The practice of omitting adjuvant radiotherapy for women aged 65 years and older who have early-stage estrogen receptor–positive (ER+) breast cancer is outdated and should be revisited, suggest two experts in an article published in the Journal of Clinical Oncology.
A modern radiation regimen delivered over 5 days is “more appealing” to older patients than the alternative of 5 years of hormonal therapy, argue George E. Naoum, MD, MMSCI, Northwestern University Memorial Hospital, Chicago, Illinois, and Alphonse G. Taghian, MD, PhD, Massachusetts General Hospital, Harvard Medical School, Boston.
Nearly one third of new breast cancer cases are diagnosed in patients older than 65 years, and their tumors are more likely to be ER+ than those in younger people, owing to their lifetime estrogen exposure.
This should allow for better outcomes, as ER+ tumors grow and spread more slowly than ER- tumors, the authors argue. Yet the optimal adjuvant therapy for patients with early-stage disease who are to undergo lumpectomy remains “debatable.”
Combining the “projected life expectancy” of these older women, who may have comorbidities and may be taking drugs for other conditions, and then planning the best approach to reduce breast cancer recurrence, taking into account the behavior of those small ER+ tumors, is a “challenge for the treating oncologist,” they comment.
There can be a disconnect between the clinical implications of clinical trial results and daily practice, as older patients are a “heterogeneous population,” and hard clinical endpoints, such as overall survival (OS), can be “less meaningful” to them than quality of life and treatment tolerance.
This leaves older patients vulnerable to both overtreatment and undertreatment.
The choice of adjuvant treatment is either radiotherapy or endocrine therapy to prevent breast cancer recurrences.
Trials investigating conventional radiotherapy have suggested that omitting it has only a minimal impact on the risk of local failure, leading to the question: “Who would want 6 weeks of daily radiotherapy for zero OS gain, while a simple daily pill for 5 years can provide all the benefits of systemic tumor control?”
However, radiotherapy regimens have changed considerably in recent years. Modern treatment plans involve, for example, only 5 days of radiotherapy.
But not all clinicians have kept up with these developments, and many older patients with early-stage breast cancer “are being denied improvement in local control through modern radiotherapy,” the authors argue.
Results from surveys suggest that older women with early ER+ breast cancer would prefer radiotherapy to endocrine therapy.
In a survey of 130 patients (median age, 74 years), 39% of participants expressed concerns over radiotherapy. By contrast, 66% expressed concerns over use of aromatase inhibitors (AI), and 57% said they would rather receive radiotherapy alone.
Another study that included more than 8700 breast cancer patients found that those aged 70 years or older significantly reported less toxicity, less fatigue, and less breast pain than younger patients after radiotherapy, while a survey of more than 2350 women found that 91% of those who received hormonal therapy reported physical changes.
But are older patients being heard?
Despite being widely recommended, Naoum and Taghain note that geriatric assessments, which help detect medical, psychosocial, and functional problems, are still “not yet well implemented in daily oncology practice.”
They argue that, taken together, a modern course of radiotherapy given over 5 days would “no doubt” sound “more appealing” to older patients than daily aromatase inhibitor (AI) therapy for 5 years, when taking into account transportation, adverse effects, cost, and day-to-day implications.
“However, the question becomes, is it safe to omit hormonal therapy for this population?”
Naoum and Taghain say that there is some evidence to suggest it is indeed safe. The question is being addressed directly in the ongoing EUROPA trial and the upcoming CAMERAN trial.
The authors underline, however, that easily available geriatric assessment tools can be used to identify patients who are poor candidates for AI therapy.
The currently available evidence suggests that modern radiotherapy for 5 days or for a similar period after lumpectomy is a “reasonable approach” as the primary treatment for women aged 65 years and older with early-stage breast cancer and that AIs should be “optional” for those who can tolerate them, they conclude.
No funding for the study has been reported. Taghian has relationships with UpToDate.
J Clin Oncol. Published online December 20, 2023. Full text
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