Tumor characteristics and therapy of elderly patients with breast cancer

  • A.-M. Grumpelt
  • A. Ignatov
  • S. N. Tchaikovski
  • E. Burger
  • S.-D. Costa
  • H. Eggemann
Original Article – Clinical Oncology

Abstract

Introduction

Elderly breast cancer patients aged ≥75 years are underrepresented in most studies. Therefore, data on cancer characteristics, adjuvant treatment and survival in elderly patients are missing.

Patients and methods

In this retrospective study, we compared tumor characteristics and adjuvant therapy in 973 women with invasive, non-metastasized breast cancer aged ≥75 years with 3377 younger postmenopausal patients (50–74 years old). Time dynamics of tumor characteristics were investigated, comparing two observation periods between the years 2000–2004 versus 2005–2008.

Results

Compared to younger women, older patients were more often treated with mastectomy and less likely to receive adjuvant treatment. Although the overall survival rate increased over the observation period in both age groups, the older study group was characterized by shorter disease-free survival. Additionally, we observed an increase in about 1.65 years in the age at diagnosis as well as an increasing rate of breast-conserving surgery and sentinel lymph node biopsy for the whole study population between 2000 and 2008. Furthermore, we found a reduction in the proportion of estrogen receptor-positive tumors in the younger women and a decrease in G3-tumors in both age groups over the study time.

Conclusion

The older group’s reduced disease-free survival could be explained by the tumor characteristics and differences in the adjuvant treatment. Remarkably, elderly women are more likely to be overtreated surgically while being undertreated in terms of adjuvant therapy.

Keywords

Breast cancer Elderly patients Adjuvant treatment 

Introduction

Breast cancer is the most frequent malignant disease in women worldwide, and despite a recent decrease in breast cancer-specific mortality, it remains one of the leading causes of death in women (Statistisches Bundesamt (Destatis) 2015). Advanced age is the major risk factor for breast cancer. However, there are only a few studies available on breast cancer features in elderly patients (Hutchins et al. 1999). Older women are thought to have biologically more favorable tumors, more often hormone receptor-positive tumors, with lower grading and a lower proliferation rate compared to younger women. However, in elderly women, breast cancer is more likely to be diagnosed at an advanced stage (Gennari et al. 2004).

Therapeutic options should be similar for all women regardless of their age. However, multimorbidity of older women often limits therapeutic options and influences patients’ compliance (Hamaker et al. 2013; Muss 2010). Furthermore, a shorter life expectancy due to concomitant diseases with consequently lower risk of locoregional recurrence should be taken into account during the decision-making process (Beadle et al. 2011; Hughes et al. 2013). Life expectancy has increased over the last decades, and gaining evidence-based data on the special features of tumors and treatment of elderly patients without limiting their quality of life has become increasingly important.

We performed a retrospective analysis of the data from the Magdeburg clinical cancer registry to compare tumor characteristics and therapy of invasive, non-metastasized breast cancer in elderly (age ≥75 years) and younger (age 50–75 years) postmenopausal patients. Furthermore, dynamics within the above-mentioned parameters over the course of the analysis were investigated. Two observation periods were compared from date of diagnosis between 2000 and 2004 versus 2005 and 2008. The investigation period covered 2000–2012.

Materials and methods

Study population

We analyzed 8163 data records from the Magdeburg clinical cancer registry of patients with primary breast cancer diagnosed between 2000 and 2009. We excluded 1491 patients younger than 50 years, 56 male patients, 441 premenopausal women and women with unknown menopausal status younger than 52 years as well as 493 cases of ductal or lobular carcinoma in situ, 21 cases of unknown histology, 309 cases of primary metastasized breast cancer, two double entries and 922 cases documented after 2008 with incomplete data on primary therapy. This resulted in 4350 postmenopausal women between 50 and 100 years of age who were included into the current analysis. For the patients with bilateral breast cancer (n = 118), the tumor with the more unfavorable prognosis was chosen for the analysis.

