It is estimated that the number of older women living with breast cancer will quadruple by 2040 [1]. Despite this, there is a lack of strong evidence and guidelines to support management decisions for this population.



This article has evolved from a conference session on this subject, held at the 2020 UK Interdisciplinary Breast Cancer Symposium (UKIBCS; West Midlands, UK, 27–28 January 2020) [2]. The UKIBCS is a biennial meeting for all those with an active interest in breast cancer research and treatment, hosted by the charity Breast Cancer Now (London, UK), in collaboration with eight other breast cancer focused specialist societies.



In this editorial, we discuss key issues in the management of breast cancer in older women, which include both tumor and patient factors. We also review current national initiatives to tackle these issues and summarize ongoing work in this field

Cheung, K-L.

Jauhari, Y.

Morgan, J.

Parks, R.M.

Wyld, L.

English

White Rose Research Online

This is a repository copy of Special issues for older women with primary breast cancer.White Rose Research Online URL for this paper:http://eprints.whiterose.ac.uk/162029/Version: Published VersionArticle:Parks, R.M., Jauhari, Y., Morgan, J. et al. (2 more authors) (2020) Special issues for older women with primary breast cancer. Breast Cancer Management. ISSN 1758-1923 https://doi.org/10.2217/bmt-2020-0022eprints@whiterose.ac.ukhttps://eprints.whiterose.ac.uk/Reuse This article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND) licence. This licence only allows you to download this work and share it with others as long as you credit the authors, but you can’t change the article in any way or use it commercially. More information and the full terms of the licence here: https://creativecommons.org/licenses/ Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. EditorialFor reprint orders, please contact: reprints@futuremedicine.comSpecial issues for older women with primarybreast cancerRuth Mary Parks1 , Yasmin Jauhari2 , Jenna Morgan3 , Lynda Wyld3 &Kwok-Leung Cheung*,11Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Royal Derby HospitalCentre, Derby, DE22 3DT, UK2Clinical Effective Unit, Royal College of Surgeons of England, London, WC2A 3PE, UK3Department of Oncology & Metabolism, The Medical School, University of Shefield, Shefield, S10 2SJ, UK*Author for correspondence: kl.cheung@nottingham.ac.uk“The future of treatment for older women with primary breast cancer should aim to utilize tumorand geriatric factors to deliver personalized cancer care, including in patients with dementia.”First draft submitted: 29 April 2020; Accepted for publication: 18 May 2020; Published online:10 June 2020Keywords: biological assessment • geriatric assessment • older women • primary breast cancerIt is estimated that the number of older women living with breast cancer will quadruple by 2040 [1]. Despite this,there is a lack of strong evidence and guidelines to support management decisions for this population.This article has evolved from a conference session on this subject, held at the 2020 UK Interdisciplinary BreastCancer Symposium (UKIBCS; West Midlands, UK, 27–28 January 2020) [2]. The UKIBCS is a biennial meetingfor all those with an active interest in breast cancer research and treatment, hosted by the charity Breast CancerNow (London, UK), in collaboration with eight other breast cancer focused specialist societies.In this editorial, we discuss key issues in the management of breast cancer in older women, which include bothtumor and patient factors. We also review current national initiatives to tackle these issues and summarize ongoingwork in this field.Key perspectivesTumor factorsEmerging data suggest that the biology of breast cancer in older women is different to that in younger women,although overall research work is still lacking in this area [3].The Nottingham group describes possibly the largest consecutive series of older women with primary breastcancer, with both clinical follow-up data and tumor samples available, documented in the literature. Between 1973and 2010, 1758 women ≥70 years of age with early stage (clinically ≤5 cm) breast cancer without evidence ofmetastases at diagnosis presented to the unit.Work in this cohort has shown there are differences in survival outcome based on the degree of ER positivity. In asubset of 1085 patients, those with tumors with ER H-score of ≥250 (out of 300, high ER expression) were