(6% vs. b1%), dyspnea (4% vs. 1%), hyperglycemia (4% vs. b1%),fatigue (4% vs. 1%), and pneumonitis (3% vs. 0%). In TAMRAD themain toxicities associated with tamoxifen plus everolimus werefatigue (72% vs. 53% with tamoxifen alone), stomatitis (56% vs. 7%,grades 3–4 11% vs. 0%), rash (44% vs. 7%), anorexia (43% vs. 18%),and diarrhea (39% vs. 11%).Conclusions: The reported efficacy data are extremely interestingbut safety concerns are clearly present. Toxic effects can influencethe practical use of, and compliance with, this class of drugs,especially in an elderly patient population where compliance withoral agents, even with favourable safety profiles, is lower than in thegeneral population. EUSOMA and SIOG recommendations for themanagement of elderly patients with breast cancer clearly statethat “there is a delicate balance between overtreatment andundertreatment of advanced disease, in which maintenance ofquality of life (QoL) is a priority”. In BOLERO-2 time to deteriorationof QoL did not statistically differ between the treatment groups.While research is focused in identifying subgroups of patients whoderive the greatest benefit from these ET+everolimus combinations,it is essential that clinicians are educated about key recommenda-tions for toxicity management and specific guideline for dosemodifications. However unfit patients are probably not idealcandidates for this strategy.

References[1] Baselga J, Campone M, Piccart M, et al. Everolimus in postmeno-

pausal hormone-receptor–positive advanced breast cancer. N Engl JCancer 2012;366:520–529.

[2] Bachelot T, Bourgier C, Cropet C, et al. Randomized Phase II Trialof Everolimus in Combination With Tamoxifen in Patients WithHormone Receptor–Positive, Human Epidermal Growth FactorReceptor 2–Negative Metastatic Breast Cancer With Prior Expo-sure to Aromatase Inhibitors: A GINECO Study. J Clin Oncol2012;30:2718–2724.

doi:10.1016/j.jgo.2012.10.141

F8Adjuvant chemotherapy in older breast cancer patients:How to decide?1

Hans Wildiers. Department of General Medical Oncology,University Hospitals Leuven, Belgium

Adjuvant chemotherapy can decrease the risk of metastases signifi-cantly in early breast cancer, but the optimal selection of patientsremains a major challenge. A sizeable proportion of elderly withoperable breast cancer dies of non-cancer related causes, but about40% of patients 80y or older still die due to breast cancer. The benefit ofadjuvant chemotherapy should first be driven by biological subtype:Luminal A tumors derive little benefit from adjuvant chemotherapyeven in younger women, so in older individuals with competingcauses of death, it is generally not acceptable to administer adjuvantchemotherapy, even in more extended tumors. Luminal B tumors arethe most difficult area in the general population for adjuvantchemotherapy decisions. The benefit of adjuvant chemotherapy inthe older population is expected to be less than in the youngerpopulation, so luminal B tumors probably don't require adjuvantchemotherapy in the majority of older cancer patients, although weare waiting the results from the recently started ASTER trial includinggene expression data. In contrast, triple negative and HER2+ breasttumors generally require adjuvant chemotherapy in the generalpopulation, and this is probably the setting where most benefit canbe achieved in older cancer patients. The extent of the disease (tumor

size and nodal status) can further help in the decision. But patientcharacteristics are much more important in older individuals than inyounger women. Biological age, assessed by geriatric assessment canhelp in estimating the life expectancy and ability to tolerate and copewith side effects, and is a better decision tool than chronological ageby itself. Last but not least, patient preference is of utmost importance,since different elderly might have different expectations and wishes.The choice of chemotherapy remains a difficult item. In theory,identical regimens can be used in older and younger women, butthere is clear evidence that toxicity and toxic mortality increaseswith age, while dose reductions might decrease efficacy. AC/CMF hasbeen shown to be superior to capecitabine, while anthracyclines aregenerally preferred above CMF. Taxanes can be added, or replaceanthracyclines. Recent data suggest that 4 cycles of chemotherapycould be sufficient.

doi:10.1016/j.jgo.2012.10.142

Melanoma

F9Epidemiology of melanoma in older patients1

M.L.G. Janssen-Heijnen. Department of Clinical Epidemiology,VieCuri Medical Centre, Venlo, The Netherlands

Purpose of the study: Giving insight into the epidemiology ofmelanoma in older patients.Methods: Besides evidence from peer-reviewed publications, popu-lation-based data from the Netherlands Cancer Registry and theEindhoven Cancer Registry were used for giving insight into the agedistribution of melanoma, the trends in incidence and survival, stage,histological subtype, the prevalence of co-morbidity, treatment andquality-of-life after treatment.Results: Elderly have an increase in incidence and mortality rates ofmelanoma that are up to 10-fold higher compared to youngerpatients. In addition, there is a more rapid increase in incidenceamong older males than older females, which has led to a reversemale–female ratio among elderly. An increase in incidence of thickmelanomas (N4.0 mm) is also seen, but only among elderly males.Elderly melanoma patients have poorer survival compared toyounger patients. The question is whether age itself is an indepen-dent prognostic factor or whether the poorer prognosis can beexplained by the fact that factors for poor prognosis are moreprevalent among older patients with melanoma (higher proportionof males, more late diagnosis, a weaker immune system, morenodular histology, more serious co-morbidity and decreased organfunctions). In addition, treatment of melanoma in elderly is complex.Since elderly are often excluded from clinical trials, few data exist onthe efficacy and safety of treatment of elderly with melanoma.Conclusions: Currently, early detection is the best chance ofinfluencing behaviour of melanoma in the elderly. Since there wasa more rapid increase in incidence of melanoma among males, andan increase in thick melanomas was only seen among elderly males,future screening campaigns should especially focus on older men.Since prognosis is poorer among elderly and elderly are oftenexcluded from clinical trials, safety and effects of (new) treatmentsneed to be investigated in elderly, with a special emphasis on theinfluence of treatment on changes in quality-of-life.

doi:10.1016/j.jgo.2012.10.143

1 Not all the biographies were available at time of printing.

1 Not all the biographies were available at time of printing.

1 Not all the biographies were available at time of printing.

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