Statistical analysis

SPSS Statistics 20.0 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, version 20.0. Armonk, NY) was used for statistical analysis. Descriptive statistics are presented as common measures of central tendency and measures of variation. The t test was used for comparison of means. Frequency tables were analyzed with Chi-quadrate tests. The effect of tumor characteristics and other factors of overall and disease-free survival were evaluated by multivariate logistic regression analysis (Cox regression). p values <0.05 were considered statistically significant.

Results

The study population of 4350 was divided into two groups with respect to the age at the diagnosis: 3377 women were between 50 und 74 years and 973 patients ≥75 years of age.

Differences in tumor characteristics and adjuvant therapy between the age groups

Tumor characteristics and adjuvant therapy are presented in Table 1.
Table 1

Differences in tumor characteristics and adjuvant therapy between the age groups

 

<75 years

≥75 years

p value

Tumor characteristics

 HR-status

  HR negative

480 (16.8)

89 (11.2)

<0.001

  HR positive

2379 (83.2)

704 (88.8)

 

  Missing

518 

180 

 

 ER-status

  ER negative

423 (18.0)

78 (11.9)

<0.001

  ER positive

1924 (82.0)

577 (88.1)

 

  Missing

1030 

318 

 

 PR-status

  PR negative

682 (29.2)

179 (27.5)

0.406

  PR positive

1655 (70.8)

473 (72.5)

 

  Missing

1040 

321 

 

 Her2neu-status

  Her2neu 1 + ; 2+

1956 (83.2)

517 (85.2)

0.268

  Her2neu 3+

394 (16.8)

90 (14.8)

 

  Missing

1027 

366 

 

 Grade

  G1

347 (10.8)

86 (9.4)

0.428

  G2

1553 (48.1)

439 (47.9)

 

  G3

1327 (41.1)

391 (427)

 

  Missing

150 

57 

 

 Histological type

  Invasive ductal

2186 (64.7)

583 (59.9)

<0.001

  Invasive lobular

546 (16.2)

164 (16.9)

 

  Invasive duct./lob.

109 (3.2)

28 (2.9)

 

  Medullar

41 (1.2)

6 (0.6)

 

  Mucinous

64 (1.9)

58 (6.0)

 

  Tubular

53 (1.6)

5 (0.5)

 

  Others

378 (11.2)

129 (13.3)

 

  Missing

 

 pT

  ypT0/ypTis (DCIS)

19 (0.6)

1 (0.1)

<0.001

  pT1

1585 (48.6)

273 (31.2)

 

  pT2

1318 (40.5)

435 (49.7)

 

  pT3

189 (5.8)

51 (5.8)

 

  pT4

147 (4.5)

115 (13.1)

 

  Missing

119 

98 

 

 pN

  pN negative

2154 (65.5)

554 (63.5)

0.281

  pN positive

1136 (34.5)

319 (36.5)

 

  Missing

87 

100 

 

Adjuvant therapy

 Breast surgery

  BCS

2033 (61.3)

344 (39.3)

<0.001

  Mastectomy

1284 (38.7)

532 (60.7)

 

  Missing

60

97

 

 Axillary surgery

  AD

2519 (77.6)

672 (85.5)

<0.001

  SNB

637 (19.6)

101 (12.8)

 

  SNB + secondary AD

90 (2.8)

13 (1.7)

 

  Missing

131

187

 

 Adjuvant radiation

  Following BCS

1826 (89.8)

268 (77.9)

<0.001

  …Missing

207 (10.2)

76 (22.1)

 

  Following RAD

633 (49.3)

167 (31.4)

<0.001

  …Missing

651 (50.7)

365 (68.6)

 

 Adjuvant chemotherapy

  CMF

161 (9.8)

22 (29.7)

<0.001

  Anthracycline

892 (54.0)

27 (36.5)

 

  Taxane

463 (28.0)

9 (12.2)

 

  Other

46 (2.8)

13 (17.6)

 

  Not specified

89 (5.4)

3 (4.1)

 

  Missing

1726

899

 

 Adjuvant endocrine therapy

  Tam

916 (52.3)

247 (55.0)

0.003

  AI

656 (37.5)

175 (39.0)

 

  Tam/AI

158 (9.0)

18 (4.0)

 

  Other

21 (1.2)

9 (2.0)

 

  Missing

892

323

 

 Adj. trastuzumab therapy

  Yes

81 (20.6)

