CARG Score Chemotherapy Options ABCSG 18 Trial | Cynthia Ma, MD, PhD | ASCO22 Breast Cancer Updates
Dr. Cynthia Ma, breast cancer care expert from Washington University, reviews the following case question, incorporating updates from the 2022 ASCO annual conference that have changed the standard of care.
A 78-year old woman presents to your clinic, s/p left mastectomy that removed a 3cm size, high grade, invasive ductal carcinoma. Sentinel lymph node biopsy found 2 of 3 positive lymph nodes (pT2N1). ER positive (Allred score 7), PR negative, HER2 1+ on IHC. Staging workup negative for distant metastasis. She has hypertension and diabetes, but well controlled. She does not exercise, but has no difficulty with activities of daily living and lives with her husband. Oncotype RS was found to be 33. Ki67 IHC MIB-1 pharmDx 30%. Her DEXA revealed T score -1.8 at lumbar spine. CARG chemo-toxicity score was 10. What is your recommendation regarding adjuvant therapy? Choose all that applies.
a. Adjuvant chemotherapy with TC (Docetaxel plus cyclophosphamide) x
b. Adjuvant aromatase inhibitor plus denosumab or zoledronic acid
c. Consider adjuvant abemaciclib x 2 years
d. Adjuvant radiation therapy to chest wall and draining lymph nodes
e. All of the above
f. b+d
g. b+c+d
h. other
Answer: the correct answer is g. Rationale: The Cancer and Aging Research Group (CARG) score is a validated geriatric assessment model for adults greater than 65 yrs to predict the risk of grade 3-5 chemotherapy toxicity in the treatment of solid tumors. The CARG score, ranging from scores of 0 to 19, incorporates measures of functional status such as fall history, hearing problems, physical capabilities, performance status as well as objective measures including age, gender, height, weight, cancer type, type and dose of chemotherapy, hemoglobin, and creatinine clearance. CARG scores were stratified as low (score 0-5), intermediate (score 6-9) and high risk (score 10-19). Since the patient has a high risk CARG toxicity score, we would not recommend adjuvant chemotherapy. In the ASTER 70s Study, which randomized patients over 70s with ER+/HER2- breast cancer with high genomic grade index to receive endocrine therapy with or without chemo, found no overall survival benefit of adjuvant chemotherapy in the intent to treat population. After adjusting the 20% of patients randomized to therapy chemotherapy arm but did not go on chemotherapy, there was a 1.7% absolute benefit at 4 years from chemotherapy, although significant, but small. Adjuvant bisphosphonate is recommended in postmenopausal women with early stage breast cancer based on benefit in reducing bone metastasis and overall survival in meta-analysis. Denosumab is another option based on its efficacy in preventing recurrence observed in the ABCSG 18 trial.
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