Breast Cancer in Older Women
In the past year alone there have been a number of conflicting studies about breast cancer in older women, especially in regard to its relative aggressiveness as compared to that in younger women.
For example, in a study presented at the recent annual meeting of the American Society for Therapeutic Radiology and Oncology in Boston, Dr. Rachana Singh of the University of Chicago reported that-contrary to long-help perceptions-breast cancer can be just as aggressive in elderly women as it is in younger women.
And yet, just a few months earlier, a report in the Journal of the National Cancer Institute touted that breast cancer in elderly women is less aggressive than in younger women.
Similarly, an earlier report in the journal Cancer concluded that women diagnosed with breast cancer in their sixties have a lower rate of local recurrence than younger women.
The University of Chicago study by Rachana Singh examined 1,248 breast cancer patients aged 40- to 70-years-old and 182 patients older than age 70 to determine if their was a difference in the cancer's aggressiveness based solely on age.
Singh noted that many doctors have long suspected that breast cancer affecting the elderly is relatively slower growing. As a result, she said, doctors often do not treat breast cancer in the elderly as aggressively as they do in younger women. Furthermore, she said that many doctors fear treating older women more intensively because of the likelihood of other health-related conditions.
However, Singh's team found that the aggressiveness of the disease appeared to be similar irrespective of age. In fact, they noted that the size of the tumor and lymph node involvement-rather than the age of the patient-were better indicators of the virulence of the disease.
They concluded that because breast cancer is similarly aggressive in older patients, the treatment options offered to women over age 79 should be equivalent to those offered to younger women.
Conversely, a study published in the Journal of the National Cancer Institute by Dr. Sami Diab of the Rocky Mountain Cancer Centers in Colorado and colleagues concluded that tumor growth is actually slower in elderly patients than in their younger counterparts.
The researchers reviewed the records of 50,828 women in the San Antonio Breast Cancer Databases and 256,287 patients in the Surveillance, Epidemiology and End Results (SEER) registry. They found that tumors in elderly women tend to have more favorable biologic characteristics, such as more expressed steroid receptors, lower rates of proliferation or spread, and more normal p53 tumor markers.
Because elderly patients tend to have less aggressive tumors, they wrote, their treatments could be tailored accordingly.
Similarly, another study published earlier in the year in the journal Cancer found that women in their sixties who are diagnosed with breast cancer have lower rates of local recurrence than their younger counterparts.
Dr. Jonathan Golledge from Charing Cross Hospital in London and colleagues reviewed the cases of 784 breast cancer patients between 1990 and 1996. They found that younger women with node-negative cancer were nearly twice as likely as older women to experience locoregional relapse. Also, for patients aged 60 to 69 years, disease-free survival was found to be 91 percent after a three-year follow-up period, compared to 78 percent for all other age groups.
In addition, the authors noted that women 70 years or older experienced better three-year disease-free survival when treated with standard therapy (72 percent) than when treated with tamoxifen alone (58 percent).
Importantly, they wrote that the most important determinants of locoregional recurrence of breast cancer in all women were failure to receive tamoxifen and failure to receive radiation therapy. They cited other studies that further confirmed the need to treat patients according to such established cancer protocols without regard to their age. But they cautioned that "there are some elderly patients, particularly in the category age 80 years or older, for whom initial therapy with tamoxifen alone is preferable."
Is cancer more or less aggressive in older women? More often than not, it is difficult-if not dangerous-to generalize. Most clinicians agree that treatments for individual patients should be tailored to their individual needs-regardless of age. The problem arises when women are not offered the full range of treatments on the basis of their age alone.
In another article published in the journal Cancer, Dr. Jeanne Mandelblatt of the Georgetown University School of Medicine and colleagues reported that for elderly women with early-stage breast cancer, age bias has a strong influence on treatment opportunities. Many very elderly women, they wrote, are clearly not being offered the full range of potential treatment options.
Their study, funded by the Agency for Healthcare Research and Quality, assessed the treatments offered to 718 women aged 67 and older who were newly diagnosed with localized breast cancer. They found that the oldest women, those 80 or older, were significantly less likely than women 67 to 79 years old to be referred to a radiation oncologist.
This was extremely disconcerting, they noted, because women referred to a radiation oncologist were 20 times more likely to have breast-conservation surgery and radiation therapy. Even if breast-conservation therapy was offered, very elderly women were 70 percent less likely to receive chemotherapy than younger women, and they were 3.4 times less likely to receive radiation therapy.
SOURCES:
Annual Meeting of the American Society for Therapeutic Radiology and Oncology, October 27, 2000, Boston, Massachusetts
Journal of the National Cancer Institute, April 5, 2000; 92:550-556
Cancer, January 15, 2000; 88:369-374
Cancer, August 1, 2000; 89:561-573
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