6 (6.7)

0.001

  No

313 (79.4)

84 (93.3)

 

Data presented in number of patients (%)

HR hormone receptor, ER estrogen receptor, PR progesterone receptor, duct. ductal, lob. lobular, pT tumor size, pN nodal status, BCS breast-conserving surgery, RAD mastectomy, AD axillary dissection, SNB sentinel-node biopsy, Tam tamoxifen, AI aromatase inhibitor

The mean age at the diagnosis in the two groups was 62.5 and 80.1 years, respectively. There were no differences in the progesterone receptor (PR), Her2-status or histological grade between the groups, but older women had more often estrogen receptor (ER)-positive tumors (p < 0.001). Additionally, the groups differed with respect to histological type of the tumor (p < 0.001). Although invasive ductal carcinoma was the most frequent histological type of breast cancer in both groups, tubular carcinomas were more common in the younger group, whereas mucinous tumors were more prevalent in elderly patients. Furthermore, the elderly women were more often diagnosed with pT3 and pT4 tumors (p < 0.001). No significant differences were noted in the axillary lymph node involvement between the groups (p = 0.281).

Elderly women were more likely to receive mastectomy and axillary dissection (AD), whereas younger patients were more often treated with breast-conserving surgery (BCS) and sentinel lymph node biopsy (SNB). Interestingly, the same was true for patients with pT1 tumors as well as for women without axillary metastasis.

Compared to the younger group, the elderly women received adjuvant radiation and systemic therapy less often, including endocrine therapy (66.3 vs. 58.2 %, p < 0.001), chemotherapy (48.5 vs. 7.6 %, p < 0.001) or trastuzumab in case of Her2-positive tumors (p = 0.001). If adjuvant chemotherapy was given, elderly patients were more likely to receive anthracycline-free and taxane-free schemata as compared to younger women. The reasons underlying therapy decisions were not evaluated because such data are not documented in the cancer registry.

Differences in tumor characteristics and therapy between 2000–2004 and 2005–2008

To gain insight about the changes in tumor characteristics and breast cancer therapy between 2000 and 2008, we compared two observation periods: 2000–2004 versus 2005–2008 (Table 2). The average age at the diagnosis in the first observation period for the whole study population was 66.4 ± 8.6 years. In the second period, it was 68 ± 9.2 years, respectively (p < 0.001).
Table 2

Differences in tumor characteristics and adjuvant therapy between 2000 and 2004 versus 2005 and 2008

 

<75 years

≥75 years

2000–2004

2005–2008

p value

2000–2004

2005–2008

p value

Tumor characteristics

 HR-status

  HR negative

192 (15.6)

288 (17.7)

0.157

37 (13.5)

52 (10.0)

0.157

  HR positive

1036 (84.4)

1343 (82.3)

 

238 (86.5)

466 (90.0)

 

  Missing

405 

113 

 

115 

65

 

 ER-status

  ER negative

135 (15.8)

288 (19.3)

0.039

29 (14.2)

49 (10.9)

0.241

  ER positive

717 (84.2)

1207 (80.7)

 

175 (85.8)

402 (89.1)

 

  Missing

781

249 

 

186 

132 

 

 PR-status

  PR negative

242 (28.6)

440 (29.5)

0.670

69 (34.2)

110 (24.4)

0.013

  PR positive

604 (71.4)

1051 (70.5)

 

133 (65.8)

340 (75.6)

 

  Missing

787 

253 

 

188 

133 

 

 Her2neu-status

  Her2neu 1+; 2+

636 (77.3)

1320 (86.4)

<0.001

123 (79.9)

394 (87.0)

0.036

  Her2neu 3+

187 (22.7)

207 (13.6)

 

31 (20.1)

59 (13.0)

 

  Missing

810

217

 

236 

130

 

 Histology

  Invasive ductal

955 (58.5)

1231 (70.6)

<0.001

221 (56.7)

362 (62.1)

0.006

  Invasive lobular

301 (18.4)

245 (14.0)

 

67 (17.2)

97 (16.6)

 

  Invasive duct./lob.

