Adjuvant Chemotherapy In Older Women Research Articles

21-gene recurrence score testing and adjuvant chemotherapy in older women with early breast cancer

Background: The benefit of adjuvant chemotherapy is unclear in women aged 70+ with breast cancer. Oncotype DX is a genomic test predicting recurrence risk for women with early oestrogen receptor-positive, HER2-negative, lymph node-negative cancers, for whom chemotherapy side effects may not outweigh the benefits. This study investigated Oncotype DX testing and chemotherapy in women aged 70+, in whom the test is not yet validated.

Abstract P2-14-04: Delayed initiation of adjuvant chemotherapy in older women with breast cancer

Abstract Background: Early stage breast cancer patients benefit from adjuvant chemotherapy, but delays in initiation of treatment can negatively impact outcomes. Delays may be more common in older women. In this study we evaluate the survival impact of delays in adjuvant chemotherapy initiation in patients over 65 years of age and identify factors associated with delays. Methods: Patients age 66 years and older diagnosed between 2001 and 2013 with localized or regional breast cancer were identified in the SEER-Medicare and Texas Cancer Registry-Medicare databases. All patients received adjuvant chemotherapy within 9 months of surgery. Patients were required to have continuous Medicare Parts A and B coverage and no HMO enrollment 12 months before and 12 months after diagnosis. We grouped patients according to time from surgery to chemotherapy in 4 groups: 0-30, 31-60, 61-90, and > 90 days. Delayed chemotherapy initiation was defined as > 90 days. We used multivariable logistic regression to identify predictors of delayed chemotherapy. We estimated overall survival (OS) and breast cancer-specific survival (BCSS) using Kaplan-Meier method. Inverse probability treatment weights were applied to survival analyses. Cox proportional hazard models were used to determine the association between delays in chemotherapy and outcome after adjustment for other variables. Results: 25,902 women were included in the analysis, and the median age was 71 years. The median time from surgery to chemotherapy was 43 days. From 2001-2013 this interval increased from 38 days to 47 days (p < 0.001). Chemotherapy delays were observed in 10.6% of the patients. In multivariable analysis, factors associated with an increased risk in chemotherapy delays included: older age, black or Hispanic race/ethnicity, being single, more comorbidities, hormone receptor positivity, mastectomy, Oncotype DX testing, and having a full state buy-in Medicare plan. Chemotherapy delay was associated with worse OS. The 5 year OS estimates for patients receiving chemotherapy 0-30, 31-60, 61-90 and > 90 days after surgery were 0.82, 0.81, 0.80 and 0.73 respectively (p < 0.001). A similar trend was seen with BCSS (p < 0.001). After multivariable adjustment chemotherapy delay was associated with worse OS (HR=1.32, 95%CI 1.24-1.40) and BCSS (HR=1.38, 95%CI 1.24 - 1.52) compared with patients in the 0-30 day category. In a stratified analysis among patients with known breast cancer subtype, we observed that a delay in adjuvant chemotherapy initiation was associated with worse OS among patients with hormone receptor-positive (HR=1.45, 95%CI 1.05-2.01), HER2-positive (HR=1.52, 95%CI 1.03-2.23), and triple negative (HR=1.90, 95%CI 1.32-2.73) breast cancer. Discussion: Delays in initiating adjuvant chemotherapy in older women with breast cancer are associated with worse OS and BCSS. Our data demonstrates that delays should be avoided and should encourage providers to initiate chemotherapy ≤ 90 days after surgery. In addition, the multidisciplinary medical team should be aware of the socioeconomic factors that may impact patients’ ability to receive timely treatment. Further studies should seek to elucidate the causes of these inequities in care. Citation Format: Demetria Smith-Graziani, Xiudong Lei, Sharon Giordano, Hui Zhao, Meghan Karuturi, Mariana Chavez-MacGregor. Delayed initiation of adjuvant chemotherapy in older women with breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-14-04.

Intrinsic brain activity changes associated with adjuvant chemotherapy in older women with breast cancer: a pilot longitudinal study.

