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Commentary (Misra/Kimmick): Managing Early-Stage Breast Cancer in Your Older Patients

Commentary (Misra/Kimmick): Managing Early-Stage Breast Cancer in Your Older Patients

The inclusion of issues important to breast cancer and geriatrics makes this review by Witherby and Muss appropriate for the general oncologist. In practice, the oncologist has little randomized data to guide the treatment of older women with breast cancer and is faced with patients whose organ function and comorbidity level may increase the potential for toxicity from treatment.

Treating Older Patients

We are faced with a distinct shortage of prospective data regarding treatment of older breast cancer patients from clinical trials of adjuvant chemotherapy. As a group and individually, older patients are different from their younger counterparts. Age brings with it changes in physiology that lead to decline in organ function and differences in tumor biology. New technologies, such as gene expression profiles, may help predict which patients will benefit from adjuvant chemotherapy.

As a group, older women have breast cancers with less aggressive features. However, this is not universally true, and treatment should be based on the individual patient and tumor. We are quite certain this is done in practice, based on the fact that older women included in clinical trials have higher-risk tumors.

For example, in the Cancer and Leukemia Group B (CALGB) meta-analysis of patients with node-positive disease that Witherby and Muss reference, only 8% were over 65 years of age, and a higher percentage of the older patients had four or more positive lymph nodes compared to younger patients (61% vs 47%).[1] This not only indicates that clinicians chose older patients at higher risk for the trial, but also suggests that oncologists are generally reluctant to offer clinical trials, or perhaps standard adjuvant chemotherapy regimens, to their older patients.

Nevertheless, ongoing trials are comparing potentially less toxic regimens, such as capecitabine (Xeloda) and liposomal doxorubicin (Doxil), with standard adjuvant chemotherapy regimens for older women with breast cancer.

As Witherby and Muss also point out, there is controversy about whether older women should receive radiation therapy following breast-conserving surgery for small tumors, as it may not have an impact on overall survival, though the risk of local recurrence is higher, and such treatment affects quality of life. This is similar to the issues involved in the omission of axillary lymph node staging, and we recommend that these decisions be made on a case-by-case basis.


Aromatase Inhibitors

Because it is less toxic, adjuvant hormonal therapy is a clear choice in older women with hormone receptor-positive tumors. The role of aromatase inhibitors has emerged in the last few years and is still evolving. Data from the Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial, suggest that women who had estrogen receptor-positive, progesterone receptor-negative tumors—a profile more commonly seen in older patients—seemed to have a much better outcome with anastrozole (Arimidex) vs tamoxifen. Furthermore, with longer follow-up of these trials, we are beginning to see evidence of a survival benefit associated with the use of aromatase inhibitors in addition to or instead of tamoxifen in postmenopausal women.[2-4]


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