breast cancer surgery in the elderly - samo-workshop.ch · breast cancer surgery in the elderly dr....

SAMO Interdisciplinary Workshop on Breast Tumors

Breast cancer surgery in the Elderly

Dr. med. Federica ChiesaBrustzentrum St. Gallen


Summary

1. Population ageing

2. Definition of «elderly»

3. Geriatric assessments

4. Impact of breast cancer on survival

2

4. Impact of breast cancer on survival

5. Surgery yes or no?

6. Primary endocrine therapy

7. Conservative surgery vs. mastectomy


Magnitude of population ageing

3

~ 50% growth in the next 40 years

Smith, Benjamin D., et al. "Improvement in breast cancer outcomes over time: Are older women missing out?." Journal of Clinical Oncology 29.35 (2011): 4647-4653.Willemien van de Water et Al. External Validity of a Trial Comprised of Elderly Patients With Hormone Receptor–Positive Breast Cancer J Natl Cancer Inst 2014 106.http://www.un.org/esa/population/publications/worldageing19502050/pdf/81chapteriii.pdf


Who is “old”?

biological age ≠ chronological age

Elderly is a controversial definition:

Chronological age of 65+ y.

4

Chronological age of 65+ y.

WHO: 60/50+ y.

Deutsches Konsensus: 70+ y. and multimorbidity

or 80+ y.

http://www.who.int/healthinfo/survey/ageingdefnolder/en/http://www.bv-geriatrie.de/presse/20070131.pdf


Heterogeneous “elderly” population

Common elderly sub-populations:

young old: 65–74 years

older old: 75–84 years

oldest old: 85+ years

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frailty


Comprehensive geriatric assessment (GA)

gold standard to detect frailty

Evaluation of:

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functional status mobility nutritional status

time-intensive, resource-consuming

Extermann, Martine, et al. "Use of comprehensive geriatric assessment in older cancer patients:: Recommendations from the task force on CGA of theInternational Society of Geriatric Oncology (SIOG)." Critical reviews in oncology/hematology 55.3 (2005): 241-252.

functional status mobility nutritional status

cognitive status mood comorbidities

polypharmacy social environment urinary and/or fecalincontinence


Cancer Specific Geriatric Screening Tools

feasible in busy oncology practices

easy & quick

prognostic

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SAKK cancer-specific geriatric assessment: Charlson Comorbidity Index

G8 – Screening tool

Short geriatric depression scale (8-item)

Mini-Cog

Decoster, L., et al. "Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOGrecommendations." Annals of Oncology (2014): mdu210.Clough-Gorr, Kerri, et al. "The SAKK cancer-specific geriatric assessment (C-SGA): a pilot study of a brief tool for clinical decision-making in older cancerpatients." BMC Med. Inf. & Decision Making 13 (2013): 93.


G8 Screening tool

Items Possible answers Score

A

Has food intake declined over the

past 3 months due to loss of

appetite, digestive problems,

chewing or swallowing difficulties?

0: severe reduction in food intake

1: moderate reduction in food

intake

2: normal food intake

………...

B

Weight loss during the last 3

months?

0: weight loss >3kg

1: does not know

2: weight loss between 1 and 3 kg

3: no weight loss

………...

C

Mobility 0: bed or chair bound

1: able to get out of bed/chair but

does not go out

2: goes out

………...

Neuropsychological problems 0: severe dementia or depression

8

Mini-Cog

E

Neuropsychological problems 0: severe dementia or depression

1: mild dementia or depression

2: no psychological problems

………...

F

Body Mass Index (weight in

kg/height in m2)

0: BMI less than 19

1: BMI 19 to less than 21

2: BMI 21 to less than 23

3: BMI 23 or greater

………...

HTakes more than 3 medications per

day

0: yes

1: no ………...

P

In comparison with other people of

the same age, how does the patient

consider his/her health status?

0: not as good

0,5: does not know

1: as good

2: better

………...

Age 0: >85

1: 80-85

2: <80

………...

Total score (0-17) A score of ≤14 is abnormal

………...


Impact of BC on survival in the elderly

SEER-Medicare data set 1992-2000

BC Stage I-II

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~ 50.000 women~ 5 years Follow-up

Alive Deaths due to breastcancer

Schonberg, Mara A., et al. "Breast cancer among the oldest old: tumor characteristics, treatment choices, and survival." Journal of Clinical Oncology 28.12 (2010)

