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Lee AY, Lyons AT, Makris V, Kamaraju S, Stolley MR, Neuner JM, Flynn KE. Adherence to adjuvant endocrine therapy for breast cancer: a qualitative exploration of attribution of symptoms among post-menopausal women. Support Care Cancer 2024; 32:265. [PMID: 38565669 DOI: 10.1007/s00520-024-08463-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 03/25/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE Oral adjuvant endocrine therapy (AET) is an effective treatment for hormone receptor positive breast cancer to decrease recurrence and mortality, but adherence is poor. This study explored post-menopausal women's experiences with AET, with a particular focus on adherence to AET as well as distress and symptoms experienced prior to and during AET treatment. METHODS Participants were recruited from a hospital registry, stratified by adherence to/discontinuation of AET. Telephone interviews followed a semi-structured interview guide and were recorded and transcribed verbatim. Transcripts were systematically coded using team-based coding, with analysis of themes using a grounded theory approach. RESULTS Thirty-three participants were interviewed; ages ranged from 57 to 86 years. Participants included 10 discontinued patients and 23 patients who completed their AET course or were adherent to AET at the time of interviewing. Both adherent and discontinued patients reported symptoms throughout their AET treatment course, and both attributed symptoms to factors other than AET (e.g., older age and pre-existing comorbidities). However, discontinued patients were more likely to attribute symptoms to AET and to describe difficulty managing their symptoms, with some directly citing symptoms as the reason for discontinuing AET therapy. Conversely, adherent patients were more likely to describe the necessity of taking AET, despite symptoms. CONCLUSIONS AET adherence was associated with beliefs about AET, symptom attribution, and symptom management. Routine symptom monitoring during AET and addressing both symptoms and patients' understanding of their symptoms may promote adherence to AET.
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Affiliation(s)
- Amy Y Lee
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 52336, USA
| | - Anna T Lyons
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 52336, USA
| | - Vaia Makris
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 52336, USA
| | - Sailaja Kamaraju
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 52336, USA
| | - Melinda R Stolley
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 52336, USA
| | - Joan M Neuner
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 52336, USA
| | - Kathryn E Flynn
- Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 52336, USA.
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2
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Gagnon ME, Talbot D, Tremblay F, Desforges K, Sirois C. Polypharmacy and risk of fractures in older adults: A systematic review. J Evid Based Med 2024; 17:145-171. [PMID: 38517979 DOI: 10.1111/jebm.12593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 02/28/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Fractures have serious health consequences in older adults. While some medications are individually associated with increased risk of falls and fractures, it is not clear if this holds true for the use of many medications (polypharmacy). We aimed to identify what is known about the association between polypharmacy and the risk of fractures in adults aged ≥65 and to examine the methods used to study this association. METHODS We conducted a systematic review with narrative synthesis of studies published up to October 2023 in PubMed, Embase, CINAHL, PsychINFO, Cochrane Library, Web of Science, and the grey literature. Two independent reviewers screened titles, abstracts, and full texts, then performed data extraction and quality assessment. RESULTS Among the 31 studies included, 11 different definitions of polypharmacy were used and were based on three medication counting methods (concurrent use 15/31, cumulative use over a period 6/31, daily average 3/31, and indeterminate 7/31). Overall, polypharmacy was frequent and associated with higher fracture risk. A dose-response relationship between increasing number of medications and increased risk of fractures was observed. However, only seven studies adjusted for major confounders (age, sex, and chronic disease). The quality of the studies ranged from poor to high. CONCLUSIONS Polypharmacy appears to be a relevant modifiable risk factor for fractures in older individuals that can easily be used to identify those at risk. The diversity of medication calculation methods and definitions of polypharmacy highlights the importance of a detailed methodology to understand and compare results.
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Affiliation(s)
- Marie-Eve Gagnon
- Faculty of Pharmacy, Université Laval, Québec, Québec, Canada
- Department of Health Sciences, Université du Québec à Rimouski (UQAR), Rimouski, Québec, Canada
- Centre de recherche du CHU de Québec - Université Laval, Québec, Québec, Canada
- Centre d'excellence sur le vieillissement de Québec, VITAM - Centre de recherche en sante durable, Québec, Québec, Canada
| | - Denis Talbot
- Centre de recherche du CHU de Québec - Université Laval, Québec, Québec, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, Québec, Canada
- Faculty of Medicine, Université Laval, Québec, Québec, Canada
| | | | - Katherine Desforges
- Faculty of Pharmacy, Université de Montréal, Montréal, Québec, Canada
- Department of Pharmacy, McGill University Health Centre, Montréal, Québec, Canada
| | - Caroline Sirois
- Faculty of Pharmacy, Université Laval, Québec, Québec, Canada
- Centre de recherche du CHU de Québec - Université Laval, Québec, Québec, Canada
- Centre d'excellence sur le vieillissement de Québec, VITAM - Centre de recherche en sante durable, Québec, Québec, Canada
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Chang X, Yu S, Pang J, Zhang W, Kong H, Huang J, Zhang G, Zhang H, Gu Y, Chen Y, Yang B, Liu J, Zeng Z. Population Sensitive to Lenvatinib Plus Anti-PD-1 for Unresectable Hepatocellular Carcinoma Infected with Hepatitis B Virus. J Hepatocell Carcinoma 2023; 10:847-861. [PMID: 37304208 PMCID: PMC10257432 DOI: 10.2147/jhc.s411748] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/01/2023] [Indexed: 06/13/2023] Open
Abstract
Background We explore the dose-efficacy relationship of lenvatinib plus anti-PD-1 in patients with unresectable hepatocellular carcinoma (u-HCC) infected with hepatitis B virus (HBV) in real-world practice. Furthermore, we identify the population sensitive to lenvatinib plus anti-PD-1 treatments. Methods This retrospective study included 70 patients treated with lenvatinib plus at least 3 cycles of anti-PD-1 and 140 with lenvatinib alone. Stabilized inverse probability of treatment weighting (SIPTW) was used to balance clinical features between the two groups. The overall survival (OS), progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR), and adverse events (AEs) were analyzed. Subpopulation treatment effect pattern plot (STEPP) estimated treatment-effect differences between the two groups. Results The median age was 54 years, and 189 (90%) cases were male. A total of 180 (85%) patients were infected with HBV. A slowly increasing 12-month survival rate was with the cycles of anti-PD-1, and 5 cycles and more of anti-PD-1 appeared the most beneficial and stable survival rate. The lenvatinib plus at least 3 cycles anti-PD-1 group had better OS (21.4 vs 14 months, p = 0.041), PFS (8.0 vs 6.3 months, p = 0.015) than the lenvatinib alone group in unadjusted cohorts, and the SIPTW adjusted cohorts had confirmed it. For patients with portal vein trunk invasion (PVTI) or extrahepatic spread (EHS) combined with Child-Pugh class B (CPB), lenvatinib plus anti-PD-1 made the 12-month survival rate increase by 38%, while, in the other population, it did only 18%. The two groups had similar AEs (p ≥ 0.05). Conclusion The lenvatinib combined with at least 3 cycles of anti-PD-1 was efficacy and safe for u-HCC patients infected with HBV. Especially, patients with PVTI or EHS combined with CPB may benefit most from the combination therapy.
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Affiliation(s)
- Xiujuan Chang
- Department of Liver Disease Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, People’s Republic of China
| | - Shumin Yu
- 302 Clinical Medical School Peking University, Beijing, 100039, People’s Republic of China
| | - Jianzhi Pang
- Department of Liver Disease Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, People’s Republic of China
| | - Wei Zhang
- Department of Liver Disease Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, People’s Republic of China
| | - Huifang Kong
- Department of Liver Disease Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, People’s Republic of China
| | - Jiagan Huang
- Department of Liver Disease Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, People’s Republic of China
| | - Guojie Zhang
- Department of Liver Disease Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, People’s Republic of China
| | - Huixin Zhang
- Department of Liver Disease Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, People’s Republic of China
| | - Yueyue Gu
- Department of Liver Disease Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, People’s Republic of China
- The Fifth School of Clinical Medicine, Anhui Medical University, Hefei, Anhui Province, 230032, People’s Republic of China
| | - Yan Chen
- Department of Liver Disease Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, People’s Republic of China
| | - Bin Yang
- Department of Liver Disease Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, People’s Republic of China
| | - Jingping Liu
- Oncology Department, Electric Power Hospital of Beijing, Beijing, 100073, People’s Republic of China
| | - Zhen Zeng
- Department of Liver Disease Medicine, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, People’s Republic of China
- 302 Clinical Medical School Peking University, Beijing, 100039, People’s Republic of China
- The Fifth School of Clinical Medicine, Anhui Medical University, Hefei, Anhui Province, 230032, People’s Republic of China
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Bryant JM, Weygand J, Keit E, Cruz-Chamorro R, Sandoval ML, Oraiqat IM, Andreozzi J, Redler G, Latifi K, Feygelman V, Rosenberg SA. Stereotactic Magnetic Resonance-Guided Adaptive and Non-Adaptive Radiotherapy on Combination MR-Linear Accelerators: Current Practice and Future Directions. Cancers (Basel) 2023; 15:2081. [PMID: 37046741 PMCID: PMC10093051 DOI: 10.3390/cancers15072081] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT) is an effective radiation therapy technique that has allowed for shorter treatment courses, as compared to conventionally dosed radiation therapy. As its name implies, SBRT relies on daily image guidance to ensure that each fraction targets a tumor, instead of healthy tissue. Magnetic resonance imaging (MRI) offers improved soft-tissue visualization, allowing for better tumor and normal tissue delineation. MR-guided RT (MRgRT) has traditionally been defined by the use of offline MRI to aid in defining the RT volumes during the initial planning stages in order to ensure accurate tumor targeting while sparing critical normal tissues. However, the ViewRay MRIdian and Elekta Unity have improved upon and revolutionized the MRgRT by creating a combined MRI and linear accelerator (MRL), allowing MRgRT to incorporate online MRI in RT. MRL-based MR-guided SBRT (MRgSBRT) represents a novel solution to deliver higher doses to larger volumes of gross disease, regardless of the proximity of at-risk organs due to the (1) superior soft-tissue visualization for patient positioning, (2) real-time continuous intrafraction assessment of internal structures, and (3) daily online adaptive replanning. Stereotactic MR-guided adaptive radiation therapy (SMART) has enabled the safe delivery of ablative doses to tumors adjacent to radiosensitive tissues throughout the body. Although it is still a relatively new RT technique, SMART has demonstrated significant opportunities to improve disease control and reduce toxicity. In this review, we included the current clinical applications and the active prospective trials related to SMART. We highlighted the most impactful clinical studies at various tumor sites. In addition, we explored how MRL-based multiparametric MRI could potentially synergize with SMART to significantly change the current treatment paradigm and to improve personalized cancer care.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Stephen A. Rosenberg
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA; (J.M.B.)
