Breast cancer among the oldest old: tumor characteristics, treatment choices, and survival

Physician-level variation in axillary surgery in older adults with T1N0 hormone receptor-positive breast cancer: A retrospective population-based cohort study

INTRODUCTION

We sought to determine how considerations specific to older adults impact between- and within-surgeon variation in axillary surgery use in women ≥70 years with T1N0 HR+ breast cancer.

MATERIALS AND METHODS

Females ≥70 years with T1N0 HR+/HER2-negative breast cancer diagnosed from 2013 to 2015 in SEER-Medicare were identified and linked to the American Medical Association Masterfile. The outcome of interest was axillary surgery. Key patient-level variables included the Charlson Comorbidity Index (CCI) score, frailty (based on a claims-based frailty index score), and age (≥75 vs <75). Multilevel mixed models with surgeon clusters were used to estimate the intracluster correlation coefficient (ICC) (between-surgeon variance), with 1-ICC representing within-surgeon variance.

RESULTS

Of the 4410 participants included, 6.1% had a CCI score of ≥3, 20.7% were frail, and 58.3% were ≥ 75 years; 86.1% underwent axillary surgery. No surgeon omitted axillary surgery in all patients, but 42.3% of surgeons performed axillary surgery in all patients. In the null model, 10.5% of the variance in the axillary evaluation was attributable to between-surgeon differences. After adjusting for CCI score, frailty, and age in mixed models, between-surgeon variance increased to 13.0%.

DISCUSSION

In this population, axillary surgery varies more within surgeons than between surgeons, suggesting that surgeons are not taking an "all-or-nothing" approach. Comorbidities, frailty, and age accounted for a small proportion of the variation, suggesting nuanced decision-making may include additional, unmeasured factors such as differences in surgeon-patient communication.

Randomized Trial of Information for Older Women About Cessation of Breast Cancer Screening Invitations

BACKGROUND

Older women receive no information about why Australia's breast screening program (BreastScreen) invitations cease after 74 years. We tested how providing older women with the rationale for breast screening cessation impacted informed choice (adequate knowledge; screening attitudes aligned with intention).

METHODS

In a three-arm online randomized trial, eligible participants were females aged 70-74 years who had recently participated in breast screening (within 5 years), without personal breast cancer history, recruited through Qualtrics. Participants read a hypothetical scenario in which they received a BreastScreen letter reporting no abnormalities on their mammogram. They were randomized to receive the letter: (1) without any rationale for screening cessation (control); (2) with screening cessation rationale in printed-text form (e.g., downsides of screening outweigh the benefits after age 74); or (3) with screening cessation rationale presented in an animation video form. The primary outcome was informed choice about continuing/stopping breast screening beyond 74 years.

RESULTS

A total of 376 participant responses were analyzed. Compared to controls (n = 122), intervention arm participants (text [n = 132] or animation [n = 122]) were more likely to make an informed choice (control 18.0%; text 32.6%, p = .010; animation 40.5%, p < .001). Intervention arm participants had more adequate knowledge (control 23.8%; text 59.8%, p < .001; animation 68.9%, p < .001), lower screening intentions (control 17.2%; text 36.4%, p < .001; animation 49.2%, p < .001), and fewer positive screening attitudes regarding screening for themselves in the animation arm, but not in the text arm (control 65.6%; text 51.5%, p = .023; animation 40.2%, p < .001).

CONCLUSIONS

Providing information to older women about the rationale for breast cancer screening cessation increased informed decision-making in a hypothetical scenario. This study is an important first step in improving messaging provided by national cancer screening providers direct to older adults. Further research is needed to assess the impact of different elements of the intervention and the impact of providing this information in clinical practice, with more diverse samples.

TRIAL REGISTRATION

ANZCTRN12623000033640.

Modulation of tumor plasticity by senescent cells: Deciphering basic mechanisms and survival pathways to unravel therapeutic options

Senescence is a cellular state in which the cell loses its proliferative capacity, often irreversibly. Physiologically, it occurs due to a limited capacity of cell division associated with telomere shortening, the so-called replicative senescence. It can also be induced early due to DNA damage, oncogenic activation, oxidative stress, or damage to other cellular components (collectively named induced senescence). Tumor cells acquire the ability to bypass replicative senescence, thus ensuring the replicative immortality, a hallmark of cancer. Many anti-cancer therapies, however, can lead tumor cells to induced senescence. Initially, this response leads to a slowdown in tumor growth. However, the longstanding accumulation of senescent cells (SnCs) in tumors can promote neoplastic progression due to the enrichment of numerous molecules and extracellular vesicles that constitutes the senescence-associated secretory phenotype (SASP). Among other effects, SASP can potentiate or unlock the tumor plasticity and phenotypic transitions, another hallmark of cancer. This review discusses how SnCs can fuel mechanisms that underlie cancer plasticity, like cell differentiation, stemness, reprogramming, and epithelial-mesenchymal transition. We also discuss the main molecular mechanisms that make SnCs resistant to cell death, and potential strategies to target SnCs. At the end, we raise open questions and clinically relevant perspectives in the field.

Does Sentinel Lymph Node Biopsy Influence Subsequent Management Decisions in Women With Breast Cancer ≥ 70 Years Old?

BACKGROUND

There have been ongoing attempts to de-escalate surgical intervention in older breast cancer patients in recent years. However, there remains ongoing hesitancy amongst surgeons to de-implement axillary staging in this cohort. The supporting argument for performing a sentinel lymph node biopsy (SLNB) is that it may guide subsequent management.

METHODS

A retrospective review was performed of 356 SLNBs, in 342 women ≥ 70 years of age with invasive breast cancer, between 2014 and 2022 in a single institution. Data were collected on patient and tumor characteristics and subsequent management for all patients and for patients with ER+/HER2-, early-stage disease.

RESULTS

Positive SLNB significantly increased likelihood of receiving adjuvant chemotherapy (CTh) in patients aged 70-75 in all clinical subtypes (OR 4.0, 95% CI, 1.6-10; P = .0035). Positive SLNB did not significantly increase likelihood of receiving adjuvant CTh in patients aged 75-80, however, an Oncotype Dx score of ≥ 26 did (OR 34.50, 95% CI, 3.00-455.2; P = .0103). Positive SLNB was significantly associated with receiving adjuvant radiotherapy (RTh) in all patients aged 70-75 (OR 4.5, 95% CI, 2.0-11; P = .0004) and 75-80 (OR 9.7, 95% CI, 2.7-46; P = .0015). In patients aged ≥ 80 years, positive SLNB did not have a significant influence on subsequent treatments.

CONCLUSION

In this study, SLNB did not significantly influence subsequent management decisions in patients over 80 and should rarely be performed in this cohort. However, SLNB still had a role in patients aged 70-80 and should be used selectively in this cohort.

Adjuvant chemotherapy and survival outcomes in older women with HR+/HER2- breast cancer: a propensity score-matched retrospective cohort study using the SEER database

OBJECTIVES

This study aimed to investigate the impact of adjuvant chemotherapy (ACT) on survival outcomes in older women with hormone receptor-positive and human epidermal growth factor receptor 2-negative (HR+/HER2-) breast cancer (BC).

DESIGN

A retrospective cohort study using data from the Surveillance, Epidemiology, and End Results database, which contains publicly available information from US cancer registries.

SETTING AND PARTICIPANTS

The study included 45 762 older patients with BC aged over 65 years diagnosed between 2010 and 2015.

METHODS

Patients were divided into two groups based on age: 65-79 years and ≥80 years. Propensity score matching (PSM) was employed to balance clinicopathological characteristics between patients who received ACT and those who did not. Data analysis used the χ2 test and Kaplan-Meier method, with a subgroup analysis conducted to identify potential beneficiaries of ACT.

OUTCOME MEASURES

Overall survival (OS) and cancer-specific survival (CSS).

RESULTS

Due to clinicopathological characteristic imbalances between patients with BC aged 65-79 years and those aged ≥80 years, PSM was used to categorise the population into two groups for analysis: the 65-79 years age group (n=38 128) and the ≥80 years age group (n=7634). Among patients aged 65-79 years, Kaplan-Meier analysis post-PSM indicated that ACT was effective in improving OS (p<0.05, HR=0.80, 95% CI 0.73 to 0.88), particularly in those with advanced disease stages, but did not show a significant benefit in CSS (p=0.09, HR=1.13, 95% CI 0.98 to 1.31). Conversely, for patients aged ≥80 years, ACT did not demonstrate any improvement in OS (p=0.79, HR=1.04, 95% CI 0.79 to 1.36) or CSS (p=0.09, HR=1.46, 95% CI 0.69 to 2.26) after matching. Subgroup analysis also revealed no positive impact on OS and CSS.

