“If she’s a well person, there’s no reason to hold back treating her cancer,” said Heather Macdonald, MD, medical director of the Early Risk Assessment Program and the Breast and Ovarian Cancer Prevention Program at Hoag Breast Center Irvine in California.
Treatment choices are more complicated if a patient is in poor health, especially if she has a condition such as dementia or Parkinson’s disease, Macdonald told MedPage Today. But even in those situations, she said, oncologists can still provide treatment to make patients more comfortable.
In the U.S., an estimated 14,800 women age 85 and over were diagnosed with breast cancer in 2019, making it the most common form of cancer in that age group, according to the American Cancer Society. In 2015, a study by NCI researchers predicted that the percentage of breast cancer cases in women ages 70-84 would grow from 24% in 2011 to 35% in 2030.
Rachel A. Freedman, MD, MPH, medical director of the Program for Older Adults with Breast Cancer at Dana-Farber Cancer Institute in Boston, noted that the oldest patient she has treated was over 100 years old.
When it comes to treatment decisions, “chronological age does not tell the whole story,” Freedman told MedPage Today. The important thing, she urged colleagues, is to consider a patient’s “functional age” by taking into account factors such as the individual’s physical limitations, comorbidities, and social support.
Macdonald recommended conducting formal assessments of functionality in older patients: “A pretty quick and easy approach is to ask her to stand from a chair without bracing herself with her hands. If she can, she’s physically strong. There’s no reason to not treat her cancer, no reason not to operate,” Macdonald said.
The Cancer and Aging Research Group, a collaboration of geriatric oncology researchers with the stated goal of designing and conducting clinical trials to improve the care of older adults with cancer, offers various tools for geriatric assessment and for predicting chemotherapy toxicity in older adults.
Macdonald said she has a patient in her early 80s who was diagnosed with triple-negative breast cancer in the earlier days of COVID. Two years later, the patient is back in her Zumba classes and doing well. “The tip-off was how mentally and physically active she was,” Macdonald said. “If a patient is in good physical shape, don’t pull your punches.”
Freedman also emphasized that advanced age isn’t a barrier to any treatment, adding, however, that “older adults are more likely to develop hematologic toxicity with chemotherapy — e.g., neutropenia, anemia — and are more likely to suffer from functional decline, all of which has to be taken into consideration for those being considered when creating a treatment plan.”
On the other hand, a 2020 study found a higher rate of survival in U.S. patients over age 70 with multiple comorbidities and estrogen receptor-positive, node-positive breast cancer who underwent chemotherapy compared with those who did not (adjusted HR 0.67, 95% CI 0.48-0.93, P=0.02).
In some cases, aggressive treatment such as surgery may not be appropriate due to the patient’s wishes or health status. In those cases, Macdonald said, hormone blockers may be a good option in appropriate patients.
Surgical intervention may be appropriate even when minimal treatment is preferred, such as when a tumor is in danger of breaking through the skin. “That’s a miserable way to die,” she said, adding that in such cases the resection of palpable disease may be the best option compared with chemotherapy.
Lack of data make it especially difficult to predict outcomes in the “oldest old” breast cancer patients. A 2018 review noted that “women over 80 are often omitted or underrepresented in clinical trials and treatment recommendations are often extrapolated from results in younger patients.”
Still, it’s clear that older patients with breast cancer fare worse than younger patients, despite a “high risk for competing causes of death,” Freedman said. “There is a lot of international attention on [the outcome discrepancy] now, with many studies underway to better understand outcomes.”
Going forward, Macdonald recommends a greater focus on breast cancer detection in older women. Guidelines don’t recommend mammography screening in women over age 70, but Macdonald said she believes mammograms should continue as long as patients don’t have a potential life-ending illness until their life expectancy dwindles. “If you’re healthy at 75, you’re more likely to live 15 years than not,” she said.
By: MedPage Today
