Geriatric Assessment in Older Patients with Breast Cancer

Restricted access

Most cases of breast cancer are diagnosed in older adults. Older women have an increased risk for breast cancer–specific mortality and are at higher risk for treatment-associated morbidity than younger women. However, they are also less likely to be offered preventive care or adjuvant therapy for this disease. Major gaps in evidence exist regarding the optimal evaluation and treatment of older women with breast cancer because of significant underrepresentation in clinical trials. Chronologic age alone is an inadequate predictor of treatment tolerance and benefit in this heterogeneous population. Multiple issues uniquely associated with aging impact cancer care, including functional impairment, comorbidity, social support, cognitive function, psychological state, and financial stress. Applying geriatric principles and assessment to this older adult population would inform decision making by providing estimates of life expectancy and identifying individuals most vulnerable to morbidity. Ongoing research is seeking to identify which assessment tools can best predict outcomes in this population, and thus guide experts in tailoring treatments to maximize benefits in older adults with breast cancer.

Correspondence: Arti Hurria, MD, Cancer and Aging Research Program, City of Hope, 1500 East Duarte Road, Duarte, CA 91001. E-mail: ahurria@coh.org
  • 1

    Ries LAG, Harkins D, Krapcho M. SEER Cancer Statistics Review, 1975-2005, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2005/, based on November 2007 SEER data submission.

    • Search Google Scholar
    • Export Citation
  • 2

    Extermann M, Overcash J, Lyman GH. Comorbidity and functional status are independent in older cancer patients. J Clin Oncol 1998;16:15821587.

    • Search Google Scholar
    • Export Citation
  • 3

    Guralnik JM, Simonsick EM, Ferrucci L. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994;49:M8594.

    • Search Google Scholar
    • Export Citation
  • 4

    Inouye SK, Peduzzi PN, Robison JT. Importance of functional measures in predicting mortality among older hospitalized patients. JAMA 1998;279:11871193.

    • Search Google Scholar
    • Export Citation
  • 5

    Freyer G, Geay JF, Touzet S. Comprehensive geriatric assessment predicts tolerance to chemotherapy and survival in elderly patients with advanced ovarian carcinoma: a GINECO study. Ann Oncol 2005;16:17951800.

    • Search Google Scholar
    • Export Citation
  • 6

    Hurria A, Naeim A, Elkin E. Adjuvant treatment recommendations in older women with breast cancer: a survey of oncologists. Crit Rev Oncol Hematol 2007;61:255260.

    • Search Google Scholar
    • Export Citation
  • 7

    Pentheroudakis G, Fountzilas G, Kalofonos HP. Palliative chemotherapy in elderly patients with common metastatic malignancies: A Hellenic Cooperative Oncology Group registry analysis of management, outcome and clinical benefit predictors. Crit Rev Oncol Hematol 2008;66:237247.

    • Search Google Scholar
    • Export Citation
  • 8

    Repetto L, Fratino L, Audisio RA. Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study. J Clin Oncol 2002;20:494502.

    • Search Google Scholar
    • Export Citation
  • 9

    Katz S, Ford AB, Moskowitz RW. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA 1963;185:914919.

    • Search Google Scholar
    • Export Citation
  • 10

    Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9:179186.

    • Search Google Scholar
    • Export Citation
  • 11

    Balducci L, Cohen HJ, Engstrom PF. Senior adult oncology clinical practice guidelines in oncology. J Natl Compr Canc Netw 2005;3:572590.

  • 12

    Extermann M, Meyer J, McGinnis M. A comprehensive geriatric intervention detects multiple problems in older breast cancer patients. Crit Rev Oncol Hematol 2004;49:6975.

    • Search Google Scholar
    • Export Citation
  • 13

    Girre V, Falcou MC, Gisselbrecht M. Does a geriatric oncology consultation modify the cancer treatment plan for elderly patients? J Gerontol A Biol Sci Med Sci 2008;63:724730.

    • Search Google Scholar
    • Export Citation
  • 14

    Retornaz F, Monette J, Batist G. Usefulness of frailty markers in the assessment of the health and functional status of older cancer patients referred for chemotherapy: a pilot study. J Gerontol A Biol Sci Med Sci 2008;63:518522.

    • Search Google Scholar
    • Export Citation
  • 15

    Del Mastro L, Perrone F, Repetto L. Weekly paclitaxel as first-line chemotherapy in elderly advanced breast cancer patients: a phase II study of the Gruppo Italiano di Oncologia Geriatrica (GIOGer). Ann Oncol 2005;16:253258.

