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Originally published June 10, 2025
Last updated June 10, 2025
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Triple-negative breast cancer is a somber diagnosis for a patient at any age. Not only is triple-negative breast cancer more aggressive than most types of breast cancer; it also has the highest probability of recurrence.
Typically more common in younger patients, triple-negative breast cancer can still occur in older patients. If it does, these patients require special consideration, especially when it comes to chemotherapy, says An Nguyen, MD, a medical oncologist with the USC Norris Comprehensive Cancer Center, part of Keck Medicine of USC, who practices in Orange County.
“Whether it’s breast cancer — or any cancer, really — when you’re treating someone who is older than 75, you really have to be cognizant of their age,” he explains. “For instance, if someone is over 80 years old and has a history of diabetes, heart disease, arthritis and other conditions — and are on five or more mediations — these patients typically have an increased likelihood of having side effects and problems with chemotherapy.” There are exceptions, he notes: “An 80-year-old who is very active, maybe playing golf or tennis every day, might tolerate chemotherapy better.”
In general, however, “For all patients who are older than 80 years old, you really have to be aware of their age and either modify chemotherapy or select a chemotherapy that is more tolerable — as well as monitor their side effects more closely,” Nguyen says.
Nguyen discusses a 79-year-old triple-negative breast cancer patient he treated a few years ago. In this patient’s case, Nguyen says, “Triple-negative breast cancer can be very aggressive, so we wanted to start treatment as quickly as possible.”
At the time of the patient’s diagnosis, an immunotherapy drug — pembrolizumab (brand name Keytruda) — had just been FDA-approved for treatment of high-risk, early-stage, triple-negative breast cancer in combination with chemotherapy as neoadjuvant treatment. Nguyen says that in patients with triple-negative breast cancer, newer research shows this combination prior to surgery can significantly reduce the risk of cancer reoccurrence.
“It eradicates the tumor cells so that at the time of surgery, there is a minimal amount of disease that needs to be removed. This can also help patients in terms of cosmetic reconstruction because the amount of tissue that needs to be removed during surgery is potentially much smaller,” he adds.
In this patient’s case, the chemotherapy and immunotherapy were administered prior to a lumpectomy. Nguyen says the results of the lumpectomy showed that the patient had a complete pathologic response, meaning no cancer cells remaining.
“Patients who have a complete pathologic response have a much better overall survival rate than patients who don’t,” he says. “So that was really encouraging. It told us that she responded very well to her neoadjuvant.”
Following surgery, the patient underwent radiation treatment “to continue to improve local disease control in the breast area,” Nguyen says.
For another year after that, she received immunotherapy, again with pembrolizumab, because studies indicate that to optimize benefit in these patients, immunotherapy should be continued again after surgery.
Due to the patient’s age, closing in on 80, Nguyen and his team lowered the chemotherapy dose because they were concerned she might not tolerate the treatment well. Instead of a standard chemotherapy dose given every three or four weeks, the patient received smaller doses weekly, giving physicians the opportunity to closely monitor her response and any side effects.
“Typically, when patients in their 80s get chemotherapy, I will see them weekly, especially at the start of chemotherapy to make sure they are tolerating the chemotherapy well,” Nguyen explains. “It’s imperative to monitor their white blood cell count, their red blood cell count and their platelets to make sure they don’t need blood transfusions or growth factors to prevent infections.”
Giving chemotherapy in smaller increments also allows physicians to change course if the patient begins to experience adverse effects. “This is especially important for elderly patients,” Nguyen says. “If an elderly patient starts developing significant side effects — for example, bad diarrhea, nausea or vomiting — then you can catch it early and intervene. You can hold off on treatment for a week and then resume the following week.”
In this patient’s case, it became clear relatively quickly that she was doing well with the weekly doses of chemotherapy, and so the team stayed the course.
A little more than three years have passed since this patient’s breast cancer was initially diagnosed, and she is doing well and enjoying life again as she used to before her diagnosis, Nguyen reports.
She makes several follow-up visits every year so the team can evaluate her condition and check for early signs of recurrence. Blood testing is performed to check for circulating tumor cells. Her tests have shown 0% signs of cancer recurrence, Nguyen says.
Checking for circulating tumor cells, instead of the older practice of checking for tumor markers, enables physicians to detect early recurrence of breast cancer at a much higher rate, he adds. “The older testing, tumor marker testing, would pick up maybe about 60%-65% of recurrent breast cancer, but it wasn’t close to 100%. The circulating tumor test is much more effective at picking up early recurrences of breast cancer at up to 95%-97%.”
This type of test is relatively new, Nguyen says, and not every oncologist offers these types of tests yet.
This patient’s case is an example of how treating older patients requires a fine balance to ensure treatment is efficacious but also that patients can tolerate the regimen.
Nguyen says that when administering chemotherapy to older patients, physicians must not only select the right type of therapy to use but also potentially reduce the chemotherapy dosage and monitor the patient very closely for side effects related to chemotherapy.
“I think the take-home message is that even older patients can receive chemotherapy plus immunotherapy and tolerate it well — if one knows how to manage the side effects and adjust the treatment so patients can tolerate it,” he concludes.
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