Elderly Breast Cancer Patients Research Articles

Intensity-modulated radiotherapy and hypofractionated volumetric modulated arc therapy for elderly patients with breast cancer: comparison of acute and late toxicities.

To evaluate the differences between conventional fractionated intensity-modulated radiotherapy (IMRT) and hypofractionated (HypoRT) volumetric modulated arc therapy (VMAT) in elderly women affected by early-stage breast cancer (BC) in terms of RT-related acute/late side effect. Between October 2011 and July 2015, 80 consecutive elderly BC patients were treated with IMRT for 5weeks (40 patients) or HypoRT-VMAT for 3weeks (40 patients). Inclusion criteria were: age ≥ 70years, early BC (pT1-2 pN0-1), no prior neoadjuvant chemotherapy and non-metastatic disease. For patients receiving IMRT or HypoRT-VMAT, a total dose of 50Gy (25 fractions) or 40.5Gy (15 fractions) was prescribed to the whole ipsilateral breast, respectively. All patients received a simultaneously integrated boost up to a total dose of 60Gy for IMRT and 48Gy for HypoRT-VMAT. Acute and late side effects were evaluated using the RTOG/EORTC radiation morbidity scoring system. With a median follow-up of 45months, acute skin toxicity was overall very low, with grade 1 in 25 cases (62.5%) of the IMRT group and 21 cases (52.5%) of the HypoRT-VMAT group, while grade 2 toxicity was reported in 10 IMRT patients (25%) and 1 HypoRT-VMAT patient (2.5%) (p = 0.001). Regarding late adverse events, only grade 1 skin toxicity was recorded. The present study showed that whole breast IMRT and HypoRT-VMAT are feasible and well tolerated in early-stage BC elderly patients and that HypoRT-VMAT is affected by lower risk of acute and late RT-related side effects.

Pretreatment neutrophil/lymphocyte, platelet/lymphocyte, lymphocyte/monocyte, and neutrophil/monocyte ratios and outcome in elderly breast cancer patients.

Several studies have found an association between peripheral inflammatory cells and outcome. However, no study has explored their impact specifically in elderly patients. We have retrospectively examined pretreatment peripheral neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), lymphocyte/monocyte ratio (LMR), and neutrophil/monocyte ratio (NMR) in 113 elderly breast cancer patients and correlated our findings with disease-free survival (DFS) and overall survival (OS). All patients ≥ 65years diagnosed from 2004 to 2018 with locally advanced breast cancer were included and classified as high vs low NLR, PLR, LMR, and NMR based on previously identified cutoffs. Estimated 1-, 3-, and 5-year DFS and OS were compared by Chi square analysis. Among 104 evaluable patients, only PLR was significantly associated with estimated 3-year DFS (85.1% vs 63.6%; P = 0.04) and OS (89.3% vs 68.1%; P = 0.03). Among 69 patients with three or more years of follow-up, PLR (P = 0.05), absolute lymphocyte count (ALC) (P = 0.01), polychemotherapy (P = 0.04), number of comorbidities (P = 0.02), polypharmacy (P = 0.005), and clinical stage (P = 0.03) were associated with 3-year DFS. Polypharmacy (OR 4.9; P = 0.02) and ALC (OR 4.6; P = 0.04) retained their significance in the multivariate analysis. We have found an association between low PLR and longer DFS in elderly breast cancer patients that is in line with findings in patients with a wider range of ages. Our findings on NLR contrast with those of other studies, indicating a potential differential effect in elderly patients. In addition, the effect of polypharmacy on outcome in elderly patients warrants further investigation.

Factors influencing surgical treatment of breast cancer in elderly patients

Factors influencing surgical treatment of breast cancer in elderly patients

Correction 2: Everolimus (EVE) and exemestane (EXE) in patients with advanced breast cancer aged ≥ 65 years: new lessons for clinical practice from the EVA study.

[This corrects the article DOI: 10.18632/oncotarget.25874.].

