Early breast cancer in the older woman

Lumpectomy Plus Hormone or Radiation Therapy Alone for Women Aged 70 Years or Older With Hormone Receptor-Positive Early Stage Breast Cancer in the Modern Era: An Analysis of the National Cancer Database

PURPOSE

Deintensification of adjuvant therapy is being considered for older women with early-stage, biologically favorable breast cancer. Although radiation therapy (RT) can be omitted in some cases, toxicity from hormone therapy (HT) is not trivial, and adherence rates vary. We hypothesized that adjuvant RT alone would produce survival outcomes comparable to those with adjuvant HT alone among elderly patients treated with lumpectomy.

METHODS AND MATERIALS

We searched the National Cancer Database (2010-2014) for healthy women (aged ≥70 years, Charlson/Deyo [CD] score 0-1) with T1N0 hormone-receptor-positive, HER-2-negative breast cancer treated with lumpectomy and adjuvant HT or RT. Propensity scores were used to match patients for analysis.

RESULTS

We identified 2995 patients (median age, 78 years), most (81%) with a CD score of 0, clinical stage IA (77%), of whom 65% received HT alone and 35% received RT only after lumpectomy. On multivariate analysis of the matched cohort, older age (hazard ratio [HR] 1.10; 95% confidence interval [CI] 1.07-1.13; P < .001), CD score 1 (HR 1.92; 95% CI 1.37-2.70; P = .0002), and living in a metropolitan (vs urban) area (HR 3.09; 95% CI 1.43-6.67; P = .004) were associated with inferior overall survival (OS), whereas treatment with HT (vs RT) was not (HR 1.13; 95% CI 0.85-1.49; P = .406). At a median follow-up of 45 months, no difference was found in OS between HT versus RT cohorts (85% and 86%, respectively; P = .44).

CONCLUSIONS

For healthy, older women with biologically favorable breast cancer treated with lumpectomy, adjuvant RT or HT is associated with equivalent 5-year OS rates. A randomized controlled trial is warranted to explore these adjuvant monotherapy options in elderly patients with hormone receptor-positive breast cancer.

The Association between Age, Comorbidities and Use of Radiotherapy in Women with Breast Cancer: Implications for Survival

Background: Radiotherapy (RT) plays an important role in the management and survival of patients with breast cancer. The aim of this study was to examine the association between age, comorbidities and use of RT in this population. Methods: Patients diagnosed with breast cancer from 2004⁻2013 were identified from the American College of Surgeons National Cancer Database (NCDB). Follow-up time was measured from the date of diagnosis (baseline) to the date of death or censoring. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were used as the measure of association. Results: Independently of comorbidities and other important outcome-related factors, patients >65 years of age who received RT survived significantly longer than those who did not receive RT (aHR = 0.53, 95% CI = 0.52⁻0.54). However, as women aged, those with comorbidities were less likely to receive RT (adjusted p-trend by age < 0.0001). Conclusions: The development of decision-making tools to assist clinicians, and older women with breast cancer and comorbidities, are needed to facilitate personalized treatment plans regarding RT. This is particularly relevant as the population ages and the number of women with breast cancer is expected to increase in the near future.

Treating Elderly Patients With Hormone Receptor-Positive Advanced Breast Cancer

As the overall population ages, the proportion of elderly patients (aged ≥65 years) with breast cancer also increases. Studies have shown that elderly patients with hormone receptor–positive breast cancer can derive as much benefit from treatment as do younger patients, yet they remain underrepresented in clinical trials and are often undertreated in clinical practice. Treatment decisions for older patients should not be based solely on chronologic age; a patient’s physiologic functioning and comorbidities must also be taken into consideration. For recurrent or metastatic disease, systemic treatment with endocrine therapies or chemotherapy may prolong a patient’s life and alleviate troublesome symptoms. Resistance to therapy remains a problem in the advanced breast cancer setting, with most patients eventually becoming resistant to additional treatment. New combination regimens that target multiple pathways, such as everolimus plus exemestane, have shown efficacy in elderly patients previously resistant to endocrine therapies, and future research may need to focus on such combinations in order to improve outcomes in this patient group. A number of investigational agents are in clinical development, although few studies identify their effects in the elderly patient population. Optimizing effective yet tolerable therapeutic regimens for elderly patients could improve their outcomes while ensuring that the goals of improved survival and quality of life are considered.

