The effect of undertreatment with adjuvant hormonal therapy, chemotherapy, or radiation was studied in elderly women with breast cancer. A prospectively maintained database was used to identify women undergoing potentially curative surgery between 1978 and 2012. The presentation, pathologic findings, treatment, and outcomes of 382 women over 70 were compared to the findings in 2065 younger patients. Subsequently, conventionally treated and undertreated elderly patients were identified and their characteristics and outcomes were compared. Both young and old patients presented most frequently with mammographic findings, but older patients presented more frequently with mammographic masses while younger patients presented more frequently with mammographic calcifications. Cancers of older patients were significantly more favorable than cancers in younger patients: smaller, with more infiltrating lobular, fewer ductal carcinoma in situ, and more frequently estrogen receptor positive and fewer were poorly differentiated. Elderly patients had less axillary sampling, fewer mastectomies, less adjuvant radiation therapy, and more hormonal therapy. Fifty-one percent of the 382 elderly patients were undertreated by conventional criteria. Undertreated patients were more frequently in situ, better differentiated, smaller, and more often estrogen receptor positive. Forty-four percent of the undertreated patients died during followup without disease recurrence. Despite undertreatment, local and distant disease-free survival was comparable to patients who were not undertreated. 1. Introduction The population of elderly individuals in the United States is increasing. Between 2000 and 2010 the population of women aged 65 and over increased by 11.3% with those 70 and over increasing by 6.4% [1]. According to the Surveillance Epidemiology and End Results (SEERs) database, from 2000 to 2009 the median age for breast cancer diagnoses in the USA was 61 years of age. Approximately 41% were diagnosed above the age of 65, of which 21% were above the age of 75 [2]. As the USA population of women over 65 increases, breast cancer in older individuals has and will continue to become more prevalent. The management of breast cancer in the elderly has been a topic of debate. There is a lack of evidence on the optimal management of this group of patients secondary to low enrollment in randomized clinical trials [3, 4]. As a result, treatment decisions have been largely based on studies in younger patients which may not be applicable to elderly patients with breast cancer. Breast cancers
References
[1]
US Census Bureau, Census 2000 Summary File 1 and 2010 Census Summary File 1, http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf, 2012.
[2]
Surveillance Epidemiology and End Results (SEER) and National Cancer Institute, http://seer.cancer.gov/statfacts/html/breast.html#incidence-mortality, 2012.
[3]
L. F. Hutchins, J. M. Unger, J. J. Crowley, C. A. Coltman, and K. S. Albain, “Underrepresentation of patients 65 years of age or older in cancer- treatment trials,” New England Journal of Medicine, vol. 341, no. 27, pp. 2061–2067, 1999.
[4]
C. A. Townsley, R. Selby, and L. L. Siu, “Systematic review of barriers to the recruitment of older patients with cancer onto clinical trials,” Journal of Clinical Oncology, vol. 23, no. 13, pp. 3112–3124, 2005.
[5]
A. DeMichele, M. Putt, Y. Zhang, J. H. Glick, and S. Norman, “Older age predicts a decline in adjuvant chemotherapy recommendations for patients with breast carcinoma: evidence from a tertiary care cohort of chemotherapy-eligible patients,” Cancer, vol. 97, no. 9, pp. 2150–2159, 2003.
[6]
C. Gajdos, P. I. Tartter, I. J. Bleiweiss, R. A. Lopchinsky, and J. L. Bernstein, “The consequence of undertreating breast cancer in the elderly,” Journal of the American College of Surgeons, vol. 192, no. 6, pp. 698–707, 2001.
[7]
H. J. Wanebo, B. Cole, M. Chung et al., “Is surgical management compromised in elderly patients with breast cancer?” Annals of Surgery, vol. 225, no. 5, pp. 579–589, 1997.
[8]
C. Bouchardy, E. Rapiti, S. Blagojevic, A. T. Vlastos, and G. Vlastos, “Older female cancer patients: importance, causes, and consequences of undertreatment,” Journal of Clinical Oncology, vol. 25, no. 14, pp. 1858–1869, 2007.
[9]
S. G. Diab, R. M. Elledge, and G. M. Clark, “Tumor characteristics and clinical outcome of elderly women with breast cancer,” Journal of the National Cancer Institute, vol. 92, no. 7, pp. 550–556, 2000.
