Navigating Breast Cancer Treatment Options for a 90-Year-Old Grandmother

My grandmother, who is over 90 years old, has been diagnosed with stage II breast cancer. What are the concerns regarding her subsequent treatment?

Recently, it was discovered that my 90-year-old grandmother has stage II breast cancer, PR+ER+Her2+(currently undergoing FISH testing).
I would like to ask:
1.
If examinations show no metastasis, but due to her age and the inherent risks of surgery, she chooses to forgo surgical intervention, can she opt for direct hormonal therapy and targeted therapy with trastuzumab (for Her2+) without undergoing radiation or chemotherapy (considering the side effects and her physical condition)? Is it possible to proceed with adjuvant therapy without surgery? Is there insurance coverage for this treatment?
2.
If examinations reveal distant metastasis, can she still choose hormonal and targeted therapy? Is there insurance coverage for this treatment?

meg, 30~39 year old female. Ask Date: 2017/05/27

Dr. Chen Sirong reply Oncology

Meg, 30 years old, female.

1.
After examination, there is no metastasis, but due to age and the inherent risks of surgery, she chooses to forgo surgical intervention.
Can she opt for direct hormonal therapy and targeted therapy with government insurance coverage for trastuzumab (for HER2+), without undergoing radiation or chemotherapy (due to side effects and physical considerations)? Or is it true that without surgery, subsequent adjuvant treatment cannot be performed? Is there insurance coverage for this?
A:
1.1 Without surgery, can subsequent adjuvant treatment still be performed?
A: Adjuvant treatment is supplementary; without primary treatment, adjuvant therapy cannot cure the disease.
What is the significance of doing or not doing it? This should be discussed with the physician; it is not that it cannot be done, but rather what the implications of doing so are.
1.2 Can she choose to directly undergo hormonal therapy and targeted therapy with government insurance coverage for trastuzumab (for HER2+), without undergoing radiation or chemotherapy (due to side effects and physical considerations)?
A: After considering the implications, such a choice can be made.
However, (the physician is not simply following your commands regarding medication).
How to communicate with the physician while respecting their expertise is also a concern for the family.
1.3 Is there insurance coverage for this?
A: It cannot be said that there is none; it depends on whether the physician prescribes such medication and whether it will be deemed ineffective treatment by the insurance review.
2.
If distant metastasis is discovered after examination, can hormonal and targeted therapy still be chosen? Is there insurance coverage for this?
A: Yes, it is reasonable and there is insurance coverage.
3.
My personal recommendations:
3.1 Follow standard treatment: surgery combined with hormonal therapy and targeted therapy, as surgery may increase the risk of stroke, heart disease, infection, and sepsis within a month.
There is also a possibility of not waking up from anesthesia during the procedure.
3.2 If opting not to undergo surgery, and if the patient is otherwise healthy and can live for several years, the tumor may grow and cause foul odors from the skin, muscle and bone pain, or spread throughout the body, leading to various symptoms regardless of whether hormonal therapy and targeted therapy are accepted.
These treatments only delay the symptoms caused by tumor growth.
3.3 Therefore, some families choose surgery, hoping for a cure; if luck is not on their side, they do not have to endure prolonged suffering.
3.4 Of course, some choose option 3.1, while others choose option 3.2, all out of love, trusting that the physician will do their utmost to assist in their choices.
Taoyuan Hospital, Dr.
Chen Sih-Rong.

Reply Date: 2017/05/27

More Info

Navigating treatment options for breast cancer, especially in elderly patients, requires careful consideration of various factors, including the patient's overall health, cancer stage, and potential treatment side effects. In the case of your 90-year-old grandmother diagnosed with stage II breast cancer (PR+, ER+, HER2+), there are several important aspects to discuss regarding her treatment options.

1. Surgery and Alternative Treatments: If your grandmother has been evaluated and found not to have metastasis, the decision to forego surgery due to her age and the associated risks is understandable. In such cases, it is indeed possible to consider hormone therapy (such as Tamoxifen or aromatase inhibitors) and targeted therapy (like trastuzumab for HER2+ cancers) as primary treatment options. These therapies can be effective in managing hormone receptor-positive breast cancer and HER2-positive breast cancer, respectively.
However, it is crucial to understand that while these treatments can help control the disease, they are not curative in the absence of surgery. The role of adjuvant therapy (which typically follows surgery) is to reduce the risk of recurrence, and without surgery, the effectiveness of these treatments may be limited. Therefore, it is essential to have a thorough discussion with her oncologist about the potential benefits and limitations of pursuing hormone and targeted therapies without surgical intervention.

Regarding insurance coverage, many health insurance plans in the U.S. do provide coverage for hormone therapy and targeted therapy, especially if they are deemed medically necessary. However, the specifics can vary based on the insurance provider and the individual’s policy. It is advisable to consult with the healthcare provider's office or the insurance company to confirm coverage details.

2. Treatment Options with Metastasis: If subsequent evaluations reveal distant metastasis, the treatment landscape changes. In cases of metastatic breast cancer, hormone therapy and targeted therapy remain viable options. Hormone receptor-positive cancers can still respond to hormone therapy, and HER2-positive cancers can benefit from targeted therapies like trastuzumab, regardless of the cancer's stage.
Again, insurance coverage for these treatments is typically available, but it is essential to verify with the insurance provider. The oncologist will also consider the patient's overall health and any comorbidities when recommending treatment options.

3. Quality of Life Considerations: Given your grandmother's advanced age, quality of life is a significant factor in treatment decisions. The side effects of chemotherapy can be particularly challenging for elderly patients, and the potential benefits must be weighed against the risks. Hormone and targeted therapies generally have a more favorable side effect profile compared to chemotherapy, making them preferable options for older patients who may not tolerate more aggressive treatments well.

4. Communication with Healthcare Providers: It is vital for family members to engage in open discussions with healthcare providers about the goals of treatment, potential side effects, and the patient's wishes. This collaborative approach ensures that the treatment plan aligns with your grandmother's values and preferences.

In summary, while surgery is often a cornerstone of breast cancer treatment, there are alternative options available for elderly patients who may not be suitable candidates for surgery. Hormone therapy and targeted therapy can be effective in managing the disease, and insurance coverage is generally available for these treatments. If metastasis is present, these therapies remain valid options. Ultimately, the decision should be made in consultation with her healthcare team, considering her overall health, treatment goals, and quality of life.

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