The 7th Symposium on primary breast cancer in older women. Theme: involving the caregivers (Held: 1 March 2024)

Abstract

The 7th Symposium on Primary Breast Cancer in Older Women, hosted by the University of Nottingham in association with the International Society of Geriatric Oncology (SIOG), was held in the Jubilee Conference Centre in Nottingham on 1 March 2024. With the theme of ‘involving the caregivers’, topics included: barriers to clinical trial participation among older women, the use of geriatric assessment tools to tailor treatments to individual patient’s level of frailty and interventions such as medication review and de-prescription to reduce toxicity and increase compliance with treatment.

The symposium began with an upbeat introduction from the symposium chair, Kwok-Leung Cheung (Professor of Breast Surgery and Medical Education, University of Nottingham, Consultant Breast Surgeon, Royal Derby Hospital; UK National Representative, SIOG). Cheung welcomed attendees and contributors from a wide range of disciplines including surgeons, geriatricians, clinical nurse specialists, pharmacists and patient representatives.

Cheung outlined how this biennial symposium, the only one of its kind to focus on primary breast cancer in older women, had grown in both size and ambition since its inception in 2010. For the first time, this year’s proceedings included a dedicated multidisciplinary team discussion of geriatric breast cancer cases submitted by delegates.

The main theme of the day’s proceedings “involving the caregivers” was also emphasized in the introductory comments.

1. Session 1: Updates

The first session discussed updates in clinical trial participation among older women with breast cancer. This was chaired by Holly Holmes (Vice President and Joan and Alexander Chair in Gerontology; Professor, UTHealth Houston, McGovern Medical School) and comprised two presentations followed by discussion with attendees.

Etienne Brain (Medical Oncologist, Institut Curie, Paris, France; Past President, SIOG) provided some updates on breast cancer care in older women. Brain provided evidence that despite the broad therapeutic repertoire that has been developed for breast cancer application of appropriate breast cancer treatment options in older patients has been hampered by a lack of clinical trial data of specific relevance to this cohort. He commented that older individuals are routinely excluded from clinical trial participation and selection is often confined to younger and fitter members of this cohort. Moreover, the desired end points for younger and older adults differ significantly. As age increases, so does the likelihood of the patient dying from a cause other than breast cancer [1]. As a consequence, many older women prioritize quality of life over longevity with regard to breast cancer treatment. Brain then went on to discuss several recent studies designed to include older women with breast cancer. The use of a form of geriatric assessment to determine level of frailty and tailor treatment accordingly was a common feature of many of these trials. Between 28 and 40% of patients have had their treatment plans altered following formal geriatric assessment, with most of these individuals switching to less intensive treatments [2]. Furthermore, geriatric assessments can identify the potential requirement for non-oncological interventions to support a comprehensive treatment plan that includes factors such as social and nutritional support.

These alterations are often associated with reduced overall toxicity and increased chance of completing treatment. These results underline the importance of considering and assessing vulnerabilities among older breast cancer patients when tailoring treatment plans.

Clinical trial inclusion among older women with breast cancer was further discussed by Ruth Parks (Breast Surgery Registrar, East Midlands; Honorary Assistant Professor, University of Nottingham). Parks explained how as the population grows and ages over time, the number of older women with breast cancer is projected to rise significantly [3]. This is a growing burden that healthcare systems are not yet prepared for. Although clinical trial enrolment and participation remains low, there is much interest and willingness from patients. Parks went on to highlight a series of protocol, patient and sponsor factors that contribute to these persistently low levels of participation. Possible solutions include modification of study design to suit older individuals, introduction of flexible end points, increased awareness of the issue among sponsors and the introduction of minimum requirements from regulatory boards to drive recruitment. The development of cognitive impairment (CI) was a topic of particular interest. This is a common comorbidity among older women with breast cancer and is often considered grounds for immediate removal from clinical trials. However, many older individuals with CI express interest in clinical trial participation [4]. As CI can be considered a spectrum of disease, those with mild CI are still able to actively consent to ongoing participation. The development of standard protocols for continued clinical trial participation in those with CI was discussed as a potential method to overcome this obstacle. The vital role of the caregiver as an individual who can serve as an advocate and promote the continued participation of breast cancer patients with increasingly severe CI was also discussed.

The discussion following these presentations particularly focused on logistical and ethical considerations relating to participation of patients with CI.

2. Session 2: Oral abstracts

After a break for poster viewing, discussion and refreshments, four oral abstract exhibitors presented their work in a session chaired by Ruth Parks.

