Elderly breast cancer is rising. Increasing age is considered a risk factor for developing breast cancer. With older age generally defined as age ≥65, it estimated that nearly half of all new breast cancer diagnosis occurring in such age group.
Multiple studies documented that elderly breast cancer patients are treated differently.
Most studies showed a pattern of “under-treatment” as well as poorer outcome compared to younger patients. While breast cancer in the elderly represent specific challenges which I will discuss, the “under-treatment” is not always because of a valid reason or a medical challenge.
What are the differences observed about elderly breast cancer treatment?
- Less utilization of surgery, and less utilization of sentinel lymph node sampling.
- As a result of the above, tendency to under-stage.
- Less utilization of radiation therapy.
- Increased use of primary endocrine therapy as the sole treatment modality.
- Less to no participation in clinical trials.
The above are observations noted by variable studies, as I will discuss later some are clearly justifiable, and in some instances occurring as a result of physician bias. The lack of clinical trials participation results in lack of valid evidence of treatment modalities in such patient population.
Breast cancer in the elderly is often understage
What are the unique features or challenges in elderly breast cancer? this can be summarized in the following table. Please note that age alone should never be an indication of functional status or comorbidities.
What are the available clinical decision-making tools? Please see the table below, however, I must stress caution in using such tools, such tools must be used by clinicians who are familiar with interpretation, and limitation of such tools. Please also note that not all tools were clinically validated.
Clinical Decision-Making Tools/Resources
|Adjuvant! Online||Currently being updated. Provide overall survival estimates with and without treatment.||https://adjuvantonline.com|
|PREDICT||Provide overall survival estimates with and without treatment.||http://www.predict.nhs.uk/index.html|
|CancerMath||Provide overall survival estimates with and without treatment.||http://www.lifemath.net/cancer/breastcancer/therapy/|
|ePrognosis||Life expectancy tool.||http://eprognosis.ucsf.edu/index.php|
|CARG (Cancer and Aging Research Group)||Geriatric assessment tool.||http://www.mycarg.org|
|CARG (Cancer and Aging Research Group)||Chemotherapy toxicity calculator.||http://www.mycarg.org|
|SIOG||An international organization that focuses on geriatric oncology, multiple topics and publications related to geriatric oncology||http://www.siog.org|
|POGOe||Multiple topics and publications related to geriatric medicine in general.||https://pogoe.org|
Suggested step by step approach: the ideal approach toward elderly breast cancer patients continue to be a work in progress. Many of the steps or the tools listed in this blog are not universally used by practicing oncologist, it is, however, important to strive to follow the provided step by step approach as much as possible. Also, please note that the sequence of steps provided below may not be applicable to every case.
Elderly breast cancer guidelines: It is impossible to list all possible clinical scenarios in managing an elderly patient with breast cancer. Here I will list some general guidelines that are commonly used by oncologists.
- Staging, in medically fit elderly patient with palpable breast lesion, work up is should be complete as younger patients, sentinel lymph sampling should not be withheld(see below for some exception).
- Surgery, in medically fit elderly patient with the diagnosis of breast cancer surgical care should mirror younger patients.
- Systemic therapy, including systemic chemotherapy, should not be omitted in medically fit elderly patient. In this review, the elderly patients were shown to derive similar benefit from systemic chemotherapy with regard to reduction in breast cancer-specific mortality.
- Sentinel lymph node, data from several trials looking at breast cancer patients age >70 with tumor <2cm, hormone positive, and clinically negative axilla treated with breast surgery with no sentinel lymph node sampling followed by adjuvant endocrine therapy have similar outcome to those who underwent sentinel lymph node sampling this was shown here, here, and here.
- Radiation therapy, While medically fit elderly breast cancer patient generally tolerate radiation therapy, as shown in here, this may be omitted in patients age >70, tumor <2cm, hormone positive and clinically negative axilla.
- Neoadjuvant endocrine therapy can also be of benefit in elderly patients as well. Please check my earlier post here.
- Decision making with regard to choice of chemotherapy regimen, endocrine therapy agent should be individualized and tailored to the patient tumor profile, functional status.