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  1. Carlson, Robert H.

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MIAMI BEACH-How to treat older women with breast cancer is becoming a critical question in the U.S., where the average age of a breast cancer patient is 61, and the vast majority of women who die of breast cancer are age 65 and older.


"That's frequently not the public's perception, though, or the perception of our colleagues," said Hyman B. Muss, MD, Director of Geriatric Oncology at Lineberger Comprehensive Cancer Center and Professor of Oncology at the University of North Carolina at Chapel Hill, speaking here at the Miami Breast Cancer Conference.


He called this the coming "tsunami" of older-age patients.


But age is not the key to choosing chemotherapy-rather it is the patient's life expectancy and overall health, he said. "The real issue in older people is whether cancer is the patient's most serious diagnosis, considering the common comorbid conditions in this population such as hypertension and diabetes. Even breast cancer patients with regional nodes usually die of non-cancer causes if they're over age 70."


The goal of adjuvant chemotherapy in elderly treatment is not always longevity, he explained.


"For the fit patient with good life expectancy, consider state-of-the-art chemotherapy. For the frail and very ill, consider endocrine therapy. For patients in the middle ground, the oncologist has to define the added value of chemotherapy, consider the expectations of the patient and family, and ask whether the potential toxicities are worth it.


Some patients may not consider therapy worth the toll on their bodies, Muss said, pointing to a survey of seriously ill patients asked to end the sentence: "I would rather die than have a treatment that causes..." The results:


* 11 percent said "high burden";


* 74 percent said "severe functional impairment"; and


* 89 percent said "severe cognitive loss."



Making the Chemotherapy Decision

Deciding whether to recommend chemotherapy to older patients is the most difficult decision, Muss said, since chemotherapy is associated with the greatest toxicity and the greatest potential for loss of function and adverse effects on quality of life.


Therefore, when considering whether to recommend chemotherapy, it is important to consider the life expectancy of the patient apart from the cancer. He said this can now be done accurately with available online models such as ePrognosis (


Based on life expectancy, the potential benefits of different chemotherapy regimens can be shown using programs such as Adjuvant!Online and PREDICT ( tools, though, have not been verified in older patients, Muss cautioned.


He said chemotherapy is likely to be most beneficial in older women with triple-negative breast cancer, and those with hormone-receptor-negative, HER2-positive breast cancers. Such therapy is likely to increase survival in most patients with these breast cancer phenotypes, provided that the patient's estimated survival is more than five years.


"The most difficult decision concerning chemotherapy use is in patients with hormone-receptor-positive, HER2-negative tumors," Muss said. "For these patients, if they have node-negative disease, and even if they have one to three positive nodes, the use of genetically based tests such as the 21-gene panel can be most helpful in making a treatment decision.

HYMAN B. MUSS, MD. H... - Click to enlarge in new windowHYMAN B. MUSS, MD. HYMAN B. MUSS, MD, said that age is not the key to choosing chemotherapy-rather it is the patient's life expectancy and overall health.

"For those with higher-risk hormone-receptor-positive, HER2-negative tumors, especially those with high-grade tumors and extensive nodes, chemotherapy is a major consideration."


Muss said adjuvant radiation after breast-conserving surgery and for patients with mastectomy who have high-risk tumors is generally well tolerated.


Breast radiation following breast conservation can be omitted without deleterious effects on survival in women with small hormone-receptor positive HER2-negative tumors, or those likely to be compliant with endocrine therapy. However, this does carry a small increased risk in local-regional recurrence, he said.


Adjuvant endocrine therapy is likely to be beneficial in reducing local-regional and distant recurrence in older women with hormone-receptor-positive breast cancers who have tumors larger than one centimeter and with estimated survival times exceeding five years, he said.


Triple-Negative Treatment Age Dependent

About 15 percent of elderly breast cancer patients have triple-negative breast cancer-"and it's just as bad in older people as in younger people," Muss said.


Most recurrences are within five years, so estimates of five-year survival are important. "More chemotherapy is better-usually with taxanes and anthracyclines-so estimating life expectancy and toxicity is key," he said. But even patients with a shorter life expectancy can benefit from treatment if the patient has large tumors or many involved nodes.


Anti-HER2 therapy in elderly patients depends on estimated survival, he said. "When there is an estimated survival of more than five years, I treat older patients like younger patients. But if the patient has cardiac comorbidities, order a cardiology consult."