found tohave equivalent breast-cancer-specific-survival (BCSS) regardless of primary surgery or primary endocrine therapy(PET), whereas for patients with tumors with an H-score <250, surgery produced better BCSS (p < 0.001) [4].Another example is in those patients with HER2-positive tumors. A comparison of 130 younger (<70 years)patients with 43 older patients identified as having HER2-positive tumors found no difference in BCSS, despiteminimal use of chemotherapy in the older age group, compared with frequent use in the younger group [5]. Theseresults were replicated in patients with triple negative breast cancer [6]. This suggests that, overall, older womenexpress a less aggressive phenotype of breast cancer compared with their younger counterparts.The Nottingham group has gone on to assess a panel of 25 biomarkers in 575 older women undergoing surgery [3].Cluster analysis demonstrated a novel subtype – low ER luminal (with low ER expression but high expression ofBreast Cancer Manag. (2020) eISSN 1758-193110.2217/bmt-2020-0022 C© 2020 Kwok-Leung CheungEditorial Parks, Jauhari, Morgan, Wyld & Cheungluminal cytokeratins), previously not seen in younger women. Its identification may explain differences in clinicaloutcome among older women and needs future investigations.Patient factorsApart from biological differences in the tumor, the older population has unique personal needs, which should beconsidered in treatment discussions. Comprehensive geriatric assessment (CGA) is a process used by healthcareprofessionals to assess an older person’s physical health and function, mental health and social circumstances. Geri-atric assessment is recommended by the International Society of Geriatric Oncology (Châtelaine, Switzerland) [7]but there is no consensus on how it should be implemented or the results interpreted.Alongside the work described above, the Nottingham group has an ongoing multicenter international prospectivestudy exploring the potential value of CGA in primary breast cancer patients. A cancer-specific validated CGAtool [8], as well as measures of quality of life (QoL) are used within 6 weeks of diagnosis and again at 6 months.Preliminary results show that increasing age, comorbidity, number of medications and slower ‘timed-up-and-go’score are associated with higher likelihood of receipt of PET over surgery [9].When exploring treatment decision making with patients, they felt breast cancer treatment was a ‘trade off ’between risks and benefits of treatment. Furthermore, older women may value QoL and retention of functionalindependence more highly than extending the length of life [8,10].Current national initiativesBridging the Age Gap studyThe Age Gap study is a multicenter prospective cohort study aiming to optimize the management of older (>70years) women with breast cancer [11]. This is an extremely important piece of research due to the difficulty ofrandomization in this population, resulting in a paucity of randomized controlled trial data. The Age Gap study iscollecting observational real-world data but then using propensity score matching to adjust for treatment allocationbias rather than randomization. The key question for the Age Gap study was to determine which subgroup of olderwomen could be safely offered nonstandard care (i.e., PET for primary treatment and omission of chemotherapyas adjuvant treatment) based on their health, fitness, frailty and tumor characteristics. A key element of the studywas to collect detailed QoL data on all patients in light of the importance of this to women in this age group.The study is now complete and data analysis is ongoing. The study recruited over 3400 women over the age of70 years from 57 centers in England and Wales. Preliminary results discussed here were presented at the UKIBCSand are yet to be published [2].A comparison of 672 patients (matched for age, frailty and comorbidity) receiving either PET or surgery showedno difference in BCSS regardless of treatment. After treatment, patients in both groups saw an initial decrease inQoL from baseline; however, this recovered for patients receiving PET, but not for patients undergoing surgery bythe 2-year mark. This suggests that there is a group of older women who will have no oncological benefit fromsurgery and in fact, surgery may be detrimental to their QoL.The second phase of the study involved the development of a predictive tool to tailor treatment options accordingto breast cancer stage and biology and