72 (4.4)

37 (2.1)

 

16 (4.1)

12 (2.1)

 

  Medullar

24 (1.5)

17 (1.0)

 

6 (1.5)

0 (0.0)

 

  Mucinous

32 (2.0)

32 (1.8)

 

20 (5.1)

38 (6.5)

 

  Tubular

46 (2.8)

7 (0.4)

 

4 (1.0)

1 (0.2)

 

  Other

203 (12.4)

175 (10.0)

 

56 (14.4)

73 (12.5)

 

  Missing

 

 

 Grade

  G1

135 (8.8)

212 (12.5)

<0.001

29 (8.0)

57 (10.3)

0.032

  G2

690 (45.0)

863 (51.0)

 

159 (44.0)

280 (50.5)

 

  G3

710 (46.3)

617 (36.5)

 

173 (47.9)

218 (39.3)

 

  Missing

98

52 

 

29 

28 

 

 pT

  ypT0/ypTis (DCIS)

4 (0.3)

15 (0.9)

0.079

0 (0.0)

1 (0.2)

0.499

  pT1

761 (48.0)

824 (49.3)

 

126 (34.1)

147 (29.1)

 

  pT2

645 (40.7)

673 (40.2)

 

178 (48.1)

257 (50.9)

 

  pT3

92 (5.8)

97 (5.8)

 

19 (5.1)

32 (6.3)

 

  pT4

83 (5.2)

64 (3.8)

 

47 (12.7)

68 (13.5)

 

  Missing

48

71 

 

20 

78 

 

 pN

  pN negative

1016 (63.8)

1138 (67.0)

0.056

236 (63.6)

318 (63.3)

0.943

  pN positive

576 (36.2)

560 (33.0)

 

135 (36.4)

184 (36.7)

 

  Missing

41 

46 

 

19 

81 

 

Adjuvant therapy

 Breast surgery

  BCS

864 (53.7)

1169 (68.4)

<0.001

124 (33.6)

220 (43.4)

0.004

  Mastectomy

745 (46.3)

539 (31.6)

 

245 (66.4)

287 (56.6)

 

  Missing

24

36

 

21

76

 

 Axillary surgery

  AD

1525 (97.4)

994 (59.2)

<0.001

326 (98.2)

346 (76.2)

<0.001

  SNB

27 (1.7)

610 (36.3)

 

4 (1.2)

97 (21.4)

 

  SNB + secondary AD

14 (0.9)

76 (4.5)

 

2 (0.6)

11 (2.4)

 

  Missing

67

64

 

58

129

 

 Adjuvant radiation

  Following BCS

756 (87.8)

1067 (91.3)

0.014

94 (75.8)

174 (79.1)

0.500

  …Missing

105 (12.2)

102 (8.7)

 

30 (24.2)

46 (20.9)

 

  Following RAD

370 (49.7)

263 (48.8)

0.777

68 (27.8)

99 (34.5)

0.111

  …Missing

375 (50.3)

276 (51.2)

 

177 (72.2)

188 (65.5)

 

 Adjuvant chemotherapy

  CMF

152 (18.2)

9 (1.1)

<0.001

19 (47.5)

3 (8.8)

<0.001

  Anthracycline

558 (66.8)

334 (40.9)

 

17 (42.5)

10 (29.4)

 

  Taxane

89 (10.7)

374 (45.8)

 

2 (5.0)

7 (20.6)

 

  Others

6 (0.7)

40 (4.9)

 

1 (2.5)

12 (35.3)

 

  Not specified

30 (3.6)

59 (7.2)

 

1 (2.5)

2 (5.9)

 

  Missing

798

928

 

350

549

 

 Adjuvant endocrine therapy

  Tam

604 (73.4)

312 (33.6)

<0.001

155 (75.2)

92 (37.9)

<0.001

  AI

128 (15.6)

528 (56.9)

 

40 (19.4)

135 (55.6)

 

  Tam/AI

87 (10.6)

71 (7.7)

 

8 (3.9)

10 (4.1)

 

  Others

4 (0.5)

17 (1.8)

 

3 (1.5)

6 (2.5)

 

  Missing

427

465

 

85

238

 

 Adjuvant trastuzumab therapy

  Yes

0 (0.0)

81 (39.1)

<0.001

1 (3.2)

