Management of elderly patients with primary breast cancer

From 1974 through 1983, three hundred forty-three patients aged 70 years or older at diagnosis received comprehensive post-operative radiation therapy for localized (Stage I-III) breast cancer following surgical procedures ranging from incisional biopsies to classical radical mastectomy. The 5- and 10-year overall survival rates for this series of elderly patients are 67% and 33%. The respective disease-free survival rates are 67% and 42%. Over one-half of these women were treated by less than total mastectomy. No differences were seen in survival, disease-free survival, or local regional control rates comparing similarly staged patients treated by radical mastectomy, modified radical mastectomy, or tylectomy. Complications were few and seen primarily in those patients subjected to axillary dissection prior to irradiation. Long term survival appears to be achievable in the majority of elderly patients with regionally confined disease at presentation and aggressive treatment with curative intent is warranted. These elderly patients are often poor candidates for radical surgery. In this patient population, conservative surgery with post-operative radiation therapy is well tolerated and provides equivalent results to more radical surgical procedures.     

Management of the frail elderly with breast cancer

By the year 2030 most patients with breast cancer will be aged 65 years or more and many will be frail. Frailty implies diminished physiologic reserve; contributors include diminished organ function, comorbidities, impaired physical function, and geriatric syndromes. Time-efficient tools for assessing frailty are being developed and, once validated, can be used to identify frail cancer patients and help direct therapy. Screening mammography in frail patients is questionable, and a clinical breast exam is likely to identify breast cancers that warrant intervention. Hormonal therapy may be a reasonable primary therapy in older frail women with hormone receptor-positive lesions. For estrogen receptor--and progesterone receptor-negative lesions, excision of the primary tumor may be adequate. Adjuvant hormonal therapy may be appropriate in frail elders with high-risk hormone receptor-positive breast cancer; chemotherapy is rarely indicated regardless of tumor status. The majority of frail elders with metastases will have hormone receptor-positive breast cancers, and endocrine therapy should be considered; those with receptor-negative tumors may be treated with single-agent chemotherapy or supportive care measures. Oncologists need to acquire the skills to appropriately identify frail elders so they select appropriate therapies that will minimize toxicity and maintain quality of life.     

Adjuvant therapy in elderly patients with breast cancer

The elderly population has been neglected by the traditional approach to clinical breast cancer research. Elderly women have been underrepresented in breast cancer clinical trials, with the majority of studies being restricted to patients aged < 70 years. Elderly patients frequently have comorbidities and/or impaired organ function. These facts may often lead to death from causes other than cancer, thus nullifying any possible benefit of adjuvant treatment; furthermore, they render extrapolation of standard treatment recommendations to the elderly potentially hazardous, particularly with respect to chemotherapy. Therefore, specific clinical trials are needed to investigate adjuvant treatments tailored for the heterogeneous older population.     

Management of elderly patients with lung cancer

Cancer management in the older patient is a growing concern, particularly with the increasing geriatric population and the high incidence of cancer among these individuals. Incidence of lung cancer in particular is known to rise with age. This article reviews prognosis, treatment options, and decision-making issues for both clinician and patient with respect to both non-small-cell and small-cell lung cancer in this population. Research findings dealing with response rates, survival rates, and symptom control in this age group are reviewed for radiotherapy, surgery, and for various chemotherapy agents, including gemcitabine, the taxanes, vinorelbine, and the topoisomerase 1 inhibitors. Quality of-life issues are also addressed.     

Management of breast cancer in the elderly

This paper examines data which has been published on breast cancer in the elderly and concludes that, wherever possible, combined modality treatment should be offered to elderly breast cancer patients. It appears from an examination of the literature that single modality treatment in the form of hormone treatment often results in very high rates of loco-regional recurrence.     

