Breast cancer surgical treatment in elderly patients

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(1)Breast cancer surgical treatment in elderly patients. IN C ER O V P A Y R M IG E H DI T C ® A. B. AMATO 1, M. DONISI 1, N. ROCCO 1, L. IANNONE 1, S. TESTA 1 R. COMPAGNA 1, G. VIGLIOTTI 1, C. RISPOLI 2, V. SALVATI 1, M. GENTILE 1, L. SIVERO 1. Breast cancer is the most diagnosed cancer and the second leading cause of mortality in women. The diagnosis of breast cancer is associated with a favorable prognosis if there is a hormonal high sensitivity, an attenuated expression of HER-2 and a low degree of mitotic indices. Although breast cancer occurs predominantly in elderly patients, this population is not well represented in clinical trials. A significant proportion of patients older than 70 years with operable breast cancer died of causes unrelated to the tumor. A Cochrane review has confirmed that hormonal therapy with tamoxifen, performed in the first instance, is less effective than surgery (with or without subsequent hormonal therapy) both for local control, and for diseasefree survival for breast cancer in older women. In conclusion, surgery should not be denied to patients with advanced age, and various treatments proposable in the elderly are similar to those performed for outcome in young patients. Key words: Breast neoplasms - Aged - Estrogen replacement therapy.. B. reast cancer is the most commonly diagnosed cancer and leading cause of cancer mortality in women worldwide. Nearly one-third of the total of breast cancer cases occurs in patients >65 years of age and in more developed countries it accounts for >40% of cases.1, 2 Diagnosis of breast cancer at an advanced age is associated with more favorable tumor biology, as indicated by increased hormone sensitivity, attenuated HER-2 overexpression and lower grades and proliferative indices.3 Elderly patients, however, are more likely to have larger and more advanced tumors, and recent reports suggest that lymph node involvement increases with age.4 Elderly patients are less likely to be treated according to accepted treatment guidelines 5 and under-treatment can, as a consequence, have a strong negative impact on survival.6 Despite the fact that breast cancer occurs mainly in elderly patients, this population is significantly underrepresented in clinical trials. Collaboration with geriatricians and comprehensive geriatric assessment are of paramount importance in detecting unaddressed problems, improving functional status and, possibly, survival in elderly patients with cancer.7 Because. M. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. CHIRURGIA 2013;26:309-11. Corresponding author: B. Amato, MD, Department of General, Geriatric, Oncologic Surgery and Advanced Technologies, Federico II University, via Pansini 5, 80131 Naples, Italy. E-mail: bramato@unina.it Vol. 26 - No. 4. 1Department of General, Geriatric Oncologic Surgery and Advanced Technologies Federico II University, Naples, Italy 2Department of General and Emergency Surgery ASL Napoli1 Centro, Naples, Italy. comorbidities and functional status significantly impact on prognosis and treatment choice,8 thorough consideration must be given to the overall health of elderly patients. A significant proportion of patients older than 70 years with operable breast cancer die of non-cancer-related causes.9 Early breast cancer surgical treatment. Breast cancer surgery-related mortality is low in the elderly population, ranging from 0% to 0.3%.10 An alternative to conventional surgery is surgery under local anesthesia, which is preferably undertaken when family support is present.11, 12 Past assumptions that elderly patients should receive less aggressive forms of breast cancer treatment and reduced life expectancy have meant that hormonal therapy alone without surgery has been considered a reasonable treatment option for elderly women with breast cancer with limited life expectancy, mainly in frail patients or the very old (>80 years).13 The impact of omitting surgery on overall survival is not clear and differs in different studies.14, 15 A Cochrane review on this topic has confirmed that primary hormonal therapy with Tamoxifen is inferior to surgery (with or without hormonal therapy) for local control and progression-free survival of breast cancer in fit-for-surgery older women.16 Surgery, however, does not result in significantly better overall survival. Elderly patients are less likely to receive breast conservation therapy (BCT).17 The conclusions of the large randomized trials of BCT versus mastectomy are not easily applied to elderly patients given that women over the age of 70 years were excluded from these trials. However, smaller studies involving patients >70 years of age have documented that BCT in comparison with mastectomy is associated. CHIRURGIA. 309.