5 (8.5)

0.660

  No

187 (100.0)

126 (60.9)

 

30 (96.8)

54 (91.5)

 

Data presented in number of patients (%)

HR hormone receptor, ER estrogen receptor, PR progesterone receptor, duct. ductal, lob. lobular, pT tumor size, pN nodal status, BCS breast-conserving surgery, RAD mastectomy, AD axillary dissection, SNB sentinel-node biopsy, Tam tamoxifen, AI aromatase inhibitor

The rate of PR-positive tumors increased in elderly patients (p = 0.013), while younger women had a decrease in ER-positive tumors (p = 0.039). There was a decrease in Her2-positive tumors in both age groups between 2005 and 2008 as compared to 2000–2004.

In addition, changes in tumor histology were documented in both age groups.

Further, G3 tumors were diagnosed less often in both age groups (young 46.3 vs. 36.5 %, p < 0.001; elderly 47.9 vs. 39.3 %, p = 0.011; Chi-quadrate G3 vs. G1 and G2), although the increasing trend of G1 and G2 tumors reached statistical significance, but only in the young women.

In the older patients, no changes in the tumor size could be detected in the course of time. Also lymph node involvement remained unchanged with a decreasing trend in women <75 years (36.2 vs. 33.0 %, p = 0.056).

The rate of surgical therapy decreased for elderly patients (97.7 vs. 94.1 %, p = 0.009), but remained unchanged at about 99 % for younger women. BCS and SNB were performed more often from 2005 to 2008 as compared to 2001 to 2004 (BCS young 53.7 vs. 68.4 %, p < 0.001; old 33.6 vs. 43.4 %, p = 0.004), while the rates of mastectomy and AD decreased in both age groups (AD young 97.4 vs. 59.2 %; p < 0.001; old 98.2 vs. 76.2 %; p < 0.001).

Interestingly, adjuvant radiation following BCS became more common during the studied time period. However, this trend reached statistical significance only for young patients (p = 0.014). In contrast, adjuvant chemotherapy was less frequently performed on both age groups (young 51.1 vs. 46.8 %, p = 0.012; elderly 10.3 vs. 5.8 %, p = 0.013). The elderly patients obtained CMF-containing regimes more often than younger patients (CMF 9.8 vs. 29.7 %, p < 0.001). In both age groups, the proportion of CMF and anthracycline use decreased during the study time, whereas the rate of taxane-containing schemata increased (young 10.7 vs. 45.8 %, p < 0.001; elderly 5.0 vs. 20.6 %; p = 0.071).

In the elderly group, the rate of women with hormone receptor-positive tumors and receiving endocrine therapy decreased between 2000 and 2008 (52.8 vs. 41.7 %, p = 0.001), but remained constant in the younger group. In both age groups, endocrine therapy has changed over time. While in the first period of time tamoxifen used to be the standard in elderly women (tamoxifen 75.2 vs. 37.9 %, p < 0.001), in the following period more patients were treated with aromatase inhibitors with or without tamoxifen (AI 19.4 vs. 55.6 %, p < 0.001).

An increase in Her2-positive patients treated with trastuzumab was observed in both groups (young 0.0 vs. 39.1 %, p < 0.001; elderly 3.2 vs. 8.5 %, p = 0.660), but reached the level of statistical significance only in the younger women.

Survival

The 5-year overall survival rate was 88.8 % for women <75 years and 72.5 % for women ≥75 years of age. The 5-year disease-free survival rate was 80.6 and 75.7 %, respectively.

The results of multivariate analysis of overall and disease-free survival are shown in Table 3. The overall survival was negatively influenced by an advanced tumor size, positive lymph node involvement, undifferentiated histological grade, negative hormone receptor status, higher age and diagnosis in the first study period. Her2-status did not significantly affect the overall survival. Disease-free survival was shortened by advanced tumor size, positive lymph node involvement, G3 tumors, negative hormone receptor status, overexpression of Her2 and older age at the diagnosis, but did not depend on the time of diagnosis.
Table 3

Multivariate analysis

 

Overall survival

Disease-free survival

HR (95 % CI)

p value

HR (95 % CI)

p value

pT1–2 versus pT3–4

1.802 (1.427–2.276)