their age, fitness and frailty. A Decision Support Instrument (DESI) wasdeveloped to assist older women in making informed decisions about their preferred treatment [11,12]. A multicentercluster randomized trial was then nested within the main Age Gap observational study in 46 of the 57 centers.These 46 centers were randomized to continue with normal decision-making practice or to have training and theuse of the online DESI. The trial has now completed recruitment and randomized 670 patients to the intervention(use of the DESI) and 669 to standard care. Preliminary results show early trends toward improved QoL andidentical BCSS in patients who use the DESI, compared with those treated by standard care. The online tool isnow freely available to use [12].A view on dementiaThe National Audit of Breast Cancer in Older Patients is part of an effort to evaluate the quality of cancer careprovided to older (>70 years) women with breast cancer in England and Wales [13]. At the time of publication ofthe third annual report in 2019 [13], 147,162 older women diagnosed with breast cancer between 2014 and 2017had been recruited from 130 centers.10.2217/bmt-2020-0022 Breast Cancer Manag. (2020) future science groupIssues for older women with breast cancer EditorialIn the 2017 report, a series of case vignettes were used to gain perspective on patient factors that influence clinicaltreatment decisions. The results highlighted inconsistencies in primary treatment preferences of women with breastcancer and complex multimorbidities such as cognitive impairment and dementia [14].Fewer women with dementia present with breast cancer at an early stage. In a large (n = 31,935) retrospectivecohort study, Raji et al. [15] found that 28% of patients with breast cancer and dementia were diagnosed with stage Idisease, compared with 50.7% of patients without dementia. Furthermore, it is reported that women with dementiaare up to 40% less likely to have surgery [16] compared with women without dementia. The reasons for this arecomplex and multifactorial. For example, patients with dementia are more likely to have competing comorbiditieswhich may affect their suitability for general anesthesia [17]. Cohort studies have demonstrated a higher rate ofpostoperative complications in patients with dementia and breast cancer [18], as well as long-term cognitive effectsand compliance issues for adjuvant therapy [19], but studies of this kind are few. At last, the impact of dementia andbreast cancer on a patient’s life expectancy remains poorly understood.Given the increasing global burden of dementia [20], it is proposed that the approach to a patient with dementiashould be as any other comorbidity – recognition, optimization and management that involves shared decisionmaking.ConclusionBoth tumor and patient factors are different in the older compared with younger woman with breast cancer. Thefuture of treatment for older women with primary breast cancer should aim to utilize tumor and geriatric factors todeliver personalized cancer care, including in patients with dementia. This could be supported using tumor-basedprognostic and predictive tools, geriatric assessment and patient decision-making tools. Research and audits in thisarea provide important insights and should continue.AcknowledgmentsThe views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Departmentof Health.Financial & competing interests disclosureThe Age Gap study represents independent research funded by the National Institute for Health Research (NIHR) under its Pro-gramme Grants for Applied Research Programme (grant reference number: RP-PG-1209-10071). The authors have no other rel-evant afiliations or inancial involvement with any organization or entity with a inancial interest in or inancial conlict with thesubject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.Open accessThis work is licensed under the Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license,visit http://creativecommons.org/licenses/by-nc-nd/4.0/ReferencesPapers of special note have been highlighted as: • of interest1. World Health Organization. International agency for research on cancer (2019). iarc.f r2. Cheung KL, Ring A. Special issues for elderly patients session. Presented at: UK Interdisciplinary Breast Cancer Symposium 2020: BreastCancer Research and Treatment. Birmingham, UK (27–28 January 2020).