CONCLUSIONS

Patients with HR+/HER2- BC ≥80 years of age may be considered exempt from ACT because no benefits were found in terms of OS and CSS.

Trends in Locoregional Therapy in Older Women with Early-Stage Hormone Receptor-Positive Breast Cancer by Frailty and Life Expectancy

BACKGROUND

In women ≥ 70 years of age with T1N0 hormone receptor-positive (HR+)/human epidermal growth factor receptor 2-negative (HER2-) breast cancer, breast surgery type and omission of axillary surgery or radiation therapy (RT) do not impact overall survival. Although frailty and life expectancy ideally factor into therapy decisions, their impact on therapy receipt is unclear. We sought to identify trends in and factors associated with locoregional therapy type by frailty and life expectancy.

METHODS

Women ≥ 70 years of age with T1N0 HR+/HER2- breast cancer diagnosed in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database between 2010 and 2015 were stratified by validated claims-based frailty and life expectancy measures. Therapy trends over time by regimen intensity ('high intensity': lumpectomy + axillary surgery + RT, or mastectomy + axillary surgery; 'moderate intensity': lumpectomy + RT, lumpectomy + axillary surgery, or mastectomy only; or 'low intensity': lumpectomy only) were analyzed. Factors associated with therapy type were identified using generalized linear mixed models.

RESULTS

Of 16,188 women, 21.8% were frail, 22.2% had a life expectancy < 5 years, and only 12.3% fulfilled both criteria. In frail women with a life expectancy < 5 years, high-intensity regimens decreased significantly (48.8-31.2%; p < 0.001) over the study period, although in 2015, 30% still received a high-intensity regimen. In adjusted analyses, frailty and life expectancy < 5 years were not associated with breast surgery type but were associated with a lower likelihood of axillary surgery (frailty: odds ratio [OR] 0.86, 95% confidence interval [CI] 0.76-0.96; life expectancy < 5 years: OR 0.22, 95% CI 0.20-0.25). Life expectancy < 5 years was also associated with a lower likelihood of RT receipt in breast-conserving surgery patients (OR 0.30, 95% CI 0.27-0.34).

CONCLUSIONS

Rates of high-intensity therapy are decreasing but overtreatment persists in this population. Continued efforts aimed at appropriate de-escalation of locoregional therapy are needed.

Stereotactic Radiosurgery for Women Older than 65 with Breast Cancer Brain Metastases

BACKGROUND

Breast cancer is the second most common cause of brain metastases (BM). Despite increasing incidence of BM in older women, there are limited data on the optimal management of BM in this age group. In this study, we assessed the survival outcomes and treatment patterns of older breast cancer patients ≥65 years old with BM compared to younger patients at our institution.

METHODS

An IRB-approved single-institutional retrospective review of biopsy-proven breast cancer patients with BM treated with 1- to 5-fraction stereotactic radiation therapy (SRS) from 2015 to 2020 was performed. Primary endpoint was intracranial progression-free survival (PFS) defined as the time interval between the end of SRS to the date of the first CNS progression. Secondary endpoints were overall survival (OS) from the end of SRS and radiation treatment patterns. Kaplan-Meier estimates and Cox proportional hazard regression method were used for survival analyses.

RESULTS

A total of 112 metastatic breast cancer patients with BMs were included of which 24 were ≥65 years old and 88 were <65 years old. Median age at RT was 72 years (range 65-84) compared to 52 years (31-64) in younger patients. There were significantly higher number of older women with ER/PR positive disease (75% vs. 49%, p = 0.036), while younger patients were more frequently triple negative (32% vs. 12%, p = 0.074) and HER2 positive (42% vs. 29%, p = 0.3). Treatment-related adverse events were similar in both groups. Overall, 14.3% patients had any grade radiation necrosis (RN) (older vs. young: 8.3% vs. 16%, p = 0.5) while 5.4% had grade 3 or higher RN (0% vs. 6.8%, p = 0.7). Median OS after RT was poorer in older patients compared to younger patients (9.5 months vs. 14.5 months, p = 0.037), while intracranial PFS from RT was similar between the two groups (9.7 months vs. 7.1 months, p = 0.580). On univariate analysis, significant predictors of OS were age ≥65 years old (hazard risk, HR = 1.70, p = 0.048), KPS ≤ 80 (HR = 2.24, p < 0.001), HER2 positive disease (HR = 0.46, p < 0.001), isolated CNS metastatic disease (HR = 0.29, p < 0.001), number of brain metastases treated with RT (HR = 1.06, p = 0.028), and fractionated SRS (HR = 0.53, p = 0.013). On multivariable analysis, KPS ≤ 80, HER2 negativity and higher number of brain metastases predicted for poorer survival, while age was not a significant factor for OS after adjusting for other variables. Patients who received systemic therapy after SRS had a significantly improved OS on univariate and multivariable analysis (HR = 0.32, p < 0.001). Number of brain metastases treated was the only factor predictive of worse PFS (HR = 1.06, p = 0.041), which implies a 6% additive risk of progression for every additional metastasis treated.

CONCLUSIONS

Although older women had poorer OS than younger women, OS was similar after adjusting for KPS, extracranial progression, and systemic therapy; and there was no difference in rates of intracranial PFS, neurological deaths, and LMD in the different age groups. This study suggests that age alone may not play an independent role in treatment-selection and that outcomes for breast cancer patients with BMs and personalized decision-making including other clinical factors should be considered. Future studies are warranted to assess neurocognitive outcomes and other radiation treatment toxicities in older patients.

Triple-negative and Her2-positive breast cancer in women aged 70 and over: prognostic impact of age according to treatment

Background

Elderly breast cancer (BC) patients have been underrepresented in clinical trials whereas ~60% of deaths from BC occur in women aged 70 years and older. Only limited data are available on the prognostic impact of age according to treatment, especially in the triple-negative (TN) and Her2-positive because of the lower frequency of these subtypes in elderly patients. We report herein the results of a multicenter retrospective study analyzing the prognostic impact of age according to treatment delivered in TN and Her2-positive BC patients of 70 years or older, including comparison by age groups.

Methods

The medical records of 31,473 patients treated from January 1991 to December 2018 were retrieved from 13 French cancer centers for retrospective analysis. Our study population included all ≥70 patients with TN or Her2-positive BC treated by upfront surgery. Three age categories were determined: 70-74, 75-80, and > 80 years.

Results

Of 528 patients included, 243 patients were 70-74 years old (46%), 172 were 75-80 years (32.6%) and 113 were >80 years (21.4%). Half the population (51.9%, 274 patients) were TN, 30.1% (159) Her2-positive/hormone receptors (HR)-positive, and, 18% (95) Her2-positive/endocrine receptors (ER)-negative BC. Advanced tumor stage was associated with older age but no other prognostic factors (tumor subtype, tumor grade, LVI). Adjuvant chemotherapy delivery was inversely proportional to age. With 49 months median follow-up, all patient outcomes (overall survival (OS), disease-free survival (DFS), breast cancer-specific survival (BCSS), and recurrence-free survival (RFS)) significantly decreased as age increased. In multivariate analysis, age >80, pT2-3 sizes, axillary macrometastases, lymphovascular involvement, and HR-negativity tumor negatively affected DFS and OS. Comparison between age >80 and <=80 years old showed worse RFS in patients aged > 80 (HR=1.771, p=0.031).

Conclusion

TN and Her2-positive subtypes occur at similar frequency in elderly patients. Older age is associated with more advanced tumor stage presentation. Chemotherapy use decreases with older age without worse other pejorative prognostic factors. Age >80, but not ≤80, independently affected DFS and OS.

