Adjuvant treatment of breast cancer in the elderly. Understanding and addressing the challenges

Breast cancer is the most common malignancy in women, and the incidence of breast cancer increases with increasing age until age 80. As the population continues to age, breast cancer in older women will become an increasing clinical challenge. A majority of breast cancer in older women is hormone receptor-positive, making hormonal therapy the mainstay of adjuvant treatment in this group. Chemotherapy clinical trials have largely excluded the elderly, and therefore limited data exists on the efficacy and tolerability of standard adjuvant chemotherapy in older women. Ongoing studies are addressing alternatives to standard adjuvant chemotherapy in this group. Emerging biologic instruments such as gene-expression profiling may be able to better identify patients who will gain benefit from adjuvant chemotherapy. Elderly patients are highly variable in their functional status, reserve capacity, and comorbidity, and better assessment tools are needed to evaluate these issues and predict which patients will tolerate cancer treatments. More work is needed to address the many challenges that affect the adjuvant treatment of breast cancer in older women.     

Chemotherapy for older women with early breast cancer

The incidence of breast cancer increases with age, reaching over 300 per 100,000 in women aged 70-75 years in the U.K., increasing to almost 400 per 100,000 in women aged over 85 years. As a healthy 70-year old woman can now expect to live for an average of 15 years, control of breast cancer is likely to significantly affect survival. Variations exist in surgical care, radiotherapy and chemotherapy, depending on age; however, virtually all elderly women with hormone-responsive disease are given adjuvant endocrine therapy, usually tamoxifen. For older women who do not have hormone-responsive cancer, and who have high-risk disease characteristics, questions remain over their best management. Overview data of adjuvant chemotherapy in clinical trials show a significant benefit of chemotherapy for women up to the age of 69 years but, for older women, there are too few data to draw any firm conclusions. When considering treatment options for older women, assessment is critical; functional status and comorbidity are some of the factors linked to shorter survival.     

Racial and socioeconomic disparities in adjuvant chemotherapy for older women with lymph node‐positive,operable breast cancer

BACKGROUND:

Consistent with findings from clinical trials, a recent population‐based study indicated that adjuvant chemotherapy for lymph node‐positive, operable breast cancer is effective at improving survival in older women, specifically those ages 65 years to 69 years; however, to the authors' knowledge, no conclusion has been reached about the relative benefit of chemotherapy for women aged ≥70 years, probably because of small number of patients. However, little is known about racial and socioeconomic disparities in adjuvant chemotherapy for breast cancer among older women.

METHODS:

This study included 14,177 white women and 1277 black women aged ≥65 years who were diagnosed with operable breast cancer (stage II‐IIIA) and positive lymph nodes between 1991 and 2002. These women were identified from the Surveillance, Epidemiology, and End Results and Medicare‐linked database. Multivariate logistic regression was used to compute the odds ratios of receiving chemotherapy among black women compared with white women, and the causal step approach was used to test whether census tract‐level poverty mediated racial disparities.

RESULTS:

Interaction terms analyses indicated that regressions should be stratified by age group. In the group ages 65 years to 69 years, the adjusted odds ratio of receiving chemotherapy were lower for black women than for white women (odds ratio, 0.85; 95% confidence interval, 0.57‐0.97). Poverty mediated the association between chemotherapy and race in this age group. No racial or socioeconomic disparities were observed among women aged ≥70 years.

CONCLUSIONS:

This study documented racial disparities in adjuvant chemotherapy that were mediated by poverty in women ages 65 years to 69 years, an age group for which there is clear evidence for the efficacy of chemotherapy, but no disparities were observed among women aged ≥70 years. The authors concluded that it is important to work toward reducing treatment disparities among older women. Cancer 2009. © 2009 American Cancer Society.     

Efficacy of systemic adjuvant therapy for breast cancer in African-American and Caucasian women.

