Common Sense Oncology: Equity, Value, and Outcomes That Matter

While some recent drug treatments have been transformative for patients with cancer, many treatments offer small benefits despite high clinical toxicity, time toxicity and financial toxicity. Moreover, treatments that do provide substantial clinical benefits are not available to many patients globally due to issues with availability and affordability. The Common Sense Oncology's vision is that patients will have access to treatments that provide meaningful improvements in outcomes that matter, regardless of where they live. In recognition of the growing challenges in the field of oncology, Common Sense Oncology seeks to achieve this vision by improving evidence generation, evidence interpretation and evidence communication.

The emerging predictive and prognostic role of HER2 in HER2-negative early breast cancer: a retrospective study

PURPOSE

Many patients with early breast cancer (eBC) undergoing neoadjuvant chemotherapy do not achieve pathological complete response (pCR), which is a prognostic factor. We examined the role of HER2-low expression in predicting pCR and prognosis in HER2-negative eBC.

METHODS

We evaluated patients with stage I-III HER2-negative BC, treated between 2013 and 2023 at The Royal Marsden NHS Foundation Trust, London. Tumors were classified based on estrogen receptor (ER) status and into HER2-low and HER2-zero subgroups. We analyzed pCR rates, relapse-free survival (RFS) and overall survival (OS).

RESULTS

754 patients were included in the analysis. pCR rate was 8.9% in the ER+ /HER2-low, 16.5% in the ER+ /HER2-zero, 38.9% in the ER- ER-/HER2-low and 35.9% in the ER-/HER2-zero eBC (p < 0.001). Multivariable analysis showed a significantly lower pCR rate in HER2-low compared to HER2-zero BC in the ER+ subgroup. At a median follow-up of 63.8 months (59.9-67.4), we observed longer OS in HER2-low compared to HER2-zero patients in the overall and in the ER+ population. There was no predictive or prognostic impact of HER2-low status in the ER- population.

CONCLUSION

This study supports the interpretation of HER2 status as a possible prognostic and predictive biomarker for HER2-negative eBC, especially among patients with ER+ disease.

Implementation of a geriatric oncology service at the Royal Marsden Hospital

INTRODUCTION

Despite significant evidence supporting the benefits of comprehensive oncogeriatric assessment in the management of older patients with cancer, the adoption of specialised geriatric oncology programs in the United Kingdom remains limited. Descriptions of clinic structure and models, patient demographics and baseline characteristics, resource utilisation, and predictors of resource utilisation are lacking in this population, which may complicate or impede the planning, resourcing, and development of further services in this subspecialty on a national and regional basis.

MATERIALS AND METHODS

Between November 2021 and April 2023, 244 patients commencing systemic anticancer treatment at the Royal Marsden Hospital, London underwent geriatric screening using the Senior Adult Oncology Programme-3 (SAOP3) screening tool. Baseline clinical factors (sex, age, Charlson Comorbidity Index score, Cumulative Illness Rating Scale-Geriatric [CIRS-G] score, Katz Index score, Barthel Index score, treatment intent, and Eastern Cooperative Oncology Group Performance Status [ECOG-PS]) were assessed as predictors of geriatric impairments and need for multidisciplinary referral and intervention using a negative binomial regression analysis. Referral rates to multidisciplinary teams were assessed against ECOG-PS score using point-biserial correlation, as well as against a historical control using descriptive statistics.

RESULTS

The median age of participants was 77; 75.8% were female. Breast cancer was the most prevalent diagnosis (61.9%). Most patients (67.6%) were undergoing treatment in the palliative setting. Two hundred eleven (86.5%) patients were identified as having at least one geriatric impairment. Six hundred forty-nine multidisciplinary referrals were made, of which 583 (86.7%) were accepted by the referred patient. Higher ECOG PS was positively associated with geriatric impairments in physiotherapy, occupational therapy, dietetics, pharmacy, and welfare rights domains, as well as with the overall number of geriatric impairments.

DISCUSSION

The Royal Marsden Senior Adult Oncology Programme represents the first geriatric oncology service in a tertiary cancer centre in the United Kingdom. Following implementation of SAOP3 screening, we observed a substantial increase in referrals to all multidisciplinary teams, suggestive of previously underrecognized needs among this population. The need for multidisciplinary intervention was strongly correlated with baseline ECOG-PS score, but not with other measured clinical variables, including comorbidity or functional indices.

Geographical Variation in Underlying Social Deprivation, Cardiovascular and Other Comorbidities in Patients with Potentially Curable Cancers in England: Results from a National Registry Dataset Analysis

AIMS

To describe the prevalence of cardiovascular disease (CVD), multiple comorbidities and social deprivation in patients with a potentially curable cancer in 20 English Cancer Alliances.

MATERIALS AND METHODS

This National Registry Dataset Analysis used national cancer registry data and CVD databases to describe rates of CVD, comorbidities and social deprivation in patients diagnosed with a potentially curable malignancy (stage I-III breast cancer, stage I-III colon cancer, stage I-III rectal cancer, stage I-III prostate cancer, stage I-IIIA non-small cell lung cancer, stage I-IV diffuse large B-cell lymphoma, stage I-IV Hodgkin lymphoma) between 2013 and 2018. Outcome measures included observation of CVD prevalence, other comorbidities (evaluated by the Charlson Comorbidity Index) and deprivation (using the Index of Multiple Deprivation) according to tumour site and allocation to Cancer Alliance. Patients were allocated to CVD prevalence tertiles (minimum: <33.3rd percentile; middle: 33.3rd to 66.6th percentile; maximum: >66.6th percentile).

RESULTS

In total, 634 240 patients with a potentially curable malignancy were eligible. The total CVD prevalence for all cancer sites varied between 13.4% (CVD n = 2058; 95% confidence interval 12.8, 13.9) and 19.6% (CVD n = 7818; 95% confidence interval 19.2, 20.0) between Cancer Alliances. CVD prevalence showed regional variation both for male (16-26%) and female patients (8-16%) towards higher CVD prevalence in northern Cancer Alliances. Similar variation was observed for social deprivation, with the proportion of cancer patients being identified as most deprived varying between 3.3% and 32.2%, depending on Cancer Alliance. The variation between Cancer Alliance for total comorbidities was much smaller.

