Breast cancer in elderly women: Can radiotherapy be omitted?

It is tempting to spare elderly women the burden of adjuvant radiotherapy after breast cancer surgery, even if such a treatment would be justified in light of the available clinical evidence. The reason is that evidence-based radiotherapy derives from clinical trials that excluded elderly women, and that breast cancer is often believed to be more indolent at advanced ages. Unfortunately, the epidemiological evidence, and the few clinical trials recruiting patients over 65 or 70 year of age, all point to the need for postoperative irradiation in a similar set-up as in younger patients. So far, there is no evidence that a subgroup exists in which radiotherapy can be safely omitted. Therefore, the decision to treat or not to treat should be openly discussed with the patient, addressing risks and benefits of both attitudes. Only in frail patients, with an obviously limited life expectancy (months or at most a few years), can omission of radiotherapy be considered, as the burden of local recurrence is likely not to appear before the patient dies from an other cause.     

Surgical treatment of elderly patients with endometrial cancer (≥ 65 years)

ObjectivesTo analyze operability, short-term morbidity and mortality in women aged 65 and older with endometrial cancer.Materials and MethodsThe study cohort consisted of 124 elderly patients, aged 65 and older, with endometrioid endometrial cancer. Patients' clinical data included age at diagnosis, body mass index, ASA (American Society of Anesthesiologists) status and comorbidities, surgical procedures, FIGO (International Federation of Gynecology and Obstetrics) stage, histologic type, occurrence of operative and postoperative complications, and long-term disease-specific survival. Patients were divided into two groups according to age: those < 75 years and those ≥ 75 years. The analysis was repeated for patients older than 80 years who represent the category most at risk for perioperative morbidities.ResultsAll patients were referred to primary surgery (abdominal versus vaginal) with the exception of 3 patients. Factors affecting significantly the choice of intervention were age, body mass index, and the presence of comorbidities. No women died during the perioperative period. The rate of perioperative complications was significantly higher for the older group. In a logistic regression model, aged ≥ 75 years (but not aged ≥ 80 years), chronic lung disease and performing lymphadenectomy correlated with a higher probability of perioperative morbidities. Long-term disease-specific survival was significantly shorter only for women aged ≥ 80.ConclusionGeriatric patients should not be denied surgical treatment because of perceived risks associated with chronologic age, since the removal of the uterus confers a survival benefit.     

Breast cancer incidence trends in European women aged 20–39?years at diagnosis

An increase in the incidence of breast cancer in women aged<40 years has been reported in recent years. Increased incidence could be partly explained by subtle detection biases, but the role of other risk factors cannot be ruled out. The purpose of the present study was to investigate the changes in temporal trends in breast cancer incidence in European women aged 20-39 years at diagnosis. Age specific breast cancer incidence rates for 17 European Cancer Registries were retrieved for the calendar period 1995-2006. Cancer registries data were pooled to reduce annual fluctuations present in single registries and increase incidence rates stability. Regression models were fitted to the data assuming that the number of cancer cases followed the Poisson distribution. Mean annual changes in the incidence rate (AIC) across the considered time window were calculated. The AIC estimated from all European registries was 1.032 (95% CI=1.019-1.045) and 1.014 (95% CI=1.010-1.018) in women aged 20-29 and 30-39 years old at diagnosis, respectively. The major change was detected among women aged 25-29 years at diagnosis: AIC=1.033 (95% CI=1.020-1.046). The upward trend was not affected when registries with high or low AIC were removed from the analysis (sensitivity analysis). Our findings support the presence of an increase in the incidence of breast cancer in European women in their 20s and 30s during the decade 1995-2006. The interpretation of the observed increase is not straightforward since a number of factors may have affected our results. The estimated annual increase in breast cancer incidence may result in a burden of the disease that is important in terms of public health and deserves further investigation of possible risk factors.     

Breast cancer in sub-Saharan Africa: how does it relate to breast cancer in African-American women?