(2) Breast cancer surgical treatment in elderly patients. espressione di HER-2 ed un basso grado di indici mitotici. Nonostante il carcinoma della mammella si verifichi prevalentemente in pazienti anziane, questa popolazione non è significativamente rappresentata nei trial clinici. Una significativa percentuale di pazienti con età superiore a 70 anni, con tumore della mammella operabile, muore per cause non correlate al tumore. Una revisione Cochrane ha confermato che la terapia ormonale con tamoxifene, eseguita in prima istanza, è meno efficace rispetto alla chirurgia (con o senza successiva terapia ormonale) sia per il controllo locale, sia per la sopravvivenza libera da malattia, per il tumore della mammella in donne anziane. In conclusione, la chirurgia non deve essere negata a pazienti con età avanzata, e i vari trattamenti proponibili nei pazienti anziani sono sovrapponibili per outcome a quelli eseguiti nei pazienti giovani. Parole chiave: Mammella, carcinoma - Età geriatrica - Terapia ormonale.. IN C ER O V P A Y R M IG E H DI T C ® A. with better quality of life 18 and is preferred by the majority of elderly patients 19 compared with mastectomy. Axillary lymph node dissection (ALND) should be performed in patients with clinical evidence of axillary lymph node involvement. Before the sentinel lymph node (SLN) procedure, older patients with breast cancer were less likely to undergo ALND than younger patients. Several studies have shown no difference in outcome in older patients with small tumors without palpable lymph nodes when ALND was omitted.20, 21 In elderly patients where the results of an ALND will not influence adjuvant chemotherapy decisions, including those with small tumors and low risk of nodal involvement, it may be appropriate to omit ALND. In recent years, however, SLN biopsy has been introduced as an alternative to ALND also in patients aged >70 years 4, 22 and is a generally accepted standard in patients of all ages with tumor size <2-3 cm and no clinical evidence of axillary involvement.23 In conclusion, surgery should not be denied to breast cancer patients >70 years of age and should not differ from procedures offered to younger patients, unless there is a different patient preference. ALND should be used when there is clinical suspicion of axillary lymph node involvement or high-risk tumors, as adjuvant treatment may depend on the pathological results of the ALND. SLN biopsy is a safe alternative to ALND in patients with clinically node-negative tumors. Elderly patients with tumor size <2-3 cm and no clinical evidence of axillary involvement should be offered an SLN biopsy. Controversy exists regarding the need for ALND after a positive SLN. Metastatic breast cancer. The main aims in treating elderly patients, like younger patients, with metastatic breast cancer are to maintain quality of life, minimize symptoms from the disease and prolong survival without causing excessive toxicity. Several hormonal treatments are available and should be the treatment of choice for women with ER-positive and/or PR- positive tumors without life-threatening disease. The use of chemotherapy should be considered in hormone receptor-negative or hormone-refractory patients. Preference should be given to chemotherapeutic agents with ‘safer’ profiles (weekly taxane regimens and newer less cardiotoxic anthracycline formulations). Particular attention should be paid to supportive care, as older patients are more likely to develop neutropenia than younger patients 24, 25 and generally have less functional reserve than their younger counterparts. In HER-2-positive patients, trastuzumab can be used in conjunction with chemotherapy.. M. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. AMATO. Riassunto Trattamento chirurgico del carcinoma della mammilla in pazienti anziani Il carcinoma della mammella rappresenta la neoplasia più diagnosticata e la seconda causa di mortalità nelle donne. La diagnosi dei carcinomi della mammella è associata ad una prognosi favorevole se sono presenti una elevata sensibilità ormonale, una attenuata 310. References. 1. Wildiers H, Kunkler I, Biganzoli L et al. Management of breast cancer in elderly individuals: recommendations of the International Society of Geriatric Oncology. Lancet Oncol 2007;8:1101-15. 