Observed variations in breast cancer survival by racial/ethnic background have been attributed to many factors, including differences in clinical and pathologic disease features at diagnosis and economic resource inequities that may affect treatment access and quality. In this report, we examine outcomes for African-American and Caucasian breast cancer patients participating in selected randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP) to determine whether prognosis or efficacy of systemic adjuvant therapy differed between these groups. Randomized clinical trials offer the advantages of a similar disease stage and a uniform treatment plan for all participants. Patients from four NSABP trials enrolling patients from 1982 through 1994 with axillary lymph node-negative disease (543 African-American and 7582 Caucasian) and three trials enrolling patients from 1984 through 1991 with axillary lymph node-positive disease (548 African-American and 4986 Caucasian) were included. Disease-free survival (DFS), which was defined as time on study free of breast cancer recurrence, second primary cancer, or death preceding these events, and survival risk ratios (RRs) with two-sided 95% confidence intervals (CIs) for African-Americans versus Caucasians were computed from Cox proportional hazards models that included relevant prognostic covariates. Treatment benefits for the therapies evaluated in these trials were estimated separately for African-Americans and for Caucasians. Among patients with lymph node-negative disease, African-Americans had similar DFS rates to Caucasians (African-American/Caucasian RR = 1.06, 95% CI = 0.92 to 1.23) but had modestly greater mortality rates (RR = 1.21, 95% CI = 1.01 to 1.46). Among lymph node-positive patients, DFS was similar (RR = 1.04, 95% CI = 0.93 to 1.17) and survival was again less favorable for African-Americans (RR = 1.18 95% CI = 1.03 to 1.34). Survival excluding deaths most likely attributable to causes other than cancer was similar between African-Americans and Caucasians (RR = 1.08 [95% CI = 0.88 to 1.33] for lymph node-negative patients and RR = 1.09 [95% CI = 0.96 to 1.25] for lymph node-positive patients). Among lymph node-negative and lymph node-positive patients, African-Americans and Caucasians realized comparable benefit from either the addition of chemotherapy or tamoxifen to surgery alone or the addition of chemotherapy to tamoxifen. In summary, African-American women and Caucasian women who were diagnosed at a comparable disease stage and were similarly treated tended to experience similar breast cancer prognosis. However, a mortality deficit persisted for African-American women relative to Caucasian women, which may be in part due to greater mortality from noncancer causes among African-Americans. Benefit from systemic adjuvant therapy for recurrence and mortality reduction was comparable between African-Americans and Caucasians. This study and investigations in other health-care settings suggest that African-American women and Caucasian women with breast cancer derive a similar benefit from systemic adjuvant therapy when it is administered in accordance with their clinical and pathologic disease presentation.     

Psychosocial determinants and outcomes of chemotherapy in older women with breast cancer: what do we know? What do we need to know?

With the aging of the U.S. population and rising breast cancer incidence with advancing age, the absolute number of women aged 65 years and older diagnosed with and surviving breast cancer will dramatically increase over the coming decades. Despite this demographic imperative, we know little about the impact of adjuvant therapies in this age group. We synthesized data to describe key findings and gaps in knowledge about the outcomes of adjuvant breast cancer treatment in women aged 65 years and and older ("older women"). We reviewed research published between 1995 and June 2005 on breast cancer outcomes among older women treated with adjuvant therapy for breast cancer. Outcomes included communication, emotional distress, satisfaction, and multiple quality-of-life domains. Only 16 articles focused exclusively on older women and chemotherapy; and only one included a large sample of older women (N = 1755). Most common domains included comorbidities, symptoms, and survival. Of the 13 clinical trials and three observational studies we reviewed, only one clinical trial measured quality of life and psychological factors such as coping. None of the studies examined patient preferences or patient-physician communication (processes of care) in older women. Few studies have been designed to specifically evaluate adjuvant therapy processes and outcomes among older women, especially interactions between treatment and comorbidity, and the impact of the processes of care on outcomes. In addition, only narrow segments of the older population with breast cancer (e.g., well-educated, nonminority women) have been included in trials to date. Thus, at present we do not have sufficient data to assist physicians and their older patients in developing adjuvant treatment decisions and plans tailored to older women's needs, preferences, and concerns.     

