European School of Oncology Advanced Course on Cancer in the Elderly Liverpool, 29–30 April 2004

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Surgical Oncology 13 (2004) 159–167

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Meeting Highlights

European School of Oncology Advanced Course on Cancerin the Elderly Liverpool, 29–30 April 2004

Caroline Brucea, Nadir Osmanb, Riccardo A. Audisiob,�, Matti S. Aaproc

aWhiston Hospital, UKbUniversity of Liverpool, UK

cIMO Clinique de Genolier, Switzerland

Abstract

The ESO Advanced Course on Cancer in the Elderly took place in Liverpool—UK, 29–30 April 2004 under the chair of Riccardo

A. Audisio and Matti A. Aapro.

This successful event gathered 82 participants from 17 countries; posters were displayed presenting original research data, and 19

lecturers updated the audience on the latest findings regarding basic science, prevention, early detection, diagnosis, treatment

options, as well as the social impact of this frequent malignancy.

This Meeting Highlights collects the panellists views; it is intended to update on the cutting edge of the present knowledge, in

order to improve our understanding of malignant disease affecting senior patients, and eventually to optimise their management.

r 2004 Elsevier Ltd. All rights reserved.

Keywords: Oncology; Cancer; Elderly; Multimodal treatment; Conference report

Colon and Rectal Cancer in the Elderly

WE LongoYale University, USA

In 2030, 1:5 Americans will be over 65 years old, andsubsequently a greater number of elderly patients withcolorectal cancer will be identified. Colorectal cancer isthe second commonest cause of cancer deaths in theUSA and accounts for two thirds of all cancers over theage of 70 years. We therefore have to prepare amanagement strategy for the older cancer patient.Our treatment goals should be to provide curative

therapy whilst minimising morbidity and mortality, toassess the need for adjuvant therapy and to take intoaccount their quality of life.It should be taken into consideration that right-sided

lesions occur more frequently in the elderly and that

e front matter r 2004 Elsevier Ltd. All rights reserved.

ronc.2004.10.001

ing author. Tel.: +44-151-430-1079; fax: +44-151-430-

ess: [email protected] (R.A. Audisio).

they may present to other specialities with anaemia,weakness, syncope, falls, etc. Left-sided lesions mayhave apparently non-sinister symptoms e.g. constipationwhich do not trigger urgent investigations. As a result ofthis many elderly colorectal cancer patients present asemergencies. Emergency surgery has a poorer prognosisdue to higher peri-operative mortality, advanced tumourstage and a poor physical status at presentation plus thegeneral lack of organ system reserve in the elderlypatient. This raises the questions should we be screeningthe elderly population for colorectal cancers and how?Faecal occult blood testing is now considered unreliable.Looking at the National Polyp Registry in the USA theincidence of right sided colonic polyps increase sig-nificantly with age and therefore screening needs to be ofthe whole colon rather simply sigmoidoscopy.

Incidence of polyps and cancers

Age 60–69
Right colon 45% 30% Left colon 55% 70%
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ARTICLE IN PRESSC. Bruce et al. / Surgical Oncology 13 (2004) 159–167160

Age 70–79
Age X 80
Therapeutic actions can be taken with colonoscopy,saving the patient further bowel preparation and stress.If a polyp is found, repeat colonoscopy is recommendedat three years, if normal then every 3–5 years. Screeningshould cease when it is unlikely to prolong a patient’slife therefore comorbidities need to be taken intoaccount when offering screening.

Elective surgery

The general medical condition of the patient is veryimportant with increasing co-morbidities increasingwith age. Potentially reversible conditions e.g. anaemiaand hypovolaemia must be identified and acted upon.Adequate preoperative staging of the tumour lookingfor local and distant spread is mandatory, as well ascolonoscopy for synchronous lesions and CEA. Anor-ectal physiology testing may be advisable if planning alow resection and considering a sphincter savingprocedure.Alternatives to the traditional transabdominal route

should be considered for the frailer patient includingtransanal excision, fulguration, radiation therapy andintraluminal stenting.