Restructuring lung cancer care to accelerate diagnosis and treatment in patients vulnerable to healthcare disparities using an innovative care model

The diagnosis and treatment of lung cancer is challenged by complex diagnostic pathways and fragmented care that can lead to disparities for vulnerable patients. Our model involved a multi-institutional, multidisciplinary conference to address the complexity of lung cancer care in vulnerable patient populations. The conference was conducted using a process adapted from the problem-solving method entitled FastTrack, pioneered by General Electric. Conference attendees established critical social determinants of health specific to lung cancer and designed a practical care model to accelerate diagnosis and treatment in this population. The resulting care delivery model, the Lung Cancer Strategist Program (LCSP), was led by a lung cancer trained advanced practice provider (APP) to expedite diagnosis, surgical and oncologic consultation, and treatment of a suspicious lung nodule. We compared the timeliness of care, care efficiency, and oncologic outcomes in 100 LCSP patients and 100 routine referral patients at the same thoracic surgery clinic. Patient triage through our integrated care model transitioned initial referral evaluation to a lung cancer trained APP to coordinate multidisciplinary patient-centered care that was highly individualized and significantly reduced the time to diagnosis and treatment among vulnerable patients at high-risk for treatment delay due to healthcare disparities.•To develop the Lung Cancer Strategist Program care model, we used a three-step (Design, Meeting, and Culmination), team-based, problem-solving process entitled FastTrack.•An advantage of FastTrack is its ability to overcome barriers embedded within hierarchal and institutional social systems, empowering those closest to the relevant issue to propose and enact meaningful change.•Under this framework, we engaged a diverse field of experts to assess systemic barriers in lung cancer care and design an innovative care pathway to improve the timeliness and efficiency of lung cancer care in patients at risk for healthcare disparities.

An androgen receptor regulated gene score is associated with epithelial to mesenchymal transition features in triple negative breast cancers

BACKGROUND

Androgen receptor (AR) is considered a marker of better prognosis in hormone receptor positive breast cancers (BC), however, its role in triple negative breast cancer (TNBC) is controversial. This may be attributed to intrinsic molecular differences or scoring methods for AR positivity. We derived AR regulated gene score and examined its utility in BC subtypes.

METHODS

AR regulated genes were derived by applying a bioinformatic pipeline on publicly available microarray data sets of AR+ BC cell lines and gene score was calculated as average expression of six AR regulated genes. Tumors were divided into AR high and low based on gene score and associations with clinical parameters, circulating androgens, survival and epithelial to mesenchymal transition (EMT) markers were examined, further evaluated in invitro models and public datasets.

RESULTS

53% (133/249) tumors were classified as AR gene score high and were associated with significantly better clinical parameters, disease-free survival (86.13 vs 72.69 months, log rank p = 0.032) when compared to AR low tumors. 36% of TNBC (N = 66) were AR gene score high with higher expression of EMT markers (p = 0.024) and had high intratumoral levels of 5α-reductase, enzyme involved in intracrine androgen metabolism. In MDA-MB-453 treated with dihydrotestosterone, SLUG expression increased, E-cadherin decreased with increase in migration and these changes were reversed with bicalutamide. Similar results were obtained in public datasets.

CONCLUSION

Deciphering the role of AR in BC is difficult based on AR protein levels alone. Our results support the context dependent function of AR in driving better prognosis in ER positive tumors and EMT features in TNBC tumors.

Excess body weight and postmenopausal breast cancer: Emerging molecular mechanisms and perspectives

Postmenopausal, obese women have a significantly higher risk of developing estrogen receptor-positive (ER+) breast tumors, that are resistant to therapies and are associated with higher recurrence and death rates. The global prevalence of overweight/obese women has reached alarming proportions and with postmenopausal ER+ breast carcinoma (BC) having the highest incidence among the three obesity-related cancers in females (i.e., breast, endometrial and ovarian), this is of significant concern. Elucidation of the precise molecular mechanisms underlying the pro-cancerous action of obesity in ER+BC is therefore critical for disease prevention and novel treatment initiatives. Interestingly, accumulating data has shown opposing relationships between obesity and cancer in either pre- or post-menopausal women. Excess body weight is associated with an increased risk of breast cancer in postmenopausal women and a decreased risk in pre-menopausal women. Moreover, excess adiposity during early life appears to be protective against postmenopausal breast cancer, including both ER+ and ER negative BC subtypes. Overall, estrogen-dependent mechanisms have been implicated as the main driving force in obesity-related breast tumorigenesis. In the present review we discuss the epidemiologic and mechanistic aspects of association between obesity and breast tumors after menopause, mainly in the context of hormone dependency. Molecular and cellular events underlying this association present as potential avenues for both therapeutic intervention as well as the prevention of BC-promoting processes linked to excess adiposity, which is proving to be vital in an increasingly obese global population.

Screening for cancer beyond recommended upper age limits: views and experiences of older people

BACKGROUND

Internationally, screening programmes and clinical practice guidelines recommend when older adults should stop cancer screening using upper age limits, but it is unknown how older adults view these recommendations.

OBJECTIVE

To examine older adults' views and experiences about continuing or stopping cancer screening beyond the recommended upper age limit for breast, cervical, prostate and bowel cancer.

DESIGN

Qualitative, semi-structured interviews.

SETTING

Australia, telephone.

SUBJECTS

A total of 29 community-dwelling older adults (≥70-years); recruited from organisation newsletters, mailing lists and Facebook advertisements.

METHODS

Interviews were audio-recorded, transcribed and analysed thematically using Framework Analysis.

RESULTS

Firstly, older adults were on a spectrum between trusting recommendations and actively deciding about cancer screening, with some who were uncertain. Secondly, participants reported limited in-depth discussions with health professionals about cancer screening. In primary care, discussions were focused on checking they were up to date with screening or going over results. Discussions mostly only occurred if older adults initiated themselves. Finally, participants had a socially- and self-constructed understanding of screening recommendations and potential outcomes. Perceived reasons for upper age limits were cost, reduced cancer risk or ageism. Risks of screening were understood in relation to their own social experiences (e.g. shared stories about friends with adverse outcomes of cancer treatment or conversations with friends/family about controversy around prostate screening).

CONCLUSIONS

Direct-to-patient information and clinician support may help improve communication about the changing benefit to harm ratio of cancer screening with increasing age and increase understanding about the rationale for an upper age limit for cancer screening programmes.

Comparative Effectiveness Analysis of Lumpectomy and Mastectomy for Elderly Female Breast Cancer Patients: A Deep Learning-based Big Data Analysis

Objectives: To evaluate the comparative effectiveness of treatments, a randomized clinical trial remains the gold standard but can be challenged by a high cost, a limited sample size, an inability to fully reflect the real world, and feasibility concerns. The objective is to showcase a big data approach that takes advantage of large electronic medical record (EMR) data to emulate clinical trials. To overcome the limitations of regression analysis, a deep learning-based analysis pipeline was developed. Study Design and Setting: Lumpectomy (breast-conserving surgery) and mastectomy are the two most commonly used surgical procedures for early-stage female breast cancer patients. An emulation trial was designed using the Surveillance, Epidemiology, and End Results (SEER)-Medicare data to evaluate their relative effectiveness in overall survival. The analysis pipeline consisted of a propensity score step, a weighted survival analysis step, and a bootstrap inference step. Results: A total of 65,997 subjects were enrolled in the emulated trial, with 50,704 and 15,293 in the lumpectomy and mastectomy arms, respectively. The two surgery procedures had comparable effects in terms of overall survival (survival year change = 0.08, 95% confidence interval (CI): -0.08, 0.25) for the elderly SEER-Medicare early-stage female breast cancer patients. Conclusion: This study demonstrated the power of "mining large EMR data + deep learning-based analysis," and the proposed analysis strategy and technique can be potentially broadly applicable. It provided convincing evidence of the comparative effectiveness of lumpectomy and mastectomy.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Development and validation of competitive risk model for older women with metaplastic breast cancer

BACKGROUND

Metaplastic breast cancer (MpBC) is a rare histological subtype of breast cancer. This study aims to establish a competitive risk model for older women with MpBC to predict patients' survival accurately.

METHODS

Data on patients diagnosed with MpBC from 2010 to 2019 are from the Surveillance, Epidemiology and End Results (SEER) program in the United States. All patients were randomly assigned to the training set and validation set. The proportional sub-distribution risk model was used in the training set to analyze the risk factors affecting patient death. Based on the risk factors for cancer-specific mortality (CSM) in patients, we constructed a competitive risk model to predict patients' 1-, 3-, and 5-year cancer-specific survival. Then we used the concordance index (C-index), the calibration curve and the area under the receiver operating characteristic curve (AUC) to validate the discrimination and accuracy of the model.