New criteria for selecting elderly patients for breast cancer adjuvant treatment studies

About 50% of breast cancers occur in women aged 65 years and older, and both the incidence and prevalence of breast cancer among older women are expected to increase in the future. Aging implies a reduction in life expectancy and tolerance to treatments that should be considered in elderly patients with early breast cancer. In fact, treatment options often carry short-term risks and toxicities that might be tempered by long-term survival gains. The choice of adjuvant treatment for elderly patients should be based on the same criteria that are currently used for younger patients: endocrine responsiveness and assessment of risk of relapse. Adjuvant endocrine therapy should be considered for women with endocrine-responsive disease, regardless of age. The value of adjuvant chemotherapy is controversial. Older women are frequently undertreated with adjuvant chemotherapy and are underrepresented in clinical trials. In particular, no convincing data are available on the role of adjuvant chemotherapy in endocrine nonresponsive tumors, partly because most of the time these tumors represent a relatively small subset in adjuvant studies focusing on the elderly population. Several phase III trials are currently ongoing in elderly patients with early breast cancer to evaluate different options of adjuvant treatments. Only one trial, coordinated by the International Breast Cancer Study Group, is investigating the role of adjuvant chemotherapy for postmenopausal women of advanced age with endocrine nonresponsive early breast cancer. Disclosure of potential conflicts of interest is found at the end of this article.     

Update in medical oncology for older patients: focus on breast cancer: management of early breast cancer

Breast cancer is a disease of older women, and its incidence continues to rise with the growth and aging of the U.S. population. Elderly women have frequently been under-treated and have been poorly represented in clinical breast cancer trials. We reviewed the literature on early breast cancer in older women. We present current information on the tumor biology of elderly women and the role of surgical therapy and adjuvant treatment with hormonal therapy, chemotherapy, biologic agents, and radiation therapy in its management. Lastly, we discuss the importance of clinical trials in the elderly and future directions for therapy.     

Systemic therapy for older women with breast cancer

Breast cancer is a common problem in older women. As the number of medical illnesses increases with age and the life expectancy decreases, the benefits of systemic therapy for women with breast cancer become questionable. All women over age 65 years are at high enough risk of breast cancer to consider the risk/benefit ratio of preventive therapy with tamoxifen (Nolvadex) or participation in the Study of Tamoxifen and Raloxifene (STAR) trial. Adjuvant chemotherapy and hormonal therapies for early breast cancer significantly improve disease-free and overall survival; recommendations for their use are based on risk of tumor recurrence. Use of tamoxifen in the adjuvant setting in women with receptor-positive tumors is a relatively simple decision in light of its favorable toxicity profile. The delivery of adjuvant chemotherapy is a more complicated decision, and the patient's wishes, estimated life expectancy, presence of comorbid conditions, and estimated benefit from treatment should be considered. The primary goal of the treatment of metastatic breast cancer is palliation. We discuss trials specific to older women and make appropriate treatment recommendations. Unfortunately, there is a paucity of data from clinical trials in women over age 70 years. However, because the clinical trial is the primary scientific mechanism for testing the efficacy of a treatment, every effort should be made to enter older women into treatment protocols.     