Older cancer patients are at increased risk of cancer-related cognitive impairment. The purpose of this study was to assess the alterations in intrinsic brain activity associated with adjuvant chemotherapy in older women with breast cancer. Chemotherapy treatment (CT) group included sixteen women aged ≥ 60years (range 60-82years) with stage I-III breast cancers, who underwent both resting-state functional magnetic resonance imaging (rs-fMRI) and neuropsychological testing with NIH Toolbox for Cognition before adjuvant chemotherapy, at time point 1 (TP1), and again within 1month after completing chemotherapy, at time point 2 (TP2). Fourteen age- and sex-matched healthy controls (HC) underwent the same assessments at matched intervals. Three voxel-wise rs-fMRI parameters: amplitude of low-frequency fluctuation (ALFF), fractional ALFF (fALFF), and regional homogeneity, were computed at each time point. The changes in rs-fMRI parameters from TP1 to TP2 for each group, the group differences in changes (the CT group vs. the HC group), and the group difference in the baseline rs-fMRI parameters were assessed. In addition, correlative analysis between the rs-fMRI parameters and neuropsychological testing scores was also performed. In the CT group, one brain region, which included parts of the bilateral subcallosal gyri and right anterior cingulate gyrus, displayed increased ALFF from TP1 to TP2 (cluster p-corrected = 0.024); another brain region in the left precuneus displayed decreased fALFF from TP1 to TP2 (cluster level p-corrected = 0.025). No significant changes in the rs-fMRI parameters from TP1 to TP2 were observed in the HC group. Although ALFF and fALFF alterations were observed only in the CT group, none of the between-group differences in rs-fMRI parameter changes reached statistical significance. Our study results of ALFF and fALFF alterations in the chemotherapy-treated women suggest that adjuvant chemotherapy may affect intrinsic brain activity in older women with breast cancer.

Gray matter density reduction associated with adjuvant chemotherapy in older women with breast cancer

PurposeThe purpose of this study was to evaluate longitudinal changes in brain gray matter density (GMD) before and after adjuvant chemotherapy in older women with breast cancer.MethodsWe recruited 16 women aged ≥ 60 years with stage I–III breast cancers receiving adjuvant chemotherapy (CT) and 15 age- and sex-matched healthy controls (HC). The CT group underwent brain MRI and the NIH Toolbox for Cognition testing prior to adjuvant chemotherapy (time point 1, TP1) and within 1 month after chemotherapy (time point 2, TP2). The HC group underwent the same assessments at matched intervals. GMD was evaluated with the voxel-based morphometry.ResultsThe mean age was 67 years in the CT group and 68.5 years in the HC group. There was significant GMD reduction within the chemotherapy group from TP1 to TP2. Compared to the HC group, the CT group displayed statistically significantly greater GMD reductions from TP1 to TP2 in the brain regions involving the left anterior cingulate gyrus, right insula, and left middle temporal gyrus (pFWE(family-wise error)-corrected < 0.05). The baseline GMD in left insula was positively correlated with the baseline list-sorting working memory score in the HC group (pFWE-corrected < 0.05). No correlation was observed for the changes in GMD with the changes in cognitive testing scores from TP1 to TP2 (pFWE-corrected < 0.05).ConclusionsOur findings indicate that GMD reductions were associated with adjuvant chemotherapy in older women with breast cancer. Future studies are needed to understand the clinical significance of the neuroimaging findings. This study is registered on ClinicalTrials.gov (NCT01992432).

The preference to receive chemotherapy and cancer-related outcomes in older adults with breast cancer CALGB 49907 (Alliance).