Adjuvant treatment

Adjuvant treatment is now considered the standardtreatment for patients with resected colon cancer at highrisk of recurrence; however, elderly patients have oftenbeen excluded in clinical trials. The efficacy and toxicity ofsuch treatment in elderly patients remains controversial.

Colorectal Cancer: Emergency Surgery and Liver

Resection

T KopernaKlagenfurt, Austria

Emergency surgery

Emergency presentation and comorbidity of patientsover the age of 70 years leads to a poor prognosis. Thehigh rate of mortality in this group of patients has madeit necessary to devise a specific therapeutic approach.Physiological stress needs to be kept to a minimum butradical surgery is the optimal oncological approach,

therefore a compromise must be attained. Primaryresection is possible in preselected patients that aregenerally fit with minimal co-morbidities and an easilyrespectable tumour. A benefit has been shown fromdelayed radical resection in patients with significant co-morbidities or a technically difficult tumour to resect.Initial surgery controls the emergency situation, i.e.diverting faeces via a stoma or expanding a stenosinglesion with a stent. A shorter operating time and lesssurgical stress leads to reduced peri-operative mortality.Reversible factors such dehydration and malnutritioncan then be addressed before secondary resection. Thosepatients with a perforation however benefit from aprimary resection despite their co-morbidities.

Liver resection

Fifteen to 25% of liver metastasis are resectable atpresentation prior to any chemotherapy. Contrary topreconceived ideas liver surgery has a low postoperativemorbidity (20–50%) and mortality (0–5%). Studies haveshown significantly increased survival rates followingresection of hepatic metastasis. Factors that increasepost resection morbidity include age 480 years, liverdysfunction, duration of surgery, three of more seg-ments resected, transfusion greater then 3 units and anASA score of 3–4. In his series 43% of patientsdeveloped post operative complications, the mostfrequent being infection. Patients older than 80 yearswith severe liver disease showed a post operativemortality of 57%, therefore liver resection cannot berecommended in this sub-group of patients.

Epidemiology and Operative Risk in Elderly Colorectal

Cancer

PP TekkisLondon, UK

A large database has been collected by combiningdata from the ACPGBI Colorectal Cancer Study, theACPGBI MBO study and the Wales-Trent Audit. Thisdata was collected with the aim of being analysed to gainfurther epidemiology information, risk stratification, toset standards of care and to enable patients to makeinformed choices. The ACPGBI have now established aweb site where patients’ data can be easily entered byspecific surgeons and where patients can look forinformation (www.cancernw.org.uk).This database can be used by patients to increase their

understanding for informed consent. Physicians can useit as an audit tool, to ensure quality of local care and toaid appraisal. Institutions can use it as a means of self-monitoring and to aid resource allocation.A range of data including age, gender, co-morbidity,

cancer staging and main diagnosis is used to predict

http://www.cancernw.org.uk

ARTICLE IN PRESSC. Bruce et al. / Surgical Oncology 13 (2004) 159–167 161

operative risk. Five important prognostic indicatorswere identified: ASA grade, age, mode of surgery, Dukesstage and tumour resection.The analysis enabled a prognostic tool to be produced.

This calculates an adjusted odds ratio for each of theabove-mentioned five variables. The odds ratio can thenbe used to calculate the probability predicted mortalityusing a ROC curve. Obviously this tool does not predictand account for adverse events. The predicted oddsmortality is given as a percentage that a patient cancomprehend, this obviously improves patient participa-tion in a difficult decision to operate or not.The future may hold a more detailed database so

hierarchical models can be constructed including factorssuch as the patients’ activities of daily living and apsychiatric assessment aiming to produce an even morepersonalised prediction.

