11 Nov 2014

Our society is aging, and with the rapid advances in medical care and technology, elderly breast cancer patients should see that they can have same and equal opportunities to positive aging and access to breast cancer care with quality life if they abandon the common low expectation that elderly means frailty but proactively seek multidisciplinary cancer treatment, said Dr Janice Tsang, Specialist in Medical Oncology, Clinical Assistant Professor in Department of Clinical Oncology, and Dr Joseph Kwan, Clinical Associate Professor in Department of Medicine at the Li Ka Shing Faculty of Medicine, The University of Hong Kong.

Background
The population is aging while cancer is an aging disease. Breast cancer is the most common female cancer locally, regionally and internationally. According to the latest update from the Hong Kong Cancer Registry, the number of new breast cancer patients in Hong Kong has tripled in the last 20 years. The latest 2011 data even showed that the number of invasive breast cancer in women increased by 13.4 % in 2011 compared with previous year in 2010. Over the past decade, there have been breakthroughs in the detection and treatment of breast cancer, including the expanding armamentarium with surgery, radiotherapy, chemotherapy, hormonal therapy and targeted therapy, leading to its mortality: incidence ratio relatively low, i.e. this is a relatively very treatable disease with advanced breast cancer even becoming a chronic illness. Among all breast cancer patients, 1 in 4 is diagnosed at the age of 65 or above, and with the number of breast cancer patients among the age of 75 or above accounting for 12.37%.

Hormone positive breast cancer
Hormone positive (HR+) breast cancer is the most common subtype of breast cancer especially among the elderly population. This is defined by the tumour histopathology with either the estrogen receptor (ER) or the progesterone receptor (PgR) being positive, and this subgroup of population increases with age. HR+ breast cancer accounts for the majority (77%) of invasive breast cancer. This subtype of breast cancer is characterized a group of cancers that express receptors for certain hormones such as estrogen and progesterone. Cancer cell growth is driven by these hormones. “Yet, the older the age of presentation, the slower the tempo of the disease with decreasing in aggressiveness of the disease, and they are more responsive to hormonal therapy on top of other treatment options and many of them even when presented or progressed as advanced disease, only affects the bones or the soft tissues with a rather stable disease course and absence of any significant symptoms”, explained by Dr Henry Sze, Specialist in Clinical Oncology, Clinical Assistant Professor in the Department of Clinical Oncology, Li Ka Shing Faculty of Medicine.

Treatment options available to maximize the clinical outcome and quality of life
Improving quality of life and prolonging progression-free survival should always be the goal of HR+ breast cancer treatment for everyone, including the elderly. According to the International Advanced Breast Cancer Consensus (ABC2), hormone therapy should often be first recommended for HR+ breast cancer, except there is visceral or life-threatening disease. In postmenopausal HR+ patient cases, aromatase inhibitors is often given as first line treatment. However there is a chance that 50% of HR+ patients do not respond to initial endocrine treatment. In those cases, there is still option to delay the initiation of chemotherapy such as combination of hormonal therapy and oral targeted agent, which can be used after failure on single hormonal agent. Chemotherapy, which is associated with much side effects, should be saved for salvage for symptomatic or life threatening disease.

Common low expectations for elderly breast cancer patients
Elderly are often labelled as too frail for any cancer treatment. Some elderly cancer patients even give up medication, perceiving themselves to be too old for anything. Dr Joseph Kwan, Clinical Associate Professor in the Department of Medicine, Li Ka Shing Faculty of Medicine said, “Old age in itself should not be a barrier to cancer treatment. Frailty of old age is treatable. Better nutrition and exercise improve physical, cognitive well-being and mood, which helps the elderly become fitter for the cancer treatments. We believe that elderly should share the equal opportunity to receive proper, personalized cancer treatment as younger people.”

Positive living with HR+ breast cancer
Speaking at the Medical Faculty today to echo the Hong Kong Senior Citizens’ Day, Dr Tsang, Dr Sze and Dr Kwan unanimously commented that, “Hong Kong population is ageing. We expect the larger elderly population will bring an increase to the number of Hormone Receptor Positive (HR+) breast cancer patients. This emerging unmet needs has led to the call for new model of multidisciplinary cancer care across disciplines to formulate a holistic and personalized HR+ cancer treatment plan for our elderly breast cancer patients. Positive Aging, quality living and equal opportunity to best breast cancer care irrespective of the age. Age should not deter the intensity to standard breast cancer treatment.”

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