Primary breast cancer in the elderly

Objectives

With respect to breast cancer in the elderly, to define “old” in the context of comorbidity and physiologic rather than chronologic age. In addition, after discussion of factors influencing decisions regarding screening, stage at presentation and treatment decisions, to present an approach to the treatment of primary breast cancer in the elderly, taking into account quality of life, expected outcomes and cost-effectiveness.

Data sources

A review of the medical literature from 1980 to 1996, using the MEDLINE database and 2 relevant studies from The Henrietta Banting Breast Centre Research Programme at Women’s College Hospital, Toronto.

Study selection

A large number of breast cancer studies that might provide a better understanding of primary breast cancer in the elderly.

Data synthesis

The studies reviewed demonstrated that the annual incidence of breast cancer increases with age, along with a longer life expectancy for women. There appears to be a delay in presentation for elderly women with breast cancer, related in part to patient and physician knowledge. Biennial mammography and physical examination are effective in women aged 50 to 74 years, but compliance with screening recommendations decreases with age. Although treatment goals are the same for women of all ages, most treatment decisions are based on studies that seldom include women over 65 years of age. Physicians tend to underestimate life expectancy and older women are less likely to seek information. Breast conserving surgery, partial mastectomy and even axillary dissection can be carried out under local anesthesia with little physiologic disturbance, but unless axillary dissection is required to make a treatment decision, it may be foregone in clinically node-negative elderly women. The role of adjuvant radiotherapy in the elderly is not yet well established; tamoxifen is the usual adjuvant systemic therapy given to older women. For those who are truly infirm, tamoxifen alone can be considered. Studies to date do not clarify whether breast cancer in older women runs a more or less favourable course. However, locoregional recurrence appears to decrease with age. Deaths from competing causes are a confounding issue.

Conclusions

It is imperative to develop a coherent strategy for the treatment of primary breast cancer in the elderly that takes into account functional status and quality of life. Clinical trials must include older women and there must be good clinical trials designed specifically for older women.