About one-quarter of cases of newly diagnosed BC occur in women aged 70 years or older. This population often suffers from multiple comorbidities, frailty, and physiological changes that can affect drug disposition.

These factors may make an older patient with BC a poor candidate for surgery. In these patients, primary endocrine therapy (ET) may be offered as an alternative; however, the International Society of Geriatric Oncology has advised that primary ET should only be used in patients with a life expectancy of less than 3 years. The latest statistics from the United Kingdom have shown that about one-quarter of women aged 70 years and older did not undergo surgical resection of their tumor, which is the recommended treatment modality for all patients with BC.

The use of comprehensive geriatric assessment (CGA) may help avoid the arbitrary selection of BC treatment modalities based on age alone in this older adult population by identifying vulnerabilities that may guide treatment decisions. CGA involves the assessment of functionality, nutrition, cognition, psychological state, social support, comorbidities, medications, and geriatric syndromes. A systematic review was conducted in 2012 that analyzed the use of CGA in older women with early BC; however, at that time there was a paucity of information to help impact clinical decision making.

The original investigators of that systematic review performed an updated systematic review on the use of CGA in older patients with early BC. A literature search was conducted using PubMed, Embase, and Cochrane Library of articles published from 2011 to 2022. To be included in the updated analysis articles had to be published in English and address the use of CGA in early BC.

A total of 18 articles met the inclusion criteria. The majority of the evidence was level III, with only one level II article (a cross-sectional study) and no level 1 evidence (the highest level of evidence) or level IV evidence (the lowest level of evidence). Of these articles, 17 involved patients aged 65 years or older and one was based on level of frailty and included a patient aged as young as 43 years.

The studies fell into one of four main themes: to determine factors influencing survival or mortality; as an adjunct to treatment decision-making; to measure quality-of-life (QoL) and functional status; and to determine which tools should be used in CGA.

In determining factors that influence survival or mortality, deficits in three or more domains of CGA increased BC-specific mortality twofold at 5 and 10 years. Falls also served as an indicator of survival in this population. Multidimensional prognostic index and the use of immune biomarkers (i.e., intratumoral CD3+ and CD15+ leukocytes) may further complement the use of CGA in identifying factors that may influence survival in this population.

CGA was found to be used as an adjunct to treatment decision-making with “fit” older patients with early BC more often being offered surgery. “Fit” was defined as having one or less CGA deficits; other categories included vulnerable or frail. CGA also identified patients who were at greater risk of developing adverse events to chemotherapy due to frailty. In fact, patients were less likely to be offered chemotherapy following CGA out of concern for adverse outcomes. Performance status as determined by CGA was often used as the basis for treatment recommendations. CGA was also found to be the best predictor of fatigue after radiation therapy. Investigators observed that with increasing age, there was a trend for patients to be less likely to opt out of receiving aggressive treatment. CGA can be used to help tailor a patient’s treatment regimen based on their level of function.

Data were mixed on measures of QoL and functionality. While radiation therapy post-BC surgery did not appear to adversely affect QoL, a poor baseline CGA score was associated with self-reported QoL. Yet, others found that QoL deteriorated over the course of BC treatment. QoL assessment did not affect surgery as a treatment modality. The authors concluded that there was no gold standard tool for QoL assessment that can be used with the CGA in older patients with early BC.

Consensus was not reached on what tools should be used in CGA in older patients with early BC. Various tools were helpful in predicting physical performance. Self-administered CGA was found to influence treatment decisions regarding chemotherapy or radiation therapy in older adults with early BC patients. The G8 screening tool was the most commonly reported screening tool found in the literature. G8 identifies older cancer patients who can benefit from CGA. This tool is available free of charge at MDCalc at https://www.mdcalc.com/calc/10426/g8-geriatric-screening-tool.

Pharmacists play an essential role in the management of geriatric patients. They should be familiar with the place that CGA has in optimizing treatment choices of their older patients with early BC.

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