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Case history

image A 74-year-old woman attended for adjuvant chemotherapy 8 weeks after surgery for a T1G3N0, oestrogen receptor (ER)-negative, progesterone receptor-negative, human epidermal growth factor receptor 2 (HER2)-positive breast cancer, with clear surgical margins. She had returned to preoperative functioning.

Her past medical history included angina, hypertension, and urinary incontinence on coughing with occasional urgency. She was Afro-Caribbean and lived with her husband. None of her four children lived nearby. She was self-caring, had normal cognitive function, occasional breathlessness and intermittent headaches.

Her medications included bisoprolol, co-amilofruse, aspirin, pravastatin, isosorbide mononitrate and glyceryl trinitrate (GTN) spray.

On examination, her performance status was 1, BMI 32 kg/m2 and BP 178/90 mmHg. An adenosine stress test demonstrated normal left ventricular function, perfusion and no inducible ischaemia. Blood tests were normal and urine culture was negative.

The patient wanted the most effective adjuvant treatment but was concerned about the impact of chemotherapy on her symptoms. She reported that she omitted her medication at times, as it worsened her urinary incontinence.

What is the evidence for the use of adjuvant chemotherapy in older patients with breast cancer?

What potential risks and toxicities should the patient be made aware of?

How can we best select older patients for adjuvant chemotherapy?

How should the hypertension and headaches be managed?

How can urinary incontinence be identified and managed in cancer services?

Patient outcome

Recent developments

What is the evidence for the use of adjuvant chemotherapy in older patients with breast cancer?

Breast cancer in the over-70s is associated with increased tumour size, nodal involvement, biological differences (more ER-positive and fewer HER2-positive cancers)1,2 and inferior outcomes.3 The incidence of male breast cancer increases with age.4 Therefore, adjuvant systemic therapy is important for some older patients.

Few adjuvant chemotherapy randomized controlled trial (RCT) data are available for breast cancer in the over-70s.5 Trials comparing adjuvant chemotherapy with no chemotherapy were closed early due to insufficient accrual (Chemotherapy Adjuvant Studies for Women at Advanced Age [CASA] and Adjuvant Cytotoxic Chemotherapy in Older Women [ACTION]). RCT data have not supported less intensive adjuvant chemotherapy: a trial of combination therapy (cyclophosphamide, methotrexate and fluorouracil [CMF] or cyclophosphamide and doxorubicin) versus less intensive capecitabine monotherapy reported decreased relapse-free survival and worse overall survival for capecitabine.6 Furthermore, inferior breast cancer outcomes were seen with weekly docetaxel compared with CMF, accompanied by poorer quality of life.7 Conversely, others support the use of docetaxel with cyclophosphamide.8 Current evidence is insufficient to recommend an optimal chemotherapy regimen, but less intensive treatment is associated with poorer outcomes. Patients with HER2-positive breast cancer, without significant cardiac disease, should also receive trastuzumab.9 Single-agent trastuzumab may be indicated in unfit patients,10 although it is not recommended in NICE guidelines.

What potential risks and toxicities should the patient be made aware of?

Increasing age, poorer function ...

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