BACKGROUND: African-American women have had a lower incidence, yet higher mortality rate from breast cancer compared with White-American women. African-American women also have had a higher risk for early-onset, high-grade, node-positive, and hormone receptor-negative disease. Similar features have characterized hereditary breast cancer, prompting speculation that risk factors could be genetically transmitted. Further evaluation of this theory required the study of breast cancer among women from sub-Saharan Africa because of their shared ancestry with African-American women. METHODS: Publications from 1988 to 2004 of English-language literature on breast cancer in Africa were reviewed. RESULTS: Women from sub-Saharan Africa were found to have a low incidence of breast cancer. This was partly explained by a largely protective reproductive history, including late menarche, early menopause, high parity with prolonged breastfeeding, irregular menses, and fewer ovulatory cycles. The average age at diagnosis, however, was approximately 10 years younger than breast cancer patients of western nations, and disease stage distribution was shifted toward more advanced disease, which resulted in higher mortality rates. These features were found to be similar to data on breast cancer in African-American women. Mutations in BRCA1 and BRCA2 have been reported in African-American women, but the extent of the contribution of BRCA1 and BRCA2 to breast cancer burden in Africa was uncertain. Limited financial resources lead to suboptimal cancer data collection, as well as delayed diagnosis and treatment of many African breast cancer patients. CONCLUSIONS: Parallels between breast cancer burdens of African-American and sub-Saharan-African women were provocative, indicating the need for further exploration of possible genetically transmitted features related to estrogen metabolism and/or breast cancer risk.     

Adjuvant radiation therapy after breast-conserving surgery in elderly women with early-stage breast cancer: controversy or consensus?

Breast-conservation therapy (BCT), which consists of breast-conserving surgery (BCS) and postoperative radiation therapy (RT), provides similar levels of local control and survival compared with mastectomy. Although the incidence of breast cancer increases with age and the proportion of elderly women in the population continues to increase, clinical trials of BCT have included few women aged > or = 65 years, limiting the ability to establish clear consensus regarding optimal therapy in this population. This article examines the literature on BCT in elderly women with early-stage breast cancer. A systematic search of the Medline and CancerLit databases was conducted to identify articles specifically addressing BCT in elderly women. The outcomes evaluated were local control, disease-free survival, overall survival, and treatment-related toxicities. The lack of consensus in breast-conservation management in elderly patients is highlighted by a paucity of prospective data and numerous retrospective series reporting diverse treatment approaches with conflicting results. The available evidence from BCT trials with and without age subgroup analyses support BCS with postoperative RT as the standard approach associated with the most favorable local control outcomes. A low-risk subset of patients in whom RT may be omitted without compromising local control remains to be defined. Despite these findings, the use of standard therapy significantly decreases with advancing patient age. Although data specifically addressing BCT in elderly patients are limited, age should not preclude consideration of standard treatment strategies to optimize local disease control. Modern clinical trials with representative samples of elderly patients evaluating cancer recurrence and survival as well as functional and quality-of-life outcomes are needed to define optimal breast-conservation management for this important patient population.     

Breast cancer research in Asia: Adopt or adapt Western knowledge?

The incidence and mortality of breast cancer continues to rise rapidly in Asian countries. However, most of our current knowledge on breast cancer has been generated in Western populations. As the socio-economic profile, life style and culture of Asian and Western women are substantially different, and genetic backgrounds vary to some extent, we need to answer the question on whether to ‘adopt’ or ‘adapt’ Western knowledge before applying it in the Asian setting.It is generally accepted that breast cancer risk factors, which have mainly been studied in Western populations are similar worldwide. However, the presence of gene–environment or gene–gene interactions may alter their importance as causal factors across populations. Diagnostic and prognostic study findings, including breast cancer prediction rules, are increasingly shown to be ‘setting specific’ and must therefore be validated in Asian women before implementing them in clinical care in Asia. Interventional research findings from Caucasian patients may not be applicable in patients in Asia due to differences in tumour biology/profiles, metabolism of drugs and also health beliefs which can influence treatment acceptance and adherence.While breast cancer research in Asia is warranted in all domains of medical research, it is felt that for Asian breast cancer patients, needs are highest for diagnostic and prognostic studies. International clinical trials meanwhile need to include breast cancer patients from various Asian settings to provide an insight into the effectiveness of new treatment modalities in this part of the world.     