Colorectal Cancer—Old Concoctions and New Drugs

CH KohneDresden, Germany

It is a known fact that patients benefit from adjuvantchemotherapy for stage III disease, however signifi-cantly more patients are offered adjuvant chemotherapyunder the age of seventy than above [1]. Sargent et al. [2]pooled the data from seven trials looking at a total of3351 patients with stage II–III colon cancers, of theseonly 506 patients were over 70 years old despite theincidence of colorectal cancer increasing with age. Todetermine if this was due to increased toxicity in theelderly they also looked at the side effect profile of thedrug and found similar rates of nausea and vomiting,diarrhoea, stomatitis and leukopenia in both age groups.The MOSAIC trial looked at the role of Oxaliplatin in

combination with infusional 5-FU. A significant benefitin 3-year survival rates was shown for patients withstage III disease and a trend towards increased 3-yearsurvival rates in stage II disease. When subdivided intoabove and below the age of 65 years then those above 65showed a greater improvement in survival rates with theaddition of oxaliplatin. What now needs to be con-sidered is the role of irinotecan, capecitabine and othernew targeted therapies as adjuvant treatment. Furtherstudies are required to determine predictive factors toidentify patients who will benefit from the adjuvanttreatment, i.e. avoid the possible toxicity in patients whohave already been cured by their surgery or who will notbenefit from chemotherapy.When considering chemotherapy with metastatic

disease we know it improves outcome. The RoyalMarsden Hospital looked at clinical outcome of 5-FUin patients with metastatic colorectal cancer in patientsunder and over 70 years old [3]. They found nosignificant increased toxicity and comparable efficacyand response rates. For those patients less than 70 years

overall survival was 11.5 months and progression freesurvival 5.5 months, compared with those over 70 yearswith an overall survival of 9.6 months and progressionfree survival at 5.4 months. Folprecht et al. [4] attainedsimilar results for comparable overall survival andprogression free survival in those under and over 70years. They also showed that infusional 5-FU shows asignificant improvement in outcome for both age groups.Irinotecan and oxaliplatin in combination with 5-FU/

FA have both been shown to increase response rate,progression free survival and overall survival; combina-tion therapy is now recommended. Studies do not showany increased toxicity purely due to age.New drugs are under development including a group

of drugs affecting the Epidermal Growth FactorReceptor (EGFR) pathway. Cetuximab is a chimericmonoclonal antibody with a high affinity for EGRF andis producing promising results in phase II trials incombination with irinotecan with or without 5FU/FA.It is also proving useful in those patients that have failedirinotecan alone.Vascular Endothelial Growth Factor Receptor Inhibi-

tors (VEGF) are another exciting field of development.Beigstand et al. [5] have shown 5FU/FA in combinationwith bevacizumab (rhuMab VEGF) leads to an increasein response rate and overall survival and progression freesurvival compared with 5FU/FA alone. There is limiteddata on these new drugs and the elderly patient.

The Impact of Age on Lung Cancer Treatment

M de RijkeMaastricht, The Netherlands

Lung cancer accounted for over 180,000 deaths in theEU in 1997. Of these over 50% were over 65 years ofage, with the peak incidence around 75 years old.Seventy five percent were male, and 80% had non-small-cell lung cancer. Treatment methods are mainly basedon trials conducted on patients under 70 years old.Standard regimes are the agreed in most units but arethen not followed for the older patient, clinicians beingconcerned regarding the age, co-morbidity, performancestatus and pulmonary function of these patients. Aretrospective study of non-small-cell lung cancer waspresented, involving 803 newly diagnosed patientsbetween January and June 1998. Twenty percent ofthe patients were female and 51% were 60–74 years oldwith 27% being greater than 75 years. Patients over 60years old were picked up at an earlier stage (25%—stageI–II) than younger patients due to chest X-rays beingperformed for reasons other than investigating chestcomplaints and in the monitoring of other chronicconditions. Co-morbidity significantly improves withage, the commonest being cardio-vascular disease,COPD and hypertension. Interestingly they also noted


that an increasing proportion of the older patients hadnot had their performance status evaluated. Treatmentguidelines had been established prior to this study forthe various stages of the disease, 72% of patients withstage IIIA and 67% of those with stage IIIB disease inthe 75+ age group were not treated in accordance withthese guidelines. It was shown that for those patientsgreater than 75 and with stage I–II disease, their co-morbidities were the main determinates as to whethermanagement guidelines were followed. For the elderlypatient with stage III disease, age alone seemed to be theonly identifiable reason for not following the guidelines.Poor pulmonary function tests gave strength to deviat-ing from the guidelines in stage IV patient over 75 years.There are three main factors that determine cancer

treatment and prognosis; the patient, the tumour andthe care provider.