First, Rachel Lee (University of Nottingham, UK) discussed findings that older women with breast cancer were less likely to elect immediate postoperative reconstructive surgery. Second, Emily Sargent (McGovern Medical School at UTHealth Houston, TX; USA) discussed an ongoing study in which initial G8 geriatric assessments are used to identify frail breast cancer survivors for referral to a more comprehensive geriatric assessment and the implementation of appropriate interventions. Third, Olivia Turner (University of Sheffield, UK) presented findings showing a correlation between the degree of frailty and treatment choices and outcomes in older breast cancer patients. Last, Brian T Collins (University of Southern Florida and Tampa General Hospital, FL; USA), discussed the application of adjuvant robotic stereotactic accelerated partial breast irradiation as an approach to treating early-stage breast cancer that is well-suited to older women as a less invasive procedure.

Next came the discussion of delegate-submitted cases among an international and multidisciplinary team.

3. Session 3: Challenging areas

Following a break for lunch and further poster viewing was a session discussing particular difficulties within the field. The session comprised two presentations and was chaired by Kwok-Leung Cheung.

J Michael Dixon (Professor of Surgery and Consultant, Edinburgh Breast Unit, Western General Hospital, Edinburgh) began with a discussion of the specific benefits of neoadjuvant endocrine therapy for older women with breast cancer. Due to the receptor profile of breast cancers in post-menopausal women, neoadjuvant endocrine therapy is more effective for older women with breast cancer than alternative treatments such as neoadjuvant chemotherapy. This treatment option also has less associated toxicity, which is an advantage for frail patients who would not be able to tolerate harsher treatment options. Dixon went on to discuss clinical examples of successful application of neoadjuvant endocrine therapy in older women, demonstrating its ability to induce concentric shrinkage of tumors that facilitates surgical removal.

Holly Holmes then discussed the burden of polypharmacy on older women with breast cancer. Polypharmacy, typically defined as the receipt of five or more medications, is prevalent in older adults [5]. It is linked to negative health outcomes due to increased incidences of adverse events and drug interactions, which can increase frailty. Moreover, these adverse events and drug interactions can be misinterpreted as separate etiologies by healthcare professionals, leading to the further prescription of medications in what is known as a ‘prescribing cascade’ [6]. Many older people also remain on preventative medications for late-stage conditions, which provide little benefit in terms of longevity but worsen quality of life. Studies suggest that, in older cancer patients who take multiple medications, there is an increase in drug interactions and chemotherapy toxicity [7]. Nonetheless, an association between polypharmacy and chemotherapy completion has been reported as well as a link between polypharmacy and lower overall survival among cancer patients in a minority of studies [7]. Although the number of medications older people receive tends to increase at the time of cancer diagnosis, the latter is a potential point of intervention and opportunity to review medications and de-prescribe those drugs that are no longer necessary.

4. Session 4: Patients & caregivers

Following a final break for discussion and poster viewing, Etienne Brain chaired a session focused on engaging older women and caregivers in their breast cancer care. This comprised an interview section and a presentation.

Joanne York (Consultant Radiographer, Royal Derby Hospital) interviewed two older women who had been diagnosed with breast cancer and were treated within the East Midlands, alongside their respective caregivers. These women, who had kindly agreed to participate, shared their experience of diagnosis and subsequent treatment. Key takeaways messages from this session included:

• Both women appreciated the support and care from the team at Derby and said that information was provided readily but not in an overwhelming manner.

• Both women expressed interest in clinical trial participation, to help themselves and others.

• These women required different types of support from their caregivers, for instance, one of the women preferred to attend appointments alone and receive support at home.

Following some questions from attendees, both women were thanked and given flowers for generously participating.

In a second presentation, Holmes discussed strategies to increase engagement of both older breast cancer patients and caregivers in cancer care. Older women with breast cancer may be dealing with multiple pre-existing health conditions and this further burden often requires greater support from healthcare professionals and caregivers. The role of caregivers in the care of older women with breast cancer is often vital, and they are relied upon to set schedules, assist with daily activities, administer medications, advocate for patients and assist in decision making. These caregivers are often older male partners who may have their own age related comorbidities that impact ability to perform tasks and may suffer from conditions such as depression and anxiety stemming from the burden of caregiving. The traditional patient-healthcare provider relationship can exclude caregivers as key players in cancer care, so efforts to support both patients and caregivers, engage them in treatment options, and identify where further interventions are required are essential.

The symposium was brought to a close by Brain who thanked attendees and contributors and awarded the prize for Best Oral Abstract and Best Poster Presentation to Olivia Turner and Ian Alabaster (University of Nottingham), respectively. Brain finished by reiterating that due to the prevalence of frailty in older women with breast cancer, strategies such as geriatric assessment are key in tailoring and optimizing treatment for individual patients.

Financial disclosure

L Selwood was granted free attendance to the 7th Symposium on Primary Breast Cancer in Older Women by The University of Nottingham. Taylor and Francis were paid a fee to publish a supplement of the abstracts presented at the conference, alongside this meeting report. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Writing disclosure

No writing assistance was utilized in the production of this manuscript.

Competing interests disclosure

L Selwood is an employee of Taylor and Francis. The author has no other competing interests or relevant affiliations with any organization or entity with the subject matter or materials discussed in the manuscript apart from those disclosed.