Update of the Phase III trial 'GRETA' of surgery and tamoxifen versus tamoxifen alone for early breast cancer in elderly women

Neoadjuvant Endocrine Therapy and Delays in Surgery for Ductal Carcinoma in Situ: Implications for the Coronavirus Pandemic

BACKGROUND

Surgical delays are associated with invasive cancer for patients with ductal carcinoma in situ (DCIS). During the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) pandemic, neoadjuvant endocrine therapy (NET) was used as a bridge until postponed surgeries resumed. This study sought to determine the impact of NET on the rate of invasive cancer for patients with a diagnosis of DCIS who have a surgical delay compared with those not treated with NET.

METHODS

Using the National Cancer Database, the study identified women with hormone receptor-positive (HR+) DCIS. The presence of invasion on final pathology was evaluated after stratifying by receipt of NET and by intervals based on time from diagnosis to surgery (≤30, 31-60, 61-90, 91-120, or 121-365 days).

RESULTS

Of 109,990 women identified with HR+ DCIS, 276 (0.3%) underwent NET. The mean duration of NET was 74.4 days. The overall unadjusted rate of invasive cancer was similar between those who received NET ((15.6%) and those who did not (12.3%) (p = 0.10). In the multivariable analysis, neither the use nor the duration of NET were independently associated with invasion, but the trend across time-to-surgery categories demonstrated a higher rate of upgrade to invasive cancer in the no-NET group (p < 0.001), but not in the NET group (p = 0.97).

CONCLUSIONS

This analysis of a pre-COVID cohort showed evidence for a protective effect of NET in HR+ DCIS against the development of invasive cancer as the preoperative delay increased, although an appropriately powered prospective trial is needed for a definitive answer.

Breast cancer in the oldest old (≥ 89 years): Tumor characteristics, treatment choices, clinical outcomes and literature review

INTRODUCTION

Risk of breast cancer increases with age and very few data are available in patients older than 89.

METHODS

A retrospective analysis on patients aged 89 and older treated between 2008 and 2019 at our certified breast center. The aim was to analyze clinical characteristics, decision-making, treatment, outcomes and open questions regarding this subpopulation for which there is a lack of guidelines.

RESULTS

58 patients included. Tumor characteristics were analyzed, 85% patients underwent surgery of which 44% had a mastectomy. The median follow-up and overall survival were 20 and 76 months, respectively.The median survival of metastatic and non-metastatic patients were 14 and 50 months, respectively. Most patients did not receive any adjuvant treatment and among these 14% had a relapse.

CONCLUSIONS

Elderly patients should not be under or over-treated because of their age; they represent a large heterogeneous group deserving a sub-stratification for a better tailored treatment.

Survival Outcomes of Early-Stage Hormone Receptor-Positive Breast Cancer in Elderly Women

BACKGROUND

Elderly women (≥ 70 years old) form a significant proportion of patients affected by breast cancer (BC); however, the treatment decisions for this patient population are complicated, owing to the presence of comorbidities, limited life expectancy, reduced tolerability of therapy, and limited enrollment in clinical trials. A growing body of evidence suggests equivalent outcomes in elderly patients with hormone receptor-positive early-stage breast cancer receiving primary endocrine therapy only or surgery with subsequent endocrine therapy. Whether these results are reproduced in the larger BC population outside of a clinical trial currently remains unclear.

PATIENTS AND METHODS

Women ≥ 70 years old diagnosed with early-stage invasive breast cancer between January 2008 and December 2013 with tumor size T1 or T2, minimal nodal involvement (N0 and N1), and estrogen and/or progesterone receptor positivity who started endocrine therapy within a year of diagnosis were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked datasets. Endocrine therapy was identified using outpatient prescription fills for anastrozole, exemestane, fulvestrant, letrozole, raloxifene, tamoxifen, and toremifene; the first fill date was used as the treatment initiation date. Surgical intervention included either breast-conserving surgery or mastectomy. Women who received chemotherapy were excluded. Trends in the use of primary endocrine therapy only were assessed using Poisson regression. Multivariable Cox proportional hazard regression was used to estimate the association between undergoing surgery within a year of diagnosis and 5-year all-cause mortality, after adjusting for patient demographics, comorbidities, and clinical cancer characteristics. Similar methods were used to assess 5-year cancer-specific mortality, where noncancer mortality was treated as a competing risk.

