Age is not the only predictor of postoperative outcome in older patients with breast cancer

There has been increased interest in recent years regarding whether consideration of patient-related factors may improve personalized management and treatment outcomes in older patients with breast cancer, the authors write in Journal of the American Academy of Dermatology Paper, which debuted online in May 2021.

Lead study author Marieke EC Van Wenden, MD, MSc at Radboud University Medical Center in the Netherlands, commented that many dermatologists still face challenges in their ability to assess patient-level factors as they relate to treatment decision making in clinical practice. current.

Van Wenden said in an email to times dermatology. “It is therefore absolutely necessary to develop more specific recommendations regarding aspects of vulnerability, as discussed in our research.”

To identify factors that predict treatment burden, outcome, and overall survival (OS) in older patients surgically treated for BCC, Dr. Winden and colleagues analyzed data from the BATOA Study, a prospective, multicenter study of patients 70 years of age and older who received treatment. Treatment of cervical cancer in the head and neck.

In analyzing treatment burden, researchers evaluated changes on the visual analog scale (0-10 cm) at 2 to 4 months after surgery. Lower scores on VAS correspond to a higher treatment burden. The secondary outcome of the analysis included the operating system.

The cohort included 539 patients (median age, 78 years) from the BATOA Study, including 296 who received Mohs micrographic surgery (MMS) and 243 who received conventional surgical excision. The mean VAS score was 8.6, indicating a low treatment burden in this population.

Significant indicators of higher treatment burden included useful activities of daily living (iADL) dependency (P < .001) and female gender (s = .002), having multiples (s = .018), tumor diameter (s = .024), and polypharmacy (s = .042). According to the researchers, these factors are often associated with and reflect high levels of vulnerability.

Corresponding study author Satish Lubeck, Ph.D., of Radboud University Medical Center, explained that because latent cancer cells grow slowly, which are often asymptomatic, effective treatment of BCC can be too stressful for some frail adults and older adults who have an average A limited life expectancy, given that these patients will not live long enough to develop symptoms of their disease. “In these cases, watchful waiting or active observation may be a more appropriate approach,” he said.

Van Wenden explained that the older ‘strong’ patients in the study had a lower treatment burden, and these patients had a higher OS compared to the general population. “For older patients without a limited life expectancy,” she said, “early treatment of BCC is often beneficial, particularly in symptomatic and/or high-risk lesions.”

Approximately 6.5% (n = 35) of patients died during follow-up, however none of these deaths were due to breast cancer. Predictors of all-cause mortality in this group included an increased Charlson comorbidity index score (s <.001) and the iADL dependency (s = .003).

“These findings further underscore our advice to include vulnerability screening in everyday dermatological care,” Van Wenden stated. “If necessary, a geriatrician or home care physician may be consulted to weigh the advantages and disadvantages of some treatments.”

Given that iADL and dependence are associated with vulnerability, the researchers added that while “the vulnerability screening can help estimate patient life expectancy in a more holistic approach” to care, current experience with this screening in everyday dermatological practice is limited.

The study showed that chronological age was not an important predictor of any of the evaluated outcomes. “Age should not be the sole reason for establishing behavioral change management continuity decisions,” Lubeck noted. “Importantly, patient characteristics associated with vulnerability should be considered, as they were significantly associated with a higher treatment burden and higher non-CCC related mortality.”

Predictors of postoperative complications included tumor diameter (s = .001) and the technique of wound closure (healing by secondary intent versus primary closure, P = .017; and reconstruction versus primary closure, s <.001). A multivariate analysis found no difference between MMS and conventional surgical excision in terms of complication rates (s = .80).

Although the observational nature of the study may have led to selection bias, the researchers note that the study results likely “represent adequate daily clinical care.”

In addition to the study’s limitations, Lübeck noted that little data is available to guide clinicians on watchful waiting and active monitoring in cases of untreated latent heart cancer. “Further studies on watchful waiting/active monitoring are needed to provide further guidance, as well as studies on life expectancy prediction tools for patients with BCC,” he said. “We hope that these studies will guide clinicians in identifying those patients who need treatment for renal cell carcinoma, and which patients it is best for them to abstain from treatment.”

Expert Comments

Jessica A. Savas, MD, associate professor of dermatology at Atrium Health Wake Forest Baptist, explained that all treatment approaches for BCC typically consider patient-related factors to guide treatment decisions regardless of age. “While most of our melanoma patients fall into the ‘older’ demographic category based on chronological age,” she said, “age itself is probably one of the least useful factors in discussing the best treatment options for a given patient.” “

Savas, who was not involved in the study, noted that in cases where these factors are not incorporated into treatment decisions, it is usually because the patient or the patient’s family members request the approach. She said, “If a patient is unwilling to undergo surgery for any reason but is a good surgical candidate, we are of course discussing treatment alternatives that may offer a lower treatment rate and/or a lower cosmetic result.”

She added that general health status, including functional and nutritional status, as well as “the degree of social support available to the patient is of paramount importance when considering all treatment options for BCC, particularly in older patients.”

“Maintaining quality of life and the ability to live independently is becoming very important at this stage of life, and fortunately BCC is a relatively slow-growing tumor with a low potential for metastasis,” said Dr. Savas. “This allows for conversations about the more conservative management of asymptomatic renal cell carcinoma that does not pose an imminent threat to work in patients who wish to avoid surgery.”

Disclosures

Study researchers report conflicts of interest with the pharmaceutical industry.

references

Van Winden MEC, Bronkhorst EM, Visch MB, et al. Predictors of surgical treatment burden, outcome, and overall survival in older adults with basal cell carcinoma: results from the multicenter prospective BATOA cohort. J Am Acad Dermatol. 2022; 86 (5): 1010-1019. doi: 10.1016/j.jaad.2021.05.041

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