Taxanes in elderly breast cancer patients

Breast cancer in elderly patients (70+) is a major health problem that will only increase in the future. Besides adequate local treatment and hormone therapy, there can be an indication for chemotherapy in this patient group. Due to concerns of excessive toxicity, there is often a defeatist attitude towards chemotherapy in elderly patients. As taxanes are considered to be the most effective drugs in breast cancer, and as the weekly regimens seem at least as effective as the 3-weekly regimens but with less toxicity, these weekly regimens are very attractive for elderly breast cancer patients. Many different doses have been used for the weekly taxane regimens in phase II trials. Although large comparative studies are lacking, pharmacological studies are suggestive for a decreased clearance of both paclitaxel and docetaxel in elderly patients compared to non-elderly patients. It seems therefore safe to use the lower range of proposed doses of the weekly regimens until further data provide stronger evidence for optimal dosing in elderly patients. A dose of paclitaxel 80 mg/m(2)/week and docetaxel 36 mg/m(2)/week seems tolerable for elderly patients without excessive toxicity and with impressive response rates. The dose limiting toxicity for 3-weekly taxanes, severe neutropaenia, is generally very limited in weekly regimens, also in the elderly or frail patients. However, neuropathy (paclitaxel) or fatigue and fluid retention (docetaxel) can be troublesome, and eventually require dose modifications. In general however, weekly taxanes are a reasonable option for older patients with metastatic breast cancer.     

Management of early breast cancer in the elderly

Breast cancer is the most common malignancy in women with an age related increase in incidence ranging from 1 in 50 at age 50 to 1 in 10 at age 80. This is particularly significant in view of the changing demographics in the western population, characterised by an aging population and increased life expectancy. However in spite of favourable prognostic factors and less aggressive biological behaviour, elderly breast cancer patients receive less aggressive treatment when compared with their younger counterparts. Appropriate treatment should be offered depending on physiological reserve and comorbidities. Primary endocrine treatment has been shown to be associated with significant morbidity in terms of disease progression. Prompt surgery and adjuvant treatment can decrease relapse and improve survival. Radiation therapy is shown to decrease local relapse and chemotherapy may have a role in a select group of patients with adverse prognostic factors. With incidence of breast cancer bound to increase in the elderly population, it is essential to establish optimum therapy in this cohort of patients as studies reveal good outcome from standard treatment.     

Management of patients with locally advanced breast cancer

Increased breast health awareness has led to earlier stage distribution among breast cancer patients in the United States; however, locally advanced tumors remain a major source of morbidity and mortality. Early attempts to control this high-risk pattern of disease with surgery or radiation alone were met with disappointingly high rates of treatment failure in locoregional and distant sites. Multimodality strategies represent a major advance in management of these difficult cancers. The current standard of care is neoadjuvant chemotherapy to improve operability, followed by breast and axillary surgery (including lumpectomy for appropriately selected patients). Following surgery, decisions regarding the need for additional chemotherapy with or without locoregional irradiation are made based on stage at presentation, response to systemic therapy, and surgical-pathology findings. Recommendations for adjuvant endocrine therapy are based on hormone receptor status. Studies of these tumors have confirmed that primary response to induction therapy is an excellent surrogate marker of success in eradicating micrometastases, as patients experiencing a complete pathologic response have a statistically significant survival advantage. Ongoing investigations of locally advanced breast cancer include studies of systemic chemotherapy with or without neoadjuvant endocrine regimens that increase the complete pathologic response rate, and correlation with outcome; integration of lymphatic mapping and sentinel lymph node biopsy into clinical trials; and defining the optimal extent of locoregional irradiation in patients who experience a strong response to neoadjuvant treatment.     

