De-Escalation of Local-Regional Therapy for Older Breast Cancer Patients

Over the past decade, prospective clinical trials and retrospective data have changed clinical guidelines for the treatment of older patients, most notably those patients with early, hormone receptor-positive, clinically node-negative breast cancer. Here is a comprehensive review of the literature supporting de-escalation of local-regional therapy in older patients with breast cancer. The de-escalation of treatment in elderly patients includes minimizing surgical interventions and adjuvant radiation therapy. Current Choosing Wisely® guidelines recommend considering the omission of surgical staging of the axilla in patients ≥ 70 with early-stage, hormone receptor-positive breast cancer. Primary endocrine therapy may be a suitable option for older patients with hormone receptor-positive breast cancer and short life-expectancy. The long-term results of the CALGB 9343 clinical trial reveal that radiotherapy omission is not associated with a survival benefit in patients ≥ 70 with early-stage, hormone receptor-positive, node-negative breast cancer, who receive 5 years of adjuvant endocrine therapy. The results of the RAPID trial support that shorter courses of radiation therapy are non-inferior to standard therapy and may be of significant value to older patients who require radiation. In addition, intraoperative radiotherapy may be useful in older patients with mobility issues who have higher-risk tumors and the current TARGIT-E aims to assess IORT in patients ≥ 70 with hormone receptor-positive tumors. Select older patients with breast cancer may benefit from the omission of axillary staging, less aggressive breast surgery, and shorter courses or total omission of radiation therapy. Current studies aim to continue to define the appropriate criteria for which older patients can benefit from de-escalation of local-regional therapy.