Chemotherapy preference refers to a patient's interest in receiving chemotherapy. This study examined whether chemotherapy preference was associated with toxicity, efficacy, quality of life (QoL), and functional outcomes during and after completion of adjuvant chemotherapy in older women with breast cancer. This study is a secondary analysis of CALGB 49907, a randomized trial that compared standard adjuvant chemotherapy versus capecitabine in patients age 65 years or older with breast cancer. A subset of 145 patients completed a questionnaire to describe chemotherapy preference pre-treatment. The association of this pre-treatment preference with the patient's perception of self-health, predicted and actual QoL, patient- and professional-reported toxicity, mental health, self-rated function, and survival was studied during and after treatment. The median age of patients was 71 years and 47% had a high preference for chemotherapy. On baseline demographics, the low preference group had a higher proportion of white patients (95% vs. 78%, p = 0.004). Before treatment, low chemotherapy preference was associated with greater nausea/vomiting (p = 0.008). Mid-treatment, low preference was associated with lower QoL, worse social, emotional and physical function (all p ≤ 0.02) and worse nausea/vomiting, cancer symptoms and financial worries (all p < 0.05). The association noted mid-treatment, resolved after treatment completion except with financial worries which persisted at 24 months. Low preference was associated with higher rates of grade 3-5 adverse events (53% vs. 34%, p = 0.02) but was not associated with survival. Low chemotherapy preference prior to treatment initiation was associated with lower QoL, worse physical symptoms and self-rated function and more adverse events mid-treatment. There is no association of chemotherapy preference with survival.

Abstract IA29: Race, ethnicity, and outcomes in breast cancer

Abstract The racial divide in breast cancer outcomes is well known. Breast cancer is the most common cause of cancer in women in the United States, and the second leading cause of cancer death.1 Black race is associated with a worse prognosis in operable breast cancer2 and in other hormone dependent cancers such as uterine and prostate cancer, but generally not other cancer types.3,4 Black women are more likely to present with advanced stage disease5, have triple negative breast cancer (TNBC), exhibit greater non-adherence and poorer tolerance to chemotherapy6 and endocrine therapy7, and have more comorbidities8 and experience more disparities in care.9-11 Black race has also been associated with worse outcome in male breast cancer.12 Although breast cancer incidence and mortality have declined by about 35% in the United States since 1990, mortality rates have declined less in black women, contributing to a widening of the racial gap which has contributed to about a 35% higher mortality rate for black women compared with others.13 However, a widening racial gap has also been observed for women in the U.S. Department of Defense healthcare system, suggesting that factors other than disparities in care may be playing a role. 14 With regard to ethnicity, Hispanic women also exhibit higher rates of TNBC, but otherwise experience similar outcomes as non-Hispanic women. There is emerging evidence that differences in outcomes may be due in part due to factors other than disparities in care. In this review, we explore some of the biological factors that may be contributing to the racial divide in breast cancer.

Weekly docetaxel versus CMF as adjuvant chemotherapy for older women with early breast cancer: final results of the randomized phase III ELDA trial

Evidence on adjuvant chemotherapy in older women with breast cancer is poor. We tested whether weekly docetaxel is more effective than standard chemotherapy. We carried out a multicenter, randomized phase III study. Women aged 65-79, operated for breast cancer, with average to high risk of recurrence, were allocated 1 : 1 to CMF (cyclophosphamide 600 mg/m², methotrexate 40 mg/m², fluorouracil 600 mg/m², days 1, 8) or docetaxel (35 mg/m(2) days 1, 8, 15) every 4 weeks, for four or six cycles according to hormone receptor status. Primary end point was disease-free survival (DFS). A geriatric assessment was carried out. Quality of life (QoL) was assessed with EORTC C-30 and BR-23 questionnaires. From July 2003 to April 2011, 302 patients were randomized and 299 (152 allocated CMF and 147 docetaxel) were eligible. After 70-month median follow-up, 109 DFS events were observed. Unadjusted hazard ratio (HR) of DFS for docetaxel versus CMF was 1.21 [95% confidence interval (CI) 0.83-1.76, P = 0.32]; DFS estimate at 5 years was 0.69 with CMF and 0.65 with docetaxel. HR of death was 1.34 (95% CI 0.80-2.22, P = 0.26). There was no interaction between treatment arms and geriatric scales measuring patients' ability or comorbidities. Hematological toxicity, mucositis and nausea were worse with CMF; allergy, fatigue, hair loss, onychopathy, dysgeusia, diarrhea, abdominal pain, neuropathy, cardiac and skin toxicity were worse with docetaxel. One death was attributed to CMF and two to docetaxel. Increasing age, impairment in instrumental daily living activities, number of comorbidities and docetaxel treatment were independently associated with severe nonhematological toxicity. QoL was worse with docetaxel for nausea-vomiting, appetite loss, diarrhea, body image, future perspective, treatment side-effects and hair loss items. Weekly docetaxel is not more effective than standard CMF as adjuvant treatment of older women with breast cancer and worsens QoL and toxicity. NCT00331097.