358O - Evaluation of functional decline in elderly breast cancer patients receiving first-line chemotherapy

358O - Evaluation of functional decline in elderly breast cancer patients receiving first-line chemotherapy

Age-related microRNAs in older breast cancer patients: biomarker potential and evolution during adjuvant chemotherapy

BackgroundMicroRNAs (miRNAs) are important regulators of cellular function and have been associated with both aging and cancer, but the impact of chemotherapy on age-related miRNAs has barely been studied.Our aim was to examine whether chemotherapy accelerates the aging process in elderly breast cancer patients using miRNA expression profiling.MethodsWe monitored age-related miRNAs in blood of women, aged 70 or older, receiving adjuvant chemotherapy (docetaxel and cyclophosphamide, TC) for invasive breast cancer (chemo group, CTG, n = 46). A control group of older breast cancer patients without chemotherapy was included for comparison (control group, CG, n = 43). All patients underwent geriatric assessment at inclusion (T0), after 3 months (T1) and 1 year (T2). Moreover, we analysed the serum expression of nine age-related miRNAs (miR-20a, miR-30b, miR-34a, miR-106b, miR-191, miR-301a, miR-320b, miR-374a, miR-378a) at each timepoint.ResultsExcept for miR-106b, which behaved slightly different in CTG compared to CG, all miRNAs showed moderate fluctuations during the study course with no significant differences between groups. Several age-related miRNAs correlated with clinical frailty (miR-106b, miR-191, miR-301a, miR-320b, miR-374a), as well as with other biomarkers of aging, particularly Interleukin-6 (IL-6) and Monocyte Chemoattractant Protein-1 (MCP-1) (miR-106b, miR-301a, miR-374a-5p, miR-378a-3p). Moreover, based on their ‘aging miRNA’ profiles, patients clustered into two distinct groups exhibiting significantly different results for several biological/clinical aging parameters.ConclusionsThese results further corroborate our earlier report, stating that adjuvant TC chemotherapy does not significantly boost aging progression in elderly breast cancer patients. Our findings also endorsed specific age-related miRNAs as promising aging/frailty biomarkers in oncogeriatric populations.Trial registrationClinicalTrials.gov, NCT00849758. Registered on 20 February 2009. This clinical trial was registered prospectively.

Patient-reported Acute Fatigue in Elderly Breast Cancer Patients Treated with and without Regional Nodal Radiation

Although regional nodal irradiation (RNI) improves outcomes in breast cancer (BC) patients, it is associated with increased toxicity. Therefore, controversy still exist surrounding its indications. The purpose of this study was to evaluate and compare patient-reported acute fatigue in elderly BC patients with and without regional nodal radiation (RNI). Elderly breast cancer patients (≥ 65 yrs) treated with adjuvant radiotherapy (RT) between 2012 and 2017 were identified from a prospective database. The validated Edmonton Symptom Assessment System (ESAS) questionnaire, which assesses fatigue, was completed prior to (baseline), during, at end of RT and first follow-up (6-12 weeks). Symptoms are rated on a 10-point Likert scale, with higher scores indicating higher fatigue. Patients and treatment characteristics were also recorded. Patients were divided into two cohorts: those who received RNI (cohort 1) and those who did not (cohort 2). A minimal clinically important difference (MCID) was defined using an anchor of ≥1-point compared to baseline. The proportion of patients reporting a change in fatigue at the end of RT was evaluated. Univariate and multivariable logistic regression were conducted to assess the association between RNI and MCID after adjusting for potential confounders. To test the robustness of the results, dynamic changes of fatigue scores over time were compared between the cohorts using a general linear mixed model after assuming individual patient with random effect. A two-tailed p-value ≤ 0.05 was considered statistically significant. Of the 1204 patients, 654 completed the ESAS at baseline and end of RT and were considered for this analysis (cohort 1 = 137, cohort 2 = 517). Mean age at diagnosis was similar between the groups: cohort 1 71± 6 vs. cohort 2 72± 5 years (total 72± 4). Overall, cohort 1 had higher stage and reception of chemotherapy (69% vs. 16%). Mean baseline fatigue was higher for cohort 1 vs. 2 (2.5 ± 2.4 vs. 2.1 ± 2.3, p=0.03). On univariate and multivariable analyses, RNI was not associated with an increased odd of MCID for fatigue at the end of RT (44% vs. 47%; OR: 0.89, 95 % CI: 0.61-1.30, p=0.56). After adjusting for confounders (age, duration of RT, endocrine therapy), higher baseline fatigue (OR: 0.86, 95% CI 0.80-0.92, p<0.001) and receipt of chemotherapy (OR: 0.53, 95 % CI:0.34-0.83, p=0.006) were the only factors associated with decreased odds of MCID. Dynamic changes showed a significant worsening of fatigue scores over time (p<0.001) with no difference between the cohorts (p=0.42); both experienced parallel worsening of fatigue levels over time (cohort*time p=0.18). The addition of RNI in elderly BC patients is not associated with a significant worsening of patient-reported fatigue. Therefore, RNI should be considered in elderly BC patient with adverse factors.

