Treating elderly patients with hormone sensitive breast cancer: what do the data show?

Elderly patients with breast cancer frequently present with one or more comorbid conditions in addition to their cancer, and this can complicate clinicians' treatment decisions. Declining estrogen levels increase the risk for conditions such as cardiovascular disease and osteoporosis in the elderly. Evidence from clinical trials suggests that the elderly are frequently underrepresented; this may be due to an inherent reluctance among physicians to prescribe the latest, most effective therapies and/or recommend elderly patients for participation in clinical trials. Nonetheless, there is evidence that breast cancer in the elderly is generally more indolent than in younger patients, with a low proliferative and invasive capacity and a high degree of hormone responsiveness, making elderly patients ideal candidates for adjuvant endocrine therapies. The aromatase inhibitors, including anastrozole, letrozole, and exemestane, have proven to be well tolerated and superior alternatives to tamoxifen for post-menopausal women with hormone-sensitive breast cancer, whether used upfront or sequentially with adjuvant tamoxifen. Although the elderly have also been underrepresented in clinical trials of the aromatase inhibitors, evidence from the major trials has not shown any decrement in efficacy or major safety concerns when these drugs are used in older populations. While recently published data from MA.17 and the Breast International Group 1-98 showed letrozole to be effective irrespective of age, clinicians should carefully consider underlying comorbidities when prescribing adjuvant endocrine treatments to elderly patients with breast cancer.