Adjuvant chemotherapy in older women with breast cancer: who and what?

A 73-year-old woman has been diagnosed with a mammographically detected grade 3, 2.2-cm invasive ductal carcinoma that is sentinel lymph node negative, estrogen receptor positive (80%), progesterone receptor negative, and human epidermal growth factor receptor 2 negative (0 by immunohistochemistry). A gene expression assay (Oncotype DX, Genomic Health, Redwood City, CA) showed a recurrence score of 28. Except for well-controlled hypertension and some aches and pains in her hands and knees, she has no other major illnesses. Her medications include an antihypertensive, vitamin D, and calcium. She discontinued cigarette smoking 20 years ago and has an occasional glass of wine. She describes her health as good, is fully functional, drives, has had no falls, and provides the majority of care for her sick husband. Her blood pressure is 146/88, her body mass index is 29.7, and her physical examination is normal. She is aware of the benefits and risks of adjuvant endocrine therapy and has been referred to discuss the role of chemotherapy.

Adjuvant chemotherapy in elderly women with breast cancer: patients' perspectives on information giving and decision making

Decisions about adjuvant chemotherapy in older women with early stage breast cancer (EBC) are often challenging. Uncertainty about benefits due to limited data about treatment efficacy and outcomes complicates decision making. This qualitative study explored older patients' experiences and preferences towards information giving and ultimate decisions about adjuvant chemotherapy. Clinicians from 24 UK breast cancer teams reported on adjuvant chemotherapy decisions for women aged ≥70 years with EBC from April 2010 to December 2011. Women who were offered chemotherapy were invited to participate in structured interviews. Self-reported quality of life (QoL) and functional ability were assessed. Qualitative methods were used to identify themes associated with information giving and decision making. A total of 58/95 eligible women (61%) participated. Median age was 73 years (range 70-83). Mean total scores for QoL and functional ability were average. The majority of women preferred to make their treatment decisions collaboratively with a clinician (59%) or on their own (19%). The main reasons influencing decisions to accept chemotherapy were categorised as prevention of recurrence and clinician recommendation. Side effects, length of treatment, impact on QoL, low survival benefits and clinician recommendation influenced decisions to decline chemotherapy. The majority (80%) were satisfied with information provision, the communication with their clinician and explanation of treatment. Older women with EBC preferred to be involved in clinical decision making. Clinician recommendation plays a significant role in either accepting or declining chemotherapy. Well-informed decision making and effective communication between clinicians, older women and their family members are therefore important.

Abstract P1-13-10: Efficacy, toxicity and quality of life in older patients with early-stage breast cancer treated with oral Tegafur-uracil or classical CMF (cyclophosphamide, methotrexate, and fluorouracil): an exploratory analysis of National Surgical Adjuvant Study for Breast Cancer (N-SAS BC) 01 Trial

