A randomised trial of primary tamoxifen versus mastectomy plus adjuvant tamoxifen in fit elderly women with invasive breast carcinoma of high oestrogen receptor content: long-term results at 20 years of follow-up

A nomogram for individually predicting overall survival for elderly patients with early breast cancer: a consecutive cohort study

Background

Elderly patients with breast cancer are highly heterogeneous, and tumor load and comorbidities affect patient prognosis. Prediction models can help clinicians to implement tailored treatment plans for elderly patients with breast cancer. This study aimed to establish a prediction model for breast cancer, including comorbidities and tumor characteristics, in elderly patients with breast cancer.

Methods

All patients were ≥65 years old and admitted to the Peking Union Medical College Hospital. The clinical and pathological characteristics, recurrence, and death were observed. Overall survival (OS) was analyzed using the Kaplan-Meier curve and a prediction model was constructed using Cox proportional hazards model regression. The discriminative ability and calibration of the nomograms for predicting OS were tested using concordance (C)-statistics and calibration plots. Clinical utility was demonstrated using decision curve analysis (DCA).

Results

Based on 2,231 patients, the 5- and 10-year OS was 91.3% and 78.4%, respectively. We constructed an OS prediction nomogram for elderly patients with early breast cancer (PEEBC). The C-index for OS in PEEBC in the training and validation cohorts was 0.798 and 0.793, respectively. Calibration of the nomogram revealed a good predictive capability, as indicated by the calibration plot. DCA demonstrated that our model is clinically useful.

Conclusion

The nomogram accurately predicted the 3-year, 5-year, and 10-year OS in elderly patients with early breast cancer.

Revisiting primary endocrine therapy versus surgery in older women with breast cancer: meta-analysis

BACKGROUND

Old age is associated with increased co-morbidities, resulting in reduced life expectancy. Primary endocrine therapy is an alternative to primary surgical therapy for patients with breast cancer and increased co-morbidities. The aim was to review outcomes of primary endocrine therapy versus primary surgical therapy in older women with breast cancer.

METHODS

PubMed, Embase (Ovid), Scopus, and the Cochrane Library were searched systematically from January 2000 to May 2022. Single-arm studies were excluded. Primary outcomes were overall survival and breast cancer-specific survival. Secondary outcomes were local and regional failure of primary endocrine therapy, recurrence after primary surgical therapy, and health-related quality of life.

RESULTS

There were 14 studies including 14 254 patients (primary endocrine therapy 2829, 19.8 per cent; primary surgical therapy 11 425, 80.2 per cent), with the addition of four major studies (9538 patients) compared with the latest review in 2014. Seven studies defined primary surgical therapy as surgery plus adjuvant endocrine therapy, and six studies included patients with oestrogen receptor-positive tumours only. Patients in the primary endocrine therapy group were older than the primary surgical therapy group (mean difference 2.43 (95 per cent c.i. 0.73 to 4.13) years). Primary endocrine therapy led to worse overall survival than primary surgical therapy (HR 1.42, 95 per cent c.i. 1.06 to 1.91). Subgroup analysis of RCTs and prospective studies, however, showed comparable overall survival. Breast cancer-specific survival was also comparable (HR 1.28, 95 per cent c.i. 0.87 to 1.87). At 6 weeks, operated patients had significant arm symptoms and illness burden following major breast surgery compared with patients receiving primary endocrine therapy. Health-related quality of life, measured by the European Organization for Research and Treatment of Cancer QLQ-C30 and EuroQol EQ-5D-5L™, was comparable in the two treatment groups.

CONCLUSION

Overall survival was worse among older women receiving primary endocrine therapy in an analysis including all studies, but comparable in RCTs and prospective studies. This may be due to confounding by age and co-morbidities in retrospective cohort studies of primary endocrine therapy.

Breast-conserving surgery without axillary surgery and radiation versus mastectomy plus axillary dissection in elderly breast cancer patients: A retrospective study

Background

The high relative mortality rate in elderly breast cancer patients is most likely the result of comorbidities rather than the tumor load. Foregoing axillary lymph node dissection or omitting radiotherapy after breast-conserving surgery (BCS) does not affect the prognosis of elderly breast cancer patients. We sought to assess the safety of breast-conserving surgery without axillary lymph node dissection as well as breast and axillary radiotherapy (BCSNR) in elderly patients with early-stage breast cancer.

Methods

We retrospectively included 541 consecutive breast cancer patients aged over 70 years with clinically negative axillary lymph nodes in one clinical center. Of these patients, 181 underwent mastectomy plus axillary lymph node dissection (MALND) with negative axillary cleaning and 360 underwent BCSNR.

Results

After a median follow-up of 5 years, there was no significant difference between the BCSNR and MALND groups in either distant recurrence-free survival (DRFS) (p=0.990) or breast cancer-specific survival (p=0.076). Ipsilateral axillary disease was found in 11 (3.1%) patients in the BCSNR group and 3 (1.7%) patients in the MALND group; this difference was not significant (p=0.334). We did not observe a significant difference in distant recurrence between the groups (p=0.574), with 25 (6.9%) patients in the BCSNR group experiencing distant recurrence compared to 15 (8.3%) patients in the MALND group. Our findings did show a significant difference in ipsilateral breast cancer recurrence (IBTR), with 31 (8.6%) patients in the BCSNR group experiencing IBTR compared to only 2 (1.1%) patients in the MALND group (p=0.003).

Conclusion

BCSNR is a safe treatment option for elderly breast cancer patients with clinically negative axillary lymph nodes.

Improving outcomes for women aged 70 years or above with early breast cancer: research programme including a cluster RCT

Background

In breast cancer management, age-related practice variation is widespread, with older women having lower rates of surgery and chemotherapy than younger women, based on the premise of reduced treatment tolerance and benefit. This may contribute to inferior outcomes. There are currently no age- and fitness-stratified guidelines on which to base treatment recommendations.

