Two studies show how older breast cancer patients can be treated more effectively

Three-dimensional culture of human breast cancer cells with DNA stained blue and a protein stained green in the cell surface membrane. Image created in 2014 by Tom Misteli, Ph.D., and Karen Meaburn, Ph.D. at the NIH IRP.

Women with breast cancer who are older than 70 years are sometimes not offered surgery, chemotherapy, or radiation therapy because doctors believe that their patients cannot tolerate these treatments and get little benefit from them. These choices can result in poorer breast cancer survival rates in older women than in younger women, although many older women may not benefit from more aggressive treatments and thus avoid harm from over-treatment.

New research, due to be unveiled at the 12th European Breast Cancer Conference on Friday, shows that the majority of older women can tolerate surgery and that it should be offered to the smallest detail to fill the gap in survival rates between older and younger women close.

Lynda Wyld, Professor of Surgical Oncology at the University of Sheffield, UK, will report at the “virtual” conference that a study of 3416 women from 56 UK breast cancer departments shows that among the 2979 women whose cancer was caused by the estrogen hormone ( ER positive), 2354 (82%) were operated on and 500 (18%) only with anti-estrogen tablets.

“The pill-only group was eight years older on average and significantly less fit than the surgical group,” she said. “Unsurprisingly, 203 of the 486 women on tablets for which we have complete data died when an unadjusted overall survival analysis was performed, compared to 336 of 2307 women who underwent surgery after a 52-month follow-up.” This corresponds to 41.8% of women who only take tablets compared to 14.6% who had an operation.

Death rates from breast cancer specifically, unadjusted for factors that could affect outcomes such as age and fitness, were 45 out of 476 (9.5%) in the tablet-only group compared to 113 out of 2,293 (4.9%) in the operations group.

After adjusting for age, tumor stage, other diseases, and activity levels, Prof. Wyld and her colleagues identified 426 women who had surgery and 240 who received only pills that were of similar age, fitness, and frailty. In this matched group of women, 79 out of 229 (34.5%) women who were treated with tablets had died of any cause, compared with 106 out of 414 (25.6%) surgical patients at 52 months.

However, in this consensus group, there were 7 out of 223 (3.1%) deaths from breast cancer in women who received pills compared to 27 out of 408 (6.6%) women who had surgery.

There were no deaths from surgery in the entire group of 3,416 elderly patients, and only 2% of the entire cohort of 2,354 women had serious side effects from the surgery (such as stroke or heart attack).

“For most women, surgery is well tolerated and should be the goal of treatment whenever possible, as we’ve shown that surgery is generally well tolerated and survival rates are slightly lower in women without surgery,” said Prof. Wyld. “However, when we looked at the two treatments in a less healthy group of older women, these differences in breast cancer survival disappeared. In addition, their quality of life and their ability to participate in everyday activities deteriorated more sharply after the operation than in women. I just had hormone pills, which also has to be weighed against the possible difference in survival between surgery and primary hormone therapy.

“These results suggest that for older, less fit, frail women with hormone-positive breast cancer, hormone therapy alone is likely to be as good as surgery if their life expectancy is less than four to five years.”

To date, there have been no guidelines to help doctors and patients choose the most appropriate treatment that takes into account different fitness levels.

Prof. Wyld said, “We have used the data from this study to develop online tools that can be used to determine whether or not older women will benefit from surgery, which can aid decision-making. These are now available in the Internet made freely available. “”

It presented the first results of a second study, a randomized, controlled trial with the world’s first web-based decision support tools developed for this purpose. An instrument supports decisions about whether an operation should be performed followed by hormone therapy (as adjuvant therapy) or hormone therapy alone. The second instrument supports decisions about whether or not to undergo adjuvant chemotherapy in older women after surgery.

A total of 1339 women from the same group in the first study were recruited for this second study. You were 70 years or older and had operable breast cancer. 46 breast cancer clinics participated in the study and were randomized. 21 clinics used the decision support tools and 25 clinics used the normal decision-making processes to help women choose whether or not to have surgery, or just hormone tablets or chemotherapy, or not after surgery.

The decision support tools consist of an algorithm available online to clinicians and brochures that patients can take with them after talking to their cancer doctor.

“We found that due to the use of the decision support tools, treatment options have changed and patients have better knowledge of the options available,” said Prof. Wyld. “Patients rated the decision-making aids highly, and there was a small difference in quality of life afterward in women who were offered a choice between surgery or hormone-only treatment.”

In clinics that used decision-making aids, women who only offered a choice of hormone tablets or surgery had greater knowledge of treatments: 94% (63 out of 67 women) versus 74% (43 out of 58 women) in women Clinics usual care. The choice of treatment was changed: 21% (123 out of 591 women) opted for hormone treatment only, compared with 15% (88 out of 570 women) in clinics with the usual decision-making processes. In women with tumors that were at high risk of recurrence or spread to other parts of the body, uptake of adjuvant chemotherapy was similar between those who used the support tools and those who did not.

Overall, the quality of life for the women was similar six months after the start of the study, although the quality of life for the women who underwent surgery and who were offered this choice decreased slightly by four points.

Prof. Wyld explained: “If we look at all the women in the centers, many will not have been offered a choice. For example, a healthy woman with no health problems was only told that she needs an operation. So if we analyze all the patients.” The quality of life was not different in the two arms of the study. However, if we only analyze those patients who were offered a choice – the more frail, less fit women – there is a difference in favor of using the decision-making tool – they tended to opt out of surgery or chemotherapy for a better quality of life . “

She said that she and her colleagues would investigate over the next five to ten years whether opting for surgery had an impact on survival, although it currently didn’t appear to have any adverse effects, with a similar number of deaths from all reasons each Arm of the process. After three years of follow-up, there were 94 deaths (14%) in the group of 670 women who used the decision aids versus 90 deaths (13.4%) in the group of 669 women who received standard care. For deaths specifically from breast cancer, there was no difference in survival; 29 out of 670 (4.3%) in the group used the decision support tools, while 34 out of 669 (5.1%) received usual care.

Although the results of the first summary showed that surgery was more effective than hormone therapy alone, the results of the second summary showed that more older women chose surgery using the decision aids.

“That was a surprise to us, but it shows how important it is to give women the right to vote based on their personal priorities,” said Prof. Wyld. “We found that while more women who used the decision support tools received hormone-only pill therapy instead of surgery, breast cancer survival rates were similar regardless. This needs to be confirmed by data after extended follow-up.”

She concluded, “We hope that use of the tools will help reduce the variability of practice in treating older women and, hopefully, improve outcomes and empower the patient to make an informed decision.”

The Co-Chair of EBCC12, Professor Javier Cortes, is clinical researcher of the Breast Cancer Research Program at the Vall d’Hebron Institute of Oncology, Barcelona, ​​Spain and Director of the Breast Cancer Program at the IOB Institute of Oncology, Madrid and Barcelona. and was not involved in this research. He commented, “Finding the best treatment for elderly breast cancer patients can be difficult. When they are frail, unsuitable, and faced with several other health problems, quality of life may be more important than lifespan. Surgery is often the most effective primary treatment The results of these two linked studies help patients and their clinicians make their decisions based on the best available evidence, the decision aids ensuring that the most appropriate treatment is selected based on the individual patient’s circumstances and desires important to see what the longer follow-up shows in terms of survival. ”

Age influences decisions related to breast cancer surgery

Provided by the European Organization for the Research and Treatment of Cancer

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