Chemotherapy Decisions for Elderly Cancer Patients

Some questions regarding chemotherapy?

Dear Dr.
Fan,
My mother is 78 years old and discovered a lump in her breast in February.
She underwent surgery at Dalin Tzu Chi Hospital, where a biopsy confirmed it was cancer.
A few weeks after the surgery, we received the pathology report, which indicated it was stage II and had a Her2+++ factor (the doctor mentioned this receptor is associated with a higher risk of recurrence).
The attending surgeon advised against chemotherapy for the time being and prescribed a medication to suppress the cancer.
My mother has been having weekly blood tests.

After a few weeks, the doctor reviewed the latest blood test results and recommended that we consult an oncologist, mentioning only that we should discuss chemotherapy options, stating that if chemotherapy is necessary, there is still time since only two months have passed since the surgery.
Upon visiting the oncology department, the attending physician reviewed the reports and simply stated that my mother had experienced a decrease in white blood cells after taking the surgeon's medication for a few weeks, and advised against continuing it due to her age and overall health (elevated liver function tests, vascular sclerosis and narrowing, hypertension, and pre-meal blood sugar of 130).
The plan was to continue monitoring her condition with weekly blood tests and outpatient visits.
By the fourth week, I couldn't help but ask the doctor what exactly we were checking for with the weekly blood tests, as it seemed like nothing was being done.
The doctor explained that they were monitoring tumor markers.
I inquired whether the markers were within normal ranges, to which the doctor replied that they were.
I then asked if treatment would still be effective if something abnormal were to be detected later, and the doctor responded that it would be too late.
I was confused and pressed further, asking why we were checking if the next recurrence would mean systemic spread and that treatment would be too late.
I also pointed out that the pathology report indicated a predisposition for recurrence, which felt like we were being told to wait for the worst outcome.
The doctor paused and explained that my mother could not tolerate chemotherapy, which might provide only minimal benefit but could also pose significant risks.
He mentioned that it was possible she might never experience a recurrence and that her current tests were normal, advising that we would address any issues as they arose.
I would like to ask you, in my mother's situation, is there truly nothing that can be done, and should we simply wait and see? I have heard quite a bit about the side effects of chemotherapy.
I also saw a previous letter from a gentleman who wrote to you about some disputes regarding chemotherapy, and I do not want to repeat those mistakes.
However, the hospital has provided no relevant educational resources, which has left me quite anxious and unsure of what to do.
I hope to seek your professional guidance on this matter.
Thank you!
Sincerely,
Yuan Qingxi

Yuan, 50~59 year old female. Ask Date: 2007/07/19

Dr. Fan Sheng reply Oncology

Dear Mr.
Yuan,
Hello.
First of all, considering your mother's age, it is highly likely that her breast cancer specimen's estrogen receptor (ER) is positive.
If this is the case, I recommend administering the oral estrogen receptor antagonist Tamoxifen for two years, followed by switching to an aromatase inhibitor for three years as a preventive treatment for recurrence.
However, if the estrogen receptor (ER) is negative and Her2 is strongly positive, for stage II breast cancer, chemotherapy should still be considered as adjuvant therapy.
Given your mother's advanced age, chemotherapy does pose risks, and the concerns of the attending physician are valid.

The oral medication prescribed by the surgeon is likely a chemotherapy drug (possibly Ufur).
I suggest considering a lower dosage of Ufur, supplemented with the monoclonal antibody targeting Her2 (Trastuzumab, brand name Herceptin), administered as an injection once a month for a total of six months.
Of course, the National Health Insurance Administration has not yet approved coverage for Herceptin used for recurrence prevention, so the monoclonal antibody would need to be self-funded.
This antibody is not inexpensive and can be a financial burden, but its side effects are significantly reduced compared to traditional standard chemotherapy.

You may want to discuss the feasibility of this treatment with your mother's attending physician.

Wishing you all the best!
Sincerely,
Sheng Fan

Reply Date: 2007/07/19

More Info

When it comes to chemotherapy decisions for elderly cancer patients, particularly those like your mother who is 78 years old and diagnosed with stage II breast cancer with HER2 positivity, there are several critical factors to consider. The decision-making process is often complex and should involve a thorough discussion between the patient, their family, and the healthcare team.

Understanding the Situation
Your mother’s diagnosis indicates that she has a higher risk of recurrence due to the HER2-positive status. Typically, HER2-positive cancers are more aggressive, and adjuvant chemotherapy is often recommended to reduce the risk of recurrence. However, the decision to proceed with chemotherapy must take into account her overall health, existing comorbidities, and her ability to tolerate treatment.

Risks and Benefits of Chemotherapy
Chemotherapy can indeed be beneficial in reducing the risk of cancer recurrence, but it is not without its risks, especially in elderly patients. Common side effects include:
- Myelosuppression: This can lead to a decrease in white blood cells, increasing the risk of infections.

