|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Journal of Clinical Oncology, Vol 23, No 18 (June 20), 2005: pp. 4238-4239 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.01.2286
In Reply:Département d'Oncologie Médicale, Centre Georges-François Leclerc, Dijon Cedex, France We appreciate the interest of Dr Alliot in our article about the study of weekly epirubicin plus tamoxifen versus tamoxifen alone as adjuvant treatment of operable, node-positive, elderly breast cancer patients. Actually, 10 years were necessary to recruit 338 patients of whom only 31% were older than 70 years. Our inclusion criteria did not limit the upper age of inclusion. Probably, some investigators had censored themselves the older patients by fear of toxicities. Moreover, patients older than 80 years were poorly addressed to specialized anticancer hospitals. In 1991, it was a challenge to initiate a clinical trial in this subset of patients. To date, this trial was the only one that included exclusively patients older than 65 years to receive chemotherapy. The lack of guidelines and recommendations for adjuvant treatment of elderly breast cancer patients led to an undertreatment; many of them do not receive any adjuvant medical treatment.1,2 We agree that treatment must be different for patients aged of 65 years and for those older than 80 years. We think that a comprehensive geriatric assessment (CGA) is necessary and could be a better approach than age itself to determine an optimal therapeutic strategy. Comments on chemotherapy modalities are also true: polychemotherapy is superior to monotherapy, the dose must be optimized, and an anthracycline could be preferred. When we started this trial, the results of the studies mentioned in your correspondence were unknown, and they did not address specifically the question of elderly women. In our opinion, the CMF regimen (cyclophosphamide, methotrexate, and fluorouracil) is not the best choice in elderly patients. As it has been described in the International Breast Cancer Study Group (IBSCG) trial, this regimen is poorly tolerated in patients older than 65 years leading to a decrease in compliance and efficacy.3 This could be explained by specific pharmacokinetic conditions related to age.4 However, this regimen could be the best option in case of clear contraindication to anthracycline-based chemotherapy such as pre-existing cardiac dysfunction. As concerns the feasibility of a weekly schedule, it could be an issue according to the organization of French hospitals. In our study, even if we have not performed a quality of life assessment, we can conclude that compliance with the treatment was good (more than 95%) as well the safety profile. New treatment options such as vinorelbine, gemcitabine or capecitabine have to be explored, and their usefulness in adjuvant setting must be investigated in clinical trials. As regards the hormonal treatment, our tamoxifen schedule was probably suboptimal. The results of the Oxford meta-analysis concerning this topic were known in 1998.5 Since this year, the duration of tamoxifen treatment was extended to 5 years, and approximately 46% of our patients received a 5-year tamoxifen therapy. The results of the meta-analysis concluded that 5 years was better than 1 or 2 years. At the present time, no data allow us to conclude to the inferiority of 3 or 4 years. What's about the use of aromatase inhibitors? Clearly, this therapeutic class will become the new standard in adjuvant setting. However, its use in elderly patients must be carefully investigated as those patients are more likely to be sensitive to the increased risk of osteoporosis and hip fractures. Undertreatment of elderly patients is an issue. We have to analyze it because if their breast cancer are often hormone-sensitive, they could be of poor prognosis.6 Our work today is to inform general practicioners and geriatricians that this disease must be treated and positive results exist. This is the main way to mobilize the medical community in order to improve the care of elderly patients and to develop coherent clinical trials with their knowledge of this specific population. Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES
1. Giordano SH, Hortobagyi GN, Kau SW, et al: Breast cancer treatment guidelines in older women. J Clin Oncol 23:783-791, 2005 2. DeMichele A, Putt M, Zhang Y, et al: Older age predicts a decline in adjuvant chemotherapy recommendations for patients with breast carcinoma: Evidence from a tertiary care cohort of chemotherapy-eligible patients. Cancer 97:2150-2159, 2003[CrossRef][Medline]
3. Crivellari D, Bonetti M, Castiglione-Gertsch M, et al: Burdens and benefits of adjuvant cyclophosphamide, methotrexate, and fluorouracil and tamoxifen for elderly patients with breats cancer: The International Breast Cancer Study Group trial VII. J Clin Oncol 18:1412-1422, 2000 4. Gelman RS, Taylor SG 4th: Cyclophosphamide, methotrexate, and 5-fluorouracil chemotherapy in women more than 65 years old with advanced breast cancer: The elimination of age trends in toxicity by using doses based on creatinine clearance. J Clin Oncol 2:1404-1413, 1984 5. Early Breast Cancer Trialists' Collaborative Group: Tamoxifen for early breast cancer: An overview of the randomised trials. Lancet 351:1451-1467, 1998[CrossRef][Medline]
6. Bouchardy C, Rapiti E, Fioretta G, et al: Undertreatment strongly decreases prognosis of breast cancer in elderly women. J Clin Oncol 21:3580-3587, 2003 Related Correspondence
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