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Battisti NML, Joshi K, Nasser MS, Ring A. Systemic therapy for older patients with early breast cancer. Cancer Treat Rev 2021; 100:102292. [PMID: 34536728 DOI: 10.1016/j.ctrv.2021.102292] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/07/2021] [Indexed: 12/16/2022]
Abstract
Over a third of breast cancers are diagnosed in patients ≥70 years. With the ageing of the population, the number of older breast cancer patients will continue to rise. Older patients are under-represented in clinical studies underpinning breast cancer therapy, and frequently do not receive guideline-concordant care. This review outlines the evidence on the efficacy and the safety of systemic treatment options for the management of early-stage breast cancer (EBC) in older adults and identifies where critical data gaps exist. Chemotherapy is beneficial for older patients with oestrogen receptor (ER)-negative EBC, whilst the benefit for those with ER-positive disease is less certain. Careful consideration should be given to the side-effect profile of the treatment regimen chosen, owing to the risks of myelosuppression and cardiac damage, as well as toxicities, such as neuropathy, that may impact independence. The impact of chemotherapy on quality of life (QOL) outcomes appears significant but reversible in this population. Gene expression profiling, benefit and chemotherapy toxicity prediction tools integrating global health considerations hold promise to better inform chemotherapy decisions in this population. Benefits on targeted anti-human epidermal growth factor receptor 2 (HER2) agents is maintained in older EBC patients with a favourable safety profile. Endocrine therapy including aromatase inhibitors is the standard of care in this population, and extended treatment decisions should consider effects on bone health and life expectancy. More trials recruiting older adults with pragmatic designs and meaningful endpoints for this population are warranted to better inform systemic treatment decisions and discussion with patients.
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Affiliation(s)
- Nicolò Matteo Luca Battisti
- Department of Medicine - Breast Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, United Kingdom; Breast Cancer Research Division, The Institute of Cancer Research, 15 Cotswold Road, Sutton, London SM2 5NG, United Kingdom.
| | - Kroopa Joshi
- Department of Medicine - Breast Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, United Kingdom.
| | - Mariam Syeda Nasser
- Department of Medicine - Breast Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, United Kingdom.
| | - Alistair Ring
- Department of Medicine - Breast Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey SM2 5PT, United Kingdom.
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Palumbo I, Borghesi S, Gregucci F, Falivene S, Fontana A, Aristei C, Ciabattoni A. Omission of adjuvant radiotherapy for older adults with early-stage breast cancer particularly in the COVID era: A literature review (on the behalf of Italian Association of Radiotherapy and Clinical Oncology). J Geriatr Oncol 2021; 12:1130-1135. [PMID: 34020908 PMCID: PMC8131185 DOI: 10.1016/j.jgo.2021.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/21/2021] [Accepted: 05/07/2021] [Indexed: 12/25/2022]
Abstract
This review is aimed at evaluating whether radiation therapy (RT) can be omitted in older adult early-stage low-risk breast cancer (BC) patients. The published data are particularly relevant at present, during the COVID-19 pandemic emergency, to define a treatment strategy and to prioritize essential therapy. Cochrane Database of Systematic Reviews and PubMED were systematically researched from outset through April 2020 using Mesh terms. Only randomized controlled trials (RCT), with one arm without adjuvant whole-breast irradiation (WBI), were included in the analysis. Recent literature regarding the COVID pandemic and BC RT was assessed. The reported RCTs identified a group of BC patients (pT1-2N0M0 R0, grade 1-2, estrogen receptor (ER) positive, human epidermal growth factor receptor 2 (HER2) negative tumours) in which the absolute risk of local recurrence (LR) was considered low enough to omit RT. The most common risk factors were tumor diameter, nodal and receptor status. Adjuvant RT had a significant impact on LR but not on distant metastasis (DM) or death. During the COVID 19 pandemic, results from RTCs were re-considered to define treatment recommendations for BC patients. International scientific societies and radiation oncology experts suggested RT omission, whenever possible, in older adult early-stage BC patients. Adjuvant RT might be omitted in a highly selected group of older adult early-stage BC patients with favourable prognostic factors. Hypofractionated regimens should be the standard. RT omission, partial breast irradiation (PBI), and ultra- hypofractionated regimens could be considered in selected cases due to the pandemic.
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Affiliation(s)
- Isabella Palumbo
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Simona Borghesi
- Radiation Oncology Department, Arezzo-Valdarno, Azienda USL Toscana Sud Est, Arezzo, Italy
| | - Fabiana Gregucci
- Radiation Oncology Division, Miulli-Felli Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Sara Falivene
- Radiation Oncology Division, Ospedale del Mare, Asl Napoli 1 centro, Napoli, Italy
| | - Antonella Fontana
- Radiation Oncology Division, Santa Maria Goretti Hospital, Latina, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Perugia, Italy,Corresponding author at: Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, Perugia General Hospital, Sant'Andrea delle Fratte, 06156 Perugia, Italy
| | - Antonella Ciabattoni
- Radiation Oncology Division, San Filippo Neri, Hospital, ASL Roma 1, Roma, Italy
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7
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Tamirisa N, Lin H, Shen Y, Shaitelman SF, Karuturi MS, Giordano SH, Babiera GV, Bedrosian I. Impact of adjuvant endocrine therapy in older patients with comorbidities and estrogen receptor-positive, node-negative breast cancer-A National Cancer Database analysis. Cancer 2021; 127:2196-2203. [PMID: 33735487 DOI: 10.1002/cncr.33489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/15/2021] [Accepted: 01/25/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Data are lacking about the benefit of adjuvant endocrine therapy (ET) in older patients with multiple comorbidities. The authors sought to determine the effect of ET on the survival of older patients who had multiple comorbidities and estrogen receptor (ER)-positive/human epidermal growth factor receptor 2 (HER2)-negative, pathologic node-negative (pN0) breast cancer. METHODS Women aged ≥70 years in the National Cancer Database (2010-2014) with Charlson/Deyo comorbidity scores of 2 or 3 who had pathologic tumor (pT1)-pT3/pN0, ER-positive/HER2-negative breast cancer were divided into 2 cohorts: adjuvant ET and no ET. Propensity scores were used to match patients based on age, comorbidity score, facility type, pT classification, chemotherapy, surgery, and radiation therapy. A Cox proportional hazards model was used to estimate the effect of ET on overall survival (OS). RESULTS In the nonmatched cohort (n = 3716), 72.8% of patients received ET (n = 2705), and 27.2% did not (n = 1011). The patients who received ET were younger (mean age, 76 vs 79 years; P < .001) and had higher rates of breast conservation compared with those who did not receive ET (lumpectomy plus radiation: 43.4% vs 23.8%, respectively; P < .001). In the matched cohort (n = 1972), the median OS was higher in the ET group (79.2 vs 67.7 months; P < .0001). In the adjusted analysis, ET was associated with improved survival (hazard ratio, 0.70; 95% CI, 0.59-0.83). CONCLUSIONS In older patients who have pN0, ER-positive/HER2-negative breast cancer with comorbidities, adjuvant ET was associated with improved OS, which may have been overestimated given the confounders inherent in observational studies. To optimize outcomes in these patients, current standard recommendations should be considered stage-for-stage based on life expectancy and the level of tolerance to treatment.
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Affiliation(s)
- Nina Tamirisa
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Heather Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yu Shen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Simona F Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Meghan S Karuturi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H Giordano
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gildy V Babiera
- MD Anderson Physician Network, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Lee YK, Lee EG, Kim HY, Lee Y, Lee SM, Suh DC, Yoo JI, Lee S. Osteoporotic Fractures of the Spine, Hip, and Other Locations after Adjuvant Endocrine Therapy with Aromatase Inhibitors in Breast Cancer Patients: a Meta-analysis. J Korean Med Sci 2020; 35:e403. [PMID: 33258332 PMCID: PMC7707928 DOI: 10.3346/jkms.2020.35.e403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/14/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Aromatase inhibitors (AIs) play an important role in the endocrine therapy of postmenopausal breast cancer patients, with a recent tendency to extend the duration of their use. However, AIs may increase the risk of osteoporotic bone fractures. This meta-analysis evaluated the risk of osteoporotic fractures of the hip, spine, and other locations in breast cancer patients using AIs. METHODS We performed a systematic search to identify randomized controlled clinical trials that investigated osteoporotic fractures in breast cancer patients on AI therapy. The main outcomes were the incidence and risk of osteoporotic fractures in general and of hip, vertebral, and non-vertebral fractures in AI users and controls. RESULTS The systematic review found a total of 30 randomized controlled trials including 117,974 participants. The meta-analysis showed a higher incidence of osteoporotic fracture in AI users: The crude risk ratio for all osteoporotic fractures was 1.35 (95% confidence interval [CI], 1.29-1.42; P < 0.001), for hip fractures 1.18 (95% CI, 1.02-1.35; P < 0.001), for vertebral fractures 1.84 (95% CI, 1.36-2.49; P < 0.001), and for non-vertebral fractures 1.18 (95% CI, 1.02-1.35; P < 0.001), respectively, compared to the controls. CONCLUSION Our meta-analysis suggested an increased risk of osteoporotic fractures for AI therapy in patients with breast cancer that was most expressed for vertebral fractures. Breast cancer patients on AIs need to be monitored for osteoporosis and osteoporotic fractures, and active prevention measures should be implemented.
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Affiliation(s)
- Young Kyun Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Gyeong Lee
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Ha Young Kim
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Youjin Lee
- Department of Internal Medicine, Center for Thyroid Cancer, National Cancer Center, Goyang, Korea
| | - Seung Mi Lee
- College of Pharmacy, Daegu Catholic University, Gyeongsan, Korea
| | - Dong Churl Suh
- Department of Pharmacy, Chung-Ang University College of Pharmacy, Seoul, Korea
| | - Jun Il Yoo
- Department of Orthopedic Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea.
| | - Seeyoun Lee
- Center for Breast Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea.
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9
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Adjuvant endocrine therapy is associated with improved overall survival in elderly hormone receptor-positive breast cancer patients. Breast Cancer Res Treat 2020; 184:63-74. [PMID: 32776217 DOI: 10.1007/s10549-020-05823-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/20/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE There is controversy regarding the survival benefit of endocrine therapy (ET) in elderly patients with early invasive hormone receptor-positive (HR+) breast cancer. In this study, we characterize a single institution's practice patterns using adjuvant ET for these patients and evaluated the effect of ET on outcomes. METHODS A review of a prospectively maintained database identified 483 women ≥ 70 years old who underwent breast -conserving surgery (BCS) for stage I-III HR+ tumors from 2004-2013. We compared clinicopathologic characteristics, overall survival (OS), disease-free survival (DFS), locoregional recurrence (LRR), and breast cancer-specific survival (BCSS) in patients who did and did not receive ET. RESULTS Compared to patients who did not get ET, patients who received ET were younger (median age 76 vs 78 years, p = 0.006), had larger tumors (median size 15 vs 14 mm, p = 0.016), underwent sentinel lymph node (LN) biopsy (83.7 vs 67.8%, p < 0.001), had positive LNs (25.5 vs 9.8%, p = 0.008), and received radiation (XRT, 76 vs 43%, p < 0.001). After adjusting for ASA score, age, LN status, tumor grade, and XRT, receipt of ET was associated with improved OS (HR 0.44; 95% CI 0.25-0.77; p = 0.004) and DFS (HR 0.42; 95% CI 0.28-0.64; p < 0.01). Receipt of ET was associated with improved LRR on univariate analysis (HR 0.25; 95% CI 0.09-0.70; p = 0.008); however, after adjusting for grade and XRT, this was not statistically significant on multivariable analysis (HR 0.38; 95% CI 0.13-1.08; p = 0.069) and was not associated with BCSS (HR 0.59; 95% CI 0.16-2.16; p = 0.43). CONCLUSIONS ET was associated with significant improvements in OS and DFS, regardless of clinicopathological features; however, receipt of ET did not impact LRR and BCSS.
