2160

Breast Cancer in Elderly Women lrvin D. Fleming, M.D., and Martin D. Fleming, M.D.

With the aging of the American population, more older women are being diagnosed with breast cancer. With the possible exception of women under 40 years of age, there is no clear evidence of a biologic or clinical difference between breast cancer in younger and older aged groups. Breast cancer is diagnosed at a more advanced stage in older women. Elderly women with breast cancer frequently are treated with less than standard therapy and are less often included in clinical trials. With the exception of specific comorbid conditions that preclude anesthesia and surgery, older women tolerate breast surgery as well as younger women. The results of good surgical and adjuvant therapy for elderly women are as good as those for younger women. Older women with breast cancer deserve the most effective screening, diagnosis, and surgical treatment available. Comer 1994; 74:2160-4. Key words: cancer, breast, elderly, treatment.

The incidence of breast cancer is increasing with the increasing median age of the American population. The average age of patients with breast cancer also increasing (Fig. 1)’ The two major risk factors for the development of breast cancer are previous breast cancer in the opposite breast and increasing age.’ Currently, 48% of all patients with breast cancer are diagnosed in women 65 years of age and older. The age-specific incidence for breast cancer for women aged 65 years and older is 1400 per 100,000, compared with 750 cases per 100,000 for women aged 50-65 y e a s 3This makes breast cancer in elderly women a major public health problem and one of the more frequent catastrophic medical events occurring in elderly women. When approaching the issue of breast cancer in the elderly, one must consider the following: Presented at the National Conference on Cancer and the Older Person, Atlanta, Georgia, February 10-12, 1994. From the University of Tennessee Center for the Health Sciences, Department of Surgery, Methodist Health Systems, Memphis, Tennessee. Address for reprints: Irvin D. Fleming, M.D., Mid-South Oncology Group, 1296 Peabody Avenue, Memphis, TN 38104. Received April 29,1994; accepted June 7,1994.

1. Is breast cancer in the elderly biologically unique? 2. Is breast cancer in the elderly clinically different from breast cancer in the younger population? 3. Should breast cancer in the elderly be treated differ-

ently? Is Breast Cancer in the Elderly Biologically Unique?

Interestingly, there are reports that breast cancer in older patients is more aggressive, whereas other reports state that the disease is more indolent and may have a protracted clinical c o ~ r s eThis . ~ confusion is probably because breast cancer in elderly women generally is more advanced at diagnosis, and other causes of death are not considered in some morbidity data.5 Studies that adjust survival for age and other medical problems support the fact that the clinical course of breast cancer is essentially the same for all age groups, with the possible exception of the younger-than-40-year aged group, which seem to have a somewhat worse prognosis1l6(Table 1). There is also evidence that breast cancer in women older than the age of 70 years more frequently has positive estrogen and progesterone receptor^.^ Tober compared the corrected survival of localized and regional breast cancer for women in their fiftieth, sixtieth, and seventieth decade and found them to be essentially the Is Breast Cancer in the Elderly Clinically Different?

Breast cancer in older patients usually is diagnosed at a more advanced clinical stage (Table 2).’-11 There are several factors that contribute to this delay in diagnosis. The first factor is a lack of the use of mammographic screening. A nationwide survey conducted by the Jacobson Foundation demonstrated that less than 30% of women older than 70 years of age are regularly screened with mammography” (Fig. 2). Physicians who care for elderly patients (i.e., cardiologists,rheumatologists, gentologists, etc.) are not as aggressive in recommending mammography as are the physicians who care

Breast Cancer in Elderly WomenlFleming and Fleming

2161

Table 2. Stage at Diagnosis of Breast Cancer in the Elderly Aee (vr)

No.

55-64 65-74 75-84 85+

29,363 20,300 16,799

Local (%1

Regional (YO)

Distant

47 50 51 36

41 38 35 34

8 9 8 9

Unknown

(%)

3 4 6 11

Data is from the Surveillance, Epidemiology, and End Results program, 19731984."

Surgical Treatment of Breast Cancer in the Elderly 30 40 50 60 70 80 90 Figure 1 . Age-adjusted rates for cancer of the breast (per 1,000,000 people; SEER data)." 10

20

for younger women (i.e., gynecologists, family practice physicians, and internists). The expense of mammography may be a real factor to older women on fixed incomes with many insurances including Medicare refusing to pay for annual mammography. Also, elderly women are more resistant to the idea of annual mammography and require considerable counsel and urging before have it performed. The very elderly (older than 75 years) are often fatalistic about health matters. Staging and Management

Unfortunately, most earlier clinical trials of women with breast cancer excluded elderly patients; consequently, most decisions regarding treatment are derived from extrapolations of data from younger patients. Even when patients are eligible, elderly patients are less likely to be entered in trials which require additional chemotherapy and radiation therapy.' The average age for patients in protocols by the Eastern Cancer Oncology Group is 4-16 years younger than the average age of patients with breast cancer in the Surveillance, Epidemiology, and End Results database.'