The patient: The physical and mental status of thepatient need to be considered, looking at their co-morbidities, performance status and nutritional level.Their environment is important regarding their socialnetwork and family, and their level of understanding ofthe treatment and its implications. The patients’preferences, beliefs and ignorance need to be taken intoconsideration. The patients’ calendar age is anotherfactor. A full geriatric assessment is important toestimate life expectancy, identify frail patients, identifyproblems, i.e. medication, transportation, etc. and toprovide a common language in outcome research andquality assurance.

The tumour: Prognosis—tumour type and stage ofdisease. Treatment opportunities—risks of treatmentand risks of withholding treatment.

Care provider: The knowledge, experience, attitudeand communication skills will all impact on thetreatment regimes offered and accepted. The hospitalpolicies and availability may well limit the options.

Lung Cancer: Treatment Today, Tomorrow and For All!

P HarperLondon, UK

At present the average age of patients with lungcancer is 68 years, and with the number of people overthe age of 65 due to double in the 25 years, the numberof elderly patients with lung cancer will expand greatly.This has got to imply significant cost issues are ahead.Should elderly patients be denied chemotherapy orshould they be given a half-hearted approach. There issignificant lack of evidence regarding this unique olderpopulation and the various treatment options available.The Elderly Lung Cancer Vinorelbine Italian StudyGroup [6] (ELVIS) trial showed a benefit in overallsurvival and palliation of symptoms in patients over 65years. However, the Southwest oncology Trials 9509

and 9308 [7] do show a trend towards shorter survivaltimes for patients over the age of 70 years compared tothose younger than 70 years. The ECOG 1594 [8] looksat a subset of elderly patients and the use of Cisplatin-based chemotherapy. They show more cardiovascularðpo0:00001Þ and non-cardiorespiratory ðp ¼ 0:008Þ co-morbidities in patients over the age of 70 years. TheTAX 326 trial again looked at various chemotherapycombinations in patients below and above the age of70 years and they found that the two groups had asimilar outcome in respect to overall survival, TTP andtoxicity [9].In summary the elderly do seem to gain some benefit

from chemotherapy in regard to overall survival andquality of life, however more studies need to beconducted to evaluate the toxicity profiles. No additionalbenefit is attained for a non-platinum based combinationin the elderly but there are no specific trials addressing therole of platinum based chemotherapy drugs.

Open versus Video Thoracoscopic Surgery for the Elderly

MT JaklitschBoston, USA

Some lung cancers are amenable to surgery; however,age is a significant risk factor for death after thor-acotomy. The Lung Cancer Study Group data [10]shows mortality post thoracotomy to be 1.3% for thosepatients under 59 years, 4.1% for patients 60–69 years,7.0% for patients 70–79 years and 8.1% for patientsover the age of 80. It is known that the elderly handlesevere stress poorly due to lack of physiological reserve.When looking at pulmonary function their respiratorymuscles atrophy, there is a reduction in the force-generating capacity of residual muscles and a change inthe mechanics of breathing. Cardiorespiratory reservedeclines exponentially in patients over 70 years old. Pre-operative optimisation is essential to reduce mortalityrates. At the Brigham and Womens Hospital they haveintroduced a pre-operative programme. Prior to surgery,patients have to walk 20min a day, have their anaemiacorrected, stop smoking, correct dehydration, undergoscreening for carotid and coronary disease, under gopulmonary rehabilitation, optimise nutrition and havetheir emotional and mood state evaluated. To plan for alobectomy or pneumonectomy their FEV141l, FEV1/FVC450%, DLCO450% predicted, PaO2445mmHgand the patient must be able to walk for at least 6min. Ifany of these targets are not met, a more limited resectionmust be considered.Video assisted thoracoscopic surgery (VATS) involves a

