecitabine group died of treatment-related complications; as compared with patients receiving capecitabine, twice as many patients receiving standard chemotherapy had moderate-to-severe toxic effects (64% vs. 33%).

CONCLUSIONS

Standard adjuvant chemotherapy is superior to capecitabine in patients with early-stage breast cancer who are 65 years of age or older. (ClinicalTrials.gov number, NCT00024102.)

Adjuvant chemotherapy for early breast cancer in the elderly

The use of cytotoxic therapy in the fit elderly breast cancer patient has been tempered with concerns of age, physical function, and co-morbid illness. In the appropriate patient with biologically aggressive disease, such as receptor poor breast cancer, it is reasonable to consider combination chemotherapy as part of an adjuvant program. If this approach is to be employed, the physician must also consider the patient's co-morbid conditions and status of function in society as potential indicators of toxicity or lack of benefit. In this case, a formal geriatric assessment is of value. A Cancer and Leukemia Group B (CALGB) trial of monotherapy vs combination cytotoxic therapy as adjuvant treatment for localized breast cancer patients over 65 years of age has determined that the combination approach is superior to single agent therapy. In an unplanned analysis of receptor rich and receptor poor tumors, the patients with receptor poor tumors seemed to achieve the greatest benefit from combination cytotoxic therapy. Adjuvant chemotherapy can also be considered for patients with high-risk receptor rich breast cancers. However, the use of chemotherapy in the elderly patient with breast cancer is largely based upon data emerging from trials in younger patients. Studies specifically for patients over 65 years of age are urgently needed in this population to provide evidence-based proof of the current approach.

Mammography Screening and Treatment of Breast Cancer in the Elderly

Breast cancer patients of an advanced age will suffer from ailments related to both senescence and cancer. Some will have been denied access to screening programmes and will present with an advanced disease. Many will need the expertise of the geriatrician and the oncologist who will participate in specific case discussions to look at social and medical issues that will affect the treatment plan (with questions regarding surgery, radiation, drug therapy, rehabilitation, supportive care, and palliative care often intertwined). This paper reviews recommendations by the International Society of Geriatric Oncology (SIOG) task force which recently assessed the available evidence on breast cancer in elderly individuals, and provided evidence-based recommendations for the diagnosis and treatment of breast cancer in such individuals. Recommendations on the topics of screening, surgery, radiotherapy, (neo)adjuvant hormone treatment, and chemotherapy, and on metastatic disease have been given. Oncologists are now learning to take into account the physiological age of their patient, which is the reflection of a normal and sometimes abnormally accelerated loss of body reserves which is certainly related to chronological age but not precisely dictated by it. Understanding the biology of breast cancer will allow to optimally adapt the treatment of the elderly patient.

Management of breast cancer in elderly individuals: recommendations of the International Society of Geriatric Oncology

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer mortality in women worldwide. Elderly individuals make up a large part of the breast cancer population, and there are important specific considerations for this population. The International Society of Geriatric Oncology created a task force to assess the available evidence on breast cancer in elderly individuals, and to provide evidence-based recommendations for the diagnosis and treatment of breast cancer in such individuals. A review of the published work was done with the results of a search on Medline for English-language articles published between 1990 and 2007 and of abstracts from key international conferences. Recommendations are given on the topics of screening, surgery, radiotherapy, (neo)adjuvant hormone treatment and chemotherapy, and metastatic disease. Since large randomised trials in elderly patients with breast cancer are scarce, there is little level I evidence for the treatment of such patients. The available evidence was reviewed and synthesised to provide consensus recommendations regarding the care of breast cancer in older adults.

Does chemotherapy-induced neutropaenia result in a postponement of adjuvant or neoadjuvant regimens in breast cancer patients? Results of a retrospective analysis

In 2005, 224 patients received adjuvant/neoadjuvant chemotherapy for breast cancer in a single institution according to daily practices. Regimens consisted of epirubicin-based chemotherapy (FEC100, four or six cycles), or three cycles of FEC100 followed by three cycles of docetaxel. An absolute blood count was carried out every 3 weeks, 1–3 days before planned chemotherapy cycle. Overall, 1238 cycles were delivered. An absolute neutrophil count (ANC) <1.5 × 10⁹ l⁻¹ before planned chemotherapy was found in 171 cycles. Of these, 130 cycles (76%) were delivered as planned regardless of whether ANC levels recovered, and 41 (24%) were delayed. None of these patients developed a febrile neutropaenia. Haematopoietic support (granulocyte colony-stimulating factor (G-CSF)) was required in 12 cycles. We found that the majority of patients with an ANC <1.5 × 10⁹ l⁻¹ before planned chemotherapy received planned doses, without complications and need for G-CSF.

Weekly epirubicin and paclitaxel with granulocyte colony-stimulating factor support in previously untreated metastatic breast cancer patients: a phase II study

We conducted a phase II study to determine the activity and tolerability of weekly epirubicin-paclitaxel and granulocyte colony-stimulating factor in breast cancer patients untreated for metastatic disease. The phase II study was designed following the Simon optimal-two stage method. Patients received epirubicin 25 mg/m and paclitaxel 80 mg/m every week, and granulocyte colony-stimulating factor on days 2 and 4 for 24 consecutive weeks in the absence of progression. From 1999 to 2004, 53 patients entered the study; 1093 weekly courses were delivered, with a median number of cycles of 22. Patients received a median relative dose intensity of 94%. No hematological grade 3-4 toxicities were observed. One patient had one episode of grade 3 mucositis and two patients (3.8%) suffered grade 2 asthenia. Eight patients (15.1%) experienced grade 2 neutropenia, grade 2 anemia was registered in seven patients (13.2%). No cardiotoxicity was observed. Ten out of 53 patients (18.9, 95% confidence interval 8.3, 29.4%) showed a complete response, whereas 28 (52.8, 95% confidence interval 39.4, 66.3%) had a partial response, with an overall response rate of 71.7% (95% confidence interval 59.6, 83.8%). In addition, 14 patients (26.4%) had stable disease. Median time to progression was 12 months (95% confidence interval 7, 17). Median response duration was 14 months (range 3-60). The 1-, 3- and 5-year survival rates were 90.1, 68.0 and 56.6%, respectively. In untreated metastatic breast cancer patients, the weekly administration of epirubicin and paclitaxel with granulocyte colony-stimulating factor support seems to be extremely tolerable and active, and deserves further investigation into a phase III trial.