    • Search Google Scholar
    • Export Citation
  • 16

    Maione P, Perrone F, Gallo C. Pretreatment quality of life and functional status assessment significantly predict survival of elderly patients with advanced non-small-cell lung cancer receiving chemotherapy: a prognostic analysis of the multicenter Italian lung cancer in the elderly study. J Clin Oncol 2005;23:68656872.

    • Search Google Scholar
    • Export Citation
  • 17

    Wedding U, Rohrig B, Klippstein A. Impairment in functional status and survival in patients with acute myeloid leukaemia. J Cancer Res Clin Oncol 2006;132:665671.

    • Search Google Scholar
    • Export Citation
  • 18

    Saliba D, Elliott M, Rubenstein LZ. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001;49:16911699.

    • Search Google Scholar
    • Export Citation
  • 19

    Rantanen T, Guralnik JM, Foley D. Midlife hand grip strength as a predictor of old age disability. JAMA 1999;281:558560.

  • 20

    Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142148.

    • Search Google Scholar
    • Export Citation
  • 21

    Hurria A, Gupta S, Zauderer M. Developing a cancer-specific geriatric assessment: a feasibility study. Cancer 2005;104:19982005.

  • 22

    Carlson RW, Moench S, Hurria A. NCCN Task Force Report: breast cancer in the older woman. J Natl Compr Canc Netw 2008;6(Suppl 4):S125; quiz S26–27.

    • Search Google Scholar
    • Export Citation
  • 23

    Wildiers H, Kunkler I, Biganzoli L. Management of breast cancer in elderly individuals: recommendations of the International Society of Geriatric Oncology. Lancet Oncol 2007;8:11011115.

    • Search Google Scholar
    • Export Citation
  • 24

    Arias E. National Vital Statistics Report. United States Life Tables, 2003. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_14.pdf. Accessed December 3, 2008.

    • Search Google Scholar
    • Export Citation
  • 25

    Lee SJ, Lindquist K, Segal MR. Development and validation of a prognostic index for 4-year mortality in older adults. JAMA 2006;295:801808.

  • 26

    Charlson ME, Pompei P, Ales KL. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373383.

    • Search Google Scholar
    • Export Citation
  • 27

    Charlson M, Szatrowski TP, Peterson J. Validation of a combined comorbidity index. J Clin Epidemiol 1994;47:12451251.

  • 28

    Satariano WA, Ragland DR. The effect of comorbidity on 3-year survival of women with primary breast cancer. Ann Intern Med 1994;120:104110.

    • Search Google Scholar
    • Export Citation
  • 29

    Hughes KS, Schnaper LA, Berry D. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 2004;351:971977.

    • Search Google Scholar
    • Export Citation
  • 30

    Muss HB, Berry DL, Cirrincione C. Standard chemotherapy (CMF or AC) versus capecitabine (X) in early-stage breast cancer patients 65 and older: results of CALGB/CTSU 49907 [abstract]. J Clin Oncol 2008;26(Suppl 1):Abstract 507.

    • Search Google Scholar
    • Export Citation
  • 31

    Ravdin PM, Siminoff LA, Davis GJ. Computer program to assist in making decisions about adjuvant therapy for women with early breast cancer. J Clin Oncol 2001;19:980991.

    • Search Google Scholar
    • Export Citation
  • 32

    Early Breast Cancer Trialists’ Collobaration Group. Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;365:16871717.

    • Search Google Scholar
    • Export Citation
  • 33

    Zauderer M, Patil S, Hurria A. Feasibility and toxicity of dose-dense adjuvant chemotherapy in older women with breast cancer. Breast Cancer Res Treat 2008; in press.

    • Search Google Scholar
    • Export Citation
  • 34

    Yancik R, Wesley MN, Ries LA. Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older. JAMA 2001;285:885892.

    • Search Google Scholar
    • Export Citation
  • 35

    Perez EA, Suman VJ, Davidson NE. Cardiac safety analysis of doxorubicin and cyclophosphamide followed by paclitaxel with or without trastuzumab in the North Central Cancer Treatment Group N9831 adjuvant breast cancer trial. J Clin Oncol 2008;26:12311238.

    • Search Google Scholar
    • Export Citation
  • 36

    Yancik R. Cancer burden in the aged: an epidemiologic and demographic overview. Cancer 1997;80:12731283.