Treatment of breast cancer in older women

Background. Breast carcinoma management in the elderly often differs from the management in younger women and there is considerable controversy about what constitutes appropriate cancer care for older women. This controversy is reflected in the persistence of age-dependent variations in care over time, with older women being less likely to receive definitive care for breast cancer. There has been a significant increase in the last years in the number of studies conducted in older patients with breast cancer. Although available age-specific clinical trials data demonstrate that treatment efficacy is not modified by age, this evidence is limited by the lack of inclusion of substantial numbers of older women, particularly those of advanced age and those with comorbidities. Method. The literature-based evidence of the last 10 years was extensively reviewed on the main issues concerning the treatment of breast cancer in older women. Results.Surgical treatment in older patients has evolved from avoidance to mastectomy to breast-conserving surgery, similarly to younger patients. Given its negative effect on the quality of life, in the last few years the role of adjuvant radiotherapy has been questioned in elderly patients with breast cancer. Adjuvant chemotherapy benefit in older patients applies mainly to Estrogen-receptor-negative patients, while in Estrogen-receptor-positive patients a major role is played by endocrine treatment. New “elderly-friendly” drugs, that can help clinicians to reduce toxicity, are now available for breast cancer.     

Adjuvant bisphosphonates in endocrine-responsive breast cancer: what is their place in therapy?

Recent advances in the treatment of early breast cancer have improved clinical outcomes and prolonged survival, especially in women with endocrine-responsive disease. However, cancer therapies including cytotoxic chemotherapy, ovarian suppression, and aromatase inhibitors can drastically reduce circulating estrogen, increasing bone loss and fracture risk. Because most women with early breast cancer will live for many years, it is important to protect bone health during cancer therapy. Several recent clinical trials combining adjuvant endocrine therapy with bisphosphonates have demonstrated efficacy for preventing cancer treatment-induced bone loss in pre- and postmenopausal women with early breast cancer. The largest body of evidence supporting the use of adjuvant bisphosphonates comes from studies with zoledronic acid; however, studies with risedronate, ibandronate, and denosumab (a biologic agent) have also demonstrated efficacy for preventing bone loss. Adding zoledronic acid to endocrine therapy prevents bone loss and improves bone mineral density (BMD). In addition, preclinical studies suggest that bisphosphonates have direct and indirect antitumor activity, such as inducing tumor cell apoptosis, reducing tumor cell adhesion and invasion, reducing angiogenesis, activating immune responses, and synergy with chemotherapy agents, among others. Clinical trials have demonstrated significantly improved disease-free survival in patients receiving adjuvant endocrine therapy plus zoledronic acid compared with endocrine therapy alone. Ongoing studies will further define the role of adjuvant bisphosphonates in maintaining bone health and improving clinical outcomes. The available evidence suggests that pre- and postmenopausal patients may receive clinical benefit from including bisphosphonates as part of their adjuvant treatment regimen for endocrine-responsive early breast cancer.     

Impact of Adjuvant Chemotherapy in Elderly Breast Patients in Taiwan,A Hospital-Based Study

Purpose: Decisions as to whether to provide adjuvant treatment in older breast cancer patients remains challenging. Side effects of chemotherapy have to be weighed against life expectancy, comorbidities, functional status, and frailty. To aid decision-making, we retrospectively analyzed 110 women with breast cancer treated with a curative intention from 2006 to 2012. Survival data with clinical and pathological parameters were evaluated to address the role of adjuvant chemotherapy in this study population. Method: A total of 110 elderly (>70 years) patients that received mastectomy at two hospitals in Taiwan were observed retrospectively for a medium of 51 months. After mastectomy, patients received conservative treatment or adjuvant chemotherapy, or hormone therapy following clinical guidelines or physician’s preference. Data were collected from the cancer registry system. Results: Median age at diagnosis was 75.7 years. Thirty-five percent of patients received adjuvant chemotherapy, these having a significantly younger age (mean=74.0±5.3 vs 77.5±5.3, p<0.001) and higher tumor staging (p=0.003) compared with their non-chemotherapy counterparts.Five-year overall survival was non-significantly higher in patients who received adjuvant chemotherapy (with chemotherapy 64.2% vs without chemotherapy 62.6%, p=0.635), while five-year recurrence free survival was non-significantly lower (with chemotherapy 64.1% vs without chemotherapy 90.5%, p=0.80). Conclusions: In this analysis, adjuvant chemotherapy tended to be given to patients with a younger age and higher tumor staging at our institute. It was not associated with any statistically significant improvement in survival and recurrence rate. Until age specific recommendations are available, physicians must use their clinical judgment and assess the tumor biology with the patient’s comorbidities to make the best choice. Clinical trials focusing on this critical issue are warranted.     

