Breast cancer in the elderly: Fighting disease patient by patient

Compared with the treatment of younger women, the treatment of breast cancer in very elderly patients is fraught with additional considerations and complications. MedWire reporter David Holmes talks to leading breast surgeon Lynda Wyld about the challenges faced and the progress being made by the clinicians and patients at the front line.

Lynda Wyld is a breast and sarcoma surgeon at the Royal Hallamshire Hospital in Sheffield, UK, and senior lecturer for the Academic Unit of Surgical Oncology at the University of Sheffield.

Shifting demographic sands put screening to the fore

More than a million women are diagnosed with breast cancer worldwide each year, accounting for a 10th of all new cancers and almost a quarter of all female cancer cases.

With the average age for cancer diagnosis in industrialized countries approaching 70 years of age and expected to increase, it is clear that breast cancer will increasingly become a disease that will affect the lives of older women. In the Western world the prevalence of the disease is projected to rise to 7% in women aged over 70 years in the near future¹.

However, despite the fact that more than half of all cancers occur in elderly patients, the information available to clinicians about cancer management in the elderly is severely limited.

“In terms of trials that show screening in this age group definitely saves lives, there really aren’t any.”

This is due in large part to the under-representation of elderly patients in clinical trials, with patients aged over 70 years accounting for only 10% of all participants in clinical trials of cancer prevention and treatment¹.

Nowhere is this lack of information more apparent than when considering the case for breast cancer screening in elderly women. .

As Wyld points out: “In terms of trials that show screening in this age group definitely saves lives, there aren’t any.

“The big screening trials didn't recruit any women over the age of 75; nobody has actually looked at this issue in the older age group.”

However, the fact that all of the previous randomized, controlled studies of mammography screening had an upper age limit of 65 or 70 years is more down to the fact that they were all done in the 1960s, 70s, and 80s, at a time when life expectancy was lower. In Britain at least, Wyld sees reasons to be optimistic.

“From a screening perspective in Britain we do quite well and we're going to be doing better in the very near future. Many European countries stop screening at 65; we're going to be screening up to age 73 by 2010.”

Women in the UK are currently invited to mammography screening between the ages of 50 and 69 years, and over that age they have open access to free 3-yearly screening if they want it.

This is in stark contrast to the current situation in The Netherlands, for example, where the Dutch government is being taken to court over their refusal to give women access to mammography over the cutoff age of 75 years.

However, the British system of open access is by no means perfect. “The problem is most women aren't aware that this facility exists: over 90 per cent of older women don't know they can have screening,” says Wyld. “The profile of screening availability for older women should be raised.”

Individualize - optimize

Detecting breast cancer in the elderly is only the first hurdle encountered on the path to successful treatment of the disease. One of the central questions that needs to be addressed for each and every elderly breast cancer patient is: What actually constitutes successful treatment?

Standard treatment for early breast cancer usually involves treatment with a combination of surgery and one or more adjuvant therapies, including chemotherapy, radiotherapy, and endocrine therapy. Younger women with early-stage breast cancer are almost always treated with surgery plus endocrine therapy².

However, women over 70 years have increasing rates of comorbidity, reduced life expectancy, and generally have more favorable breast cancer disease biology³, while competing causes of death mean that they are less likely to die of their breast cancer, stage for stage, than a younger woman.

“If you look at the causes of death of older ladies with breast cancer, probably more than half of them die of something completely unrelated, which is completely different to 30 year olds with breast cancer,” says Wyld.

And it gets more complicated, as the tolerance of older women to some of the therapies is reduced, increasing treatment-related morbidity and reducing the risk/benefit ratio.

As Wyld explains: “If you've got a very frail 90 year old with a heart problem, then clearly an operation might not be in her best interests.

“You can't just lump them all together.”

“The important thing when dealing with older ladies is that you have to tailor treatment much more because you have to take into account their life expectancy because of their other conditions, and their frailty levels. Frail patients won't tolerate chemotherapy, and won’t tolerate a major surgical procedure.”

As a result, the very standardized treatment protocols used for younger women are rarely suitable for an older patient, and the goals of treatment are aligned more with improving quality of life than with curing the disease.

“You can't just lump them all together,” says Wyld. “For older ladies you have to do a very thorough assessment of their fitness levels and then decide what they need to treat their cancer that they can tolerate.”

Such careful individual evaluation inevitably increases the time required and cost involved in treating older women with breast cancer, but Wyld is adamant that these added pressures do not have an impact on the quality of care available.

“The vast majority of British oncologists and surgeons do a very good job of tailoring treatment so that they get the most treatment that they can tolerate to get them the best outcome from their cancer and balance that against the best quality of life and the best side effects from the treatment on offer,” she says.

“Maybe 20 or 30 years ago there was quite a lot of undertreatment without very much evidence to back it up but I think nowadays people are much more keen to optimize treatment. I think things have improved a lot.

“I don't think they suffer as a result of being older.”

Starved for knowledge

Ultimately though, Wyld acknowledges that an increased understanding and improved standard of care for the elderly breast cancer population can only be achieved through more and better research.

“It comes back to the research issue. There is a pressing need to actually get trials going in this age group. That's number one on the wish list.”

“The reality is we are not going to make progress in this age group unless we have data from studies to actually guide us,” she says.

“We've got this whole issue with Herceptin [trastuzumab] for example, which tends not to be used in older ladies because there are some risks of it being toxic to the heart. But we haven't really done any research to see whether that's a major issue.”

Similarly with chemotherapy, Wyld explains: “We don't routinely give chemo because we think it's probably more toxic and not as advantageous, but we don't really know. So most [patients] don't get it, whereas if we did some studies to look at it we might be able to offer a subgroup of older ladies the more aggressive treatment with safety.

“It comes back to the research issue. There is a pressing need to actually get trials going in this age group. That's number one on the wish list.”

Wyld concludes: “It's a difficult research area, I think, and I can understand why doctors and nurses don't want to put older ladies through the inconvenience of trial participation, which can sometimes be quite onerous. But things aren't going to improve much for older ladies unless they do. So it is ultimately in their best interest”