Abstract ES06-1: Adjuvant chemotherapy in the elderly: Making the right decision
Authors: Muss HB 
Published: August 2014

The major risk factor for breast cancer is increasing age and we all need to get ready to care for the tsunami of older breast cancer patients resulting from our aging population. In the U.S., breast cancer specific survival is lower among older patients as compared to their younger cohorts - likely related in part to underuse of adjuvant therapies. Adjuvant chemotherapy has led to improvements in overall survival in patients with breast cancer but many older patients who might potentially benefit are not offered treatment. Moreover, in the past, older patients were either excluded or underrepresented in most adjuvant chemotherapy trials, limiting the generalizability of results for older women for commonly used regimens. None the less, an increasing body of data suggests that older patients, especially those with hormone receptor negative tumors, derive significant benefits from adjuvant chemotherapy (Muss et al, Jama 293:1073, 2005). In caring for older women with breast cancer, life expectancy, which is based on a host of factors, is the most important consideration in the treatment decision. Calculating life expectancy can be rapidly and accurately done using web-based calculators (www.eprognosis.org). As in younger women, the type of systemic treatment offered to older women is based on tumor size, nodal status, grade, hormone receptor, and HER-2 status. What's different for elders is that life expectancy must be accounted for in treatment recommendations. For patients with limited life expectancy - less than five years - adjuvant chemotherapy is not likely to be of any benefit irrespective of tumor type and stage. For the 75% or so older women with hormone-receptor positive, HER-2 negative tumors, the mainstay of treatment is endocrine therapy and the major treatment decision relates to whether to recommend chemotherapy. Genomic assays such as the 21 gene recurrence score can help in making these decisions in women with node-negative tumors and for some with one to three positive nodes. Older women with HER-2 positive tumors should be considered for chemotherapy and trastuzumab after calculating their estimated survival, risk of recurrence, and hormone receptor status. Non-anthracycline regimens should be considered in these women (Slamon et al, New Engl J Med 365:1273, 2011). Older women with triple-negative cancers, except for those with very small node-negative tumors or who have with life expectancies less than 5 years, should be offered chemotherapy. The added value of chemotherapy in women with tumors that are hormone-receptor negative and HER-2 negative (“triple negative”) can be assessed using web-based calculators (www.adjuvantonline.org). For women with HER-2 positive cancers a newer web-based calculator is available (www.predict.nhs.uk) that includes age, and which provides five and ten year mortality data for trastuzumab and chemotherapy. To help with toxicity prediction, helpful calculators include the CARG/Hurria model (Hurria et al, J Clin Oncol 29:3457, 2011) and the CRASH score (Extermann et al, Cancer 118:3377, 2012). Trials in progress and the new opportunities to analyze “big data” related to breast cancer treatment and outcomes will continue to add to our knowledge base for providing optimal treatment for older women with breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr ES06-1.