Breast Radiotherapy: Considerations in Older Patients

With an ageing population, the number of older women with breast cancer eligible for adjuvant irradiation after breast conserving surgery and mastectomy is rising. There is a dearth of level 1 data on the effect of adjuvant irradiation on local control, quality of life and survival. In large part this reflects the exclusion of patients over the age of 70 years from randomised trials. The prevention of local recurrence may reduce the risks of dissemination. However, older women with early breast cancer and a life expectancy of less than 5 years are unlikely to derive a survival benefit from adjuvant radiotherapy. Rates of access of older patients to adjuvant irradiation are lower than for younger patients. Physician and patient bias and co-morbidities are contributory factors. There are also competing risks of mortality from co-morbidities, particularly in women over the age of 80 years. Postoperative radiotherapy after breast conserving surgery does not seem to compromise overall quality of life of older patients. Although the absolute reduction in local recurrence from adjuvant radiotherapy is modest in lower risk older patients after breast conserving surgery and adjuvant systemic therapy, there has to date been no group of fitter old patients defined from whom radiotherapy can be reasonably omitted. Guidelines for postmastectomy radiotherapy should not differ from younger patients. Adequately powered randomised trials are needed to assess the effect of adjuvant irradiation in older patients on outcomes after breast conserving surgery and mastectomy to provide a more robust basis for evidence-based radiotherapy practice.     

Outcomes among African-Americans and Caucasians in colon cancer adjuvant therapy trials: findings from the National Surgical Adjuvant Breast and Bowel Project

BACKGROUND: African-Americans generally have lower survival rates from colon cancer than Caucasian Americans. This disparity has been attributed to many sources, including diagnosis at later disease stage and other unfavorable disease features, inadequate treatment, and socioeconomic factors. The randomized clinical trial setting ensures similarity in disease stage and a uniform treatment plan between blacks and whites. In this study, we evaluated survival and related end points for African-American and Caucasian patients with colon cancer participating in randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP) to determine whether outcomes were less favorable for African-Americans. METHODS: The study included African-American (n = 663) or Caucasian (n = 5969) patients from five serially conducted, randomized clinical trials of the NSABP. We compared recurrence-free survival, disease-free survival (recurrence, new primary cancer, or death), and survival (death from any cause) between blacks and whites by using statistical modeling to account for differences in patient and disease characteristics between the groups. Statistical tests were two-sided. RESULTS: Dukes' stage and number of positive lymph nodes were remarkably similar between African-American and Caucasian patients in each trial. Over all trials combined, an 8% (95% confidence interval [CI] = -6% to 25%; P =.27) excess risk of colon cancer recurrence that was not statistically significant was observed for blacks. A greater disparity in survival was seen, with blacks experiencing a statistically significant 21% (95% CI = 6%-37%; P =.004) greater risk of death. Treatment efficacy appeared similar between the groups. CONCLUSIONS: While the overall survival prognosis was less favorable for African-Americans compared with Caucasians in these trials, other outcomes measured were considerably more similar than those seen in the population at large, suggesting that earlier detection and adjuvant therapy could appreciably improve colon cancer prognosis for African-Americans. Continued investigations into causes of the deficits noted are warranted.     

