Drs. Dittus and Muss have extensively discussed the concept of frailty, illustrated the role of geriatric assessments to better define the "status" of the older patient, and proposed appropriate therapeutic interventions for frail women with breast cancer. In particular, the authors recommend a minimalist approach for patients with early breast cancer.
We would like to remark on three specific issues:
1. The identification of frail patients in clinical practice and implications for treatment decisions
Elderly cancer patients are in many cases suboptimally treated due to the assumption that treatments would be too toxic for them to tolerate. It would therefore be extremely important, as clearly stated by Dittus and Muss, to differentiate patients who are fit from those who are currently functioning but at risk of treatment complications, and from those who are too frail to receive aggressive treatments.
At a recent consensus meeting, scientists failed to agree upon a definition of frailty. They also did not find a consensus on which criteria should be used for the recognition of frailty and its relationship with aging, disability, and chronic disease. Nonetheless, it was agreed that the distinctive trait in frail patients is an increased vulnerability to stress factors due to impairments in multiple systems that lead to a decline in homeostatic reserve and resiliency. The key point then becomes how to differentiate patients who present with reduced functional reserve and could be proposed for tailored treatments from those who have exhausted functional reserve and should be proposed only for supportive treatment.
According to an algorithm for the management of the older cancer patient based on a comprehensive geriatric assessment (CGA), patients with dependence in one or more activities of daily living (ADLs), with severe comorbidity, and with one or more geriatric syndromes are considered candidates for symptom management only, whereas patients with nonreversible dependency in instrumental ADLs and some comorbidity should be considered for personalized treatments. Since a CGA is time-consuming and possibly redundant, screening tests for vulnerability—ie, the Vulnerable Elders Survey (VES-13)—could be used to better identify patients who should undergo a complete CGA.
Unfortunately, to the best of our knowledge, no studies have been conducted that validate CGA as a tool for treatment decision-making in elderly patients with breast cancer. In the Breast International Group (BIG) 4-04 trial, women aged 65 years and older are being evaluated before being randomized to ibandronate alone or capecitabine (Xeloda) plus ibandronate (Boniva), by the means of the Charlson score and VES-13. This study, coordinated by the German Breast Group, will evaluate the role of these two geriatric assessments in predicting treatment-associated adverse events and limited life expectancy in this cohort of early breast cancer patients.
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