Targeted therapy in older women with breast cancer – What's the target?

Narrative Review of Multidisciplinary Management of Central Nervous Involvement in Patients with HER2-Positive Metastatic Breast Cancer: Focus on Elderly Patients

The tumor biology of human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC) promotes the development of central nervous system (CNS) metastases, with 25% of patients with HER2-positive BC developing CNS metastases. Furthermore, the incidence of HER2-positive BC brain metastases has increased in the last decades, likely because of the improved survival with targeted therapies and better detection methods. Brain metastases are detrimental to quality of life and survival and represent a challenging clinical problem, particularly in elderly women, who comprise a substantial proportion of patients diagnosed with BC and often have comorbidities or an age-related decline in organ function. Treatment options for patients with BC brain metastases include surgical resection, whole-brain radiation therapy, stereotactic radiosurgery, chemotherapy, and targeted agents. Ideally, local and systemic treatment decisions should be made by a multidisciplinary team, with input from several specialties, based on an individualized prognostic classification. In elderly patients with BC, additional age-associated conditions, such as geriatric syndromes or comorbidities, and the physiologic changes associated with aging, may impact their ability to tolerate cancer therapy and should be considered in the treatment decision-making process. This review describes the treatment options for elderly patients with HER2-positive BC and brain metastases, focusing on the importance of multidisciplinary management, the different points of view from the distinct disciplines, and the role of oncogeriatric and palliative care in this vulnerable patient group.

The Prognostic Value of the Age-Adjusted Charlson Comorbidity Index Among the Elderly with Breast Cancer

Purpose

This study aimed to assess the effect of comorbidities on prognosis using the Age-adjusted Charlson Comorbidity Index (ACCI) among the elderly with breast cancer (BC).

Methods

This study included 745 patients divided into two groups following the ACCI score (≤3 vs >3). Multivariate logistic regression analysis was conducted for all kinds of outcomes, including BC-specific death (BCSD) and non-breast cancer-specific death (NBCSD). The Kaplan-Meier curves were plotted, and survival analysis was conducted for disease-free survival (DFS), overall survival (OS), BC-specific survival (BCSS), and non-BCSS (NBCSS).

Results

A significantly higher NBCSD was found in the high-score (ACCI > 3) group than in the low-score (ACCI < 3) group (p = 0.032). The multivariate logistic regression analysis revealed ACCI score as an independent affecting factor for all-cause death (hazard ratio [HR] = 0.42, 95% confidence interval [CI]: 0.22-0.83, p = 0.012) and NBCSD (HR = 0.41, 95% CI: 0.20-0.87, p = 0.020). The Kaplan-Meier curves revealed statistical differences only in NBCSS between the two groups (p = 0.039). Subgroup analysis revealed a worse prognosis in the high-score group for OS and NBCSS among hormone receptor-positive participants and those who without undergoing axillary dissection or receiving chemotherapy (all p < 0.05). Multivariate Cox regression analysis revealed ACCI as an independent prognostic predictor for OS (HR = 2.18, 95% CI: 1.22-3.92, p = 0.009) and NBCSS (HR = 2.04, 95% CI: 1.02-4.08, p = 0.044).

Conclusion

ACCI was indeed an effective indicator of the effects of comorbidities on survival among elderly patients with BC. However, the co-effect from age and comorbidities was not significant enough on cancer-specific prognosis, although it exerted a significant effect on treatments received.

Adjuvant Treatment of Elderly Breast Cancer Patients: Offer the Best Chances of Cure

Background

Breast cancer remains the most common cancer in women and a leading cause of death. Elderly people have a higher incidence of breast cancer since it increases with age. Furthermore, the extended life expectancy and advances in imaging techniques have led to an increased number of cases. Guidelines concerning the management of this specific age group are rare, mainly due to underrepresentation of seniors in clinical trials. Moreover, increased frailty, comorbidities, and a poor performance status make it complex to determine the best therapeutic approach.

Summary

In this review, we attempt to summarize the current literature and aim to provide specific approaches and recommendations for prompt diagnosis, treatment, and management of breast cancer in the elderly.

Key Messages

The establishment of applicable protocols is imperative and efforts are being made in this direction. A careful geriatric assessment and adequate consultation should be the standard of care and patient's preferences should always be considered.

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.

Breast cancer in octogenarian. Are we doing our best? A population-registry based study

BACKGROUND

The number of old people with breast cancer is estimated to increase during the next years in developed countries. However, management of breast cancer in octogenarians is not well established. The main objective was to evaluate if patients older than 80 years with breast cancer are receiving the most convenient treatment by using a population registry cancer analysis.

PATIENTS AND METHODS

A retrospective analysis of a population cancer registry was designed. Data were retrieved from the Castellon Cancer Registry (Valencian Community, Spain). Patient records were analyzed from January 1, 1995 to December 31, 2013. Two groups were defined: group A, <80 years; and group B, >= 80 years. Survival analyses were sequentially performed into three phases. First, a non-adjusted Kaplan Meier analysis was conducted. For the second survival analyses, Cox's proportional hazards model of Overall survival was used adjusting for condensed-TNM stage and adjuvant treatments. Finally, the third specific adjustment was carried out adding information of life expectancy by age for Spanish women, corresponding to year 2008 with condensed-TNM stage and Propensity Score variable, as an approximation to relative or disease-specific survival.

RESULTS

The total number of included patients was 1304. Women ≥80 years presented a more extended disease, larger tumors and less in situ carcinomas. A lower proportion of women ≥80 years received adjuvant therapies. In the absence of any adjustment of results, the overall survival in women ≥80 years was poorer than in younger patients (median of 14.1 years for <80y vs. 5.7 years for ≥80y), the crude HR was 4.6 (95% CI: 2.9-7.5) p < 0.001. For second survival analysis, the HR was 2.5 (95% CI: 1.8-3.5) p < 0.001. After the third adjustment the HR was 1.7 (95% CI: 1.2-2.4) p = 0.004.

CONCLUSIONS

Octogenarians with operable breast cancer are receiving suboptimal treatments, which can have repercussions on survival. New studies are required to identify a subgroup of women age ≥80 years who may benefit from more aggressive treatment and a population of older women on the basis of tumor characteristics, comorbidities and life expectancy who may not need as aggressive treatment.