Older patients

Guidance curated for

Most breast cancer patients, particularly in an ageing population, are older adults. However, evidence is lacking for the treatment of older patients, partly because they are underrepresented in clinical trials – especially chemotherapy trials. The lack of evidence has led to a lack of evidence-based guidelines. The SIOG/EUSOMA source guideline for older patients used in this guidance, and the most recent comprehensive guideline specifically for breast cancer among older patients, was published in 2012.

There are specific considerations for the management of older patients with early breast cancer, such as biological age and life expectancy, complex comorbidities, risk of adverse and side events, and drug interactions.

Biological age or functional age should be considered rather than chronological age. Frailty should be regarded as a spectrum rather than binary. Treatment decisions are assisted by screening and if necessary, a full geriatric assessment. Data emphasise the need for multidisciplinary coordination in making individualised treatment recommendations for older patients. Collaborative geriatric and oncology management can optimise care.

Recommendations and practice points are included on the appropriate considerations for the management of older patients, treatment options, use of geriatric assessment including assessment of general health and functional status, and involvement of a geriatrician.

Recommendation

Radiation therapy boost after breast-conserving surgery
In patients who have undergone breast-conserving surgery and who are at high risk of local recurrence (age ≤50 years with any grade, age 51-70 years with higher grade, or a positive margin), offer radiation therapy boost following whole-breast radiation therapy.
13 October 2020
Recommendation

Radiation therapy after breast-conserving surgery – Older women
Discuss the benefits and risks of omitting radiation therapy after breast-conserving surgery in women over 70 years of age with very low risk of local recurrence and who are suitable and willing to take endocrine therapy for five years.
13 October 2020
Recommendation

Primary endocrine therapy without surgery in older patients
Primary endocrine therapy (endocrine therapy alone without surgery) should only be offered to older patients with ER-positive tumours who have a short-estimated life expectancy (<2–3 years), who are considered unfit for surgery after optimisation of comorbid medical conditions, or who decline surgery. The involvement of a geriatrician is strongly recommended to estimate life expectancy and guide management of reversible comorbidities. It is reasonable to choose tamoxifen, or an aromatase inhibitor based on potential side-effects.
15 October 2020
Recommendation

Adjuvant endocrine therapy in older patients
Omission of adjuvant endocrine therapy is an option for older patients with a very low risk tumour (pT1aN0) or those with life-limiting comorbidities.
15 October 2020
Recommendation

Geriatric assessment
1. Treatment planning, information and support
2. Assessment and referral
A screening geriatric assessment is a reasonable first step in identifying patients who may benefit from an extended comprehensive geriatric assessment.
07 April 2021
Recommendation

Hypofractionated radiation therapy after breast-conserving surgery
Offer a hypofractionated course of radiation therapy to women with breast cancer who have undergone breast-conserving surgery with clear surgical margins and who require post-operative whole breast radiation therapy.
13 October 2020
Recommendation

Cognitive impairment – Assessment and management
If cognitive impairment in association with breast cancer or its treatment is suspected, assess for and treat reversible contributing factors (e.g. thyroid dysfunction), discuss coping strategies, and offer referral to an appropriate health professional (geriatrician, neurologist, psychiatrist or psychologist) experienced in the assessment and management of cognitive impairment.
13 October 2020
Practice Point

MDT treatment planning – Cardiac care
1. Treatment planning, information and support
2. Multidisciplinary care and Care coordination
Close and early collaboration between oncologists and cardiologists is recommended for those patients that require treatment with a potentially cardiotoxic treatment, particularly in the context of existing cardiovascular disease or multiple cardiovascular risk factors.
07 April 2021
Recommendation

Treatment planning considerations – Older patients
1. Treatment planning, information and support
2. Multidisciplinary care and Care coordination
Generally, age alone should not dictate treatment decisions, however all management decisions for an older patient should consider life expectancy; potential risks versus absolute benefits; treatment tolerance; patient preferences; potential barriers to treatment; polypharmacy; and assessment of functional status, comorbidities, falls, depression, cognition, nutritional status and social situation.
09 October 2020