Aim

We aimed to optimise treatment choice and outcomes for older women (aged ≥ 70 years) with operable breast cancer.

Objectives

Our objectives were to (1) determine the age, comorbidity, frailty, disease stage and biology thresholds for endocrine therapy alone versus surgery plus adjuvant endocrine therapy, or adjuvant chemotherapy versus no chemotherapy, for older women with breast cancer; (2) optimise survival outcomes for older women by improving the quality of treatment decision-making; (3) develop and evaluate a decision support intervention to enhance shared decision-making; and (4) determine the degree and causes of treatment variation between UK breast units.

Design

A prospective cohort study was used to determine age and fitness thresholds for treatment allocation. Mixed-methods research was used to determine the information needs of older women to develop a decision support intervention. A cluster-randomised trial was used to evaluate the impact of this decision support intervention on treatment choices and outcomes. Health economic analysis was used to evaluate the cost–benefit ratio of different treatment strategies according to age and fitness criteria. A mixed-methods study was used to determine the degree and causes of variation in treatment allocation.

Main outcome measures

The main outcome measures were enhanced age- and fitness-specific decision support leading to improved quality-of-life outcomes in older women (aged ≥ 70 years) with early breast cancer.

Results

(1) Cohort study: the study recruited 3416 UK women aged ≥ 70 years (median age 77 years). Follow-up was 52 months. (a) The surgery plus adjuvant endocrine therapy versus endocrine therapy alone comparison: 2854 out of 3416 (88%) women had oestrogen-receptor-positive breast cancer, 2354 of whom received surgery plus adjuvant endocrine therapy and 500 received endocrine therapy alone. Patients treated with endocrine therapy alone were older and frailer than patients treated with surgery plus adjuvant endocrine therapy. Unmatched overall survival and breast-cancer-specific survival were higher in the surgery plus adjuvant endocrine therapy group (overall survival: hazard ratio 0.27, 95% confidence interval 0.23 to 0.33; p < 0.001; breast-cancer-specific survival: hazard ratio 0.41, 95% confidence interval 0.29 to 0.58; p < 0.001) than in the endocrine therapy alone group. In matched analysis, surgery plus adjuvant endocrine therapy was still associated with better overall survival (hazard ratio 0.72, 95% confidence interval 0.53 to 0.98; p = 0.04) than endocrine therapy alone, but not with better breast-cancer-specific survival (hazard ratio 0.74, 95% confidence interval 0.40 to 1.37; p = 0.34) or progression-free-survival (hazard ratio 1.11, 95% confidence interval 0.55 to 2.26; p = 0.78). (b) The adjuvant chemotherapy versus no chemotherapy comparison: 2811 out of 3416 (82%) women received surgery plus adjuvant endocrine therapy, of whom 1520 (54%) had high-recurrence-risk breast cancer [grade 3, node positive, oestrogen receptor negative or human epidermal growth factor receptor-2 positive, or a high Oncotype DX® (Genomic Health, Inc., Redwood City, CA, USA) score of > 25]. In this high-risk population, there were no differences according to adjuvant chemotherapy use in overall survival or breast-cancer-specific survival after propensity matching. Adjuvant chemotherapy was associated with a lower risk of metastatic recurrence than no chemotherapy in the unmatched (adjusted hazard ratio 0.36, 95% confidence interval 0.19 to 0.68; p = 0.002) and propensity-matched patients (adjusted hazard ratio 0.43, 95% confidence interval 0.20 to 0.92; p = 0.03). Adjuvant chemotherapy improved the overall survival and breast-cancer-specific survival of patients with oestrogen-receptor-negative disease. (2) Mixed-methods research to develop a decision support intervention: an iterative process was used to develop two decision support interventions (each comprising a brief decision aid, a booklet and an online tool) specifically for older women facing treatment choices (endocrine therapy alone or surgery plus adjuvant endocrine therapy, and adjuvant chemotherapy or no chemotherapy) using several evidence sources (expert opinion, literature and patient interviews). The online tool was based on models developed using registry data from 23,842 patients and validated on an external data set of 14,526 patients. Mortality rates at 2 and 5 years differed by < 1% between predicted and observed values. (3) Cluster-randomised clinical trial of decision support tools: 46 UK breast units were randomised (intervention, n = 21; usual care, n = 25), recruiting 1339 women (intervention, n = 670; usual care, n = 669). There was no significant difference in global quality of life at 6 months post baseline (difference –0.20, 95% confidence interval –2.7 to 2.3; p = 0.90). In women offered a choice of endocrine therapy alone or surgery plus adjuvant endocrine therapy, knowledge about treatments was greater in the intervention arm than the usual care arm (94% vs. 74%; p = 0.003). Treatment choice was altered, with higher rates of endocrine therapy alone than of surgery in the intervention arm. Similarly, chemotherapy rates were lower in the intervention arm (endocrine therapy alone rate: intervention sites 21% vs. usual-care sites 15%, difference 5.5%, 95% confidence interval 1.1% to 10.0%; p = 0.02; adjuvant chemotherapy rate: intervention sites 10% vs. usual-care site 15%, difference 4.5%, 95% confidence interval 0.0% to 8.0%; p = 0.013). Survival was similar in both arms. (4) Health economic analysis: a probabilistic economic model was developed using registry and cohort study data. For most health and fitness strata, surgery plus adjuvant endocrine therapy had lower costs and returned more quality-adjusted life-years than endocrine therapy alone. However, for some women aged > 90 years, surgery plus adjuvant endocrine therapy was no longer cost-effective and generated fewer quality-adjusted life-years than endocrine therapy alone. The incremental benefit of surgery plus adjuvant endocrine therapy reduced with age and comorbidities. (5) Variation in practice: analysis of rates of surgery plus adjuvant endocrine therapy or endocrine therapy alone between the 56 breast units in the cohort study demonstrated significant variation in rates of endocrine therapy alone that persisted after adjustment for age, fitness and stage. Clinician preference was an important determinant of treatment choice.