• You can find all of the conference proceedings from the UK Interdisciplinary Breast Cancer Symposium 2020 here.3. Syed BM, Green AR, Paish EC et al. Biology of primary breast cancer in older women treated by surgery: with correlation withlong-term clinical outcome and comparison with their younger counterparts. Br. J. Cancer 108(5), 1042–1051 (2013).• This is a summary of analysis of a panel of biological markers in a large cohort of older women with primary breast cancer. Tothe best of our knowledge, this cohort is the largest of its kind, for this type of research, worldwide.4. Syed BM, Al-Khyatt W, Johnston SJ et al. Long-term clinical outcome of oestrogen receptor-positive operable primary breast cancer inolder women: a large series from a single centre. Br. J. Cancer 104(9), 1393–1400 (2011).5. Syed BM, Green AR, Ellis IO, Cheung KL. Human epidermal growth receptor-2 overexpressing early operable primary breast cancers inolder (≥70 years) women: biology and clinical outcome in comparison with younger (<70 years) patients. Ann. Oncol. 25(4), 837–842(2014).future science group 10.2217/bmt-2020-0022Editorial Parks, Jauhari, Morgan, Wyld & Cheung6. Syed BM, Green AR, Nolan CC, Morgan DAL, Ellis IO, Cheung KL. Biological characteristics and clinical outcome of triple negativeprimary breast cancer in older women: comparison with their younger counterparts. PLoS ONE 9(7), e100573 (2014).7. Wildiers H, Heeren P, Puts M et al. International society of geriatric oncology consensus on geriatric assessment in older patients withcancer. J. Clin. Oncol. 32(24), 2595–2603 (2014).8. Hurria A, Gupta S, Zauderer M et al. Developing a cancer-specific geriatric assessment: a feasibility study. Cancer 104(9), 1998–2005(2005).9. Parks RM, Hall L, Tang SW et al. The potential value of comprehensive geriatric assessment in evaluating older women with primaryoperable breast cancer undergoing surgery or non-operative treatment: a pilot study. J. Geriatr. Oncol. 6(1), 46–51 (2015).• This is a pilot study examining the use of a breast cancer specific comprehensive geriatric assessment, specifically in older womenwith primary breast cancer.10. Zahit RA, Parks RM, Howard P, Blake H, Cheung KL. Baseline quality of life evaluation in older women with primary operable breastcancer and its relationship with different treatments. J. Clin. Oncol. 36(Suppl. 15), e12601 (2018).11. The University of Sheffield. Bridging the age gap in breastcancer (2020). www.sheffield.ac.uk/medicine/research/research-themes/cancer/age-gap• This is the main reference to the Bridging the Age Gap study and contains information on study design, analysis and relevantpublication to date.12. The University of Sheffield. Age gap decision tool (2020). https://agegap.shef.ac.uk/13. National Audit of Breast Cancer in Older Patients. NABCOP: annual report 2019 (2019).www.nabcop.org.uk/reports/nabcop-2019-annual-report/• This 2019 report from National Audit of Breast Cancer in Older Patients contains the most recent published findings from thisnationwide audit.14. National Audit of Breast Cancer in Older Patients. NABCOP: annual report 2017 (2017).www.nabcop.org.uk/reports/nabcop-2017-annual-report/15. Raji MA, Kuo Y-F, Freeman JL, Goodwin JS. Effect of a dementia diagnosis on survival of older patients after a diagnosis of breast,colon, or prostate cancer: implications for cancer care. Arch. Intern. Med. 168(18), 2033–2040 (2008).16. Gorin SS, Heck JE, Albert S, Hershman D. Treatment for breast cancer in patients with Alzheimer’s disease. J. Am. Geriatr. Soc. 53(11),1897–1904 (2005).17. Prince M KM, Guerchet M, McCrone P et al. Dementia UK: update second edition report produced by KCL and the LSE for theAlzheimer’s society (2014). http://eprints.lse.ac.uk/59437/1/Dementia UK Second edition - Overview.pdf18. Hu CJ, Liao CC, Chang CC, Wu CH, Chen TL. Postoperative adverse outcomes in surgical patients with dementia: a retrospectivecohort study. World J. Surg. 36(9), 2051–2058 (2012).19. Phillips KA, Ribi K, Sun Z et al. Cognitive function in postmenopausal women receiving adjuvant letrozole or tamoxifen for breastcancer in the BIG 1–98 randomized trial. Breast 19(5), 388–395 (2010).20. GBD 2016 Dementia Collaborators. Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: asystematic analysis for the global burden of disease study 2016. Lancet Neurol. 18(1), 88–106 (2019).• This study is important in understanding the impact of dementia in the population on a worldwide scale and has significantfindings.10.2217/bmt-2020-0022 Breast Cancer Manag. (2020) future science group