Management of patients with locally advanced breast cancer

Increased breast health awareness has led to earlier stage distribution among breast cancer patients in the United States; however, locally advanced tumors remain a major source of morbidity and mortality. Early attempts to control this high-risk pattern of disease with surgery or radiation alone were met with disappointingly high rates of treatment failure in locoregional and distant sites. Multimodality strategies represent a major advance in management of these difficult cancers. The current standard of care is neoadjuvant chemotherapy to improve operability, followed by breast and axillary surgery (including lumpectomy for appropriately selected patients). Following surgery, decisions regarding the need for additional chemotherapy with or without locoregional irradiation are made based on stage at presentation, response to systemic therapy, and surgical-pathology findings. Recommendations for adjuvant endocrine therapy are based on hormone receptor status. Studies of these tumors have confirmed that primary response to induction therapy is an excellent surrogate marker of success in eradicating micrometastases, as patients experiencing a complete pathologic response have a statistically significant survival advantage. Ongoing investigations of locally advanced breast cancer include studies of systemic chemotherapy with or without neoadjuvant endocrine regimens that increase the complete pathologic response rate, and correlation with outcome; integration of lymphatic mapping and sentinel lymph node biopsy into clinical trials; and defining the optimal extent of locoregional irradiation in patients who experience a strong response to neoadjuvant treatment.     

Baseline cognitive functions among elderly patients with localised breast cancer

PurposeCognitive deficits (CD) are reported among cancer patients receiving chemotherapy, but may also be observed before treatment. Though elderly patients are expected to be more prone to present age-related CD, poor information is available regarding the impact of cancer and chemotherapy on this population. This study assessed baseline cognitive functions (before adjuvant treatment) in elderly early stage breast cancer (EBC) patients.MethodsWomen >65 years-old with newly diagnosed EBC were included in this prospective study. Episodic memory, working memory, executive functions and information processing speed were assessed by neuropsychological tests. Questionnaires were used to assess subjective CD, anxiety, depression, fatigue, quality of life and geriatric profile. Objective CD were defined using International Cognition and Cancer Task Force criteria. A group of elderly women without cancer coupled with published data related to healthy women were used for comparison (respectively to subjective and objective CD).ResultsAmong the 123 elderly EBC patients (70 ± 4 years) included, 41% presented objective CD, which is greater than expected in healthy population norms (binomial test P < .0001). Verbal episodic memory was mainly impaired (21% of patients). No correlation was observed between objective CD and cancer stage or geriatric assessment. Subjective CD only correlated with verbal episodic memory (P = .01).ConclusionsThis is the first large series assessing baseline cognitive functions in elderly EBC patients. More than 40% presented objective CD before any adjuvant therapy, which is higher than what is reported among younger patients. Our results reinforce the hypothesis that age is a risk factor for CD in EBC patients.     

Assessment of surgical treatment in elderly patients with breast cancer

AIMS AND BACKGROUND: The incidence of breast cancer increases with advancing age and in clinical practice approximately 50% of new cases occur in women over the age of 65 years. Although breast cancer in elderly patients presents more favorable biological characteristics than similar-stage cancer in younger women, disease control still remains uncertain and is becoming a major health problem. PATIENTS AND METHODS: Between 1984 and 2006, 133 patients aged over 65 with operable breast cancer underwent surgical treatment. Patients with ductal or lobular carcinoma in situ, bilateral breast cancer or a previous malignancy were excluded. The mean age was 72.8 years (range, 66-89). Breast-conserving surgery was performed in patients with early breast cancer (T1, T2 < 2.5 cm), while most patients with advanced tumors (T2 >2.5 cm, T3, T4) were treated by modified radical mastectomy. RESULTS: The pathological stage was I in 44, IIA in 54, IIB in 18, IIIA in 10 and IIIB in 7 patients. Postoperative complications occurred in 13 patients (9%); there were no postoperative deaths. Eighty-nine patients underwent adjuvant therapy (chemotherapy, hormonal therapy). After a median follow-up of 96 months (range, 5-266), disease progression was observed in 21 patients (15.8%). The overall mortality from breast cancer was 11%, whereas the cancer-unrelated mortality was 9%. CONCLUSION: There is no evidence that breast cancer has a more favorable prognosis in the elderly and surgical procedures should be carried out as has been established in younger women. At present, elderly patients are much less likely to be entered into randomized clinical trials and are often undertreated. However, in the absence of serious comorbid disease, they are able to withstand standard multimodal treatment options as well as do younger patients.     