Conclusions

This study demonstrates that, for older women with oestrogen-receptor-positive breast cancer, there is a cohort of women with a life expectancy of < 4 years for whom surgery plus adjuvant endocrine therapy may offer little benefit and simply have a negative impact on quality of life. The Age Gap decision tool may help make this shared decision. Similarly, although adjuvant chemotherapy offers little benefit and has a negative impact on quality of life for the majority of older women with oestrogen-receptor-positive breast cancer, for women with oestrogen-receptor-negative breast cancer, adjuvant chemotherapy is beneficial. The negative impacts of adjuvant chemotherapy on quality of life, although significant, are transient. This implies that, for the majority of fitter women aged ≥ 70 years, standard care should be offered.

Limitations

As with any observational study, despite detailed propensity score matching, residual bias cannot be excluded. Follow-up was at median 52 months for the cohort analysis. Longer-term follow-up will be required to validate these findings owing to the slow time course of oestrogen-receptor-positive breast cancer.

Future work

The online algorithm is now available (URL: https://agegap.shef.ac.uk/; accessed May 2022). There are plans to validate the tool and incorprate quality-of-life and 10-year survival outcomes.

Trial registration

This trial is registered as ISRCTN46099296.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 6. See the NIHR Journals Library website for further project information.

The Present and Future of Neoadjuvant Endocrine Therapy for Breast Cancer Treatment

Simple Summary

The treatment of breast cancer has evolved considerably over the last two decades, leading toward individualized disease management. Hormone-sensitive breast cancers constitute the vast majority of cases and endocrine therapy is the mainstay of their treatment. On the other hand, neoadjuvant or pre-surgical treatments provide a number of advantages for tumor management. In this review we will discuss the existing evidence on neoadjuvant endocrine therapy, as well as its possible future indications.

Abstract

Endocrine therapy (ET) has established itself as an efficacious treatment for estrogen receptor-positive (ER+) breast cancers, with a reduction in recurrence rates and increased survival rates. The pre-surgical approach with chemotherapy (NCT) has become a common form of management for large, locally advanced, or high-risk tumors. However, a good response to NCT is not usually expected in ER+ tumors. Good results with primary ET, mainly in elderly women, have encouraged studies in other stages of life, and nowadays neoadjuvant endocrine treatment (NET) has become a useful approach to many ER+ breast cancers. The aim of this review is to provide an update on the current state of art regarding the present and the future role of NET.

Neoadjuvant endocrine therapy in women with operable breast cancer: A retrospective analysis of real-world use

BACKGROUND

A retrospective study of the real-world use of neoadjuvant endocrine therapy (NET) is important for standardizing its role in breast cancer care.

MATERIALS AND METHODS

In a consecutive series of women with operable breast cancer who received NET for ≥28 days, NET objectives, NET outcomes, adjuvant chemotherapy use after NET, and survivals, were examined for the correlation with clinicopathological factors.

RESULTS

NET objectives were for surgery extent reduction in 49 patients, surgery avoidance in 31, and treatment until scheduled surgery in 8. The mean duration of NET was 349.5 (range, 34-1923), 869.8 (range, 36-4859), and 55.8 (range, 39-113) days in the above cohorts (success: 79.6%, 64.5%, and 100%), respectively, with significant difference. In patients of the former two cohorts, better progression-free survival was significantly correlated with stage 0 or I, ductal carcinoma in situ or invasive ductal carcinoma, ≥71% estrogen receptor (ER) positivity, and the surgery extent reduction cohort than the other counterparts. Postoperative chemotherapy use was significantly correlated with lymph node metastasis, a high Ki67 labeling index, lymphovascular invasion, and a high Preoperative Endocrine Prognostic Index, at surgery after NET. Better recurrence-free survival after surgery was significantly correlated with high ER expression after NET and high PgR expression before and after NET.

CONCLUSIONS

NET can help to reduce the surgery extent or to avoid surgery in women with breast cancer of early-stage, ductal carcinoma, or high ER expression. NET may also contribute to appropriate decision of postoperative systemic therapy to improve survivals.

Acceptability of a patient decision aid for women aged 70 and older with stage I, estrogen receptor-positive, HER2-negative breast cancer

OBJECTIVES

A comprehensive decision aid (DA) for women ≥70 years with Stage I ER+/HER2-negative breast cancer was developed to support locoregional and systemic treatment decision-making. We aimed to test the acceptability of this novel DA in women newly-diagnosed with breast cancer.

MATERIALS AND METHODS

Women ≥70 diagnosed with Stage I, ER+/HER2- breast cancer were recruited from three Boston-area hospitals. They underwent baseline interviews after initial surgical consultation, reviewed the DA, and were surveyed <2 weeks later to determine DA acceptability (e.g., was it helpful?), changes in decisional conflict, stage of decision-making, and knowledge. Participants could optionally complete a three-month follow-up. Paired t-tests and McNemar's tests were used for statistical comparisons, and thematic analyses were conducted to identify themes in participants' open-ended comments.

RESULTS

Thirty-three of 56 eligible patients approached completed the baseline and acceptability surveys, and 25 completed the three-month follow-up. Participants' mean age was 74.7 years (±3.8). Nearly all participants (n = 31, 94%) strongly agreed that the DA was helpful and felt that the DA prepared them for treatment decision-making, with a mean decision preparation score of 4.1 (out of 5.0); 6% (n = 2) found it very anxiety provoking. Knowledge improved with a mean of 9.0 out of 14 questions correct at baseline to 10.6 correct on the acceptability survey (p < 0.0001).

CONCLUSIONS

A DA tailored to women ≥70 with Stage I, ER+, HER2- breast cancer increased knowledge and was perceived to be helpful by older women. A randomized controlled trial is needed to evaluate its efficacy.