Special issues for older women with primary breast cancer

It is estimated that the number of older women living with breast cancer will quadruple by 2040. Despite this, there is a lack of strong evidence and guidelines to support management decisions for this population.This article has evolved from a conference session on this subject, held at the 2020 UK Interdisciplinary Breast Cancer Symposium (UKIBCS; West Midlands, UK, 27–28 January 2020). The UKIBCS is a biennial meeting for all those with an active interest in breast cancer research and treatment, hosted by the charity Breast Cancer Now (London, UK), in collaboration with eight other breast cancer focused specialist societies.In this editorial, we discuss key issues in the management of breast cancer in older women, which include both tumor and patient factors. We also review current national initiatives to tackle these issues and summarize ongoing work in this field

Parks, Ruth Mary

Jauhari, Yasmin

Morgan, Jenna

Wyld, Lynda

Cheung, Kwok-Leung

Repository@Nottingham

EditorialFor reprint orders, please contact: reprints@futuremedicine.comSpecial issues for older women with primarybreast cancerRuth Mary Parks1 , Yasmin Jauhari2 , Jenna Morgan3 , Lynda Wyld3 &Kwok-Leung Cheung*,11Nottingham Breast Cancer Research Centre, School of Medicine, University of Nottingham, Royal Derby HospitalCentre, Derby, DE22 3DT, UK2Clinical Effective Unit, Royal College of Surgeons of England, London, WC2A 3PE, UK3Department of Oncology & Metabolism, The Medical School, University of Sheffield, Sheffield, S10 2SJ, UK*Author for correspondence: kl.cheung@nottingham.ac.uk“The future of treatment for older women with primary breast cancer should aim to utilize tumorand geriatric factors to deliver personalized cancer care, including in patients with dementia.”First draft submitted: 29 April 2020; Accepted for publication: 18 May 2020; Published online:10 June 2020Keywords: biological assessment • geriatric assessment • older women • primary breast cancerIt is estimated that the number of older women living with breast cancer will quadruple by 2040 [1]. Despite this,there is a lack of strong evidence and guidelines to support management decisions for this population.This article has evolved from a conference session on this subject, held at the 2020 UK Interdisciplinary BreastCancer Symposium (UKIBCS; West Midlands, UK, 27–28 January 2020) [2]. The UKIBCS is a biennial meetingfor all those with an active interest in breast cancer research and treatment, hosted by the charity Breast CancerNow (London, UK), in collaboration with eight other breast cancer focused specialist societies.In this editorial, we discuss key issues in the management of breast cancer in older women, which include bothtumor and patient factors. We also review current national initiatives to tackle these issues and summarize ongoingwork in this field.Key perspectivesTumor factorsEmerging data suggest that the biology of breast cancer in older women is different to that in younger women,although overall research work is still lacking in this area [3].The Nottingham group describes possibly the largest consecutive series of older women with primary breastcancer, with both clinical follow-up data and tumor samples available, documented in the literature. Between 1973and 2010, 1758 women ≥70 years of age with early stage (clinically ≤5 cm) breast cancer without evidence ofmetastases at diagnosis presented to the unit.Work in this cohort has shown there are differences in survival outcome based on the degree of ER positivity. In asubset of 1085 patients, those with tumors with ER H-score of ≥250 (out of 300, high ER expression) were found tohave equivalent breast-cancer-specific-survival (BCSS) regardless of primary surgery or primary endocrine therapy(PET), whereas for patients with tumors with an H-score <250, surgery produced better BCSS (p < 0.001) [4].Another example is in those patients with HER2-positive tumors. A comparison of 130 younger (<70 years)patients with 43 older patients identified as having HER2-positive tumors found no difference in BCSS, despiteminimal use of chemotherapy in the older age group, compared with frequent use in the younger group [5]. Theseresults were replicated in patients with triple negative breast cancer [6]. This suggests that, overall, older womenexpress a less aggressive phenotype of breast cancer compared with their younger counterparts.The Nottingham group has gone on to assess a panel of 25 biomarkers in 575 older women undergoing surgery [3].Cluster analysis demonstrated a novel subtype – low ER luminal (with low ER expression but high expression ofBreast Cancer Manag. (2020) eISSN 1758-193110.2217/bmt-2020-0022 C© 2020 Kwok-Leung CheungEditorial Parks, Jauhari, Morgan, Wyld & Cheungluminal cytokeratins), previously not seen in younger women. Its identification may explain differences in clinicaloutcome among older women and needs future investigations.Patient factorsApart from biological differences in the tumor, the older population has unique personal needs, which should beconsidered in treatment discussions. Comprehensive geriatric assessment (CGA) is a process used by healthcareprofessionals to assess an older person’s physical health and function, mental health and social circumstances. Geri-atric assessment is recommended by the International Society of Geriatric Oncology (Chaˆtelaine, Switzerland) [7]but there is no consensus on how it should be implemented or the results interpreted.Alongside the work described above, the Nottingham group has an ongoing multicenter international prospectivestudy exploring the potential value of CGA in primary breast cancer patients. A cancer-specific validated CGAtool [8], as well as measures of quality of life (QoL) are used within 6 weeks of diagnosis and again at 6 months.Preliminary results show that increasing age, comorbidity, number of medications and slower ‘timed-up-and-go’score are associated with higher likelihood of receipt of PET over surgery [9].When exploring treatment decision making with patients, they felt breast cancer treatment was a ‘trade off ’between risks and benefits of treatment. Furthermore, older women may value QoL and retention of functionalindependence more highly than extending the length of life [8,10].Current national initiativesBridging the Age Gap studyThe Age Gap study is a multicenter prospective cohort study aiming to optimize the management of older (>70years) women with breast cancer [11]. This is an extremely important piece of research due to the difficulty ofrandomization in this population, resulting in a paucity of randomized controlled trial data. The Age Gap study iscollecting observational real-world data but then using propensity score matching to adjust for treatment allocationbias rather than randomization. The key question for the Age Gap study was to determine which subgroup of olderwomen could be safely offered nonstandard care (i.e., PET for primary treatment and omission of chemotherapyas adjuvant treatment) based on their health, fitness, frailty and tumor characteristics. A key element of the studywas to collect detailed QoL data on all patients in light of the importance of this to women in this age group.The study is now complete and data analysis is ongoing. The study recruited over 3400 women over the age of70 years from 57 centers in England and Wales. Preliminary results discussed here were presented at the UKIBCSand are yet to be published [2].A comparison of 672 patients (matched for age, frailty and comorbidity) receiving either PET or surgery showedno difference in BCSS regardless of treatment. After treatment, patients in both groups saw an initial decrease inQoL from baseline; however, this recovered for patients receiving PET, but not for patients undergoing surgery bythe 2-year mark. This suggests that there is a group of older women who will have no oncological benefit fromsurgery and in fact, surgery may be detrimental to their QoL.The second phase of the study involved the development of a predictive tool to tailor treatment options accordingto breast cancer stage and biology and their age, fitness and frailty. A Decision Support Instrument (DESI) wasdeveloped to assist older women in making informed decisions about their preferred treatment [11,12]. A multicentercluster randomized trial was then nested within the main Age Gap observational study in 46 of the 57 centers.These 46 centers were randomized to continue with normal decision-making practice or to have training and theuse of the online DESI. The trial has now