Prevalence of women with early-stage breast cancer receiving active management using electronic health records from oncology clinics in the United States

The purpose of this study was to estimate the prevalence of women receiving treatment or active surveillance for stage I-III breast cancer in the United States from 2009 to 2012, stratified by patient age and tumor characteristics. In each study year, electronic medical records were used to identify women aged ≥18 years with stage I-III breast cancer and treated or under active surveillance (≥4 visits) at an oncology clinic that contributes data to the Oncology Services Comprehensive Electronic Records database. Prevalence was projected to the national level overall and within strata (by tumor characteristics, year of breast cancer diagnosis, and age). We identified 5,219 female breast cancer patients (18 % <age 50; 58 % <age 65) representing 787,082 (95 % CI 778,012-796,153) women in the US in 2012. At diagnosis, 44 % had stage I, 42 % stage II, and 14 % stage III disease; 69 % had estrogen receptor (ER) and progesterone receptor (PR) expression-positive tumors; 19 % were ER- and PR-negative; and 14 % had triple-negative phenotype (ER-, PR-, and HER2-negative). Overall 56 % of patients received treatment in 2012, 22 % chemotherapy, 8 % biologic therapy, and 36 % endocrine therapy. Treatment prevalence was higher among younger patients and at more advanced disease stages. Approximately half of women with ER-negative, PR-positive, HER2-negative, or triple-negative tumors received chemotherapy. As a conclusion, in 2012, approximately 800,000 women in the US were under treatment or active surveillance for early-stage breast cancer. Treatment prevalence differed by patient age, disease stage, and tumor histology.

Are breast cancer patients treated with radiotherapy younger now than ten years ago?

AIM

The aim of the present study was to analyze the age of breast cancer patients managed with curative approach at the time of treatment with radiotherapy.

BACKGROUND

Breast cancer is the most frequent neoplasm in women. Little is known with regard to the age of patients at diagnosis, and some authors have suggested that breast cancer is now affecting women who are younger than before.

MATERIALS AND METHODS

We performed a descriptive study of our series of breast cancer patients from 1998 to 2011. The age of patients, city of residence, year of treatment and uni- or bilateral location were extracted from the administrative database of the Radiation Oncology Department. The demographical and reference populational data were extracted from the Catalan Institute of Statistics.

RESULTS

3382 patients were obtained. The mean age was 57.79 years. No statistical differences were observed in the mean age during the period of study (p > 0.05), nor in patients with bilateral neoplasias with regard to unilateral tumours (p > 0.5). Patients aged less than 30, 40, 50 and 65 years were 0.3%, 6.3%, 27.0% and 69.1%, respectively. The proportion of patients aged less, equal or more than 40 and 50 years was not statistically different.

CONCLUSIONS

Breast cancer patients treated with adjuvant radiotherapy after radical surgery have not experienced significant changes in their mean age at treatment. The subgroups of patients that remain out of the mammographic screening programmes were unchanged as well. The observed differences can be explained by demographical disparities and by a probable increase in the indications for adjuvant radiotherapy.

[Special aspects of breast cancer surgery in the elderly]

Due to the aging population of Western countries and the high-quality health care system, breast cancer in the elderly generally affects women of good or satisfactory performance status pursuing active lifestyle. Over the last decade, it became evident that, in contrast to previous dogmas, age alone cannot be the contraindication to standard oncological treatment, and adequate multidisciplinary therapy aiming full recovery rather than compromise treatment is required. A number of specific aspects needs to be taken into account regarding surgery, such as life expectancy, co-morbidities, individual mobility, mental and emotional status as well as family background, which may result in changes to the individual treatment plan. Objective evaluation of the above mentioned parameters necessitates a close co-operation of professions. Interestingly, the evidence-based protocols of modern oncology often originate from the generalizations of results from clinical trials representing younger population, due to the typical under representation of elderly patients in clinical studies. Clinical trials should be extended to elderly patients as well or should specifically aim this patient population. The authors of the present paper review the special oncological and reconstructive surgical aspects of breast cancer in the elderly, such as breast conserving surgery versus mastectomia, sentinel lymph node biopsy, axillary lymphadenectomy or the omission of surgery in axillary staging, and questions regarding implant based and autologous reconstructive techniques.