Older cancer patients and COVID-19 outbreak: Practical considerations and recommendations

Since the COVID-19 outbreak started, it has been affecting mainly older individuals. Among the most vulnerable older individuals are those with cancer. Many published guidelines and consensus papers deal with prioritizing cancer care. Given the lack of high-quality evidence for management of cancer in older patients also in normal times, it is even more stringent to provide some resources on how to avoid both undertreatment and overtreatment in this population, who as of now is twice challenged to death, due to both a greater risk of getting infected with COVID-19 as well as from cancer not adequately addressed and treated. We hereby discuss some general recommendations (implement triage procedures; perform geriatric assessment; carefully assess comorbidity; promote early integration of palliative care in oncology; acknowledge the role of caregivers; maintain active take in charge to avoid feeling of abandonment; mandate seasonal flu vaccination) and discuss practical suggestions for specific disease settings (early-stage and advanced-stage disease for solid tumors, and hematological malignancies). The manuscript provides resources on how to avoid both undertreatment and overtreatment in older patients with cancer, who as of now is twice challenged to death, due to both a greater risk of getting infected with COVID-19 as well as from cancer not adequately addressed and treated.

Bridging the age gap in breast cancer. Impacts of omission of breast cancer surgery in older women with oestrogen receptor positive early breast cancer. A risk stratified analysis of survival outcomes and quality of life

Background

Age-related breast cancer treatment variance is widespread with many older women having primary endocrine therapy (PET), which may contribute to inferior survival and local control. This propensity-matched study determined if a subgroup of older women may safely be offered PET.

Methods

Multicentre, prospective, UK, observational cohort study with propensity-matched analysis to determine optimal allocation of surgery plus ET (S+ET) or PET in women aged ≥70 with breast cancer. Data on fitness, frailty, cancer stage, grade, biotype, treatment and quality of life were collected. Propensity-matching (based on age, health status and cancer stage) adjusted for allocation bias when comparing S+ET with PET.

Findings

A total of 3416 women (median age 77, range 69–102) were recruited from 56 breast units—2854 (88%) had ER+ breast cancer: 2354 had S+ET and 500 PET. Median follow-up was 52 months. Patients treated with PET were older and frailer than patients treated with S+ET. Unmatched overall survival was inferior in the PET group (hazard ratio, (HR) 0.27, 95% confidence interval (CI) 0.23–0.33, P < 0.001). Unmatched breast cancer–specific survival (BCSS) was also inferior in patients treated with PET (HR: 0.41, CI: 0.29–0.58, P < 0.001 for BCSS). In the matched analysis, PET was still associated with an inferior overall survival (HR = 0.72, 95% CI: 0.53–0.98, P = 0.04) but not BCSS (HR = 0.74, 95% CI: 0.40–1.37, P = 0.34) although at 4–5 years subtle divergence of the curves commenced in favor of surgery. Global health status diverged at certain time points between groups but over 24 months was similar when adjusted for baseline variance.

Interpretation

For the majority of older women with early ER+ breast cancer, surgery is oncologically superior to PET. In less fit, older women, with characteristics similar to the matched cohort of this study (median age 81 with higher comorbidity and functional impairment burdens, the BCSS survival differential disappears at least out to 4–5 year follow-up, suggesting that for those with less than 5-year predicted life-expectancy (>90 years or >85 with comorbidities or frailty) individualised decision making regarding PET versus S+ET may be appropriate and safe to offer. The Age Gap online decision tool may support this decision-making process (https://agegap.shef.ac.uk/).

Trial registration number

ISRCTN: 46099296.

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Propensity matched study of women >70 with breast cancer comparing surgery or PET

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Unmatched analysis found surgery improves overall & disease-specific survival.

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Matched analysis (stage, age, health, frailty) found similar disease-specific survival

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Surgery led to adverse events in 19% & negative impacts on QoL and physical function

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Less fit women >85 may be offered PET to reduce morbidity, without survival detriment

Omitting radiotherapy is safe in breast cancer patients ≥ 70 years old after breast-conserving surgery without axillary lymph node operation

To verify whether omitting radiotherapy from breast cancer treatment for patients ≥ 70 years old following breast-conserving surgery (BCS) without axillary lymph node dissection is safe. Previous studies have shown that omitting breast radiotherapy after BCS and axillary lymph node dissection is safe for elderly breast cancer patients. We aimed to evaluate the safety of BCS without axillary surgery or breast radiotherapy (BCSNR) in elderly patients with breast cancer and clinically negative axillary lymph nodes. We performed a retrospective analysis of 481 patients with breast cancer, aged ≥ 70 years, between 2010 and 2016. Of these, 302 patients underwent BCSNR and 179 underwent other, larger scope operations. Local recurrence rate, ipsilateral breast tumor recurrence (IBTR) rate, distant metastasis rate, breast-related death, disease-free survival (DFS), and overall survival (OS) were compared between the two groups. After a median follow-up of 60 months, no significant differences in local recurrence, distant metastasis rate, breast-related death, and DFS were noted. The OS was similar (P = 0.56) between the BCSNR group (91.7%) and other operations group (93.0%). The IBTR rate was considered low in both groups, however resulted greater (P = 0.005) in the BCSNR group (5.3%) than in other operations group (1.6%). BCSNR did not affect the survival of elderly patients with breast cancer with clinically negative axillary lymph nodes. IBTR was infrequent in both groups; however, there was a significant difference between the two groups. BCSNR is a feasible treatment modality for patients with breast cancer ≥ 70 years old with clinically negative axillary lymph nodes.

Matched case-control survival analysis of older chinese breast cancer patients treated with surgery or primary endocrine therapy

BACKGROUND

Primary endocrine therapy (PET) has been used as an alternative to primary surgery for elderly with estrogen receptor (ER) positive breast tumors. Such practices are less commonly performed in Asian countries and the response to PET in Chinese cohort is still lacking. This study aims to compare the clinical outcome of PET to primary surgery.

