Adjuvant therapy for women over age 65 with breast cancer

Women over age 65 with breast cancer are often not treated in accordance with current guidelines as far as adjuvant therapy is concerned, because of the lack of adequate scientific evidence.

This article is based on a selective review of pertinent literature retrieved by a PubMed search, as well as on the German S3 guidelines for the diagnosis, treatment, and follow-up care of breast cancer, the treatment recommendations of the German Working Group on Gynecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie, AGO) and the German Society of Radiation Oncology (Deutsche Gesellschaft für Radioonkologie), US National Comprehensive Cancer Network, and the Cochrane database.

Women over age 65 are underrepresented in randomized trials of treatments for breast cancer. Geriatric assessment is essential for therapeutic decision-making. Endocrine treatment is feasible for nearly all patients with hormone-sensitive tumors. In selected patients over age 65, chemotherapy significantly improves overall survival. The best evidence regarding toxicity is available for anthracycline monotherapy and for combined therapy with doxorubicin/cyclophosphamide or taxane/doxorubicin. Women without cardiac disease can be given trastuzumab, which may lead to reversible cardiotoxicity. Adjuvant radiotherapy significantly improves local tumor control and survival. Adjuvant radiotherapy that is carried out with modern treatment planning, as recommended by the current guidelines, is no more toxic to older patients than to younger ones; thus, it should always be given, unless there is a special reason not to.

Women with breast cancer over age 65 whose life expectancy is greater than 5 years, and who are not otherwise too ill, should be given chemotherapy, trastuzumab, and radiotherapy as standard adjuvant treatment. Adjuvant therapy can be reduced or omitted in frail patients. Patients over age 65 should be given the opportunity to enroll in clinical trials.