- Nausea and Vomiting: These can significantly affect quality of life and nutritional intake.

- Fatigue: Many patients experience significant fatigue, which can impact daily activities.

- Organ Toxicity: Given your mother’s elevated liver enzymes and other health issues, the risk of chemotherapy-induced toxicity is a concern.

In your mother’s case, the oncologist has indicated that the potential benefits of chemotherapy may not outweigh the risks, especially considering her age and health status. The oncologist’s recommendation to monitor her condition and perform regular blood tests to check tumor markers is a common approach in such scenarios. This strategy allows for close observation without immediately subjecting her to the potential harms of chemotherapy.

The Role of Monitoring
The monitoring approach can be frustrating, especially when there is a fear of cancer recurrence. However, it is essential to understand that not all patients will experience a recurrence, and some may live for years without the cancer returning. The oncologist’s perspective is that your mother is currently stable, and the risks associated with chemotherapy may not justify the potential benefits.

Alternative Treatments
In cases where chemotherapy is deemed too risky, other treatment options may be considered, such as:
- Targeted Therapy: For HER2-positive breast cancer, medications like trastuzumab (Herceptin) can be effective and may have a different side effect profile compared to traditional chemotherapy.

- Hormonal Therapy: If applicable, hormonal treatments can also be a part of the management plan, especially if the cancer is hormone receptor-positive.

- Palliative Care: If the focus shifts towards quality of life, palliative care can help manage symptoms and improve comfort without aggressive treatments.

Communication with Healthcare Providers
It is crucial to maintain open communication with your mother’s healthcare team. If you have concerns about the monitoring approach or the lack of immediate treatment, express these concerns directly to her oncologist. Ask for clarity on the monitoring process, the criteria for initiating treatment, and what signs or symptoms would warrant a change in the current management plan.

Conclusion
In summary, while the fear of cancer recurrence is valid, the decision to pursue chemotherapy in elderly patients must be balanced against their overall health and quality of life. Your mother’s healthcare team is likely considering her best interests, and it may be beneficial to explore all available options, including targeted therapies and supportive care. Engaging in an open dialogue with her doctors can provide clarity and help you make informed decisions moving forward.

Similar Q&A

Understanding Lung Tumors: Treatment Options for Elderly Patients

Hello, my grandmother is nearly 90 years old, weighs 48 kg, and is able to take care of herself. She requires a cane to walk due to knee joint degeneration. She has been experiencing a long-term cough and has only been receiving cough and expectorant medication from the clinic. R...

Dr. Ke Zhengchang reply Pulmonology
Hello: Based on your description, if a 90-year-old patient has lung cancer, the first step is to identify the type of cancer cells and determine the stage of the lung cancer. If it is stage I or II, radiation therapy or surgical resection may be considered (provided that cardiac ...

Is Chemotherapy Suitable for Elderly Patients After Pancreatic Cancer Surgery?

Dear Dr. Chen, I would like to ask you a few questions regarding my mother, who is 88 years old. She underwent surgery for a pancreatic tumor in mid-May, and nearly three months later, on July 20, her CA 19-9 level was 408. On August 5, her CA 19-9 level rose to 3390, while her ...

Dr. Chen Yunfang reply Oncology
Hello: Based on the questions you raised, I can see that you have thought deeply and far about future matters. Pancreatic cancer surgery is considered one of the most complex procedures in surgery (it is difficult to perform, the operation time is extremely long, and the wound ta...

Understanding Treatment Options for Advanced Liver Cancer in Elderly Patients

Dear Doctor, My mother is 89 years old. Last year, she was diagnosed with liver cancer, and after undergoing transarterial embolization and radiofrequency ablation, it was discovered that there were metastases, which were also treated with radiofrequency ablation. This year, it ...

Dr. Lai Yicheng reply Oncology
Dear Sir, Regarding your inquiry, according to the National Health Insurance regulations, there are conditions that qualify for coverage. However, whether your mother’s physical condition can tolerate the side effects of targeted therapy or chemotherapy needs to be assessed thro...

Understanding Lymphoma: Treatment Options and Care for Elderly Patients

Hello Doctor, my grandfather was recently diagnosed with lymphoma. However, the doctor advised against surgery due to concerns about infection. Could you explain why? Wouldn't the cure rate be higher if surgery were performed? Additionally, the doctor mentioned chemotherapy,...

Dr. Lin Zongzhe reply Oncology
Hello: Surgery for lymphoma generally does not improve the cure rate; chemotherapy is the primary treatment for most lymphomas. The cure rate is determined by prognostic factors such as the patient's overall health, the classification of the cancerous tissue, and the clinica...