RESULTS

One thousand, four hundred twelve older women with MpBC were included in this study. Age, T stage, N stage, M stage, tumor size, surgery and radiotherapy were risk factors for CSM. We established a competitive risk model to predict 1-, 3-, and 5-year cancer-specific survival in older women with MpBC. The C-index of the model was 0.792 in the training set and 0.744 in the validation set. The calibration curves in the training and validation sets showed that the model's predicted values were almost consistent with the actual observed values. The AUC results show that the prediction model has good accuracy.

CONCLUSION

We developed a competitive risk model based on these risk factors to predict cancer-specific survival in older women with MpBC. The validation results of the model show that it is a very effective and reliable prediction tool. This predictive tool allows doctors and patients to make individualized clinical decisions.

A risk stratification model to predict chemotherapy benefit in medullary carcinoma of the breast: a population-based SEER database

Whether patients with medullary breast carcinoma (MBC) receive chemotherapy is controversial. Therefore, the aim of our study was to screen out patients with MBC who benefit from chemotherapy. We enrolled 618 consecutive patients with MBC from The Surveillance, Epidemiology, and End Results (SEER) database (2010-2018). Cox regression analysis was used to identify independent prognostic factors. Next, a nomogram was constructed and evaluated using calibration plots and the area under the curve (AUC) of receiver operating characteristic (ROC) curves. Kaplan‒Meier curves were used to evaluate the overall survival (OS) benefit of chemotherapy in different risk groups. A total of 618 MBC patients were involved in our study, and an 8:2 ratio was used to randomly split them into a training cohort (n = 545) and a validation cohort (n = 136). Next, a nomogram predicting 3- and 5-year OS rates was constructed based on the five independent factors (age at diagnosis, T stage, N status, subtype and radiation). The nomogram AUCs for 3- and 5-year OS (training set: 0.793 and 0.797; validation set: 0.781 and 0.823) and calibration plots exhibited good discriminative and predictive ability. Additionally, a novel risk classification system for MBC patients demonstrated that we do not have enough evidence to support the benefit effect of chemotherapy for the high-risk group as the result is not statistically significant (total population: p = 0.180; training set: p = 0.340) but could improve OS in the low-risk group (total population: p = 0.001; training set: p = 0.001). Our results suggested that chemotherapy should be selected more carefully for high-risk groups based on a combination of factors and that the possibility of exemption from chemotherapy should be confirmed by more clinical trials in the future.

Association of Surgery With Frailty Status in Older Women With Early-Stage Breast Cancer

This cohort study examines associations between type of breast cancer surgery and changes in frailty status among US women aged 70 years or older with early-stage breast cancer.

Not Too Little, Not Too Much: Optimizing More Versus Less Locoregional Treatment for Older Patients With Breast Cancer

Although undertreatment of older women with aggressive breast cancers has been a concern for years, there is increasing recognition that some older women are overtreated, receiving therapies unlikely to improve survival or reduce morbidity. De-escalation of surgery may include breast-conserving surgery over mastectomy for appropriate candidates and omitting or reducing extent of axillary surgery. Appropriate patients to de-escalate surgery are those with early-stage breast cancer, favorable tumor characteristics, are clinically node-negative, and who may have other major health issues. De-escalation of radiation includes reducing treatment course length through hypofractionation and ultrahypofractionation regimens, reducing treatment volumes through partial breast irradiation, omission of radiation for select patients, and reducing radiation dose to normal tissues. Shared decision making, which aims to facilitate patients making decisions concordant with their values, can guide health care providers and patients through complicated decisions optimizing breast cancer care.

Characteristics of Postoperative Patients with Breast Cancer Aged 65 Years and Older

Objective: This study aimed to compare postoperative patients with breast cancer aged ≥65 years with those aged <65 years and clarify the characteristics of postoperative patients with breast cancer aged ≥65. Methods: In total, 376 patients in whom we were able to evaluate survey items one month after surgery were included in the study. Comorbidity, including diabetes mellitus and hypertension, shoulder range of motion (ROM), upper-limb function, and psychological problems, was evaluated. Results: Hypertension and diabetes mellitus were significantly higher in patients aged ≥65 years (the elderly group) than in those aged <65 years (the non-elderly group) (p < 0.05). Preoperative shoulder flexion ROM was significantly restricted in the elderly group compared with the non-elderly group (p < 0.05). Preoperative shoulder abduction ROM was significantly restricted in the elderly group compared with the non-elderly group (p < 0.05). At one month after surgery, upper-limb function was more impaired in the non-elderly group than in the elderly group (p < 0.05). In both groups, both ROM and upper-limb function were significantly impaired one month after surgery compared with before surgery (p < 0.05). Conclusions: Postoperative patients with breast cancer aged ≥65 years should be careful about risk management and intervention during rehabilitation. Preoperative evaluation of shoulder ROM should be performed because patients aged ≥65 years have limited ROM before surgery.

'ADVANCE' (a pilot trial) ADjuVANt chemotherapy in the elderly: Developing and evaluating lower-toxicity chemotherapy options for older patients with breast cancer

INTRODUCTION

Older adults with breast cancer receiving neo/adjuvant chemotherapy are at high risk for poor outcomes and are underrepresented in clinical trials. The ADVANCE (ADjuVANt Chemotherapy in the Elderly) trial evaluated the feasibility of two neo/adjuvant chemotherapy regimens in parallel-enrolling cohorts of older patients with human epidermal growth factor receptor 2-negative breast cancer: cohort 1-triple-negative; cohort 2-hormone receptor-positive.

MATERIALS AND METHODS

Adults age ≥ 70 years with stage I-III breast cancer warranting neo/adjuvant chemotherapy were enrolled. Cohort 1 received weekly carboplatin (area under the curve 2) and weekly paclitaxel 80 mg/m2 for twelve weeks; cohort 2 received weekly paclitaxel 80 mg/m2 plus every-three-weekly cyclophosphamide 600 mg/m2 over twelve weeks. The primary study endpoint was feasibility, defined as ≥80% of patients receiving ≥80% of intended weeks/doses of therapy. All dose modifications were applied per clinician discretion.

RESULTS

Forty women (n = 20 per cohort) were enrolled from March 25, 2019 through August 3, 2020 from three centers; 45% and 35% of patients in cohorts 1 and 2 were age > 75, respectively. Neither cohort achieved targeted thresholds for feasibility. In cohort 1, eight (40.0%) met feasibility (95% confidence interval [CI] = 19.1-63.9%), while ten (50.0%) met feasibility in cohort 2 (95% CI = 27.2-72.8). Neutropenia was the most common grade 3-4 toxicity (cohort 1-65%, cohort 2-55%). In cohort 1, 80% and 85% required ≥1 dose holds of carboplatin and/or paclitaxel, respectively. In cohort 2, 10% required dose hold(s) for cyclophosphamide and/or 65% for paclitaxel.

DISCUSSION

In this pragmatic pilot examining chemotherapy regimens in older adults with breast cancer, neither regimen met target goals for feasibility. Developing efficacious and tolerable regimens for older patients with breast cancer who need chemotherapy remains an important goal.

CLINICALTRIALS

gov Identifier: NCT03858322.

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

Background

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

Methods

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

Results

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

Conclusion

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

Impact of Sentinel Lymph Node Biopsy on Treatment Decision and Survival in Patients Aged ≥70 Years with Breast Cancer: A Retrospective Study

Background: Whether sentinel lymph node biopsy should be performed in patients ≥70 years old with early-stage invasive breast cancer is controversial. We examined the effect of sentinel lymph node biopsy on the treatment and outcomes in this population. Materials and Methods: In this retrospective study, patients aged ≥70 years who were treated for invasive breast cancer with sentinel lymph node biopsy followed by mastectomy or lumpectomy between 2010 and 2019 were identified from our database. Patients were compared according to sentinel lymph node status. Outcomes were analyzed using the Kaplan-Meier method and Cox multivariate analysis. Results: Of the 376 patients enrolled in this study, 311 (82.7%) were sentinel lymph node-negative and 65 (17.3%) were sentinel lymph node-positive. The median follow-up duration for all patients was 70 months. Systemic treatment and radiation were similar between sentinel lymph node-negative and -positive groups. Disease-free survival, distant disease-free survival, breast cancer-specific survival, overall survival were not significantly different between groups (88.2% vs 87.6%, 96.7% vs 94.8%, 96.2% vs 93.6%, and 93.5% vs 90.0%, respectively). Sentinel lymph node status, tumor size, chemotherapy, endocrine therapy, and adjuvant radiation were included in Cox multivariate analysis. None of the variables were found to significantly affect disease-free survival, distant disease-free survival, breast cancer-specific survival, and overall survival. Conclusions: Our analysis indicated that sentinel lymph node status may not affect systemic treatment decisions or survival in patients aged ≥70 years with breast cancer.