Failure to Apply Eligibility Criteria per CALGB 9343 When Omitting Radiation Therapy Results in Excess Locoregional Failures in Elderly Breast Cancer Patients

Failure to Apply Eligibility Criteria per CALGB 9343 When Omitting Radiation Therapy Results in Excess Locoregional Failures in Elderly Breast Cancer Patients

Palliative Local Surgery for Locally Advanced Breast Cancer Depending on Hormone Receptor Status in Elderly Patients

BackgroundMany elderly breast cancer patients might just receive palliative local surgery, especially those with locally advanced breast cancer (LABC). However, palliative tumor removal might lead to perioperative residual tumor growth. In this study, we aimed to determine the survival effect of palliative local surgery without definitive axillary surgery for LABC in elderly patients. Patients and MethodsPatients age 70 years or older diagnosed with T3/4M0 breast cancer, who received no surgery, mastectomy, or lumpectomy without axillary surgery, were identified in the Surveillance, Epidemiology, and End Results cancer database from 1973 to 2014. The overall survival effect of palliative local surgery was determined by using multivariable Cox regression, and propensity score matching was applied to confirm the results. ResultsA total of 2616 female breast cancer patients age 70 years or older diagnosed with T3/4M0 (without inflammatory breast cancer) were identified; 1374 received no cancer-directed surgery, 583 received lumpectomy without axillary surgery, and 659 received mastectomy without axillary surgery. Adjusted for potential confounders, both types of palliative local surgeries (lumpectomy: hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.71-1.27; P = .719; mastectomy: HR, 0.88; 95% CI, 0.65-1.17; P = .371) were not associated with overall survival compared with no surgery within hormone receptor-positive patients. However, mastectomy strongly improved survival within hormone receptor-negative patients. Palliative local surgery did not change the patterns of mortality. ConclusionFor elderly patients diagnosed with LABC, not candidates for standard therapies, mastectomy should be recommended as palliative therapy for hormone receptor-negative, but not for hormone receptor-positive patients.

Overall survival of elderly patients with breast cancer is not related to breast-cancer specific survival: A single institution experience in Japan

As the aging population grows, the number of elderly breast cancer patients has rapidly increased especially in Japan; a suitable treatment for elderly patients, considering chronic comorbidities and treatment tolerance, is urgently needed. In this retrospective study, 286 elderly breast cancer patients were investigated. Tumor characteristics and survival outcome were compared between 70-79-year-old and ≥ 80-year-old groups. Disease-free survival, overall survival, and breast cancer-specific survival were compared, and the effect of variables was analyzed statistically. For resectable cases, prognoses were compared based on treatment (standard therapy or undertreated). Tumor characteristics were similar between groups, but the Ki-67 labeling index tended to be higher in older patients. Elderly patients with resectable cancer tended to be undertreated. During the median 59-month follow-up period, overall survival was significantly worse in the ≥80-year-old than in the 70-79-year-old group (p < 0.001), but disease-free and breast cancer-specific survivals were equivalent. Recurrence or death event hazard rates tended to be lower in patients receiving standard treatment. Standard multidisciplinary treatment for breast cancer prevents recurrence and metastasis and tends to extend breast cancer-specific survival even in elderly patients.