2. Ferlay J. Cancer incidence, mortality and prevalence Worldwide IARC CancerBase No. 5, version 2.0 [Abstr]. Lyon, France: IARCPress. GLOBOCAN 2002 2004. 3. Diab SG, Elledge RM, Clark GM. Tumor characteristics and clinical outcome of elderly women with breast cancer. J Natl Cancer Inst 2000;92:550-6. 4. Gennari R, Curigliano G, Rotmensz N et al. Breast carcinoma in elderly women-features of disease presentation, choice of local and systemic treatments compared with younger postmenopausal patients. Cancer 2004;101:1302-10. 5. Ballard Barbash R, Potosky AL, Robertson C et al. Factors associated with surgical and radiation therapy for early stage breast cancer in older women. J Natl Cancer Inst 1996;88:716-26. 6. Bouchardy C, Rapiti E, Fioretta G et al. Undertreatment strongly decreases prognosis of breast cancer in elderly women. J Clin Oncol 2003;21:3580-7. 7. Extermann M, Aapro M, Bernabei RB et al. Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol 2005;55:241-52. 8. Louwman WJ, Janssen-Heijnen MLG, Houterman S et al. Less extensive treatment and inferior prognosis for breast cancer patient with comorbidity: a population-based study. Eur J Cancer 2005;41:779-85. 9. Yancik R, Wesley MN, Ries LAG et al. Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older. JAMA 2001;285:885-92. 10. Audisio RA. The surgical risk of elderly patients with cancer. Surg Oncol 2004;13:169-73. 11. Tan LR, Guenther JM. Outpatient definitive breast cancer surgery. Am Surgeon 1997;63:865-7. 12. Najarian MM, Johnson JM, Landercasper J et al. Paravertebral block: an alternative to general anesthesia in breast cancer surgery. Am Surgeon 2003;69:213-8. 13. Rai S, Stotter A. Management of elderly patients with breast cancer: the time for surgery. Anz J Surg 2005;75:863-5. 14. Fentiman IS, Christiaens MR, Paridaens R et al. Treatment of operable breast cancer in the elderly: a randomised clinical trial EORTC 10851 comparing tamoxifen alone with modified radical mastectomy. Eur J Cancer 2003;39:309-16. 15. Fennessy M, Bates T, MacRae K et al. Late follow-up of a randomized trial of surgery plus tamoxifen versus tamoxifen alone in women aged over 70 years with operable breast cancer. Br J Surg 2004;91:699-704. 16. Hind D, Wyld L, Beverley CB, Reed MW. Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database of Systematic Reviews 2006. 17. Giordano SH, Hortobagyi GN, Kau SWC et al. Breast cancer treatment guidelines in older women. J Clin Oncol 2005;23:783-91.. CHIRURGIA. AGOSTO 2013.

(3) AMATO. node mapping valuable for patients in their seventies and beyond? Am J Surg 2005;190:366-70. 23. Lyman GH, Giuliano AE, Somerfield MR et al. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 2005;23:770320. 24. Dees EC, O’Reilly S, Goodman SN et al. A prospective pharmacologic evaluation of age-related toxicity of adjuvant chemotherapy in women with breast cancer. Cancer Invest 2000;18:521-9. 25. Rispoli C, Rocco N, Iannone L, Compagna R, Cacciapuoti MT, Bellino A et al. Breast reconstruction in older women: a growing request. BMC Ger 2009;9S1:28. Received on November 15, 2012. Accepted for publication on June 5, 2013.. IN C ER O V P A Y R M IG E H DI T C ® A. 18. de Haes JCJM, Curran D, Aaronson NK, Fentiman IS. Quality of life in breast cancer patients aged over 70 years, participating in the EORTC 10850 randomised clinical trial. Eur J Cancer 2003;39:94551. 19. Sandison AJP, Gold DM, Wright P, Jones PA. Breast conservation or mastectomy: treatment choice of women aged 70 years and older. Br J Surg 1996;83:994-6. 20. Truong PT, Bernstein V, Wai E et al. Age-related variations in the use of axillary dissection: a survival analysis of 8038 women with T1-ST2 breast cancer. Int J Radiat Oncol Biol Phys 2002;54:794803. 21. Veronesi U, Paganelli G, Viale G et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. New Engl J Med 2003;349:546-53. 22. McMahon LE, Gray RJ, Pockaj BA. Is breast cancer sentinel lymph. M. This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.. Breast cancer surgical treatment in elderly patients. Vol. 26 - No. 4. CHIRURGIA. 311.

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