Breast cancer therapy: finding the right treatment for every woman

The motto "one size fits all" no longer applies to breast cancer treatment. More attention goes to the right therapy for each case, as Dr Adrian Lee discusses.

Interview with Dr. Adrian Lee

Especially for older women, less is sometimes more

Not every breast cancer is the same. And this also applies across the patients who have the disease. Especially at an older age, when a recurrence becomes rarer, the question over which may be the most suitable therapy to be applied arises.

That is why there are clinical guidelines in the USA that have been developed specifically for women over 70. According to experts, this segment of patients - especially those with oestrogen receptor-positive tumours in the early stages - can do without radiation. Sentinel lymph node biopsy can also be spared for many sufferers from the same group.

Risk-benefit analysis is particularly important for older patients

The background for these recommendations is an increased risk of adverse effects and toxicities in this age group. The older a person gets, the more likely he or she is to develop severe side effects. The question for treating physicians and researchers is therefore whether it is possible to shift this risk-benefit ratio - and thus achieve a better quality of life for sufferers.

What does therapy de-escalation mean for survival?

If fewer different therapies are used overall, for example by omitting a sentinel lymph node biopsy or radiation, patients and relatives often ask themselves whether this procedure influences survival and leads to a shorter life expectancy.

But the omission of therapies does not mean a reduction in effectiveness. Rather, the goal is not to overtreat patients, says Dr Lee. Studies have shown that de-escalation of certain treatment modalities is associated with the same outcomes and has the positive side effect of reducing the risk of toxicities and other side effects. The aim is to offer a tailor-made solution.

Who is eligible for de-escalation?

For whom does the strategy of therapy de-escalation is relevant is often not an easy answer. Often, there is no standardised test for or against a treatment option. One possibility is, for example, a geriatric examination in the sense of a frailty assessment. In particular, polypharmacy, which is often ubiquitous in the elderly population, can lead to serious complications. The assessments, which are specially adapted to the geriatric population, can help to correctly assess the risk.

Age and standard therapy: further modifications are possible

A lot has happened in the field of breast cancer therapy. There are now some guidelines for the treatment of older women aged 70 and over, which focus on tailored therapy. But it is likely that much will develop in the coming years. It is possible, for example, that other therapeutic measures can be removed from the standard repertoire without leading to worse outcomes. The age cut-off of 70 years could also be shifted, for example to 65 or even 60 years.