Many older patients with breast cancer have significant comorbidities, increasing the challenges of treatment. These challenges are compounded by the fact that elderly patients with multiple comorbidities are frequently excluded from participating in clinical trials, resulting in a lack of treatment data for this population. Nina Tamirisa, MD, and colleagues recently published a study in JAMA Oncology reporting that in older patients with multiple comorbidities and estrogen receptor–positive, node-positive breast cancer, chemotherapy improves survival. In this interview with i3 Health, Dr. Tamirisa discusses her findings, reviews strategies for determining which older patients could benefit from chemotherapy, and shares advice regarding how to improve care for elderly patients with breast cancer.
What are the challenges of treating elderly patients with breast cancer?
Nina Tamirisa, MD: In addition to considering the patient's age, we have to weigh treatment options in the context of the patient's associated comorbidities, their functional status, the impact of different treatments' respective toxicities on quality of life, and the patient's estimated life expectancy. Treatment of breast cancer is very multidisciplinary in nature, and making sure we take into account all of those factors is important. In addition, we need to consider the caregivers who are involved in taking care of the older patients, where patients live, who they live with, and what their ability is to be able to get to appointments. These are all challenges that are important to take into consideration when treating older patients.
Can you comment on the significance of your study's results?
Dr. Tamirisa: We found that older patients with a Charlson comorbidity score of 2 or 3––so significant comorbidities––with hormone receptor–positive, node-positive breast cancer had an associated, improved survival in those who received chemotherapy compared with those who didn't. Now, I think that anytime we study these patients retrospectively, while we try to minimize bias, there are always certain unmeasured variables that impact the results.
So while we did see an associated benefit with chemotherapy, I think one of the more important takeaways is that we have to take into consideration that older patients with comorbidities should be included in clinical trials so that we have a standardized way to approach these patients and really assess what treatments will benefit them. With the aging population increasing in the United States, it's essential to be more inclusive of these older patients with comorbidities; right now, they are very much underrepresented.
How should oncologists weigh the benefits of chemotherapy versus the adverse effects when deciding whether or not to give chemotherapy to an older patient?
Dr. Tamirisa: There are the Cancer and Aging Research Group (CARG) Chemo-Toxicity Calculator and the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score, just as examples of the scales that are used to assess patients and their tolerance to chemotherapy, but there is also the ePrognosis tool to estimate life expectancy. When you take those sort of more tangible measures into account along with factors such as a patient's functional status, I think that physicians can generally gain a good sense of how much the patient will be able to tolerate just by sitting down in the room with them, having a conversation, seeing them get up on the exam table, and getting a sense of their general day-to-day lifestyle. In addition to that, as I mentioned before, it is important to take into account whether patients have caregivers or providers that help them and to ascertain whether patients will be able to get to appointments or have help when they need it. The entire multidisciplinary team must understand a patient's goals of care and make treatment recommendations that balance survival benefits against the impact that treatment would have on the patient's quality of life.
How is treatment evolving for elderly patients with breast cancer?
Dr. Tamirisa: There are recent tools that have been developed that take into account life expectancy and predict tolerance to treatment. In terms of trial data, there have been a lot of data recently in support of scaling back on certain treatments: for example, omitting sentinel lymph node biopsy in older patients who meet the criteria, or omitting radiation in certain older patients who meet criteria. There has been a focus on minimizing treatments that haven't been shown to have a significant impact on recurrence or survival outcomes. There's a lot to say that we can scale back on certain treatments, but maybe not so much regarding what we can do to improve their survival with potentially more treatment than we would otherwise give.
What further research is needed regarding how additional treatment could potentially improve survival?
Dr. Tamirisa: Inclusion of older patients with comorbidities in randomized controlled trials is the research we need to understand the true impact of various treatments on survival and quality of life. Having a better sense of the factors that physicians take into consideration when offering treatments to some patients versus others cannot be measured well using retrospective data.
Finally, what advice can you share with members of the cancer care team as they seek to provide the best care for their elderly patients with breast cancer?
Dr. Tamirisa: It can be highly beneficial to involve geriatric physicians in the multidisciplinary care of elderly patients. They have a different perspective to offer with regard to patients' functional status and mental status. Different toxicities of treatment could potentially be minimized, with measures that can be taken prior to surgery or treatment with chemotherapy to improve their outcomes. Multidisciplinary care to include geriatrics is something that I hope will be considered in the care of these patients in the future.
About Dr. Tamirisa
Nina Tamirisa, MD, is an Assistant Professor of Breast Surgical Oncology at The University of Texas MD Anderson Cancer Center in Houston, Texas. Her research focuses on the treatment of breast cancer, particularly in older patients. She was the first recipient of the American Society of Clinical Oncology (ASCO) Darla C. Ellis Endowed Women Who Conquer Cancer Merit Award for her project entitled "The Impact of Chemotherapy Sequence on Survival in Node-Positive Invasive Lobular Carcinoma," presented at the 2018 ASCO Annual Meeting.
For More Information
Tamirisa N, Lin H, Shen Y, et al (2020). Association of chemotherapy with survival in elderly patients with multiple comorbidities and estrogen receptor–positive, node-positive breast cancer. JAMA Oncol. [Epub ahead of print] DOI:10.1001/jamaoncol.2020.2388
Extermann M, Boler I, Reich RR, et al (2012). Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer, 118(13):3377-3386. DOI:10.1002/cncr.26646
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of i3 Health.