RESULTS

Overall, 8784 women were included in the analysis: 8006 (91%) received surgery with endocrine therapy and 778 (9%) received primary endocrine therapy alone. The proportion of women not receiving surgery remained consistent between 2008 and 2013 (p = 0.10). The 5-year mortality was 11% (n = 619), and 19% of all deaths were due to cancer causes (n = 117). After adjustment, 5-year mortality was lower among women undergoing surgery (HR 0.59, 95% CI 0.47-0.74, p < 0.0001). Similar results were found when looking at 5-year cancer-specific mortality (HR 0.52, 95% CI 0.30-0.90, p < 0.0001).

CONCLUSIONS

Elderly breast cancer patients with early-stage hormone-receptor-positive disease receiving primary surgical intervention plus endocrine therapy may have significantly improved survival than those receiving primary endocrine therapy alone. This study suggests the importance of surgical intervention for elderly breast cancer patients and warrants further investigation and comprehensive geriatric assessment to identify subsets of elderly breast cancer patients who may benefit significantly from surgical intervention.

Breast Cancer Management Guidelines During COVID-19 Pandemic

The coronavirus disease (COVID-19) pandemic in 2020 has brought about complex challenges in healthcare delivery. With the new rules of lockdown and social distancing and with resources diverted to the management of COVID-19, there are difficulties in continuing usual cancer care. Patients are at risk of contracting COVID-19 with a high chance of patient to healthcare transmission and vice versa. Hospital visits, investigations and all modalities of treatment have potential complications that put patients at risk, some more than others. In this situation, there is a need to change our approach in the management of breast cancer to deliver it safely. We present modified guidelines based on the available consensus statements and evidence.

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.

Neoadjuvant endocrine therapy in breast cancer patients

Highlights

The overall response rate to neoadjuvant endocrine therapy (NET) was 54.55%.The eight patients proposed to tumour's downstage, after 9.71 months of NET, preserved their breast.In the group which achieved response, 10.28 months was the mean time to accomplish it.Even patients who had the worst outcome only began to suffer latter in the course of therapy.NET can be done beyond the conventional 3-4 months to allow additional downstage of the tumour.

Background

The aim of this study is to evaluate if the extension of neoadjuvant endocrine therapy (NET), beyond the conventional time, allows additional downstage of the tumour, in order to perform a breast conservative surgery (BCS), and to analyze if it is a good option for long-term control in patients who refuse or are unfit for surgery.

Patients and methods

We retrospectively reviewed a database containing all patients treated in our institution with NET. All included patients were post-menopausal with primary local disease. The type of response obtained was assessed using modified RECIST criteria.

Results

Thirty-three patients were included. Two patients had tumours with 90% expression of oestrogen receptors and all the others had 100%. The tumour size in the largest diameter was 6.51 cm before treatment and 5.18 cm after. Eighteen patients achieved a partial response after 10.28 months of therapy. Patients that were proposed to downstage the tumour performed 9.71 months of therapy until surgery and all were submitted to BCS. Progression occurred after 27.5 months.

Conclusion

Endocrine therapy is a feasible option for a longer time to allow additional downstage of the tumour and is a good solution in patients who refuse or are unfit for surgery.

Adjuvant treatment for older women with invasive breast cancer

Older women experience a large share of breast cancer incidence and death. With the projected rise in the number of older cancer patients, adjuvant chemo-, radiation and endocrine therapy management will become a key component of breast cancer treatment in older women. Many factors influence adjuvant treatment decisions including patient preferences, life expectancy and tumor biology. Geriatric assessment predicts important outcomes, identifies key deficits, and can aid in the decision making process. This review utilizes clinical vignettes to illustrate core principles in adjuvant management of breast cancer in older women and suggests an approach incorporating life expectancy and geriatric assessment.