Characteristics and chronologically changing patterns of late-onset breast cancer in Korean women of age ≥ 70 years: A hospital based-registry study

BACKGROUND

Women from Asian and western countries have vastly different ages of onset of breast cancer, with the disease tending to occur at an older age in the West. Through an investigation of the patterns of old-onset breast cancer (OBC) in Korean women, we aimed to identify the characteristics of Korean OBC and evaluate whether these patterns are changing in relation to increasing westernization.

METHODS

This study retrospectively evaluated 102,379 patients who underwent surgical treatment of primary breast cancer between January 1, 2000 and December 31, 2013 in Korea. We used hospital -based breast cancer registry and analyzed data from these patients using multiple linear regression analysis to compare the characteristics and chronologically changing patterns between OBC (70 years of age or older) and non-OBC (40-69 years of age) patients in Korea.

RESULTS

A total of 6% of the 102,379 patients had OBC. Overall, OBC had more favorable biological features, such as a higher incidence of luminal A subtype, than did non-OBC, except for a higher incidence rate of triple-negative breast cancer (TNBC). However, OBC also presented with a higher overall disease stage, including higher T and M stages. Although the incidence rates of both OBC and non-OBC have increased overtime, the relative proportion of OBC patients has slightly increased, whereas that of non-OBC has slightly decreased. The increase in the incidence of both OBC and non-OBC was primarily due to the luminal A subtype.

CONCLUSIONS

Based on a hospital-based registry, overall, Korean OBC had favorable biological features but showed a higher rate of TNBC and advanced cancer stages. The incidence trend of breast cancer in Korea is slowly shifting toward an older age at onset, largely due to the luminal A subtype. Our results may provide novel insights into OBC in Asia, and aid in the development of optimal management of the disease in Asia.

TRIAL REGISTRATION

Retrospectively registered.

Survival benefit from axillary surgery in patients aged 70 years or older with clinically node-negative breast cancer: A population-based propensity-score matched analysis

BACKGROUND

Older patients with breast cancer have good prognosis and most die from diseases other than breast cancer. Previous studies suggested that the surgical extent in older patients could be reduced. We aimed to compare survival outcomes in patients aged ≥70 years with clinically node-negative breast cancer, based on whether axillary surgery was performed.

METHODS

A total of 2,995 patients with breast cancer aged ≥70 years who underwent breast surgery were included in the Korean Breast Cancer Registry. Patients were classified into two groups according to the performance of axillary surgery. We used propensity score matching for demographic and treatment factors to minimize selection bias. We compared the 5-year overall survival (OS) and breast cancer-specific survival (BCSS).

RESULTS

Among 708 patients after 3:1 propensity score matching, 531 underwent breast surgery with axillary surgery and 177 underwent breast surgery alone. Of all patients, 51.7% had T1 stage, and 73.2% underwent mastectomy. Approximately 31.2% of patients received chemotherapy. Among patients who did not undergo axillary surgery, the 5-year OS and BCSS rates were 85.2% and 96.7%, respectively. The hazard ratio of axillary surgery for OS was 0.943 (95% confidence interval 0.652-1.365, p = 0.757), indicating no significant difference between two groups.

CONCLUSIONS

Our study demonstrates that axillary surgery in a matched cohort of older patients with breast cancer and clinically negative nodes does not provide a survival benefit compared to patients undergoing breast surgery alone. These findings suggest that axillary surgery may be safely omitted in a select group of patients aged ≥70 years with clinically node-negative cancer. Further studies are needed to identify potential candidates for omitting axillary surgery.

Immediate breast reconstruction uptake in older women with primary breast cancer: systematic review

BACKGROUND

Postmastectomy immediate breast reconstruction (PMIBR) may improve the quality of life of patients with breast cancer, of whom older women (aged 65 years or more) are a growing proportion. This study aimed to assess PMIBR in older women with regard to underlying impediments (if any).

METHODS

MEDLINE, Embase, and PubMed were searched by two independent researchers up to June 2022. Eligible studies compared PMIBR rates between younger and older women with invasive primary breast cancer.

RESULTS

A total of 10 studies (2012-2020) including 466 134 women were appraised, of whom two-thirds (313 298) were younger and one-third (152 836) older. Only 10.0 per cent of older women underwent PMIBR in contrast to 45.0 per cent of younger women. Two studies explored factors affecting uptake of PMIBR in older women; surgeon-associated (usual practice), patient-associated (socioeconomic status, ethnicity, and co-morbidities), and system-associated (insurance status and hospital location) factors were identified.

CONCLUSION

Uptake of PMIBR in older women is low with definable (and some correctable) barriers.

The effect of chemotherapy on survival in oldest old patients with nonmetastatic triple negative breast cancer: A populationbased observational study

WHAT IS KNOWN AND OBJECTIVE

Chemotherapy is the primary pharmacotherapy of triple-negative breast cancer (TNBC). But the benefit of adjuvant chemotherapy in the oldest old TNBC patients remains controversial. Hence, we designed this population based observational study in order to assess the survival benefit of adjuvant chemotherapy in oldest old TNBC patients with early-stage disease.

METHODS

TNBC patients aged 80 years and older that with stage I to III invasive disease were identified in the surveillance, epidemiology, and end results cancer database from 2010 to 2016.

RESULTS AND DISCUSSION

Of 1611 patients enrolled, 1356 (84.17%) did not receive chemotherapy. Age, race, histology, grade, T stage, N stage, and radiation were found to be strong predictors of chemotherapy recipient by multivariate logistic regression analysis. Chemotherapy significantly prolonged overall survival (OS) (HR, 0.62, 95% CI: 0.49-0.79, p < 0.001), but did not significantly reduce breast cancer specific death (BCSD) (HR, 0.92, 95% CI: 0.63-1.35, p = 0.675). These results were further confirmed by propensity score matching analysis. Chemotherapy was associated with better OS in the subgroup of patients aged 80-84 years old (HR, 0.54, 95% CI: 0.40-0.74, p < 0.001), T2-4 stage disease (HR, 0.58, 95% CI: 0.44-0.76, p < 0.001), or grade 3-4 disease (HR, 0.54, 95% CI: 0.41-0.71, p < 0.001). However, chemotherapy did not reduce the cumulative incidence of BCSD in any subgroup.

WHAT IS NEW AND CONCLUSION

Chemotherapy should be considered for TNBC patients aged 80-84 years old, T2-4 disease, or grade 3-4 disease.

Treatment and survival outcomes in older women with primary breast cancer: A retrospective propensity score-matched analysis

PURPOSE

Changes in biological features and functional status make management decisions in older women with primary breast cancer complicated. We aimed to provide an overview of the clinicopathological characteristics and survival outcomes of older breast cancer patients based on the current treatment strategies.

METHODS

Female patients diagnosed with primary invasive breast cancer at Fudan University Shanghai Cancer Centre from 2008 to 2016 were included. Patients were divided into a younger group (<65 years) and older group (≥65 years). Propensity score matching was utilised to generate balanced cohorts.

RESULTS

A total of 13,707 patients met the study criteria. Compared with younger patients, older patients had a higher Charlson Comorbidity Index (p < 0.001), less lymph node metastasis (p = 0.009), more advanced tumour stage (p = 0.038), and a larger proportion of estrogen receptor-positive (p < 0.001) and epidermal growth factor receptor 2-negative (p < 0.001) tumours. Older patients were likely to receive mastectomy and axillary lymph node dissection in addition to a lower proportion of adjuvant chemotherapy. Adjuvant chemotherapy (HR [hazard ratio] 0.69, p = 0.039) was independently correlated with better overall survival in the older patients. This survival benefit (HR 0.58, p = 0.041) was confirmed in matched cohorts. Among the older patients with larger tumours (HR 0.48, p = 0.038) and more lymph node involvement (HR 0.44, p = 0.040), adjuvant chemotherapy was associated with a significant survival benefit.