  • 37

    Dees EC, O’Reilly S, Goodman SN. A prospective pharmacologic evaluation of age-related toxicity of adjuvant chemotherapy in women with breast cancer. Cancer Invest 2000;18:521529.

    • Search Google Scholar
    • Export Citation
  • 38

    Extermann M, Aapro M. Assessment of the older cancer patient. Hematol Oncol Clin North Am 2000;14:6377, viiiix.

  • 39

    Mohile SG, Bylow K, Dale W. A pilot study of the vulnerable elders survey-13 compared with the comprehensive geriatric assessment for identifying disability in older patients with prostate cancer who receive androgen ablation. Cancer 2007;109:802810.

    • Search Google Scholar
    • Export Citation
  • 40

    Plassman BL, Langa KM, Fisher GG. Prevalence of dementia in the United States: the aging, demographics, and memory study. Neuroepidemiology 2007;29:125132.

    • Search Google Scholar
    • Export Citation
  • 41

    Plassman BL, Langa KM, Fisher GG. Prevalence of cognitive impairment without dementia in the United States. Ann Intern Med 2008;148:427434.

  • 42

    Kelley BJ, Petersen RC. Alzheimer’s disease and mild cognitive impairment. Neurol Clin 2007;25:577609, v.

  • 43

    Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med 2004;256:183194.

  • 44

    Wolfson C, Wolfson DB, Asgharian M. A reevaluation of the duration of survival after the onset of dementia. N Engl J Med 2001;344:11111116.

  • 45

    Gupta SK, Lamont EB. Patterns of presentation, diagnosis, and treatment in older patients with colon cancer and comorbid dementia. J Am Geriatr Soc 2004;52:16811687.

    • Search Google Scholar
    • Export Citation
  • 46

    Heck JE, Albert SM, Franco R. Patterns of dementia diagnosis in surveillance, epidemiology, and end results breast cancer survivors who use chemotherapy. J Am Geriatr Soc 2008; in press.

    • Search Google Scholar
    • Export Citation
  • 47

    Gorin SS, Heck JE, Albert S. Treatment for breast cancer in patients with Alzheimer’s disease. J Am Geriatr Soc 2005;53:18971904.

  • 48

    Goodwin JS, Samet JM, Hunt WC. Determinants of survival in older cancer patients. J Natl Cancer Inst 1996;88:10311038.

  • 49

    Hurria A, Goldfarb S, Rosen C. Effect of adjuvant breast cancer chemotherapy on cognitive function from the older patient’s perspective. Breast Cancer Res Treat 2006;98:343348.

    • Search Google Scholar
    • Export Citation
  • 50

    Chen H, Cantor A, Meyer J. Can older cancer patients tolerate chemotherapy? A prospective pilot study. Cancer 2003;97:11071114.

  • 51

    Hurria A, Rosen C, Hudis C. Cognitive function of older patients receiving adjuvant chemotherapy for breast cancer: a pilot prospective longitudinal study. J Am Geriatr Soc 2006;54:925931.

    • Search Google Scholar
    • Export Citation
  • 52

    Hurria A, Zuckerman E, Panageas KS. A prospective, longitudinal study of the functional status and quality of life of older patients with breast cancer receiving adjuvant chemotherapy. J Am Geriatr Soc 2006;54:11191124.

    • Search Google Scholar
    • Export Citation
  • 53

    Chodosh J, Petitti DB, Elliott M. Physician recognition of cognitive impairment: evaluating the need for improvement. J Am Geriatr Soc 2004;52:10511059.

    • Search Google Scholar
    • Export Citation
  • 54

    Blessed G, Tomlinson BE, Roth M. The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects. Br J Psychiatry 1968;114:797811.

    • Search Google Scholar
    • Export Citation
  • 55

    Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189198.

    • Search Google Scholar
    • Export Citation
  • 56

    Borson S, Scanlan JM, Chen P. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc 2003;51:14511454.

    • Search Google Scholar
    • Export Citation
  • 57

    Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975;23:433441.

    • Search Google Scholar
    • Export Citation
  • 58

    Hamberg P, Verweij J, Seynaeve C. Cytotoxic therapy for the elderly with metastatic breast cancer: a review on safety, pharmacokinetics and efficacy. Eur J Cancer 2007;43:15141528.

    • Search Google Scholar
    • Export Citation
  • 59

    Hurria A, Lichtman SM. Clinical pharmacology of cancer therapies in older adults. Br J Cancer 2008;3:517522.

