Controversial issues in the management of older adults with early breast cancer

Mislang, Anna Rachelle; Cheung, Kwok-Leung; Hamaker, Marije E.; Kunkler, Ian; Markopoulos, Christos; Orecchia, Roberto; Brain, Étienne; Biganzoli, Laura

doi:10.1016/j.jgo.2017.05.004

Cited by 9 publications

(12 citation statements)

References 76 publications

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“…Ongoing studies may confirm this for broader patient selections or other locoregional treatments such as the axillary treatment. The low cumulative incidences raise the question of how much there is to gain in reducing the locoregional recurrence risk in older patients and whether treatments that only reduce locoregional recurrence risk but do not affect breast cancer‐specific survival, such as radiotherapy after BCS, are always appropriate .…”

Section: Discussionmentioning

confidence: 99%

Impact of Older Age and Comorbidity on Locoregional and Distant Breast Cancer Recurrence: A Large Population-Based Study

et al. 2019

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Background Studies have demonstrated worse breast cancer‐specific mortality with older age, despite an increasing risk of dying from other causes due to comorbidity (competing mortality). However, findings on the association between older age and recurrence risk are inconsistent. The aim of this study was to assess incidences of locoregional and distant recurrence by age, taking competing mortality into account. Materials and Methods Patients surgically treated for nonmetastasized breast cancer between 2003 and 2009 were selected from The Netherlands Cancer Registry. Cumulative incidences of recurrence were calculated considering death without distant recurrence as competing event. Fine and Gray analyses were performed to characterize the impact of age (70–74 [reference group], 75–79, and ≥80 years) on recurrence risk. Results A total of 18,419 patients were included. Nine‐year cumulative incidences of locoregional recurrence were 2.5%, 3.1%, and 2.9% in patients aged 70–74, 75–79, and ≥80 years, and 9‐year cumulative incidences of distant recurrence were 10.9%, 15.9%, and 12.7%, respectively. After adjustment for tumor and treatment characteristics, age was not associated with locoregional recurrence risk. For distant recurrence, patients aged 75–79 years remained at higher risk after adjustment for tumor and treatment characteristics (75–79 years subdistribution hazard ratio [sHR], 1.25; 95% confidence interval [CI], 1.11–1.41; ≥80 years sHR, 1.03; 95% CI, 0.91–1.17). Conclusion Patients aged 75–79 years had a higher risk of distant recurrence than patients aged 70–74 years, despite the higher competing mortality. Individualizing treatment by using prediction tools that include competing mortality could improve outcome for older patients with breast cancer. Implications for Practice In this population‐based study of 18,419 surgically treated patients aged 70 years or older, patients aged 75–79 years were at higher risk of distant recurrence than were patients aged 70–74 years. This finding suggests that patients in this age category are undertreated. In contrast, it was also demonstrated that the risk of dying without a recurrence strongly increases with age, and patients with a high competing mortality risk are easily overtreated. To identify older patients who may benefit from more treatment, clinicians should therefore take competing mortality risk into account. Prediction tools could facilitate this and thereby improve treatment strategy.

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Section: Discussionmentioning

confidence: 99%

Impact of Older Age and Comorbidity on Locoregional and Distant Breast Cancer Recurrence: A Large Population-Based Study

et al. 2019

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“…While age and comorbidities should be considered, they should never alone be a barrier to standard treatment. This includes the benefits of RT for older women [ 19 , 20 , 21 , 22 , 23 ].…”

Section: Discussionmentioning

confidence: 99%

“…In some cases, it may be reasonable to omit RT in those with a low chance of recurrence (e.g., ≤2 cm with clear margins, negative axillary lymph nodes, HR + ), or when risk of toxicity, advancing age and comorbidities outweigh the risk of recurrence [ 5 , 10 , 21 , 22 , 23 , 31 ]. Older women with a life expectancy <5 years may not derive a survival benefit from RT [ 12 ].…”

Section: Discussionmentioning

confidence: 99%

“…While some instruments, such as the Comprehensive Geriatric Assessment tool, are useful to measure comorbidities and functional/mental status, they are limited in predicting survival rates in older women with breast cancer [ 20 , 21 ]. An appropriate decision tool should consider the benefits of RT, especially in the context of tumor biology, toxicity, life expectancy, patient preference, quality of life and comorbidities [ 11 , 23 , 33 ]. Tools that assist older women with breast cancer to make decisions regarding RT also would be valuable.…”

Section: Discussionmentioning

confidence: 99%

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The Association between Age, Comorbidities and Use of Radiotherapy in Women with Breast Cancer: Implications for Survival

et al. 2018

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Background: Radiotherapy (RT) plays an important role in the management and survival of patients with breast cancer. The aim of this study was to examine the association between age, comorbidities and use of RT in this population. Methods: Patients diagnosed with breast cancer from 2004–2013 were identified from the American College of Surgeons National Cancer Database (NCDB). Follow-up time was measured from the date of diagnosis (baseline) to the date of death or censoring. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were used as the measure of association. Results: Independently of comorbidities and other important outcome-related factors, patients >65 years of age who received RT survived significantly longer than those who did not receive RT (aHR = 0.53, 95% CI = 0.52–0.54). However, as women aged, those with comorbidities were less likely to receive RT (adjusted p-trend by age < 0.0001). Conclusions: The development of decision-making tools to assist clinicians, and older women with breast cancer and comorbidities, are needed to facilitate personalized treatment plans regarding RT. This is particularly relevant as the population ages and the number of women with breast cancer is expected to increase in the near future.

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“…Although all patients with breast cancer, including older patients, should be treated according to standard treatment protocols, older patients are frequently under-evaluated or under-treated because of comorbidities, insufficient socio-economic support, or the decisions of their caregivers[6,20].Surgery is the most important modality for treating breast cancer disease and achieving optimal outcomes and is generally supported by adjuvant treatments[21][22][23]. These general principles hold true for elderly.…”

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confidence: 99%

Oncologic Results of Breast Conserving Surgery under Procedural Sedation in Elderly Patients

et al. 2019

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Purpose: Although surgery is the most frequently implemented treatment modality for breast cancer, many older patients with breast cancer are under-or untreated because of their high incidence of postoperative complications. We assessed the efficacy and safety of breast surgery under procedural sedation in older patients (aged > 70 years) by comparing selected clinical and oncologic factors after surgery for breast cancer under general anesthesia versus procedural sedation. Methods: Of 79 older patients with breast cancer, 49 underwent breast-conserving surgery, 30 under general anesthesia and 19 under procedural sedation, and relevant clinical and oncologic variables were compared and analyzed between groups. Results: The mean age was younger in the general anesthesia group and the mean operation time, hospital stay, and fasting time shorter in the procedural sedation group. There were no statistically significant differences in oncologic results between the two groups during follow-up. Conclusion: Breast surgery under procedural sedation is a safe and effective means of reducing tumor burden in older patients with breast cancer when their American Society of Anesthesiologists (ASA) physical status indicates a high risk of life-threatening perioperative complications associated with general anesthesia. And we also found that the oncologic results may be not inferior to same procedure under general anesthesia.

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Controversial issues in the management of older adults with early breast cancer

Cited by 9 publications

References 76 publications

Impact of Older Age and Comorbidity on Locoregional and Distant Breast Cancer Recurrence: A Large Population-Based Study

Impact of Older Age and Comorbidity on Locoregional and Distant Breast Cancer Recurrence: A Large Population-Based Study

The Association between Age, Comorbidities and Use of Radiotherapy in Women with Breast Cancer: Implications for Survival

Oncologic Results of Breast Conserving Surgery under Procedural Sedation in Elderly Patients

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