The Surgical Management of Breast Cancer in Elderly Women

Abstract

Owe third of all women diagnosed with breast cancer are over 70 years of age, equating to some 13,000 women in the UK annually. As the UK population ages, this number will increase. Whilst many of these older women will be fit for standard therapies, increasing age, frailty, and co-morbidity levels may render some women unfit for certain treatments. This chapter will deal with the role of surgery in these women. It has long been recognized that older women do not receive the same surgical and adjuvant treatments as younger women (Balasubramanian et al. 2003; Wyld et al. 2004; Lavelle et al. 2007; Mustacchi et al. 2003; Eaker et al. 2006; Louwman et al. 2005; BCCOM 2007). Chemotherapy is usually omitted, surgery may be omitted or minimized to be less onerous, (in particular axillary staging is less likely to be performed) and radiotherapy may be omitted after surgery. How these changes impact on local and systemic disease control has been largely studied in the context of observational studies with few good-quality randomized clinical trials having been performed. Rates of local control are inferior when surgery is omitted and there is some suggestion that systemic disease control rates are impaired in the elderly generally, although this is based on few good quality studies (Bouchardy et al. 2003). This is a difficult area to research as survival in this age group is heavily influenced by competing causes of death and the very heterogeneous nature of the population in terms of basal health status. Recent research has demonstrated that surgery, supported by modern anesthetic techniques (general, regional, and local), is well-tolerated, precluding fewer women (Wildiers et al. 2007). However, there are still women for whom extreme age, co-morbidity, and frailty render surgery more hazardous. This chapter will examine the evidence for the role of surgery in older women and suggest alternative strategies for those in whom the risks are raised. The evidence base for these modified strategies is poor, due to a lack of good-quality primary research in this age group and the inherent difficulties in studying disease processes, patient-related variance, and treatment variance in such a heterogeneous patient group.