SIOG 2014

Age and chemotherapy: risk factors versus benefit?

Dr Christos Markopoulos - Athens University Medical School, Athens, Greece

MAGIC stands for multidisciplinary application of genomic assays in clinical practice. So that was an internet-based survey; it was on-line for six months and about 900 practising physicians took part from 52 countries. So we created a huge database but mainly what we explored was what parameters they used in order to make treatment decisions and in how many cases, according to the profile of the patient, they would like to have more information, which actually could be provided by multigene assay analysis.

What factors did the physicians look for?

They looked for age of the patient and for tumour size, grade, ER and PR expression, HER2 expression and Ki-67 and, of course, lymph node status. So we asked them to tell us the index of importance of using these factors and the result was that age was the most important factor to make a treatment decision and it works both ways. In ER positive patients if you are over 70 years old then your chance of having chemotherapy is much less compared to younger patients but if you are very young then almost certainly you are going to have chemotherapy. So age proved to be the most important factor to undergo, or not, chemotherapy additionally to hormone therapy.

Why did physicians make a big distinction between younger and older patients?

I believe, because I have the experience of other studies we did in elderly patients, there are a lot of reasons. Mainly it’s the general perception that elderly people will die from something else and probably they will not have the life expectancy to die of breast cancer. However, in another study we did in the past, the [?? 2:23] trial, we found out that those patients who do not die of comorbidities or short life expectancy, they are over-treated, mainly in terms of chemotherapy, and they are not doing very well compared to younger patients. So we have to take specifically for elderly patients.

What should be done about the lack of chemotherapy in this group?

There are two things. First of all to realise that elderly patients, when they are fit and we can have that according to geriatric assessments, they would be given the appropriate treatment they need according to the tumour characteristics, according to their disease. Of course, probably we have to work towards developing drugs which are more suitable for not that fit elderly patients so we can help them a lot and not say that we shouldn’t give chemotherapy because they are going to die or have serious side effects of treatment.

You surveyed doctors to see which factors then needed more information on – what did you find?

We did find that it was a profile of a patient, an elderly patient, with very high risk for recurrence parameters. Even in these profiles elderly patients are receiving less treatment than younger ones but there it was also the question, ‘Would you like to have more information?’ Indeed, for elderly patients we have the greatest demand for more information. This, in my mind, says that physicians are willing to give proper treatment to elderly patients but they would like to be more convinced that this specific patient of 80 years old needs this treatment. In this point we believe that multigene assays predicting the benefit of, let’s say, chemotherapy would help because if a physician knows that according to an Oncotype-DX result that this specific patient will have great benefit of chemotherapy then it will make him decide more easily.

What are your recommendations for clinicians?

The first recommendation is that we should assess elderly patients with geriatric tools to know how fit they are. Then take into consideration all risk factors in order to decide about treatment and, of course, we would like to have available for this population the tools we have, the multigene assays, the tools we use very often for younger patients. Probably this is a very good population that multigene assays would help us to make more informed decisions.

What’s the take-home message?

Give the elderly patients the right treatment and if you want more help then assess the parameters but multigene assays are there, you can use them.