Multidisciplinary approaches in the management of older adults with hormone positive early breast cancer

Dr Eline Naert, medical oncologist from Ghent University Hospital and Rani Vanhoudt, clinical nurse specialist breast cancer from University hospitals Leuven summarised the session that focused on the management of frail older adults with early-stage breast cancer. They highlighted the complexity of treatment decision-making in this growing patient population.

The session opened with a clinical case of a frail older woman diagnosed with oestrogen receptor–positive early breast cancer. The central question concerned the choice between standard surgical management and primary endocrine therapy. This case reflected a common clinical dilemma in geriatric oncology, where established treatment guidelines may not be fully applicable to frail older patients. In daily practice, clinicians are frequently required to consider alternative, less intensive strategies and to individualise care beyond standard protocols.

A multidisciplinary panel, including medical oncologists, radiation oncologists, surgeons, geriatricians, and nurse specialists, discussed evidence-based de-escalation strategies and decision-support tools relevant to this population. Surgical management was addressed with a focus on the impact of omitting surgery. It was emphasised that the omission of surgery may negatively affect overall survival, whereas breast-conserving surgery can still offer benefit in selected older patients. However, adequate patient selection and the potential role of prehabilitation to optimise functional status prior to surgery were highlighted as key considerations.

Radiotherapy de-escalation strategies were reviewed, with particular attention to hypofractionated and ultra-hypofractionated radiotherapy schedules. These approaches were shown to offer comparable efficacy with improved tolerability, making them attractive options for older patients. In addition, emerging biomarkers such as the POLAR genomic signature were discussed. This tool, similar in concept to established assays such as Oncotype DX or MammaPrint, appears promising in distinguishing low-risk from high-risk patients and may help identify individuals in whom radiotherapy could safely be omitted. However, while clinical validity has been demonstrated, evidence for clinical utility from prospective trials is still lacking.

Systemic treatment decisions were addressed through the presentation of decision-support tools and trial data. The use of the ‘Age Gap Decision Tool’ was discussed as a means to support decisions between surgery and primary endocrine therapy. Results from the phase III ASTER-70 trial were highlighted, showing no added benefit of chemotherapy compared with endocrine therapy alone in patients aged 70 years and older with oestrogen receptor–positive breast cancer and a high genomic grade index. These findings suggest that chemotherapy can safely be omitted in selected older patients and may inform treatment decisions in frail populations. In contrast, the session acknowledged an important gap in guidance regarding the use of adjuvant CDK4/6 inhibitors. While many older patients meet eligibility criteria from trials such as MONARCH-E and NATALEE, frailty and the risk of treatment-related toxicity complicate decision-making, underscoring the need for tools that better integrate biological age and overall treatment goals.

The geriatric perspective emphasised that frailty is a dynamic and evolving condition rather than a static baseline characteristic. Continuous assessment of frailty throughout the treatment trajectory is essential, as increasing frailty during therapy is associated with poorer outcomes and reduced tolerance of treatment. The nursing perspective further highlighted the importance of comprehensive geriatric assessment combined with repeated face-to-face evaluations. Nurses play a critical role in patient empowerment, symptom management, and advocacy, particularly when patients experience treatment-related toxicity or functional decline.