The session on cancer in the elderly was based on a fictional patient, an 83 years old lady with a triple negative breast cancer. Triple negative breast cancers have a bad prognosis and the whole discussion was then to ask the pathologist,Rania Bakar, does this exist and, yes, elderly patients have aggressive tumours; asking the surgeon, Riccardo Audisio, on how he would approach this patient; asking the radiation therapist, Roberto Orecchia, on his view and finally indication for adjuvant chemotherapy in spite of the age because of the very aggressive biology of the disease. I must say, the questions from the audience were numerous so we will repeat this kind of session next year.

What questions were asked?

The question about radiation therapy was related to do we actually have data to show that radiation therapy is useful in the older patients. So we have to differentiate the older patients with a less aggressive disease that we would call luminal from the more aggressive ones, HER2 positive or triple negatives, because in those cases the local relapse rate is much higher and those patients, if they have no contraindication for some reason to receive radiation and today there are also easier ways to give radiation on a weekly basis rather than a daily basis, they should receive radiation. Patients who have a good prognosis disease, they might not need the radiation provided they accept a slightly higher local relapse rate that seems not to have, when it’s a luminal disease, any relation then to ultimate survival.

The surgeon was asked the question, ‘But wouldn’t you offer a mastectomy? Even you can have a conservative surgery in this patient because that would then avoid the need for radiation therapy.’ Of course the answer is yes if the patient accepts such a procedure. This has to be discussed with the patient.

The medical oncologist had to discuss the fact that we have little data on older patients and chemotherapy. The tolerability of chemotherapy is, of course, a question that remains open. We have some suggestions that come from City of Hope, Arti Hurria, and come from Martine Extermann at Tampa University in Florida that tell us how to evaluate a patient for tolerability of chemotherapy. So if we take that into account we can predict that is going to be tolerable yes/no but even so it is complex. A lot of the people in the audience were still reluctant to use chemotherapy in spite of the evidence in favour of chemotherapy in triple negative disease.

Do you think the location of the conference influenced the discussion?

One of the questions that came from the audience is that in this area of the world even if a patient seems to be fit at a certain age these are very rare. The majority of the older patients in this area tend to have a past history of hepatitis which can be reactivated by the chemotherapy. It’s a potential risk, it has not been shown to be really true. Patients can also have diabetes, quite common, and that can complicate because either they will have decreased creatinine clearance because of the diabetes or they have pre-existing neuropathy which will be complicated by some of the chemotherapeutic agents. Plus they might have past cardiac issues so all of that has to be taken into account in order to be certain that what we apply is not going to transform an independent elderly patient into a dependent one.

Is there anything you would like to conclude from that discussion?

The main message from this session was that we have to come back next year with another type of situation and expend more time in the discussion of the adjustment of treatments according to the different potential problems the patient might have because of the age.