  • 60

    Corcoran M. Polypharmacy in the older patient with cancer. Cancer Control 1997;4:419428.

  • 61

    Sokol K, Knudsen JF, Li MM. Polypharmacy in older oncology patients and the need for an interdisciplinary approach to side-effect management. J Clin Pharm Ther 2007;32:169175.

    • Search Google Scholar
    • Export Citation
  • 62

    Flood K, Carroll MB, Le CV. Geriatric syndromes in elderly patients admitted to an oncology-acute care for elders unit. J Clin Oncol 2006;24:22982303.

    • Search Google Scholar
    • Export Citation
  • 63

    Ingram S, Seo PH, Martell RE. Comprehensive assessment of the elderly cancer patient: the feasibility of self-report methodology. J Clin Oncol 2002;20:770775.

    • Search Google Scholar
    • Export Citation
  • 64

    Girre V, Falcou MC, Gisselbrecht M. Does a geriatric oncology consultation modify the cancer treatment plan for elderly patients? J Gerontol A Biol Sci Med Sci 200863:724730.

    • Search Google Scholar
    • Export Citation
  • 65

    Fick D, Cooper JW, Wade WE. Updating the Beers criteria for potentially inappropriate medication used in older adults: results of a US consensus panel of experts. Arch Intern Med 2003;163:27162724.

    • Search Google Scholar
    • Export Citation
  • 66

    Newman AB, Yanez D, Harris T. Weight change in old age and its association with mortality. J Am Geriatr Soc 2001;49:13091318.

  • 67

    Andreyev HJ, Norman AR, Oates J, Cunningham D. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cancer 1998;34:503509.

    • Search Google Scholar
    • Export Citation
  • 68

    Buccheri G, Ferringo D. Importance of weight loss definition in the prognostic evaluation of non-small-cell lung cancer. Lung Cancer 2001;34:433440.

    • Search Google Scholar
    • Export Citation
  • 69

    Dewys WD, Begg C, Lavin PT. Prognostic effect of weight loss prior to chemotherapy in cancer patients. Eastern Cooperative Oncology Group. Am J Med 1980;69:491497.

    • Search Google Scholar
    • Export Citation
  • 70

    Vellas B, Guigoz Y, Garry PJ. The mini nutritional assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999;15:116122.

    • Search Google Scholar
    • Export Citation
  • 71

    Holland JC, Bultz BD. The NCCN guideline for distress management: a case for making distress the sixth vital sign. J Natl Compr Canc Netw 2007;5:37.

    • Search Google Scholar
    • Export Citation
  • 72

    Vinokur AD, Threatt BA, Vinokur-Kaplan D. The process of recovery from breast cancer for younger and older patients. Changes during the first year. Cancer 1990;65:12421254.

    • Search Google Scholar
    • Export Citation
  • 73

    Sollner W, DeVries A, Steixner E. How successful are oncologists in identifying patient distress, perceived social support, and need for psychosocial counseling? Br J Cancer 2001;84:179185.

    • Search Google Scholar
    • Export Citation
  • 74

    Hoffman BM, Zevon MA, D’Arrigo MC. Screening for distress in cancer patients: the NCCN rapid-screening measure. Psychooncology 2004;13:792729.

    • Search Google Scholar
    • Export Citation
  • 75

    Roth AJ, Kornblith AB, Batel-Copel L. Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer 1998;82:19041908.

    • Search Google Scholar
    • Export Citation
  • 76

    Ransom S, Jacobsen PB, Booth-Jones M. Validation of the Distress Thermometer with bone marrow transplant patients. Psychooncology 2006;15:604612.

    • Search Google Scholar
    • Export Citation
  • 77

    Jacobsen PB, Donovan KA, Trask PC. Screening for psychologic distress in ambulatory cancer patients. Cancer 2005;103:14941502.

  • 78

    Kua J. The prevalence of psychological and psychiatric sequelae of cancer in the elderly - how much do we know? Ann Acad Med Singapore 2005;34:250256.

    • Search Google Scholar
    • Export Citation
  • 79

    Penninx BW, Guralnik JM, Ferrucci L. Depressive symptoms and physical decline in community-dwelling older persons. JAMA 1998;279:17201726.

  • 80

    Langa KM, Valenstein MA, Fendrick AM. Extent and cost of informal caregiving for older Americans with symptoms of depression. Am J Psychiatry 2004;161:857863.

    • Search Google Scholar
    • Export Citation
  • 81

    Yesavage JA, Brink TL, Rose TL. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982;17:3749.

