Breast Cancer in the Elderly

Which Lessons Have We Learned?

Natalie Turner; Elena Zafarana; Dimitri Becheri; Giuseppe Mottino; Laura Biganzoli

Disclosures

Future Oncol. 2013;9(12):1871-1881. 

In This Article

Abstract and Introduction

Abstract

Management of older breast cancer patients is challenging due to a lack of good quality evidence regarding the role of adjuvant chemotherapy. Older women can benefit as much from adjuvant chemotherapy as younger women, although they have an increased risk of toxicities. Decisions regarding adjuvant chemotherapy should be made based on tumor biology and biological age, rather than chronological age. Geriatrician assessment can detect subtle functional deficits that may impact on the ability of the patient to tolerate chemotherapy; however, implementation of comprehensive geriatric assessment in the oncology setting is challenging. Instead, numerous frailty screening tools are in development. Future advances should incorporate more accurate and efficient means for determining the biological age of elderly breast cancer patients, which will better define the risk:benefit ratio of adjuvant chemotherapy.

Introduction

One of the biggest risk factors for the development of breast cancer is age. The median age for breast cancer diagnosis is approximately 60 years, and over 40% of all breast cancers diagnosed are in women aged 65 years or older.[101] It is anticipated that, by the year 2030, approximately 20% of the population will be aged over 65 years; therefore, the proportion of older women with early breast cancer will grow considerably in the near future. Data relating to the treatment of breast cancer in older women, however, are very limited, and the need to develop appropriate treatment recommendations becomes even more crucial when considering the expected rise in the number of older women with early-stage breast cancer.

There are few standardized guidelines for the management of older breast cancer patients, primarily due to the lack of level one evidence, and lack of representation of older women in adjuvant therapy trials,[1] with clinicians often required to make treatment decisions in the face of this uncertainty. This may frequently lead to undertreatment, or less commonly, overtreatment of the patient, and consequently poorer outcomes.

Since circa 1990, breast cancer death rates have been steadily falling;[2,3] however, this improvement has preferentially been in women younger than 75 years old. Comparison between breast cancer death rates in 1990 and 2007 demonstrated that, while the rate of breast cancer death in the general population decreased by 2.5% per year for women aged <75 years, this rate decreased by only 1.1% per year for women aged ≥75 years. Similarly, for patients diagnosed with breast cancer from 1980 to 1997, the decrease in 10-year absolute risk of breast cancer death for women aged 50–64 years was double that of women aged ≥75 years, (15.3 vs 7.5% for younger vs older patients, respectively).[3] There has also been declining breast cancer mortality recorded in Europe, where between the years 1990–1994 and 2000–2004, breast cancer mortality declined by 13% for all ages. However, by age group, the decrease was significantly higher in women aged 35–64 years at 17%, compared with 6% for women aged ≥65 years.[2]

The major determinants for improvement in breast cancer survival appear to be adjuvant therapy and breast screening.[4] However, with regards to screening, the US Preventive Services Task Force has stated that, for women ≥70 years, there are insufficient data to determine the effect of mammographic screening on breast cancer mortality.[5]

In general, chemotherapy treatment given to elderly patients tends to be less aggressive, or adjuvant chemotherapy may not be given at all. Observational studies have demonstrated a link between undertreatment and poorer breast cancer outcomes,[6,7] while age has been shown to be an independent risk factor for receiving less than the standard treatment.[6] Older patients are also less likely to be considered for clinical trial enrollment[8] while, interestingly, age does not appear to be a barrier to participating in clinical trials if offered the opportunity.[8] This is despite the fact that older women receiving adjuvant chemotherapy have similar survival benefits to those seen in younger patients.[9] Furthermore, with life expectancy for a fit 65-year old, 75-year old and 85-year old at approximately 19, 12 and 6 more years, respectively, adjuvant therapy aimed at breast cancer cure is important. However, unlike in younger age groups, end points relating to functionality are also critically important.

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