Breast cancer cell lines: friend or foe?

The majority of breast cancer research is conducted using established breast cancer cell lines as in vitro models. An alternative is to use cultures established from primary breast tumours. Here, we discuss the pros and cons of using both of these models in translational breast cancer research.     

Long-term outcome and axillary recurrence in elderly women (≥70 years) with breast cancer: 10-years follow-up from a matched cohort study

Background and objectivesThe oncological benefit of axillary surgery (AS), with sentinel lymph node biopsy (SLNB) or axillary dissection (ALND), in elderly women affected by breast cancer (BC) is controversial. We evaluated AS trends over a 10-year follow-up period as well as locoregional and survival outcomes in this subset of patients.MethodsPatients aged 70 years or older, treated between 1994 and 2008, were selected and divided in two groups, depending on whether or not AS was performed. A (1:1) matched analysis for all relevant clinicopathological features was performed. Outcomes were analyzed using the Kaplan–Meier method and univariate Cox-proportional hazard ratio analysis.ResultsA total of 1.748 patients were identified and stratified by age (70–74, 75–79, 80–84). A matched analysis was performed for 252 patients: 122 who underwent AS and 122 who did not. At 10-year follow-up, ipsilateral breast tumor recurrence, distant metastasis and contralateral BC were similar, p = 0.83, p = 0.42 and p = 0.28, respectively. In the no-AS group, a significant increased risk of axillary lymph-node recurrence was identified at 5- and confirmed at 10-years (p = 0.038), without impact on overall survival at 5- and 10-years (p = 0.52). In the non-AS group, higher rate of axillary recurrence at 10-years was observed in patients with poorly differentiated (24.1%, 95% CI 7.2–46.2), highly proliferative (Ki67 ≥ 20%: 17.1%, 95% CI 0.6–33.3) and luminal B tumors (16.8%, 95% CI 5.9–35.5).ConclusionsAxillary staging in elderly women does not impact long-term survival. Tailoring surgery according to tumor biology and age may improve locoregional outcome.     

Palliative treatment of unresectable bile duct cancer: which stent? which approach?

Nonsurgical options for the palliative treatment of unresectable bile duct cancer are discussed. Despite all of the available approaches, the disease remains uniformly fatal. The goal of managing unresectable bile duct cancer is to treat the symptoms that still contribute to significant morbidity and mortality. Further development of new treatment strategies and modalities is needed to improve the quality of life and survival of patients with this disease.     

Letter in response: breast cancer screening of women aged 70–74 years

The purpose of this study is to critically appraise the claim by Nickson et al. [1] that they have evidence supporting the Australian Government’s recent decision to extend the national free invitation for biennial mammography program (BreastScreen) to women aged 70–74 years. Since their claim was made on the basis of a significant difference in the incidence of larger primary breast cancers between women in this age group who are already participating in BreastScreen versus those who are not, an analysis of the stage at diagnosis of breast cancer in the USA versus mammographic screening over 30 years, evidence from breast cancer adjuvant endocrine and chemotherapy (adjuvant therapy) trials and data from an evaluation of BreastScreen and adjuvant therapy use in Australia were examined. By 1999, most Australian women aged 40–79 years were receiving adjuvant therapy that could cure breast cancer no matter what the size of the primary cancer. Further, the incidence primary breast cancers of all sizes had doubled in the USA during 30 years of mammographic screening, but the incidence of more advanced breast cancers had almost remained constant, indicating that adjuvant therapy, not mammographic screening, was the main cause of the 28 % reduction in breast cancer mortality that had been observed. In conclusion, the claim by Nickson et al. is not supported by available evidence. Further, BreastScreen should not have been extended to these older women before the UK trial, which is testing the efficacy of mammographic screening of women aged 70–74 years [8], had reported its results.