Adjuvant Chemotherapy in Older Breast Cancer Patients
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Chemotherapy’s Limited Benefit for older Women with Common Breast Cancer Type Confirmed by ASTER 70s trial
Despite being the most common breast cancer subtype in women aged 70 and older,clinical decision-making regarding adjuvant chemotherapy has historically relied on evidence generated from younger cohorts,where the benefits of chemotherapy are more pronounced. now, results from the phase 3 ASTER 70s trial (NCT01564056), recently published in The Lancet, shed critical light on this issue, suggesting that chemotherapy may offer limited survival benefit in this population while substantially increasing toxicity risks.
The ASTER 70s trial enrolled over 1000 women aged 70 or older with newly diagnosed hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative early breast cancer or isolated recurrence. All tumor specimens were assessed with the Genomic Grade Index (GGI), an 8-gene test used to classify risk. Patients with high-risk disease were randomized to receive adjuvant chemotherapy followed by endocrine therapy or solely endocrine therapy. The median age of the participants was 75,and around 40% had a score of 14 or less on the G8 frailty test,indicating common health issues in this group.
After a median follow-up of 7.8 years, no statistically meaningful survival benefit was observed for chemotherapy.At 4 years, overall survival (OS) was 90.5% in the chemotherapy-endocrine group versus 89.3% with sole endocrine therapy. At 8 years, OS was 72.7% versus 68.3%, neither reaching statistical meaning (HR, 0.83; 95% CI, 0.63-1.11; P = 0.21). These findings challenge the routine use of adjuvant chemotherapy in older patients with genomically high-risk HR-positive disease.
Severe adverse effects were seen in 34% of the patients receiving chemotherapy, compared with only 9% in those who received endocrine treatment. Treatment-related deaths occurred only in the chemotherapy group. Such toxicity has extreme implications for older patients, who often face risks from other non-cancer health issues.
These results highlight the importance of weighing quality of life against modest, if any, survival gains from chemotherapy. As noted in an editorial accompanying the study, the trial may have lacked the sensitivity to detect smaller subgroup effects, emphasizing the need for careful, individualized analysis rather than a blanket restriction on chemotherapy for older adults.
While the ASTER 70s study provides key insights, it’s crucial to note some limitations. The trial used a less commonly applied genomic assay compared to tests like Oncotype DX and MammaPrint.Further research is needed to determine if these findings apply to all subgroups of older women with breast cancer.
this research underscores the need for a tailored approach to cancer treatment,recognizing the unique vulnerabilities and considerations of older patients. The findings suggest that for many older women with HR-positive,HER2-negative breast cancer,endocrine therapy alone may be a sufficient and less toxic treatment option.