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Breast Cancer in Elderly (>65 Years) Recommendations of the International Society of Geriatric Oncology Surgical recommendations are similar to those in younger patients Radiotherapy – Considered after breast conservation therapy, taking into account patient health, functional status, and local recurrence risk Unlikely to affect overall survival – Postmastectomy if 4+ lymph nodes or T3–4 May be omitted if life expectancy <5 years and low risk of locoregional recurrence Adjuvant systemic therapy – Tamoxifen and/or aromatase inhibitor (AI) appropriate for hormone-sensitive tumors Consider toxicity profiles and slightly higher efficacy of AI – Chemotherapy choices should take into account absolute benefit, life expectancy, and tolerability Treatment goals for metastatic disease are similar to those in younger patients Wildiers H, et al. Lancet Oncol. 2007;8:1101. Age and Molecular Subtypes Basal-like (P < .0001) HER2 Positive/ ER Negative Luminal Luminal Unclass A B -ified Premenopause 55% 40% 41% 47% 53% Postmenopause 45% 60% 59% 53% 47% Millikan RC, et al. Breast Cancer Res Treat. Epub ahead of print. Quantative ER and Age Tamoxifen-Treated Arms B-14 and B-20 ER (fmol/mg) Median 120 P <.0001 105 100 44–231 80 70 30–132 60 40 37 21–69 20 0 ≤40 1 50–59 2 Age (years) ≥60 3 Quantative ER and Therapeutic Efficacy NSABP Studies B–14 B–20 100% 90% Event-Free at 12 y Postsurgery 90% 80% 70% 82% 78% 69% 88% 82% 76% Placebo 68% Tamoxifen CMFT 60% 50% 40% 30% 20% 10% 0% 10–49 1 ≥50 2 10–49 3 ER (fmol/mg) Median ≥50 4 Chemotherapy Toxicity by Age 6174 patients treated in 3 chemotherapy trials • CALGB 8541: CAF at varying schedules and doses • CALGB 9344: AC at varying doses, with or without paclitaxel • CALGB 9741: Dose-dense vs standard AC-paclitaxel ≤50 Years (n = 3393) 51–64 Years (n = 2323) >65 Years (n = 458) WBC (grade 4; P < .0001) 16% 17% 17% Platelets (grade 4) 3% 4% 4% Hemoglobin (grade 4) 1% 1% 1% Nausea/vomiting (grade 3–4) 10% 7% 7% Diarrhea (grade 3–4) 1% 2% 1% Stomatitis (grade 3–4) 5% 4% 5% Neurologic (grade 3–4) 8% 9% 9% Muss HB, et al. J Clin Oncol. 2007;25:3699. Clinicopathologic Differences in Breast Cancer in Older Women Histology1,2 – Increased mucinous, lobular – Decreased medullary Favorable biologic characteristics – Endocrine responsive2 – Fewer p53 mutants2 – Lower proliferative indices2 – Fewer basal-like and more luminal A3 1. Li C, et al. Cancer Epidemiol Biomarkers Prev. 2006;15:946. 2. Diab S, et al. J Natl Cancer Inst. 2000;92:550. 3. Millikan RC, et al. Breast Cancer Res Treat. Epub ahead of print. Carcinogenesis • High ER • Differentiated • Luminal markers • Induced by HRT • Sensitive to endocrine therapy Dontu G, et al. Trends Endocrinol Metab. 2004;15:193. Breast Cancer in African-American Women Lower overall risk, but recent decrease in incidence not seen in African Americans – Annual percentage change (1999–2004) Caucasians: 2.9% African Americans: 0.5%1 Less likely to receive adequate mammography and more likely to have higher stage at diagnosis2 Differences in molecular subtypes – Higher prevalence of basal-like – Lower prevalence of luminal A3 Worse survival, partly due to differences in screening, tumor characteristics, and treatment4 1. Li C, et al, Cancer Epidemiol Biomarkers Prev. 2007;16:2773. 2. Smith-Bindman R, et al. Ann Intern Med. 2006;144:541. 3.Carey LA, et al. JAMA. 2006;295:2492. 4. Curtis E, et al. Cancer. 2008;112:171-180.