Weathering the Storm: Managing Older Adults With Breast Cancer Amid COVID-19 and Beyond

Caring for older patients with breast cancer presents unique clinical considerations because of preexisting and competing comorbidity, the potential for treatment-related toxicity, and the consequent impact on functional status. In the context of the COVID-19 pandemic, treatment decision making for older patients is especially challenging and encourages us to refocus our treatment priorities. While we work to avoid treatment delays and maintain therapeutic benefit, we also need to minimize the risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exposures, myelosuppression, general chemotherapy toxicity, and functional decline. Herein, we propose multidisciplinary

[1]  T. Rea,et al.  Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington , 2020, The New England journal of medicine.

[2]  G. Onder,et al.  Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. , 2020, JAMA.

[3]  Christl A. Donnelly,et al.  Estimates of the severity of coronavirus disease 2019: a model-based analysis , 2020, The Lancet Infectious Diseases.

[4]  R. Redfield,et al.  Covid-19 — Navigating the Uncharted , 2020, The New England journal of medicine.

[5]  C. Tournigand,et al.  6 months versus 12 months of adjuvant trastuzumab in early breast cancer (PHARE): final analysis of a multicentre, open-label, phase 3 randomised trial , 2019, The Lancet.

[6]  C. Caldas,et al.  6 versus 12 months of adjuvant trastuzumab for HER2-positive early breast cancer (PERSEPHONE): 4-year disease-free survival results of a randomised phase 3 non-inferiority trial , 2019, The Lancet.

[7]  Yuan Yuan,et al.  Functional versus chronological age: geriatric assessments to guide decision making in older patients with cancer. , 2018, The Lancet. Oncology.

[8]  H. Cohen,et al.  Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology. , 2018, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[9]  E. Winer,et al.  Breast cancer‐specific survival by age: Worse outcomes for the oldest patients , 2018, Cancer.

[10]  O. Abdel-Rahman Impact of timeliness of adjuvant chemotherapy and radiotherapy on the outcomes of breast cancer; a pooled analysis of three clinical trials. , 2018, Breast.

[11]  M. Goetz,et al.  Predicting Nodal Positivity in Women 70 Years of Age and Older with Hormone Receptor-Positive Breast Cancer to Aid Incorporation of a Society of Surgical Oncology Choosing Wisely Guideline into Clinical Practice , 2017, Annals of Surgical Oncology.

[12]  H. Gómez,et al.  Anthracyclines in Early Breast Cancer: The ABC Trials-USOR 06-090, NSABP B-46-I/USOR 07132, and NSABP B-49 (NRG Oncology). , 2017, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[13]  E. Winer,et al.  Surveillance Mammography in Older Patients With Breast Cancer—Can We Ever Stop?: A Review , 2017, JAMA oncology.

[14]  L. V. van't Veer,et al.  70-Gene Signature as an Aid to Treatment Decisions in Early-Stage Breast Cancer. , 2016, The New England journal of medicine.

[15]  L. Fan,et al.  Influence of delayed initiation of adjuvant chemotherapy on breast cancer survival is subtype-dependent , 2016, Oncotarget.

[16]  C. Perou,et al.  Efficacy of Neoadjuvant Carboplatin plus Docetaxel in Triple-Negative Breast Cancer: Combined Analysis of Two Cohorts , 2016, Clinical Cancer Research.

[17]  S. Giordano,et al.  Delayed Initiation of Adjuvant Chemotherapy Among Patients With Breast Cancer. , 2016, JAMA oncology.

[18]  C. Gross,et al.  The evolving role of adjuvant radiotherapy for elderly women with early‐stage breast cancer , 2015, Cancer.

[19]  T. Ohmura,et al.  A phase I study of combination therapy with nanoparticle albumin-bound paclitaxel and cyclophosphamide in patients with metastatic or recurrent breast cancer , 2015, International Journal of Clinical Oncology.

[20]  D. Cameron,et al.  Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial. , 2015, The Lancet. Oncology.

[21]  N. Bhavsar,et al.  The use of adjuvant radiotherapy in elderly patients with early‐stage breast cancer: Changes in practice patterns after publication of Cancer and Leukemia Group B 9343 , 2015, Cancer.

[22]  Barbara L. Smith,et al.  Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. , 2013, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[23]  P. Boracchi,et al.  Axillary Dissection Versus No Axillary Dissection in Older Patients With T1N0 Breast Cancer: 15-Year Results of a Randomized Controlled Trial , 2012, Annals of surgery.

[24]  Benjamin D. Smith,et al.  Fractionation for whole breast irradiation: an American Society for Radiation Oncology (ASTRO) evidence-based guideline. , 2011, International journal of radiation oncology, biology, physics.

