Association for Academic Surgery
Operation with less adjuvant therapy for elderly breast cancer

https://doi.org/10.1016/j.jss.2016.05.031Get rights and content

Abstract

Background

The standard of care for elderly women with breast cancer remains controversial. The aim of this study was to clarify the management of elderly breast cancer patients who undergo surgery.

Materials and methods

This retrospective single-center cohort study included 2276 breast cancer patients who underwent surgery between 1993 and 2014. The patients were divided into three groups according to age: ≤64 y (young), 65-74 y (older), and ≥75 y (elderly).

Results

The elderly had more advanced stage disease at diagnosis (stage III and IV, 16.2%, 17.5%, and 22.1% for the young, older, and elderly groups, respectively). The elderly were more likely to undergo mastectomy (43.3%, 41.4%, and 50.7%, respectively), omit axillary operation (0.6%, 1.1%, and 9.3%, respectively), and skip radiotherapy after breast-conserving surgery (93.1%, 86.8%, and 29.1%, respectively). Endocrine therapy was widely used in all the groups (94.4%, 93.8%, and 90.1%, respectively), but frequency of chemotherapy was lower in the elderly regardless of hormone receptor (HR) status (40.8%, 25.5%, and 9.3% in HR(+), 87.2%, 75.3%, and 39.5% in HR(−), respectively). Although the locoregional recurrence rate was higher in the elderly (4.2%, 3.4%, and 7.0% at 5 y, respectively; P = 0.028), there were no differences among groups in distant metastasis–free survival or breast cancer–specific survival.

Conclusions

Although elderly patients had more advanced stages of cancer and received less treatment, there were no differences in survival. Omission of axillary dissection, radiation, and chemotherapy after operation may be an option for breast cancer patients aged ≥75 y.

Introduction

Breast cancer is the most common malignant disease among women in the world. The incidence has been increasing substantially in Japan and other Asian countries over the past 3 decades, and it has a high incidence in the United States and Europe.1, 2, 3 In Asia including Japan, breast cancer incidence peaks among women in their 40s, whereas it peaks among women in their 60s in the United States and Europe.1, 4 Despite the difference in median age at diagnosis, the number of breast cancer patients is increasing in Japan due to a rapid increase in the number of elderly individuals. The population that is aged over 65 y accounted for 9.1% of the total in 1980, 19.9% in 2005, and it is estimated to reach 31.8% by the year 2030.5, 6

Although the number of elderly patients with breast cancer is increasing, knowledge about the possible differences in the biology and clinical outcomes of elderly cases of breast cancer that should reflect management according to age remains limited. Currently, treatment for elderly women with breast cancer is largely extrapolated from data derived from trials that enrolled younger patients; thus, the standard of care for elderly breast cancer patients is far from being established.7 Several reports demonstrated that elderly breast cancer patients are less likely to undergo surgery, radiation, or chemotherapy.8, 9, 10, 11 Although studies consistently show that older women are undertreated for breast cancer, the impact of undertreatment on breast cancer survival among older women remains controversial.10 Furthermore, little has been reported on the management of elderly breast cancer patients in Asian countries.

The aim of this study was to clarify the management of elderly breast cancer patients who underwent surgery and to investigate any effect of management choice on their outcomes.

Section snippets

Patients and methods

The study included 2276 patients with breast cancer referred for surgery at Yokohama City University Medical Center between May 1993 and June 2014. Data on patient medical history, histopathologic factors of the breast cancers, and management including surgery, radiation, and systemic treatment (hormonal therapy or chemotherapy) were recorded. This study was approved by the Institutional Review Board of Yokohama City University, Kanagawa, Japan.

