Breast Cancer in the Elderly-Should it be Treated Differently?

Breast cancer risk increases with age and about a third of female breast cancers are diagnosed in patients aged older than 70. Breast cancer in the elderly has, however, poorer outcome with lower survival rate compared to younger subjects. This may be partly explained by the delay in diagnosis and the 'under-treatment' of elderly breast cancer patients. In this review I try to provide recommendations for screening, surgery, radiotherapy, (neo) adjuvant hormone treatment and chemotherapy, and also the treatment of metastatic disease. Since large randomized trials usually exclude elderly patients with breast cancer, there is still an insufficient evidence for the treatment of such patients.

Background
Breast cancer is one of the most common types of cancer affecting women, accounting for about 6500 new cases annually in the Czech Republic. Almost one-half of the newly diagnosed breast cancers occur in women older than 65 years. Age is the most important risk factor for breast cancer. As the median age of the general population in Western European countries steadily increases, occurrence of those diseases which manifest typically in elderly people (e.g. diabetes and rheumatic, cardiovascular and pulmonary disease), including cancer is also on the rise.

Although we could expect that the elderly will be treated with similarly intensive treatment as applied in younger age groups, the elderly patients with breast cancer are frequently under-treated, even after adjustment for confounding factors, such as co-morbidities, need for social support, and functional status. Elderly women are less likely to undergo breast conserving therapy and axillary lymph node dissection; radiation therapy (RT) is more likely to be omitted after breast conserving surgery and elderly patients also less frequently receive systemic therapy, particularly chemotherapy. In contrast, the use of adjuvant hormonal therapy has been reported to be independent of patient age.

The reasons for these differences in approach to the care of older patients are probably multifactorial and may include a higher rate of patient co-morbidities, poorer performance status, limited social support, difficulty with transportation, patient or family preference, concerns about quality of life, lower life expectancy. In addition, because so few research studies have included older women, the lack of available evidence may also lead to less aggressive care.

Studies that have examined the predictors of surgery and adjuvant radiation have found that chronologic age was associated with substandard therapy independently of performance status, or co-morbidities, suggesting that physicians may be under-treating even otherwise "healthy" elderly women.

Elderly women with breast cancer are thus considered under-diagnosed and under-treated, and this adversely affects their overall survival. Most women who die of breast cancer are much more frequently older than 65 years of age. Despite this information, it has been confirmed by many studies that elderly patients do not receive a standard treatment given to their younger counterparts.

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