video thoracoscope and an 8 cm utility incision, the limitedincision preserves muscle function. In a series of 896patients undergoing VATS at the Brigham and Women’sHospital from July 1991 to June 1994, 307 patients were


older than 65 years. Their morbidity rate was 14% andmortality 1%, their average length of stay in hospital was3–5 days [11]. Their rates of postoperative confusion wereless, with 2.6% for VATS compared with 13–19% foropen thoracic surgery. These positive results have beenreproduced by other similar series. Elderly patients tolerateoperations but not complications. In a series by McKenna[12] complications included: air leak 5%, blood transfusion1.4%, intra-operative bleeds 0.9%, serous drainage 0.9%,arrhythmias 0.9%, PE 0.5%, pneumonia 0.5%. Read-mission rates included 0.9% with PE and 0.9% withARDS, pneumonia. In McKenna’s series of 1120, 119(11.6%) required conversion to open thoracotomy.Seventy percent were for oncological reasons, i.e. centrallylocated lesions requiring vascular control, a sleeve resec-tion or unsuspected T3 tumours, and 30% for non-oncological reasons such as pleural adhesions and calcifiednodes. Tumour recurrence in the incision occurred in0.35% of the VATS lobectomies, this recurrence risk waseliminated when a bag was used for removal of the lobe.VATS should be the same operation performed as in anopen procedure including anatomical dissection with nodedissection or sampling, i.e. it should not compromise ononcological technique. Swanson et al. [13] conducted amulti centre phase II trial of VATS lobectomy in the USAfor cT1 lung tumours. They found an acceptable 80% 3-year survival.When the patient is not a candidate for lobectomy a

wedge excision of the lesion can be considered. Jaklitschet al. performed 563 thoracoscopic wedge resection fornon-small cell lung cancer between 1989 and 1998.Ninety-eight were 75 years or older. The decision toproceed to wedge resection instead of lobectomy wasmade by the surgeon guided by the parametersmentioned earlier. The rate of wedge resection increasedwith age. In the patients 75 years and over undergoingwedge resection, their 30-day operative mortality wasnil, and their average length of stay 6 days. Theyobserved that the long-term survival in the elderlypatient selected for treatment of Stage 1 NSCLCappears to not be affected by the surgeons choice ofwedge verses lobectomy.Comparison of risk and benefit using data from

Jacklitsch [11] and Landreneau

Operativemortality(%)

Localrecurrence(%)

5-yearsurvival(%)

Recovery

Lobectomy
3 6 50 Months Wedge o1 17 50 Weeks
‘‘The onus is upon the modern thoracic surgeon to
apply new technology to tailor the best risk/benefitoption to each elderly patient.’’
Optimising Care for Elderly Cancer Patients

N KearneyStirling, UK

The elderly are an expanding group and represent asignificant portion of the cancer population. Age-relatedvariations in cancer treatment and care exist includingunder diagnosis in older people, delayed diagnosis, lessfrequent use of rigorous staging of tumours, tendency tounder-treat, ineffective symptom management and low-er survival rates. There have been some reasonssuggested for these inequalities; ageist views andstereotypes, lack of adequate geriatric assessment incancer care and a lack of data on treatment effectivenessin older people. In addition older people are underrepresented in clinical trials. This has led to a lack ofevidence on older people’s views, a lack of a systematicresearch and clinical framework and homogeneityassumptions about this group.The comprehensive geriatric assessment (CGA) al-

lows for the recognition of potentially treatable condi-tions, assessment of functional reserve, a gross estimateof life expectancy and importantly the adoption of acommon language.

Patient Advocacy—the Role of the Geriatrician

M GosneyReading, UK

Whilst advocacy has been well described in variousaspects of cancer management, the role of the geriatricianis still poorly explored. The role of the geriatrician incancer management includes screening, early diagnosis,decisions regarding treatment, support at the end of life,the management of multiple pathology and possiblypreventing harm by the oncologist. The geriatrician mustnot stop patients having beneficial treatment or makepatients have futile treatment. This can be achievedthrough a good knowledge of geriatric medicine, aworking knowledge of oncology, good liaison withpalliative care services, aptitude to evidence basedpractice, to listen to patients and to truly be an advocate.To facilitate this good training of geriatricians inoncology as well as good training of oncologists ingeriatrics is needed. This could be done through jointtraining posts and joint rounds, clinics and meetings. Inthe future there should be more research and meetingsuch as this.