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Abstract
PURPOSE OF REVIEW Breast cancer incidence and mortality increase with age. Older patients (≥ 70) are often excluded from studies. Due to multiple factors, it is unclear whether this population is best-treated using standard guidelines. Here, we review surgical management in older women with breast cancer. RECENT FINDINGS Geriatric assessments can guide treatment recommendations and aid in predicting survival and quality of life. Surgery remains a principal component of breast cancer treatment in older patients, though differences exist compared with younger women, including higher mastectomy rates and evidence-based support of omission of post-lumpectomy radiation or axillary dissection in subsets of patients. In those forgoing surgical management, there is increased use of endocrine therapy. Hospice is also a valuable element of end-of-life care. Physicians should utilize geriatric assessment to make treatment recommendations for older breast cancer patients, including omission of radiation therapy, alterations to standard surgeries, or enrollment in hospice care.
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Derks MGM, van de Velde CJH, Giardiello D, Seynaeve C, Putter H, Nortier JWR, Dirix LY, Bastiaannet E, Portielje JEA, Liefers GJ. Impact of Comorbidities and Age on Cause-Specific Mortality in Postmenopausal Patients with Breast Cancer. Oncologist 2019; 24:e467-e474. [PMID: 30606886 DOI: 10.1634/theoncologist.2018-0010] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 11/15/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The aim was to study the impact of comorbidities and age on breast cancer mortality, taking into account competing causes of death. SUBJECTS, MATERIALS, AND METHODS Cohort analysis of Dutch and Belgian patients with postmenopausal, early hormone receptor-positive breast cancer included in the Tamoxifen and Exemestane Adjuvant Multinational (TEAM) trial between 2001 and 2006. This is a randomized controlled trial of patients who had completed local treatment with curative intent and were randomized to receive exemestane for 5 years, or sequential treatment of tamoxifen followed by exemestane for a duration of 5 years. Patients were categorized by number of comorbidities (no comorbidities, 1-2 comorbidities, and >2 comorbidities) and age (<70 years and ≥70 years). Main outcome was breast cancer mortality considering other-cause mortality as competing event; cumulative incidences were calculated using the Cumulative Incidence Competing Risk Methods, and the Fine and Gray model was used to calculate the effect of age and comorbidities for the cause-specific incidences of breast cancer death, taking into account the effect of competing causes of death. RESULTS Overall, 3,159 patients were included, of which 2,203 (69.7%) were aged <70 years and 956 (30.3%) were aged ≥70 years at diagnosis. Cumulative incidence of breast cancer mortality was higher among patients ≥70 without comorbidities (22.2%, 95% CI, 17.5-26.9) compared with patients <70 without comorbidities (15.6%, 95% CI, 13.6-17.7, reference group), multivariable subdistribution hazard ratio (sHR) 1.49 (95% CI, 1.12-1.97, p = .005) after a median follow-up of 10 years. Use of chemotherapy was lower in older patients (1%, irrespective of the number of comorbidities) compared with younger patients (50%, 44%, and 38% for patients with no, 1-2, or >2 comorbidities, p < .001). CONCLUSION Older patients without comorbidities have a higher risk of dying due to breast cancer than younger counterparts, even when taking into account higher competing mortality, while use of chemotherapy in this group was low. These findings underline the need to take into account comorbidities, age, and competing mortality in the prognosis of breast cancer for accurate decision making. IMPLICATIONS FOR PRACTICE Older patients without comorbidity are at increased risk of dying from breast cancer, despite a higher other-cause mortality. This study shows that including age and comorbidity for the assessment of breast cancer mortality and other-cause mortality is indispensable for treatment decision making in older patients. Future prognostic tools for breast cancer prognosis should incorporate these items as well as risk of toxicity of adjuvant chemotherapy to adequately predict outcomes to optimize personalized treatment for older patients with early breast cancer.
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Affiliation(s)
- Marloes G M Derks
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Daniele Giardiello
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
- Department of Molecular Pathology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Caroline Seynaeve
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan W R Nortier
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Luc Y Dirix
- Oncology Center, Sint-Augustinus, Wilrijk-Antwerp, Belgium
| | - Esther Bastiaannet
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Gerrit-Jan Liefers
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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12
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Shelby RA, Dorfman CS, Bosworth HB, Keefe F, Sutton L, Owen L, Corsino L, Erkanli A, Reed SD, Arthur SS, Somers T, Barrett N, Huettel S, Gonzalez JM, Kimmick G. Testing a behavioral intervention to improve adherence to adjuvant endocrine therapy (AET). Contemp Clin Trials 2019; 76:120-131. [PMID: 30472215 PMCID: PMC6346744 DOI: 10.1016/j.cct.2018.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/15/2018] [Accepted: 11/19/2018] [Indexed: 02/01/2023]
Abstract
Adjuvant endocrine therapy (AET) is used to prevent recurrence and reduce mortality for women with hormone receptor positive breast cancer. Poor adherence to AET is a significant problem and contributes to increased medical costs and mortality. A variety of problematic symptoms associated with AET are related to non-adherence and early discontinuation of treatment. The goal of this study is to test a novel, telephone-based coping skills training that teaches patients adherence skills and techniques for coping with problematic symptoms (CST-AET). Adherence to AET will be assessed in real-time for 18 months using wireless smart pill bottles. Symptom interference (i.e., pain, vasomotor symptoms, sleep problems, vaginal dryness) and cost-effectiveness of the intervention protocol will be examined as secondary outcomes. Participants (N = 400) will be recruited from a tertiary care medical center or community clinics in medically underserved or rural areas. Participants will be randomized to receive CST-AET or a general health education intervention (comparison condition). CST-AET includes ten nurse-delivered calls delivered over 6 months. CST-AET provides systematic training in coping skills for managing symptoms that interfere with adherence. Interactive voice messaging provides reinforcement for skills use and adherence that is tailored based on real-time adherence data from the wireless smart pill bottles. Given the high rates of non-adherence and recent recommendations that women remain on AET for 10 years, we describe a timely trial. If effective, the CST-AET protocol may not only reduce the burden of AET use but also lead to cost-effective changes in clinical care and improve breast cancer outcomes. Trials registration: ClinicalTrials.gov, NCT02707471, registered 3/3/2016.
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Affiliation(s)
- Rebecca A Shelby
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, United States.
| | - Caroline S Dorfman
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, United States.
| | - Hayden B Bosworth
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, United States; Department of Population Health Sciences, Duke University, Durham, NC, United States; Department of Medicine, Duke University, Durham, NC, United States.
| | - Francis Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, United States.
| | - Linda Sutton
- Duke Cancer Network, Duke University, Durham, NC, United States.
| | - Lynda Owen
- Duke Cancer Network, Duke University, Durham, NC, United States.
| | - Leonor Corsino
- Division of Endocrinology, Duke University, Durham, NC, United States.
| | - Alaattin Erkanli
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States.
| | - Shelby D Reed
- Department of Population Health Sciences, Duke University, Durham, NC, United States; Department of Medicine, Duke University, Durham, NC, United States.
| | - Sarah S Arthur
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, United States.
| | - Tamara Somers
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, United States.
| | - Nadine Barrett
- Office of Health Equity and Disparities, Duke Cancer Institute, Duke University, Durham, NC, United States.
| | - Scott Huettel
- Department of Psychology and Neuroscience, Duke University, Durham, NC, United States.
| | - Juan Marcos Gonzalez
- Department of Population Health Sciences, Duke University, Durham, NC, United States.
| | - Gretchen Kimmick
- Division of Medical Oncology, Duke University, Durham, NC, United States.
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Tseng OL, Spinelli JJ, Gotay CC, Ho WY, McBride ML, Dawes MG. Aromatase inhibitors are associated with a higher fracture risk than tamoxifen: a systematic review and meta-analysis. Ther Adv Musculoskelet Dis 2018; 10:71-90. [PMID: 29619093 DOI: 10.1177/1759720x18759291] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 01/20/2018] [Indexed: 12/11/2022] Open
Abstract
Background In this paper, our aim was to systematically evaluate published evidence of bone fracture risk associated with tamoxifen and aromatase inhibitors in women aged 65 and under, and diagnosed with nonmetastatic breast cancer. Methods We comprehensively searched MEDLINE, EMBASE and CINAHL databases from January 1997 through May 2015, and reference lists of the selected articles to identify English-language randomized controlled trials and cohort studies of fracture risk. Two independent reviewers screened articles and assessed methodological quality using Risk of Bias assessment for randomized controlled trials and the Newcastle-Ottawa Scale for cohort studies. Fracture risk was estimated as pooled risk ratios using a random-effects model and inverse variance method. Results Of 1926 identified articles, 21 independent studies fulfilled our selection criteria. Similar fracture risk was observed in women treated and not treated with tamoxifen [pooled risk ratio (RR) 0.95; 95% confidence interval (CI) 0.84-1.07]. A 35% (95% CI 1.21-1.51) higher fracture risk was observed in the aromatase inhibitor group compared with the tamoxifen group. A 17% (95% CI 1.07-1.28) higher fracture risk was observed in the aromatase inhibitor group than the no aromatase inhibitor group. Compared with the tamoxifen group, aromatase inhibitor-associated fracture risk increased by 33% (pooled RR 1.33; 95% CI 1.21-1.47) during the tamoxifen/aromatase inhibitor treatment period, but did not increase (pooled RR 0.99; 95% CI 0.72-1.37) during the post-tamoxifen/aromatase inhibitor treatment period. Conclusions Fracture risk is significantly higher in women treated with aromatase inhibitors, especially during the treatment period. Tamoxifen is not associated with lower fracture risk while tamoxifen could potentially preserve bone mass. Better osteoporosis management programs, especially during the treatment period, are needed for this group of women.
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Affiliation(s)
- Olivia L Tseng
- Department of Family Practice, University of British Columbia, 3rd floor David Strangway Building, 5950 University Boulevard Building, Vancouver, BC V6T 1Z3, Canada
| | - John J Spinelli
- Cancer Control Research Department, BC Cancer Research Centre, BC, Canada School of Population and Public Health, University of British Columbia, BC, Canada
| | - Carolyn C Gotay
- Cancer Control Research Department, BC Cancer Research Centre, BC, Canada School of Population and Public Health, University of British Columbia, BC, Canada
| | - Wan Y Ho
- Faculty of Pharmaceutical Science, University of British Columbia, Vancouver, BC, Canada
| | - Mary L McBride
- Cancer Control Research Department, BC Cancer Research Centre, BC, Canada School of Population and Public Health, University of British Columbia, BC, Canada
| | - Martin G Dawes
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
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Glaser R, Marinopoulos S, Dimitrakakis C. Breast cancer treatment in women over the age of 80: A tailored approach. Maturitas 2018; 110:29-32. [PMID: 29563032 DOI: 10.1016/j.maturitas.2018.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 01/05/2018] [Accepted: 01/12/2018] [Indexed: 11/17/2022]
Abstract
Breast cancer treatment in women over the age of 80 remains a complex issue due to pre-existing comorbidities, therapy-related toxicities, and the lack of evidence-based data in this population, leading to both overtreatment and under treatment. The average life expectancy of an 80-year-old woman is 9.7 years and chronologic age alone should not be a factor in withholding therapy. Women over age 80 should be treated on an individual basis, taking into account their overall health and life expectancy, their risk of dying from breast cancer versus other causes, and the benefits versus toxicities of therapies for their tumor. Invaluable online tools are readily available to easily assess life expectancy (ePrognosis), as well as the absolute survival benefits for every tumor type and stage in individual patients (PREDICT, Ajuvant!). This information should be presented to the patient so that they are able to make an informed decision based on their goals, wishes and quality of life. Vulnerable patients should not be bullied or scared into taking unwanted or unnecessary treatments.
