Biology, not chronology, driven treatment of breast cancer in the elderly

M. Aapro
2008 EJC Supplements  
The European Breast Cancer Conference (EBCC) was recently held in Berlin. Among the many topics discussed, treatment of the ageing breast cancer patient was highlighted during an EuropaDonna teaching lecture, which is summarised here. Breast cancer is the most common cancer site in women, with 1.15 million new cases worldwide each year, of which 361,000 (27.3% of all cancers in females) are in Europe and 230,000 (31.3%) in Northern America. This means that half, if not more, of these patients
more » ... of these patients are in other parts of the world, a fact recognised by the World Health Organization (WHO), which has put cancer among its health priorities on a global scale. In 2002, 411,000 women died of breast cancer worldwide, and most of these were aged 65 years or older. This is and to provide evidence-based recommendations for the diagnosis and treatment of breast cancer in such individuals. A review of the published work was performed via the results of a search on Medline for Englishlanguage articles published between 1990 and 2007 and of abstracts from key international conferences. Recommendations on the topics of screening, surgery, radiotherapy, (neo)adjuvant hormone treatment and chemotherapy and metastatic disease are found in these recommendations. 4 Oncologists are now learning to take into account the physiological age of their patient, which is the reflection of a normal and sometimes abnormally accelerated loss of body reserves, certainly related to chronological age but not precisely dictated by it. Understanding the biology of breast cancer will allow clinicians to optimally adapt the treatment of the elderly patient, considering that cancer treatments should not be synonymous with undue hardship imposed on patients who would in any case die from another competing cause of mortality. 5, 6 A question addressed during one of the plenary sessions at the EBCC was related to post-operative radiotherapy following breast-conserving surgery (BCS). Combined with appropriate systemic therapy, post-operative radiotherapy has been shown to achieve an absolute risk reduction in fiveyear local recurrence from 26 to 7%, and a 15-year absolute breast cancer mortality risk reduction from 35.9 to 30.5%. Despite these benefits, elderly patients continue to receive radiotherapy less frequently after BCS than younger patients. A number of randomised trials usually limited to an upper age limit of 70 years show a statistically significant reduction in risk of local recurrence from post-operative breast irradiation, but no impact on overall survival. Some trials have found age to be a factor that predicts for a lower risk of local recurrence after whole-breast irradiation compared with conservative surgery alone. Several studies have specifically evaluated the benefits of radiotherapy in the elderly. All large studies have shown a relative decrease in local relapse rate. However, the absolute incidence of relapse, as well as the absolute benefit from radiotherapy, tended to be low, and data on overall survival were generally absent, with the exception of one trial. 4 Some have concluded that radiotherapy may be avoided in low-risk older patients, while others have suggested that it may offer benefits in terms of slight reductions in local relapse rates and improvements in overall survival, and maintain that post-operative breast irradiation should be considered in all patients undergoing BCS, irrespective of age. For women aged >70 years with a low risk of recurrence (e.g. small tumours )2cm, clear margins, axillary node-negative, hormone-receptor-positive with plans to receive endocrine therapy), the absolute reductions in local recurrence tend to be slight, and mortality is usually associated with non-breast-cancer-related conditions. The use of radiotherapy in such patients should therefore depend on a multidimensional evaluation, including the absolute benefit of radiotherapy, co-morbidity, life expectancy and patient preference. However, biases prevail in the treatment of breast cancer in the elderly; for example, although adjuvant breast cancer chemotherapy is yet to be accepted and codified in the elderly, there is a remarkable exercise of schizophrenic thinking about chemotherapy, with lymphoma experts feeling that anthracyclines are part of curative treatment in the elderly while breast cancer experts debate the potential for cardiac insufficiency related to these drugs. Women over 70 years of age who are treated with chemotherapy for metastatic disease derive similar benefits to their younger counterparts. The use of chemotherapy should thus always be considered in hormone-receptor-negative or hormone-refractory patients. Preference should be given to chemotherapeutic agents with 'safer' profiles such as weekly taxane regimens, newer, less cardiotoxic anthracycline formulations, capecitabine, gemcitabine and vinorelbine. Treatment proposals should be made on the basis of objective evidence and evidence-based reasoning; 7 the subjective and sometimes highly emotional discussions are understandably part of the patient's reactions. I
doi:10.1016/s1359-6349(08)70692-x fatcat:h2f6aijw4ne4dce5ehrwaizbzq