Choices in surgery for older women with breast cancer

Breast cancer is a major cause of mortality worldwide. As the population ages and life expectancy increases, the burden of cancer on health services will increase. Older patients with breast cancer are becoming more suitable for surgery; tailored surgical techniques and increasing healthy life expectancy alongside improved assessment of patients are aiding this trend. Surgery is also becoming a favoured treatment of personal choice for older patient with breast cancer. Evidence shows that surgery is almost always feasible for the older patient with outcomes (survival, progression, and recurrence rates) comparable to younger groups and superior to non-surgical treatments. We aim to describe the current status of surgery for the older patient with breast cancer, showing it is an option that should not be denied. Surgery should always be considered regardless of age, after evaluation of co-morbidities.

Nomogram to predict the benefit of radiation for older patients with breast cancer treated with conservative surgery

PURPOSE

The role of radiation therapy (RT) after conservative surgery (CS) remains controversial for older patients with breast cancer. Guidelines based on recent clinical trials have suggested that RT may be omitted in selected patients with favorable disease. However, it is not known whether this recommendation should extend to other older women. Accordingly, we developed a nomogram to predict the likelihood of long-term breast preservation with and without RT.

METHODS

We used Surveillance, Epidemiology, and End Results-Medicare data to identify 16,092 women age 66 to 79 years treated with CS between 1992 and 2002, using claims to identify receipt of RT and subsequent mastectomy. Time to mastectomy was estimated using the Kaplan-Meier method. Cox proportional hazards models determined the effect of covariates on mastectomy-free survival (MFS). A nomogram was developed to predict 5- and 10-year MFS, given associated risk factors, and bootstrap validation was performed.

RESULTS

With a median follow-up of 7.2 years, the overall 5- and 10-year MFS rates were 98.1% (95% CI, 97.8% to 98.3%) and 95.4% (95% CI, 94.9% to 95.8%), respectively. In multivariate analysis, age, race, tumor size, estrogen receptor status, and receipt of RT were predictive of time to mastectomy and were incorporated into the nomogram. Nodal status was also included given a significant interaction with RT. The resulting nomogram demonstrated good accuracy in predicting MFS, with a bootstrap-corrected concordance index of 0.66.

CONCLUSION

This clinically useful tool predicts 5- and 10-year MFS among older women with early breast cancer using readily available clinicopathologic factors and can aid individualized clinical decision making by estimating predicted benefit from RT.

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.

Hormone receptor and ERBB2 status in gene expression profiles of human breast tumor samples

The occurrence of large publically available repositories of human breast tumor gene expression profiles provides an important resource to discover new breast cancer biomarkers and therapeutic targets. For example, knowledge of the expression of the estrogen and progesterone hormone receptors (ER and PR), and that of the ERBB2 in breast tumor samples enables choice of therapies for the breast cancer patients that express these proteins. Identifying new biomarkers and therapeutic agents affecting the activity of signaling pathways regulated by the hormone receptors or ERBB2 might be accelerated by knowledge of their expression levels in large gene expression profiling data sets. Unfortunately, the status of these receptors is not invariably reported in public databases of breast tumor gene expression profiles. Attempts have been made to employ a single probe set to identify ER, PR and ERBB2 status, but the specificity or sensitivity of their prediction is low. We enquired whether estimation of ER, PR and ERBB2 status of profiled tumor samples could be improved by using multiple probe sets representing these three genes and others with related expression.We used 8 independent datasets of human breast tumor samples to define gene expression signatures comprising 24, 51 and 14 genes predictive of ER, PR and ERBB2 status respectively. These signatures, as demonstrated by sensitivity and specificity measures, reliably identified hormone receptor and ERBB2 expression in breast tumors that had been previously determined using protein and DNA based assays. Our findings demonstrate that gene signatures can be identified which reliably predict the expression status of the estrogen and progesterone hormone receptors and that of ERBB2 in publically available gene expression profiles of breast tumor samples. Using these signatures to query transcript profiles of breast tumor specimens may enable discovery of new biomarkers and therapeutic targets for particular subtypes of breast cancer.