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Affiliation(s)
- Rebecca Glaser
- Millennium Wellness Center, 228 E. Spring Valley Road, Dayton, Ohio 45458, USA; Wright State University Boonshoft School of Medicine, Department of Surgery, 3460 Colonel Glenn Highway, Dayton, Ohio 45435, USA.
| | - Spyridon Marinopoulos
- 1st Department of Ob-Gyn, Athens University Medical School, 80 Vas Sophias Street, 11528, Athens, Greece
| | - Constantine Dimitrakakis
- 1st Department of Ob-Gyn, Athens University Medical School, 80 Vas Sophias Street, 11528, Athens, Greece; National Institutes of Health, NICHD, Bldg. 10, 10 Center Drive, Bethesda, MD 20892-1103
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15
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Current Strategies of Endocrine Therapy in Elderly Patients with Breast Cancer. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6074808. [PMID: 29581979 PMCID: PMC5822785 DOI: 10.1155/2018/6074808] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 12/19/2017] [Indexed: 11/17/2022]
Abstract
Currently, the growing population of the elderly is one of biggest problems in terms of increase in geriatric diseases. Lack of data from large prospective studies on geriatric breast cancer patients often makes it difficult for clinicians to make treatments decisions for them. Because both benefit and risk of treatment should be taken into account, treatment is usually determined considering life expectancy or comorbidities in elderly patients. Treatment of breast cancer is differentiated according to histologic classifications, and hormone therapy is even adopted for patients with metastatic breast cancer if tumor tissue expresses hormone receptors. Endocrine therapy can offer great benefit to elderly patients considering its equivalent efficacy to chemotherapy with fewer toxicities if it is appropriately used. Aromatase inhibitors are usually prescribed agents in hormone therapy for elderly breast cancer patients due to their physiology after menopause. Here, endocrine therapy for elderly patients with breast cancer in neoadjuvant, adjuvant, and palliative setting is reviewed along with predictive adverse events resulting from the use of hormone agents.
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16
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Impact of an osteoporosis specialized unit on bone health in breast cancer survivals treated with aromatase inhibitors. ACTA ACUST UNITED AC 2017; 15:211-217. [PMID: 29032291 DOI: 10.1016/j.reuma.2017.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/02/2017] [Accepted: 08/31/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Considering the increased fracture risk in early breast cancer patients treated with aromatase inhibitors (AI), we assessed the impact of a preventive intervention conducted by a specialized osteoporosis unit on bone health at AI treatment start. MATERIAL AND METHODS Retrospective cohort of postmenopausal women who started treatment with AI after breast cancer surgical/chemotherapy treatment and were referred to the osteoporosis unit for a comprehensive assessment of bone health. Bone densitometry and fracture screening by plain X-ray were performed at the baseline visit and once a year for 5 years. RESULTS The final record included 130 patients. At AI treatment start, 49% had at least one high-risk factor for fractures, 55% had osteopenia, and 39% osteoporosis. Based on the baseline assessment, 79% of patients initiated treatment with bisphosphonates, 88% with calcium, and 79% with vitamin D. After a median of 65 (50-77) months, 4% developed osteopenia or osteoporosis, and 14% improved their densitometric diagnosis. Fifteen fractures were recorded in 11 (8.5%) patients, all of them receiving preventive treatment (10 with bisphosphonates). During the follow-up period, patients with one or more high-risk factors for fracture showed a greater frequency of fractures (15% vs. 3%) and experienced the first fracture earlier than those without high-risk factors (mean of 99 and 102 months, respectively; P=0.023). CONCLUSIONS The preventive intervention of a specialized unit at the start of AI treatment in breast cancer survivors allows the identification of patients with high fracture risk and may contribute to preventing bone events in these patients.
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Abstract
Aging poses an unique opportunity to study cancer biology and treatment in older adults. Breast cancer is often studied in young women; however, much investigation remains to be done on breast cancer in our expanding elderly population. Diagnostic and management strategies applicable to younger patients cannot be empirically used to manage older breast cancer patients. Lack of evidence-based data continues to be the major impediment toward delivery of personalized cancer care to elderly breast cancer patients. This article reviews the relevant literature on management of curable breast cancer in the elderly, the role of geriatric assessment, complex treatment decision making within the context of patient's expected life expectancy, comorbidities, physical function, socioeconomic status, barriers to health care delivery, goals of treatment, and therapy-related side effects. Continuing efforts for enrolling elderly breast cancer patients in contemporary clinical trials, and thus improving age-appropriate care, are emphasized.
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18
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Dellapasqua S. Systemic Treatment for Specific Medical Situations. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Germain V, Dabakuyo-Yonli TS, Marilier S, Putot A, Bengrine-Lefevre L, Arveux P, Manckoundia P, Quipourt V. Management of elderly patients suffering from cancer: Assessment of perceived burden and of quality of life of primary caregivers. J Geriatr Oncol 2016; 8:220-228. [PMID: 27974265 DOI: 10.1016/j.jgo.2016.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 09/30/2016] [Accepted: 12/01/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the perceived burden and the quality of life (QoL) at 3 and 6months of the primary caregiver (PC) of patients aged 70 and over suffering from cancer and the predictors of QoL in this population. METHODS In this prospective observational study, 98 patients aged 70 and older with cancer and 96 PCs were included between 01/06/2014 and 18/03/2015. The Medical Outcomes Study 12-item Short Form Health Survey (SF-12) was used to assess the QoL of PCs and the Zarit Burden Interview (ZBI) was used to measure the perceived burden at 3 and 6months. The major determinants of QoL were identified using mixed linear models for the dimensions of the SF-12 that showed an average difference of at least 5 points between baseline and follow-up at 6months. RESULTS The QoL scores of PCs showed a decrease in the dimensions "role emotional" and "bodily pain" over 6months. In multivariate analysis, the main determinants of QoL for "role emotional" were the PC's age (p=0.005), a low perceived burden (p<0.0001) and a functionally independent patient (p=0.01), and for "bodily pain" was a low perceived burden (p<0.0001) and the non-use of hormone therapy during the treatment (p<0.0001). CONCLUSION The main determinants of the QoL of PCs concerned factors inherent to the PC (age and perceived burden) and patient (functional independence).
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Affiliation(s)
- Victor Germain
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France; Geriatric Oncology Coordination Unit in Burgundy, University Hospital, Dijon, France
| | - Tienhan Sandrine Dabakuyo-Yonli
- Côte d'Or Breast and Gynaecological Cancer Registry, Centre George François Leclerc, 1 rue du Professeur Marion, BP 77980, Dijon Cedex, France; National Clinical Research Platform for Quality of Life in Oncology, France
| | - Sophie Marilier
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France; Geriatric Oncology Coordination Unit in Burgundy, University Hospital, Dijon, France
| | - Alain Putot
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France; Geriatric Oncology Coordination Unit in Burgundy, University Hospital, Dijon, France
| | - Leila Bengrine-Lefevre
- Medical Oncology Department, Centre George François Leclerc, 1 rue du Professeur Marion, BP 77980, Dijon Cedex, France
| | - Patrick Arveux
- Côte d'Or Breast and Gynaecological Cancer Registry, Centre George François Leclerc, 1 rue du Professeur Marion, BP 77980, Dijon Cedex, France; National Clinical Research Platform for Quality of Life in Oncology, France
| | - Patrick Manckoundia
- Department of Geriatric Rehabilitation, Hospital of Champmaillot, University Hospital, Dijon F-21079, France; UMR Inserm/U1093 Cognition, Action, Sensorimotor Plasticity, University of Burgundy, Dijon, France.
| | - Valérie Quipourt
- Department of Geriatrics and Internal Medicine, Hospital of Champmaillot, University Hospital, Dijon, France; Geriatric Oncology Coordination Unit in Burgundy, University Hospital, Dijon, France
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Colzani E, Clements M, Johansson ALV, Liljegren A, He W, Brand J, Adolfsson J, Fornander T, Hall P, Czene K. Risk of hospitalisation and death due to bone fractures after breast cancer: a registry-based cohort study. Br J Cancer 2016; 115:1400-1407. [PMID: 27701383 PMCID: PMC5129831 DOI: 10.1038/bjc.2016.314] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 08/18/2016] [Accepted: 09/11/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Bone fractures may have an impact on prognosis of breast cancer. The long-term risks of bone fracture in breast cancer patients have not been thoroughly studied. METHODS Poisson regression was used to investigate the incidence of hospitalisation due to bone fracture comparing women with and without breast cancer based on Swedish National registers. Cox regression was used to investigate the risk of being hospitalised with bone fracture, and subsequent risk of death, in a regional cohort of breast cancer patients. RESULTS For breast cancer patients, the 5-year risk of bone fracture hospitalisation was 4.8% and the 30-day risk of death following a bone fracture hospitalisation was 2.0%. Compared with the general population, breast cancer patients had incidence rate ratios of 1.25 (95% CI: 1.23-1.28) and 1.18 (95% CI: 1.14-1.22) for hospitalisation due to any bone fracture and hip fracture, respectively. These ratios remained significantly increased for 10 years. Comorbidities (Charlson Comorbidity Index ⩾1) were associated with the risk of being hospitalised with bone fracture. Women taking aromatase inhibitors were at an increased risk as compared with women taking tamoxifen (HR=1.48; 95% CI: 0.98-2.22). Breast cancer patients hospitalised for a bone fracture showed a higher risk of death (HR=1.83; 95% CI: 1.50-2.22) compared with those without bone fracture. CONCLUSIONS Women with a previous breast cancer diagnosis are at an increased risk of hospitalisation due to a bone fracture, particularly if they have other comorbidities.
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Affiliation(s)
- Edoardo Colzani
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
- Department of Health Sciences, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, Monza 20126, Italy
| | - Mark Clements
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
| | - Anna L V Johansson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
| | - Annelie Liljegren
- Department of Oncology and Pathology, Karolinska University Hospital, Karolinska Institutet, P.O. Box 260, Stockholm SE-171 76, Sweden
| | - Wei He
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
| | - Judith Brand
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
| | - Jan Adolfsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm SE-171 77, Sweden
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm SE-102 33, Sweden
| | - Tommy Fornander
- Department of Oncology and Pathology, Karolinska University Hospital, Karolinska Institutet, P.O. Box 260, Stockholm SE-171 76, Sweden
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobelsväg 12A, Stockholm SE-171 77, Sweden
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Abstract
Breast cancer is the most common cancer in women, with an incidence that rises dramatically with age. The average age at diagnosis of breast cancer is 61 years, and the majority of woman who die of breast cancer are age 65 years and older. Major improvements in public health and medical care have resulted in dramatic increases in longevity. The oldest old (those age 80 years and older) are a rapidly expanding group and now comprise 9 million members of the US population. The treatment of individuals who are age 80 years and older is complex and involves clearly defining the goals and value of treatment while also weighing risks, such as the potential effects of treatment on functional loss and quality of life. Limited evidence-based treatment guidelines exist for the caring of this older cohort of patients with breast cancer. Data from clinical trials that enroll primarily younger patients lack the information needed to estimate the likelihood of toxicities that can be life changing in older adults. Clinicians who make treatment recommendations should place the available evidence in the context of the patient's life expectancy and geriatric assessment results that include an evaluation of a patient's functional status, comorbidities, cognition, social support, nutritional status, and psychological state. Furthermore, these decisions should be placed in the context of the patient's goals for treatment, preferences, and values. This review summarizes the current literature and focuses on the role of geriatric assessment in treatment recommendations for patients age 80 years and older with early and metastatic breast cancer.