PATIENTS AND METHODS

Medical records of Chinese patients aged 70 and above with stage I to III, ER positive breast cancer treated at a University affiliated tertiary hospital from 2008 to 2017 were reviewed. Excluding those with extreme comorbidity, a one-to-one case-control survival analysis of patients treated with PET or primary operation was performed, using propensity score case-match analysis to adjust for confounding factors.

RESULTS

292 patients fulfilled the inclusion criteria during the study period. 209 patients received primary operation, whereas 83 patients received PET. Excluding those with extreme comorbidity, a one-to-one matching was performed, and the dataset was stratified into survival time within 0-5 years and beyond 5 years. Both groups had similar survival within 0-5 years (p = 0.63). The survival curves diverged beyond 5 years, with a significantly better outcome in patients operated than those treated with PET (p = 0.0029).

CONCLUSIONS

For frail older patients with limited life expectancy, PET may be appropriate since equivalent survival can be achieved for PET with or without surgery. Those patients with longer life expectancy may gain survival benefits from local treatment. A comprehensive geriatric assessment is useful to predict the survival probability and guide the optimal treatment.

Neoadjuvant endocrine therapy in locally advanced estrogen or progesterone receptor-positive breast cancer: determining the optimal endocrine agent and treatment duration in postmenopausal women-a literature review and proposed guidelines

Introduction

For patients with locally advanced estrogen receptor or progesterone receptor-positive breast cancer, neoadjuvant endocrine therapy (NET) facilitates down-staging of the tumor and increased rates of breast-conserving surgery. However, NET remains under-utilized, and there are very limited clinical guidelines governing which therapeutic agent to use, or the optimal duration of treatment in postmenopausal women. This literature review aims to discuss the evidence surrounding (1) biomarkers for patient selection for NET, (2) the optimal neoadjuvant endocrine agent for postmenopausal women with locally advanced breast cancer, and (3) the optimal duration of NET. In addition, we make initial recommendations towards developing a clinical guideline for the prescribing of NET.

Method

A wide-ranging search of online electronic databases was conducted using a truncated PIC search strategy to identify articles that were relevant to these aims and revealed a number of key findings.

Results

Randomized trials have consistently demonstrated that aromatase inhibitors are more effective than tamoxifen, in terms of objective response rate and rate of BCS, and should be used as first-line NET. The three available aromatase inhibitors have so far been demonstrated to be biologically equivalent, with the choice of aromatase inhibitor not having been shown to affect clinical outcomes. There is increasing evidence for extending the duration of NET beyond 3 to 4 months, to at least 6 months or until maximal clinical response is achieved. While on-treatment levels of the proliferation marker Ki67 are predictive of long-term outcome, the choice of adjuvant therapy in patients who have received NET and then surgery is best guided by the preoperative endocrine prognostic index, or PEPI, which incorporates Ki67 with other clinical parameters.

Conclusion

This study reveals that in appropriately selected patients, NET can provide equivalent clinical benefit to neoadjuvant chemotherapy in the same cohort, if suitable treatments and durations are chosen. Our findings highlight the need for better defined biomarkers both for guiding patient selection and for measuring outcomes. Development of standard guidelines for the prescribing of NET has the potential to improve both clinical outcomes and quality of life in this patient cohort.

Adapting care for older cancer patients during the COVID-19 pandemic: Recommendations from the International Society of Geriatric Oncology (SIOG) COVID-19 Working Group

The COVID-19 pandemic poses a barrier to equal and evidence-based management of cancer in older adults. The International Society of Geriatric Oncology (SIOG) formed a panel of experts to develop consensus recommendations on the implications of the pandemic on several aspects of cancer care in this age group including geriatric assessment (GA), surgery, radiotherapy, systemic treatment, palliative care and research. Age and cancer diagnosis are significant predictors of adverse outcomes of the COVID-19 infection. In this setting, GA is particularly valuable to drive decision-making. GA may aid estimating physiologic reserve and adaptive capability, assessing risk-benefits of either providing or temporarily withholding treatments, and determining patient preferences to help inform treatment decisions. In a resource-constrained setting, geriatric screening tools may be administered remotely to identify patients requiring comprehensive GA. Tele-health is also crucial to ensure adequate continuity of care and minimize the risk of infection exposure. In general, therapeutic decisions should favor the most effective and least invasive approach with the lowest risk of adverse outcomes. In selected cases, this might require deferring or omitting surgery, radiotherapy or systemic treatments especially where benefits are marginal and alternative safe therapeutic options are available. Ongoing research is necessary to expand knowledge of the management of cancer in older adults. However, the pandemic presents a significant barrier and efforts should be made to ensure equitable access to clinical trials and prospective data collection to elucidate the outcomes of COVID-19 in this population.

Impact of older age on local treatment decisionss

Managing elderly breast cancer patients brings challenges both to physicians and patients themselves. There are certain controversial issues regarding local treatment of early breast cancer in this population. Since elderly patients are more likely to have comorbidities and functional limitations, they are more prone to undertreatment. Although surgical treatment in elderly patients were reported to be safe, severity and number of comorbidities are shown to be related with increased complications, hence may lead to higher mortality and lower life quality. Therefore, frailty is one of the concerns which prevents elderly patients to receive standard-of-care local treatment. Nevertheless, breast cancers developing in elderly are more likely to be low grade and luminal type. Until now, primary endocrine treatment without surgical resection, omitting whole breast irradiation after partial mastectomy and avoiding sentinel lymph node biopsy, which are otherwise accepted as standard-of-care, were questionned in healthy, low-risk, elderly fit patients. Two main issues were suggested to be considered when assessing the impact of local treatment options in this patient group; the clinical significance of treatments' effects, and the patients' expectations. Due to their vulnerability, baseline geriatric assessment should be the initial step for management in elderly breast cancer patients. Even in those who are healthy and fit with long life-expectancy, de-escalation in management might be an option in low-risk patients after considering patients' individual expectations and limited clinical benefits of standard local treatment options.

