88 with HR+ breast cancer and the dr said she has probably had it for 5 to 10 years. She wants to do nothing about...

Understanding Your Mother's Situation: Treatment Options for Older Adults with HR+ Breast Cancer

I understand how challenging this situation is for your family. Your mother's age and preferences are important factors in decision-making, and you're asking the right questions about balancing treatment benefits with quality of life.

1) Similar Experiences: Older Adults Choosing Limited or No Treatment

Yes, your mother's situation is more common than you might think. According to the NCCN Guidelines for Metastatic Breast Cancer, treatment decisions should always consider:

• Patient preferences and goals of treatment (what matters most to your mother)
• Performance status (how active she is in daily life)
• Medical comorbidities (other health conditions)
• Quality of life priorities

What the Guidelines Say About Older Patients

The NCCN emphasizes that "goals of treatment may change over time" and that "your preferences and goals of treatment are always important." For patients who choose not to pursue aggressive testing or treatment, supportive care (also called palliative care) remains available to manage symptoms and maintain comfort.

The PET Scan Question

Your mother's reluctance about the PET scan is understandable. However, knowing whether cancer has spread can actually help with symptom management planning—even if she doesn't want aggressive treatment. The scan information helps doctors:

• Anticipate which symptoms might develop
• Plan preventive supportive care (like bone-strengthening therapy if there are bone metastases)
• Make better decisions about gentle treatment options

Questions to ask her doctor:

1. "If we skip the PET scan, how will that affect our ability to manage symptoms as they arise?"
2. "What symptoms should we watch for that might indicate spread?"
3. "Can we do the scan later if her symptoms change or if she changes her mind about treatment?"

---

2) Kisqali (Ribociclib) as an Option for Your Mother

Kisqali is indeed used for HR+ breast cancer, but whether it's appropriate for your 88-year-old mother depends on several factors.

What Kisqali Is and How It Works

According to the NCCN Guidelines, CDK4/6 inhibitors (which include Kisqali/ribociclib) are targeted therapies used specifically for hormone receptor-positive (HR+) breast cancer. These medications:

• Work by blocking proteins (CDK4 and CDK6) that help cancer cells divide
• Are typically given in combination with endocrine therapy (like letrozole or fulvestrant)
• Are taken as pills, usually 3 weeks on, 1 week off

Important Considerations for Your Mother

1. Endocrine Therapy Alone Might Be Gentler

For HR+ breast cancer, endocrine therapy (hormone therapy) is often the first-line treatment and is generally well-tolerated in older adults. Options include:

• Aromatase inhibitors (like letrozole, anastrozole)
• Selective estrogen receptor modulators like tamoxifen
• Selective estrogen receptor degraders like fulvestrant

These have fewer side effects than chemotherapy and can be effective at controlling HR+ breast cancer for years.

2. Adding Kisqali: Benefits vs. Burdens

The NCCN Guidelines note that CDK4/6 inhibitors like Kisqali are added to endocrine therapy to improve effectiveness, but they come with additional side effects:

Common side effects of Kisqali:

• Low blood cell counts (requiring frequent blood tests)
• Fatigue
• Nausea
• Liver function changes
• Potential heart rhythm changes (requiring EKG monitoring)

At age 88, the key question is: Would the potential benefit of adding Kisqali outweigh the burden of:

• More frequent doctor visits and blood tests
• Additional side effects
• Complexity of medication management

The Cost Question

You're absolutely right that Kisqali is expensive (often $10,000-15,000+ per month without assistance). Financial assistance options include:

1. Manufacturer patient assistance programs (Novartis, which makes Kisqali, has programs)
2. Medicare Extra Help (if she has Medicare)
3. State pharmaceutical assistance programs
4. Nonprofit copay assistance organizations

However, cost should not be the primary driver of whether to use Kisqali—the more important question is whether it's the right clinical choice for her situation.

---

What I'd Recommend Discussing with Her Oncologist

Priority Questions:

About Treatment Philosophy:

1. "Given my mother's age and her preference to avoid aggressive treatment, what would you recommend as the gentlest approach that could still help manage her cancer?"
2. "Would endocrine therapy alone (without Kisqali) be a reasonable option that might control her cancer with fewer side effects?"
3. "What would happen if we chose supportive care only—how would you help manage symptoms as they arise?"

About Kisqali Specifically: 4. "What specific benefits would adding Kisqali provide for my mother compared to endocrine therapy alone?" 5. "What would the monitoring requirements be (blood tests, doctor visits)?" 6. "How would we know if the treatment is working without doing scans?" 7. "If we start treatment, can we stop if the side effects affect her quality of life?"

About Prognosis and Symptom Management: 8. "Without knowing if it has spread, what symptoms should we watch for?" 9. "What supportive care services are available to help maintain her quality of life?" 10. "Can we involve palliative care specialists to help with symptom management, even if we pursue some treatment?"

---

A Balanced Perspective

What We Know from the Guidelines:

From NCCN Guidelines for Metastatic Breast Cancer:

• "Treatment decisions are very personal. What is important to you may not be important to someone else."
• "Quality of life and length of life" are both valid considerations
• "Supportive care is sometimes called palliative care" and continues regardless of whether cancer treatment is given
• For HR+ breast cancer, endocrine therapy is often the first approach because it's generally well-tolerated

The Reality for an 88-Year-Old:

If your mother has had this cancer for 5-10 years without major symptoms, it suggests it may be slow-growing. HR+ breast cancers often are, especially in older adults. This means:

• Gentle treatment (endocrine therapy alone) might control it for years
• Aggressive treatment might not significantly extend her life but could reduce her quality of life
• Supportive care only is a legitimate choice if that aligns with her values

---

Summary: Strong Evidence vs. Limited Coverage

✅ Strong Evidence Available:

• Treatment approaches for HR+ breast cancer in older adults
• Role of endocrine therapy as first-line treatment
• CDK4/6 inhibitors (Kisqali) as add-on therapy
• Importance of patient preferences and quality of life
• Supportive care options

⚠️ Limited Specific Coverage:

• Outcomes specifically for patients 85+ who choose no treatment
• Direct patient experiences (though your situation is common)
• Specific financial assistance program details (these change frequently)

---

Final Thoughts

Your mother's desire to avoid aggressive intervention at 88 is completely reasonable and supported by medical ethics. The goal should be maintaining her quality of life while respecting her autonomy.

A middle-ground approach might be:

1. Consider endocrine therapy alone (gentler than Kisqali combination)
2. Focus on symptom management and supportive care
3. Keep communication open—she can always change her mind
4. Involve palliative care specialists (they help with quality of life, not just end-of-life care)

This information is for educational purposes only. Always consult your healthcare team for personalized medical advice and decisions.

Would you like me to provide more specific information about endocrine therapy options or supportive care services that might be appropriate for your mother?