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Affiliation(s)
- Shlomit Strulov Shachar
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Rambam Health Care Campus, Haifa, Israel; and City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Arti Hurria
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Rambam Health Care Campus, Haifa, Israel; and City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Hyman B Muss
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC; Rambam Health Care Campus, Haifa, Israel; and City of Hope Comprehensive Cancer Center, Duarte, CA
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Jerzak KJ, Desautels DN, Pritchard KI. An update on adjuvant systemic therapy for elderly patients with early breast cancer. Expert Opin Pharmacother 2016; 17:1881-8. [PMID: 27539883 DOI: 10.1080/14656566.2016.1219339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Elderly women with early breast cancer require an individualized approach to risk assessment and treatment. Unfortunately, there are limited data to inform optimal adjuvant therapy decisions in this population. Cytotoxic chemotherapy, biologic treatments and endocrine agents, while important in reducing breast cancer recurrence and mortality, are associated with the potential for adverse effects that may be of particular significance to elderly patients. AREAS COVERED In this review, we summarize the evidence for geriatric assessment in elderly patients with early breast cancer, outline special considerations for the use of chemotherapy and trastuzumab in older adults, and describe the age-specific risks of endocrine therapy in the adjuvant breast cancer setting. EXPERT OPINION The treatment of elderly women with early breast cancer should take into account cancer risk, life expectancy, comorbidities, functional status, physiologic changes, and patient values. Formal geriatric assessment may better inform treatment recommendations for individual patients. In general, there is no strong evidence to suggest that older women benefit less from standard adjuvant therapies than do their younger counterparts. When choosing between endocrine therapies, the differential risks associated with each agent should be considered and particular attention to the fracture risk on aromatase inhibitors (AIs) is warranted. Enrolment of women over 70 years of age into breast cancer clinical trials should be encouraged to better inform treatment guidelines.
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Adjuvant medical treatment for breast cancer in elderly and old women. MEMO-MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2016; 9:17-19. [PMID: 27069512 PMCID: PMC4786591 DOI: 10.1007/s12254-016-0258-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 02/16/2016] [Indexed: 12/27/2022]
Abstract
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.
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Smith IE, Fribbens C. Management of breast cancer in older and frail patients. Breast 2015; 24 Suppl 2:S159-62. [DOI: 10.1016/j.breast.2015.07.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Biganzoli L, Lichtman S, Michel JP, Papamichael D, Quoix E, Walko C, Aapro M. Oral single-agent chemotherapy in older patients with solid tumours: A position paper from the International Society of Geriatric Oncology (SIOG). Eur J Cancer 2015; 51:2491-500. [DOI: 10.1016/j.ejca.2015.08.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/09/2015] [Indexed: 10/23/2022]
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Rumiato E, Brunello A, Ahcene-Djaballah S, Borgato L, Gusella M, Menon D, Pasini F, Amadori A, Saggioro D, Zagonel V. Predictive markers in elderly patients with estrogen receptor-positive breast cancer treated with aromatase inhibitors: an array-based pharmacogenetic study. THE PHARMACOGENOMICS JOURNAL 2015; 16:525-529. [PMID: 26503812 DOI: 10.1038/tpj.2015.73] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/27/2015] [Accepted: 09/08/2015] [Indexed: 11/09/2022]
Abstract
So far, no reliable predictive clinicopathological markers of response to aromatase inhibitors (AIs) have been identified, and little is known regarding the role played by host genetics. To identify constitutive predictive markers, an array-based association study was performed in a cohort of 55 elderly hormone-dependent breast cancer (BC) patients treated with third-generation AIs. The array used in this study interrogates variants in 225 drug metabolism and disposition genes with documented functional significance. Six variants emerged as associated with response to AIs: three located in ABCG1, UGT2A1, SLCO3A1 with a good response, two in SLCO3A1 and one in ABCC4 with a poor response. Variants in the AI target CYP19A1 resulted associated with a favourable response only as haplotype; haplotypes with increased response association were also detected for ABCG1 and SLCO3A1. These results highlight the relevance of host genetics in the response to AIs and represent a first step toward precision medicine for elderly BC patients.
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Affiliation(s)
- E Rumiato
- Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | - A Brunello
- Medical Oncology 1 Unit, Department of Clinical and Experimental Oncology, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | - S Ahcene-Djaballah
- Medical Oncology 1 Unit, Department of Clinical and Experimental Oncology, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | - L Borgato
- Hemato-Oncology Unit, Medical Science Department ULSS 13, Mirano, Venezia, Italy
| | - M Gusella
- Division of Oncology, Rovigo General Hospital, ULSS 18, Rovigo, Italy
| | - D Menon
- Division of Oncology, Rovigo General Hospital, ULSS 18, Rovigo, Italy
| | - F Pasini
- Division of Oncology, Rovigo General Hospital, ULSS 18, Rovigo, Italy
| | - A Amadori
- Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy.,Department of Surgery, Oncology, and Gastroenterology, Oncology Section, University of Padova, Padova, Italy
| | - D Saggioro
- Immunology and Molecular Oncology Unit, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | - V Zagonel
- Medical Oncology 1 Unit, Department of Clinical and Experimental Oncology, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
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Dimitrakopoulos FID, Kottorou A, Antonacopoulou AG, Makatsoris T, Kalofonos HP. Early-Stage Breast Cancer in the Elderly: Confronting an Old Clinical Problem. J Breast Cancer 2015; 18:207-17. [PMID: 26472970 PMCID: PMC4600684 DOI: 10.4048/jbc.2015.18.3.207] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 07/20/2015] [Indexed: 01/06/2023] Open
Abstract
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.
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Affiliation(s)
| | - Anastasia Kottorou
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
| | - Anna G Antonacopoulou
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
| | - Thomas Makatsoris
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
| | - Haralabos P Kalofonos
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
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Accelerated partial breast irradiation using intensity-modulated radiotherapy technique compared to whole breast irradiation for patients aged 70 years or older: subgroup analysis from a randomized phase 3 trial. Breast Cancer Res Treat 2015; 153:539-47. [DOI: 10.1007/s10549-015-3565-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 09/04/2015] [Indexed: 10/23/2022]
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Turner N, Zafarana E, Sanna G, Mottino G, Biganzoli L. The best treatment for older patients with breast cancer. EJC Suppl 2015. [PMID: 26217152 PMCID: PMC4041185 DOI: 10.1016/j.ejcsup.2013.07.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Natalie Turner
- Hospital of Prato, Istituto Toscano Tumori, Prato, Italy
| | - Elena Zafarana
- Hospital of Prato, Istituto Toscano Tumori, Prato, Italy
| | | | | | - Laura Biganzoli
- Hospital of Prato, Istituto Toscano Tumori, Prato, Italy
- Corresponding author: Tel.: +39 0574 434766.
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Mislang AR, Biganzoli L. Adjuvant Systemic Therapy in Older Breast Cancer Women: Can We Optimize the Level of Care? Cancers (Basel) 2015; 7:1191-214. [PMID: 26151681 PMCID: PMC4586766 DOI: 10.3390/cancers7030833] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/17/2015] [Accepted: 06/26/2015] [Indexed: 01/03/2023] Open
Abstract
Defining optimal adjuvant treatment for older women with breast cancer is challenged by the lack of level-1 clinical evidence and the heterogeneity of the older population. Nevertheless, recommendations based on reviews of available evidence mainly from retrospective subgroup analyses and extrapolation of study results from younger patients, and expert opinions, may be useful to guide treatment decisions in fit patients. But how can we properly define a "fit" older patient? In clinical practice, age by itself and clinical impression generally drive treatment decision, although the appropriateness of this judgment is under-documented. Such an approach risks overtreatment or, more frequently, undertreatment. A geriatric assessment can be valuable in oncology practice to address this issue. In this review article, we will focus only on systemic treatment and will discuss "standard" adjuvant systemic treatment strategies for fit older breast cancer patients and the role of "personalized" systemic therapy in unfit patients. The concepts conveyed in this review cannot be extrapolated to locoregional therapy.
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Affiliation(s)
- Anna Rachelle Mislang
- Sandro Pitigliani Medical Oncology Unit, Nuovo Ospedale Santo Stefano, Instituto Toscano Tumori, 59100 Prato, Italy
| | - Laura Biganzoli
- Sandro Pitigliani Medical Oncology Unit, Nuovo Ospedale Santo Stefano, Instituto Toscano Tumori, 59100 Prato, Italy.
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Freedman O, Fletcher G, Gandhi S, Mates M, Dent S, Trudeau M, Eisen A. Adjuvant endocrine therapy for early breast cancer: a systematic review of the evidence for the 2014 Cancer Care Ontario systemic therapy guideline. Curr Oncol 2015; 22:S95-S113. [PMID: 25848344 PMCID: PMC4381796 DOI: 10.3747/co.22.2326] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cancer Care Ontario's Program in Evidence-Based Care (pebc) recently created an evidence-based consensus guideline on the systemic treatment of early breast cancer. The evidence for the guideline was compiled using a systematic review to answer the question "What is the optimal systemic therapy for patients with early-stage, operable breast cancer, when patient and disease factors are considered?" The question was addressed in three parts: cytotoxic chemotherapy, endocrine treatment, and her2 (human epidermal growth factor receptor 2)-targeted therapy. METHODS For the systematic review, the literature in the medline and embase databases was searched for the period January 2008 to May 2014. The Standards and Guidelines Evidence directory of cancer guidelines and the Web sites of major oncology guideline organizations were also searched. The basic search terms were "breast cancer" and "systemic therapy" (chemotherapy, endocrine therapy, targeted agents, ovarian suppression), and results were limited to randomized controlled trials (rcts), guidelines, systematic reviews, and meta-analyses. RESULTS Several hundred documents that met the inclusion criteria were retrieved. Meta-analyses from the Early Breast Cancer Trialists' Collaborative Group encompassed many of the rcts found. Several additional studies that met the inclusion criteria were retained, as were other guidelines and systematic reviews. SUMMARY The results of the systematic review constitute a comprehensive compilation of high-level evidence, which was the basis for the 2014 pebc guideline on systemic therapy for early breast cancer. The review of the evidence for systemic endocrine therapy (adjuvant tamoxifen, aromatase inhibitors, and ovarian ablation and suppression) is presented here; the evidence for chemotherapy and her2-targeted treatment-and the final clinical practice recommendations-are presented separately in this supplement.
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Affiliation(s)
| | - G.G. Fletcher
- Program in Evidence-Based Care, Cancer Care Ontario; and Department of Oncology, McMaster University, Hamilton, ON
| | - S. Gandhi
- Sunnybrook Health Science Centre, Toronto, ON
| | - M. Mates
- Cancer Centre of Southeastern Ontario, Kinston General Hospital, and Queen’s University, Kingston, ON
| | - S.F. Dent
- The Ottawa Hospital Cancer Centre and University of Ottawa, Ottawa, ON
| | | | - A. Eisen
- Durham Regional Cancer Centre, Oshawa, ON
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Le Saux O, Ripamonti B, Bruyas A, Bonin O, Freyer G, Bonnefoy M, Falandry C. Optimal management of breast cancer in the elderly patient: current perspectives. Clin Interv Aging 2015; 10:157-74. [PMID: 25609933 PMCID: PMC4293298 DOI: 10.2147/cia.s50670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Olivia Le Saux
- Medical Oncology Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Bertrand Ripamonti
- Gynaecology-Obstetrics Department, University Hospital, Saint-Etienne, France
| | - Amandine Bruyas
- Croix Rousse University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France ; Lyon University, Lyon, France
| | | | - Gilles Freyer
- Medical Oncology Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France ; Lyon University, Lyon, France
| | - Marc Bonnefoy
- Lyon University, Lyon, France ; Geriatric Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Claire Falandry
- Lyon University, Lyon, France ; Geriatric Unit, Lyon Sud University Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
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Abstract
Minimizing toxicity while maximizing efficacy is a common goal in the treatment of any condition but its importance is underscored in the discipline of oncology because of the serious nature of many chemotherapeutic toxicities and the risk of cancer recurrence or disease progression. The challenge of achieving an optimal therapeutic index is especially augmented in the elderly population because of age-related metabolism changes and interacting concurrent medications. Additional factors, such as germline mutations in drug-metabolizing enzymes and other pharmacogenomic alterations, may have more pronounced effects in elderly patients, given their predisposition to altered pharmacokinetics and pharmacodynamics with resulting increased risk of toxicity. Examples of the possible interplay of these factors will be discussed using tamoxifen, paclitaxel, codeine, and fluorouracil as starting points. Limited participation of the elderly in many cancer trials, especially trials assessing drug exposure, makes much knowledge on the interaction of these patient and environmental factors speculative in nature but presents an opportunity for future research to achieve better optimization of chemotherapeutic agents in the elderly.