CONCLUSION

Social deprivation, CVD and other comorbidities in patients with a potentially curable malignancy in England show significant regional variations, which may partly contribute to differences observed in treatments and outcomes.

Reporting of older subgroups in registration breast cancer trials 2012-2021

INTRODUCTION

Adequate reporting of data specific to older populations enrolled to breast cancer trials is critical, given the high incidence of the disease among this demographic. This study aimed to examine the completeness of reporting of older subgroups among patients recruited to registration clinical trials investigating systemic treatments for breast cancer.

METHODS

Clinical trials leading to a US food and drug administration (FDA) approval in breast cancer between 2012 and 2021 were included. Primary study reports and and all available secondary publications were systematically and objectively assessed with regard to the availability of data regarding efficacy, baseline characteristics, safety, and health-related quality of life (HRQOL) outcomes among older subgroups.

RESULTS

27 trials and 216 publications were assessed. 20.3% of patients were aged ≥65. 70.0% of patients had an eastern cooperative oncology group (ECOG) performance status of 0. Although complete reporting of primary endpoints was adequate (72.7%), most protocol-defined primary endpoints were surrogate endpoints (84.8%). Overall survival data among older populations was unavailable in 50.0% of studies. Reporting was poor for secondary efficacy endpoints (81.8% unreported), baseline characteristics (70.4% unreported), toxicity (55.6% unreported), and health-related quality of life outcomes (87.5% unreported).

CONCLUSION

The findings underline significant deficits in the reporting of age-specific data in breast cancer registration trials. The underreporting of key efficacy, safety, and HRQOL outcomes highlights the need for mandatory reporting standards and a dedicated emphasis on older populations' priorities and needs in the reporting of registration clinical trials.

Geriatric assessment for older people with cancer: policy recommendations

Most cancers occur in older people and the burden in this age group is increasing. Over the past two decades the evidence on how best to treat this population has increased rapidly. However, implementation of new best practices has been slow and needs involvement of policymakers. This perspective paper explains why older people with cancer have different needs than the wider population. An overview is given of the recommended approach for older people with cancer and its benefits on clinical outcomes and cost-effectiveness. In older patients, the geriatric assessment (GA) is the gold standard to measure level of fitness and to determine treatment tolerability. The GA, with multiple domains of physical health, functional status, psychological health and socio-environmental factors, prevents initiation of inappropriate oncologic treatment and recommends geriatric interventions to optimize the patient's general health and thus resilience for receiving treatments. Multiple studies have proven its benefits such as reduced toxicity, better quality of life, better patient-centred communication and lower healthcare use. Although GA might require investment of time and resources, this is relatively small compared to the improved outcomes, possible cost-savings and compared to the large cost of oncologic treatments as a whole.

Cancer literacy - Informing patients and implementing shared decision making

In order to tailor treatment to their needs, cancer patients are encouraged to be more active and engaged in their care decisions and to be autonomous yet collaborative with their healthcare professionals when it comes to aspects of their treatment in order to get better results. However, this can only happen after providing them with accurate information about cancer and the different treatment alternatives and their potential side effects. However, sharing robust data-based information is often hindered by exposure to misleading information through different media and online platform, where patients might come across unscientifically founded health practices. Increasing health literacy and cancer-specific literacy is essential to fight this negative trend. The idea is that more knowledgeable patients will be able to debunk more easily misinformation they encounter. This is also related to inequalities among cancer patients. Not only levels of cancer literacy within Europe are uneven across and within countries, but there are social groups that, due to specific social determinants, are systematically less informed and skilled regarding cancer care. In this paper an overview of gaps in addressing literacy issues, and the importance of health literacy to empower patients in their journey through treatment is delineated, concluding with some recommendations to improve cancer literacy in Europe.

The Predictive Value of the G8 Questionnaire in Older Patients with Lung Cancer or Mesothelioma before Systemic Treatment

AIMS

The standard evaluation of older lung cancer or mesothelioma patients for systemic anti-cancer treatment, based on performance status, is inaccurate. We used the G8 questionnaire to assess a patient's fitness for chemotherapy and explored the correlations between G8 scores, treatment decisions and clinical outcomes.

MATERIALS AND METHODS

In total, 201 older patients (≥70 years) with advanced lung cancer or mesothelioma were prospectively assessed by standard clinical methods and a G8 questionnaire. Treatment decisions before and after reviewing the G8 score were documented. Patients were divided into low (<11), intermediate (11-14) and high (>14) G8 score groups. Patients' characteristics, treatment plans and clinical outcomes among each G8 score group were compared. Similar analyses were compared between good (<2) and poor (≥2) performance status.

RESULTS

10.1% of patients' treatment plans changed after oncologists reviewed G8 scores. The G8 score correlated inversely with performance status. More patients with low G8 scores (22.5%) were offered the best supportive care compared with 4.5% in intermediate and 1.9% in high G8 score groups. More patients (30.1%) with low G8 scores had treatment changed from chemotherapy to best supportive care on the planned day of their treatment, compared with intermediate (7.5%) and high (6.1%) G8 score groups. High G8 score patients received higher chemotherapy intensity and survived longer than patients with intermediate or low G8 scores.

CONCLUSIONS

The G8 score with two cut-off values can predict functional status, chemotherapy tolerability and prognosis in older patients with lung cancer or mesothelioma, thus supporting oncologists on treatment decisions for this population.

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.

International Survey on Frailty Assessment in Patients with Cancer

Background

Frailty negatively affects the outcomes of patients with cancer, and its assessment might vary widely in the real world. The objective of this study was to explore awareness and use of frailty screening tools among the ONCOassist healthcare professionals (HCPs) users.

Materials and Methods

We sent 2 emails with a cross-sectional 15-item survey in a 3-week interval between April and May 2021. Differences in the awareness and use of tools according to respondents’ continents, country income, and job types were investigated.

