Drugs & Aging

, Volume 27, Issue 10, pp 791–800

Quality-of-Life Considerations in the Treatment of Early-Stage Breast Cancer in the Elderly

Review Article


Breast cancer is a common tumour in the elderly population and management of early disease in particular is a major challenge for oncologists and geriatricians alike. An important aspect is a differentiated knowledge about the short-term effects and long-term perspectives regarding levels of functioning and subjective well-being associated with different treatment strategies. The article focuses on available quality-of-life (QOL) measurement instruments in elderly patients with early breast cancer and the impact of various local or systemic treatments on QOL scores.

A selective literature search was carried out in the PubMed database from January 2000 to May 2010 using the terms ‘early breast cancer’, ‘elderly’ and ‘quality of life’. Contributions to international congresses on breast cancer in 2009 were also included. Of the 80 articles retrieved, 46 publications were excluded from further consideration due to failure to fulfil inclusion criteria (e.g. not restricted to the elderly, inclusion of patients with metastatic disease, no adjuvant treatment). Sixteen papers focusing on complementary treatment were also rejected. The remaining 18 articles were extensively reviewed.

The selection of described QOL measurements was very heterogeneous in these 18 studies. Commonly used QOL instruments were the European Organization for Research and Treatment of Cancer QOL questionnaires (EORTC QLQ-C30, EORTC QLQ-BR23) and the Functional Assessment of Cancer Therapy questionnaires (FACT-G, FACT-B) and its subscales. Additionally, the Medical Outcomes Study 36-Item Short-Form Health Survey (MOS-SF-36), the Hospital Anxiety and Depression Scale (HADS) and the International Breast Cancer Study Group (IBCSG) approach were used by various study groups. The general limitations of QOL assessment in the elderly population are discussed in the review.

Surgery, when considered from a technical point of view, does not differ significantly with patient age. Furthermore, age in itself should not be a contraindication to breast-conserving surgery (BCS) because QOL appears somewhat better after conservative surgical treatment. Avoiding axillary surgery and undergoing sentinel lymph node dissection in elderly patients are both associated with better short-term QOL. However, conventional axillary surgery has little effect on long-term QOL in older women.

The advent of innovative radiotherapy techniques has resulted in marked improvements in short-term tolerability together with reductions in the incidence and severity of late normal tissue damage. A potential alternative to conventional postoperative radiotherapy after BCS in the future is the intraoperative radiotherapy technique. Chemotherapy has considerable effects on QOL in breast cancer patients. Most studies found that overall QOL was maintained or improved in patients receiving either aromatase inhibitors or tamoxifen but patients reported different adverse effects. For the majority of older breast cancer survivors, cancer-specific well-being and general emotional health do not change substantially after a breast cancer diagnosis.

In summary, issues related to baseline co-morbidities in frail elderly, the adverse effects of novel chemotherapeutic agents (e.g. nanoparticle albumin-bound paclitaxel) or target drugs (biologicals) and compliance in the elderly population should receive more attention in evaluations of QOL in elderly breast cancer patients. Future studies that include QOL measurements should also provide details on the data collection and quality control methodologies used.


