Abstract
When managing older patients with lower-risk hormone-receptor-positive (HR+), HER2 negative (HER2−) early-stage breast cancer (EBC), the harms and benefits of adjuvant therapies should be taken into consideration. A survey was conducted among Canadian oncologists on the definitions of “low risk” and “older”, practice patterns, and future trial designs. We contacted 254 physicians and 21% completed the survey (50/242). Most respondents (68%, 34/50) agreed with the definition of “low risk” HR+/HER2− EBC being node-negative and either: ≤3 cm and low histological grade, ≤2 cm and intermediate grade, or ≤1 cm and high grade. The most popular chronological and biological age definition for older patients was ≥70 (45%, 22/49; 45% 21/47). In patients ≥ 70 with low risk EBC, most radiation and medical oncologists would recommend post-lumpectomy radiotherapy (RT) and endocrine therapy (ET). Seventy-eight percent (38/49) felt that trials are needed to evaluate RT and ET’s role in patients ≥ 70. The favored design was ET alone, vs. RT plus ET (39%, 15/38). The preferred primary and secondary endpoints were disease-free survival and quality of life, respectively. Although oncologists recommended both RT and ET, there is interest in performing de-escalation trials in patients ≥ 70.
Highlights
Managing older patients with early-stage breast cancer (EBC) requires a careful evaluation of the potential risks and benefits of treatment, as well as the integration of competing risks of non-cancer-related mortality
This review showed that in patients treated with adjuvant endocrine therapy (ET), the addition of adjuvant RT reduced inbreast tumor recurrence (IBTR) at 5 years (summary risk ratio (SRR) 0.15, 95% CI 0.08–0.28), but had no effect on survival (SRR 0.97, 95% CI 0.79–1.2) [13]
The definition of low-risk HR+ HER2− EBC varies in studies, a majority of respondents agreed with the definition proposed by Sparano et al [17], which defined low-risk breast cancer as: a tumor ≤ 3 cm with a low histological grade, a tumor ≤ 2 cm with an intermediate grade, or a tumor ≤ 1 cm with a high grade
Summary
Managing older patients with early-stage breast cancer (EBC) requires a careful evaluation of the potential risks and benefits of treatment, as well as the integration of competing risks of non-cancer-related mortality. A few trials have been performed to identify older patients with a lower risk EBC, for whom it might be appropriate to de-escalate adjuvant therapies. These trials tend to focus mainly on omitting RT [5,6,7]. A recent study evaluating the benefits of adjuvant ET for EBC has shown that when competing risks for death are taken into account, are disease-free survival (DFS) and distant recurrence-free survival (DRFS) events significantly reduced, but the overall benefits of ET become more modest, for older patients and those with lower-risk disease [14]
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