DR CAREY: I’d give her poly chemotherapy. She’s 83 years old and otherwise healthy. You’re getting into the point at which comorbidity and disease and stuff don’t matter as much. In truth, a very healthy 83-year-old who’s riding horses or whatever, actuarially speaking, has a good chance of living another 10 years or so. The biggest risk to her is this cancer, and it’s triple-negative.
The other element is older patients tend to tolerate chemotherapy reasonably well. They have a little more neutropenia, but they generally tolerate the drugs fairly well. In a motivated patient, I would treat her. This is a high-risk situation with early relapse being her biggest risk.
DR LOVE: And what specific regimen?
DR CAREY: You can either use TC, if you’re worried about her heart, which I think in an 83-year-old you might be, or CMF, to be honest. That’s an underutilized regimen. But if her heart is very strong, I wouldn’t shy away from anthracycline/taxane.
DR LOVE: Eight-nine?
DR CAREY: No. At 85, it’s the points at which employing standard of care, you’d start not seeing the benefit of that, really. It actually hits in the American population at about 85.
DR LOVE: Edith?
DR PEREZ: Actually, in northern Florida, we see a lot of 83/85s who are playing golf better than any of us. So we really follow the patient’s overall condition to make decisions, not the age. And we evaluate ejection fraction with mostly echocardiogram and make decisions based on that.
DR GRADISHAR: I was just going to make one comment. One of the lessons we learned from Hyman Muss’ capecitabine trial a while back is, if you’re making a decision to give therapy, the lesson we learned is: Give therapy that’s established — not to make up something or try and water it down.
DR BRUFSKY: So, to push Hyman Muss a little bit and to combine it with NSABP-B-20, so we can be very kosher about it, Hyman Muss says that CMF in the classical regimen is better than capecitabine in the elderly as adjuvant therapy.
DR BRUFSKY: But we know from B-20 that MF is equivalent to CMF pretty much.
DR CAREY: In ER-positive.
DR BRUFSKY: So just give her MF.
DR CAREY: In ER-positives. NSABP-B-20 was ER-positive patients.
DR PEREZ: And we know that 6 cycles of anthracyclines are better than CMF.
DR BRUFSKY: Right. So we’re going to give anthracyclines to an 83-year-old woman?
DR PEREZ: Why not?
DR LOVE: Hope?
DR RUGO: I think that the way people have given CMF and the duration in ER-positive versus ER-negative, HER2-positive, we don’t have any idea what the distribution was in those older trials. But we do know that CMF is not an unreasonable regimen for triple-negative disease. Although I’ve found in older women, it can be a very tough.
DR PEREZ: Toxic.
DR RUGO: They’re all IV. Memorial’s style, all IV — it can be very toxic. They’re supposed to get 8 cycles. By the time they get to 6, they’re pretty beat up. But I also think that if it’s, for example, a younger older patient and you are deciding that — 79 — you’re going to give that patient ACT or something like that, you can start with T. And if they fall apart with the T, it’s a really good sign.
DR BRUFSKY: I’ve done that.
DR RUGO: And then you have to switch gears. So the in vivo test is critical in these older patients.
DR BRUFSKY: I’ve done that. I’ve gone the reverse.
DR LOVE: Monica, any observations on the medical oncology community in terms of their decision-making, particularly in older patients in the United States?
DR MORROW: Why don’t you all just get a gun and shoot me now. No.
I think what has been said is very reasonable in the sense that, obviously, you’re looking at comorbidities and you’re looking at time to relapse. In someone with triple-negative disease, where the time to recurrence is short and within the patient’s lifetime, that would make me think about this differently than in someone where you’re worried about relapses occurring 5 to 10 years later.
Having said all that, I think that there clearly are some older people who say, “I’m very happy the way I am now and I’ve had a good life, and if I’m going to die, so be it, and I don’t want to be treated,” and that’s an individual decision.