<0.001

1.322 (0.998–1.750)

0.052

pNnegative versus pNpositive

1.663 (1.366–2.025)

<0.001

2.120 (1.686–2.667)

<0.001

G1–2 versus G3

1.509 (1.234–1.846)

<0.001

1.600 (1.251–2.046)

<0.001

HRnegative versus HRpositive

0.581 (0.461–0.731)

<0.001

0.428 (0.332–0.551)

<0.001

Her2neg versus Her2pos

1.020 (0.906–1.148)

0.740

1.159 (1.019–1.318)

0.025

2000–2004 versus 2005–2008

0.601 (0.492–0.733)

<0.001

0.864 (0.681–1.097)

0.229

<75 versus ≥75 years

2.619 (2.143–3.199)

<0.001

1.388 (1.050–1.833)

0.021

HR hormone receptor, pT tumor size, pN nodal status, G Grading, Her2 Her2neu-status. 2000–2004 versus 2005–2008, time of diagnosis

Discussion

In the present study, we showed that in postmenopausal women breast cancer characteristics seem to vary with increasing age. In line with other studies (Gennari et al. 2004; Honma et al. 2003), our data revealed that women ≥75 years had more often hormone receptor-positive breast cancer and mucinous tumors than younger postmenopausal women. Elderly breast cancer patients had more often advanced stage disease (pT4) most likely due to late diagnosis (Pappo et al. 2007). However, the rate of axillary lymph node involvement was not increased in the older group, suggesting that there is not necessarily a direct relationship between the tumor growth and nodal metastasis in elderly women. However, the data on this issue remain controversial (Schonberg et al. 2010; Wang et al. 2010).

Despite introduction of the mammography screening in 2007/2008 in Germany, we observed an increase in age at the time of diagnosis by 1.65 years in 2005–2008 as compared to 2001–2004, which might be explained by demographic changes in Germany (Statistische Ämter des Bundes und der Länder 2015) as well as by the fact that in situ carcinoma that is particularly often diagnosed in the screening was excluded from our survey. Interestingly, we did not observe any changes either in tumor size or in lymph nodes involvement during the study time and, therefore, could not confirm the observation of Schrodi et al. (Schrodi et al. 2013), who showed a decrease in advanced invasive tumors after introduction of the screening.

Similarly to the findings of other groups (Schrodi et al. 2013; Ewijk et al. 2013), we demonstrated a relative decline in G3-tumors in our study population as well as an increase in ER-positive tumors in younger patients and a rise of PR-positive tumors in elderly women between 2000 and 2008. The observed decreasing trend of Her2-positive tumors, however, must be treated with precaution due to the possible influence of the developments in the Her2 evaluation that occurred in the studied time period.

Like Schrodi et al. (Schrodi et al. 2013), we observed a tendency toward less radical surgical therapy in all age groups. Nevertheless, there were still surprisingly, more older patients with pT1-tumors, who received a mastectomy also during the later time period, despite the widely accepted AGO guidelines, recommending less aggressive local surgery and radiotherapy in frail elderly women with a life expectancy of less than 5 years (AGO 2013).

It has been shown by others (Wang et al. 2010; Mustacchi et al. 2007) that elderly women feel more comfortable and safer when they are treated with mastectomy, probably due to traditional, widely spread beliefs that radical surgery is safer than breast conservation and due to a general reluctance toward adjuvant radiation. Despite the fact that the SNB technique is standardly recommended for women with clinically disease-free lymph nodes independently of age, a relatively large group of patients in our study population received AD, which could possibly be explained by treatment in small local hospitals with little or no experience with SNB. Particularly, AD was more often performed in older women, despite the fact that axillary surgery in patients without clinical evidence of lymph node involvement (cN0) does not change the disease-free survival in patients ≥60 years of age and impairs quality of life (Rudenstam et al. 2006). In contrast, older women were less likely to receive adjuvant radiation as compared to the younger group, irrespective of the type of surgery.

