Inclusion of Geriatric Populations in Breast Cancer Research Needed to Improve Care

Enrique Soto Pérez de Celis, MD, MSc

Geriatric patients with lung cancer are a vastly underrepresented patient population in clinical trials. As such, developing a strong understanding of how to optimally treat older patients with breast cancer has proven to be particularly challenging, according to Enrique Soto Pérez de Celis, MD, MSc.

“With age, changes occur in the way organs work, physical function, and tolerance to treatment,” said Soto. “We need to think about this when we are offering treatments because we want to offer the best possible option as well as avoid toxicity.”

When treating older patients with breast cancer, a geriatric assessment must be performed; this will provide insight into the patient’s cognitive and physical function, any psychological issues, as well as their social support systems, explained Soto.

The patient’s chronological age must also be considered and their life expectancy without cancer must be calculated, as treatment may not be beneficial for patients with a limited life expectancy due to other comorbidities. Additionally, the risks and benefits of treatment must be weighed and then a shared decision between patient and provider can be reached.

Although the treatment options are the same for older and younger patients alike, the challenge is determining which older patients are able to tolerate certain regimens, added Soto.

“We are not going to evolve to an era in which we have some treatments that are for older adults and some treatments that aren't,” said Soto. “Tailoring treatments and figuring out which options are better tolerated by older patients is something that we need to work on.”

In an interview with OncLive, Soto, a geriatric oncologist and researcher in the Department of Geriatrics at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, discussed some of the challenges of treating geriatric patients with breast cancer, emerging treatment options for this patient population, and recommendations for treating older patients.

OncLive: What are some of the challenges of treating older patients with breast cancer?

Soto: A significant issue when we're treating older women with breast cancer is that these patients are usually underrepresented in clinical trials for breast cancer therapies. Although older women account for half of all breast cancer cases, not only in the United States but worldwide, their representation in clinical trials is very low, at about 15% to 20%. As such, we don't have enough evidence to provide high-quality treatment for this population.

We also know that older patients are different [than younger patients]. You can evaluate older patients by using a geriatric assessment, a multidisciplinary evaluation that geriatricians have been using for over 50 years. This assessment includes several aspects that are particularly important for older patients and are not usually performed in an oncology visit, such as assessing cognition, physical function, psychological issues, and social support systems, among measures. With all this information, we can get a better picture of the older patient in front of us. It is important to not only use chronological age, but also these biological and functional measures of aging.

Could you expand on some of the steps need to be taken when treating an older patient with this disease?

When treating an older woman with triple-negative breast cancer (TNBC), you need to do a series of steps. First, you have to do a geriatric assessment. Geriatric oncology guidelines recommend exactly what tools to use, and that's very useful for everyday clinical practice. You also have to calculate the patient's life expectancy without cancer because these patients have competing risks and other comorbidities. The benefits of our treatments are not going to be appropriate for a patient who has a very limited life expectancy due to other diseases.

Then, you have to assess the risks and benefits of treatment. Several tools can be utilized to predict chemotherapy toxicity in older women. Finally, you have to align these risks and benefits with patient preferences. Often, older adults do not prioritize prolonging survival; they may value other outcomes more, such as maintaining their independence, maintaining their cognition, or avoiding symptoms. Taking that into consideration when making [treatment] decisions that give incremental gains is always very important. After doing all that, you can have a discussion with the patient in which a shared decision is reached.

In what ways does your treatment approach differ for older patients with breast cancer versus younger patients?

The treatments are the same for our younger and older adults; however, we need to figure out which older adults are able to tolerate the same treatments we would give a 40- or 50-year-old. We need to learn which older adults require treatment adjustments or which patients we need to keep a close eye on during treatment because they are at higher risk of toxicity.

We need to work on understanding which options are better tolerated by older patients. However, this is particularly difficult because even the trials that are potentially very interesting for older patients who cannot tolerate usual chemotherapy are not including enough older patients. Fortunately, there is a drive to change inclusion criteria in clinical trials to have more older patients enrolled.

How are PARP inhibitors emerging in the breast cancer space, specifically for older patients?

In the case of older women with TNBC, PARP inhibitors are potentially interesting type of treatment. Older women are vastly underrepresented in trials with PARP inhibitors, but it seems that older women benefit from PARP inhibitors the same as their younger counterparts, and the toxicity is comparable. This could be an interesting [approach for] older adults who should avoid chemotherapy. Additionally, since PARP inhibitors are used in patients with BRCA mutations, ongoing studies ongoing are looking at the mutation in older women, and it seems that it's almost comparable to what is seen in their younger counterparts. This is something that we could potentially use more of in the future, particularly in women with TNBC.