Results

Seven hundred thirty-seven HCPs from 91 countries (81% physicians, 13% nurses, and 5% other HCPs) completed the survey. Three hundred and eighty-five (52%) reported assessing all or the majority of their patients; 518 (70%) at baseline and before starting a new treatment. Three hundred and four (43%) HCPs were aware of performance status (PS) scores only, 309 (42%) age/frailty/comorbidity (AFC) screening, and 102 (14%) chemotoxicity predictive tools. Five hundred and thirty-seven (73%) reported using tools; 423 (57%) just PS, 237 (32%) AFC, and 60 (8%) chemotoxicity ones. Reasons for tools non-use (485 responders) were awareness (70%), time constraints (28%), and uselessness (2%). There were significant differences in awareness and use of screening tools among different continents, country income, job types, and medical specialties (P < .001 for all comparisons).

Conclusion

Among selected oncology HCPs, there is still a worldwide lack of knowledge and usage of frailty screening tools, which may differ according to their geography, country income, and education. Targeted initiatives to raise awareness and education are needed to implement frailty assessment in managing patients with cancer.

Preventing late recurrence in hormone receptor-positive early breast cancer: a review

Late recurrences are a key challenge for patients with early-stage oestrogen receptor-positive breast cancer, with the risk of disease relapse continuing steadily from 5 to more than 20 years after diagnosis. Five years of adjuvant endocrine therapy with tamoxifen or an aromatase inhibitor was shown many years ago to improve survival. More recently, the trials of extended adjuvant endocrine therapy for more than 5 years have shown a further small gain, but with an associated small risk of increased long-term toxicity including bone loss, cardiovascular impairment and impaired quality of life. This review describes the efficacy and safety of extended endocrine therapy, the optimal selection criteria for patient benefit and the potential for novel agents to improve long-term outcomes.

Prevalence of Cardiovascular Disease in Patients With Potentially Curable Malignancies

Background

Although a common challenge for patients and clinicians, there is little population-level evidence on the prevalence of cardiovascular disease (CVD) in individuals diagnosed with potentially curable cancer.

Objectives

We investigated CVD rates in patients with common potentially curable malignancies and evaluated the associations between patient and disease characteristics and CVD prevalence.

Methods

The study included cancer registry patients diagnosed in England with stage I to III breast cancer, stage I to III colon or rectal cancer, stage I to III prostate cancer, stage I to IIIA non-small-cell lung cancer, stage I to IV diffuse large B-cell lymphoma, and stage I to IV Hodgkin lymphoma from 2013 to 2018. Linked hospital records and national CVD databases were used to identify CVD. The rates of CVD were investigated according to tumor type, and associations between patient and disease characteristics and CVD prevalence were determined.

Results

Among the 634,240 patients included, 102,834 (16.2%) had prior CVD. Men, older patients, and those living in deprived areas had higher CVD rates. Prevalence was highest for non-small-cell lung cancer (36.1%) and lowest for breast cancer (7.7%). After adjustment for age, sex, the income domain of the Index of Multiple Deprivation, and Charlson comorbidity index, CVD remained higher in other tumor types compared to breast cancer patients.

Conclusions

There is a significant overlap between cancer and CVD burden. It is essential to consider CVD when evaluating national and international treatment patterns and cancer outcomes.

Abstract P1-17-08: Abemaciclib and endocrine therapy for hormone receptor-positive, HER2-negative advanced breast cancer: A real-world UK multicentre experience

Background Abemaciclib is approved in 1st and 2nd line for hormone receptor (HR)-positive HER2-negative advanced breast cancer (ABC). However, outcomes on this agent are unclear in the real world.We determined the safety and efficacy profile of abemaciclib across 15 institutions in the United Kingdom. Methods We retrospectively identified HR-positive, HER2-negative ABC patients who received abemaciclib between July 2018 and June 2020. Demographics, disease characteristics, prior treatments, blood tests, toxicities, treatment delays and responses were recorded. Simple statistics, Fisher’s exact test, chi-squared method and Cox regression were used as appropriate. Results 228 patients identified had median age of 64 (31-93). 172 (75.4%) were postmenopausal and 209 (91.7%) had ECOG Performance Status 0-1. 145 (63.6%) had visceral involvement and 44 (19.3%) only bone disease. Patients received a median 1 (range 0-7) prior lines of treatment and 0 (range 0-5) prior chemotherapy lines.148 patients (64.9%) experienced diarrhoea (grade ≥3 in 16 [7.0%]). 146 patients (64.0%) developed neutropenia (grade ≥3 in 40 [17.5%]). 5 experienced febrile neutropenia (2.2%). 32 patients (14.0%) required hospitalisation due to toxicity (diarrhoea in 9 [3.95%]).Dose reductions were required in 107 patients (46.9%), mainly due to diarrhoea (55 [24.1%]) and to 50mg BD in 30 patients (13.2%). Dose delays were in median 14 (range 2-118). Abemaciclib was discontinued in 121 patients (53.1%) due to disease progression in 61 (26.7%) and toxicity in 48 (21.0%) (diarrhoea in 16 [7.0%]).Abemaciclib produced clinical benefit rate of 82.8% and overall response rate of 47.2% in 163 patients assessed. Overall, median progression-free survival (PFS) was 6.4 months (95% confidence interval [CI] 4.4-7.8) and median overall survival (OS) was 8.8 months (95% CI 7.6-10.6). Conclusions This a large real-world analysis of the safety and efficacy of abemaciclib in combination with endocrine therapy for advanced HR-positive breast cancer. In this analysis, the rates of diarrhoea were lower compared with the pivotal trial data, while neutropenia was more frequent. Although the PFS outcomes were similar to those previously reported, median OS was worse in this cohort which may reflect the different population of patients included, who were older and had more frequent visceral involvement. The selection of patients suitable for abemaciclib is crucial to ensure adequate efficacy and safety outcomes in this setting.