Abstract Background: It is critically important to consider the issue of treatment for older breast cancer patients in developed countries where aging has been rapidly advanced such as in Japan. According to Oxford Overview analysis of 15-year results, benefit of adjuvant chemotherapy in older than 70 years remains uncertain. Recently CALGB 49907 trial clearly showed standard chemotherapy of either cyclophosphamide, methotrexate, and fluorouracil (CMF) or doxorubicin plus cyclophosphamide (AC) is superior to capecitabine in patients with early-stage breast cancer who are 65 years or older. In contrast, we demonstrated equivalent efficacy between six cycles of classical CMF and 2 years of oral Tegafur-uracil (UFT) in phaseIII randomized controlled trial: N-SAS BC01 (Watanabe T et al, JCO 2009). Of interest, UFT showed a trend toward better suppression of recurrence in patients over 50 years of age in this trial. In current exploratory analysis, we sought to examine whether UFT is not inferior to CMF in terms of efficacy, toxicity and quality of life (QOL) in older patients with early-stage breast cancer. Patients and Methods: N-SAS BC 01 trial was a randomly assigned trial comparing adjuvant oral UFT with classical CMF in patients with node negative, high risk breast cancer. In this exploratory analysis, patients of 65 years or older enrolled in N-SAS BC 01 trial were analyzed in terms of efficacy, toxicity and quality of life. Results: Of the 707 patients enrolled in N-SAS BC 01 trial, 97 patients (13.7%) were 65 years or older. Median age was 68 years (range, 65 to 75 years). The 5-year relapse-free survival (RFS) rate was 92.5% in the CMF arm and 93.0% in the UFT arm. Overall survival (OS) rate at 5 years were 98.1% and 97.7%, respectively. The hazard ratios of the UFT arm relative to the CMF arm were 1.07 for RFS (95% CI, 0.31 to 3.55) and for OS (95% CI, 0.15 to 10.25). However 95 % CIs were very wide due to the small sample size. Among patients who received CMF, frequency of grade 3/4 leukopenia (3.8%) and neutropenia (13.5%) were higher than 0% and 4.8% with UFT, respectively. Similarly, grade 3/4 increased liver enzyme and nausea/vomiting were more frequent with CMF than with UFT. In contrast, elevation of total bilirubin and diarrhea were more observed in UFT arm. Compared with patients received CMF, patients with UFT had better QOL scores assessed by EORTC QLQ-C30/BR23 and the FACT-B questionnaire. The rate of adherence was 79.2% (42/53) at 6 months in the CMF arm and 74.4% (32/43) at 2 years in the UFT arm. Conclusion: The result of this study indicated that UFT might not be inferior to CMF in patient with early stage breast cancer who are 65 years of age or older in terms of efficacy, toxicity and QOL. UFT would be a promising option for adjuvant chemotherapy in older women with node-negative, high-risk breast cancer. Further larger randomized clinical trial in this patient population would be warranted to validate these results. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-13-10.

Predictors of timing of adjuvant chemotherapy in older women with hormone receptor–negative, stages II–III breast cancer

Predictors of timing of adjuvant chemotherapy in older women with hormone receptor–negative, stages II–III breast cancer

ES6-3: Breast Cancer in the Older Adult.

Abstract Breast cancer is a disease associated with aging. In the US, the median age of breast cancer diagnosis and death is 61 years and 68 years, respectively. The number of older adults in the US is rising, and the number of individuals age 65 and older is expected to double by the year 2030. This demographic shift will lead to an increase in the number of individuals diagnosed with breast cancer. It is estimated that from 2010 to 2030 there will be a 57% growth in the number of new cases of breast cancer in patients age 65 and older.1 A challenge in caring for older adults with breast cancer is that they have been historically underrepresented in clinical trials that set the standard for breast cancer care.2 However, a growing body of evidence-based literature can be utilized to inform and optimize the care of the older adults with breast cancer. This presentation will focus on the treatment of early stage breast cancer in older adults, including the risks and benefits of local and systemic therapies, as well as survivorship issues. Recently reported phase III studies have led to advances in the treatment of older adults with breast cancer. A phase III randomized study evaluated the role of radiation therapy following lumpectomy in patients age 70 and older with stage I hormone receptor (HR) positive breast cancer who received treatment with tamoxifen. Receipt of radiation therapy was associated with a decrease in the risk of locoregional recurrence; however, there was no difference in overall survival. The study results underscore the importance of competing comorbidity as a cause of death in older adults with early stage breast cancer.3 The role of axillary lymph node dissection was evaluated in a randomized study of women over age 60 with node-negative, HR positive breast cancer who received treatment with tamoxifen. Patients were randomized to breast surgery and axillary dissection, or breast surgery alone. There was no difference between disease-free and overall survival in the 2 study arms.4 A phase III randomized study evaluated the efficacy of standard adjuvant IV chemotherapy (doxorubicin and cyclophosphamide [AC] or cyclophosphamide, methotrexate, and 5-fluorouracil [CMF]) versus oral chemotherapy (capecitabine) in patients age 65 and older with stage I-III breast cancer. Those patients who received standard chemotherapy showed improvement in progression-free and overall survival compared with patients who received capecitabine. This study demonstrates that IV polychemotherapy regimens remain the standard of care for older adults who are prescribed adjuvant chemotherapy.5 These phase III studies advance our understanding in the care of older adults with breast cancer. Furthermore, they demonstrate the feasibility and importance of accruing older adults to phase III trials, which will improve our evidence-based care of this growing population.

