The role of surgery in the management of older women with breast cancer
Introduction
The ‘Gold Standard’ treatment for breast cancer is a complete surgical excision of the tumour and staging of the axillary lymph nodes, followed by appropriate combinations of adjuvant therapies.
This strategy may be inappropriate for older women (over 70 years) for a variety of reasons.
Breast cancer is a less biologically aggressive disease in older women, although this is partially counterbalanced by a slightly later stage of diagnosis. Competing causes of death assume a greater importance with increasing age, with 80% of older women having one or more significant co-morbid diseases which impact substantially on life expectancy.1 Physiological reserves are reduced independently of defined co-morbidities. The risk to benefit ratio of treatment alters, with increased treatment toxicity and reduced breast cancer specific mortality. Consequently, applying the same treatment practices to older women may be inappropriate.
Older women with breast cancer are currently treated differently to younger women, with reports of age dependent variance in practice from the UK,2, 3 USA,4, 5 and Europe.6 This may improve quality of life and reduce treatment related morbidity and mortality. Whether this adversely affects disease control and breast cancer mortality is not known.
A number of clinical trials are currently on-going to evaluate optimal treatment strategies for older women. Until these trials provide guidance, older women should ideally be treated according to standard protocols, tailored to their tolerances and wishes. A multi-disciplinary approach to assessment (involving surgeons, geriatricians, anaesthetists and oncologists) is recommended to optimise treatment.
These issues are discussed in more detail in this review.
Section snippets
Characteristics of breast cancer in older women
Breast cancer in the elderly differs from the disease in younger women in both stage at diagnosis and biological characteristics. The biological features of breast cancer are more favourable in older women, with tumours being of lower grade with increased oestrogen receptor (ER) expression (Table 1). This is counterbalanced by higher rates of locally advanced and metastatic disease at diagnosis and larger primary tumours (Table 1). Nodal disease is slightly less common. These differences may be
The physiological and pathological effects of aging
The effects of ageing can be categorised as physiological (or senescent), psychological or disease related. The changes are substantial, affect all bodily systems and significantly influence treatment tolerances. Physiological changes are summarised in Table 2 and co-morbid diseases are summarised in Table 3.
These age-related senescent changes and co-morbidities interact with disease stage. A number of researchers have tried to quantify their impact on predicted life expectancy by devising
Treatment preferences
There has been little research relating to older women’s preferences for breast cancer treatments. It is not known whether they would prefer less aggressive therapies with reduced morbidity to standard treatment, if given full information concerning outcomes. Older women are more passive in their information seeking behaviour32 and are more likely to allow doctors to advise them. Cosmesis may be less important to older women 33, although most older women would choose breast conservation over
General anaesthesia for breast surgery
The increased incidence of co-morbidity in the elderly renders general anaesthesia more hazardous. Breast surgery itself is generally regarded as low risk body surface surgery with low reported mortality rates. The mortality rate for mastectomy under general anaesthesia 20 years ago was approximately 1% in the elderly35, 36, and may well be less than this now with modern anaesthetic and surgical techniques. Wide local excision either under local or general anaesthesia in the over 70s has a
High thoracic epidural
This technique gives excellent anaesthesia and post-operative analgesia, is well tolerated and permits a wide range of surgical procedures, including mastectomy and axillary clearance.37 However, it is technically demanding due to the anatomy of the thoracic spine and the high incidence of spinal degenerative disease in the elderly. Complications include back pain, sympathetic blockade and reduced respiratory capacity.38
Surgery
(a) Surgery to the breast
There are two main strategies to remove the primary cancer: mastectomy or wide local excision plus radiotherapy. Older women may be more likely to be offered wide local excision than mastectomy and adjuvant radiotherapy is often omitted post-operatively.2 The preference of older patients given a choice between mastectomy and wide local excision is for breast conservation surgery.34 A number of studies have compared wide local excision with and without radiotherapy in
Axillary surgery
Axillary surgery aims to control axillary metastases if present and to determine disease stage for selection of adjuvant therapies such as chemotherapy. As older women rarely receive chemotherapy, axillary surgery is often omitted.7, 42, 43, 44 However, therapies other than chemotherapy may depend on nodal status, e.g. chest wall radiotherapy after mastectomy,45 and therefore omission of axillary staging may result in under-treatment as well as inadequate staging.
For decades the gold standard
Breast reconstruction
Older women are less likely to have breast reconstruction following mastectomy than younger women.61, 62 This reflects the fact that older women are less likely to have reconstructive surgery,63 as physical appearance is less important to older women than to younger.64, 65 although body image is still an important consideration for some.66, 33 and there are a number of reported series of women over the age of 65 having reconstructive surgery with good results, including autologous tissue
Surgical complications
Although the mortality rate for breast cancer surgery is very low, the morbidity may be substantial and should not be ignored simply because this type of surgery is rarely life threatening. The complications may be physical or psychological.71
The physical complications of breast surgery include scarring, acute and chronic wound pain, seroma formation, haematoma, infection and skin necrosis after mastectomy. Complications of axillary surgery include paraesthesia, seroma, haematoma, lymphoedema,
Primary endocrine therapy
The anti-oestrogen Tamoxifen is widely used as an adjuvant to surgery. In the United Kingdom (UK), however, recent audits demonstrate that 40% of women over 70% and 55% of women over 80 are treated with tamoxifen only for their breast cancer, omitting surgery completely.2, 87 This is called primary endocrine therapy (PET). It has much to recommend it from the patient’s perspective: avoidance of surgery, few side effects and efficacy in up to 90% of oestrogen receptor (ER) positive cancers.
A surgical management strategy for the treatment of breast cancer in older women
For patients who are fit for general anaesthesia (Fig. 1a) the management algorithm is similar to that for younger women where patients with tumours suitable for surgical treatment by breast conservation (tumour size ⩽5 cm with an appropriate tumour to breast size ratio) can be offered a choice between breast conservation and mastectomy whereas patients with tumours unsuitable for conservation (e.g. T3 tumours, or multi focal tumours) should be offered mastectomy. Treatment with adjuvant
Summary of recommendations
This overview of the surgical treatment of breast cancer in the elderly highlights the lack of an adequate evidence base for treatment planning, in stark contrast to the situation for younger women (<70 years) with breast cancer. The physiological changes and increased frequency of co-morbidity in this group of patients should not be ignored. For the majority of patients and particularly those aged <75 there is good evidence for a beneficial effect of surgical treatment in terms of local or
Conclusions
Older women should be offered a tailored approach to the treatment of their breast cancer which takes into account their disease stage, fitness level, personal preferences and predicted life expectancy. Selective omissions of some treatments may be appropriate without detriment to survival or local disease control because of the altered risk to benefit ratio of therapies in this age group. Surgery may be possible using local or regional anaesthetic techniques and is safe and well tolerated in
Conflict of interest statement
None declared.
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Management of positive margins after initial lumpectomy in elderly women with breast cancer
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