Table 1. Five-year Survival of Breast Cancer in the Elderly* Herbesman (1991)6 Varich (1981)29 Tabar (1993)7,8 Shottenfield (1971129 * Relative age adjusted

Aee (vr)

Local (%)

Reeional(%)

> 70 60-69 60-69 > 65

90 91-90 92 85

65 69-66 67

59

A review by August et al. of a series of older patients treated surgically for breast cancer reveals a wide range and variety of surgical procedures and an inconsistent application of adjuvant radiation therapy and chemotherapy. These elder patients were managed by modified radical mastectomy (total mastectomy with axillary dissection), simple mastectomy (total mastectomy without axillary dissection), partial mastectomy, local excision, or biopsy only. August defines "standard surgical therapy" as mastectomy with axillary dissection or lumpectomy with axillary dissection, and reported in a review series that 98% of women younger than 65 years of age received "standard therapy," whereas only 8 1YO of the patients older than 65 years of age received this "standard surgical" treatment.I3 Kesseler reported that in a series of 82 elderly patients treated surgically for invasive breast cancer, 24 were treated with simple mastectomy or partial maste~tomy.'~ When breast conservation surgery is considered, the standard therapy is to combine complete local excision plus or minus axillary dissection and add postresection radiation therapy to the remaining breast tissue. Elderly patients are treated more frequently with lessthan-recommended local therapy, i.e., lumpectomy without radiation therapy or simple mastectomy without axillary d i s s e ~ t i o n . ~ ,In ' ~ addition, ,'~ elderly patients are less likely to receive adjuvant hormonal or chemotherapy than younger patients with the same stage of breast cancer.'*," In the records of elderly patients with breast cancer, the reason for modification of therapy is not always stated clearly. However, when stated, the reasons are usually age, performance status, comorbid disease, or patient choice. Also, a review of the Eastern Cooperative Group protocol revealed that elderly patients are much less likely to be entered in clinical treatment trials. Again, the reasons gven are physician preference, patient refusal, comedical problems, anticipated difficulty with follow-up, and other nonspecified reasons.'

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CANCER Supplement October 2, 2994, Volume 74, No. 7

60 1%92 SURVEY

Table 4. Goldman’s Criteria of Factors Predicting Cardiac Risk in Noncardiac Surgery

~ l 9 9 SURVEY 0

50

Factor S3 gallop/JVD Myocardial infarction within 6 mos. Ectopy (nonsinus rhythm) More than five premature ventricular contractions Intraperitoneal, thoracic, or aortic procedure Age above 70 years Aortic stenosis Emergency surgery Poor medical condition

40 -30 20 10

0

40

50

60

70

A number of studies have been done comparing the surgical complication in elderly patients with younger aged groups, and in the absence of serious comorbid disease, elderly patients tolerate standard breast surgical procedure as well as younger patientsI3,l6(Table 3). August et al. reported a 35% surgical complication rate for younger patients compared with a 25% surgical complication rate for elderly patients. The majority of these complications were minor wound infections and postoperative seromas. Serious complicationswere rare in both age groups.13Hunt et al. reported that in a series of 94 patients aged 65-98 years treated surgically, complications such as wound seromas developed in 16 only, and superficial wound infections developed in 15 only. There was one postoperative death (1.O%) of cardiovascular cause.16They concluded that in the absence of serious comorbid disease, elderly patients tolerated breast surgery as well as younger patients. Comorbid conditions that may impact on decisions regarding breast surgery and treatment are those which

Table 3. Surgical Complications of Breast Cancer in the Elderly

August (1993)13

77

Mortality

>65

26 Hunt (1988)16 94 > 6 5 33 Kessler (1989)’* 250 >70 11 Herbesman (198016 138 > 70 (less with mastectomy)

P < 0.001 P < 0.001 P < 0.001

11 10 7

P i0.001

7

P < 0.001 P = 0.007 P = 0.007 P = 0.007 P = 0.027

3 5 5 4

3

* Based on multivariant analysis.

Figure 2 . Percentage of women following guidelines for mammography by age in years (Jacobs Institute on Women’s Health Study). From Horton JA, Romans MC, Cruess DF. Mammography attitudes and usage study. Women Health Issues 1992; 2:180-8. With permission.

No.of Age Cases (vr) Comulications (%)

Pointst

t Based on discriminant analysis.

