Tailoring Treatment, Personalized Care for Older Adult Patients With Advanced Breast Cancer

Older adult patient receiving mammogram | Image Credit: Peakstock - stock.adobe.com

Older adults living with advanced breast cancer represent a diverse patient population that should receive various evidence-based recommendations tailored based on physical fitness, cognitive function, and patient values, as well as specific preferences.

A consensus of a Canadian treatment landscape expressed the importance in offering fit patients standard of care regardless of chronological age, while patients that are more vulnerable and frailer should have their health optimized, if possible, with considerations of modified treatment options and more frequent monitoring.

The review aimed to approach treatment decision-making among older adults with breast cancer while providing evidence-based recommendations and practical guidance for health care professionals involved in care management. Health care providers can recognize and address the specific needs of older adults to optimize treatment outcomes and improve the overall quality of care for this population.

Key treatment considerations among older adults included the risk of undertreatment and overtreatment. Current guidelines suggest treating older patients the same regardless of their biological sex. However, the review argued a shared decision-making process that respects a patient’s values and goals for their health care is the recommended path in determining treatment.

Patient status, comorbidities, and life expectancy should be carefully considered for optimal cancer treatment. Older adults, often underrepresented in trials, require careful assessment to predict treatment effects and tolerance based on potential limitations or other health conditions. Regularly evaluating life expectancy ensures future treatments offer meaningful benefit.

Another key consideration is cognitive assessments for cancer patients. An increased risk of cancer treatment toxicity and poorer survival rates may be associated with cognitive decline. Possible implications include patient ability to properly take medication or report adverse events (AEs) from treatment to physicians. Overall, clinicians should encourage family members and caregiver involvement whenever possible.

Older adults experience an increased risk of drug interactions, AEs, and treatment nonadherence since they are more likely to take multiple medications. Ensuring consistent and dedicated pharmacy reviews could eliminate any unnecessary medications or dangerous medication interactions throughout each line of therapy. Older adults also have an increased risk in experiencing distinct toxicities due to the potential differences in the timing of treatment toxicities. Patients should receive special attention for any digestive symptoms, malnutrition, depression, and pain control to manage the impact of treatment and maintain quality of life (QOL).

The authors recommended that providers discuss individual health goals and values with patients who either value maximizing their lifespan as long as possible or prioritizing their QOL. These preferences are influenced by various factors, including access to care, social determinants of health, and physical limitations.

Introducing palliative care in a timely manner should be a key consideration for the treatment of advanced breast cancer in older adults. Conversations surrounding the risk of dying are helpful in revealing patient preferences during advanced care planning. The authors stressed that the cultural and social values of each patient must be respected and supported whenever possible to ensure satisfaction.

Studies show cyclin dependent kinase (CDK) 4/6 inhibitors with hormone therapy are standard for advanced, hormone-sensitive, HER2-negative breast cancer. While all 3 approved CDK 4/6 inhibitors (palbociclib, ribociclib, abemaciclib) improve progression-free survival (PFS), only ribociclib extends overall survival (OS) in the first line setting. For frail patients, single-agent options like fulvestrant or tamoxifen can be used.

While risk lessens with age, advanced HER2-positive breast cancer can strike older adults. Standard treatment (pertuzumab, docetaxel, trastuzumab) improves PFS and OS, but paclitaxel or endocrine therapy may be better tolerated for patients that have an increased risk of toxicity due to chemotherapy and now have a frail physique.

Authors argue the apparent need for more treatment options since “chemotherapy remains the mainstay of treatment” but is heavily associated with higher toxicity levels.

The study design limited researchers' ability to understand how well treatments would work for older adults, how safe they would be, and if patients would be able to handle the adverse effects.

This study bridges clinical gaps by focusing on factors that matter to patients rather than age and combines disease biology with treatment options to guide patient advocacy.

Reference

Jackson EB, Curry L, Mariano C, et al. Key considerations for the treatment of advanced breast cancer in older adults: An expert consensus of the Canadian treatment landscape. Curr. Oncol. 2024; 31(1):145-167. doi:10.3390/curroncol31010010