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Breast cancer surgery in the Elderly Dr. med. Federica Chiesa Brustzentrum St. Gallen

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Breast cancer surgery in the Elderly Dr. med. Federica Chiesa Brustzentrum St. Gallen 2 Summary 1. Population ageing 2. Definition of «elderly» 3. Geriatric assessments 4. Impact of breast cancer on survival
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Breast cancer surgery in the Elderly Dr. med. Federica Chiesa Brustzentrum St. Gallen 2 Summary 1. Population ageing 2. Definition of «elderly» 3. Geriatric assessments 4. Impact of breast cancer on survival 5. Surgery yes or no? 6. Primary endocrine therapy 7. Conservative surgery vs. mastectomy 3 Magnitude of population ageing ~ 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 (2011): 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 4 Who is old? biological age chronological age Elderly is a controversial definition: Chronological age of 65+ y. WHO: 60/50+ y. Deutsches Konsensus: 70+ y. and multimorbidity or 80+ y. 5 Heterogeneous elderly population Common elderly sub-populations: young old: years older old: years oldest old: 85+ years frailty 6 Comprehensive geriatric assessment (GA) gold standard to detect frailty Evaluation of: functional status mobility nutritional status cognitive status mood comorbidities polypharmacy social environment urinary and/or fecal incontinence 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 the International Society of Geriatric Oncology (SIOG). Critical reviews in oncology/hematology 55.3 (2005): 7 Cancer Specific Geriatric Screening Tools feasible in busy oncology practices easy & quick prognostic 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 SIOG recommendations. 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 cancer patients. BMC Med. Inf. & Decision Making 13 (2013): 93. 8 G8 Screening tool A B Items Possible answers Score Has food intake declined over the 0: severe reduction in food intake past 3 months due to loss of 1: moderate reduction in food... appetite, digestive problems, intake chewing or swallowing difficulties? Weight loss during the last 3 months? 2: normal food intake 0: weight loss 3kg 1: does not know 2: weight loss between 1 and 3 kg... Mini-Cog Mobility 3: no weight loss 0: bed or chair bound C 1: able to get out of bed/chair but does not go out... Neuropsychological problems 2: goes out 0: severe dementia or depression E 1: mild dementia or depression... F Body Mass Index (weight in kg/height in m2) 2: no psychological problems 0: BMI less than 19 1: BMI 19 to less than 21 2: BMI 21 to less than H P Takes more than 3 medications per day In comparison with other people of the same age, how does the patient consider his/her health status? 3: BMI 23 or greater 0: yes 1: no... 0: not as good 0,5: does not know... 1: as good 2: better Age 0: 85 1: Total score (0-17) 2: 80 A score of 14 is abnormal... 9 Impact of BC on survival in the elderly SEER-Medicare data set BC Stage I-II ~ women ~ 5 years Follow-up Alive Deaths due to breast cancer 75-79y 59.8% 19.4% 80-84y 45.0% 16.5% 85-89y 30.2% 15.9% 90y 14.1% 17.8 % Schonberg, Mara A., et al. Breast cancer among the oldest old: tumor characteristics, treatment choices, and survival. Journal of Clinical Oncology (2010) 10 Challenges of breast cancer treatment in the elderly Comorbidities Treatment-related toxicity Patients and families wishes 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 (2011): 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 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 cancer clinical trials. J Clin Oncol 21: Ess, S., et al. Predictors of state-of-the-art management of early breast cancer in Switzerland. Annals of oncology (2010) Operable breast cancer Initial treatment by age at diagnosis Schonberg M A et al. JCO 2010;28: Study proposal: Swiss elderly breast cancer study Medical recommendations & Performed treatment «standard» treatment Breast Cancer Stage I,II, operable III 80+y or Frail 70-79y outcome «tailored» treatment follow-up 13 Breast surgery in the elderly: yes or no? 14 Surgery risks in the Elderly Breast surgery mortality rate 1% low specific risk surgery anesthetic risk: related to co-morbidities not to age Elderly tolerate breast surgery like younger patients Moller, Jakob Trier, et al. Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study. The Lancet (1998): Samain, Emmanuel, et al. Anesthesia for breast cancer surgery in the elderly. Critical reviews in oncology/hematology 46.2 (2003): Audisio, Riccardo A., et al. Preoperative assessment of surgical risk in oncogeriatric patients. The Oncologist 10.4 (2005): 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 high oestrogen receptor content: long-term results at 20 years of follow-up. Annals of oncology 23.9 (2012): Response duration on primary Tamoxifen time to best response ~ 5 mo time to local relapse ~ 19 mo local progression 38% after 5 years 43% after 10 years Hind, Daniel, et al. Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database Syst Rev 1.1 (2006). O Connor, Tracey, et al. Managing Breast Cancer in the Older Patient. Clinical advances in hematology & oncology: H&O 11.6 (2013): 341 17 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: 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 randomised controlled trial and cohort study findings. European Journal of Surgical Oncology (EJSO) 40.6 (2014): 18 Breast Conserving Surgery or Mastectomy? If given a choice, older women prefer breast conservation over mastectomy 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): Di Maio, Massimo, and Francesco Perrone. Quality of Life in elderly patients with cancer. Health and Quality of Life Outcomes 1.1 (2003): 44. SAMO Interdisciplinary Workshop on Breast Tumors 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 (2013): Hughes K S et al. JCO 2013;31: SAMO Interdisciplinary Workshop on Breast Tumors Take home messages SIOG and EUSOMA recommendations Elderly tolerate surgery like younger patients 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 lancet oncology 8.12 (2007):
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