Citation Format: Nicolò Matteo Luca Battisti, Laura Morrison, Tamsin Nash, Nishanti Senthivel, Samantha Kestenbaum, Parvin Begum, Mariam Obeid, William Hayhurst, Dorothy Yang, Shafiah Gafoor, Caroline Brown, Farah Rehman, Laura Kenny, Olivia Hatcher, Susan Susan, Jennet Williams, Anna Brown, Hamoun Rozati, Alexandros Alexandros, Elinor Sawyer, Charalampos Gousis, Eleni Karapanagiotou, Anna Rigg, Kleopatra Rapti, Rebecca Roylance, Mark Beresford, Abigail L Gee, Apostolos Konstantis, Judy King, Mark Nathan, Emma Spurrell, Mark Pearce, Dane Bradwell, Arshi Denton, Kate Swain, Sophie McGrath, Mark Allen, Alistair Ring, Stephen Johnston, Fharat Raja. Abemaciclib and endocrine therapy for hormone receptor-positive, HER2-negative advanced breast cancer: A real-world UK multicentre experience [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-17-08.

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.

Observational cohort study in older women with early breast cancer: Use of radiation therapy and impact on health-related quality of life and mortality

BACKGROUND

Radiotherapy reduces in-breast recurrence risk in early breast cancer (EBC) in older women. This benefit may be small and should be balanced against treatment effect and holistic patient assessment. This study described treatment patterns according to fitness and impact on health-related quality-of-life (HRQoL).

METHODS

A multicentre, observational study of EBC patients aged ≥ 70 years, undergoing breast-conserving surgery (BCS) or mastectomy, was undertaken. Associations between radiotherapy use, surgery, clinico-pathological parameters, fitness based on geriatric parameters and treatment centre were determined. HRQoL was measured using the European Organisation for the Research and Treatment of Cancer (EORTC) questionnaires.

RESULTS

In 2013-2018 2811 women in 56 UK study centres underwent surgery with a median follow-up of 52 months. On multivariable analysis, age and tumour risk predicted radiotherapy use. Among healthier patients (based on geriatric assessments) with high-risk tumours, 534/613 (87.1%) having BCS and 185/341 (54.2%) having mastectomy received radiotherapy. In less fit individuals with low-risk tumours undergoing BCS, 149/207 (72.0%) received radiotherapy. Radiotherapy effects on HRQoL domains, including breast symptoms and fatigue were seen, resolving by 18 months.

CONCLUSION

Radiotherapy use in EBC patients ≥ 70 years is affected by age and recurrence risk, whereas geriatric parameters have limited impact regardless of type of surgery. There was geographical variation in treatment, with some fit older women with high-risk tumours not receiving radiotherapy, and some older, low-risk, EBC patients receiving radiotherapy after BCS despite evidence of limited benefit. The impact on HRQoL is transient.

Bridging The Age Gap: observational cohort study of effects of chemotherapy and trastuzumab on recurrence, survival and quality of life in older women with early breast cancer

BACKGROUND

Chemotherapy improves outcomes for high risk early breast cancer (EBC) patients but is infrequently offered to older individuals. This study determined if there are fit older patients with high-risk disease who may benefit from chemotherapy.

METHODS

A multicentre, prospective, observational study was performed to determine chemotherapy (±trastuzumab) usage and survival and quality-of-life outcomes in EBC patients aged ≥70 years. Propensity score-matching adjusted for variation in baseline age, fitness and tumour stage.

RESULTS

Three thousands four hundred sixteen women were recruited from 56 UK centres between 2013 and 2018. Two thousands eight hundred eleven (82%) had surgery. 1520/2811 (54%) had high-risk EBC and 2059/2811 (73%) were fit. Chemotherapy was given to 306/1100 (27.8%) fit patients with high-risk EBC. Unmatched comparison of chemotherapy versus no chemotherapy demonstrated reduced metastatic recurrence risk in high-risk patients(hazard ratio [HR] 0.36 [95% CI 0.19-0.68]) and in 541 age, stage and fitness-matched patients(adjusted HR 0.43 [95% CI 0.20-0.92]) but no benefit to overall survival (OS) or breast cancer-specific survival (BCSS) in either group. Chemotherapy improved survival in women with oestrogen receptor (ER)-negative cancer (OS: HR 0.20 [95% CI 0.08-0.49];BCSS: HR 0.12 [95% CI 0.03-0.44]).Transient negative quality-of-life impacts were observed.

CONCLUSIONS

Chemotherapy was associated with reduced risk of metastatic recurrence, but survival benefits were only seen in patients with ER-negative cancer. Quality-of-life impacts were significant but transient.

TRIAL REGISTRATION

ISRCTN 46099296.

Perspectives on functional status in older adults with cancer: An interprofessional report from the International Society of Geriatric Oncology (SIOG) nursing and allied health interest group and young SIOG

Most adults with cancer are over 65 years of age, and this cohort is expected to grow exponentially. Older adults have an increased burden of comorbidities and risk of experiencing adverse events on anticancer treatments, including functional decline. Functional impairment is a predictor of increased risk of chemotherapy toxicity and shorter survival in this population. Healthcare professionals caring for older adults with cancer should be familiar with the concept of functional status and its implications because of the significant interplay between function, cancer, anticancer treatments, and patient-reported outcomes. In this narrative review, we provide an overview of functional status among older patients with cancer including predictors, screening, and assessment tools. We also discuss the impact of functional impairment on patient outcomes, and describe the role of individual members of an interprofessional team in addressing functional impairment in this population, including the use of a collaborative approach aiming to preserve function.

Incidence of cardiotoxicity and validation of the Heart Failure Association-International Cardio-Oncology Society risk stratification tool in patients treated with trastuzumab for HER2-positive early breast cancer

PURPOSE

Trastuzumab improves survival in patients with HER2+ early breast cancer. However, cardiotoxicity remains a concern, particularly in the curative setting, and there are limited data on its incidence outside of clinical trials. We retrospectively evaluated the cardiotoxicity rates [left ventricular ejection fraction (LVEF) decline, congestive heart failure (CHF), cardiac death or trastuzumab discontinuation] and assessed the performance of a proposed model to predict cardiotoxicity in routine clinical practice.

