Frailty-Independent Undertreatment Negative Impact on Survival in Older Patients With Breast Cancer

Abstract

Purpose The management of older adults with breast cancer (BC) remains controversial. The challenging assessment of aging idiosyncrasies and the scarce evidence of therapeutic guidelines can lead to undertreatment. Our goal was to measure undertreatment and assess its impact on survival. Methods Consecutive patients with BC aged 70 years or older were prospectively enrolled in 2014. Three frailty screening tools (G8, fTRST, and GFI) and two functional status scales (Karnofsky performance score and Eastern Cooperative Oncology Group Performance Status) were applied. Disease characteristics, treatment options, and causes of mortality were recorded during a 5-year follow-up. In addition, we defined undertreatment and correlated its survival impact with frailty. Results A total of 92 patients were included in the study. The median age was 77 (range 70–94) years. The prevalence of frailty was discordant (G8, 41.9%; fTRST, 74.2%; GFI, 32.3%). Only 47.8% of the patients had a local disease, probably due to a late diagnosis (73.9% based on self-examination). Thirty-three patients (35.6%) died, of which 15 were from BC. We found a considerably high proportion (53.3%) of undertreatment, which had a frailty-independent negative impact on the 5-year survival (hazard ratio [HR], 5.1; 95% confidence interval [CI], 2.1–12.5). Additionally, omission of surgery had a frailty-independent negative impact on overall survival (HR, 3.9; 95% CI, 1.9–7.9). Conclusion BC treatment in older adults should be individualized. More importantly, assessing frailty (not to treat) is essential to be aware of the risk-benefit profile and the patient's well-informed willingness to be treated. Undertreatment in daily practice is frequent and might have a negative impact on survival, as we report.

Quality Indicators Compliance and Survival Outcomes in Breast Cancer according to Age in a Certified Center

“…As for HER2-positive tumors, a difference was seemingly uncovered, though inconclusive, since HER2 over-expression was not studied in 5.8% of older patients. Like Ki67 (not performed in 85.9% of ≥70 years), this incomplete IHC study regarding HER2 status in older adults discloses a potential preconceived advanced age intention-not-to-treat [26]. Considering genetic assessment, there was inevitably an age bias, as more younger patients were studied, and more genetic mutations were identified in ≤45 years women.…”

“…However, this was not observed for adjuvant radiotherapy in pN+ disease or adjuvant chemotherapy in TN tumors, mainly for ≥70 years women [37]. Nonetheless, a possible correlation between EUSOMA QIs noncompliance and possible undertreatment in older patients could not be concluded, because neither the former is sufficiently discriminatory in monitoring BC best practices and outcomes [15,16,18], or includes age-specific standards, such as geriatric covariates, nor is the latter consensually defined in the literature [25,26]. The EUSOMA QIs assess compliance of mandatory variables to adequate BC diagnosis and treatment but are not helpful as a tool for predicting an objective outcome, such as the 5-year BCSS.…”

“…Chronological age should not be a determinant of BC prognosis or treatment [7,25]. This is well-defined in the youngest women thanks to several consensus meetings, but despite similar experts' efforts, a therapeutic stigma on advanced age persists in daily practice nowadays [7,[25][26][27][28][29][30]. The postulated consensus that advanced age is associated with a more favorable tumor biology (more luminal tumors, fewer TN or HER2 tumors, lower proliferative rates) that allows less intensive treatment is contradicted by the observed poorer outcome of BC in older patients [8,26,[31][32][33][34][35][36].…”