CONCLUSION

Older breast cancer patients showed less aggressive biological characteristics, intensive surgical and moderate medical preferences. The addition of adjuvant chemotherapy should be considered for older patients, especially for patients with large tumours and more lymph node involvement.

Local and systemic therapy may be safely de-escalated in elderly breast cancer patients in China: A retrospective cohort study

Background

For elderly patients with breast cancer, the treatment strategy is still controversial. In China, preoperative axillary lymph node needle biopsy is not widely used, resulting in many patients receiving axillary lymph node dissection (ALND) directly. Our study aims to determine whether local and systemic therapy can be safely de-escalated in elderly breast cancer.

Methods

Patients aged ≥70 years were retrospectively enrolled from our institution’s medical records between May 2013 and July 2021. Groups were assigned according to local and systemic treatment regimens, and stratified analysis was performed by molecular subtypes. Univariate and multivariate survival analyses were used to compare the effects of different regimens on relapse-free survival (RFS).

Results

A total of 653 patients were enrolled for preliminary data analysis, and 563 patients were screened for survival analysis. The mean follow-up was 19 months (range, 1–82 months). Axillary lymph node metastases were pathologically confirmed in only 2.1% of cN0 cases and up to 97.1% of cN+ cases. In the aspect of breast surgery, RFS showed no significant difference between mastectomy and BCS group (p = 0.3078). As for axillary surgery, patients in the ALND group showed significantly better RFS than those in the sentinel lymph node biopsy (SLNB) group among pN0 patients (p = 0.0128). Among these cases, the proportion of cN+ in ALND was significantly higher than that in SLNB (6.4% vs. 0.4%, p = 0.002), which meant axillary lymph nodes (ALNs) of ALND patients were larger in imaging and more likely to be misdiagnosed as metastatic. With regard to adjuvant therapy, univariate and multivariate analyses showed that RFS in different comprehensive adjuvant regimens were similar especially among hormone receptor (HR)+/human epidermal growth factor receptor 2 (HER2)− subgroup where patients who did not receive any adjuvant therapy accounted for 15.7% (p > 0.05).

Conclusions

It is feasible to reduce some unnecessary local or systemic treatments for elderly breast cancer patients, especially in HR+/HER2− subtype. Multiple patient-related factors should be considered when making treatment plans.

Cellular and molecular mechanisms of breast cancer susceptibility

There is a plethora of recognized risk factors for breast cancer (BC) with poorly understood or speculative biological mechanisms. The lack of prevention options highlights the importance of understanding the mechanistic basis of cancer susceptibility and finding new targets for breast cancer prevention. Until now, we have understood risk and cancer susceptibility primarily through the application of epidemiology and assessing outcomes in large human cohorts. Relative risks are assigned to various human behaviors and conditions, but in general the associations are weak and there is little understanding of mechanism. Aging is by far the greatest risk factor for BC, and there are specific forms of inherited genetic risk that are well-understood to cause BC. We propose that bringing focus to the biology underlying these forms of risk will illuminate biological mechanisms of BC susceptibility.

Cost-effectiveness analysis of trastuzumab monotherapy versus adjuvant chemotherapy plus trastuzumab in elderly patients with HER2-positive early breast cancer

BACKGROUND

In elderly patients with human epidermal growth factor 2-positive breast cancer, adjuvant chemotherapy was associated with decreased quality of life, with relatively small benefits for prognosis. We examined the cost-effectiveness of trastuzumab monotherapy versus adjuvant chemotherapy plus trastuzumab in elderly patients with human epidermal growth factor 2-positive breast cancer.

METHODS

A Markov model was developed to evaluate the costs and benefits of trastuzumab monotherapy over adjuvant chemotherapy plus trastuzumab for elderly patients with human epidermal growth factor 2-positive breast cancer. We built the model with a yearly cycle over a 20-year time horizon and five health states: disease-free, relapse, post-relapse, metastasis and death. The parameters in the model were based on a previous randomized controlled trial and a nationwide administrative database in Japan. The incremental cost-effectiveness ratio, expressed as Japanese yen per the quality-adjusted life-years, was estimated from the perspective of health care payers. One-way deterministic sensitivity analysis and probabilistic sensitivity analysis with Monte-Carlo simulations of 10 000 samples were conducted.

RESULTS

The incremental cost-effectiveness ratio of trastuzumab monotherapy over adjuvant chemotherapy plus trastuzumab was $\sim$1.8 million Japanese yen /quality-adjusted life-year. The one-way deterministic sensitivity analysis showed that transition probability from disease-free to metastasis status and cost of metastasis status had the greatest influence on the incremental cost-effectiveness ratio. More than half the estimates in the probabilistic sensitivity analysis were located below a threshold of willingness-to-pay of 5 million Japanese yen /quality-adjusted life-year.

CONCLUSION

In this first comparative cost-effectiveness analysis of adjuvant chemotherapy plus trastuzumab versus trastuzumab monotherapy in the elderly, the latter was found favorable for elderly patients with human epidermal growth factor 2-positive breast cancer.

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

Background

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

Aim

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

Objectives

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

Design

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

Main outcome measures

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

Results

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

Conclusions

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

Limitations

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

Future work

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

Trial registration

This trial is registered as ISRCTN46099296.

Funding

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Age and competing concerns in treatment selection for women with non-metastatic HR+ and HER2- breast cancer: Current clinical practice

BACKGROUND

Newer adjuvant treatment options for non-metastatic breast cancer have increased survival. There is a need to investigate whether demographic and clinical characteristics of women with hormone receptor-positive, human epidermal growth receptor 2-negative non-metastatic breast cancer (stages I-III) differentially influence treatment decisions in older (age 65 or older) versus younger patients (under age 65).

METHODS

In a retrospective electronic medical record review, prevalence ratio with 95% confidence interval for treatment decisions in older vs younger patients was calculated using log binomial regression adjusted for race, stage, and total number of comorbidities.

RESULTS

In a sample of 537 patients, 66% were age < 65 and 34% age ≥ 65. Older patients included a higher proportion of White women (85% vs 75%, P = .02), higher number of comorbidities (P ≤0.0001), and lower stage tumors (P = .0004). In multivariable analysis, age ≥ 65 was independently associated with fewer mastectomies (95% CI 0.65-0.96, P = .02), more lumpectomies (95% CI 1.05-1.42, P = .01), and less receipt of radiation treatment (95% CI 0.78-0.97, P = .01) and/or chemotherapy (95% CI 0.73-0.95, P = .006). In multivariate analysis, stage was independently significant for all treatment modalities, except endocrine therapy, and race was not.

CONCLUSIONS

This study suggests that age, in addition to breast cancer stage, is a predictor of treatment modality, independent of race and number of comorbidities. Treatment modality reflects a combination of patient preference and clinician assessment of fitness for current standard of care.

Primary Care Providers’ Perceptions of the Acceptability, Appropriateness, and Feasibility of a Mammography Decision Aid for Women Aged 75 and Older

Background. Clinicians need to find decision aids (DAs) useful for their successful implementation. Therefore, we aimed to conduct an exploratory study to learn primary care clinicians’ (PCPs) perspectives on a mammography DA for women ≥75 to inform its implementation. Methods. We sent a cross-sectional survey to 135 PCPs whose patients had participated in a randomized trial of the DA. These PCPs practiced at 1 of 11 practices in Massachusetts or North Carolina. PCPs were asked closed-ended and open-ended questions on shared decision making (SDM) around mammography with women ≥75 and on the DA’s acceptability, appropriateness, and feasibility. Results. Eighty PCPs participated (24 [30%] from North Carolina). Most (n = 69, 86%) thought that SDM about mammography with women ≥75 was extremely/very important and that they engaged women ≥75 in SDM around mammography frequently/always (n = 49, 61%). Regarding DA acceptability, 60% felt the DA was too long. Regarding appropriateness, 70 (89%) thought it was somewhat/very helpful and that it would help patients make more informed decisions; 55 (70%) would recommend it. Few (n = 6, 8%) felt they had other resources to support this decision. Regarding feasibility, 53 (n = 67%) thought it would be most feasible for patients to receive the DA before a visit from medical assistants rather than during or after a visit or from health educators. Most (n = 62, 78%) wanted some training to use the DA. Limitations. Sixty-nine percent of PCPs in this small study practiced in academic settings. Conclusions. Although PCPs were concerned about the DA’s length, most found it helpful and informative and felt it would be feasible for medical assistants to deliver the DA before a visit. Implications. Study findings may inform implementation of this and other DAs.

