A review of major studies and the current literature underscored the role of geriatric assessment in making treatment recommendations for patients aged 80 years and older with early and metastatic breast cancer. The review was published in the Journal of Oncology Practice. The corresponding author of this article is Hyman B. Muss, MD, of the University of North Carolina School of Medicine, Chapel Hill.
“Geriatric assessment is the cornerstone for effectively measuring key domains associated with aging,” the investigators noted, and “can identify major issues not usually found by oncologists, many with proven beneficial interventions,” such as those taken to prevent falls. “The use of performance status as a global estimation of function for older patients is inadequate,” the authors added. They preferred the Cancer and Aging Research Group tool “for performing a brief geriatric assessment because its use is feasible in the clinical trial and community settings and because it can be used to predict chemotherapy-related toxicity.” That tool can be accessed at www.mycarg.org.
Life expectancy should be estimated before making a treatment plan. The researchers reported that in an analysis of 52,000 Medicare beneficiaries, “for age 80 years and older with no or low/medium comorbidities, average life expectancy was ≥ 5 years.”
Management of Primary Lesion
Most patients 80 years and older will have hormone receptor–positive, HER2-negative tumors. In general, primary endocrine therapy “can control tumor growth for about 18 to 24 months, which makes it an ideal strategy for patients with a short life expectancy,” the investigators noted. Those with unresectable primary lesions may benefit from preoperative endocrine therapy to shrink the tumor and allow for mastectomy or breast-conservation surgery.
Surgery remains the standard of care for managing the primary lesion in most women, and patients 80 years and older generally tolerate surgery well and have low complication rates. Breast-conserving therapy and endocrine therapy without breast radiation therapy are considered viable options for women with small (≤ 3 cm) node-negative tumors that are hormone receptor–positive and HER2-negative.
“Omission of radiation has no effect on overall survival but is associated with a higher risk of in-breast recurrence,” the researchers stated. They recommended radiation for older patients with hormone receptor–negative, node-negative breast cancers treated with breast conservation, because the most local regional recurrences in these patients are likely to occur within several years after diagnosis. “For patients with larger lesions, especially those with nodal involvement, local regional radiation can improve survival,” the researchers wrote. “However, survival benefits usually are not noted until 5 to 10 years after diagnosis, which makes such treatment of marginal or no benefit in those with life expectancies < 5 years.”
Online models to estimate the potential value of adjuvant systemic therapy have not been validated for women aged 80 and older. “Therefore, clinical judgment and the patient’s wishes are paramount in making these decisions,” the authors wrote. Studies show that women aged 80 and older are more likely to decline recommended endocrine therapy, and those who do start are less likely to complete 5 years of therapy.
“The best value of chemotherapy will be in older patients with hormone receptor–negative tumors, where the majority of relapses occur < 5 years from diagnosis,” the investigators stated. The decision to use chemotherapy should be individualized, but generally for patients 80 years and older with life expectancies of at least 5 years, the authors “do not recommend adjuvant chemotherapy for an absolute survival benefit of less than 3% at 5 years, would consider chemotherapy for an absolute survival of 3% to 5%, and recommend chemotherapy for an absolute survival benefit of > 5%.” Potential toxicity of chemotherapy agents should be carefully reviewed, as well as the possibility for adverse events requiring hospitalization, which in older patients “frequently is associated with functional decline and shortened survival.”
Most older patients with metastatic breast cancer will have hormone receptor–positive/HER2-negative disease and be treated with endocrine therapy. An aromatase inhibitor has a more favorable toxicity profile than tamoxifen in older patients. The researchers cited recent data suggesting that adding palbociclib (Ibrance) to first-line treatment can increase progression-free survival over endocrine therapy alone. “For second-line therapy, both palbociclib and everolimus [Afinitor] added to endocrine therapy can substantially improve progression-free intervals compared with endocrine therapy alone,” the authors added, although there are limited toxicity data about these agents in older patients.
Chemotherapy should be considered for older patients with metastatic disease refractory to endocrine therapy or with triple-negative tumors. Among the agents that have shown efficacy in older adults are capecitabine, paclitaxel, eribulin (Halaven), and trastuzumab (Herceptin).
“Although older patients with metastatic breast cancer are more likely to be involved in a palliative care program at the end of life, a high percentage die without a hospice referral, which highlights an opportunity for improvement,” the investigators stated.
“Major gaps in the care of older patients with cancer, especially in this 80 years and older group, persist,” the authors concluded. They listed five ASCO Task Force recommendations to fill these gaps: “Use clinical trials to improve the evidence base for treating older adults with cancer, leverage research designs and infrastructure for generating evidence on older adults with cancer, increase U.S. Food and Drug Administration authority to incentivize and require research that involves older adults with cancer, increase clinicians’ recruitment of older adults with cancer to clinical trials, and use journal policies to improve researchers’ reporting on the age distribution and health risk profiles of research participants.” ■