Breast-conserving surgery without axillary lymph node surgery or radiotherapy is safe for HER2-positive and triple negative breast cancer patients over 70 years of age

PURPOSE

The prognosis of elderly patients with hormone receptor-positive breast cancer is very good, and their survival is unaffected by performing breast-conserving surgery (BCS) without radiotherapy. Therefore, we aimed to verify that BCS without axillary lymph node dissection, sentinel lymph node biopsy, or radiotherapy (BCSNR) is safe for patients over 70 years of age with luminal-type breast cancer, as well as for those with HER2-positive and triple negative breast cancer (TNBC).

METHODS

This study retrospectively included 450 patients > 70-year-old with breast cancer from 2010 to 2016. The patients were divided into two groups, one treated with BCSNR and the other treated with mastectomy and axillary lymph node dissection (MALND), with a median follow-up period of 5 years. Disease-free survival (DFS), overall survival, local recurrence, distant metastasis, and ipsilateral breast tumor recurrence (IBTR) were compared between the two groups.

RESULTS

The 5-year DFS for patients who underwent BCSNR and MALND was 90.1 and 91.3% (p = 0.903), respectively. In the BCSNR and MALND groups, respectively, the 5-year DFS for patients with luminal A type breast cancer was 99.2 and 100% (p = 0.167), that for patients with luminal B type breast cancer was 89.2 and 95.5% (p = 0.138), that for patients with HER2-positive breast cancer was 86.7 and 75.9% (p = 0.455), and that for TNBC patients was 71.7 and 89.7% (p = 0.195). IBTR significantly differed between the BCSNR and MALND groups for patients with TNBC (18.9% vs 0.0%, p = 0.040) and luminal B type patients (5.6% vs 0.0%, p = 0.043).

CONCLUSION

BCSNR is not only suitable for elderly patients with luminal-type breast cancer but also for those with HER2-positive breast cancer and TNBC.

Outcomes of primary endocrine therapy in elderly women with stage I-III breast cancer: a SEER database analysis

BACKGROUND

Frail elderly women with nonmetastatic hormone receptor-positive breast cancer often receive primary endocrine therapy. Limited data are available on the outcomes associated with this population and treatment approach.

METHODS

We selected patients with an initial primary diagnosis of stage I-III ER-positive breast cancer from 2001 to 2015 in Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Patients were excluded if they received surgery, radiation, chemotherapy, or other targeted drug treatment including anti-HER2 agents. Two Cox proportional-hazards models were constructed to determine the predictors of breast cancer-specific survival and overall survival after a cancer diagnosis.

RESULTS

A total of 552 patients were identified, with 82.1% of the patients being 80 years or older and 81.7% of patients being non-Hispanic White. PR positive (OR 1.77; 95% CI 1.09-2.85; p = 0.025) and tumor size larger than 50 mm (OR 1.99; 95% CI 1.05-3.75; p = 0.035) were associated with higher adherence to endocrine therapy. In the multivariable Cox analyses, patients who were adherent of endocrine therapy had significantly worse survival (HR 1.40; 95% CI 1.17-1.69; p < 0.001). The other two factors associated with worse survival were larger tumor size and more comorbidities. The competing risk model demonstrated no statistically significant difference between patients who were adherent to endocrine therapy and those who were not in terms of risk of dying from breast cancer.

CONCLUSION

In elderly women with localized ER-positive breast cancer, there were no statistically significant differences in breast cancer-specific or overall mortality between those who were adherent to endocrine therapy and those who were not.

Treatment of elderly breast cancer patients in a breast center in India

CONTEXT

The management of breast cancer in older patients is challenging due to factors such as comorbidities, limited mobility, functional dependence, cognitive functions, and socioeconomic aspects. Data about the outcomes in elderly patients with breast cancer in our country are sparse.

AIMS

The aim of this study was to evaluate and compare the clinical and pathological variables, treatment, and survival outcomes of elderly women (those of 70 years and above) with women under 50 years and those between the ages of 50 and 69 years treated at our center.

SUBJECTS AND METHODS

Prospectively collected clinical and pathological data from January 2007 to December 2014 were recorded and entered into OncoCollect™ software. Statistical analysis was done using Microsoft R Open software. Survival analysis was estimated using Kaplan-Meier curves.

RESULTS

A total of 1226 Stage I-III breast cancer patients were treated between January 2007 and December 2014. Of these, 11.3% (139) were aged 70 years and above. Invasive ductal carcinoma was predominant and majority had Stage II disease and grade 1 tumors. Receptor positivity was observed in 79% of elderly patients and 9% had triple-negative disease. Primary hormone therapy was given to 7% of the patients and chemotherapy was administered to 12%. The 5-year overall survival for patients 70 years and older is 85%.

CONCLUSIONS

Elderly patients are more likely to have an indolent course with low grade and estrogen receptor-positive tumors. For healthy older women, treatment according to standard guidelines including surgery, chemotherapy, and radiation should be followed. However, for those who are unfit and cannot tolerate surgery, primary endocrine therapy is a suitable option.

Endocrine Therapy for Breast Cancer: A Model of Hormonal Manipulation

Oestrogen receptor (ER) is the driving transcription factor in 70% of breast cancer. Endocrine therapies targeting the ER represent one of the most successful anticancer strategies to date. In the clinic, novel targeted agents are now being exploited in combination with established endocrine therapies to maximise efficacy. However, clinicians must balance this gain against the risk to patients of increased side effects with combination therapies. This article provides a succinct outline of the principles of hormonal manipulation in breast cancer, alongside the key evidence that underpins current clinical practice. As the role of endocrine therapy in breast cancer continues to expand, the challenge is to interpret the data and select the optimal strategy for a given clinical scenario.

Primary Endocrine Therapy in Older Women with Breast Cancer

Purpose of Review

Breast cancer incidence increases with age. In recent years, primary endocrine therapy has been increasingly used as a treatment option for frail elderly women with breast cancer, although surgery is still the guideline-recommended treatment. In this review, we discuss the evidence for primary endocrine therapy versus surgical treatment in older women with early breast cancer.