Predictors of timing of adjuvant chemotherapy in older women with hormone receptor–negative,stages II–III breast cancer

Adherence to consensus guidelines for cancer care may vary widely across health care settings and contribute to differences in cancer outcomes. For some women with breast cancer, omission of adjuvant chemotherapy or delays in its initiation may contribute to differences in cancer recurrence and mortality. We studied adjuvant chemotherapy use among women with stage II or stage III, hormone receptor–negative breast cancer to understand health system and socio-demographic correlates of underuse and delayed adjuvant chemotherapy. We used Surveillance Epidemiology and End Results (SEER)-Medicare linked data to examine the patterns of care for 6,678 women aged 65 and older diagnosed with stage II or stage III hormone receptor–negative breast cancer in 1994–2002, with claims data through 2007. Age-stratified logistic regression was employed to examine the potential role of socio-demographic and structural/organizational health services characteristics in explaining differences in adjuvant chemotherapy initiation. Overall utilization of guideline-recommended adjuvant chemotherapy peaked at 43% in this population. Increasing age, higher co-morbidity burden, and low-income status were associated with lower odds of chemotherapy initiation within 4 months, whereas having positive lymph nodes, more advanced disease, and being married were associated with higher odds (P < 0.05). Health system–related structural/organizational characteristics and race/ethnicity offered little explanatory insight. Timely initiation of guideline-recommended adjuvant chemotherapy was low, with significant variation by age, income, and co-morbidity status. Based on these findings, future studies should seek to explore the more nuanced reasons why older women do not receive chemotherapy and why delays in care occur.     

Functional status is well maintained in older women during adjuvant chemotherapy for breast cancer.

BACKGROUND: While adjuvant chemotherapy is known to improve survival in older women with breast cancer, there is little information about its effects on physical function and health-related quality of life. PATIENTS AND METHODS: 'Young' (<65 years of age) and 'older' (> or = 65 years of age) postmenopausal women completed the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core Module (QLQ-C30) and BR23 questionnaires and other measures prior to, during and at the completion of anthracycline-based adjuvant chemotherapy, and then 6 and 12 months later. RESULTS: Physical, role and social function decreased during chemotherapy and emotional function improved (all P <0.01). The decline in physical function was more marked in young (age range 31-64 years; n = 45) than in older women (65-80 years; n = 20) (P <0.05), despite similar baseline values and drug dose intensities. Physical and role function had recovered at 6 months post-chemotherapy. Older patients had consistently better emotional function (P <0.01). CONCLUSIONS: Physical function and other functional domains are impaired in postmenopausal women during adjuvant chemotherapy for breast cancer, but recover subsequently. Physical function appeared to be better maintained in the older women, who tolerated adjuvant chemotherapy well overall. A knowledge of these effects is important for clinical decision-making and when defining social support needs during adjuvant chemotherapy.     

Prospects of neoadjuvant aromatase inhibitor therapy in breast cancer

Over 40% of breast cancer patients are older than 70 years of age. In the last three decades, several clinical trials have attempted to determine the most effective and well-tolerated systemic treatments, especially for elderly women. Tamoxifen had been the standard adjuvant endocrine treatment for postmenopausal women with hormone-sensitive breast cancer, but recent trials have shown advantages in using third-generation aromatase inhibitors. Patients with large, operable or locally advanced breast cancer are often treated initially with neoadjuvant therapy to reduce their tumor size and allow for breast-conserving surgery. Neoadjuvant chemotherapy has been widely studied, but little has been published on neoadjuvant endocrine therapy. This article reviews the use of neoadjuvant aromatase inhibitors in postmenopausal women with hormone-sensitive breast cancer.     

The Impact of Age and Adjuvant Chemotherapy Modifications on Survival Among Black Women With Breast Cancer

BackgroundBlack women receive less relative dose intensity with more dose reductions and early chemotherapy cessation compared with White women. Adding further risk, older patients with breast cancer are most at risk for treatment modifications; however, it is unclear if this remains true for Black patients. Furthermore, the clinical implications of treatment modifications and delays on survival is uncertain, particularly in Black patients.Patients and MethodsThe purpose was to investigate whether age was a moderator for the association between treatment modifications (dose held, dose delayed, and early cessation) and overall survival and disease-free survival (DFS) in Black women with breast cancer using a retrospective cohort study of patients with early stage breast cancer treated with adjuvant chemotherapy.ResultsAcross the entire sample (n = 115), 37.4% (n = 43) of patients experienced a treatment modification. There was a significant interaction between age group and held dose for DFS (P = .026). Specifically, those diagnosed at 55 years of age and older, who had doses of chemotherapy held, experienced worse DFS compared with those who did not (hazard ratio, 4.185; 95% confidence interval, 1.187-14.75). In contrast, there was no difference in DFS between those who did and did not have doses held in patients diagnosed below 55 years of age (hazard ratio, 0.626; 95% confidence interval, 0.177-2.218).ConclusionIn this study, Black women receiving adjuvant chemotherapy for treatment of early stage breast cancer had roughly equal treatment modifications across age groups. However, held doses of chemotherapy in older Black patients were associated with worse DFS. Age may impact clinical outcomes seen with adjuvant chemotherapy treatment modifications.     