Commentary on adjuvant chemotherapy for the older woman with early stage breast cancer

The number of older women diagnosed with early stage breast cancer has increased in recent years, due to improved general health and an average life expectancy of around 80 years in many countries. In the US, the average age at diagnosis of breast cancer is 63 years and in most instances is early stage disease. Many of these women are fit with no or minimal co-morbid illnesses and have a predicted longevity of many years into the future. Thus, decisionmaking regarding adjuvant chemotherapy options is an increasingly common clinical challenge. What age defines an “older woman with breast cancer” in and of itself is controversial, but for the purpose of this commentary will generally refer to 65 years of age and older. The extent of clinical trial-based evidence on the benefit of adjuvant chemotherapy in older women is limited, resulting in a lack of statistical power to address the benefits and risks of these treatments in age subgroups over 65, especially 70+ or 75+ years. Meta-analyses help in this regard, but outcomes are still unstable in the 70+ age group due to relatively small subsets. This leads to uncertainty in degree of benefit to adjuvant chemotherapy in older women. While large cancer clinical trials cooperative groups generally accrue women and African Americans at rates commensurate with their frequency in the general population, this is not the case for older persons with cancer. For example, in the Southwest Oncology Group (SWOG) experience, marked underaccrual of patients over age 65 occurred, even after mandates to Medicare to cover the costs of clinical trials. Across 12 common cancer types for the years 1993–1996, 1997–2000 and 2000–2003, respectively, only 25%, 31% and 38% were over age 65, versus 61% in the general population. The reason for this under-accrual of older patients (and resulting limited data on chemotherapy efficacy) is multi-factorial, but more recent analyses suggest that stringent trial eligibility criteria and

Adjuvant chemotherapy in older women (ACTION) study – what did we learn from the pilot phase?

Background:The ACTION trial was initiated to provide evidence from a randomised trial on the effects of chemotherapy in women aged over 70 years where evidence for risk and benefit are lacking.Methods:This was a randomised, phase III clinical trial for high risk, oestrogen receptor (ER) negative/ER weakly positive early breast cancer. The trial planned to recruit 1000 women aged 70 years and older, randomised to receive 4 cycles of anthracycline chemotherapy or observation. The primary endpoint was relapse-free interval. The trial included a pilot phase to assess the acceptability and feasibility of recruitment.Results:The trial opened at 43 UK centres. Information on number of patients approached was available from 38 centres. Of the 43 eligible patients that were approached, 39 were not randomised due to patients declining entry. After 10 months only 4 patients had been randomised and after discussion with the research funder, the trial was closed and funding terminated.Conclusion:Despite widespread support at several public meetings, input from patient groups including representation on the Trial Management Group, the trial failed to recruit due to the inability to convince patients to accept randomisation. It would therefore seem that randomising the patients to receive chemotherapy vs observation is not a viable design in the current era for this patient population.

