Antonella Brunello KwokLeung Cheung Disclosure No conflict of interests Learning objectives To discuss the pros and cons of adjuvant chemotherapy for breast cancer in the elderly To ID: 779496
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Slide1
A case of localized breast cancer
Antonella Brunello Kwok-Leung Cheung
Slide2Disclosure
No conflict of interests
Slide3Learning objectives
To discuss the pros and cons of adjuvant chemotherapy for breast cancer in the elderlyTo discuss the initial diagnostic work-up for breast cancer
To
incorporate Comprehensive Geriatric Assessment in the multidisciplinary evaluation of the patient
To
discuss treatment options for localized breast cancer
To
learn about tools to help balancing expected benefits and risks from adjuvant chemotherapyToxicity management
Slide4Past medical history
Diabetes since 2002HypercholesterolemiaHypertension
Obesity
Psoriasis
Mild visual impairment due to exudative diabetic maculopathy
Slide5History of present illness
76 year-old ladyIn November 2012 found a nodule in the left breast.
She was referred by her GP to a community hospital surgeon.
At mammogram a 1.5 cm nodule was confirmed, and there was a clinically suspicious axillary
lymphnode
Biopsy
was performed on the left breast nodule which confirmed
IDC grade 2, ER 100% PgR50% Ki67 15%, HER2 1+. A FNAC of the axillary
lymphnode
was not diagnostic.
Staging
with chest x-ray and abdominal ultrasound was negative.
Slide6Q#1
Which is the life expectancy of this patient?
Slide7Q#2
What would you do at this point?
Surgery
Neoadjuvant
chemotherapy
Neoadjuvant
endocrine therapy
Radiation therapy
Slide8Comprehensive Geriatric
AssessmentADL=6/6, IADL=8/8 Comprehensive Geriatric Assessment
MMSE: 29/30
BMI=22.7 (87 kg, 156 cm)
GDS=3/15
7 drugs:
-
repaglinide -
lercanidipine
- metformin -
nebivolol
- lysine acetylsalicylate - valsartan/hydrochlorothiazide
- esomeprazole -
doxazosine
- simvastatin
Slide9Q#3
Based on CGA, how would you classify this lady in the grandfather of Geriatric Oncology’s scale?
Slide10Comprehensive Geriatric
AssessmentAssuming she went for conservative surgery upfront
Final pathologic report:
“
IDC grade 2 stage pT1c (1.5 cm) pN3a (12 metastatic axillary
lymphnode out of 24 examined), ER 100% PgR45% Ki67 14%, HER2 2+, FISH negative”.
Q#4
Further
work-up / treatment?
Slide11History of present illness
10/2/2013: left upper outer quadrantectomy and lymphnode dissection (after positive sentinel node biopsy).
Patient was referred to our Institution for further management.
Staging was completed with bone scan, which revealed mild and
disomogenous
uptake in D12. Plain x-ray did not show bone lesions
Slide12Adjuvant therapy?
Discussion with patient and her family on adjuvant treatment options. Patient
was very motivated to be treated with all available options, therefore a plan for adjuvant chemotherapy and subsequent endocrine therapy, plus radiation therapy was proposed.
Slide13Adjuvant chemotherapy
After cardiology evaluation (good cardiac function, LVEF 64%), adjuvant chemotherapy was planned with sequential schedule Epirubicin/Cyclophosphamide (EC) 4 cycles followed by Paclitaxel weekly, given the N3 stage.
After second cycle of EC patient presented
diarrhea
with progressive dehydration, decompensated diabetes and subsequent acute renal failure and she was admitted to hospital for intensive care.
Slide14Would the choice of giving only endocrine therapy an option?
LOW-RISK
HIGH-RISK
Slide15Which is the expected benefit of
chemotherapy in this patient ?
Slide16Adjuvant endocrine therapy
After recovering, the adjuvant chemotherapy was stopped and patient was started on Letrozole, and received radiation therapy.
In January 2014 patient developed back pain, and new x-ray and MRI revealed L3-L4 vertebral fracture. A biopsy was taken which revealed no neoplastic cells, and patient underwent
vertebroplasty
. DEXA showed lumbar T-score -2.6 and left femur T-score -3.6. She was therefore started on
Zoledronate
5 mg once a year.
At last follow-up on December
2017 patient status was NED
.
March 2018: diagnosis of AML, started on
Oncocarbide
Exitus
September 2018
Slide17Recurrence Data: All Women
Slide18‡ includes women aged < 45 if unknown
Heterogeneity between menopausal groups χ21 = 5.6 ; P=0.02
Premenopausal
‡
Postmenopausal
Coleman RE, Lancet 2015
Bone
recurrence
by menopausal status
Slide19Mortality: all women
Slide20Breast Cancer Mortality by Menopausal Status
‡ includes women aged < 45 if unknown
Premenopausal
‡
Postmenopausal
Coleman RE, Lancet 2015
Slide21Conclusions
Metabolic syndrome must be taken into account for a very high risk of toxicity from chemotherapy, CGA-based tools may help in considering the toxicity risk.
Hormonal therapy alone may be a good treatment option in the older patients with high-risk ER+HER2- breast cancer
.
Early start of bisphosphonate may be beneficial for comorbidity but also for oncological
outcomes
.
Multidisciplinary evaluation should be applied along with CGA in order to have a full picture and to allow the best treatment plan.