METHODS

Patients receiving curative trastuzumab between 2011 and 2018 were identified. Demographics, treatments, assessments and toxicities were recorded. Fisher's exact test, Chi-squared and logistic regression were used.

RESULTS

931 patients were included in the analysis. Median age was 54 years (range 24-83) and Charlson comorbidity index 0 (0-6), with 195 patients (20.9%) aged 65 or older. 228 (24.5%) were smokers. Anthracyclines were given in 608 (65.3%). Median number of trastuzumab doses was 18 (1-18). The HFA-ICOS cardiovascular risk was low in 401 patients (43.1%), medium in 454 (48.8%), high in 70 (7.5%) and very high in 6 (0.6%). Overall, 155 (16.6%) patients experienced cardiotoxicity: LVEF decline ≥ 10% in 141 (15.1%), falling below 50% in 55 (5.9%), CHF NYHA class II in 42 (4.5%) and class III-IV in 5 (0.5%) and discontinuation due to cardiac reasons in 35 (3.8%). No deaths were observed. Cardiotoxicity rates increased with HFA-ICOS score (14.0% low, 16.7% medium, 30.3% high/very high; p = 0.002).

CONCLUSIONS

Cardiotoxicity was relatively common (16.6%), but symptomatic heart failure on trastuzumab was rare in our cohort. The HFA-ICOS score identifies patients at high risk of cardiotoxicity.

Biological aspects of aging that influence response to anticancer treatments

PURPOSE OF REVIEW

Cancer is a disease of older adults, where fitness and frailty are a continuum. This aspect poses unique challenges to the management of cancer in this population. In this article, we review the biological aspects influencing the efficacy and safety of systemic anticancer treatments.

RECENT FINDINGS

The organ function decline associated with the ageing process affects multiple systems, including liver, kidney, bone marrow, heart, muscles and central nervous system. These can have a significant impact on the pharmacokinetics and pharmacodynamics of systemic anticancer agents. Comorbidities also represent a key aspect to consider in decision-making. Renal disease, liver conditions and cardiovascular risk factors are prevalent in this age group and may impact the risk of adverse outcomes in this setting.

SUMMARY

The systematic integration of geriatrics principles in the routine management of older adults with cancer is a unique opportunity to address the complexity of this population and is standard of care based on a wide range of benefits. This approach should be multidisciplinary and involve careful discussion with hospital pharmacists.

Bridging the Age Gap in breast cancer: Impact of chemotherapy on quality of life in older women with early breast cancer

INTRODUCTION

Older patients with early breast cancer (EBC) derive modest survival benefit from chemotherapy but have increased toxicity risk. Data on the impact of chemotherapy for EBC on quality of life in older patients are limited, but this is a key determinant of treatment acceptance. We aimed to investigate its effect on quality of life in older patients enrolled in the Bridging the Age Gap study.

MATERIALS AND METHODS

A prospective, multicentre, observational study of EBC patients ≥70 years old was conducted in 2013-2018 at 56 UK hospitals. Demographics, patient, tumour characteristics, treatments and adverse events were recorded. Quality of life was assessed using the European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaires (EORTC-QLQ) C30, BR23 and ELD 15 plus the Euroqol-5D (eq-5d) over 24 months and analysed at each time point using baseline adjusted linear regression analysis and propensity score-matching.

RESULTS

Three thousand and four hundred sixteen patients were enrolled in the study; 1520 patients undergoing surgery and who had high-risk EBC were included in this analysis. 376/1520 (24.7%) received chemotherapy. At 6 months, chemotherapy had a significant negative impact in several EORTC-QLQ-C30 domains, including global health score, physical, role, social functioning, cognition, fatigue, nausea/vomiting, dyspnoea, appetite loss, diarrhoea and constipation. Similar trends were documented on other scales (EORTC-QLQ-BR23, EORTC-QLQ-ELD15 and EQ-5D-5L). Its impact was no longer significant at 18-24 months in unmatched and matched cohorts.

CONCLUSIONS

The negative impact of chemotherapy on quality-of-life is clinically and statistically significant at 6 months but resolves by 18 months, which is crucial to inform decision-making for older patients contemplating chemotherapy.

TRIAL REGISTRATION NUMBER ISRCTN

46099296.

Do we still need breast cancer screening in the era of targeted therapies and precision medicine?

Breast cancer (BC) is the most common female cancer and the second cause of death among women worldwide. The 5-year relative survival rate recently improved up to 90% due to increased population coverage and women's attendance to organised mammography screening as well as to advances in therapies, especially systemic treatments. Screening attendance is associated with a mortality reduction of at least 30% and a 40% lower risk of advanced disease. The stage at diagnosis remains the strongest predictor of recurrences. Systemic treatments evolved dramatically over the last 20 years: aromatase inhibitors improved the treatment of early-stage luminal BC; targeted monoclonal antibodies changed the natural history of anti-human epidermal growth factor receptor 2-positive (HER2) disease; immunotherapy is currently investigated in patients with triple-negative BC; gene expression profiling is now used with the aim of personalising systemic treatments. In the era of precision medicine, it is a challenging task to define the relative contribution of early diagnosis by screening mammography and systemic treatments in determining BC survival. Estimated contributions before 2000 were 46% for screening and 54% for treatment advances and after 2000, 37% and 63%, respectively. A model showed that the 10-year recurrence rate would be 30% and 25% using respectively chemotherapy or novel treatments in the absence of screening, but would drop to 19% and 15% respectively if associated with mammography screening. Early detection per se has not a curative intent and systemic treatment has limited benefit on advanced stages. Both screening mammography and systemic therapies continue to positively contribute to BC prognosis.