Estrogen receptor (ER) level, progesterone

Pathologic characteristics by age group

Of the 2276 women in our study population, 1632 (71.7%) were aged below 64 y (young), 400 (17.6%) were between 65 and 74 y (older), and 244 (10.7%) were aged older than 75 y (elderly). The patients' characteristics are summarized in Table 1. The elderly patients had larger and more advanced tumors, but no significant difference was observed among groups in terms of lymph node involvement. Because of the increased frequency of larger tumors, the elderly patients had significantly advanced stage

Discussion

The elderly patients (older than 75 y) in our cohort had more advanced disease (stages III and IV), which is consistent with other studies.8, 23 This is partially explained by the delay in diagnosis because fewer elderly patients undergo screening mammograms.24 Wan et al.25 reported that the distribution of breast cancer subtypes varies by race and/or ethnicity, and subtype plays an important role in the biology of breast cancer. Breast cancers arising in elderly women have less ER expression

Conclusion

In conclusion, our study showed that local and systemic therapies were administered less frequency to elderly patients, aged ≥75 y than younger patients. Locoregional recurrence–free survival was worse in elderly patients, but survival was not affected. The findings of this observational study could represent the outcomes of different management choices in the elderly population. We need to consider the variety of elderly patients' characteristics when developing guidelines for personalized

Acknowledgment

The authors thank Dr Shoko Adachi, Dr Fumi Harada, Dr Hidetaka Shima, Dr Kumiko Kida, Dr Shinya Yamamoto, and Dr Kazuhiro Shimada for collecting clinicopathological data. They also thank Dr Mikiko Tanabe for pathologic opinions. K.T. is supported by NIH/NCI grant R01CA160688 and Susan G. Komen Investigator Initiated Research Grant IIR12222224.

Authors' contributions: A.Y., K.N., S.S., and D.S. conceptualized and collected data described in the article. A.Y., K.T., and T.I. prepared and revised

References (40)

  • Japanese National Cancer Center, Center for Cancer Control and Information Services 2015. Available at:...
  • Japanese Ministry of Health Labour and Welfare 2015. Available at: http://www.mhlw.go.jp/toukei/list/dl/81-1a2.pdf....
  • L. Talarico et al.

    Enrollment of elderly patients in clinical trials for cancer drug registration: a 7-year experience by the US Food and Drug Administration

    J Clin Oncol

    (2004)
  • R. Gennari et al.

    Breast carcinoma in elderly women: features of disease presentation, choice of local and systemic treatments compared with younger postmenopausal patients

    Cancer

    (2004)
  • E.B. Elkin et al.

    Adjuvant chemotherapy and survival in older women with hormone receptor-negative breast cancer: assessing outcome in a population-based, observational cohort

    J Clin Oncol

    (2006)
  • M.A. Schonberg et al.

    Breast cancer among the oldest old: tumor characteristics, treatment choices, and survival

    J Clin Oncol

    (2010)
  • B.M. Syed et al.

    Biology of primary breast cancer in older women treated by surgery: with correlation with long-term clinical outcome and comparison with their younger counterparts

    Br J Cancer

    (2013)
  • D.C. Allred et al.

    Prognostic and predictive factors in breast cancer by immunohistochemical analysis

    Mod Pathol

    (1998)
  • R. Leake et al.

    Immunohistochemical detection of steroid receptors in breast cancer: a working protocol. UK Receptor Group, UK NEQAS, the Scottish Breast Cancer Pathology Group, and the Receptor and Biomarker Study Group of the EORTC

    J Clin Pathol

    (2000)
  • M.E. Hammond et al.

    American Society of Clinical Oncology/College of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer (unabridged version)

    Arch Pathol Lab Med

    (2010)
  • Cited by (9)

    • A population-based study of treatment patterns, 10-year recurrence and breast cancer-specific mortality in a cohort of elderly patients with breast cancer

      2021, American Journal of Surgery
      Citation Excerpt :

      Schonberg (2010) found that mastectomy was the most common treatment for women 80–84 years of age with stage I-II disease while very elderly women (≥85 years) more often received BCS alone.8 We also found that older women were less likely to have re-excision of positive margins after BCS and less likely to undergo axillary staging, including SLNB and ALND, results also reported by others.6,7,10,19,27,28 Higher mastectomy rates in elderly patients may be a reflection of physician recommendations, patient’s choice (e.g., avoidance of radiotherapy due to toxicity or burden of daily treatment visits), or elderly patients presenting more often with larger tumours requiring mastectomy 8,15,29.

    View all citing articles on Scopus
    View full text