key: cord-0861476-04bt69aa
authors: Benn, Carol-Ann; Ramdas, Yastira; Smit, Teresa; Shaw, Vernon; Rapoport, Bernardo Leon
title: Analysis of primary endocrine therapy in patients older than 70 years with breast cancer rejecting surgery from a single unit in South Africa including COVID-19 issues
date: 2021-03-02
journal: J Geriatr Oncol
DOI: 10.1016/j.jgo.2021.02.024
sha: 812d237d59418e0099e2431cd4fe322e745be589
doc_id: 861476
cord_uid: 04bt69aa

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meta-analysis of 20 clinical studies with 3,490 patients demonstrated that primary endocrine therapy (PET), even as monotherapy, is associated with comparable response rates compared to NACT in patients with estrogen receptor (ER) positive tumors. PET is associated with considerably lower toxicity, indicating that PET could be reevaluated as a potential alternative in the appropriate patient [3] . The International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA) breast cancer guidelines recommend surgery as the optimal treatment for patients with ER-positive, HER2-negative disease. At the same time, PET should only be offered to older patients with ER-positive tumors who have a short estimated life expectancy (<2-3 years) and who are considered unfit for surgery after optimizing medical conditions patients who refuse surgery. The involvement of a geriatrician as part of the team is strongly recommended to assess the life expectancy accurately, comorbidities as competing causes of mortality, drug safety, drug-drug interactions, treatment compliance, and manage reversible comorbidities. In this setting, it is reasonable to choose PET in the form of tamoxifen or an aromatase inhibitor, based on potential side-effects and patient preferences [4] .

This retrospective study aimed to evaluate a subset of patients with endocrine sensitive breast cancer, refusing to undergo surgery or were not eligible for surgery.

PET was decided as the initial treatment of choice, following extensive discussion between the patient and the treating clinician.

In the current climate of COVID-19, this study demonstrates how PET can create a viable alternative for those patients over 70 years of age, preceding surgery, and highlights the importance of patient navigation. At the Netcare Breast Care The end-point of this retrospective study was to determine the time to progression.

The primary tumor and regional nodes were evaluated at baseline. Follow-up consisted of at least bi-annual clinical with or without radiological assessments. For the purpose of this study, older patients were defined as patients 70 years and older at the time of diagnosis [5] . Patients to be eligible for this analysis were required to be receptor-positive and electing not to undergo surgery as a primary treatment mode. The analysis was performed on patients presenting at the NCBC between Advanced age is considered a risk factor for breast cancer. In Sub-Saharan Africa, the older age population increases from 46 million in 2015 to a projected 157 million by 2050 [6] ; this trend is observed globally. Therefore, it is likely that breast cancer in older adults will become a health care burden in the future. However, there is limited evidence-based data related to screening and management strategies specifically focused on this patient population. Currently, the COVID-19 pandemic has resulted in challenges to our ability to safely perform surgery in older adult is not unreasonable to recommend PET to older patients displaying Luminal-A breast cancer, particularly if the patient refuses surgery. This study demonstrates that PET is a safe approach in patients over the age of 70 years. Our data shows that 96% of patients did not have significant complications during the first six months of treatment, and 9% of the patients developed disease progression within 18 months of PET.

A potential outcome predictor for hormone-sensitive breast cancer is the use of the preoperative endocrine prognostic index (PEPI score) during endocrine therapy [9] . This index considers treatment-related interval changes, including the ER status, Ki67 proliferation index, histological grade, pathological tumor size, node status, and treatment response.

Areas for future research should include investigating the impact of medical co-morbidities, geriatric assessments, the Charlson co-morbidity index, and genetic tumor profiling to refine the selection criteria of patients benefiting from treatment with PET [10] . Furthermore, well-designed prospective studies should evaluate the interactions of endocrine therapy with patient co-morbidities.

The limitations of this study relate to the retrospective nature of the research, the complexities in controlling for selection bias, and the lack of a control group; however, this hypothesis-generating study should provide the framework for further research in this rapidly evolving field. 

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