  1. 1.
    Robert Koch Institute and Association of Population-based Cancer Registries in Germany, editors. Cancer in Germany, 2003–2004: incidence and trends. 6th ed. Berlin: Robert Koch Institute and Association of Population-based Cancer Registries in Germany, 2008Google Scholar
  2. 2.
    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: 885–92PubMedCrossRefGoogle Scholar
  3. 3.
    Montazeri A. Quality of life data as prognostic indicators of survival in cancer patients: an overview of the literature from 1982 to 2008. Health Qual Life Outcomes 2009; 7: 102PubMedCrossRefGoogle Scholar
  4. 4.
    Di Maio M, Perrone F. Quality of life in elderly patients with cancer. Health Qual Life Outcomes 2003; 1: 44PubMedCrossRefGoogle Scholar
  5. 5.
    Montazeri A. Health-related quality of life in breast cancer patients: a bibliographic review of the literature from 1974 to 2007. J Exp Clin Cancer Res 2008; 27: 32PubMedCrossRefGoogle Scholar
  6. 6.
    Albrand G, Terret C. Early breast cancer in the elderly: assessment and management considerations. Drugs Aging 2008; 25: 35–45PubMedCrossRefGoogle Scholar
  7. 7.
    Terret C, Zulian GB, Naiem A, et al. Multidisciplinary approach to the geriatric oncology patient. J Clin Oncol 2007; 25: 1876–81PubMedCrossRefGoogle Scholar
  8. 8.
    Clough-Gorr KM, Stuck AE, Thwin SS, et al. Older breast cancer survivors: geriatric assessment domains are associated with poor tolerance of treatment adverse effects and predict mortality over 7 years of follow-up. J Clin Oncol 2010; 28: 380–6PubMedCrossRefGoogle Scholar
  9. 9.
    Muss HB, Tu D, Ingle JN, et al. Efficacy, toxicity, and quality of life in older women with early-stage breast cancer treated with letrozole or placebo after 5 years of tamoxifen: NCIC CTG intergroup trial MA.17. J Clin Oncol 2008; 26: 1956–64PubMedCrossRefGoogle Scholar
  10. 10.
    Prescott RJ, Kunkler IH, Williams LJ, et al. A randomised controlled trial of postoperative radiotherapy following breast-conserving surgery in a minimum-risk older population: the PRIME trial [letter]. Health Technol Assess 2007; 11: 31Google Scholar
  11. 11.
    International Breast Cancer Study Group. Randomized trial comparing axillary clearance versus no axillary clearance in older patients with breast cancer: first results of International Breast Cancer Study Group Trial 10–93. J Clin Oncol 2006; 24: 337–44CrossRefGoogle Scholar
  12. 12.
    De Haes JC, Curran D, Aaronson NK, et al. Quality of life in breast cancer patients aged over 70 years, participating in the EORTC 10850 randomised clinical trial. Eur J Cancer 2003; 39: 945–51PubMedCrossRefGoogle Scholar
  13. 13.
    Hind D, Wyld L, Beverley CB, et al. Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database Syst Rev 2006; 1: CD004272PubMedGoogle Scholar
  14. 14.
    Aaronson NK, Ahmedzai S, Bergman B, et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993; 85: 365–76PubMedCrossRefGoogle Scholar
  15. 15.
    Cella DF, Tulsky DS, Gray G, et al. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol 1993; 11: 570–9PubMedGoogle Scholar
  16. 16.
    Sprangers MA, Groenvold M, Arraras JI, et al. The European Organization for Research and Treatment of Cancer breast cancer-specific quality-of-life questionnaire module: first results from a three-country field study. J Clin Oncol 1996; 14: 2756–68PubMedGoogle Scholar
  17. 17.
    Brady MJ, Cella DF, Mo F, et al. Reliability and validity of the Functional Assessment of Cancer Therapy — Breast quality-of-life instrument. J Clin Oncol 1997; 15: 974–86PubMedGoogle Scholar
  18. 18.
    Levine MN, Guyatt GH, Gent M, et al. Quality of life in stage II breast cancer: an instrument for clinical trials. J Clin Oncol 1988; 6: 1798–810PubMedGoogle Scholar
  19. 19.
    Giesinger J, Kemmler G, Meraner V, et al. Towards the implementation of quality of life monitoring in daily clinical routine: methodological issues and clinical implication. Breast Care 2009; 4: 148–54PubMedCrossRefGoogle Scholar
