Early breast cancer in the elderly - Assessment and management considerations
Early breast cancer in the elderly - Assessment and management considerations
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DOI：
10.2165/00002512-200825010-00004
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发表时间：
2008-01-01
期刊：
影响因子：
2.8
通讯作者：
Terret, Catherine
中科院分区：
文献类型：
--
作者：
Albrand, Gilles;Terret, Catherine
乳腺癌是老年人的常见肿瘤，早期疾病的治疗对于肿瘤学家和老年病学家来说尤其是一个重大挑战。该过程应从综合老年评估（CGA）开始，该评估应在做出任何治疗决定之前进行。在做出治疗决定时还需要考虑合并症的重要作用及其对预期寿命的影响。早期乳腺癌的主要治疗方法是手术、辅助放疗和辅助全身治疗。不幸的是，缺乏与老年人早期乳腺癌相关的具体文献意味着在这种情况下制定基于证据的治疗方法很困难。我们开发了一种基于 CGA 和综合肿瘤学评估的新方法。这种方法有利于根据以下几个因素制定个性化的癌症老年护理计划和随访：特定年龄患者的平均预期寿命；患者的合并症、依赖性程度以及这些考虑因素对诊断和治疗选择以及预期寿命的影响；以及治疗的潜在获益-风险平衡。对于老年乳腺癌患者，标准的主要治疗是手术切除（乳房切除术或保乳治疗）。虽然淋巴结清扫是乳腺癌分期和局部控制的主要组成部分，但没有数据可以指导 70 岁以上女性的决策。仅当患有雌激素受体（ER）阳性乳腺癌的老年女性不适合或拒绝手术时，才应接受主要内分泌治疗（他莫昔芬）。需要进行试验来评估芳香酶抑制剂作为患有 ER 阳性肿瘤的体弱老年患者主要疗法的临床有效性。应建议预期寿命 > 5 年的老年女性进行乳房照射，特别是肿瘤较大、淋巴结阳性或激素受体阴性的女性。对于激素受体肿瘤阳性的老年女性，辅助激素治疗仍然是一种合理的治疗选择。在年轻绝经后女性中，芳香酶抑制剂作为辅助治疗表现出比他莫昔芬更好的毒性特征和有效性，但尚未在老年人群中进行专门研究。乳腺癌辅助化疗的疗效已通过荟萃分析和大量随机试验确定，但此类试验很少纳入 70 岁以上的女性。目前，对于老年乳腺癌患者辅助化疗的使用很难提供有效的建议。早期乳腺癌治疗后没有专门针对老年患者的后续建议。然而，美国临床肿瘤学会乳腺癌监测指南建议，持续 3 年每 3-6 个月进行一次医生办公室就诊，随后持续 2 年每 6-12 个月进行一次医生办公室就诊，然后每年一次。服用芳香酶抑制剂的女性还应每两年进行一次骨矿物质密度测量。本文概述的评估和管理老年人早期乳腺癌的新方法应被视为中间步骤，因为仍需要更多证据来支持临床实践。考虑到这一点，医生应鼓励老年乳腺癌患者参加临床试验。
Breast cancer is a common tumour in the elderly and management of early disease in particular is a major challenge for oncologists and geriatricians alike. The process should begin with the Comprehensive Geriatric Assessment (CGA), which should be undertaken before any decisions about treatment are made. The important role of co-morbidities and their effect on life expectancy also need to be taken into account when making treatment decisions.The primary treatments for early breast cancer are surgery, adjuvant radiotherapy and adjuvant systemic therapy. Unfortunately, lack of a specific literature relating to early breast cancer in the elderly means formulating an evidence-based approach to treatment in this context is difficult. We have developed a new approach based on the CGA and comprehensive oncological assessment. This approach facilitates the development of an individualized oncogeriatric care plan and follow-up based on several considerations: the average patient's life expectancy at a given age; the patient's co-morbidities, level of dependence, and the impact of these considerations on diagnostic and therapeutic options as well as life expectancy; and the potential benefit-risk balance of treatment.In the elderly patient with breast cancer, the standard primary therapy is surgical resection (mastectomy or breast-conserving therapy). While node dissection is a major component of staging and local control of breast cancer, no data are available to guide decision-making in women aged >70 years. Primary endocrine therapy (tamoxifen) should be offered to elderly women with estrogen receptor (ER)-positive breast cancer only if they are unfit for or refuse surgery. Trials are needed to evaluate the clinical effectiveness of aromatase inhibitors as primary therapy for infirm older patients with ER-positive tumours. Breast irradiation should be recommended to older women with a life expectancy >5 years, particularly those with large tumours, positive lymph nodes or negative hormone receptors.Adjuvant hormone therapy remains a reasonable therapeutic option in elderly women with positive hormone receptor tumours. Aromatase inhibitors have demonstrated a better toxicity profile and effectiveness as adjuvant therapy than tamoxifen in young postmenopausal women but have not been specifically studied in the elderly population. The efficacy of adjuvant chemotherapy for breast cancer has been established by meta-analysis and numerous randomized trials but, again, women aged >= 70 years have rarely been included in such trials. At present, it is difficult to provide a validated recommendation for use of adjuvant chemotherapy in elderly patients with breast cancer.There are no follow-up recommendations specifically for elderly patients after treatment of early breast cancer. However, American Society of Clinical Oncology breast cancer surveillance guidelines suggest physician office visits every 3-6 months for 3 years, followed by visits every 6-12 months for 2 years, then annually. Women taking aromatase inhibitors should also undergo bone mineral density measurement every 2 years.The new approach to assessment and management of early breast cancer in the elderly outlined in this article should be considered an intermediate step because additional evidence to support clinical practice is still needed. Bearing this in mind, physicians should encourage enrolment of elderly breast cancer patients in clinical trials.