Breast cancer treatment for the over-80s in New Zealand
Breast surgeon Dr Eva Juhasz has recently finished a study of the current treatment of elderly breast cancer patients in Waitematā DHB.
Overseas research has shown that 10% of breast cancer patients are aged over 80. They are more likely to have oestrogen-receptor (ER)-positive disease than younger women. In many countries, elderly women tend to present later, receive less treatment and have higher mastectomy rates. Because clinical trials often exclude elderly patients, there is generally less information on how they might respond to different treatments.
Dr Juhasz examined the records of 207 patients aged 80 years or more, who were diagnosed with primary invasive breast cancer between 2010 and 2016. Most (91%) identified as NZ European, 4% as Maori, 3% as Pasifika, 1% as Asian and 1% as other ethnicities. In total, 51% were aged 80 to 84 years, 36% aged 85 to 89 years, and 13% were over 90 years old. As has been found in other countries, 83% had ER-positive and 14% had triple negative breast cancer.
Just over half (57%) of the patients received surgery. Only 20% of the group that received surgery had positive lymph nodes, most (65%) had Stage I or II cancer, and most had had a sentinel node biopsy. Older patients were progressively less likely to be treated with surgery: 74% of 80 to 84-year-olds had surgery, 51% of 85 to 89-year-olds, and only 4% of those aged over 90 years.
The main reason for not undergoing surgery was patients choosing not to (43%), followed by clinicians advising endocrine treatment only (27%).
Compared with younger patients, elderly women undergoing surgery were more likely to receive a mastectomy than a breast-conserving operation. Difficulty in organizing travel to get to repeated radiotherapy sessions, which may be needed after breast-conserving surgery, was often raised as an issue for older patients deciding to have a mastectomy. Dr Juhasz suggested that making radiotherapy more accessible for older patients could be of benefit.
After surgery, 38% received radiotherapy, 3% chemotherapy and 53% were given endocrine therapy.
Patients who had surgery had better survival (breast-cancer-specific and overall) than those who did not. However, those who did not receive surgery were generally older and more frail, some had metastatic disease and some were unfit for surgery; these factors could also have contributed to their poorer outcomes.
Dr Juhasz concluded that, although surgery was not possible or advisable in some cases, generally speaking patients are likely to do better if they are suitable for surgery and undergo surgery. She noted that breast surgery is relatively low risk and recommended that all breast cancer patients over 80 should be assessed using a Clinical Frailty Scale (https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.html) to see if they are suitable for surgery. After 80, it is better to consider a person’s frailty, rather than their chronological age, when assessing risks and benefits of treatment options.
She recommended that all breast cancer cases in elderly women should be discussed among clinicians at multidisciplinary meetings. Suitable candidates should be offered breast-conserving surgery if possible, as there are advantages over mastectomy in terms of quality of life and psycho-social health, and any radiotherapy needed is generally well tolerated in this age group. Those who are too frail for surgery may be suitable for endocrine therapy if they are ER-positive and radiotherapy may be useful for some. Women with a medium frailty score should undergo careful evaluation of options – lumpectomy and endocrine treatment could be useful.
Modified chemotherapy should be considered for those between 80 and 84 who have triple negative or HER2-positive breast cancer and have scored well on the frailty test. Radiotherapy could benefit patients with tumours larger than 5cm or more than 4 nodes involved.
Dr Juhasz has produced a flow chart version of these guidelines to help clinicians and patients make the best decisions based on their situation.
Even though the BreastScreen Aotearoa programme covers the cost of mammograms for those aged 45-69, with a promised extension to those aged up to 74, Dr Juhasz recommends that her cancer patients have annual mammograms up to the age of 80 if they can afford it.
Breast cancer advice for older women:
- Get regular mammograms up to age 80 if you can afford them
- Breast surgery is relatively low risk surgery
- If you are not too frail, breast cancer surgery could give you more years of life
- Breast conserving surgery instead of mastectomy can still be a good option if you are over 80.
13 July 2020