Treatment strategies and predicting prognoses in elderly patients with breast cancer.

ObjectiveThe prevalence of breast cancer in elderly women (older than 80 years) is expected to rise more dramatically than its incidence. In this study, we evaluated the evidence for treatment guidelines for elderly breast cancer patients.Patients and methodsAll included patients were enrolled from 2010 to 2013 from the Surveillance, Epidemiology, and End Results (SEER) database. The Akaike information criterion (AIC) and Harrell’s C statistic were used to perform comparisons. In addition, a propensity score analysis was used to avoid bias caused by data selection criteria. Prognostic factors were selected as nomogram parameters to develop a model to predict survival.ResultsA total of 16998 patients included in the SEER database from 2010 to 2013 had breast cancer and fulfilled the study criteria. Of whom, 13007 patients underwent surgery. Overall survival and cancer-specific survival were significantly better in patients who underwent surgery and/or radiotherapy than in those who did not (P<0.001). In addition, a nomogram system with a C index of 0.83 and an AIC index of 11112.85 was better able to predict prognoses and estimate cancer-specific survival in elderly patients with breast cancer.ConclusionA localized surgical approach might provide better results in elderly breast cancer patients. However, radiotherapy improved cancer-specific survival and overall survival in these patients. In addition, a prognostic nomogram directly quantified patient risk by accounting for various prognostic factors without forming risk groups and was better able to estimate cancer-specific survival.

Everolimus (EVE) and exemestane (EXE) in patients with advanced breast cancer aged ≥ 65 years: new lessons for clinical practice from the EVA study

BACKGROUNDThe present analysis focuses on real-world data of Everolimus-Exemestane in advanced HR+ve, HER2-ve elderly breast cancer patients (aged 65 years) included in the EVA study, with unique findings in those aged 70 years.METHODSData are collected from clinical records and analysed according to age cut-off (< 65 years; 65 - 69 years and {greater than or equal to} 70 years). Relationship of analyzed variables with response were tested by mean of a Mantel-Haenszel chi square test. Time to event analysis was described by Kaplan Meier approach and association with baseline characteristics was analysed by stratified log-rank test and proportional hazard model.RESULTSFrom July 2013 to December 2015, the EVA study enrolled overall 404 pts. 154 patients out of 404 (38,1%) were aged {greater than or equal to} 65 years, of whom 87 were {greater than or equal to} 70 years. Median duration of EVE treatment was 28.5 weeks (95% CI 19.0 - 33.8) in patients aged 65-69 years and 24,4 weeks (95% CI 19,2 - 33,2) in those aged {greater than or equal to} 70 years. Fewer patients aged 65 years received the highest EVE Dose-Intensity (>7.5 mg/day) in comparison to younger patients (49,6% vs. 66,8%). Grade 3–4 toxicities occurred to 55 patients (35,7%), mainly stomatitis (10,9%), rash (5,8%) and non-infectious pneumonitis (NIP) (3,6%). Some toxicities, such as weight loss and anaemia were peculiarly observed in patients aged {greater than or equal to} 70 years. Five treatment-related deaths were collected (3,2%).CONCLUSIONSEVE-EXE combination remains one of the potential treatments in HR+ patients also for elderly ones.

The rationale for and long-term outcome of incomplete axillary staging in elderly women with primary breast cancer

