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Breast Cancer in the Elderly: How BCRF Researchers are Treating this Growing Patient Population
Guidelines in treating older cancer patients are lacking. BCRF researchers want to change that.
Breast cancer is a disease of aging. The median age of breast cancer is 62 and around one quarter are women between ages 75-84, according to the Surveillance Epidemiology and End Results registry. And as the population continues to age, projections estimate invasive breast cancer cases will double by 2030. Most of the cases will be in women ages 70-84.
While older adults represent the majority of cancer patients, there are limited guidelines on how to treat this population.
“When my elderly grandmother was diagnosed with early stage breast cancer, I realized that there is no clear consensus on treating breast cancer in older women,”said Dr. Dean Shumway, assistant professor of radiation oncology at the University of Michigan. Dr. Shumway is a former BCRF/Conquer Cancer Foundation young investigator.
There are many reasons for this. Older adults are often excluded from clinical trials, which form the basis of standards of care. This can be based on an eligibility cutoff age, or by restricting participation to healthier patients. This results in a lack of clear evidence-based guidelines on how to treat breast cancer in older women and men.
“Understanding how toxicities of cancer therapies will affect older patients remains an unanswered question, largely due to the underrepresentation of these patients in clinical trials,” said Dr. Hyman Muss, BCRF investigator and director of geriatric oncology at the Lineberger Comprehensive Cancer Center at University of North Carolina.
“New drugs are not tested in adequate numbers of older patients,” he added. “We don’t know if they will have the same benefit or side effect profile as they do for a younger, healthier population.”
Challenges in treating older patients
Older patients respond to treatment differently. They are at a greater risk of side effects and treatment-related mortality, however undertreatment at any age is linked to poor outcomes.
For chemotherapy, treating older patients requires a balance of providing the standard of care at recommended doses while being aware of potential side effects and impact on quality of life.
This is a major focus for BCRF investigator Arti Hurria, director of the Center for Cancer and Aging Research at the City of Hope Comprehensive Cancer Center. Her work is aimed at better predicting which patients are likely to experience more adverse side effects.
Dr. Hurria’s team is conducting a multi-site clinical trial in older patients with early stage breast cancer to assess how chemotherapy affects health and daily functioning. They are collecting patient blood to identify genetic markers that may predict risk of severe side effects.
“This study will allow us to pinpoint the risk of side effects of treatment and help us to identify patients who are mostly likely to be at risk,” she said.
“We will also be able to determine whether the treatment improves outcomes in these patients,” she said.
What is the best local therapy for older breast cancer patients?
The standard treatment for early stage breast cancer with favorable biology includes surgery, radiation, and adjuvant hormonal therapy.
However, there is a growing body of evidence that many older women with early stage breast cancer who undergo breast conserving surgery do well on hormonal therapy alone, and might not need radiation.
A BCRF-supported study by Dr. Shumway found that many radiation oncologists and surgeons consider omission of radiation to be substandard therapy. One-third would continue to recommend radiation for an unhealthy 81-year-old patient.
“We found that many physicians overestimate the benefits of radiation. At the same time, many women are living longer, and since local recurrence remains a key problem, doctors are hesitant to omit radiation that could reduce the risk of recurrence,” said Dr. Shumway.
“Our results emphasize the need for multidisciplinary coordination in making personalized treatment recommendations for older patients,” he added.
His hope is to conduct a randomized study to compare monotherapy with either endocrine therapy or radiation, on the local recurrence rates and quality of life of women who are over 70 years old.
“I think that would help to answer some of the questions about the benefits and harms of treatments for older patients,” he said.
Personalizing breast cancer care in older adults: age is just a number.
Based on current knowledge, the biology of breast cancer in older adults is not much different from breast cancer at younger ages. Up to 80 percent of cases are ER-positive. A recent analysis showed that the percentage of luminal breast cancers increase with age, while the percentage of aggressive basal-like tumors decrease. While more favorable breast cancer subtypes are prevalent in older women, more aggressive breast cancers are not uncommon.
Regardless of breast cancer subtype and prognosis, patients over 75 years do not always receive appropriate treatment. Improper assessment of functional age as well as lack of available data in older adults with cancer contribute to this disparity.
“The geriatric oncologist is a rare breed,” said Dr. Muss. “Oncologists don’t have geriatric training, and few get any formal training in geriatrics at a time when the population is aging, and we need more.”
Functional age is different for individual patients. One 75-year-old person may be very independent and active, while another may be confined to home and require daily assistance. How cancer treatment affects the individual patient will very much depend on functional status.
Dr. Muss believes that incorporating a few basics of geriatric assessment into practice can accurately evaluate older patients, guide treatment and care.
Examples of questions that are part of geriatric assessment include:
1) Is the patient able to walk one block?
2) Is the patient experiencing decreased social activities because of physical or emotional problems?
3) Has the patient had any falls in the last six months?
4) Does the patient require assistance with taking medications?
We talk a little about cancer and a lot about life.
Older cancer patients are not only unique in their cancer experiences. To the doctors who dedicate their practice to older patients, they are a special group of individuals who often view their diagnoses through the lens of a life’s journey.
“I am so blessed to work with this population. Because of their life’s experiences and wisdom, they can somehow appreciate and accept the boundaries of our knowledge,” said Dr. Hurria.
“I advise them on their cancer and they advise me on life. I become part of their family and vice versa. Hugs and kisses are a big part of my clinic day."
Read more about the BCRF research of Drs. Hurria and Muss on our Meet the Researchers page. Dr. Shumway is a former BCRF awardee through our partnership with the Conquer Cancer Foundation of the American Society of Clinical Oncology. His BCRF early career award laid the groundwork for his current research which continues to build on his BCRF project.