Anaesthesia in the Elderly

A SevernLancaster, UK

The notion that a group, such as the elderly, ofincreasing number and varied pathology, can be identified


as posing particular and specific problems is not uni-versally accepted by surgeons and anaesthetists. Age is notgenerally seen as an independent factor affecting clinicaldecision making or ward waiting list management. Age issimply seen as a risk factor for a pathology that gets worsewith age (e.g. atheroma, joint disease). The question iswhether such reasoning is sound and whether we couldimprove if we looked critically at the physiological processof ageing as opposed to age related disease.Unfortunately there is not much published literature

looking at the elderly age group. A recent search of‘‘anaesthesia’’ on PubMed returned 110,000 results ofwhich only 3% were for the over 80 group. However,from the available literature there is a consistentmessage that the techniques and drugs which have beendescribed for the young are inappropriately being usedin the elderly without modification [14].Another point of interest for the so-called ‘‘geriatric

anaesthetist’’ is the phenomenon of loss of cognitivefunction in the postoperative period [15]. This can becaused by pain, infection, withdrawal of alcohol,unfamiliar environment, etc. More important than thistransient confusion is the condition of perioperativecognitive dysfunction (POCD).

Nutritional Issues

F BozzettiPrato, Italy

Nutritional support of elderly cancer patients followsthe same recommendations as regards indications androutes of access that apply to the adult population, butthe nutritional regimen has some specificity withreference to requirements and substrates. With regardsto water, the basic clinical tenet is that elderly patientshave a poor tolerance of fluid and sodium overload.From an energy perspective, an adequate regimenshould include 30–35 kcal/kg/day: despite the low energyexpenditure and reduced physical activity of the elderlypatients, this intake of calories is required to meet theextra demand due to the presence of disease (malig-nancy, surgical trauma, infection, etc.) and to restorebody cell mass in depleted patients, a task which provesto be more difficult in patients over 65. With regards toprotein it is recommended that the dose of amino acid tobe administered in normal conditions should be at least1–1.2 g/kg/day and up to 1.5 g/kg/day in the elderly sick.

Pancreatic Cancer

P GhanehLiverpool, UK

Pancreatic cancer is responsible for 200,000 deaths peryear world-wide and has increasing incidence with age.

The overall 5 year survival is 0.4% and with resection it is10–20%. The survival rate of patients with all stages ofdisease is poor. Surgical resection, when possible, remainsthe primary treatment modality and can result in long-term cure. This should be done in a high volume centre asit allows a lower postoperative mortality reduced post-operative morbidity, reduced postoperative hospital stayand cost, and an increased resectability rate [16] Newinsights into the molecular pathogenesis may influencechoice of treatment modalities and provide avenues fornovel therapeutic strategies. With regards to the manage-ment of the elderly there should be careful selection, theresection should be feasible and should be done byspecialist teams at specialist centres. Chemotherapy(novel therapy) may improve survival and quality of life.

Non-Hodgkin’s Lymphoma in the Elderly

V ZagonelRome, Italy

Non-Hodgkin’s lymphomas (NHL) are the fifth mostfrequent cancer among men in the US, and the sixth inEurope. For the last 50 years the incidence has increasedby more than 50% in patients over 60 [17]. Elderly patientsusually have more advanced lymphoma than the middle-age group. Complete remission rate declines steadily withage, from 68% in the young to 45% in the elderly. Medianevent-free and overall survival also decline with age. Thishas been ascribed to two main causes: the poor drugtolerability in the elderly due to co-morbidity and tendencyby physicians to administer a weaker, better tolerated(hence less effective) chemotherapy in elderly patients.Several studies have led to the conclusion that the

CHOP regime at standard dosage should be recom-mended for elderly patients with aggressive lymphoma,except for patients with a definitive cardiac contra-indication to doxorubicin [18,19].The routine prophylactic use of granulocyte colony

stimulating factor (G-CSF) is suggested for all patientsaged 70 years and receiving CHOP or a drug combina-tion of similar dose intensity by the National Compre-hensive Cancer Network (NCCN from the US [20]) andalso the EORTC Cancer in the Elderly group [21].

