An Urgent Challenge: Older Women with Breast Cancer
BY EWA MROZEK, MD, Division of Medical Oncology, Stefanie Spielman Comprehensive Breast Center
More than 232,000 women in the United States were diagnosed with breast cancer in 2013, and 43 percent of those cancers occurred in women age 65 and older. Breast cancer incidence increases with age. By 2030, almost 20 percent of the American population will be older than 65 years.
We therefore face significant growth in the number of older women with breast cancer, and this presents oncologists with an urgent challenge of determining appropriate treatments for this highly heterogeneous patient population. To help meet this growing need for cancer care, The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC – James) opened the Senior Adult Breast Cancer Clinic at the Stefanie Spielman Comprehensive Breast Center.
Many women reach old age free of severe medical conditions and with nearly complete functional capacity. Other aging women present with diminished functional reserves and social support, multiple comorbidities and common geriatric syndromes, including frailty, cognitive impairment, depression, failure to thrive and frequent falls.
They often have deficits in skills needed to live independently in the community (called “instrumental activities of daily living,” or IADL) and in skills needed for independence at home (called “activities of daily living,” or ADL). They are likely to take multiple medications, including inappropriate medications, which can lead to adverse drug events in cancer patients. The multiple medical problems of a frail breast cancer patient can have a greater longer-term impact on health than the cancer itself.
Typically, older patients have been under-represented in, or excluded from, chemotherapy trials. Thus, national guidelines for treating these patients generally lacka high level of evidence.
Studies have shown that older breast cancer patients are often under-treated. They have lower odds of receiving surgical therapy, adjuvant radiotherapy or chemotherapy, in spite of the evidence of significant survival benefit of standard chemotherapy regimens in healthy older patients who meet stringent eligibility criteria. On the other hand, older women may experience overtreatment and possible adverse events.
Consequently, older breast cancer patients have not fully benefted from improvements in outcomes achieved in the last two decades. A recent study reported that breast cancer mortality was 25 percent higher for women aged 65 to 74, and 63 percent higher for women 75 years or older, compared with women under age 65.
Tools are available that allow physicians and patients to estimate the benefits versus risks of therapies. A comprehensive geriatric assessment (CGA) can objectively assess functional status; comorbidities; physical, cognitive and mental health; nutritional status; and social support of an older person.
Application of the CGA, supplementing a general oncologic examination, and categorizing patients as frail, vulnerable or fit, has been shown to improve prediction of survival, chemotherapy toxicity, and postoperative morbidity and mortality.
The guidelines of the National Comprehensive Cancer Network and the European Organization for Research and Treatment of Cancer recommend that all patients age 70 years and older with cancer should undergo some form of CGA. Since the care of older patients with breast cancer and multiple comorbidities is often provided by a fragmented group of clinicians, such care must be organized to ensure that it is well-coordinated and comprehensive.
Importantly, clinical research is needed to identify the benefts and harms of various treatment options for older breast cancer patients. This requires including older adults in the data collected on cancer interventions.
Patients referred to the Senior Adult Breast Cancer Clinic are evaluated by a medical oncologist, geriatric medicine nurse practitioner, pharmacist and social worker. Patients’ functional status is assessed using ADL/IADL scales and “timed up and go” testing, which has been shown to predict the risk of falls in older patients with cancer.
Physical therapy and rehabilitation referrals are made for patients with the risk of falls and limitations in ADL/IADL. Cognitive impairment and depression are assessed by the Mini Mental State Examination and the Geriatric Depression Scale, respectively, and appropriate referrals for further cognitive testing, psychological evaluation or both are recommended.
A pharmacist completely reviews medications and assesses patients’ adherence to and knowledge about their medications, along with inappropriate medication use as determined by Beer’s criteria. The Mini Nutritional Assessment identifes patients at risk for malnutrition. We refer malnourished patients for nutrition counseling and education. A social worker evaluates social support, identifes barriers to treatment and assists with advanced-care planning.
At the end of each visit, the multidisciplinary team develops an individualized oncologic treatment plan based on CGA results and goals of care established by the patient and caregiver.
To refer patients to the Senior Adult Breast Cancer Clinic, please call The James Line New-Patient Referral Center toll free: 1-800-293-5066.