Predictors of timing of adjuvant chemotherapy in older women with hormone receptor–negative, stages II–III breast cancer

Adherence to consensus guidelines for cancer care may vary widely across health care settings and contribute to differences in cancer outcomes. For some women with breast cancer, omission of adjuvant chemotherapy or delays in its initiation may contribute to differences in cancer recurrence and mortality. We studied adjuvant chemotherapy use among women with stage II or stage III, hormone receptor-negative breast cancer to understand health system and socio-demographic correlates of underuse and delayed adjuvant chemotherapy. We used Surveillance Epidemiology and End Results (SEER)-Medicare linked data to examine the patterns of care for 6,678 women aged 65 and older diagnosed with stage II or stage III hormone receptor-negative breast cancer in 1994-2002, with claims data through 2007. Age-stratified logistic regression was employed to examine the potential role of socio-demographic and structural/organizational health services characteristics in explaining differences in adjuvant chemotherapy initiation. Overall utilization of guideline-recommended adjuvant chemotherapy peaked at 43% in this population. Increasing age, higher co-morbidity burden, and low-income status were associated with lower odds of chemotherapy initiation within 4 months, whereas having positive lymph nodes, more advanced disease, and being married were associated with higher odds (P < 0.05). Health system-related structural/organizational characteristics and race/ethnicity offered little explanatory insight. Timely initiation of guideline-recommended adjuvant chemotherapy was low, with significant variation by age, income, and co-morbidity status. Based on these findings, future studies should seek to explore the more nuanced reasons why older women do not receive chemotherapy and why delays in care occur.

Clinical outcome of triple-negative primary breast cancer in older women: Comparison with their younger counterparts.

1057 Background: It is generally believed that triple-negative (ER-/PR-/HER2-) primary breast cancers have poor prognosis. Following surgery, adjuvant chemotherapy is currently the only treatment that could potentially improve survival. On the other hand, the absolute benefit of adjuvant chemotherapy in older women appears small and its precise value remains to be proven. As such its use tends to be very limited in this population. Methods: Over 36 years (1973−2009), 2,000+ older (≥70 years) women with early operable primary breast cancer were managed in a dedicated clinic. Of these 127 patients with triple negative invasive carcinoma (defined as ER/PR = 0% positive cells, HER2 = 1+ or 2+ on IHC and CISH negative) underwent primary surgery and had good quality tumour samples available for tissue microarray (TMA) analysis using indirect immunohistochemistry. The results were compared with their younger (<70 years) counterparts from a previously characterised, consecutive series (N=1,809) treated in the same unit (1986–1998). Among them, there were 342 patients who had triple negative tumors. Results: At a median follow-up of 46 months (longest=204) (≥70 years) and 119 months (longest=135) (<70 years), the results are shown in the table. Conclusions: Despite not having received adjuvant chemotherapy, the older series had clinical outcome similar to the younger patients almost half of which had chemotherapy. This may be due to other biomarkers (in addition to ER/PR/HER2) which have different patterns in these age groups influencing prognosis. The place of adjuvant chemotherapy in the treatment of these patients has yet to be identified. Treatment pattern <70 years ≥70 years With adjuvant chemotherapy 149 (47.0%) 0 Without adjuvant chemotherapy 168 (53.0%) 127 (100%) Outcome at 5 years P value Breast cancer-specific survival 73% 79% 0.39 Local recurrence 10% 14% 0.16 Regional recurrence 11% 14% 0.40 Metastases 30% 27% 0.56

Specialist breast care and research nurses’ attitudes to adjuvant chemotherapy in older women with breast cancer