BackgroundThe proportion of elderly women diagnosed with breast cancer is rising. Standard treatment, including axillary staging, is often not given to these patients. This study aimed to investigate reasons to omit any surgical axillary staging or to refrain from completion axillary lymph node dissection (cALND) after positive-sentinel lymph node biopsy (SLNB); so-called “incomplete staging”. Furthermore, the impact of incomplete staging on regional control and survival in patients aged 75 or older was evaluated. MethodsA retrospective cohort study was conducted including all primary breast cancer patients aged 75 or older, diagnosed between 2001 and 2008, and documented by the Netherlands Cancer Registry (NCR). Patients with incomplete staging were compared to patients with complete axillary staging. Survival analyses were used to determine the risk of local, regional and distant recurrence and overall survival. ResultsIn total, 1467 of 2116 (69%) patients were considered eligible, of whom 258 (17.2%) had incomplete axillary staging. For 93 patients, diagnosed in 6 of the 10 hospitals in the NCR-area, examination of clinical records revealed that age, comorbidities and patient preferences were the main reason for omitting complete axillary staging. The 10-year axillary recurrence rate in these 93 patients was 5.2% (95% CI, 0.03–10.1). Of the 77 patients who had died, 64 (83%) died of non-breast-cancer-related causes. No significant difference in overall survival was observed between patients with or without complete axillary staging. ConclusionThis study demonstrates that the omission of complete axillary staging is common in selected elderly breast cancer patients with ≥2 comorbidities, with no apparent impact on regional control and 10-year overall survival.

Axillary Nodal Evaluation in Elderly Breast Cancer Patients: Potential Effects on Treatment Decisions and Survival.

Recent studies suggest that surgical lymph node (LN) evaluation may be omitted in select elderly breast cancer patients as it may not influence adjuvant therapy decisions. To evaluate differences in adjuvant therapy receipt and overall survival (OS), we compared clinically node-negative (cN0) elderly patients who did and did not undergo axillary surgery. Patients aged ≥70years in the National Cancer Database (2004-2014) with cT1-3, cN0 breast cancer were divided into two cohorts-those with surgical LN evaluation (one or more nodes removed) and those without (no nodes removed). Propensity scores were used to match patients based on age, year of diagnosis, tumor grade, cT stage, estrogen receptor status, and Charlson-Deyo comorbidity score. A Cox proportional hazards model was used to estimate the effect of LN surgery on OS. Overall, 133,778 patients were matched, of whom 102,247 patients (76.4%) underwent nodal surgery. Patients undergoing nodal surgery were more likely to receive chemotherapy (pN1-3: 22.2%; pN0: 5.8%; cN0-no nodal surgery: 2.8%; p<0.001), radiation (pN1-3: 49.7%; pN0: 47.5%; cN0-no nodal surgery: 26%; p<0.001), and endocrine therapy (pN1-3: 72%; pN0: 58.5%; cN0-no nodal surgery: 46.5%; p<0.001). After adjustment for known covariates, patients who did not undergo nodal surgery had a worse OS (hazard ratio 1.66, 95% confidence interval 1.61-1.70). For elderly cN0 breast cancer patients, axillary surgery was associated with higher rates of adjuvant therapy and improved OS. A selective approach to omitting nodal surgery should be considered in elderly patients with cN0 breast cancer as axillary staging may influence subsequent treatment decisions and long-term outcomes.

Change of paradigm in treating elderly with breast cancer: are we undertreating elderly patients?

Developed countries face significant population ageing in the near future. Within 20years, the average age will approach 50years and the largest population cohort will be those over 65years. The incidence of breast cancer increases with age, with a risk in women of 0.44% by the age of 30, 3.82% by the age of 70 and 10% by the age of 80. Breast cancer is responsible for one out of every three cancer-related deaths. Elderly patients have higher mortality rates and most breast cancer-related deaths are observed in women over 65. There appears to be a trend that elderly patients with breast cancer receive less than the standard treatment compared to younger counterparts and this leads to poorer outcomes. The rationale for treating elderly breast cancer patients more conservatively is that breast cancers in this cohort are more commonly oestrogen receptor (ER) positive which gives the clinician the option to treat with hormonal manipulation alone. In addition, elderly patients present at a later stage compared to younger patients who frequently present with early (stages I and II) breast cancer. This review aims to give an overview of the diagnosis, treatment options and surveillance of breast cancer in elderly women (over 75years) and to discuss the change in perception of the term 'elderly' and the reasons for undertreatment in the elderly patients.

Discontinuation of hormone therapy for elderly breast cancer patients after hypofractionated whole-breast radiotherapy.

