Two studies show how to treat older breast cancer patients more effectively

Women with breast cancer over the age of 70 may not be offered surgery, chemotherapy, or radiation therapy because doctors believe that patients cannot tolerate these treatments and have little benefit. These decisions may contribute to worsening breast cancer survival in older women than in younger women, but overtreatment is due to the fact that many older women do not benefit from more aggressive treatment. You can avoid harm.

A new study presented at the 12th European Breast Cancer Conference on Friday Older woman All but the minimum fit must be provided to withstand surgery and bridge the survival gap between the elderly young woman..

Linda Wilde, a professor of surgical oncology at the University of Sheffield, UK, talks about a “virtual” conference from a study of 56,3416 women in the UK. breast cancer The unit is among 2979 women cancer Driven by estrogen hormone (ER positive), 2354 (82%) were treated with surgery and 500 (18%) were treated with anti-estrogen tablets only.

“The pill-only group averaged eight years old and was considerably iller than the surgery group,” she said. “Unsurprisingly, when an unadjusted analysis of overall survival was performed, 203 of the 486 pill-only women with complete data died, compared to after 52 months of follow-up. Of the 2307 women who underwent surgery, 336 died. ”This is 41.8% of women taking tablets alone, compared to 14.6% who underwent surgery.

Breast cancer mortality, in particular, in the pill-only group compared to 113 of 2293 (4.9%) in the surgery group, without adjusting for factors that could affect outcomes such as age and physical fitness. It was 45 out of 476 (9.5%). ..

After adjusting for age, tumor stage, other illnesses, and activity levels, Professor Wilde and her colleagues received only 426 women who had surgery and tablets of similar age, fitness, and frail levels. We have identified 240 women. In this matched group of women, 79 of 229 (34.5%) women treated with pills died for any reason, compared to 106 of 414 (25.6%) at 52-month follow-up. The surgical patient died.

However, in this matched group, pill-only women died of breast cancer in 7 of 223 (3.1%), compared with 27 of 408 (6.6%) who underwent surgery.

There were no surgical deaths in the entire group of 3416 elderly patients, and only 2% of the total cohort of 2354 women suffered from serious side effects from surgery (such as stroke and heart attack).

“For most women, surgery is well tolerated and should be the goal of treatment if possible. Surgery is generally well tolerated and the survival rate of unoperated women is slightly lower. It shows that, “said Professor Wyld. “But looking at the two treatments for older women in poor health, these differences in breast cancer survival have disappeared. In addition, post-surgery quality of life and ability to live daily are post-surgery. It was worse than women. I just had a hormone tablet, which also needs to be weighed against the potential difference in survival between surgery and first-line hormone therapy.

“These findings suggest that for older, sick, and frail women with hormone-positive breast cancer, hormone therapy alone is likely to be as good as surgery if life expectancy is less than 4-5 years. doing.”

To date, there have been no guidelines to help clinicians and patients choose the most appropriate treatment for different levels of fitness.

Professor Wild said: “Developed using the data from this study. Online tools This is to determine if older women will benefit from surgery Decision-Manufacturing process. These are now available for free on the web. ”

She published the first results from a second study, the world’s first randomized controlled trial of a web-based decision support tool created for this purpose. 1 tool It helps you decide whether to give hormone therapy (as an adjunct therapy) or just hormone therapy after surgery. The second tool helps older women decide whether to receive adjuvant chemotherapy after surgery.

A total of 1339 women from the same group were employed in this second study in the first study. They were over 70 years old and had surgical breast cancer. Forty-six breast cancer clinics participated in the trial and were randomized. Twenty-one clinics used decision support tools and 25 clinics used the usual decision-making process to help women choose surgery or hormone tablets only, or chemotherapy. Whether after surgery.

Decision support tools consist of algorithms available to online clinicians and a booklet that patients can take home after discussing with their cancer doctor.

“We found that the use of decision support tools changed treatment options and improved patient knowledge of the available options,” said Professor Wyld. “Patients appreciated decision support and then there was a slight difference in quality of life among women who were offered surgery or hormone-only treatment options.”

In clinics that use decision support tools, women who offered only hormone tablets or surgery options had more knowledge about treatment: 94% (63 out of 67 women) vs. 74% (58 women) 43 of them) Normal care. The choice of treatment has changed. Twenty-one percent (123/591 women) chose only hormone therapy, compared to 15% (88/570 women) in clinics that used the normal decision-making process. Among women with tumors that were at high risk of recurrence or spreading to other parts of the body, the intake of adjuvant chemotherapy was similar between women who used support tools and those who did not.

Overall, women’s quality of life was similar six months after the study began, but women who underwent surgery and were offered this option had a slightly lower quality of life score of 4 points.

Professor Wild explains: “Looking at all the women in the center, many women are not offered a choice. For example, healthy women with no health problems were just told that they needed surgery. Therefore, all Analyzing patients showed no difference in quality of life between the two arms of the study, but analyzing only patients for whom options were provided (weak and ill women) favored the use of decision support. There is a difference. They tended to oppose surgery and chemotherapy in favor of better quality of life. “

She said she would investigate whether deciding to oppose surgery would affect her survival within the next five to ten years, but at this time there are similar numbers of deaths from all causes. , It seems that there was no adverse effect. Each arm of the trial. After three years of follow-up, 94 (14%) died in the group of 670 women who used decision support tools, compared to 90 (14%) in the group of 669 women who received regular care. 13.4%) died. There was no difference in survival, especially for breast cancer deaths. Twenty-nine of the 670 people (4.3%) in the group using decision support tools were 34 of the 669 people (5.1%) receiving regular care.

The results presented from the first summary showed that surgery was more effective than hormone therapy alone, while the results of the second summary were more elderly when using decision support tools. Showed that the woman chose not to undergo surgery.

“This was a surprise to us, but it reflects the importance of giving women the right to make choices based on their personal priorities,” said Professor Wilde. “Many women who used decision support tools were treated only with hormone tablets rather than surgery, but breast cancer survival was the same, but this is with longer follow-up data. verification needed. .”

She concluded that: “We hope that the use of tools will help reduce variability in treatment practices for the elderly. Female And hopefully, it can improve results and strengthen the patient’s role in making informed decisions. “

Professor Javier Cortes, co-chair of EBCC12, is a clinical researcher in the Breast Cancer Research Program at the Val d’Hebron Institute of Oncology in Barcelona, ​​Spain, and is responsible for the Breast Cancer Program at the IOB Institute of Oncology in Madrid and Barcelona. I was not involved in this study. He commented: milk cancer. When they are frail, ineligible and have some other health problems Quality of life For them, it may be more important than lifespan. However, Surgery It is often the most effective first-line treatment. The results of these two linked studies are available to patients and their physicians using decision support tools that ensure that the most appropriate treatment is selected based on the individual patient’s situation and wishes. Helps you make decisions based on the best evidence. It will be important to see what the longer follow-up reveals in terms of survival. ”

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Provided by European organizations for cancer research and treatment