Management of breast cancer in older and frail patients

Evolution of breast cancer incidence in young women in a French registry from 1990 to 2018: Towards a change in screening strategy?

BACKGROUND

The worldwide incidence of invasive breast cancer in women is increasing according to several studies. This increase in incidence seems to be higher in young women (< 40 years). However, the reasons for this trend are poorly understood. This article aims to provide the most recent estimates of this trend and assess whether there is indeed an increase in the incidence of breast cancer among young women to strengthen prevention campaigns.

METHODS

We collected data from the Isere cancer registry in France of all invasive breast cancers from January 1990 to December 2018. The standardized incidence rate was calculated for four age groups (< 40 years, 40-49 years, 50-74 years, ≥ 75 years) for this period. The 10-year relative survival was evaluated for each age group age for two periods (1990-1999 and 2000-2008). From 2011 to 2013, we analyzed the incidence and 5-year relative survival by tumor subtype (triple negative, luminal, HER2 amplified) for each age group.

RESULTS

A total of 23,703 cases were selected, including 1343 young women (< 40 years). The incidence of invasive breast cancer increased annually by 0,8% (95% CI 0,7; 1) in all age groups combined from 1990 to 2018. The highest incidence increase is found among young women, by 2,1% annually (95% CI 1,3; 2,8). Regarding tumor subtypes from 2011 to 2018, the incidence of triple negatives increases higher in young women (+ 1,4% by year, 95% CI - 8,2; 11) and those over 75 years (+ 4% by year, 95% CI - 5,1; 13,2), but the results are not statistically significant. 10-year relative survival in young women increased from 74,6% (95% CI 69,6; 78,9) to 78,3%(95% CI 73,7; 82,1) between 1990-1999 and 2000-2008, respectively. Five-year relative survival is better in young women among triple negative and HER2 amplified.

CONCLUSION

Our study confirms the current trend of increasing the incidence of breast cancer in young women, associated with improved survival very likely attributable to earlier diagnosis due to increased awareness, and improvements in treatment. A better individualized risk-based screening strategy is needed for these patients. Additional studies will be needed to more accurately assess the risk of developing breast cancer and improve diagnostic performance.

Prognostic role of radiotherapy in low-risk elderly breast cancer patients after breast-conserving surgery: a cohort study

BACKGROUND

Previous research suggested that radiotherapy (RT) had a small absolute benefit in patients with low-risk breast cancer over the age of 65. To reduce the patient's treatment burden and cost, as well as the damage to normal tissue, this study sought to explore the prognostic role of RT after breast-conserving surgery (BCS) in elderly patients.

METHODS

Patients who were aged ≥65 years, stage T1N0M0, and estrogen receptor/progesterone receptor positive (ER+/PR+) were included in this study. Age, marital status, histology, race, grade, human epidermal growth factor receptor 2 (HER2), subtype, treatment method, and survival were also collected from the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2015. We compared overall survival (OS) and breast cancer-specific survival (BCSS) before and after propensity score matching (PSM) in the patients who underwent BCS with or without RT. Kaplan-Meier method and Cox proportional hazards regression analyses were used in our study.

RESULTS

The data of 3,623 patients were analyzed in this study. Among them, 2,851 (78.69%) patients had received RT. The multivariate analyses before PSM showed that RT resulted in better OS [hazard ratio (HR) 0.51, 95% confidence interval (CI): 0.42-0.62, P<0.001], and BCSS (HR 0.40, 95% CI: 0.27-0.58, P<0.001). The multivariate analyses after PSM (n=1,538) confirmed that patients who received RT (n=769) had a longer survival time than those who did not (n=769) (OS: HR 0.73, 95% CI: 0.57-0.95, P=0.018; and BCSS: HR 0.57, 95% CI: 0.35-0.93, P=0.025). The survival analysis showed that patients receiving RT had a better OS (P=0.028) and BCSS (P=0.016) than those who did not receive RT. However, there were no significant differences in patients' OS and BCSS with or without RT across the different age subgroups (P>0.05).

CONCLUSIONS

In our study, patients who received RT had a longer survival time. However, the age subgroup analysis showed that RT did not have any survival benefit in elderly patients with T1N0M0 and ER+/PR+ breast cancer. Furthermore, at the age of 65-69 years, the P value for OS approached 0.05, which suggests that the decision to administer RT in this patient group should be made based on each patient's condition.

Trends in incidence, mortality and survival in women with breast cancer from 1985 to 2012 in Granada, Spain: a population-based study

BACKGROUND

The incidence of breast cancer has increased since the 1970s. Despite favorable trends in prognosis, the role of changes in clinical practice and the introduction of screening remain controversial. We examined breast cancer trends to shed light on their determinants.

METHODS

Data were obtained for 8502 new cases of breast cancer in women between 1985 and 2012 from a population-based cancer registry in Granada (southern Spain), and for 2470 breast cancer deaths registered by the Andalusian Institute of Statistics. Joinpoint regression analyses of incidence and mortality rates were obtained. Observed and net survival rates were calculated for 1, 3 and 5 years. The results are reported here for overall survival and survival stratified by age group and tumor stage.

