Locally advanced breast cancer in elderly patients

Frequency of use and characterization of frailty assessments in observational studies on older women with breast cancer: a systematic review

BACKGROUND

Breast cancer and frailty frequently co-occur in older women, and frailty status has been shown to predict negative health outcomes. However, the extent to which frailty assessments are utilized in observational research for the older breast cancer population is uncertain. Therefore, the aim of this review was to determine the frequency of use of frailty assessments in studies investigating survival or mortality, and characterize them, concentrating on literature from the past 5 years (2017-2022).

METHODS

MEDLINE, EMBASE and Cochrane Library were systematically queried to identify observational studies (case-control, cohort, cross-sectional) published from 2017-2022 that focus on older females (≥ 65 years) diagnosed with breast cancer, and which evaluate survival or mortality outcomes. Independent reviewers assessed the studies for eligibility using Covidence software. Extracted data included characteristics of each study as well as information on study design, study population, frailty assessments, and related health status assessments. Risk of bias was evaluated using the appropriate JBI tool. Information was cleaned, classified, and tabulated into review level summaries.

RESULTS

In total, 9823 studies were screened for inclusion. One-hundred and thirty studies were included in the final synthesis. Only 11 (8.5%) of these studies made use of a frailty assessment, of which 4 (3.1%) quantified frailty levels in their study population, at baseline. Characterization of frailty assessments demonstrated that there is a large variation in terms of frailty definitions and resulting patient classification (i.e., fit, pre-frail, frail). In the four studies that quantified frailty, the percentage of individuals classified as pre-frail and frail ranged from 18% to 29% and 0.7% to 21%, respectively. Identified frailty assessments included the Balducci score, the Geriatric 8 tool, the Adapted Searle Deficits Accumulation Frailty index, the Faurot Frailty index, and the Mian Deficits of Accumulation Frailty Index, among others. The Charlson Comorbidity Index was the most used alternative health status assessment, employed in 56.9% of all 130 studies. Surprisingly, 31.5% of all studies did not make use of any health status assessments.

CONCLUSION

Few observational studies examining mortality or survival outcomes in older women with breast cancer incorporate frailty assessments. Additionally, there is significant variation in definitions of frailty and classification of patients. While comorbidity assessments were more frequently included, the pivotal role of frailty for patient-centered decision-making in clinical practice, especially regarding treatment effectiveness and tolerance, necessitates more deliberate attention. Addressing this oversight more explicitly could enhance our ability to interpret observational research in older cancer patients.

Locally Advanced Breast Cancer: Treatment Patterns and Predictors of Survival in a Saudi Tertiary Center

Background  Breast cancer (BC) is the most common cancer in the Kingdom of Saudi Arabia (KSA) and the second leading cause of cancer-related mortality. About 40% of BC in KSA is locally advanced BC (LABC), which has been associated with poorer survival compared with early diagnosed BC. Objective To review the presentation and outcomes of LABC, including the characteristics of the disease, different treatment modalities, overall survival (OS), disease-free survival (DFS), and local recurrence in relation to different radiotherapy (RT) techniques. Methods  We retrospectively reviewed the medical records of 153 female patients with pathologically proven LABC diagnosed at King Abdulaziz University Hospital, Jeddah, KSA, between 2009 and 2017. We obtained data on patient demographics, stage of cancer at diagnosis, tumor characteristics (subtype and receptor status), type of surgery, systemic treatments received (hormonal, targeted therapy, and chemotherapy), RT variables, and recurrence and death dates. Data were analyzed to assess OS and DFS by using Kaplan-Meier analyses and the log-rank test. Univariate and multivariate Cox proportional hazard regression analyses were used to explore and identify factors associated with survival. Results  The median survival time in the study population was 9.16 years. Older age (65+ years) was associated with worse OS and DFS than was younger age (<65 years) (hazard ratio (HR) 3.20, 95% CI 1.48-6.90, P = 0.003 and HR 2.21, 95% CI 1.12-4.36, P = 0.022, respectively). Regarding the type of surgery, having a mastectomy was associated with worse OS and DFS than was having a lumpectomy (HR 2.44, 95% CI 0.97-6.12, P = 0.05 and HR 2.41, 95% CI 1.13-5.14, P = 0.023, respectively). Positive estrogen and progesterone receptor status was associated with better OS and DFS than was a negative estrogen or progesterone receptor status (HR 0.13, 95% CI 0.05-0.30, P < 0.001 and HR 0.21, 95% CI 0.11-0.41, P < 0.001, respectively). Patients who received RT had a lower risk of recurrence than did those who did not receive RT (P = 0.011). Moreover, three-dimensional conformal RT was associated with lower local recurrence than intensity-modulated RT or volumetric-modulated arc therapy (P = 0.003). Conclusion  Multiple factors can affect the OS and DFS in LABC. Younger patients, having hormone-positive disease, and undergoing lumpectomy were associated with better outcomes. Adjuvant RT may improve local control and the use of three-dimensional conformal RT was superior for local control. Prospective studies with larger sample sizes are needed to further highlight these findings and to assess the role of chemotherapy and targeted therapy in patients with LABC.