completed recruitment and randomized 670 patients to the intervention(use of the DESI) and 669 to standard care. Preliminary results show early trends toward improved QoL andidentical BCSS in patients who use the DESI, compared with those treated by standard care. The online tool isnow freely available to use [12].A view on dementiaThe National Audit of Breast Cancer in Older Patients is part of an effort to evaluate the quality of cancer careprovided to older (>70 years) women with breast cancer in England and Wales [13]. At the time of publication ofthe third annual report in 2019 [13], 147,162 older women diagnosed with breast cancer between 2014 and 2017had been recruited from 130 centers.10.2217/bmt-2020-0022 Breast Cancer Manag. (2020) future science groupIssues for older women with breast cancer EditorialIn the 2017 report, a series of case vignettes were used to gain perspective on patient factors that influence clinicaltreatment decisions. The results highlighted inconsistencies in primary treatment preferences of women with breastcancer and complex multimorbidities such as cognitive impairment and dementia [14].Fewer women with dementia present with breast cancer at an early stage. In a large (n = 31,935) retrospectivecohort study, Raji et al. [15] found that 28% of patients with breast cancer and dementia were diagnosed with stage Idisease, compared with 50.7% of patients without dementia. Furthermore, it is reported that women with dementiaare up to 40% less likely to have surgery [16] compared with women without dementia. The reasons for this arecomplex and multifactorial. For example, patients with dementia are more likely to have competing comorbiditieswhich may affect their suitability for general anesthesia [17]. Cohort studies have demonstrated a higher rate ofpostoperative complications in patients with dementia and breast cancer [18], as well as long-term cognitive effectsand compliance issues for adjuvant therapy [19], but studies of this kind are few. At last, the impact of dementia andbreast cancer on a patient’s life expectancy remains poorly understood.Given the increasing global burden of dementia [20], it is proposed that the approach to a patient with dementiashould be as any other comorbidity – recognition, optimization and management that involves shared decisionmaking.ConclusionBoth tumor and patient factors are different in the older compared with younger woman with breast cancer. Thefuture of treatment for older women with primary breast cancer should aim to utilize tumor and geriatric factors todeliver personalized cancer care, including in patients with dementia. This could be supported using tumor-basedprognostic and predictive tools, geriatric assessment and patient decision-making tools. Research and audits in thisarea provide important insights and should continue.AcknowledgmentsThe views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Departmentof Health.Financial & competing interests disclosureThe Age Gap study represents independent research funded by the National Institute for Health Research (NIHR) under its Pro-gramme Grants for Applied Research Programme (grant reference number: RP-PG-1209-10071). The authors have no other rel-evant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with thesubject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.Open accessThis work is licensed under the Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license,visit http://creativecommons.org/licenses/by-nc-nd/4.0/ReferencesPapers of special note have been highlighted as: • of interest1. World Health Organization. International agency for research on cancer (2019). iarc.f r2. Cheung KL, Ring A. Special issues for elderly patients session. Presented at: UK Interdisciplinary Breast Cancer Symposium 2020: BreastCancer Research and Treatment. Birmingham, UK (27–28 January 2020).• You can find all of the conference proceedings from the UK Interdisciplinary Breast Cancer Symposium 2020 here.3. Syed BM, Green AR, Paish EC et al. Biology of primary breast cancer in older women treated by surgery: with correlation withlong-term clinical outcome and comparison with their younger counterparts. Br. J. Cancer 108(5), 1042–1051 (2013).