  20. 20.
    Guyatt GH, Eagle DJ, Sackett B, et al. Measuring quality of life in the frail elderly. J Clin Epidemiol 1993; 46: 1433–44PubMedCrossRefGoogle Scholar
  21. 21.
    Overcash J, Extermann M, Parr J, et al. Validity and reliability of the FACT-G scale for use in the older person with cancer. Am J Clin Oncol 2001; 24: 591–6PubMedCrossRefGoogle Scholar
  22. 22.
    McHorney CA, Ware Jr JE, Lu JF, et al. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patients groups. Med Care 1994; 32: 40–66PubMedCrossRefGoogle Scholar
  23. 23.
    Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67: 361–70PubMedCrossRefGoogle Scholar
  24. 24.
    Bernhard J, Hürny C, Coates AS, et al. Quality of life assessment in patients receiving adjuvant therapy for breast cancer: The IBCSG approach. Ann Oncol 1997; 8: 825–35PubMedCrossRefGoogle Scholar
  25. 25.
    Collin C, Wade DT, Davies S, et al. The Barthel ADL Index: a reliability study. Int Disability Study 1988; 10: 61–3CrossRefGoogle Scholar
  26. 26.
    Audisio RA, Bozetti F, Gennari R, et al. The surgical management of elderly cancer patients: recommendations of the SIOG surgical task force. Eur J Cancer 2004; 40: 926–38PubMedCrossRefGoogle Scholar
  27. 27.
    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: 1101–15PubMedCrossRefGoogle Scholar
  28. 28.
    Keating NL, Landrum MB, Ayanian JZ, et al. Consultation with a medical oncologist before surgery and type of surgery among elderly women with early-stage breast cancer. J Clin Oncol 2003; 21: 4532–9PubMedCrossRefGoogle Scholar
  29. 29.
    Fleissig A, Fallowfield LJ, Langridge CI, et al. Post-operative arm morbidity and quality of life. Results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer. Breast Cancer Res Treat 2006; 95: 279–93PubMedCrossRefGoogle Scholar
  30. 30.
    Lee JC, Truong PT, Kader HA, et al. Postmastectomy radiotherapy reduces locoregional recurrence in elderly women with high-risk breast cancer. Clin Oncol (R Coll Radiol) 2005; 17: 623–9CrossRefGoogle Scholar
  31. 31.
    Smith BD, Haffty BG, Hurria A, et al. Postmastectomy radiation and survival in older women with breast cancer. J Clin Oncol 2006; 24: 4901–7PubMedCrossRefGoogle Scholar
  32. 32.
    Smith BD, Gross CP, Smith GL, et al. Effectiveness of radiation therapy for older women with early breast cancer. J Natl Cancer Inst 2006; 98: 681–90PubMedCrossRefGoogle Scholar
  33. 33.
    Huguenin P, Glanzmann C, Lutolf UM. Acute toxicity of curative radiotherapy in elderly patients. Strahlenther Onkol 1996; 172: 658–63PubMedGoogle Scholar
  34. 34.
    Wyckoff J, Greenberg H, Sanderson R, et al. Breast irradiation in the older women: a toxicity study. J Am Geriatr Soc 1994; 42: 150–2PubMedGoogle Scholar
  35. 35.
    Hancke K, Denkinger MD, König J, et al. Standard treatment of female patients with breast cancer decreases substantially for women aged 70 years and older: a German clinical cohort study. Ann Oncol 2010; 21: 748–53PubMedCrossRefGoogle Scholar
  36. 36.
    Lemanski C, Azria D, Gourgon-Bourgade S, et al. Intraoperative radiotherapy in early-stage breast cancer: results of the Montpellier phase II trial. Int J Radiat Oncol Biol Phys 2010; 76: 698–703PubMedCrossRefGoogle Scholar
  37. 37.
    Goodwin PJ, Black JT, Bordeleau LJ, et al. Health-related quality-of-life measurements in randomized clinical trials in breast cancer: taking stock. J Natl Cancer Inst 2003; 95: 263–81PubMedCrossRefGoogle Scholar
  38. 38.
    Muss HB, Berry DA, Cirrincione C, et al. Toxicity of older and younger patients treated with adjuvant chemotherapy for node positive breast cancer: the Cancer and Leukemia Group B experience. J Clin Oncol 2007; 25: 3699–704PubMedCrossRefGoogle Scholar
  39. 39.