RESULTS

Overall, age-adjusted (European Standard Population) incidence rates increased from 48.0 cases × 100,000 women in 1985-1989 to 83.4 in 2008-2012, with an annual percentage change (APC) of 2.5% (95%CI, 2.1-2.9) for 1985-2012. The greatest increase was in women younger than 40 years (APC 3.5, 95%CI, 2.4-4.8). For 2000-2012 the incidence trend increased only for stage I tumors (APC 3.8, 95%CI, 1.9-5.8). Overall age-adjusted breast cancer mortality decreased (APC - 1, 95%CI, - 1.4 - - 0.5), as did mortality in the 50-69 year age group (APC - 1.3, 95%CI, - 2.2 - - 0.4). Age-standardized net survival increased from 67.5% at 5 years in 1985-1989 to 83.7% in 2010-2012. All age groups younger than 70 years showed a similar evolution. Five-year net survival rates were 96.6% for patients with tumors diagnosed in stage I, 88.2% for stage II, 62.5% for stage III and 23.3% for stage IV.

CONCLUSIONS

Breast cancer incidence is increasing - a reflection of the evolution of risk factors and increasing diagnostic pressure. After screening was introduced, the incidence of stage I tumors increased, with no decrease in the incidence of more advanced stages. Reductions were seen for overall mortality and mortality in the 50-69 year age group, but no changes were found after screening implementation. Survival trends have evolved favorably except for the 70-84 year age group and for metastatic tumors.

The characteristics, management and outcomes of older women with breast cancer in New Zealand

The aim of this study was to understand the characteristics of older women with breast cancer and to describe the current patterns of treatment and outcomes. The study included data from the combined Auckland and Waikato breast cancer registers, which hold information for 12, 372 women diagnosed with stage I-IV breast cancer between June 2000 and May 2013. Of these women, 2671 (21.6%) were over 70 years of age. Patient characteristics, treatment type and survival were compared across four-year age groups (70-74, 75-79, 80-84, 85+) and hormone receptor status. Of the women aged over 70 years, 2485 (93.0%) had stage I-III disease. Increasing age was significantly associated with decreasing use of surgery, adjuvant radiotherapy, endocrine therapy and chemotherapy, even after adjustment for stage and level of co-morbidity. Nine hundred and one women (33.7%) had co-morbidities at the time of diagnosis. The 5-year breast cancer-specific survival rate for women aged 70-74 and that for women aged 75-79 were similar, but was worse in women aged over 80. Generally, older women are treated as per guidelines, although chemotherapy may be under-used. However, age is a significant factor influencing whether women are treated or not.

Short-term, postoperative breast cancer outcomes in patients with advanced age

BACKGROUND

This study compares early postoperative breast cancer outcomes between patients 80 years and older (older patients) and those younger than 80 years (<80 years).

METHODS

The National Surgical Quality Improvement Program database was used to identify patients who had breast surgery between 2005 and 2013 for malignancy.

RESULTS

Older patients had a significantly higher percentage of comorbidities and partial mastectomies. Postoperatively, they had higher rates of pneumonia, urinary tract infection, cardiac arrest, and mortality but had lower rates of wound dehiscence, deep wound, and organ space infections. Thirty-day mortality is independently associated with hypertension, coronary artery disease, American Society of Anesthesiology class IV, and older age.

CONCLUSIONS

The overall perioperative morbidity and mortality after breast surgery, regardless of age, is low. Older patients had a significantly higher rate of mortality and systemic complications but a lower rate of wound complications, likely because of less invasive surgical procedures.

Trends in the Application of Postmastectomy Radiotherapy for Breast Cancer With 1 to 3 Positive Axillary Nodes and Tumors ≤5 cm in the Modern Treatment Era: A Retrospective Korean Breast Cancer Society Report

Despite high-level evidence, the benefit of postmastectomy RT in these patients in recent years has not been fully elucidated. We investigated postmastectomy radiotherapy (RT) use and evaluated clinicopathologic and treatment factors influencing RT use in Korean women with pT1-2N1 breast cancer.We identified women diagnosed with pT1-2N1 breast cancer between 1994 and 2009 using the Korean Breast Cancer Registry. Factors associated with RT use were evaluated using logistic regression analysis. The median follow-up was 95 months.Of the 6196 women, 11.9% underwent postmastectomy RT. RT was applied more frequently in women with 3 positive lymph nodes (adjusted odds ratio [OR], 2.69) and larger tumors (OR per centimeter, 1.10). RT use was not significantly associated with well-established risk factors (e.g., tumor grade, hormone receptor status, and lymphovascular space invasion). Although RT utilization increased gradually during the study period (OR per year, 1.07), factors associated with RT were similar over time. The estimated 5-year overall survival increased significantly from 84.1% in 1994 to 2000 to 94.6% in 2005 to 2009.This population-based analysis revealed that the indications for postmastectomy RT in pT1-2N1 breast cancer in Korea are based solely on conventional anatomical factors, although their survival has increased significantly in the modern treatment era. There is a significant unmet need for better risk stratification in these patients and for tailored RT with the incorporation of tumor biology-associated factors.

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.