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Mariano C, Francl M, Pope J, Wong L, Lim HJ, Lohrisch C. Comparison of toxicity experienced by older versus younger patients enrolled in breast cancer clinical trials. Clin Breast Cancer 2014; 15:73-9. [PMID: 25445420 DOI: 10.1016/j.clbc.2014.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 09/06/2014] [Accepted: 09/17/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Elderly patients form a large proportion of patients with breast cancer but are underrepresented in clinical trials. We examined whether elderly patients experience more toxicity than younger patients within breast cancer clinical trials. MATERIALS AND METHODS All breast cancer trials open from 1999 to 2012 at BCCA, Vancouver Center, were reviewed. The primary endpoint was meaningful toxicity (MTOX), defined as any grade 3 or 4 adverse event (AE), any AE leading to dose delay or reduction, or premature discontinuation of therapy. RESULTS In the 46 trials enrolling 799 patients, the therapy given was chemotherapy to 18% of the patients, hormonal therapy to 40%, skeletal therapy to 14%, and targeted therapy and a combination of chemotherapy and targeted therapy to 14%. Elderly patients were more likely to enroll in hormonal and skeletal therapy trials, and younger patients were evenly distributed among the therapy types. Toxicity data were available for 778 patients (97%). Elderly patients and younger patients experienced a similar number and frequency of MTOX. The therapy type was the strongest predictor of toxicity on multivariate analysis. In non-chemotherapy-containing trials, elderly and younger patients had a similar frequency and number of toxicities. Few elderly patients were enrolled in cytotoxic chemotherapy trials, but they experienced no more toxicity than did the younger patients. CONCLUSION The appropriate selection of elderly patients using eligibility criteria, self selection, and/or clinician assessment will allow safe participation of elderly patients in breast cancer trials.
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Affiliation(s)
- Caroline Mariano
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada.
| | - Mia Francl
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Janice Pope
- Clinical Trials Unit, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Linda Wong
- Clinical Trials Unit, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Howard J Lim
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Caroline Lohrisch
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
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Abdel-Rahman O, ElHalawani H. Adjuvant systemic treatment for elderly breast cancer patients; addressing safety concerns. Expert Opin Drug Saf 2014; 13:1443-67. [PMID: 25244502 DOI: 10.1517/14740338.2014.955848] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Omar Abdel-Rahman
- Ain Shams University, Clinical Oncology Department, Faculty of Medicine , Lotfy Elsayed street, Cairo, Postal code: 11665 , Egypt +20 33028656 ;
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Garimella V, Hussain T, Agarwal V, Radhakrishna S, Fox JN, Kneeshaw PJ, Long ED, Mahapatra TK, McManus PL, Lind MJ, Drew PJ, Cawkwell L. Clinical response to primary letrozole therapy in elderly patients with early breast cancer: possible role for p53 as a biomarker. Int J Surg 2014; 12:821-6. [PMID: 25010604 DOI: 10.1016/j.ijsu.2014.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 06/16/2014] [Accepted: 06/20/2014] [Indexed: 01/23/2023]
Abstract
Primary tamoxifen therapy has been widely used to treat elderly women with ER-positive breast cancer in the past. Aromatase inhibitors may be more beneficial than tamoxifen when used as primary endocrine therapy in elderly patients. We aimed to retrospectively evaluate a series of elderly women with ER-positive breast cancer treated with primary letrozole therapy as sole therapy with a minimum of 5 years follow up. To identify possible predictive biomarkers a pilot immunohistochemical analysis was performed to assess the expression of PR, HER2, EGFR, BCL2 and p53. A total of 45 women, aged more than 70 years with a diagnosis of ER-positive breast cancer that was treated with primary letrozole therapy were identified. A case note review was undertaken to obtain clinical information. Formalin fixed paraffin embedded tumour tissue from diagnostic core biopsies was available for all patients. Immunohistochemical analysis was performed to establish the protein expression status of p53, PR, HER2, EGFR and BCL2. The mean age of the 45 patients was 87 years (range 70-101). Clinical benefit was seen in 60% of the patients. Median progression free survival was 53 months (95% CI - 34-72) and the median time to progression was 43 months (95% CI - 22-64). BCL2 was expressed in 45/45 (100%); PR in 38/45 (84%); EGFR in 13/45 (28%); HER2 in 9/45 (20%) and p53 in 5/45 (11%) of tissue samples. Positive expression of p53 was associated with poor progression free survival (p = 0.03) in this pilot study. This study demonstrates that letrozole as sole treatment appears to be a suitable treatment option for elderly patients with ER-positive breast cancer who are not fit for, or decline, surgery. The analysis of p53 in a larger study is warranted in order to assess its role as a biomarker in this patient group.
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Affiliation(s)
- Veerabhadram Garimella
- Postgraduate Medical Institute of the University of Hull, Hull, UK; Breast Care Unit, Hull and East Yorkshire NHS Trust, Hull, UK
| | - Tasadooq Hussain
- Postgraduate Medical Institute of the University of Hull, Hull, UK; Breast Care Unit, Hull and East Yorkshire NHS Trust, Hull, UK; Hull York Medical School, Hull, UK
| | - Vijay Agarwal
- Postgraduate Medical Institute of the University of Hull, Hull, UK; Queens Centre for Oncology and Haematology, Hull and East Yorkshire NHS Trust, Hull, UK; Hull York Medical School, Hull, UK
| | - Selvi Radhakrishna
- Postgraduate Medical Institute of the University of Hull, Hull, UK; Breast Care Unit, Hull and East Yorkshire NHS Trust, Hull, UK
| | - John N Fox
- Breast Care Unit, Hull and East Yorkshire NHS Trust, Hull, UK
| | | | - Ervine D Long
- Histopathology Department, Hull and East Yorkshire NHS Trust, Hull, UK
| | | | | | - Michael J Lind
- Postgraduate Medical Institute of the University of Hull, Hull, UK; Queens Centre for Oncology and Haematology, Hull and East Yorkshire NHS Trust, Hull, UK; Hull York Medical School, Hull, UK
| | - Philip J Drew
- Postgraduate Medical Institute of the University of Hull, Hull, UK; Breast Care Unit, Hull and East Yorkshire NHS Trust, Hull, UK; Hull York Medical School, Hull, UK
| | - Lynn Cawkwell
- Postgraduate Medical Institute of the University of Hull, Hull, UK; Hull York Medical School, Hull, UK.
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Lee HS, Lee JY, Ah YM, Kim HS, Im SA, Noh DY, Lee BK. Low adherence to upfront and extended adjuvant letrozole therapy among early breast cancer patients in a clinical practice setting. Oncology 2014; 86:340-9. [PMID: 24925302 DOI: 10.1159/000360702] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 02/15/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the prevalence and causes of early discontinuation and non-adherence to upfront and extended adjuvant letrozole therapy in breast cancer patients. METHODS Adherence was assessed using medical charts and longitudinal pharmacy records of 609 patients who initiated adjuvant letrozole between January 2002 and April 2011. A Cox proportional hazards regression model was adopted to identify potential predictors of non-adherence. RESULTS The overall adherence rate after 1 year of therapy was 79.5%, with cumulative rates declining to 63.7% after 3 years and 57.1% after 5 years. A significantly lower rate of adherence in the extended adjuvant group was observed compared with the upfront adjuvant group (49.0 vs. 72.5%, p < 0.001). Adverse events (50.4%) were the major cause of early discontinuation, with musculoskeletal pain (73.2%) being the single most cited reason. Additional factors correlating with non-adherence in the upfront adjuvant group included a delay in initiation of adjuvant hormone therapy, breast-conserving surgery, calcium supplements, bisphosphonate therapy and concomitant medication for co-morbidity. CONCLUSIONS We observed that approximately 57% of patients fully adhered to letrozole therapy over a 5-year treatment period, and that the adherence to extended letrozole was meaningfully lower than the upfront adjuvant letrozole in a clinical practice setting.
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Affiliation(s)
- Hye-Suk Lee
- Division of Life and Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul, South Korea
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Knutson TP, Lange CA. Tracking progesterone receptor-mediated actions in breast cancer. Pharmacol Ther 2014; 142:114-25. [PMID: 24291072 PMCID: PMC3943696 DOI: 10.1016/j.pharmthera.2013.11.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 11/15/2013] [Indexed: 12/13/2022]
Abstract
Ovarian steroid hormones contribute to breast cancer initiation and progression primarily through the actions of their nuclear transcription factors, the estrogen receptor alpha (ERα) and progesterone receptors (PRs). These receptors are important drivers of the luminal A and B subtypes of breast cancer, where estrogen-blocking drugs have been effective endocrine therapies for patients with these tumors. However, many patients do not respond, or become resistant to treatment. When endocrine therapies fail, the luminal subtypes of breast cancer are more difficult to treat because these subtypes are among the most heterogeneous in terms of mutation diversity and gene expression profiles. Recent evidence suggests that progestin and PR actions may be important drivers of luminal breast cancers. Clinical trial data has demonstrated that hormone replacement therapy with progestins drives invasive breast cancer and results in greater mortality. PR transcriptional activity is dependent upon cross-talk with growth factor signaling pathways that alter PR phosphorylation, acetylation, or SUMOylation as mechanisms for regulating PR target gene selection required for increased cell proliferation and survival. Site-specific PR phosphorylation is the primary driver of gene-selective PR transcriptional activity. However, PR phosphorylation and heightened transcriptional activity is coupled to rapid PR protein degradation; the range of active PR detected in tumors is likely to be dynamic. Thus, PR target gene signatures may provide a more accurate means of tracking PR's contribution to tumor progression rather than standard clinical protein-based (IHC) assays. Further development of antiprogestin therapies should be considered alongside antiestrogens and aromatase inhibitors.
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Affiliation(s)
- Todd P Knutson
- Departments of Medicine, Division of Hematology, Oncology, and Transplantation and Pharmacology, Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA
| | - Carol A Lange
- Departments of Medicine, Division of Hematology, Oncology, and Transplantation and Pharmacology, Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA.
