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Geriatric Oncology
Biology- not Chronology-driven Treatment of Breast Cancer in the Elderly
a report by
Matti S Aapro
Executive Director, International Society for Geriatric Oncology (SIOG)
The European Breast Cancer Conference (EBCC) was recently held in important, especially as the modern world moves very fast – faster than
Berlin. Among the many topics discussed, treatment of the ageing most elderly (and not so elderly) people can apprehend.
2
breast cancer patient was highlighted during an EuropaDonna teaching
lecture, which is summarised here. It is therefore interesting to note that there are data that confirm that,
when faced with the disease, individuals on both sides of the Atlantic react
Breast cancer is the most common cancer site in women, with 1.15 in a similar way, even when they are ‘senior citizens’. Indeed, a view often
million new cases worldwide each year, of which 361,000 (27.3% of all held in Europe is that older Europeans are less willing than older
cancers in females) are in Europe and 230,000 (31.3%) in Northern Americans to undertake chemotherapy.
3
Three hundred and twenty
America. This means that half, if not more, of these patients are in French and American outpatients aged 70 years and older (29% were 80
other parts of the world, a fact recognised by the World Health years or older) with and without cancer were interviewed (and 61%
Organization (WHO), which has put cancer among its health priorities responded) via anonymous questionnaires. The patients were given two
on a global scale. In 2002, 411,000 women died of breast cancer scenarios to evaluate: a strong chemotherapy (platinum/taxane
worldwide, and most of these were aged 65 years or older. This is combination-like) and a milder chemotherapy (weekly vinorelbine-like).
explained by the following figures. The crude incidence of breast cancer The options were to refuse chemotherapy or to accept it for a threshold
in Northern America in comparison with North and Western Europe is chance of cure, life prolongation or symptom relief. The questionnaire
141.9 and 130.0 per 100,000 females per year, respectively. Breast- contained items assessing the functional status, education and self-rated
cancer-related mortality is 29.8 and 41.0 per 100,000 females, health and depression of the respondents. The French non-cancer patients
respectively. For those aged 65 years and older, crude incidence rates (34% accepted) were less willing to accept the strong chemotherapy than
are 432.7 per 100,000 females in Northern America and 295.0 per French cancer patients (77.8% accepted), American non-cancer patients
100,000 in Northern and Western Europe; corresponding breast cancer (73.8% accepted) and American cancer patients (70.5% accepted;
mortality figures are 121.2 and 135.0 per 100,000 females, p<0.001 for each pair). This was also true for the moderate
respectively. Similar incidence rates and mortality figures are found in chemotherapy, with acceptance rates of 67.9 versus 100, 95.2 and
South America (Argentina and Uruguay), New Zealand and Australia, 88.5%, respectively (p<0.001 for each pair). While outpatient age and sex
and in Central/Eastern Europe. did not correlate with response, self-rated health, cancer status and
nationality did.
With increasing age, patients will suffer from ailments related both to
senescence and to cancer. Many will need the expertise of the geriatrician The International Society of Geriatric Oncology (SIOG) has created a task
and of the oncologist, who will participate in specific case discussions to force to assess the available evidence on breast cancer in elderly individuals,
look at social and medical issues that will affect the treatment plan (with and to provide evidence-based recommendations for the diagnosis and
surgery, radiation and drug therapy, rehabilitation and supportive and treatment of breast cancer in such individuals. A review of the published
palliative care questions often intertwined). The wishes of the patient are work was performed via the results of a search on Medline for English-
key in this discussion.
1
The variable reality of family or community support language articles published between 1990 and 2007 and of abstracts from
must also be taken into consideration, as this differs so widely among key international conferences. Recommendations on the topics of screening,
cultures; the ways in which these cultures are changing are also surgery, radiotherapy, (neo)adjuvant hormone treatment and chemotherapy
and metastatic disease are found in these recommendations.
4
Oncologists
are now learning to take into account the physiological age of their patient,
Matti S Aapro is Executive Director of the International
Society for Geriatric Oncology (SIOG) and Past President
which is the reflection of a normal and sometimes abnormally accelerated
of the Multinational Association for Supportive Care in loss of body reserves, certainly related to chronological age but not precisely
Cancer (MASCC). In addition to being a Member of the
dictated by it. Understanding the biology of breast cancer will allow
Board of the European Organisation for Research and
Treatment of Cancer (EORTC), he chairs the EORTC
clinicians to optimally adapt the treatment of the elderly patient, considering
Cancer in the Elderly Task Force. Dr Aapro is also Dean
that cancer treatments should not be synonymous with undue hardship
of the Multidisciplinary Oncology Institute in Genolier,
Editor in Chief of Critical Reviews in Oncology/Hematology
imposed on patients who would in any case die from another competing
and www.cancerworld.org, Associate Editor of Annals of Oncology and Section Editor for cause of mortality.
5,6
The Oncologist. He has authored more than 180 publications and his major interests are
new drug development, breast cancer, cancer in the elderly and supportive care.
A question addressed during one of the plenary sessions at the EBCC was
E: maapro@genolier.net
related to post-operative radiotherapy following breast-conserving surgery
(BCS). Combined with appropriate systemic therapy, post-operative
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