PurposeBreast cancer largely affects older women (≥70 y) who have historically been excluded from clinical trials; consequently, treatment is often not evidence-based. Older women may not be offered adjuvant chemotherapy due to assumptions that they would not benefit, cannot tolerate it or do not wish to have it. Specialist breast care nurses (BCN) and research nurses (RN) play an important role influencing decisions. We report the roles, attitudes and involvement of such nurses regarding adjuvant chemotherapy in older women. MethodA questionnaire examined 259 UK BCN and RN’s views about efficacy and desirability of chemotherapy in older women, participation in decision-making in MDTs, and roles when chemotherapy was discussed with patients. Results72% of BCN and 48% of RN agreed that age should not be a factor influencing who is offered chemotherapy. BCNs indicated involvement in decision-making with older breast cancer patients, discussing chemotherapy with patients at different points following diagnosis and during treatment, and proposing chemotherapy in MDT meetings. RNs were involved to a lesser extent. 69% of all nurses had not received specific training in the area and 70% thought training would be beneficial. Nurses disagreed that older patients would not tolerate or did not want chemotherapy but 1/3 agreed or were uncertain that burdens of chemotherapy outweighed benefits. A third felt that older women had less control over treatment decisions than younger women. ConclusionsThis study suggests a need to develop the role of specialist nurses to facilitate treatment decision-making relating to chemotherapy in older women.

Adjuvant Chemotherapy in Older Women with Early-Stage Breast Cancer

Adjuvant Chemotherapy in Older Women with Early-Stage Breast Cancer

Adjuvant Chemotherapy for Older Adults with Breast Cancer: Making the Standard a Standard

Muss HB, Berry DA, Cirrincione CT et al.: Adjuvant chemotherapy in older women with early-stage breast cancer. N. Engl. J. Med. 360, 2055-2065 (2009). To date, only two prospective trials evaluating adjuvant therapy for breast cancer in older adults have been published. The second and more recent trial, Cancer and Leukemia Group B (CALGB) 49907, provides substantial evidence supporting the use of standard adjuvant chemotherapy regimens (doxorubicin-cyclophosphamide or cyclophosphamide-methotrexate-5-fluorouracil) as opposed to simplified oral regimens (capecitabine). In this trial, both the risk of relapse (hazard ratio: 2.09; 95% CI: 1.38-3.17; p < 0.001) and the risk of death (hazard ratio: 1.85; 95% CI: 1.11-3.08; p = 0.02) were significantly higher with capecitabine compared with standard chemotherapy. The current review explores both the implications and potential caveats of this innovative trial. CALGB 49907 represents a paradigm for further studies of adjuvant cancer therapy in older adults.

Racial and socioeconomic disparities in adjuvant chemotherapy for older women with lymph node‐positive, operable breast cancer

Consistent with findings from clinical trials, a recent population-based study indicated that adjuvant chemotherapy for lymph node-positive, operable breast cancer is effective at improving survival in older women, specifically those ages 65 years to 69 years; however, to the authors' knowledge, no conclusion has been reached about the relative benefit of chemotherapy for women aged > or =70 years, probably because of small number of patients. However, little is known about racial and socioeconomic disparities in adjuvant chemotherapy for breast cancer among older women. This study included 14,177 white women and 1277 black women aged > or =65 years who were diagnosed with operable breast cancer (stage II-IIIA) and positive lymph nodes between 1991 and 2002. These women were identified from the Surveillance, Epidemiology, and End Results and Medicare-linked database. Multivariate logistic regression was used to compute the odds ratios of receiving chemotherapy among black women compared with white women, and the causal step approach was used to test whether census tract-level poverty mediated racial disparities. Interaction terms analyses indicated that regressions should be stratified by age group. In the group ages 65 years to 69 years, the adjusted odds ratio of receiving chemotherapy were lower for black women than for white women (odds ratio, 0.85; 95% confidence interval, 0.57-0.97). Poverty mediated the association between chemotherapy and race in this age group. No racial or socioeconomic disparities were observed among women aged > or =70 years. This study documented racial disparities in adjuvant chemotherapy that were mediated by poverty in women ages 65 years to 69 years, an age group for which there is clear evidence for the efficacy of chemotherapy, but no disparities were observed among women aged > or =70 years. The authors concluded that it is important to work toward reducing treatment disparities among older women.