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Simon R, Latreille J, Matte C, Desjardins P, Bergeron E. Adherence to adjuvant endocrine therapy in estrogen receptor-positive breast cancer patients with regular follow-up. Can J Surg 2014; 57:26-32. [PMID: 24461223 DOI: 10.1503/cjs.006211] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Adjuvant hormonal therapy is crucial in the treatment of estrogen receptor-positive breast cancer. The nonadherence rate to hormonal treatment is reported to be as high as 60%. The goal of this study was to evaluate the factors evoked by the patients as well as the demographic and disease-related factors that could be associated with nonadherence to adjuvant hormonal therapy. METHODS All consecutive patients treated for an estrogen receptor-positive breast cancer who showed up for regular follow-up with a single breast specialist between November 2008 and April 2009 were included in the study. We assessed adherence to hormonal therapy (either with tamoxifen or aromatase inhibitor). Reasons for adherence and nonadherence were collected. Records were also reviewed for demographic and cancer characteristics and for treatment components. RESULTS We included 161 patients in the study; 150 (93.2%) adhered to hormonal treatment. Side effects and absence of conviction were the main reasons for nonadherence. The importance of the diagnosis of cancer, fear of recurrence and regular follow-up were reported as the main reasons for adherence. CONCLUSION Severity of disease and side effects are associated with nonadherence to treatment. Strict follow-up appears to be a necessary adjunct in the adherence to treatment. The association between demographic and cancer characteristics and treatment components needs further investigation. However, these factors may help identify patients at risk of nonadherence and help the oncology team.
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Affiliation(s)
- Renée Simon
- The Department of Surgery, Hôpital Charles LeMoyne, Greenfield Park, and the Centre Intégré de Cancérologie, Montérégie, Que
| | - Jean Latreille
- The Department of Oncology, Hôpital Charles LeMoyne, Greenfield Park, and the Centre Intégré de Cancérologie, Montérégie, Que
| | - Claire Matte
- The Department of Surgery, Hôpital Charles LeMoyne, Greenfield Park, and the Centre Intégré de Cancérologie, Montérégie, Que
| | - Pierre Desjardins
- The Department of Oncology, Hôpital Charles LeMoyne, Greenfield Park, Que., Centre Intégré de Cancérologie, Montérégie, Que
| | - Eric Bergeron
- The Department of Surgery, Hôpital Charles LeMoyne, Greenfield Park, Que
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Huiart L, Bouhnik AD, Rey D, Rousseau F, Retornaz F, Meresse M, Bendiane MK, Viens P, Giorgi R. Complementary or alternative medicine as possible determinant of decreased persistence to aromatase inhibitor therapy among older women with non-metastatic breast cancer. PLoS One 2013; 8:e81677. [PMID: 24367488 PMCID: PMC3867346 DOI: 10.1371/journal.pone.0081677] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 10/15/2013] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Aromatase inhibitor therapy (AI) significantly improves survival in breast cancer patients. Little is known about adherence and persistence to aromatase inhibitors and about the causes of treatment discontinuation among older women. METHODS We constituted a cohort of women over 65 receiving a first AI therapy for breast cancer between 2006 and 2008, and followed them until June 2011. Women were selected in the population-based French National Health Insurance databases, and data was collected on the basis of pharmacy refills, medical records and face-to-face interviews. Non-persistence to treatment was defined as the first treatment discontinuation lasting more than 3 consecutive months. Time to treatment discontinuation was studied using survival analysis techniques. RESULTS Overall among the 382 selected women, non-persistence to treatment went from 8.7% (95%CI: 6.2-12.1) at 1 year, to 15.6% (95%CI: 12.2-19.8) at 2 years, 20.8% (95%CI: 16.7-25.6) at 3 years, and 24.7% (95%CI: 19.5-31.0) at 4 years. In the multivariate analysis on a sub-sample of 233 women with available data, women using complementary or alternative medicine (CAM) (HR = 3.2; 95%CI: 1.5-6.9) or suffering from comorbidities (HR = 2.2; 95%CI: 1.0-4.8) were more likely to discontinue their treatment, whereas women with polypharmacy (HR = 0.4; 95%CI: 0.2-0.91) were less likely to discontinue. In addition, 13% of the women with positive hormonal receptor status did not fill any prescription for anti-hormonal therapy. CONCLUSION AI therapy is discontinued prematurely in a substantial portion of older patients. Some patients may use CAM not as a complementary treatment, but as an alternative to conventional medicine. Improving patient-physician communication on the use of CAM may improve hormonal therapy adherence.
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Affiliation(s)
- Laetitia Huiart
- Unité de Soutien Méthodologique, CHU La Réunion, Saint-Denis, France
- U912 (SESSTIM), INSERM, Marseille, France
- Université Aix Marseille, IRD, UMR-S912, Marseille, France
| | - Anne-Deborah Bouhnik
- U912 (SESSTIM), INSERM, Marseille, France
- Université Aix Marseille, IRD, UMR-S912, Marseille, France
| | - Dominique Rey
- U912 (SESSTIM), INSERM, Marseille, France
- Université Aix Marseille, IRD, UMR-S912, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | | | | | - Mégane Meresse
- U912 (SESSTIM), INSERM, Marseille, France
- Université Aix Marseille, IRD, UMR-S912, Marseille, France
| | - Marc Karim Bendiane
- U912 (SESSTIM), INSERM, Marseille, France
- Université Aix Marseille, IRD, UMR-S912, Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d'Azur, Marseille, France
| | - Patrice Viens
- Medical Oncology Department, Institut Paoli-Calmettes, Marseille, France
- Université Aix Marseille, Centre de Recherche en Cancérologie de Marseille, INSERM U891, Marseille, France
| | - Roch Giorgi
- U912 (SESSTIM), INSERM, Marseille, France
- Université Aix Marseille, IRD, UMR-S912, Marseille, France
- Service Biostatistique et Technologies de l'Information et de la Communication, Hôpital de la Timone, Assistance Publique – Hopitaux de Marseille, Marseille, France
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Mandelblatt JS, Hurria A, McDonald BC, Saykin AJ, Stern RA, VanMeter JW, McGuckin M, Traina T, Denduluri N, Turner S, Howard D, Jacobsen PB, Ahles T. Cognitive effects of cancer and its treatments at the intersection of aging: what do we know; what do we need to know? Semin Oncol 2013; 40:709-25. [PMID: 24331192 PMCID: PMC3880205 DOI: 10.1053/j.seminoncol.2013.09.006] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
There is a fairly consistent, albeit non-universal body of research documenting cognitive declines after cancer and its treatments. While few of these studies have included subjects aged 65 years and older, it is logical to expect that older patients are at risk of cognitive decline. Here, we use breast cancer as an exemplar disease for inquiry into the intersection of aging and cognitive effects of cancer and its therapies. There are a striking number of common underlying potential biological risks and pathways for the development of cancer, cancer-related cognitive declines, and aging processes, including the development of a frail phenotype. Candidate shared pathways include changes in hormonal milieu, inflammation, oxidative stress, DNA damage and compromised DNA repair, genetic susceptibility, decreased brain blood flow or disruption of the blood-brain barrier, direct neurotoxicity, decreased telomere length, and cell senescence. There also are similar structure and functional changes seen in brain imaging studies of cancer patients and those seen with "normal" aging and Alzheimer's disease. Disentangling the role of these overlapping processes is difficult since they require aged animal models and large samples of older human subjects. From what we do know, frailty and its low cognitive reserve seem to be a clinically useful marker of risk for cognitive decline after cancer and its treatments. This and other results from this review suggest the value of geriatric assessments to identify older patients at the highest risk of cognitive decline. Further research is needed to understand the interactions between aging, genetic predisposition, lifestyle factors, and frailty phenotypes to best identify the subgroups of older patients at greatest risk for decline and to develop behavioral and pharmacological interventions targeting this group. We recommend that basic science and population trials be developed specifically for older hosts with intermediate endpoints of relevance to this group, including cognitive function and trajectories of frailty. Clinicians and their older patients can advance the field by active encouragement of and participation in research designed to improve the care and outcomes of the growing population of older cancer patients.
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Affiliation(s)
- Jeanne S Mandelblatt
- Departments of Oncology and Population Sciences, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC.
| | - Arti Hurria
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Brenna C McDonald
- Center for Neuroimaging, Department of Radiology and Imaging Sciences and the Melvin and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Andrew J Saykin
- Center for Neuroimaging, Department of Radiology and Imaging Sciences and the Melvin and Bren Simon Cancer Center, Indiana University School of Medicine, Indianapolis, IN
| | - Robert A Stern
- Departments of Neurology and Neurosurgery and Director, Clinical Core, BU Alzheimer's Disease Center, Boston University School of Medicine, Boston, MA
| | - John W VanMeter
- Department of Neurology, Georgetown University Medical Center, Georgetown University, Washington, DC
| | - Meghan McGuckin
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Tiffani Traina
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Neelima Denduluri
- Department of Medicine, Georgetown University; Virginia Cancer Specialists, US Oncology, Arlington, VA
| | - Scott Turner
- Department of Neurology, Georgetown University Medical Center, Georgetown University, Washington, DC
| | - Darlene Howard
- Department of Psychology, Georgetown University, Washington, DC
| | - Paul B Jacobsen
- Division of Population Science, Moffitt Cancer Center, Tampa, FL
| | - Tim Ahles
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY; Department of Psychiatry, Weill Cornell Medical College, New York, NY
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Luque M, Arranz F, Cueva JF, de Juan A, García-Teijido P, Calvo L, Peláez I, García-Palomo A, García-Mata J, Antolín S, García-Estévez L, Fernández Y. Breast cancer management in the elderly. Clin Transl Oncol 2013; 16:351-61. [PMID: 24085574 DOI: 10.1007/s12094-013-1113-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 09/15/2013] [Indexed: 01/02/2023]
Abstract
The increase in life expectancy in the western world means that we are faced with patients diagnosed with breast cancer in old age with increasing frequency. The management of these cases is a challenge for the oncologist, who must take into account the conditions associated with advanced age and the lack of trials in this population. In this review, we addressed the incorporation of geriatric assessment methods that may be useful in making decisions, the particular biological characteristics of breast cancer in elderly patients and their treatment in both localized and advanced disease. Finally, we collected recommendations based on scientific evidence regarding the monitoring and life-style after finishing treatment.
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Affiliation(s)
- M Luque
- Medical Oncology Department, Hospital Universitario Central de Asturias, C/Julian Clavería s/n, 33006, Oviedo, Spain,
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Ayres LR, Baldoni ADO, Borges APDS, Pereira LRL. Adherence and discontinuation of oral hormonal therapy in patients with hormone receptor positive breast cancer. Int J Clin Pharm 2013; 36:45-54. [PMID: 23934310 DOI: 10.1007/s11096-013-9833-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 07/27/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Oral treatment in women with breast cancer has been increasingly used. However, a potentially negative side of oral medication is poor patient adherence and/or discontinuation, which reduces the treatment effectiveness, accelerating progression of the disease and reducing the patient survival rate. AIM OF THE REVIEW To compare the rates of adherence and/or discontinuation and the methodologies used to assess these outcomes. It was conducted an integrative review of original articles published from 2000 to 2012, in which their primary outcome was to quantify medication adherence and/or discontinuation of oral hormonal therapy in patients with hormone receptor positive breast cancer. METHODS Original studies were searched in the PubMed/MEDLINE, Scopus, Embase and SciELO databases. The Medical Subject Heading was used to define descriptors. The descriptor "breast neoplasms" was used in all combinations. Each of the descriptors "medication adherence" and "patient compliance" were combined with each of the following descriptors "tamoxifen", "aromatase inhibitors", "selective estrogen receptor modulators", or the terms "letrozole", "anastrozole", and "exemestane". RESULTS Twenty-four original articles were included. Our study showed a wide range of adherence and discontinuation rates, ranging from 45-95.7 and 12-73 %, respectively. Regarding the methodological development of the selected articles, a high prevalence (87.5 %) of prospective and/or retrospective longitudinal studies was found. In addition, there was a high prevalence of studies using a database (70.8 %). Among some of the studies, it was shown that patient adherence to hormonal therapy gradually reduces, while discontinuation increases during the treatment. CONCLUSIONS It was observed a great diversity among rates of adherence and/or discontinuation of hormonal therapy for breast cancer, which may be due to a lack of methodology standardization. Therefore, adequate and validated methods to ensure reliability of the results and allow comparison in the literature are needed. Furthermore, adherence decreases and discontinuation increases over time, suggesting the need for patient continuous education and a pharmacotherapeutic follow up by health professionals to improve these clinical outcomes.