The purpose of the study was to examine adherence to hormone therapy (HT) in elderly breast cancer patients (≥ 65years old) treated with hypofractionated radiotherapy. We analyzed data on 550 ER-positive breast cancer patients given hypofractionated whole-breast radiotherapy from June 2009 to September 2016. Baseline comorbidities considered in the hypertension-augmented Charlson Comorbidity Index (hCCI) were retrospectively retrieved. Total hCCI scores were classified as no comorbidity (hCCI = 0), low burden of comorbidity (hCCI = 1), and high burden of comorbidity (hCCI ≥ 2). Competing risk analysis was used to estimate the 5-year cumulative incidence of HT discontinuation. Fine and Gray models were used to estimate the adjusted subhazard ratio (SHR) of HT discontinuation by hCCI score. HT was initially prescribed for 85.6% of patients and almost all of them (468/471) took it for at least one month. It was subsequently discontinued by 45 patients (9.6%), for an overall 5-year cumulative incidence of 11.7%. The 5-year cumulative incidence of HT discontinuation rose from 3.9% in the youngest age group (65-69years) to 23.3% in the oldest (≥ 80years) (p = 0.005). Baseline comorbidity had some effect on the likelihood of discontinuing HT, but only among patients with a low burden of comorbidity (hCCI = 1, SHR 2.00, 95%CI 0.95-4.20). Adherence to HT was better in our sample than in the literature, probably because patients were selected and motivated to continue HT. This confirms the importance of communication with patients to improve adherence to HT. We confirmed the association between HT discontinuation and older age, while comorbidity had a limited influence.

Evaluation of trastuzumab without chemotherapy as a postoperative adjuvant therapy in HER2-positive elderly breast cancer patients: Randomized controlled trial (RESPECT).

510Background: The relative value of trastuzumab (H) monotherapy as an adjuvant treatment compared to the standard combination treatment with chemotherapy (CT) is not clear for elderly breast cance...

Molecular features in young vs elderly breast cancer patients and the impacts on survival disparities by age at diagnosis.

Young and elderly breast cancer patients are more likely to have a poorer outcome than middle‐aged patients. The intrinsic molecular features for this disparity are unclear. We obtained data from the Cancer Genome Atlas (TCGA) on May 15, 2017 to test the potential mediation effects of the molecular features on the association between age and prognosis with a four‐step approach. The relative contributions of the molecular features (PAM50 subtype, risk stratification, DNAm age, and mutations in TP53,PIK3CA,MLL3,CDH1,GATA3, and MAP3K1) to age disparities in survival were estimated by Cox proportional hazard models with or without the features. Young patients were significantly more likely to have basal‐like subtype, GATA3 mutations, and younger DNA methylation (DNAm) age than middle‐aged patients (P < .05). Both the young and elderly patients had a significantly increased risk of breast cancer recurrence after adjusted by race, tumor size, and node status (Hazard ratio [HR] (95% confidence interval [CI]): 2.81 [1.44, 5.45], 2.37 [1.45, 3.89], respectively). This increased risk was weakened in the young patients after further adjustments in the molecular features, particularly basal‐like subtype, GATA3 mutations, and DNAm age (HR [95%CI]: 1.87 [0.81, 4.32]), resulting in 33.5% decreased risk of recurrence. Meanwhile, the adjustments of the molecular features did not alter the recurrence risk for the elderly patients. Compared with middle‐aged patients of breast cancer, poorer prognosis of elderly patients may be caused by aging, while poorer prognosis of young patients was probably mediated through intrinsic characteristics, such as basal‐like subtype, GATA3 mutations, and DNAm age of the cancerous tissues.

Factors Associated with Functional Decline in Elderly Female Breast Cancer Patients in Appalachia.