Immunotherapy in older patients with non-small cell lung cancer: Young International Society of Geriatric Oncology position paper

Immunotherapy with checkpoint inhibitors against programmed cell death receptor (PD-1) and programmed cell death ligand (PD-L1) has been implemented in the treatment pathway of patients with non-small cell lung cancer (NSCLC) from locally advanced disease to the metastatic setting. This approach has resulted in improved survival and a more favourable toxicity profile when compared with chemotherapy. Following the successful introduction of single-agent immunotherapy, current clinical trials are focusing on combination treatments with chemotherapy or radiotherapy or even other immunotherapeutic agents. However, most of the data available from these trials are derived from, and therefore might be more applicable to younger and fitter patients rather than older and often frail lung cancer real-world patients. This article provides a detailed review of these immunotherapy agents with a focus on the data available regarding older NSCLC patients and makes recommendations to fill evidence gaps in this patient population.

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.

Caring for older patients with cancer during the COVID-19 pandemic: A Young International Society of Geriatric Oncology (SIOG) global perspective

The ongoing coronavirus disease 2019 (COVID-19) pandemic has affected millions of people in over 180 territories, causing a significant impact on healthcare systems globally. Older adults, as well as people living with cancer, appear to be particularly vulnerable to COVID-19 related morbidity and mortality, which means that older adults with cancer are an especially high-risk population. This has led to significant changes in the way geriatric oncologists provide care to older patients, including the implementation of novel methods for clinical visits, interruptions or delays in procedures, and modification of therapeutic strategies, both in the curative and palliative settings. In this manuscript, we provide a global overview of the perspectives of geriatric oncology providers from countries across Europe, America, and Asia, regarding the adaptive strategies utilized to continue providing high quality care for older patients with cancer during the COVID-19 pandemic. Through these perspectives, we attempt to show that, although each country and setting has specific issues, we all face similar challenges when providing care for our older patients with cancer during these difficult times.

Embracing the complexity: Older adults with cancer-related cognitive decline-A Young International Society of Geriatric Oncology position paper

Cancer-related cognitive decline (CRCD) may have particularly significant consequences for older adults, impacting their functional and physical abilities, level of independence, ability to make decisions, treatment adherence, overall quality of life, and ultimately survival. In honor of Dr. Hurria's work we explore and examine multiple types of screening, assessment and non-pharmacologic treatments for CRCD. We then suggest future research and clinical practice questions to holistically appreciate the complexity of older adults with cancer's experiences and fully integrate the team-based approach to best serve this population.

Social support for older adults with cancer: Young International Society of Geriatric Oncology review paper

Older adults with cancer have increasing needs in physical, cognitive, and emotional domains, and they can experience decline in all domains with the diagnosis and treatment of cancer. Social support plays a key role in supporting these patients, mitigating negative effects of diagnosis and treatment of cancer, and improving cancer outcomes. We review the importance of social support in older adults with cancer, describe the different components of social support and how they are measured, discuss current interventions that are available to improve social support in older adults, and describe burdens on caregivers. We also highlight Dr. Arti Hurria's contributions to recognizing the integral role of social support to caring for older adults with cancer.

Abstract P2-14-08: Use of systemic therapy for early stage breast cancer in older adults: Results from the Bridging the Age Gap study

Background: Older patients with early breast cancer (EBC) are a heterogenous population which is often treated less aggressively than their younger counterparts. This may lead to increased variance in the use of adjuvant systemic therapy and consequent inferior outcomes.Use of adjuvant systemic therapy in a population of older EBC patients was evaluated within a large UK prospective multicentre cohort study (Bridging the Age Gap).

Methods: A prospective, multicentre, observational study of women aged over 70 with EBC was conducted between 2013 and 2018 at 57 Institutions in the UK. Women were recruited at diagnosis and baseline demographics, patient and tumour characteristics, treatment details, adverse events and quality of life were recorded for up to 24 months. Simple statistics, Fisher’s exact test, chi-squared and Cox regression were used as appropriate. The interaction between systemic therapy use, tumour and patient characteristics and survival and toxicity outcomes were evaluated using uni- and multivariate analysis and propensity score matching.

Results: 3,649 patients were enrolled in the study of whom 3416 were eligible. 2,816 (82.4%) underwent surgery within 6 months of diagnosis. Of those patients undergoing surgery, 2,554 (90.7%) had Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) 0-1 and 2,710 (96.2%) had a modified Charlson comorbidity Index ≥2. Activities of Daily Living (ADL) were impaired in 568 cases (20.2%) and Instrumental Activities of Daily Living (IADL) in 498 (17.7%). 1,876 patients (66.2%) had normal Mini-Mental State Examination (MMSE). In the overall population, 382 patients (13.6%) received chemotherapy. Its use increased substantially in patients with tumours larger than 50 mm (25.2%), involving axillary lymph nodes (23.6%) and grade 3 (27.4%). Chemotherapy was given in 34.6% of patients with ER-negative and in 47.76% of patients with HER2-positive disease. However, its use decreased with age from 20.7% in patients aged 70-74 to 3.6% in those aged ≥80. Chemotherapy was used in 14.1% of patients with ECOG PS 0-1, 15.6% of those with normal ADL score, 15.6% of those with normal IADL score and 14.2% of those with normal MMSE.Of the total cohort of 3416 women, 1520 (44.5%) had high recurrence risk cancer and 381 (25.0%) patients subsequently underwent chemotherapy. The chemotherapy and no chemotherapy groups differed significantly in age, fitness and frailty. Unadjusted all cause mortality was 17.6% for no chemotherapy and 9.3% for chemotherapy patients. Baseline variation in health status was propensity score adjusted yielding a matched cohort of 381 no chemotherapy and 225 chemotherapy patients. Matched all cause mortality was 10.8% for no chemotherapy versus 10.7% for chemotherapy. EBC specific mortality was 7.0% for no chemotherapy and 8.1% for chemotherapy patients. These data suggest that chemotherapy confers little survival benefit in this age group.

Conclusions: The use of chemotherapy in this population is consistent with published data, with a substantial proportion of fit older patients with high-risk breast cancer not receiving it. However, undertaking a matched analysis of outcomes suggests that there is little benefit in this age group at short follow-up. Incorporating geriatric assessment may better inform the management of these complex patients in a multidisciplinary setting.

