Surgical Management of Breast Cancer in the Elderly Patient - #67
Take QuizDetermine appropriate surgical management for elderly breast cancer patients.
Older women tolerate surgery for breast cancer well.1 Surgical management for breast cancer includes both breast and axillary surgery.
Key Points:
· Breast surgery consists of breast conserving surgery (BCS, e.g., lumpectomy) or mastectomy.
· Axillary surgery is indicated with invasive breast cancer and consists of either a sentinel node biopsy (SNB) or axillary lymph node dissection (ALND).
· Breast and axillary surgery are usually performed at the same time. Axillary surgery may not be necessary for some older breast cancer patients.
· Older women may undergo different combinations of surgeries as part of their treatment for their breast cancer, depending on the tumor histology and size as well as pathological axillary node involvement.
· Determining whether the patient is a surgical candidate is one of the first steps in breast cancer treatment. Surgery is used in combination with other neoadjuvant (pre-surgical) and adjuvant (post-surgical) treatments, including chemotherapy, targeted therapy, radiation therapy (RT), and hormonal therapy.
· Surgery is mainly used for locoregional control. It is recommended for patients who have at least a 5 year life expectancy.5 Although age is considered a risk factor for surgery, comorbidity is the major factor influencing post-operative morbidity and mortality. Breast surgery can be performed under local anesthesia or a regional nerve block if the risk of general anesthesia is too great.
Breast conserving surgery (BCS):
· BCS consists of removing the tumor and a small amount of normal surrounding tissue.
· BCS is the standard treatment for early stage tumors (stage I-IIIA) as it provides the same locoregional control and disease free survival (DFS) as a mastectomy when performed in conjunction with adjuvant RT.6,7
· Neoadjuvant chemotherapy and endocrine therapy may be used to make larger tumors amenable to BCS.
· Radiation therapy may not be possible or practical for older patients. Although generally well tolerated, treatment consists of daily radiation, five days a week, for 3-6 weeks. Breast irradiation may be omitted in patients ≥70 with ER+, T1 (<2cm), clinically node negative tumors who receive adjuvant endocrine therapy (standard of 5 years) as one trial demonstrated no difference in overall survival (OS) or DFS with the addition of RT to this population after BCS. However, there was a statistically significant 8% increase in locoregional recurrence rate over 10 years.8
Mastectomy:
· Mastectomy is indicated for tumors not amenable to BCS (e.g., large tumor size in comparison to the breast or peristant positive margins with BCS) or if the patient cannot undergo RT (e.g., history of RT, cannot travel for daily treatments).
· Older women tend to be treated more often with mastectomy vs. BCS,9 which can be partially attributed to avoiding the inconvenience of daily RT10. However,there has been a shift in recent decades from more extensive surgery to BCS in older women.10,11
· Elderly patients may elect reconstruction following mastectomy for aesthetic appearance. Reconstruction is generally tolerated well by older women with similar complication rates as younger women.12
Sentinel Node Biopsy (SNB):
· Sentinel node biopsy (SNB) is standard for routine assessment of axillary nodal involvement for the clinically node negative invasive breast cancer patient and is important in determining stage and prognosis as well as the course of adjuvant treatment.
· SNB consists of injecting a radioactive or blue dye into the breast to determine the location of the sentinel node(s). The dye is taken up by the axillary nodes (the sentinel node(s)), which are the most likely to be positive for metastases if there is nodal involvement with cancer. These sentinel node(s) are then removed and examined to determine pathologic node status. SNB may be omitted if axillary node status would not influence adjuvant treatment decisions (e.g., if the patient would decline chemotherapy).
· SNB is less morbid and invasive than axillary lymph node dissection (ALND) which entails removing all the axillary nodes, as SNB harbors a 3-7% risk of lymphedema, compared to the 15-20% risk associated with ALND.13 This risk is important, as lymphedema may decrease functional status, which is important for elderly women who live independently.
Axillary Lymph Nodes Biopsy (ALNB):
· Axillary lymph nodes are typically biopsied for the presence of metastasis prior to surgery if they are found to be abnormal on clinical exam via palpation or imaging (i.e. ultrasound).
· ALND is considered standard surgical management for biopsy proven metastasis to axillary nodes and if a clinically node negative patient undergoing a mastectomy has a SNB that is positive for metastasis.
· Surgical management of the axilla by ALND is more extensive and causes greater morbidity than SNB. One study found that ALND could be omitted in women who had undergone BCS plus RT with a positive SNB with no difference in survival.15 It is important to note that elderly patients were not well represented in this trial, a large majority of the participants received adjuvant systemic therapy (97%), and RT is not always feasible for the older patient.
An older woman with breast cancer in the pre-operative/ oncologic clinic setting.
Apply key concepts in determination of appropriate surgical management of breast cancer in older women.
Women have a 12% or 1-in-11 lifetime risk of developing breast cancer, but their risk for developing breast cancer between 60 and 80 years of age is 7%.2 Breast cancer incidence increases with age, peaking between ages 75-79.3 Approximately 43% of invasive breast cancers and 34% of in situ cases are women ≥ 65 years, though this group represents only 14% of the total US population.4
Science Principles
Determine appropriate surgical management for elderly breast cancer patients.
Review of Systems (ROS)
Geriatric Topics
ACGME Compentencies
Science Principles
1. