<p>Data presented at the <strong>ESMO Congress 2025</strong> highlighted the value of geriatric assessments in older patients with HR+/HER2- metastatic breast cancer. These data support assessing functional age, comorbidities, and frailty to help guide therapy, optimize dose intensity, and predict toxicity, reinforcing that treatment decisions should be individualized to balance efficacy, tolerability, and quality of life.</p> <p><br></p> <p><em>Following these presentations, featured expert Sara M. Tolaney, MD, MPH, was interviewed by</em> Conference Reporter <em>Associate Editor-in-Chief Christopher Ontiveros, PhD. Clinical perspectives from Dr Tolaney on these findings are presented here.</em></p>

We do have an aging population of patients with breast cancer; in fact, we are seeing that patients are getting diagnosed with breast cancer at older ages more frequently. A challenge we face is trying to balance someone’s underlying comorbidities as they age with their ability to tolerate therapy. We also need to consider the patient’s life expectancy and whether the cancer is life-limiting. There are competing risks in this population, and older patients may die of causes not related to their breast cancer. So, it is important to understand their predicted life expectancy, performance status, and underlying comorbidities when making treatment decisions. Age is just a number, and it certainly should not be used to make treatment decisions. It is about assessing a patient’s functional age to determine the right approach.

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We need to take all these factors into account when deciding whether someone can tolerate chemotherapy. Can they tolerate an oral targeted drug? Are other medical problems being managed correctly? Many older patients who have multiple health problems receive a lot of medications. What are the potential risks for drug interactions?

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At my institution, we have an older adult program with coordinators who do full geriatric assessments. They perform a pharmacy check for drug interactions, and there is a system in place to refer to a geriatrician when needed because caring for older adults can be complicated, particularly patients who have multiple underlying health problems. That support can be very helpful.

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A couple of studies presented at the recent ESMO Congress 2025 were interesting, including the PalomAGE study of palbociclib in women aged 70 years and older with HR+/HER2- locally advanced or metastatic disease (abstract 493P). Brain and colleagues looked at 2 different patient cohorts: a group with endocrine-sensitive disease and another group with more endocrine-resistant disease. This was a prospective, observational, real-world study investigating dose intensity, toxicity, impact on quality of life, and whether there was an association between baseline characteristics, dose intensity, and outcomes in this older population.

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PalomAGE was interesting because one of the challenges we face with these drugs, CDK4/6 inhibitors in particular, is that they are well known to cause neutropenia, and we have seen slightly higher rates of toxicity in older patients compared with younger patients, at least in the clinical trials evaluating these drugs. In practice, some providers start these patients at lower doses because they worry about the potential toxicity risk. What they saw in PalomAGE was that patients with a geriatric assessment scale score suggesting that they were more at risk for toxicities had worse outcomes. So, they looked at time to treatment failure and real-world progression-free survival and found that if you had a reduced initial dose of palbociclib, you were also at higher risk for having worse outcomes.

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Obviously, these analyses are quite complicated because there are reasons related to a patient’s underlying performance status and comorbidities that would lead one to choose a lower starting dose. The PalomAGE investigators did correct for these factors and still found that they were independently predictive of worse outcomes, particularly having an impaired geriatric assessment score. In my view, the PalomAGE study highlighted that geriatric assessments can be very informative because they are highly predictive of who may not do as well and of when you may need to monitor patients more carefully or start them at a lower dose (ie, individuals who are considered frail by the geriatric assessment tools). I think that PalomAGE confirmed what we all suspected, which was really helpful.

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Also at this year’s ESMO Congress, Ramos-Esquivel and Mora-Hidalgo presented an assessment of predictors of survival and the impact of chemotherapy dose intensity in older patients with different subtypes of breast cancer, including HR+/HER2- breast cancer (abstract 2943eP). This was a retrospective analysis of patients who were over the age of 65 and had received chemotherapy in the early-disease setting. The investigators found that a reduced relative dose intensity was independently associated with worse survival. This is important to note because sometimes people make a knee-jerk decision to make dose reductions up front for all of their older patients, which, again, you can see is associated with worse survival outcomes.

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I think that we have to be cautious. It should not just be that all older patients get a dose reduction, but maybe just those patients who have high frailty scores and are at risk for worse outcomes. Those are the patients in whom dose reductions should be entertained; we should not just do that across the board in older individuals. Greater dose intensity has been associated with better outcomes, particularly in the early-stage setting. You do not want to compromise a patient’s outcomes without taking into account how that individual may tolerate treatment. I think that, again, this study by Ramos-Esquivel and Mora-Hidalgo was consistent with the overall theme that geriatric assessments can really be helpful in making treatment decisions.