BackgroundFunctional status has been previously shown in the elderly cancer population to predict both mortality as well as treatment tolerance. The goal of this study was to determine if there are certain subsets of the elderly breast cancer population that are at higher risk of experiencing functional decline following treatment.MethodsPatient charts from the Edwards Comprehensive Cancer Center in Huntington, West Virginia, from January 2006 – January 2016 were reviewed. Relevant inclusion criteria included patients of 65 years of age and older with a new diagnosis of Stage 0-III breast cancer. Functional decline was defined as an increase of at least one point in Eastern Cooperative Oncology Group (ECOG) scores within one year of diagnosis. ECOG performance status was subjectively determined by the physician. Fisher’s exact test and Pearson’s Chi-squared test were initially utilized to assess potential factors associated with functional decline such as pretreatment ECOG score, age at diagnosis, stage, hormone receptor status, type of surgery received, whether radiation therapy, chemotherapy, or hormonal therapy was received, medical comorbidities, body mass index (BMI), complaints of weakness at diagnosis, and ambulatory status. Factors that were found to be significant were further assessed via multivariate logistic regressions.ResultsThree-hundred and fourteen patients were identified as meeting inclusion criteria. At one-year follow-up, 45 patients (14.3% of the cohort) had documented functional decline. On initial analysis, factors associated with functional decline included Stage III disease (p=0.002) and complaints of weakness at diagnosis (p=0.004). Following multivariate analysis, Stage III disease (p = 0.02), complaints of weakness at diagnosis (p = 0.04), and bilateral mastectomy (p = 0.03) were significantly associated with functional decline.ConclusionPatients who were diagnosed with Stage III breast cancer, had complaints of weakness at time of diagnosis, or had bilateral mastectomies were more likely to have a decline in functional status at one-year follow-up. Awareness of factors associated with functional decline in the elderly Appalachian population with Stage 0-III breast cancer will be useful during discussions regarding patient expectations, treatment, and goals of care. Elderly breast cancer patients for whom bilateral prophylactic mastectomies are not indicated may be better served by lumpectomy alone (based on patient age, hormone receptor status, and tumor size), lumpectomy followed by radiation therapy, or unilateral mastectomy to maximize the likelihood of functional preservation following treatment.

Hypofractionated Whole-Breast Irradiation With or Without Boost in Elderly Patients: Clinical Evaluation of an Italian Experience

PurposeTo examine local control, disease-free survival (DFS), and toxicity in elderly (≥ 65 years) breast cancer patients treated with hypofractionated radiotherapy (hypo-RT) with or without a boost to the tumor bed. Patients and MethodsThe study was conducted on 752 patients treated from April 2009 to February 2017. Patients received 42.4 Gy in 16 daily fractions (2.65 Gy per fraction). A boost was only administered in cases of grade 3 primary tumor and close or positive margins. Acute and late toxicity was prospectively assessed during and after hypo-RT, based on the Radiation Therapy Oncology Group scale. DFS and local recurrence–free survival were estimated by the Kaplan-Meier method for cumulative probability. Log-rank tests were used to identify differences by subtype. Cox proportional hazard models were used to investigate the impact of various factors on the risk of disease progression. ResultsAmong the 752 patients treated, 41 (5.5%) experienced disease progression, including 7 (17.1%) exclusively local recurrences; 1 (2.4%) local and nodal recurrence; 1 (2.4%) local and nodal recurrence plus metastasis; 7 (17.1%) nodal recurrences plus metastases; and 25 (61%) exclusively distant metastases. The 5-year DFS, local recurrence–free survival, breast cancer–specific survival, and overall survival rates were 91.8% (95% confidence interval [CI], 88.6-94.2), 98.0% (95% CI, 96.1-99.1), 98.2% (95% CI, 96.5-99.1), and 87.5% (95% CI, 83.8-90.5), respectively. On univariate analysis, the administration of a boost, disease grade (grades 1 and 2 vs. 3), and molecular subtype (triple negative or human epidermal growth factor receptor 2 [HER2] positive, or luminal B vs. luminal A) significantly affected disease progression (P < .01). These findings were confirmed by multivariate analysis. ConclusionHypo-RT is effective and well tolerated in the elderly population, and the routine use of a boost for patients over 65 years is not justified. Further studies on the boost issue are strongly advocated.