In line with previous reports (Mustacchi et al. 2007; Bastiaannet et al. 2011; Enger et al. 2006), we showed that the proportion of patients treated with adjuvant chemotherapy as well as its type was also dependent on the patient’s age, which could be explained as an attempt to avoid toxicity of chemotherapeutic agents in multimorbid elderly patients. Elderly patients with Her2-positive breast cancer received also less often trastuzumab in combination or subsequent to chemotherapy (Chavez-MacGregor et al. 2013), for reasons that we could not determine. In contrast to other studies (Ewijk et al. 2013; Bastiaannet et al. 2011), we observed a reduction in adjuvant chemotherapies between 2005 and 2008 as compared to 2001–2004, possibly due to the change toward individualized indication for adjuvant treatment, which is dependent on the tumor features and patient characteristics. However, we could confirm the trend in the development of adjuvant chemotherapy with a less frequent use of CMF and anthracyclines that are currently being replaced by anthracycline- and taxane-containing regimens (Giordano et al. 2012).

The rate of endocrine therapy in our study remained constant over the studied time period in postmenopausal women younger than 75 years and slightly declined in elderly patients. Surprisingly, elderly women were less likely to receive endocrine therapy as compared to younger patients, which can probably be explained by forgoing any type of adjuvant therapy in patients with comorbidities and lower life expectancy. Like others (Ewijk et al. 2013), we observed less frequent use of tamoxifen with a contrary trend for aromatase inhibitors between 2005 and 2008 as compared to 2001 and 2004. To our knowledge, most oncologists treat elderly patients with ER-positive tumors with aromatase inhibitors (AI) rather than with tamoxifen to avoid thromboembolic events that are more often associated with tamoxifen. This must be seen critically because treatment with AI improves disease-free survival but does not improve overall survival in comparison with tamoxifen (Cuzick et al. 2010). Furthermore, there are studies (Garreau et al. 2006) which show more AI users switching to tamoxifen to improve side effect than tamoxifen users switching to AIs.

The data on the determinants of overall and disease-free survival for the patients with breast cancer remain controversial (Ewijk et al. 2013; Rosenberg et al. 2005; Schoppmann et al. 2004). In our study, overall survival was dependent on the tumor size, lymph node involvement, histological grade, hormone receptor status, age at diagnosis and time of diagnosis. Interestingly, disease-free survival in our analysis was determined by lymph node involvement, histological grade, hormone receptor status, Her2 status and the age at the diagnosis, whereas it was not influenced by the time of diagnosis. This observation differed from the data of Ewijk et al. (Ewijk et al. 2013), who showed a 4 % lower recurrence in patients with diagnosis of breast cancer in a certain year as compared to that for similar patients diagnosed in the preceding year. In our study, older patients had a worse prognosis as compared to the younger group, which could be explained by a more advanced stage of the disease at the time of diagnosis as well as restricted adjuvant therapy.

The strengths of our study are the large data set including information on the tumor characteristics, therapy and outcome and the long follow-up (12 years). However, several limitations should also be mentioned: the study’s retrospective design, unbalanced data set with some “lost to follow-up” cases, and the unequal patient number in the groups. The present analysis concerns only the Magdeburg cancer registry, so regional differences in the breast cancer management also might play a role.

Conclusion

The difference in disease-free survival between younger and elderly women could be explained by differences in the tumor characteristics and adjuvant treatment between the groups. Remarkably, elderly women are more likely to be overtreated surgically while being undertreated in terms of adjuvant therapy.

Notes

Acknowledgments

We thank Elke Burger and all employees of the Magdeburg cancer registry who helped us with the collection, management and storage of the presented data. We especially thank all physicians who transmitted patient data into the Magdeburg cancer registry, enabling scientific use of this information.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with animals performed by any of the authors.

Informed consent

Written informed consent was obtained from all patients before treatment. An additional individual consent for this analysis was not needed.

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Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • A.-M. Grumpelt
    • 1
  • A. Ignatov
    • 1
  • S. N. Tchaikovski
    • 2
  • E. Burger
    • 3
  • S.-D. Costa
    • 1
  • H. Eggemann
    • 1
  1. 1.University Womens HospitalOtto-von-Guericke UniversityMagdeburgGermany
  2. 2.University Womens HospitalRWTH Aachen UniversityAachenGermany
  3. 3.Cancer Registry MagdeburgMagdeburgGermany

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