Clinical Epidemiology of Breast Cancer in Elderly

Women

JWW CoeberghThe Netherlands

The incidence of breast cancer in the elderly is risingeverywhere except in Switzerland, while the mortality isrising by up to 3% annually everywhere except Switzer-land, Sweden, Finland and The Netheralands [22]. Thereis a wider variation in relative 5 year survival in the


elderly when compared to the young of Europeancountries. Survival is best in northern and middleEuropean countries and more prosperous areas withinthe countries. Upward trends in relative survival in theelderly may be due to better access to care and possiblybetter treatment. Data from registry based studies hasshown that co-morbidity has a modest influence onprimary treatment of breast cancer and more on stagingin those over age 80. Worse, survival is seen for womenwith BC and COPD, diabetes, cardiovascular condi-tions, cerebrovascular conditions and dementia.With regards to screening, mass programmes usually

stop at age 70 (65–74 years). However, there is evidence fora favorable effect of 430% on mortality in participantsbut only emerging after about 7 years. Therefore there aretwo options, either the extension of mass screening to 80years or an individual approach to screening. Advantagesof mass screening are early diagnosis which facilitates localtreatment, it could lower cancer mortality, it provides astimulus to better ‘evidence-based’ multi-disciplinary careand can lead to broader investment in diagnostic care. Theindividualised approach weighs quantitative and qualita-tive aspects and is based on thorough assessment andexplanatory communication.

Targeting Surgical Treatment for Breast Cancer

R GennariMilan, Italy

Ageing remains one of the single greatest risk factors fordevelopment of new breast cancer. In a study of 2999consecutive postmenopausal patients [23] with breastcancer referred to surgery, it was found that in spite oflarger tumour size at presentation, older patients hadtumours with more favourable biological characteristics,when compared with younger postmenopausal patients.Reluctance to prescribe systemic treatments was due to thecomplexity of evaluation for these patients. Taking intoaccount the data from this study and given the climate ofuncertainty regarding optimal treatment, the authorsdecided to individualise care on the basis of biologiccharacteristics, co-morbidity, social support, functionalstatus, and patient preferences. Trials of tailored adjuvanttherapy should be a health care priority.

Adjuvant Therapy in Elderly Patients with Breast Cancer

L BiganzoliPrato, Italy

Breast cancer in the elderly represents a significanthealth problem if we consider that roughly 50% of thecases of early breast cancer are diagnosed in personsover 65. Elderly cancer patients have generally beenexcluded from clinical trials, and therefore adequate

information on how treat them is often lacking,particularly with respect to chemotherapy. Focussingon the adjuvant treatment of healthy breast cancerpatients, the important questions are whether tamoxifenstill represents the gold standard in hormone-receptorpositive patients and what role does chemotherapy playin hormone-receptor negative patients.Based on the data of the Early Breast Cancer

Trialists’ Collaborative Group (Oxford Overview),tamoxifen for a 5-year period represents the standardtreatment to be proposed to endocrine responsivepatients. However, based on the data of the ATACtrial (better DFS with anastrozole than with tamoxifen)and considering DFS is a more important endpoint thansurvival in elderly cancer patients, aromatase inhibitorsmight play a key role in the adjuvant treatment ofelderly women with endocrine sensitive breast cancer.The use of adjuvant chemotherapy is controversial dueto paucity of data supporting its efficacy in the olderpopulation. Data from the Oxford Overview showedhow the benefit related to adjuvant polychemotherapyboth in terms of disease-free and overall survivalprogressively decreases with advancing age. This pro-gressive reduction in efficacy does not seem to beconfirmed when looking oestrogen receptor-poor sub-group suggesting that patients aged 70 years or oldercould benefit from adjuvant chemotherapy. Prospectiverandomised clinical trials targeting elderly patients aredefinitively needed to understand the role of adjuvantchemotherapy in the group of patients.