75-79y 59.8% 19.4%

80-84y 45.0% 16.5%

85-89y 30.2% 15.9%

>90y 14.1% 17.8 %


Challenges of breast cancer treatment in the elderly

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Comorbidities

Treatment-related toxicity

Patients and families wishes

Lack of evidence-based data Lack of evidence-based data

34-fold probability of non “state-of-the-art” treatment

Smith, Benjamin D., et al. "Improvement in breast cancer outcomes over time: Are older women missing out?." Journal of Clinical Oncology 29.35 (2011): 4647-4653.Willemien van de Water et Al. External Validity of a Trial Comprised of Elderly Patients With Hormone Receptor–Positive Breast Cancer J Natl Cancer Inst 2014 106.Lewis JH, Kilgore ML, Goldman DP, Trimble EL, Kaplan R, Montello MJ, Housman MG, Escarce JJ (2003) Participation of patients 65 years of age or older in cancerclinical trials. J Clin Oncol 21: 1383–1389Ess, S., et al. "Predictors of state-of-the-art management of early breast cancer in Switzerland." Annals of oncology (2010)


Operable breast cancer

Schonberg M A et al. JCO 2010;28:2038-2045

Initial treatment by age at diagnosis


Study proposal: Swiss elderly breast cancer study

Breast CancerStage I,II, operable

«standard» treatment

outcome

Medicalrecommendations

&Performed treatment

Stage I,II, operableIII80+y orFrail 70-79y

«tailored» treatment

outcome

follow-up


Breast surgery in the elderly: yes or no?

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Surgery risks in the Elderly

Breast surgery mortality rate <1%

low specific risk surgery

anesthetic risk: related to co-morbidities not to age

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→ Elderly tolerate breast surgery like younger patients

Moller, Jakob Trier, et al. "Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study." The Lancet 351.9106 (1998): 857-861.Samain, Emmanuel, et al. "Anesthesia for breast cancer surgery in the elderly." Critical reviews in oncology/hematology 46.2 (2003): 115-120.Audisio, Riccardo A., et al. "Preoperative assessment of surgical risk in oncogeriatric patients." The Oncologist 10.4 (2005): 262-268.


Primary endocrine therapy

Same OS Less local control

Johnston, S. J., et al. "A randomised trial of primary tamoxifen versus mastectomy plus adjuvant tamoxifen in fit elderly women with invasive breast carcinoma of highoestrogen receptor content: long-term results at 20 years of follow-up." Annals of oncology 23.9 (2012): 2296-2300.


Response duration on primary Tamoxifen

time to best response ~ 5 mo

time to local relapse ~ 19 mo

Hind, Daniel, et al. "Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus)." Cochrane Database Syst Rev1.1 (2006).O’Connor, Tracey, et al. "Managing Breast Cancer in the Older Patient." Clinical advances in hematology & oncology: H&O 11.6 (2013): 341

local progression

38% after 5 years

43% after 10 years


Primary endocrine therapy (PET)

systematic review of the literature

Six RCT and 31 non-randomised studies

older patients with life expectancy >5 years: surgery better than PET for:

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BC specific survival (90% vs 85% p< .01)

Overall survival (67% vs 49% p< .01)

aromatase inhibitors work better than Tamoxifen

PET: good for women unfit for surgery or who refuse surgery

Morgan, J. L., M. W. Reed, and L. Wyld. "Primary endocrine therapy as a treatment for older women with operable breast cancer–A comparison of randomisedcontrolled trial and cohort study findings." European Journal of Surgical Oncology (EJSO) 40.6 (2014): 676-684.


Breast Conserving Surgery or Mastectomy?

If given a choice, older women prefer breastconservation over mastectomy

Better QOL after conservative treatment also for elderly

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Better QOL after conservative treatment also for elderly

Old women do care!

Sandison, A. J. P., et al. "Breast conservation or mastectomy: treatment choice of women aged 70 years and older." British journal of surgery 83.7 (1996): 994-996.Di Maio, Massimo, and Francesco Perrone. "Quality of Life in elderly patients with cancer." Health and Quality of Life Outcomes 1.1 (2003): 44.


Radiation after breast conserving surgery

Time to local or regional recurrence.

Smith, Benjamin D., and Thomas A. Buchholz. "Radiation treatments after breast-conserving therapy for elderly patients." Journal of Clinical Oncology 31.19(2013): 2367-2368.Hughes K S et al. JCO 2013;31:2382-2387


Take home messagesSIOG and EUSOMA recommendations

Elderly tolerate surgery like younger patients

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They should be offered the same surgical options

Standard of care is BCS and RT or mastectomy +/- RT

Biganzoli, Laura, et al. "Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology(SIOG) and European Society of Breast Cancer Specialists (EUSOMA)." The lancet oncology 13.4 (2012): e148-e160.Wildiers, H. et al. "Management of breast cancer in elderly individuals: recommendations of the International Society of Geriatric Oncology." The lancetoncology 8.12 (2007): 1101-1115.

breast cancer surgery in the elderly - samo-workshop.ch · breast cancer surgery in the elderly dr....

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