Adjuvant medical treatment for breast cancer in elderly and old women

The probability of developing breast cancer increases with age. Therefore, more than 50?% of women with breast cancer are older than 65 years at the time of diagnosis. However, elderly patients are often undertreated and clinical trials for elderly patients in the adjuvant setting are lacking. Elderly patients who are otherwise fit should receive the standard treatment regimen independent of age.Endocrine therapy should not be withheld from patients by age alone. Thus, there are more adverse events in the elderly population.The decision on adjuvant chemotherapy should be made taking into consideration the patient’s comorbidities and frailty. A less toxic single-agent regimen may influence overall survival, but are associated with much less toxicity. Trastuzumab has a similar effect in elderly patients to that in younger patients. The risk of cardiotoxicity should be carefully considered in each patient.     

Chemotherapy: updates and new perspectives

Treatment options for patients with breast cancer have progressively improved over the past 40 years, from an era of no chemotherapy to the introduction of taxanes, hormonal therapy, and biologic therapy. These advances have resulted in substantial, 15%-20% improvements in clinical outcomes. However, progress has yet to be made to improve the prognosis in many breast cancer patients, and research is currently under way to test new tools, or new applications of older tools, to advance breast cancer management. Chemotherapy clearly remains a cornerstone of adjuvant breast cancer treatment, because breast cancer can be very sensitive to the currently available agents. Meanwhile, the era of a one-size-fits-all approach to breast cancer management is over, and the maximum potential of chemotherapy should now be reached by targeting specific populations. Effective biomarkers are therefore needed to optimize chemotherapy, define more selective populations, and clearly tailor treatment. This paper discusses recent data, including new trials that are more fully incorporating current knowledge with respect to molecular markers and the underlying biology of breast cancer.     

Risk of subsequent dementia diagnoses does not vary by types of adjuvant chemotherapy in older women with breast cancer

Objective Little is known about long-term cognitive side effects of adjuvant chemotherapy for breast cancer. We thus examined incidence of dementia diagnoses in older women diagnosed with breast cancer, stratified by types of chemotherapy regimen. Methods We identified patients with incident dementia diagnoses through Medicare claims linked to the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) tumor registry data. The study population (n = 6,932) consisted of women at least 68 years of age, who were diagnosed with early-stage breast cancer from 1994 through 2002 in one of the SEER areas and received chemotherapy as part of their cancer treatment. Excluded were women with a diagnosis of dementia within the 3 years prior to their cancer diagnosis. Results Our sample comprised mostly white women. The mean age was 74. Fifty-seven percent were estrogen receptor positive. Over 70% had no comorbidity. The use of taxol and anthracycline-based treatments increased from mid-1990s to early 2000. Increasing age at cancer diagnosis, Black ethnicity, living in a census tract with lower level of education, and increasing number of comorbidities were associated with new claims of dementia diagnoses after chemotherapy. There was no significant association between types of chemotherapy agents and risk of subsequent dementia diagnoses. Conclusion No association was found between types of adjuvant chemotherapy agents for breast cancer and risk of new dementia diagnoses. Our findings suggest that concerns about post-chemotherapy dementia should not be a major factor in determining type of adjuvant chemotherapy regimen to prescribe for older women with breast cancer.