Breast cancer in the elderly

Breast cancer is largely a disease of older women.

Almost half of new breast cancers diagnosed in the United States annually occur in women ages 65 and older.

26% of breast cancer diagnoses are in women, 65 to 74 years of age.

The prevalence of breast cancer among older adults is rising.

The risk of developing breast cancer increases with age, and peaks in incidence around 80 years.

Elderly women age 70 years and older comprise approximately 30% of all invasive breast cancer cases.

Breast cancer in older women are less likely to exhibit aggressive tumor characteristics compared with breast cancers of younger women.

Breast cancer diagnosed in women ≥70 years of age tends to be early stage and hormone receptor (HR)-positive.


Breast cancers diagnosed in women ≥70 years of age carry an excellent prognosis: omission of routine sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy are acceptable strategies. 

The percentage of ER positive breast cancers increase with age, so that less than 60% of patients age 30-34 years are positive, where it is as high as 85% in patients aged 80-84 years.

Older women with breast cancer are more likely to have tumors with lower proliferative indexes and less likely to have HER2 gene overexpression.

Despite more favorable tumor characteristics, outcomes for older women with breast cancer does not report survival advantages.

Five-year relative survival of patients age 70 and over is lower than that of patients age 15-70 (Rosso S et al).

Elderly patients with breast cancer are less likely be treated with standard protocols, potentially increasing risk of disease recurrence and mortality.

Improvements in outcomes in younger women with BC have been significant, while improvements in older women has been much more modest.

Treatment of the elderly women with breast cancer older than 80 years is often less aggressive and deviates from standard practices established for younger women.

Elderly women are less likely to undergo surgery, are usually precluded from participating in clinical trials, rendering treatment approach largely on the basis of performance status and comorbidities.

Surgical management of patients with breast cancer who are elderly is quite safe, with a mortality rate significantly less than 1%.

Extremely frail and debilitated patients with breast cancer, and who cannot tolerate surgery should receive primary endocrine therapy if it is hormonally responsive.

Meta-analyses suggest primary treatment with tamoxifen is inferior to surgery in terms of local control in progression free survival in women who are medically fit age 70 years and older, but overall survival is not different.

For the management of primary breast cancer, the average response time to tamoxifen is 18-24 months.

Same surgical options exist with breast conserving surgery or mastectomy as in younger patients.

Elderly breast cancer patients are, however, more likely to be treated with mastectomy than younger women, and arevless likely to undergo breast reconstruction.

Sentinel lymph node biopsy is routinely applied In the evaluation of elderly breast cancer patients, as in younger women.

The use of axillary lymph node dissection is standard care for patients with at least three positive sentinel nodes.

The efficacy of axillary lymph node dissection in patients with T1 disease and 1-2 positive sentinel nodes is being questioned.

It is also questionable if patients have comorbid conditions that preclude adjuvant chemotherapy whether axillary lymph node assessment is even of value.

TheInternational Breast Cancer Study Group trial 10-93 randomly assigned older women to primary surgery and tamoxifen with or without axillary lymph node dissection, and had a follow-up 6.6 years:the rates of disease free survival and overall survival were the same.

It is reasonable in patients with small, less than 2 cm lesions, ER positive tumors, clinically negative axilla, and who are receiving adjuvant endocrine therapy to consider to withhold axillary evaluation.

The addition of adjuvant radiotherapy to patients who undergo breast conservative surgery is well tolerated and an acceptable consideration for elderly breast cancer patients.

The rate of ipsilateral breast cancer recurrence decreases with age so that radiation after breast conserving surgery has similar proportionate reductions in local recurrence across age groups, the absolute benefits of treatment are lower in older females, since their risk of recurrence is less (Clarke M et al).

In a study of 1326 women, the omission of irradiation included women, 65 years of age or older, who at hormone receptor, node negative, T1 or T2 primary breast cancer: there was an increased incidence of local recurrence, but had no detrimental effect on this recurrence is the first event, or overall survival among women 65 years of age or older, with low risk, hormone receptor, positive early breast cancer ( Kunkler, I A).



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