    Muss HB, Woolf S, Berry D, et al. Adjuvant chemotherapy in older and younger women with lymph node-positive breast cancer. JAMA 2005; 293: 1073–81PubMedCrossRefGoogle Scholar
  40. 40.
    Giordano SH, Duan Z, Kuo YF, et al. Use and outcomes of adjuvant chemotherapy in older women with breast cancer. J Clin Oncol 2006; 24: 2750–6PubMedCrossRefGoogle Scholar
  41. 41.
    Crivellari D, Bonetti M, Castiglione-Gertsch M, et al. Burdens and benefits of adjuvant cyclophosphamide, methotrexate, and fluorouracil and tamoxifen for elderly patients with breast cancer: the IBCSG Trial VII. J Clin Oncol 2000; 18: 1412–22PubMedGoogle Scholar
  42. 42.
    Fargeot P, Bonneterre J, Roche H, et al. Disease-free survival advantage of weekly epirubicin plus tamoxifen versus tamoxifen alone as adjuvant treatment of operable, node-positive, elderly breast cancer patients: 6-year follow-up results of the French Adjuvant Study Group 08 trial. J Clin Oncol 2004; 22: 4674–82CrossRefGoogle Scholar
  43. 43.
    Muss HB, Berry DA, Cirrincione CT, et al. Adjuvant chemotherapy in older women with early-stage breast cancer. N Engl J Med 2009; 360: 2055–65PubMedCrossRefGoogle Scholar
  44. 44.
    Kornblith AB, Archer L, Lan L, et al. Quality of life of early stage breast cancer patients 65 years old or older randomized to standard chemotherapy or capecitabine: a Cancer and Leukemia Group B study (CALGB 49907) [abstract]. Cancer Res 2009; 69 Suppl.: 776sCrossRefGoogle Scholar
  45. 45.
    Reimer T, Nitz U, Potenberg J, et al. Capecitabine as adjuvant treatment in elderly patients with early breast cancer: an interim safety analysis of the ICE study [abstract]. Breast Cancer Res Treat 2006; 100Suppl. 1: S112Google Scholar
  46. 46.
    Reimer T, Joel B, von Minckwitz G, et al. Quality of life in elderly patients with early-stage breast cancer treated with ibandronate with or without capecitabine: results of the GBG 32 ICE trial [abstract]. Eur J Cancer Suppl 2009; 7: 219CrossRefGoogle Scholar
  47. 47.
    Smith IE, Procter M, Gelber R, et al. Trastuzumab after adjuvant chemotherapy in older patients [authors’ reply]. Lancet 2007; 369: 991–2CrossRefGoogle Scholar
  48. 48.
    Cella D, Fallowfield L, Barker P, et al. Quality of life of postmenopausal women in the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial after completion of 5 years’ adjuvant treatment for early breast cancer. Breast Cancer Res Treat 2006; 100: 273–84PubMedCrossRefGoogle Scholar
  49. 49.
    Fallowfield L, Cella D, Cuzick J, et al. Quality of life of postmenopausal women in the Arimidex, Tamoxifen Alone or in Combination (ATAC) adjuvant breast cancer trial. J Clin Oncol 2004; 22: 4261–71PubMedCrossRefGoogle Scholar
  50. 50.
    Crivellari D, Sun Z, Coates AS, et al. Letrozole compared with tamoxifen for elderly patients with endocrine-responsive early breast cancer: the BIG 1-98 trial. J Clin Oncol 2008; 26: 1972–9PubMedCrossRefGoogle Scholar
  51. 51.
    Grimison PS, Stockler M. Quality of life and adjuvant systemic therapy for breast cancer. Expert Rev Anticancer Ther 2007;7: 1123–34PubMedCrossRefGoogle Scholar
  52. 52.
    Ganz PA, Guadagnoli E, Landrum MB, et al. Breast cancer in older women: quality of life and psychosocial adjustment in the 15 months after diagnosis. J Clin Oncol 2003; 21: 4027–33PubMedCrossRefGoogle Scholar
  53. 53.
    Clough-Gorr KM, Ganz PA, Silliman RA. Older breast cancer survivors: factors associated with change in emotional well-being. J Clin Oncol 2007; 25: 1334–40PubMedCrossRefGoogle Scholar
  54. 54.
    Ganz PA, Desmond KA, Leedham B, et al. Quality of life in long-term, disease-free survivors of breast cancer: a follow-up study. J Natl Cancer Inst 2002; 94: 39–49PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2010

Authors and Affiliations

  1. 1.Department of Obstetrics and GynecologyUniversity of Rostock, Klinikum SuedstadtRostockGermany

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