Early stage breast cancer treatment and outcome of older patients treated in an oncogeriatric care and a standard care setting: an international comparison

Omission of multimodal therapy in older adults with high-risk breast cancer

PURPOSE

Treatment guidelines recommend multimodal therapy for non-metastatic high-risk breast cancer in older adults. However, older patients may be less likely to receive this due to varying abilities to withstand intensive therapy. We aimed to quantify the incidence of, factors associated with, and reasons behind omission of multimodal therapy in older high-risk breast cancer patients.

METHODS

Women ≥ 70 years diagnosed with stage 2-3 HR-/HER2+ or triple-negative breast cancer were identified in the National Cancer Database, 2010-2020. Multimodal therapy was defined as surgery and systemic therapy; omission of multimodal therapy was defined as patients who did not receive one or both therapies. Chi-square tests were used to assess differences by therapy intensity. Multivariable logistic regression models adjusting for patient and disease-level characteristics were performed to determine the factors associated with therapy omission.

RESULTS

Of 22,644 patients, 63.4% were ≤ 80 years old. Overall, 59.7% received multimodal therapy, 35.3% received either surgery or systemic therapy, and 5.0% received no therapy. Factors significantly associated with increased likelihood of multimodal therapy omission included increased age, Black race, Medicaid or uninsured status, and higher Charlson Comorbidity Index scores. The most common reason for omission was that it was "not part of planned treatment," (59.2% for omission of surgery, 52.4% for omission of systemic therapy), with patient refusal (17.4% for omission of surgery, 28.3% for omission of systemic therapy) being second most common.

CONCLUSIONS

While most older patients received multimodal therapy, demographic and socioeconomic factors associated with treatment omission suggest that some vulnerable women with high-risk disease may be undertreated.

Adjuvant chemotherapy in elderly patients with HER2-negative early breast cancer: A systematic review and meta-analysis

Evidence from randomized trials regarding adjuvant chemotherapy and its impact on survival in older patients with resected breast cancer is limited. This study evaluates the current evidence on the use of adjuvant chemotherapy and its effects on overall mortality and breast cancer-specific mortality in older patients. A systematic review and meta-analysis were conducted on the impact of adjuvant chemotherapy in elderly patients with HER2-negative breast cancer. Searches in PubMed, Embase, and The Cochrane Library up to May 2024 included terms such as "breast cancer," "adjuvant," "chemotherapy," "elderly," and "HER2-negative." Eligible studies involved women aged 65 years or older with HER2-negative breast cancer, comparing those receiving adjuvant chemotherapy versus those who did not. Excluded were studies on neoadjuvant therapy, HER2-positive disease, or non-English publications. The primary outcome was overall mortality. Among 2345 articles, 35 studies met the inclusion criteria, comprising 376,900 patients. Adjuvant chemotherapy significantly reduced overall mortality (hazard ratio [HR] = 0.73; 95% CI: 0.68-0.78) and breast cancer-specific mortality (HR = 0.81; 95% CI: 0.73-0.9), with the most pronounced benefit in triple-negative breast cancer (HR = 0.63; 95% CI: 0.60-0.67). Adjuvant chemotherapy reduces overall mortality and breast cancer-specific mortality in older patients, particularly those with triple-negative breast cancer. However, the evidence is predominantly based on retrospective or observational studies, highlighting inherent limitations. Comprehensive geriatric evaluations are crucial for patient selection, and dedicated clinical trials focused on older populations are urgently needed.

Process indicators outshine outcome measures: assessing hospital quality of care in breast cancer treatment in China

Reporting the results of quality indicators can narrow the gap in the quality of care between hospitals. While most studies rely on outcome indicators, they may not accurately measure the quality of care. Process indicators are not only strongly associated with treatment outcomes, but are also more sensitive to whether patients are treated accurately, enabling timely intervention. Our study aims to investigate whether process indicators provide a more reasonable assessment of hospital quality of care compared to outcome indicators. Data were sourced from the Specific Disease Medical Service Quality Management and Control System in China. A total of 113,942 patients with breast cancer treated in 298 hospitals between January 2019 and April 2023 were included in this retrospective study. The rankability of 11 process indicators was calculated and used as a weight to create a new composite indicator. The composite indicators and outcome measures were compared using the O/E ratio categories. Finally, in order to determine the impact of different years on the results, a sensitivity analysis was conducted using bootstrap sampling. The rankability ( ρ ) values of the eleven process indicators showed significant differences, with the highest ρ value for preoperative cytological or histological examination before surgery (0.919). The ρ value for the outcome indicator was 0.011. The rankability-weighting method yielded a comprehensive score ( ρ  = 0.883). The comparison with categorical results of the outcome indicator has different performance classifications for 113 hospitals (37.92%) for composite scores and 140 (46.98%) for preoperative cytological or histological examinationbefore surgery. Process indicators are more suitable than outcome indicators for assessing the quality of breast cancer care in hospitals. Healthcare providers can use process indicators to identify specific areas for improvement, thereby driving continuous quality improvement efforts.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Research into ageing and frailty

Research into ageing covers opportunities and challenges posed by an older population, and research to understand the ageing processes across the lifespan. The evidence base for Comprehensive Geriatric Assessment (CGA) is well established and efforts should now shift to understanding how to implement its principles across different healthcare contexts. Research around syndromes common in older people has progressed with variable success; while effective therapies for falls and cognitive impairment have been identified, older people with advanced frailty have commonly been excluded from Parkinson's disease and continence research. Research to understand the mechanisms of ageing has potential to mitigate against or treat emerging sarcopenia and cognitive impairment, and thus modify frailty trajectories. Pharmacogenetics could individualise therapeutics to reduce polypharmacy. These issues can only be addressed with development of infrastructure, capacity and expertise in ageing research. Commonly used research methodologies must be adapted to take account of frailty, cognitive impairment and functional dependency.