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Affiliation(s)
- Lorena Rocha Ayres
- Departamento de Ciências Farmacêuticas, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Centro de Pesquisa em Assistência Farmacêutica e Farmácia Clínica (CPAFF), Universidade de São Paulo, Avenida do Café, s/no., Campus Universitário da USP, Ribeirão Preto, SP, 14040-903, Brazil,
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Hashem MG, Cleary K, Fishman D, Nichols L, Khalid M. Effect of concurrent prescription antiarthralgia pharmacotherapy on persistence to aromatase inhibitors in treatment-naive postmenopausal females. Ann Pharmacother 2013; 47:29-34. [PMID: 23324501 DOI: 10.1345/aph.1r369] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Aromatase inhibitors function by suppressing estrogen biosynthesis in peripheral tissues. The resulting estrogen deprivation is considered the underlying cause for aromatase inhibitor-induced arthralgia, which affects patients' quality of life and may affect their persistence to aromatase inhibitor therapy. The effect of concurrent treatment with aromatase inhibitors and prescription antiarthralgia pharmacotherapy on improving persistence to aromatase inhibitor therapy is unknown. OBJECTIVE To evaluate the effect of concurrent prescription antiarthralgia pharmacotherapy on persistence to aromatase inhibitor therapy in treatment-naïve postmenopausal women. METHODS This retrospective cohort pharmacy claims study examined the drug utilization pattern between July 2008 and October 2009 of postmenopausal females, naïve to aromatase inhibitor therapy, with 18 months of continuous prescription benefit eligibility. Patients were divided into 2 groups: group A (control) included patients who did not have a claim for a prescription antiarthralgia medication in a 1-year follow-up period, while group B (active) included patients with prescription antiarthralgia medications started within the 1-year follow-up period after starting treatment with an aromatase inhibitor. Persistence to aromatase inhibitor therapy was compared between the 2 groups. RESULTS The study population comprised 29,967 patients: 24,804 (82.8%) in group A, and 5163 (17.2%) in group B. Aromatase inhibitor discontinuation rates within the first year of therapy were not statistically significantly different between groups: 40.9% in group A (10,145/24,804) and 34.5% in group B (1781/5163) (HR 1.127; 95% CI 0.900-1.411; p = 0.297). Persistence for the 2 groups did not differ statistically significantly for any of the 3 aromatase inhibitors measured separately. CONCLUSIONS Postmenopausal females treatment-naïve to aromatase inhibitor therapy who also received treatment with a prescription antiarthralgia medication did not have significantly higher persistence with aromatase inhibitor therapy. Further research should focus on other possible causes of poor persistence in patients using aromatase inhibitor therapy.
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Becker T, Lipscombe L, Narod S, Simmons C, Anderson GM, Rochon PA. Systematic review of bone health in older women treated with aromatase inhibitors for early-stage breast cancer. J Am Geriatr Soc 2012; 60:1761-7. [PMID: 22985145 DOI: 10.1111/j.1532-5415.2012.04107.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To review data from randomized controlled trials (RCTs) that evaluate adverse bone outcomes in older women using aromatase inhibitors (AIs) for early-stage hormone receptor-positive breast cancer. DESIGN Systematic review. SETTING International RCTs referenced in Medline and EMBASE databases through August 1, 2011. PARTICIPANTS Postmenopausal women with early-stage hormone receptor-positive breast cancer receiving adjuvant endocrine therapy. MEASUREMENTS Fracture rates and changes in bone turnover markers and bone mineral density. RESULTS Eleven RCTs were identified. The majority of trials included women with a mean age in the 60s; and women aged 75 and older and 80 and older were excluded from two studies. Fracture rates ranged from 0.9% to 11%, with AIs having a 1.5 times higher risk than tamoxifen or placebo. Fracture data were not systematically collected in many of these trials. In a small subpopulation of women, AIs were associated with higher markers of bone turnover and lower bone density. The relationship between age and fracture was not described. CONCLUSION AIs are associated with low bone density and high fracture risk in women with a mean age in their early 60s. There is a paucity of data describing the effect of baseline fracture risk factors, particularly age, and the longer-term effects on bone health in older women. Future research is needed regarding baseline fracture risk, interventions, and long-term effects on bone in this vulnerable population to inform management decisions to optimize AI duration and ensure quality of life after breast cancer.
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Affiliation(s)
- Taryn Becker
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Khan AJ, Haffty BG. Issues in the Curative Therapy of Breast Cancer in Elderly Women. Semin Radiat Oncol 2012; 22:295-303. [DOI: 10.1016/j.semradonc.2012.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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47
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McCowan C, Thompson AM. The importance of nonpharmacogenetic factors in endocrine therapy. Pharmacogenomics 2012; 13:721-8. [PMID: 22515614 DOI: 10.2217/pgs.12.29] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Nonpharmacogenetic factors may play a key role in the success of oral endocrine therapy for breast cancer. Adherence, defined as following medical advice as well as persistence and duration of use for patients prescribed endocrine therapy, may impact significantly on recurrence and survival. Side effects from tamoxifen or aromatase inhibitors may lead to patients stopping or switching therapy, while comorbidities, consequent coprescribing and patient perceptions may also influence outcomes. Interventions to improve adherence and persistence are required and could have as great an effect on survival as applying pharmacogenetic principles to the endocrine management of breast cancer.
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Affiliation(s)
- Colin McCowan
- Dundee Cancer Centre, Ninewells Hospital & Medical School, Dundee, DD1 9SY, UK
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Joerger M, Thürlimann B, Savidan A, Frick H, Rageth C, Lütolf U, Vlastos G, Bouchardy C, Konzelmann I, Bordoni A, Probst-Hensch N, Jundt G, Ess S. Treatment of breast cancer in the elderly: a prospective, population-based Swiss study. J Geriatr Oncol 2012; 4:39-47. [PMID: 24071491 DOI: 10.1016/j.jgo.2012.08.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 06/16/2012] [Accepted: 08/03/2012] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The primary objective of this population-based study is to describe the patterns of care of elderly patients with breast cancer (BC), and evaluate potential causative factors for the decrease in BC-specific survival (BCSS) in the elderly. PATIENTS AND METHODS We included all or representative samples of patients with newly diagnosed BC from seven Swiss cancer registries between 2003 and 2005 (n=4820). Surgical and non-surgical BC treatment was analyzed over 5 age groups (<65, 65 to <70, 70 to <75, 75 to <80 and ≥80years), and the predictive impact of patient age on specific treatments was calculated using multivariate logistic regression analysis. RESULTS The proportion of locally advanced, metastatic and incompletely staged BC increased with age. The odds ratio for performing breast-conserving surgery (BCS) in stages I-II BC (0.37), sentinel lymph node dissection (SLND) in patients with no palpable adenopathy (0.58), post-BCS radiotherapy (0.04) and adjuvant endocrine treatment (0.23) were all in disfavor of patients ≥80years of age compared to their younger peers. Only 36% of patients ≥80years of age with no palpable adenopathy underwent SLND. In the adjusted model, higher age was a significant risk factor for omitting post-BCS radiotherapy, SLND and adjuvant endocrine treatment. CONCLUSIONS This study found an increase in incomplete diagnostic assessment, and a substantial underuse of BCS, post-BCS radiotherapy, SLND and adjuvant endocrine treatment in elderly patients with BC. There is a need for improved management of early BC in the elderly even in a system with universal access to health care services.
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Affiliation(s)
- M Joerger
- Cancer Registry St. Gallen-Appenzell, St.Gallen, Switzerland; Department of Medical Oncology, Cantonal Hospital, St. Gallen, Switzerland.
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Age effect on bone mineral density changes in breast cancer patients receiving anastrozole: results from the ARBI prospective clinical trial. J Cancer Res Clin Oncol 2012; 138:1569-77. [PMID: 22552718 PMCID: PMC3418493 DOI: 10.1007/s00432-012-1233-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/10/2012] [Indexed: 11/09/2022]
Abstract
Purpose We investigated whether age at anastrozole (A) initiation influences the effect of treatment on bone mineral density (BMD). We conducted a post hoc analysis of the dataset of Arimidex Bone Mass Index Oral Bisphosphonates prospective trial, studying the effect of risedronate (R) on BMD of postmenopausal, early breast cancer patients receiving A. Methods Patients were stratified into those with normal BMD or mild osteopenia (T > −2) receiving A-only and patients with mild or severe osteopenia (T ≤ −2) or osteoporosis (T < −2.5) receiving A and per os R (A + R). Depending on age on treatment initiation, patients were grouped into two age cohorts, above and below 65 years. BMD change in lumbar spine (LS) and hip (HP) was evaluated at 12 months. An analysis of patients with normal BMD at baseline was additionally performed. Results Among patients receiving A-only, women ≤65 years were more likely to have a decrease in LS-BMD than older (p = 0.034). HP-BMD decrease at 12 months was not related to age (p = 0.182). In patients with mild or severe osteopenia or osteoporosis, treated with A + R, no age effect was observed for LS or HP (p = 0.099 and p = 0.939, respectively). Among patients with normal BMD at baseline, the age effect on LS-BMD change was more profound (p = 0.026). Conclusions Our study suggests that younger postmenopausal women with normal BMD or mild osteopenia receiving A-only face an increased risk of bone loss in LS. Among patients with mild or severe osteopenia or osteoporosis treated with A + R, 12 months LS or HP BMD variations were configured regardless of age group.
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50
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Biganzoli L, Wildiers H, Oakman C, Marotti L, Loibl S, Kunkler I, Reed M, Ciatto S, Voogd AC, Brain E, Cutuli B, Terret C, Gosney M, Aapro M, Audisio R. Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA). Lancet Oncol 2012; 13:e148-60. [PMID: 22469125 DOI: 10.1016/s1470-2045(11)70383-7] [Citation(s) in RCA: 394] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
As the mean age of the global population increases, breast cancer in older individuals will be increasingly encountered in clinical practice. Management decisions should not be based on age alone. Establishing recommendations for management of older individuals with breast cancer is challenging because of very limited level 1 evidence in this heterogeneous population. In 2007, the International Society of Geriatric Oncology (SIOG) created a task force to provide evidence-based recommendations for the management of breast cancer in elderly individuals. In 2010, a multidisciplinary SIOG and European Society of Breast Cancer Specialists (EUSOMA) task force gathered to expand and update the 2007 recommendations. The recommendations were expanded to include geriatric assessment, competing causes of mortality, ductal carcinoma in situ, drug safety and compliance, patient preferences, barriers to treatment, and male breast cancer. Recommendations were updated for screening, primary endocrine therapy, surgery, radiotherapy, neoadjuvant and adjuvant systemic therapy, and metastatic breast cancer.
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Affiliation(s)
- Laura Biganzoli
- Sandro Pitigliani Medical Oncology Unit, Istituto Toscano Tumori, Hospital of Prato, Prato, Italy.
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