Targeted Agents for HER2-Positive Breast Cancer: Optimal Use in Older Patients

Systemic Therapy in Elderly Patients With Her2/Neu-Positive Breast Cancer: A SEER Database Study

BACKGROUND

The use of systemic therapy in elderly patients with Her2/neu-positive breast cancers has been questioned given the potential for cardiac side effects with several of the agents frequently used. This study aimed to evaluate trends in use of systemic therapy in patients 70 years and older.

METHODS

The 2010-2016 SEER database was used to collect data on female patients with non-metastatic Her2/neu-positive breast cancer. Data was stratified to compare systemic therapy use in patients <70 vs ≥70.

RESULTS

A total of 62,014 patients were included in the study. Of those, 79.0% (38,760) of patients <70 years old received systemic therapy while only 45.2% (5844) of patients ≥70 received systemic therapy (P < .001). Of patients ≥70 with ER positive tumors, 42.1% received systemic therapy and those with ER negative tumors, 52.1% received systemic therapy. The mortality rate in patients ≥70 was 8.5% in those who received systemic therapy and 12.1% in those who did not (P < .001).

CONCLUSIONS

There remains a significant difference in rates of systemic therapy administration in the elderly population with an associated increase in mortality due to their cancer. Continuing educational efforts could be of benefit.

Neurospora crassa is a potential source of anti-cancer agents against breast cancer

Fungi are an excellent source of pharmaceuticals including anti-tumor agents. Neurospora crassa generates metabolites with diverse structural classes, however, its potential as an anti-tumor agent source has not been explored. The purpose of this study aimed to investigate the potential of Neurospora crassa mixture against breast cancer. The in vitro T-47D and MDA-MB-231 experiments showed that N. crassa mixture at the concentrations of both 1.7 and 0.85 µg/ml significantly inhibited tumor cell proliferation, migration and invasion, and 3D spheroid formation. However, the inhibition rates of MCF-10A ranged 10-20% at concentrations of 0.85 and 1.7 µg/ml. The mixture at the concentration of 0.85 µg/ml could significantly downregulate the expressions of transcription factors of E2F1 and E2F3, cancer stem cell-related genes of LIN28, HIWI, and CD133, and onco-lncRNA HOTAIR, and increase CASP3 activity in either T-47D or MDA-MD-231 breast cancer cell lines. In vivo breast cancer C3H mouse model results showed that N. crassa mixture significantly inhibited tumor growth. These findings suggest that N. crassa contains an antitumor component(s) against breast cancer invasiveness, which may inhibit the self-renewal and differentiation of breast cancer stem cells possibly by downregulating cancer stem cell-associated and/or transcription factor genes and oncogenes, and promoting apoptosis.

Age-related disparities in older women with breast cancer

Improvements in breast cancer (BC) mortality rates have not been seen in the older adult community, and the fact that older adults are more likely to die from their cancer than younger women establishes a major health disparity. Studies have identified that despite typically presenting with more favorable histology, older women present with more advanced disease, which may be related in part to delayed diagnosis. This is supported by examination of screening practices in older adults. Older women have a worse prognosis than younger women in both early stage disease, and more advanced and metastatic disease. Focus on the treatment of older adults has often concentrated on avoiding overtreatment, but in fact undertreatment may be one reason for the age-related differences in outcomes, and treatments need to be individualized for every older adult, and take into account patient preferences and functional status and not chronologic age alone. Given the aging population in the US, identifying methods to improve early diagnosis in this population and identify additional factors will be important to reducing this age-related disparity.

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.

Clinical pharmacology of oncology agents in older adults: A comprehensive review of how chronologic and functional age can influence treatment-related effects

Unique challenges exist when managing older adults with cancer. Associations between cancer and age-related physiologic changes have a direct impact on pharmacokinetics and pharmacodynamics of cancer therapies and can affect drug dosing, dose intensity, efficacy, safety and quality of life. The breadth and depth of these issues, however, have not been fully evaluated because the majority of clinical trials have focused on a younger and healthier population. As a consequence, little information is available to support clinicians in making evidence-based decisions regarding treatment with cancer therapies in older adults, especially those over age 75. Prior clinical pharmacology reviews summarized the literature on how age-related physiologic changes can influence and affect conventional and targeted anti-cancer treatments. Our article provides an updated review with expanded information that includes small molecule kinase inhibitors, monoclonal antibodies, immunotherapies, hormonal, conventional, and miscellaneous agents. Additionally, our article integrates how functional age, determined by the geriatric assessment (GA), can also influence treatment-related effects and health outcomes. Broadening cancer therapy trials to capture not only chronologic age but also functional age would allow clinicians to better identify subsets of older adults who benefit from treatment versus those most vulnerable to morbidity and/or mortality.