• This is a summary of analysis of a panel of biological markers in a large cohort of older women with primary breast cancer. Tothe best of our knowledge, this cohort is the largest of its kind, for this type of research, worldwide.4. Syed BM, Al-Khyatt W, Johnston SJ et al. Long-term clinical outcome of oestrogen receptor-positive operable primary breast cancer inolder women: a large series from a single centre. Br. J. Cancer 104(9), 1393–1400 (2011).5. Syed BM, Green AR, Ellis IO, Cheung KL. Human epidermal growth receptor-2 overexpressing early operable primary breast cancers inolder (≥70 years) women: biology and clinical outcome in comparison with younger (<70 years) patients. Ann. Oncol. 25(4), 837–842(2014).future science group 10.2217/bmt-2020-0022Editorial Parks, Jauhari, Morgan, Wyld & Cheung6. Syed BM, Green AR, Nolan CC, Morgan DAL, Ellis IO, Cheung KL. Biological characteristics and clinical outcome of triple negativeprimary breast cancer in older women: comparison with their younger counterparts. PLoS ONE 9(7), e100573 (2014).7. Wildiers H, Heeren P, Puts M et al. International society of geriatric oncology consensus on geriatric assessment in older patients withcancer. J. Clin. Oncol. 32(24), 2595–2603 (2014).8. Hurria A, Gupta S, Zauderer M et al. Developing a cancer-specific geriatric assessment: a feasibility study. Cancer 104(9), 1998–2005(2005).9. Parks RM, Hall L, Tang SW et al. The potential value of comprehensive geriatric assessment in evaluating older women with primaryoperable breast cancer undergoing surgery or non-operative treatment: a pilot study. J. Geriatr. Oncol. 6(1), 46–51 (2015).• This is a pilot study examining the use of a breast cancer specific comprehensive geriatric assessment, specifically in older womenwith primary breast cancer.10. Zahit RA, Parks RM, Howard P, Blake H, Cheung KL. Baseline quality of life evaluation in older women with primary operable breastcancer and its relationship with different treatments. J. Clin. Oncol. 36(Suppl. 15), e12601 (2018).11. The University of Sheffield. Bridging the age gap in breastcancer (2020). www.sheffield.ac.uk/medicine/research/research-themes/cancer/age-gap• This is the main reference to the Bridging the Age Gap study and contains information on study design, analysis and relevantpublication to date.12. The University of Sheffield. Age gap decision tool (2020). https://agegap.shef.ac.uk/13. National Audit of Breast Cancer in Older Patients. NABCOP: annual report 2019 (2019).www.nabcop.org.uk/reports/nabcop-2019-annual-report/• This 2019 report from National Audit of Breast Cancer in Older Patients contains the most recent published findings from thisnationwide audit.14. National Audit of Breast Cancer in Older Patients. NABCOP: annual report 2017 (2017).www.nabcop.org.uk/reports/nabcop-2017-annual-report/15. Raji MA, Kuo Y-F, Freeman JL, Goodwin JS. Effect of a dementia diagnosis on survival of older patients after a diagnosis of breast,colon, or prostate cancer: implications for cancer care. Arch. Intern. Med. 168(18), 2033–2040 (2008).16. Gorin SS, Heck JE, Albert S, Hershman D. Treatment for breast cancer in patients with Alzheimer’s disease. J. Am. Geriatr. Soc. 53(11),1897–1904 (2005).17. Prince M KM, Guerchet M, McCrone P et al. Dementia UK: update second edition report produced by KCL and the LSE for theAlzheimer’s society (2014). http://eprints.lse.ac.uk/59437/1/Dementia UK Second edition - Overview.pdf18. Hu CJ, Liao CC, Chang CC, Wu CH, Chen TL. Postoperative adverse outcomes in surgical patients with dementia: a retrospectivecohort study. World J. Surg. 36(9), 2051–2058 (2012).19. Phillips KA, Ribi K, Sun Z et al. Cognitive function in postmenopausal women receiving adjuvant letrozole or tamoxifen for breastcancer in the BIG 1–98 randomized trial. Breast 19(5), 388–395 (2010).20. GBD 2016 Dementia Collaborators. Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: asystematic analysis for the global burden of disease study 2016. Lancet Neurol. 18(1), 88–106 (2019).• This study is important in understanding the impact of dementia in the population on a worldwide scale and has significantfindings.10.2217/bmt-2020-0022 Breast Cancer Manag. (2020) future science group

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Special issues for older women with primary breast cancer

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