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Adjuvant Systemic Therapy

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Management of Breast Cancer in Older Women

Abstract

Breast cancer is prevalent in older women. In this population, a different disease biology, competing comorbidities, a shorter life expectancy and concerns about patient fitness make decision-making for early-stage breast cancer particularly challenging in the context of a lack of age-specific evidence. As a result, older breast cancer patients are offered adjuvant systemic therapy less frequently.

However, the use of adjuvant chemotherapy is supported by retrospective evidence showing an overall reduction in mortality compared to patients who are not offered any treatment and similar benefits derived from more aggressive forms of chemotherapy compared to their younger counterparts, despite a worse overall survival owing to comorbidities. Prospective data are lacking but suggest improved outcomes for high risk older patients in the absence of survival benefit. Nonetheless, more gentle forms of chemotherapy did not appear beneficial and the preferred therapeutic regimen for older women is still uncertain.

Older patients derive from Trastuzumab the same benefit as younger women. Nevertheless, data are again limited since only a small proportion of older women were enrolled in the pivotal trials testing Trastuzumab. Retrospective studies confirmed that Trastuzumab is safe and well tolerated and prospective studies demonstrated that anthracycline-free regimens are an appealing option for older HER2-positive breast cancer patients.

Acute and long-term chemotherapy-related toxicities are more frequent in older breast cancer patients, who are generally subject to increased mortality and haematological adverse events. Cardiac toxicity is also a frequent concern when anthracyclines are used, while neurotoxicity is associated with the use of taxanes. The potential impact on cognitive status and function and an increased risk of acute myeloid leukaemia have also been described. Despite Trastuzumab is safe in this population, careful monitoring should also be considered for older patients on anti-HER2 treatment, especially regarding the increased risk of cardiotoxicity.

The prevalence of low-risk disease biological features, the incidence of frailty and functional limitations and the impact of comorbidities on life expectancy should always guide therapeutic decisions, which may also benefit from the use of risk and chemotherapy toxicity prediction tools and of molecular profiling. The use of screening tools and a comprehensive geriatric assessment may also detect problems that are usually underestimated by routine evaluation.

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  1. Department of Medicine – Breast Unit, The Royal Marsden NHS Foundation Trust, Sutton, UK

    Nicolò Matteo Luca Battisti & Alistair Ring

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  1. Nicolò Matteo Luca Battisti
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  1. Brighton and Sussex Medical School, Brighton, UK

    Malcolm Reed

  2. Department of Surgery, Sahlgrenska University Hospital, Institute of Clinical Sciences, Gothenburg, Sweden

    Riccardo A. Audisio

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Battisti, N.M.L., Ring, A. (2019). Adjuvant Systemic Therapy. In: Reed, M., Audisio, R. (eds) Management of Breast Cancer in Older Women. Springer, Cham. https://doi.org/10.1007/978-3-030-11875-4_10

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