[25]  N. Taira,et al.  Evaluation of trastuzumab without chemotherapy as a post-operative adjuvant therapy in HER2-positive elderly breast cancer patients: randomized controlled trial [RESPECT (N-SAS BC07)]. , 2011, Japanese journal of clinical oncology.

[26]  D. Lake,et al.  Dose dense cyclophosphamide, methotrexate, fluorouracil is feasible at 14-day intervals: a pilot study of every-14-day dosing as adjuvant therapy for breast cancer. , 2010, Clinical breast cancer.

[27]  J. Sakamoto,et al.  Phase I study of combination therapy with weekly paclitaxel and cyclophosphamide for advanced or recurrent breast cancer , 2010, Cancer Chemotherapy and Pharmacology.

[28]  P. Sismondi,et al.  Conservative surgery with and without radiotherapy in elderly patients with early-stage breast cancer: a prospective randomised multicentre trial. , 2009, Breast.

[29]  J R Yarnold,et al.  The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial , 2008, The Lancet.

[30]  M. Reed,et al.  Surgery, with or without tamoxifen, vs tamoxifen alone for older women with operable breast cancer: Cochrane review , 2007, British Journal of Cancer.

[31]  R. Pötter,et al.  Lumpectomy plus tamoxifen or anastrozole with or without whole breast irradiation in women with favorable early breast cancer. , 2005, International journal of radiation oncology, biology, physics.

[32]  Melania Pintilie,et al.  Tamoxifen with or without breast irradiation in women 50 years of age or older with early breast cancer. , 2004, The New England journal of medicine.

[33]  Barbara L. Smith,et al.  Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. , 2004, The New England journal of medicine.

[34]  M. Baum,et al.  Late follow‐up of a randomized trial of surgery plus tamoxifen versus tamoxifen alone in women aged over 70 years with operable breast cancer , 2004, The British journal of surgery.

[35]  Barbara L. Smith,et al.  Randomized trial of dose-dense versus conventionally scheduled and sequential versus concurrent combination chemotherapy as postoperative adjuvant treatment of node-positive primary breast cancer: first report of Intergroup Trial C9741/Cancer and Leukemia Group B Trial 9741. , 2003, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[36]  S. Milani,et al.  Tamoxifen alone versus adjuvant tamoxifen for operable breast cancer of the elderly: long-term results of the phase III randomized controlled multicenter GRETA trial. , 2003, Annals of oncology : official journal of the European Society for Medical Oncology.

[37]  I. Fentiman,et al.  Treatment of operable breast cancer in the elderly: a randomised clinical trial EORTC 10851 comparing tamoxifen alone with modified radical mastectomy. , 2003, European journal of cancer.

[38]  I. Olivotto,et al.  Age-related variations in the use of axillary dissection: a survival analysis of 8038 women with T1-ST2 breast cancer. , 2002, International journal of radiation oncology, biology, physics.

[39]  F. Cavalli,et al.  Dose-finding study of paclitaxel and cyclophosphamide in advanced breast cancer. , 1997, Annals of oncology : official journal of the European Society for Medical Oncology.

[40]  R. Coombes,et al.  Prospective randomized trial of tamoxifen vs surgery in elderly patients with breast cancer. , 1994, European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology.

[41]  M. Beckmann,et al.  Neoadjuvant trastuzumab, pertuzumab, and chemotherapy versus trastuzumab emtansine plus pertuzumab in patients with HER2-positive breast cancer (KRISTINE): a randomised, open-label, multicentre, phase 3 trial. , 2018, The Lancet. Oncology.

[42]  A. Jemal,et al.  Patterns of axillary evaluation in older patients with breast cancer and associations with adjuvant therapy receipt , 2017, Breast Cancer Research and Treatment.

[43]  C. Lawton Long-Term Results of Hypofractionated Radiation Therapy for Breast Cancer , 2011 .

[44]  Robert B Livingston,et al.  Prognostic and predictive value of the 21-gene recurrence score assay in postmenopausal women with node-positive, oestrogen-receptor-positive breast cancer on chemotherapy: a retrospective analysis of a randomised trial. , 2010, The Lancet. Oncology.

[45]  J. Forbes,et al.  Randomized trial comparing axillary clearance versus no axillary clearance in older patients with breast cancer: first results of International Breast Cancer Study Group Trial 10-93. , 2006, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[46]  F. Cavalli,et al.  Dose-finding study of paclitaxel and cyclophosphamide in women with advanced breast cancer. , 1997, Seminars in oncology.