Recent Findings

Both randomised controlled trials and recent observational studies showed a favourable progression-free survival but not overall survival for surgery plus adjuvant endocrine therapy versus primary endocrine therapy. Information about quality of life with either treatment strategy is so far lacking. Deciding who is fit for surgery and has sufficiently long life expectation to be at risk of disease progression can be supported by performing an individual geriatric assessment.

Summary

This review suggests that primary endocrine therapy is a reasonable alternative to primary surgery in frail older women with breast cancer. Future studies should focus on the long-term effects on quality of life and physical functioning.

Neoadjuvant endocrine therapy in breast cancer patients

Highlights

The overall response rate to neoadjuvant endocrine therapy (NET) was 54.55%.The eight patients proposed to tumour's downstage, after 9.71 months of NET, preserved their breast.In the group which achieved response, 10.28 months was the mean time to accomplish it.Even patients who had the worst outcome only began to suffer latter in the course of therapy.NET can be done beyond the conventional 3-4 months to allow additional downstage of the tumour.

Background

The aim of this study is to evaluate if the extension of neoadjuvant endocrine therapy (NET), beyond the conventional time, allows additional downstage of the tumour, in order to perform a breast conservative surgery (BCS), and to analyze if it is a good option for long-term control in patients who refuse or are unfit for surgery.

Patients and methods

We retrospectively reviewed a database containing all patients treated in our institution with NET. All included patients were post-menopausal with primary local disease. The type of response obtained was assessed using modified RECIST criteria.

Results

Thirty-three patients were included. Two patients had tumours with 90% expression of oestrogen receptors and all the others had 100%. The tumour size in the largest diameter was 6.51 cm before treatment and 5.18 cm after. Eighteen patients achieved a partial response after 10.28 months of therapy. Patients that were proposed to downstage the tumour performed 9.71 months of therapy until surgery and all were submitted to BCS. Progression occurred after 27.5 months.

Conclusion

Endocrine therapy is a feasible option for a longer time to allow additional downstage of the tumour and is a good solution in patients who refuse or are unfit for surgery.

Survival of de novo stage IV breast cancer patients over three decades

BACKGROUND

De novo stage IV breast cancer patients (BC_IV) depict a clinical picture not influenced by adjuvant therapy. Therefore, the time-dependent impact of changes in diagnostics and treatments on progression and survival can best be evaluated in this subgroup.

METHODS

BC_IV patients from 1978 to 2013 registered in the Munich Cancer Registry were divided into four periods, and the trends were analysed. Survival was estimated by Kaplan-Meier methods, and prognostic factors were fitted with Cox proportional hazard models.

RESULTS

Between 1978 and 2013, 88,759 patients were diagnosed with 92,807 cases of invasive and non-invasive BC. Of these patients, 4756 patients had distant metastases (MET) at diagnosis. The 5-year survival rate improved from 17.4 to 24.7%, while the pattern of metastases did not change. Improved staging diagnostics, a screening programme and primary systemic therapy changed the composition of prognostic strata. Patients with a similar composition as the 1978-1987 cohort exhibited a median survival difference of 13 months; however, neither univariate nor multivariate analysis showed a survival effect for the four periods as a surrogate indicator for changing treatments. HER2+ patients have with 27.6 months a slightly longer survival than all other BC_IV patients.

CONCLUSIONS

Survival of de novo BC_IV has only modestly improved since the late 1970s, partially masked by changing distributions of prognostic factors due to changes in diagnostics.

Adjuvant treatment for older women with invasive breast cancer

Older women experience a large share of breast cancer incidence and death. With the projected rise in the number of older cancer patients, adjuvant chemo-, radiation and endocrine therapy management will become a key component of breast cancer treatment in older women. Many factors influence adjuvant treatment decisions including patient preferences, life expectancy and tumor biology. Geriatric assessment predicts important outcomes, identifies key deficits, and can aid in the decision making process. This review utilizes clinical vignettes to illustrate core principles in adjuvant management of breast cancer in older women and suggests an approach incorporating life expectancy and geriatric assessment.

Specific Aspects of Breast Cancer Therapy of Elderly Women

Breast cancer is the leading cause of death among women, and its incidence increases with age. The average age at diagnosis is 61 years, and the majority of deaths occurs after the age of 65 years. Optimal approach to elderly women with breast cancer is still a major challenge. Elderly patients with cancer should have at least a brief geriatric assessment to detect potentially treatable problems not always adequately evaluated by the oncologists. Therapeutic nihilism should be avoided and effective treatment provided, unless there are compelling reasons against it. Sharing the care for the patient with geriatricians or primary care physicians trained in geriatrics should be considered for all vulnerable and frail elderly patients.

Construction of tissue microarrays from core needle biopsies - a systematic literature review

In some clinical circumstances, core needle biopsy (CNB) may be the only source of material from cancer tissue for diagnostic use. The volume of tissue available in a CNB is low, and opportunities for research use can therefore be limited. The tissue microarray (TMA) principle, if applied to the use of CNBs, could facilitate research studies in circumstances where CNB specimens are available. However, various challenges are expected in applying such a technique in CNBs, which has limited their use in research. We therefore conducted a systematic review of the literature on this subject. A systematic search was carried out with CINAHL, EMBASE, the Cochrane library, and MEDLINE, to identify studies that have primarily developed methods for constructing TMAs from CNBs. Eight studies were found to meet the inclusion criteria; six of these employed the vertical rearrangement technique, and two used multiple layers of biopsy tissue. Representation of the CNB was significantly influenced by the quantity of tumour cells present in the original biopsy and the degree of heterogeneity of biomarker expression. This review shows that technologies have been developed to enable construction of TMAs from CNBs. However, challenges remain to improve amplification and representation.