    • Search Google Scholar
    • Export Citation
  • 82

    Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361370.

  • 83

    Chochinov HM, Wilson KG, Enns M. “Are you depressed?” Screening for depression in the terminally ill. Am J Psychiatry 1997;154:674676.

  • 84

    Mahoney J, Drinka TJ, Abler R. Screening for depression: single question versus GDS. J Am Geriatr Soc 1994;42:10061008.

  • 85

    Osborn DP, Fletcher AE, Smeeth L. Performance of a single screening question for depression in a representative sample of 13 670 people aged 75 and over in the UK: results from the MRC trial of assessment and management of older people in the community. Fam Pract 2003;20:682684.

    • Search Google Scholar
    • Export Citation
  • 86

    Bried EM, Scheffler RM. The financial stages of cancer in the elderly. Oncology (Williston Park) 1992;6:153160.

  • 87

    Warren JL, Brown ML, Fay MP. Costs of treatment for elderly women with early-stage breast cancer in fee-for-service settings. J Clin Oncol 2002;20:307316.

    • Search Google Scholar
    • Export Citation
  • 88

    Penberthy L, Retchin SM, McDonald MK. Predictors of Medicare costs in elderly beneficiaries with breast, colorectal, lung, or prostate cancer. Health Care Manag Sci 1999;2:149160.

    • Search Google Scholar
    • Export Citation
  • 89

    Kim Y, Given BA. Quality of life of family caregivers of cancer survivors: across the trajectory of the illness. Cancer 2008;112:25562568.

    • Search Google Scholar
    • Export Citation
  • 90

    Dubenske LL, Wen KY, Gustafson DH. Caregivers’ differing needs across key experiences of the advanced cancer disease trajectory. Palliat Support Care 2008;6:265272.

    • Search Google Scholar
    • Export Citation
  • 91

    Osborne C, Ostir GV, Du X. The influence of marital status on the stage at diagnosis, treatment, and survival of older women with breast cancer. Breast Cancer Res Treat 2005;93:4147.

    • Search Google Scholar
    • Export Citation
  • 92

    Silliman RA, Dukes KA, Sullivan LM. Breast cancer care in older women: sources of information, social support, and emotional health outcomes. Cancer 1998;83:706711.

    • Search Google Scholar
    • Export Citation
  • 93

    Mandelblatt JS, Edge SB, Meropol NJ. Predictors of long-term outcomes in older breast cancer survivors: perceptions versus patterns of care. J Clin Oncol 2003;21:855863.

    • Search Google Scholar
    • Export Citation
  • 94

    Kroenke CH, Kubzansky LD, Schernhammer ES. Social networks, social support, and survival after breast cancer diagnosis. J Clin Oncol 2006;24:11051111.

    • Search Google Scholar
    • Export Citation
  • 95

    DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol 2004;23:207218.

  • 96

    Bernabei R, Venturiero V, Tarsitani P. The comprehensive geriatric assessment: when, where, how. Crit Rev Oncol Hematol 2000;33:4556.

  • 97

    Inouye SK, Studenski S, Tinetti ME. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc 2007;55:780791.

    • Search Google Scholar
    • Export Citation
  • 98

    Koroukian SM, Murray P, Madigan E. Comorbidity, disability, and geriatric syndromes in elderly cancer patients receiving home health care. J Clin Oncol 2006;24:23042310.

    • Search Google Scholar
    • Export Citation
  • 99

    Flood KL, Carroll MB, Le CV. Geriatric syndromes in elderly patients admitted to an oncology-acute care for elders unit. J Clin Oncol 2006;24:22982303.

    • Search Google Scholar
    • Export Citation
  • 100

    Anpalahan M, Gibson SJ. Geriatric syndromes as predictors of adverse outcomes of hospitalization. Intern Med J 2008;38:1623.

  • 101

    Extermann M, Hurria A. Comprehensive geriatric assessment for older patients with cancer. J Clin Oncol 2007;25:18241831.

  • 102

    Wedding U, Hoffken K. Care of breast cancer in the elderly woman–what does comprehensive geriatric assessment (CGA) help? Support Care Cancer 2003;11:769774.

    • Search Google Scholar
    • Export Citation
  • 103

    Katzman R, Brown T, Fuld P. Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry 1983;140:734739.

    • Search Google Scholar
    • Export Citation
  • 104

    Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991;32:705714.

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 77 51 4
PDF Downloads 43 26 4
EPUB Downloads 0 0 0