Pegylated liposomal doxorubicin in elderly patients with metastatic breast cancer

Breast cancer incidence is increasing among elderly patients. Age is a risk factor for toxicity after chemotherapy for breast cancer. In particular, anthracycline-induced cardiac toxicity is increased in elderly patients. Novel liposomal anthracyclines are associated with less cardiotoxicity. Pegylated liposomal doxorubicin (PLD) is active in breast cancer patients and, has shown comparable efficacy to conventional doxorubicin in clinical trials. Most toxicities during PLD treatment are hematological and mucocutaneous (in particular stomatitis and palmo-plantar erythrodysesthesia), and cardiac toxicity is rare. Tolerability of this agent in elderly patients has been confirmed by clinical trials in the advanced disease. Due to its efficacy and safety profile, PLD is an appealing treatment option for elderly breast cancer patients.     

Efficacy and safety of oral chemo-endocrine therapy for elderly patients with breast cancer

We often encounter elderly patients who are difficult to treat with standard treatment (e. g. anthracycline, taxane or operation) because of complication, age and so on, though there are no standard treatments for such elderly patients. We analyzed retrospectively the efficacy and safety of oral chemo-endocrine therapy for patients more than 65 years old who were difficult to treat with standard chemotherapy or operation because of complications and other reasons. Seventeen patients were analyzed. The response rate (RR) was 76.5%, and the clinical benefit rate (CBR) was 94.1%. The two-year survival rate from the start of treatment was 91.7%, and the median progression free survival (PFS) was 1, 230 days. Grade 1 anorexia and grade 1 Hand-Foot Syndrome were observed in only one patient, and it was remarkable that patients could continue to receive treatment for such a long time. In conclusion, oral chemo-endocrine therapy is effective for elderly patients difficult to treat with standard treatment, because it has better anti-tumor effect and tolerability.     

Omission of surgery in elderly patients with early stage breast cancer

AimTo assess national trends over time in surgery for elderly patients with resectable breast cancer (BC) and to evaluate clinical outcome and cause of death after the omission of surgery in a regional cohort of elderly patients.MethodsNational trends in 1995–2005 were calculated using cancer registry data. In addition, a chart review was performed in a cohort of patients aged ?75 years, with early stage BC but no primary surgery, diagnosed at five Dutch hospitals in 1990–2005. Patient characteristics, comorbidity and reason for the omission of surgery were collected from the chart. Cause of death was retrieved from death certificate data registered at Statistics Netherlands.ResultsOmission of surgery increased significantly over time for patients aged 80 years and older (p < 0.05). Of the 187 patients in the regional cohort (median age 85.9 years (range 75.0–97.7), 174 (92%) received hormonal therapy. Omission of surgery was at the patient’s request in 59 patients (32%). Of the 178 patients that died during follow-up, 60 patients (34%) died of BC. For 81 patients (45%), BC was not clinically relevant at the time of death. Median overall survival was 2.3 years (range 0.2–10.7) and did not differ between BC and other causes of death (p = 0.9).ConclusionOmission of surgery for elderly patients with resectable BC has increased significantly over the past decade; instead patients often received primary endocrine treatment. Although this may appear an effective alternative to surgery, the potential for a longer term negative impact on disease control and quality of life deserves further investigation.     

Adjuvant chemotherapy in elderly patients with breast cancer: key challenges

Elderly women with early breast cancer (BC) form a heterogeneous and large subgroup (41.8% of women with BC are over 65). Decision making in this subgroup is made more difficult by lack of familiarity with their physical, cognitive and social issues. Adequate management depends on biological factors and accurate clinical evaluation through comprehensive geriatric assessment (CGA). CGA can help to better select and determine potential risks factors for patients who are candidates for adjuvant chemotherapy. It is still recently introduced in geriatric oncology and there is a lack of awareness of its importance. Available data on adjuvant chemotherapy for BC is limited but suggests it can be of benefit for well selected patients, though the risk of short and long-term toxicity is significant. Here we provide a discussion of the key practical issues in decision making in the setting of adjuvant chemotherapy for elderly BC patients.