[10]
W. A. Satariano and D. R. Ragland, “The effect of comorbidity on 3-year survival of women with primary breast cancer,” Annals of Internal Medicine, vol. 120, no. 2, pp. 104–110, 1994.
[11]
L. Biganzoli, H. Wildiers, C. Oakman, et al., “Management of elderly patients with breast cancer: updated recommendations of the international society of geriatric oncology (SIOG) and European society of breast cancer specialists (EUSOMA),” Lancet Oncology, vol. 13, no. 4, pp. e148–e160, 2012.
[12]
E. Kaplan and P. Meier, “Nonparametric estimation from incomplete observations,” Journal of the American Statistical Association, vol. 53, no. 282, pp. 457–481, 1958.
[13]
D. R. Cox, “Regression models and life tables,” Journal of the Royal Statistical Society, vol. 34, no. 2, pp. 187–220, 1972.
[14]
I. Weggelaar, K. Aben, M. Warle, L. Strobbe, and D. van Spronsen, “Declined guideline adherence in older breast cancer patient: a population-based study in the Netherlands,” The Breast Journal, vol. 17, no. 3, pp. 239–245, 2011.
[15]
M. A. Schonberg, E. R. Marcantonio, D. Li, R. A. Silliman, L. Ngo, and E. P. McCarthy, “Breast cancer among the oldest old: tumor characteristics, treatment choices, and survival,” Journal of Clinical Oncology, vol. 28, no. 12, pp. 2038–2045, 2010.
[16]
S. G. Diab, R. M. Elledge, and G. M. Clark, “Tumor characteristics and clinical outcome of elderly women with breast cancer,” Journal of the National Cancer Institute, vol. 92, no. 7, pp. 550–556, 2000.
[17]
W. Van de Water, E. Bastiaannet, O. Dekkers, et al., “Adherence to treatment guidelines and survival in patients with early-stage breast cancer by age at diagnosis,” British Journal of Surgery, vol. 99, no. 6, pp. 813–820, 2012.
[18]
E. Bastiaannet, G. J. Liefers, A. J. M. De Craen et al., “Breast cancer in elderly compared to younger patients in the Netherlands: stage at diagnosis, treatment and survival in 127,805 unselected patients,” Breast Cancer Research and Treatment, vol. 124, no. 3, pp. 801–807, 2010.
[19]
B. Van Leeuwen, K. Rosenkranz, L. Feng, et al., “The effect of under-treatment of breast cancer in women 80 years of age and older,” Critical Reviews in Oncology / Hematology, vol. 79, no. 3, pp. 315–320, 2011.
[20]
C. Bouchardy, E. Rapiti, G. Fioretta et al., “Undertreatment strongly decreases prognosis of breast cancer in elderly women,” Journal of Clinical Oncology, vol. 21, no. 19, pp. 3580–3587, 2003.
[21]
K. S. Hughes, L. A. Schnaper, D. Berry et al., “Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer,” New England Journal of Medicine, vol. 351, no. 10, pp. 971–977, 2004.
[22]
K. I. Bland, C. E. H. Scott-Conner, H. Menck, and D. P. Winchester, “Axillary dissection in breast-conserving surgery for stage I and II breast cancer: a National Cancer Data Base study of patterns of omission and implications for survival,” Journal of the American College of Surgeons, vol. 188, no. 6, pp. 586–596, 1999.
[23]
A. E. Giuliano, K. K. Hunt, K. V. Ballman et al., “Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial,” Journal of the American Medical Association, vol. 305, no. 6, pp. 569–575, 2011.
[24]
C. P. Gross, J. Herrin, N. Wong, and H. M. Krumholz, “Enrolling older persons in cancer trials: the effect of sociodemographic, protocol, and recruitment center characteristics,” Journal of Clinical Oncology, vol. 23, no. 21, pp. 4755–4763, 2005.
[25]
M. T. E. Puts, J. Monette, V. Girre et al., “Characteristics of older newly diagnosed cancer patients refusing cancer treatments,” Supportive Care in Cancer, vol. 18, no. 8, pp. 969–974, 2010.