Breast Cancer: Treatment of Advanced Disease

L RepettoRome, Italy

Elderly patients with hormone receptor positivemetastatic breast cancer are generally treated withendocrine therapy. Aromastase inhibitors are standardfirst line endocrine therapy. After the first line, availableendocrine treatments are tamoxifen and progestinics.Chemotherapy is less frequently used compared withyoung patients. However, both some new drugs and newschedules of old drugs are associated with an improvedtoxicity profile, thus allowing the administration ofactive chemotherapy also in elderly patients. Mono-chemotherapy regimen tested in elderly patients led toan objective response rate ranging from 24% to 54%.Drugs evaluated in such studies were weekly docetxeland pacitaxel, oral doxifluorodina and vinorelbine,mitoxantrone. New available drugs which are associatedwith mild toxicity, such as Trastuzumab and theinhibitors of tyrosine kinase associated with epidermalgrowth factor receptor may lead to new regimens, basedon their combinations with chemotherapy, useful inelderly patients.


In elderly patients, both endocrine and chemotherapytreatments need careful evaluation of side effects anduse of supportive care for both prevention and treat-ment of toxic effects.

Conclusions

The geriatric population is expanding, and hence theclinical decision making is often confused by effects ofageing. Age should not be the only parameter con-sidered when addressing a medical problem [24]. Thereis much evidence that the booming elderly populationwith cancer does not receive potentially curativetreatment afforded to younger cancer patient [25]. Notonly surgery is sub-optimal, but medical and radiationtreatments are sub-standard, staging is not adequate,and diagnosis is delayed.Several surgical series have proven that no significant

difference in postoperative mortality and long termsurvival but slightly higher morbidity between youngerpatient receiving surgical management [25]. However,selection of these patients and their outcomes arecontinually debated and there has been a selection biasof patients to be offered curative treatment for cancer inelderly. Outcome of elective cancer operations in elderlycould be improved by optimising selection and takingutmost care around peri-operative period.The concern has been raised of epidemiological

changes and population dynamics. Trends in specificorgan cancers and their current treatment have beendiscussed.The meeting successfully met its target in increasing

awareness among the medical community, and stimulatea debate about the urge to update the overall manage-ment of elderly oncology patient differently. Completemanagement of cancer in this population group, andtheir eventual outcome, could be improved by specialistonco-geriatric multidisciplinary team. Preparing themedical community to deal with this impendingepidemiological time bomb has been extensively dis-cussed.

Lecturers:Laura Biganzoli—‘‘Sandro Pitigliani’’ Oncology Cen-

tre, Prato, ItalyFederico Bozzetti—INT, Milan, ItalyJan Willem W. Coebergh—Erasmus University,

Rotterdam, The NetherlandsJ. Marjan de Rijke—University of Maastricht, The

NetherlandsRoberto Gennari—EIO, Milan, ItalyPaula Ghaneh—University of Liverpool, UKMargot Gosney—University of Reading, UKPeter Harper—Guy’s Hospital, London, UKMichael T Jaklitsch—Brigham and Women’s Hospital,

Boston, USA

Nora Kearney—University of Stirling, Scotland, UKClaus-Henning Kohne—University of Dresden, Ger-

manyThomas Koperna—Hospital Mistelbach, Mistelbach,

AustriaWalter E. Longo—Yale University, New Haven,

USALazzaro Repetto—INRCA, Rome, ItalyAndrew Severn—Royal Lancaster Infirmary, Lan-

caster, UKParis P. Tekkis—St. Mark’s Hospital, London, UKVittorina Zagonel—Ospedale Fatebenefratelli, Rome,

Italy

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European School of Oncology Advanced Course on Cancer in the Elderly Liverpool, 29–30 April 2004

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