The Utility of Pathology Reports to Identify Persons With Cancer Recurrence

BACKGROUND

Cancer recurrence is an important measure of the impact of cancer treatment. However, no population-based data on recurrence are available. Pathology reports could potentially identify cancer recurrences. Their utility to capture recurrences is unknown.

OBJECTIVE

This analysis assesses the sensitivity of pathology reports to identify patients with cancer recurrence and the stage at recurrence.

SUBJECTS

The study includes patients with recurrent breast (n=214) or colorectal (n=203) cancers.

RESEARCH DESIGN

This retrospective analysis included patients from a population-based cancer registry who were part of the Patient-Centered Outcomes Research (PCOR) Study, a project that followed cancer patients in-depth for 5 years after diagnosis to identify recurrences.

MEASURES

Information abstracted from pathology reports for patients with recurrence was compared with their PCOR data (gold standard) to determine what percent had a pathology report at the time of recurrence, the sensitivity of text in the report to identify recurrence, and if the stage at recurrence could be determined from the pathology report.

RESULTS

One half of cancer patients had a pathology report near the time of recurrence. For patients with a pathology report, the report's sensitivity to identify recurrence was 98.1% for breast cancer cases and 95.7% for colorectal cancer cases. The specific stage at recurrence from the pathology report had a moderate agreement with gold-standard data.

CONCLUSIONS

Pathology reports alone cannot measure population-based recurrence of solid cancers but can identify specific cohorts of recurrent cancer patients. As electronic submission of pathology reports increases, these reports may identify specific recurrent patients in near real-time.

Invasive Breast Cancer Treatment Patterns in Women Age 80 and Over: A Report from the National Cancer Database

BACKGROUND

There are no established treatment guidelines for women with breast cancer aged ≥80 despite increasing representation in the US population. Here we identify national treatment patterns and survival outcomes in women with stage I-III invasive breast cancer.

PATIENTS AND METHODS

Women age ≥80 diagnosed with stage I-III invasive breast cancer (IBC) were identified from 2005-2014 in the National Cancer Database. χ², Fisher's exact test, and logistic regression models were used to identify factors influencing receipt of breast surgery, and Cox proportional hazard models were used to evaluate overall survival (OS).

RESULTS

A total of 62,575 women with IBC met inclusion criteria, of which the majority received surgery (94%). Receipt of surgery was associated with White race, age <90, lower stage, and fewer comorbidities. OS was higher for those who received surgery compared to those who did not (HR 3.3 [3.18-3.46] P < .001). Molecular subtype analysis demonstrated improved survival with receipt of surgery or radiation for all subtypes, as well as improved survival with chemotherapy for those with triple negative breast cancer.

CONCLUSION

The vast majority of breast cancer patients aged ≥80 in the National Cancer Database with IBC received primary surgical management, which was associated with a significant OS benefit. Due to this finding, surgical resection should be considered for all patients ≥80 who are suitable operative candidates.

Risk factors at five-year survival in grade 3 breast cancer: a retrospective observational study of the New Zealand population

BACKGROUND

Breast cancer is the most common cancer in New Zealand, with approximately 3000 new registrations annually, affecting one in nine women and resulting in more than 600 deaths. This study analyzed data of patients with selected prognostic factors of Nottingham grade 3 tumors over a specified five-year period. The study aimed to identify factors that result in differential survival in the female, New Zealand population.

METHOD

This is an observational, retrospective cohort study of prospectively collected data from New Zealand Breast Cancer Register. The selected period of 1st January 2011 to 31st, December 2015 allowed a consistent overlap for a national five-year data of grade 3 breast cancer in New Zealand. Mortality was carried out using univariate Fine-Gray competing risk statistical models.

RESULTS

This study showed that women in the older age group (> 70 years) had higher five-year mortality risk (HR: 1.7, 95% CI: 0.9-3.0, p = 0.053). Hormonal receptor analysis showed that ER positive, PR negative, and ER negative, PR negative subjects were at increased risk (HR = 3.5, 95% CI 2.3-5.4, p < 0.001) and (HR = 2.6, 95% CI, 1.8-3.9, p < 0.001) respectively. Molecular subtypes Triple Negative Breast Cancer and Luminal B subjects were at increased risk (HR = 3.0, 95% CI, 1.8-4.7, p < 0.001 and (HR = 3.3, 95% CI, 1.7-6.3, p < 0.001) respectively. HER2 enriched subjects were at a higher, but not significant, risk of five-year mortality compared to luminal A (HR = 1.6, 95% CI, 0.8-3.0, p = 0.10). NZ Europeans were at increased risk (HR = 1.7, 95% CI, 0.8-3.2, p = 0.11), with the highest Cumulative Incidence Function CIF, the largest proportion of HER2 enriched and TNBC across ethnicities.; however, Pacific Islanders experienced the highest HER2 CIF.

CONCLUSION

The survival rates for grade 3 breast cancer vary across the selected prognostic factors and ethnicity. The results of this study make an initial contribution to the understanding of grade 3 breast cancer in the New Zealand population.

Breast Cancer in Women Over 65 years- a Review of Screening and Treatment Options

Breast cancer is becoming increasingly prevalent in the women greater than 65 years of age. Most tumors are hormone receptor-positive in this group. Breast cancer screening recommendations for older women should be tailored based on life expectancy. Early stage breast cancer should be treated with conservative surgery followed by adjuvant endocrine therapy in HR+ patients. Primary endocrine therapy is a low-risk option for those with limited life expectancy. Adjuvant radiation therapy can be avoided in early stage, low-risk cancers. Evaluation should include comprehensive geriatric assessment. Treatment with less cytotoxic chemotherapy, HER-2 targeted therapies, and other biomarker-driven, molecularly targeted therapies should be sought whenever possible.

A mixed-methods study of multi-level factors influencing mammography overuse among an older ethnically diverse screening population: implications for de-implementation

BACKGROUND

There is growing concern that routine mammography screening is overused among older women. Successful and equitable de-implementation of mammography will require a multi-level understanding of the factors contributing to mammography overuse.

METHODS

This explanatory, sequential, mixed-methods study collected survey data (n= 52, 73.1% Hispanic, 73.1% Spanish-speaking) from women ≥70 years of age at the time of screening mammography, followed by semi-structured interviews with a subset of older women completing the survey (n=19, 63.2% Hispanic, 63.2% Spanish-speaking) and providers (n=5, 4 primary care, 1 obstetrics and gynecology) to better understand multi-level factors influencing mammography overuse and inform potential de-implementation strategies. We conducted a descriptive analysis of survey data and content analysis of qualitative interview data. Survey and interview data were examined separately, compared, integrated, and organized according to Norton and Chambers Continuum of Factors Influencing De-Implementation Process.

RESULTS

Survey findings show that 87.2% of older women believe it is important to plan for an annual mammogram, 80.8% received a provider recommendation, and 78.9% received a reminder in the last 12 months to schedule a mammogram. Per interviews with older women, the majority were unaware of or did not perceive to have experienced overuse and intended to continue mammography screening. Findings from interviews with older women and providers suggest that there are multiple opportunities for older women to obtain a mammogram. Per provider interviews, almost all reported that reducing overuse was not viewed as a priority by the system or other providers. Providers also discussed that variation in mammography screening practices across providers, fear of malpractice, and monetary incentives may contribute to overscreening. Providers identified potential strategies to reduce overscreening including patient and provider education around harms of screening, leveraging the electronic health record to identify women who may receive less health benefit from screening, customizing system-generated reminder letters, and organizing workgroups to develop standard processes of care around mammography screening.

CONCLUSIONS

Multi-level factors contributing to mammography overuse are dynamic, interconnected, and reinforced. To ensure equitable de-implementation, there is a need for more refined and empirical testing of theories, models, and frameworks for de-implementation with a strong patient-level component that considers the interplay between multilevel factors and the larger care delivery process.

Population-based analysis of non-operative management and treatment patterns in older women with estrogen receptor-positive breast cancer

PURPOSE

To examine the proportion of older women with ER + HER2- breast cancer receiving non-operative management versus surgery, and to evaluate the use of axillary staging and adjuvant radiation in this population.

METHODS

We queried the SEER database to identify all women aged 70 years or older with stage I-III ER + HER2- invasive breast cancer diagnosed between 2010 and 2016. We evaluated trends in non-operative management, breast surgery, axillary staging, and adjuvant radiation according to age at diagnosis.