Early-Stage Breast Cancer in the Elderly: Confronting an Old Clinical Problem

Breast cancer generally develops in older women and its incidence is continuing to increase with increasing age of the population. The pathology and biology of breast cancer seem to be different in the elderly, often resulting in the undertreatment of elderly patients and thus in higher rates of recurrence and mortal-ity. The aim of this review is to describe the differences in the biology and treatment of early breast cancer in the elderly as well as the use of geriatric assessment methods that aid decision-making. Provided there are no contraindications, the cornerstone of treatment should be surgery, as the safety and efficacy of surgical resection in elderly women have been well documented. Because most breast cancers in the elderly are hormone responsive, hormonal therapy remains the mainstay of systemic treatment in the adjuvant setting. The role of chemotherapy is limited to patients who test negative for hormone receptors and demonstrate an aggressive tumor profile. Although the prognosis of breast cancer patients has generally improved during the last few decades, there is still a demand for evidence-based optimization of therapeutic interventions in older patients.

The role of primary endocrine therapy in older women with operable breast cancer

ABSTRACT 

A Cochrane review of randomized trials shows no difference in overall survival between surgery and primary endocrine therapy (PET) in older women with operable primary breast cancer. Most of these trials were small and unselected for estrogen receptor (ER) status. Evidence exists showing a significant correlation between the degree of ER-positivity and response and outcome in patients receiving PET. Although surgery remains the treatment of choice, patients with ER-rich tumors tend to do equally well on PET. When deciding optimal therapies, co-morbidities and frailty (which impact on the likelihood of death due to competing causes), patient choice, agent of choice (notably the third-generation aromatase inhibitors) and biology (more than just being ER-positive) should all be taken into account.

Optimal management of breast cancer in the elderly patient: current perspectives

Breast cancer (BC) is the most common female malignancy in the world and almost one third of cases occur after 70 years of age. Optimal management of BC in the elderly is a real challenge and requires a multidisciplinary approach, mainly because the elderly population is heterogeneous. In this review, we describe the various possibilities of treatment for localized or metastatic BC in an aging population. We provide an overview of the comprehensive geriatric assessment, surgery, radiotherapy, and adjuvant therapy for early localized BC and of chemotherapy and targeted therapies for metastatic BC. Finally, we attempt to put into perspective the necessary balance between the expected benefits and risks, especially in the adjuvant setting.

Update of the Phase III trial 'GRETA' of surgery and tamoxifen versus tamoxifen alone for early breast cancer in elderly women

BACKGROUND

In the Phase III 'GRETA' trial 474 women aged ≥70 years with early breast cancer were randomly assigned to surgery plus tamoxifen for 5 years or tamoxifen alone for 5 years. This is a long-term update.

PATIENTS & METHODS

Focusing on patients still alive in 2003, outcome end points has been recalculated.

RESULTS

Median distant metastases disease-free survival is longer with tamoxifen alone for 5 years; (48.8 vs 37.9 months; p = 0.009). No difference was found in distant metastases rate, disease-free survival, breast cancer and overall survival.

CONCLUSION

Primary endocrine treatment until the the best response, followed by minimal surgery and prosecution endocrine treatment for 5-10 years is a suitable option for elderly breast cancer patients. Delayed surgery does not prejudice overall survival.

Management of operable primary breast cancer in older women

A considerable number of breast cancer diagnoses are made in older women. Differing physiological needs of older patients and biology of tumors compared with younger patients may alter treatment options between surgery and nonsurgical primary approaches. Adjuvant therapies may benefit these patients; however, concerns about toxicity and physical demands of treatment may affect patient choice regarding treatment. Furthermore, quality of life may be more important to the older individual than curative treatment alone. Growing evidence is emerging for employing Comprehensive Geriatric Assessment to determine other factors that may contribute to treatment decision-making in the older population. The way geriatric oncology is delivered varies, bringing the importance of the multidisciplinary team to the forefront of care delivery in this age group. Future research in this area should include combined consideration of tumor biology and geriatric needs.

Adjuvant systemic treatment for elderly breast cancer patients; addressing safety concerns

INTRODUCTION

The issue of systemic treatment for early breast cancer in the elderly has always been challenging and in spite of the clear evidence of the potential benefits of adjuvant treatment in older women, they are usually undertreated with the potential consequence of worse outcomes.

AREAS COVERED

This article will review the evidence surrounding the various systemic options in the treatment armamentarium of early-stage breast cancer in elderly patients. The risks and benefits, with particular attention to a number of newly introduced targeted agents, along with the potential role of incorporating a combined geriatric/oncologic assessment as a routine part of the management of elderly patients with breast cancer are considered.

EXPERT OPINION

Administration of available options for (neo)adjuvant endocrine, chemo, as well as targeted therapeutics in fit elderly patients is feasible and tolerable; however, a routine input from geriatric medicine and psycho-oncology experts as well as the training of specialized oncology staff with special interest in geriatric oncology are believed to improve the outcome of elderly patients.

Primary endocrine therapy as a treatment for older women with operable breast cancer - a comparison of randomised controlled trial and cohort study findings

INTRODUCTION

One third of all breast cancers occur in women over the age of 70. Primary endocrine therapy (PET) is used in some women to minimise morbidity in a population with higher rates of comorbidity and frailty. In the UK up to 40% of women over 70 are treated with PET although there is a high rate of variability of practice between centres reflecting a lack of guidance about case selection.

METHODS

A systematic review of the literature was performed to try and establish if this form of treatment is still valid in modern breast practice.

RESULTS

Six randomised controlled trials (RCTs) and 31 non-randomised studies were deemed eligible. Available data demonstrate an advantage for surgery over PET in terms of disease control and a likely survival benefit in patients with a predicted life expectancy of five years or more. Patients treated only with aromatase inhibitors (AIs) had superior rates of disease control when compared to Tamoxifen.

CONCLUSIONS

Guidelines to aid selection are needed but PET should be reserved for patients with reduced predicted life expectancy (e.g. less than five years), with AIs being preferable over Tamoxifen.