Table 1 - Chemotherapy use based on tumour and patient characteristics.CharacteristicsChemotherapy givenYesNoN (%)N (%)Tumour size (mm)≤2093 (7.3)1,182 (92.7)21-50 233 (17.7)1,085 (82.3)≥5050 (25.2)148 (74.7)Unknown6 (24.0)19 (76.0)pN stagepN0 (incl. micrometastases)174 (9.0)1,751 (91.0)pN1116 (18.7)504 (81.3)pN254 (33.5)107 (66.5)pN334 (40.5)50 (59.5)Unknown4 (15.4)22 (84.6)Grade15 (1.3)384 (98.7)2129 (8.6)1,378 (91.4)3239 (27.4)632 (72.6)Unknown9 (18.4)40 (81.6)HistologyInvasive ductal carcinoma287 (14.4)1,701 (85.6)Invasive lobular carcinoma59 (14.6)345 (85.4)Tubular0 (0.0)31 (100.0)Mucinous2 (2.5)78 (97.5)Other29 (10.1)257 (89.9)Unknown5 (18.5)22 (81.5)Receptor statusER statusPositive247 (10.3)2,144 (89.7)Negative129 (34.6)244 (65.4)Unknown6 (11.5)46 (88.5)HER2 statusPositive160 (47.8)175 (52.2)Negative210 (9.1)2,095 (90.9)Inconclusive4 (17.4)19 (82.6)Unknown8 (5.2)145 (94.8)Oncotype DX testYes6 (14.6)35 (85.4)No376 (13.5)2,399 (86.4)Age70-74242 (20.7)928 (79.3)75-79120 (13.4)777 (86.6)80-8418 (3.6)487 (96.4)≥851 (0.4)11 (91.7)ECOG Performance status0301 (15.5)1,646 (84.5)160 (9.9)547 (90.1)23 (3.7)77 (96.2)32 (5.6)34 (94.4)40 (0.0)1 (100.0)Unknown16 (11.0)129 (89.0)ADL score20309 (15.6)1,669 (84.4)1932 (10.6)270 (89.4)≤1815 (5.6)251 (94.4)Unknown26 (9.6)244 (90.4)IADL score8315 (15.6)1,699 (84.4)727 (10.8)222 (89.2)≤67 (2.8)242 (97.2)Unknown33 (10.9)271 (89.1)Modified Charlson comorbidity index0-10 (0.0)0 (0.0)≥2371 (13.7)2,339 (86.3)Unknown11 (10.4)95 (89.6)MMSE&gt;24267 (14.2)1,609 (85.8)20-247 (17.5)33 (82.5)&lt;204 (12.9)27 (87.1)Unknown104 (12.0)765 (88.0)

Citation Format: Nicolò Matteo Luca Battisti, Alistair Ring, Mike Bradburn, Lynda Wyld, Age Gap Trial Steering Group. Use of systemic therapy for early stage breast cancer in older adults: Results from the Bridging the Age Gap study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-14-08.

Pathological complete response to neoadjuvant systemic therapy in 789 early and locally advanced breast cancer patients: The Royal Marsden experience

PURPOSE

Pathological complete response (pCR) after neoadjuvant chemotherapy (NACT) for breast cancer predicts the risk of recurrence and increasingly may indicate the need for additional therapy postoperatively.

METHODS

We identified non-metastatic breast cancer patients receiving NACT during 2013-2017. Patients' and disease characteristics, rates of pCR (ypT0-is ypN0), toxicities, dose delays and reductions, and survival outcomes were recorded.

RESULTS

789 patients had median age of 50 years. 67.8% had stage II disease, 71.1% had grade 3 , and 91.8% had ductal histopathology. 32.8% had estrogen receptor (ER)-positive/human epidermal growth factor receptor 2 (HER2)-negative, 25.5% had triple-negative (TN), and 38.0% HER2-positive disease. 6.8% received platinum. 48.2% of the HER2-positive patients received trastuzumab and pertuzumab and 51.8% received trastuzumab. Overall pCR rate was 33.5% and differed according to disease subtype, receptor status, grade, histology, and early discontinuation, but not according to age, dose reductions/delays, or year of treatment. The addition of pertuzumab to trastuzumab marginally improved the pCR rates. Survival outcomes were better following pCR.

CONCLUSIONS

In our analysis, pCR rates are consistent with the published data. Even with contemporary therapies, many patients have residual disease following NACT, suggesting a significant risk of recurrence, and may benefit from additional postoperative systemic therapy.

Abstract P1-15-08: Pathologic complete response rates following neoadjuvant systemic therapy in 794 patients with early breast cancer: The Royal Marsden experience

Background

The presence and extent of residual invasive cancer after neoadjuvant treatment (NACT) is a strong prognostic factor for risk of recurrence, especially in triple-negative (TN) and human epidermal growth factor receptor 2-positive (HER2+) breast cancer (BC). Recent advances in the standard-of-care NACT improved pathological complete response (pCR) rates in published clinical trials.

We evaluated the pCR rates, defined as ypT0-is ypN0, in our real-world BC population and in estrogen receptor-positive [ER+] HER2-, HER2+ and TN subgroups and their association with tumour, patients' characteristics and disease-free survival (DFS).

Methods

We retrospectively identified early BC patients receiving NACT between January 2013 and December 2017. Demographics, patient and disease characteristics, pathological responses, toxicities, dose delays and reductions were recorded. Simple statistics, Fisher's exact test, chi-squared method and Cox regression were used as appropriate.