RESULTS

We identified 57,351 older women with ER + HER2- disease. Overall, 3538 (6.2%) of the cohort underwent non-operative management, 38,452 (67.0%) underwent breast-conserving surgery (BCS), and 15,361 (26.8%) underwent mastectomy. The proportion of patients undergoing non-operative management increased from 2.8% among 70-74-year-old women to 30.1% in those ≥ 90 years old (p < 0.001). In 53,813 women who underwent surgery, 36,850 (68.5%) underwent sentinel lymph node biopsy, while 10,861 (20.2%) underwent axillary lymph node dissection. Subgroup analysis of 29,032 older women undergoing BCS for stage I ER + HER2- breast cancer revealed a 14.2% rate of omission of axillary staging, increasing from 5.3% in those 70-74 years to 67.6% in those ≥ 90 years old (p < 0.001). Receipt of adjuvant radiation occurred in 63.3% of older women following BCS and 18% post-mastectomy, with similar trends towards omission in older age groups.

CONCLUSION

Primary breast surgery remains the dominant management strategy for the majority of older women with ER + HER2- breast cancer. Omission of axillary staging and adjuvant radiation are used in a minority of eligible women undergoing breast conservation for early-stage disease.

Systemic therapy for older patients with early breast cancer

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.

Higher-risk breast cancer in women aged 80 and older: Exploring the effect of treatment on survival

Background

To understand the association between various treatments and survival for older women with higher-risk breast cancer when controlling for patient and tumor factors.

Materials and methods

We conducted a retrospective, population-based study. Women aged 80 years or older and diagnosed between 2004 and 2017 with non-metastatic, higher-risk breast cancer were identified form the provincial cancer registry in Alberta, Canada. Higher-risk was defined as any of following: T3/4, node positive, human epidermal factor receptor-2 (Her2) positive or triple negative disease. Treatments were surgery, radiotherapy and systemic therapy (hormonal therapy, and/or chemotherapy and/or trastuzumab) or a combination of the previous. Cox regression models were used to examine the association between treatments and breast cancer specific survival (BCSS) and overall survival (OS).

Results

1369 patients were included. The median age was 84 years. 332 (24%) of women had T3-T4 tumors, 792 (58%) had nodal involvement, 130 (10%) had Her2 positive tumors, 124 (9%) had triple negative tumors. After a median follow-up of 35 months, 29.5% of patients died of breast cancer whereas 34.2% died from other causes. Patients had a lower adjusted hazard for BCSS if they had surgery (hazard ratio [HR] = 0.37 95% confidence interval [CI]: 0.27, 0.51), or systemic therapy (HR = 0.75, 95%CI: 0.58, 0.98). Patients had an increased probability of breast cancer death in the first 5 years after diagnosis compared to death from other causes.

Conclusions

Surgery and systemic therapy were associated with longer BCSS and OS. This suggests that maximizing treatments might benefit higher-risk patients.

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Breast cancer patients aged 80 or older are rarely represented in clinical trials.

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Association between survival and treatment is unknown for higher-risk patients.

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Breast cancer death affected around one-third of the higher-risk population.

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Surgery and systemic therapy were associated with lower breast cancer death.

Real world data on adjuvant treatment of older HER2-positive breast cancer patients - A single institution experience through 8 years

BACKGROUND

The large randomized trials on trastuzumab for primary breast cancer (BC) included few old patients. With exception of endocrine treatment, trials on adjuvant therapy for the old group specifically are scarce.

AIMS

To compare adjuvant treatment, recurrences and survival in old and older-old patients with primary HER2 positive BC.

MATERIAL AND METHODS

Patients ≥ 70 years with diagnose of primary HER2 positive BC from 2008 through 2015 were included in this retrospective non-randomized investigation. Standard clinical and biological data (age, surgery, tumor size, nodal status, histopathological grade, vascular invasion, expression of hormone receptors, recurrences and death) were extracted from patient's charts. Comparisons were performed according to age (old; 70-74 years vs older old; ≥ 75 years) and treatment with trastuzumab or not. Patients that initiated adjuvant trastuzumab but did not complete one year (n = 8) were included in the trastuzumab group in survival analyzes. Recurrence-free survival (RFS) and overall survival (OS) were calculated in uni- and multivariate analyses.

RESULTS

A total of 115 patients were registered, eleven patients had distant metastasis and seven were omitted from all treatment including primary surgery due to serious concomitant illness and a poor general condition leaving 97 patients for analysis. There were no differences between the groups (70-74; n = 40), (≥75; n = 57) in tumor size (p = 0.86), nodal status (p = 0.10), ER (p = 0.25), PgR (p = 1.0) or vascular invasion (p = 1.0). A lower proportion of patients ≥ 75 years received adjuvant trastuzumab (21% versus 70%, p < 0.001). Adjuvant trastuzumab improved RFS (p = 0.027) and OS (p = 0.002) in univariate analyses. The corresponding figures in multivariate analysis adjusted for tumor size, nodal status and grade were RFS (p = 0.0052) and OS (p = 0.0003) respectively. Brain was the most common site of distant metastasis (15% of patients at first recurrence).

CONCLUSIONS

We show a large difference in delivered adjuvant treatment between old and older old patients with a small proportion of patients aged 75 years or more receiving HER2 directed therapy that resulted in a worse survival. The vast majority can complete the planned treatment. Our results indicate that brain metastases is common also among older patients.

Systemic therapy for early breast cancer in older adults: current status and prospects

PURPOSE OF REVIEW

In this review, we describe the evidence on the efficacy and the safety of systemic treatments for the management of early breast cancer (EBC) in older individuals.

RECENT FINDINGS

Chemotherapy has a temporary impact on quality of life (QoL) for older EBC patients and improves survival outcomes for those with oestrogen receptor (ER)-negative disease. Benefits were seen also in the context of comorbidities, although these may be influenced by selection bias. The Cancer and Aging Research Group-Breast Cancer tool can predict the risk of severe toxicities on chemotherapy in older patients. Gene expression profiling is less frequently used in older adults although it holds promise to better inform patient selection also in this age group.Postneoadjuvant systemic therapy and novel agents remain poorly described in older patients with EBC. No disease-free survival benefits were seen in older patients receiving abemaciclib plus adjuvant endocrine therapy.

SUMMARY

Chemotherapy is beneficial for selected older patients with high-risk, ER-negative EBC. Although its impact on QoL is temporary, preferences, higher risk of toxicity and competing risks need to be carefully considered. Open questions remain on novel therapeutic approaches and gene expression profile in older EBC patients and more real-world evidence is warranted.

Lung Cancer Strategist Program: A novel care delivery model to improve timeliness of diagnosis and treatment in high-risk patients

INTRODUCTION

The diagnosis and treatment of lung cancer is challenged by complex diagnostic pathways and fragmented care that can lead to care disparities for vulnerable patients.

METHODS

A multi-institutional, multidisciplinary conference was convened to address the complexity of lung cancer care particularly in patients at high-risk for treatment delay. The resulting care delivery model, called the Lung Cancer Strategist Program (LCSP), was led by a thoracic-trained advanced practice provider (APP) with emphasis on expedited surgery and early oncologic consultation in the assessment of a newly diagnosed suspicious lung nodule. We performed a retrospective review to evaluate care efficiency and oncologic outcomes in the first 100 LCSP patients compared to 100 concurrent patients managed via routine surgical referral.

RESULTS

In the 78 LCSP and 41 routine referral patients managed via nodule surveillance, LCSP patients had a shorter time from suspicious finding to work-up (3 vs. 26 days, p < 0.001) and to surveillance decision (12.5 vs. 39 days, p < 0.001). In the 22 LCSP and 59 routine referral patients treated for intrathoracic malignancy, LCSP patients had fewer hospital visits (4 vs 6, p < 0.001), clinicians seen (1.5 vs. 2, p = 0.08), and diagnostic studies (4 vs 5, p = 0.01) with a shorter time to diagnosis (30.5 vs. 48 days, p = 0.02) and treatment (40.5 vs. 68.5 days, p = 0.02).

CONCLUSIONS

Patient triage through a thoracic-trained APP in consultation with surgical, medical, and radiation oncology facilitates rapid assessment of benign versus malignant lesions with reduced time to diagnosis and treatment, even among patients at high-risk for treatment delay.