AGE (YEARS)

Author hear)

Statistical significance*

0 1 1 0

From Goldman L. Cardiac risks and complications of noncardiac surgery. Ann

Surg 1983; 198:780-91. With permission.

increase the risk of anesthesia and appreciably shorten life expectancy. These include advanced pulmonary disease, end-stage renal disease, control nervous system dysfunction, and cardiac disease. Pulmonary dysfunction and cardiac disease represent the greatest anesthesia risks. Goldman has developed some criteria for assessing the risk of cardiac disease in evaluating patients for noncardiac surgery (Table 4). The most significant risks are associated with a gallop rhythm, recent myocardial infarction, and ectopic nonsinus rhythm with frequent premature ventricular contractions. Points were assigned to cardiac abnormalities based on clinical significance, and an accumulation of 26 or more points was associated with a greater than 50% mortality. Thirteen to 25 points was associated with only a 2% rn0rta1ity.l~ When making a decision regarding the treatment of elderly patients with breast cancer, the surgeon must weigh the risk of the surgical procedure against the risk of the morbidity and mortality of a proven breast cancer diagnosis. Age and comorbid conditions must be considered when attempting to determine the expected longevity of the patients. The average natural survival of patient aged 65 years is 16, aged 75 years is 10, and aged 85 years is 6 years, and this information must be factored into treatment decision^.^ The goals for cancer surgery in the elderly patient with breast cancer are to obtain long term control of the cancer (cure), continue a maximum level of patient independence, control any symptoms of cancer, and maintain the personal dignity of the patient. When considering alternatives to standard therapy in elderly patients with high risk medical problems, we must use data extrapolated from clinical trials per-

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Breast Cancer in Elderly Women/Fleming and Fleming

formed with younger, healthier patients, because older patients generally have been excluded from previous clinical trials. Simple Mastectomy Without Axillary Dissection

Based on data from Haffty and Fisher, mastectomy without axillary dissection was associated with clinical an axillary recurrence rate of 15-25%. Axillary dissection reduced the axillary recurrence to less than 3% with minimal addition morbidity.1s-20 Excision (Lumpectomy)Without Radiation

Based on National Surgical Adjuvant Breast and Bowel Project data, lumpectomy alone is associated with a local recurrence rate of 27% compared with only 6% when radiation is added.” Excision Plus Hormone Therapy

There are those who suggest managing breast cancer in the elderly with local excision or biopsy plus tamoxifen therapy as an alternative to definitive treatment. This approach achieves only a 60-70% response rate with tumor reduction for varying periods of months followed by clinical progress of the Reasons for less-than-standard therapy usually are advanced age, comorbid disease, and patient choice. Considerably more time is necessary to discuss options in the workup and treatment of elderly patients, and this time must be spent to ensure that patients make informed decisions based on their knowledge of options and their projected outcomes. It is easy to state ”refused treatment” on the patient’s the record. However, this decision must be the result of careful, and sometimes tedious, discussion with the patient and family. The discussion of treatment options must include possible outcomes and risks of suboptimal treatment or no treatment of a breast malignancy. The evidence is clear that many elderly patients with breast cancer are screened inadequately with examination and mammography.” Many have incomplete workups, stagmg, and less-than-ideal treatment, simply because of advanced age.z4Breast cancer in the elderly is essentially the same as that in younger aged groups. In the absence of serious comorbid conditions, older women with breast cancer can tolerate effective treatment weii.15,25,26 The relative survival of older women with breast cancer is essentially the same as that of younger women given effective treatment. Today’s senior citizens deserve the best that we have to offer in cancer detection and treatment.26-28

References

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23. Dunser M, Haussler B, Fuchs H, Martgreiter R. Lumpectomy plus tamoxifen for the treatment of breast cancer in the elderly. Eur] Surg Oncol 1993; 19:529-31. 24. Singletary SE, Shallonberger R, Goinec VF. Factors influencing management of breast cancer in elderly women. Clin Geriatr M e d 1993; 9~107-13. 25. Zenilman ME. Consideration of surgery in the elderly. Advances in surgery in the elderly. New York: Medical World Press, 1993;l-20. 26. Satoriana W. Co-morbidity, and functional status in women in

breast cancer: implications for screening, treatment, and prognosis. Geronfol 1992; 47:24-9. 27. Stewart JA, Foster RS. Breast cancer and aging. Semin Oncol 1989; 16:41-50. 28. France AC, Namez MD, Ruddler EW, Weinberg AD. Controlling breast cancer in older women: the physicians’ role. Tex Med ] 1992; 88~68-70. 29. Stottenfield D, Robbins GF. Breast cancer in the elderly woman. Geriatrics 1971; 26:121.