Results

794 patients identified had median age of 50 years (range 24-87) and 93.9% (745 patients) ECOG performance status (PS) 0. 3.0% (24) had clinical stage I disease, 68.0% (540) stage II and 29.0% (230) stage III. 71.0% (564) had grade 3 disease and 91.8% (729) ductal histology. 33.7% (257) had ER+/HER2-, 25.8% (205) had TN and 38.0% (301) HER2+ disease. Overall, 6.8% (54) patients received platinum. 36.6% (291) patients had dose reductions and 24.3% (193) dose delays. Along with NACT, 51.6% (147) of the HER2+ patients received Trastuzumab and Pertuzumab and 48.4% (138) Trastuzumab alone.

pCR rate was 33.1% in the overall population and significantly different in ER+/HER2-, HER2+ and TN subgroups (12.84% versus 52.0% versus 28.43% respectively, p&lt;0.001). pCR was influenced by grade (1: 0%; 2: 24.3%; 3: 36.1%, p 0.005) and histology (ductal: 34.2%; lobular: 10.0%; mixed 25.0%; p 0.01). In the HER2+ subgroup, there was a trend for improved pCR rates for patients receiving Pertuzumab and Trastuzumab (57.0%) versus Trastuzumab alone (51.0%). No statistically significant differences were seen based on patients' characteristics including age and PS or in case of treatment dose reductions and delays. Early discontinuation of NACT was associated with lower pCR rates (20.5% vs 36.29%, p &lt;0.001).

Of interest, pCR rates remained consistent across the period 2013-2017 in the overall population. We observed a trend for improved pCR in the HER2+ (2013: 47.5%; 2014: 44.4%; 2015: 66.7%; 2016: 51.0%; 2017: 51.4%) and TN cohorts (2013: 23.5%; 2014: 25.0%; 2015: 25.0%; 2016: 33.3%; 2017: 34.1%) but not in the ER+/HER2- group.

Median DFS was 83.8 months (95% CI 62.0-NR) in the overall population. Although not reached in the TN cohort, median DFS was different according to disease subgroups (HER2+: 83.78 months; TN: NR; ER+/HER2-: 62.0 months, p &lt;0.0001).

Conclusions

In our analysis pCR rates are consistent with data published in literature and higher in HER2+ and TN disease. The impact of new agents had a relatively low impact on pCR rates in our overall population over the last 5 years, although they produced gradual improvements in the HER2+ and TN subgroups.

Citation Format: Battisti NML, True V, Chaabouni N, Chopra N, Lee K, Shepherd S, Shapira-Rotenberg T, Joshi R, Mohammed K, Allen M, Ring A. Pathologic complete response rates following neoadjuvant systemic therapy in 794 patients with early breast cancer: The Royal Marsden experience [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-08.

Use of cyclin-dependent kinase 4/6 (CDK4/6) inhibitors in older patients with ER-positive HER2-negative breast cancer: Young International Society of Geriatric Oncology review paper

The current standard of care for the management of estrogen receptor (ER)-positive and human epidermal growth factor receptor 2 (HER2)-negative breast cancer has been redefined by the introduction of cyclin-dependent kinase 4/6 (CDK4/6) inhibitors. Although adults aged 65 years and older account for the majority of patients with breast cancer, limited data are available about the age-specific dosing, tolerability, and benefit of CDK4/6 inhibitors in this growing population. Older adults are under-represented in clinical trials and as a result, clinicians are forced to extrapolate from findings in younger and healthier patients when making treatment decisions for older patients. In this article, we review the limited age-specific evidence on the efficacy, toxicity, and quality of life (QoL) outcomes associated with the use of CDK4/6 inhibitors in older adults. We also describe ongoing trials evaluating CDK4/6 inhibitors in the older population and highlight that only a minority of adjuvant and metastatic trials of CDK4/6 inhibitors in the general breast cancer population includes geriatric assessments. Finally, we propose potential strategies to help guide decision making for fit and unfit older patients based on disease endocrine sensitivity, the need for rapid response and geriatric assessment.

PARP inhibitors in older patients with ovarian and breast cancer: Young International Society of Geriatric Oncology review paper

Breast and ovarian cancer are common malignancies among older adults, causing significant morbidity and mortality. Although most cases of breast and ovarian cancer are sporadic, a significant proportion is caused by mutations in cancer susceptibility genes, most often breast cancer susceptibility genes (BRCA) 1 and 2. Furthermore, some breast and ovarian tumors are phenotypically similar to those with BRCA mutations, a phenomenon known as "BRCAness". BRCA mutations and "BRCAness" lead to defects in DNA repair, which may be a target for therapeutic agents such as Poly ADP-Ribose Polymerase (PARP) inhibitors. PARP inhibitors are novel medications which lead to double-strand breaks resulting in cell death due to synthetic lethality, and which have been shown to be effective in patients with advanced breast and ovarian cancers with or without BRCA mutations. Three different PARP inhibitors (olaparib, niraparib, and rucaparib) have been approved for the treatment of ovarian cancer and one (olaparib) for breast cancer harboring BRCA mutations. Here, we review the currently available evidence regarding the use of PARP inhibitors for the treatment of patients with breast and ovarian cancer, with a particular focus on the inclusion of older adults in clinical trials of these therapies. Additionally, we provide an overview of currently ongoing studies of PARP inhibitors in breast and ovarian cancer, and include recommendations for increasing the evidence-base for using these medications among older patients.

Targeted agents for HER2-positive breast cancer in older adults: current and future perspectives

INTRODUCTION

One-third of breast cancer (BC) cases worldwide occur in women aged 65 years and older, with 10 to 15% overexpressing the human epidermal growth factor receptor 2 (HER2). Although several HER2-targeted therapies have been developed, the lack of data regarding their use in older patients hampers evidence-based decision-making for this population.

AREAS COVERED

We review current evidence on the efficacy and safety of HER2-targeted therapies in older adults with BC, focusing on approved therapies such as trastuzumab, lapatinib, pertuzumab, ado-trastuzumab-emtansine, and neratinib. Additionally, we discuss drugs under development to target the HER2-receptor, and to overcome resistance to existing therapies. Finally, we highlight the cardiotoxicity of HER2-targeted drugs among older adults.

EXPERT OPINION

Older adults are underrepresented in trials of HER2-targeted therapies in BC. We propose strategies to increase recruitment of older adults in clinical trials in order to increase the evidence base to treat this growing population.