Is Age 50 Relevant for Decisions in Early HR-Positive Breast Cancer?

At the Great Debates and Updates in Women’s Oncology meeting, Denise Yardley, MD, Sarah Cannon Research Institute, Nashville, Tennessee, participated in a debate on whether age 50 is relevant marker for patients with early hormone receptor (HR)-positive breast cancer.

Dr Yardley explained, “Medicine remains an art, and you have to factor in multiple other data points in making decisions for those hormone receptor-positive, early-stage breast cancer patients.”

Transcript:

We're here at the Great Debates in Women’s Oncology. I'm Denise Yardley. I am a breast medical oncologist and associate director of breast cancer research at the Sarah Cannon Research Institute in Nashville, Tennessee. And the topic that I will actually be debating today is a very pertinent topic on the role of age in determining decision trees for the hormone receptor-positive, early-stage breast cancer patients.

I think we struggle with what are the permutations in making these decisions for our hormone receptor-positive patients. Endocrine therapies are a pretty well-established and accepted option that encompasses most of these hormone receptor-positive patients. But it really comes down to the role of chemotherapy and who benefits and who does not and how do we make those decisions.

One of those is an arbitrary decision based on age and age 50 is a cutoff that's derived often from the fact that it's a good marker in time to reassess menopause status of whether a patient is premenopausal or postmenopausal — not that the body knows it's supposed to stop at age 50. There are clearly patients that menstruate past that and those that stop beforehand. And that, again, you can already see is a premise of the arbitrariness of using age as a cutoff. In looking at the data and trying to validate, I think we still struggle.

We've come a long way in terms of looking at genomic markers and tumors, and while in one way that should be a peer assessment of itself in measuring genetic profiles in tumors, which genes are on, which genes are off in terms of proliferation or oncogenic signaling, but then we do know, and I'll present some of the data with respects to that that gene expression signals do differ by age, but not by age 50. We have a factor of looking at many of the studies look at 40. Even age 50 is perplexing —50 and above or less than 50 as just one indication again. Does a tumor know you’re 50? Is it when the tumor starts? It started growing in the 40s and was found at the 50s. You can see the challenges start.

I had a patient in my clinic who was diagnosed and saw me at 49, and she had a birthday interval when I sent off her genomic profiling. She came back from surgery, and she was 50. It makes it a little hard to see straddling just a specific point in time. I looked at some data and if you look at a patient pre-menopausal at age 50 and post-menopausal at age 50, just using that same identical age, the outcomes are different.

This highlights that while it is a caveat that we use in making decisions, it does come with its own struggles and how to factor in age and mental health status. Even looking at the time menarche starts for a patient. There are studies saying 11 or 12 is an average. If a patient started at age 9, that really increases the risk much more than someone menstruating past age 50. It shows the struggles in that role age plays on the biologic challenges of a tumor, these gene expression sets, and the menopausal status.

That gets us back to age 50 as an easy backstreet marker, but is not clean, and by all means, I think medicine remains an art, and you have to factor in multiple other data points in making decisions for those hormone receptor-positive, early-stage breast cancer patients.

Source:

Yardley, D. “Debate: Decisions in Early HR+ Disease: Does Age 50 Really Matter THAT Much? — No” Presented at Great Debates and Updates in Women’s Oncology. May 3-4, 2024; New York, NY.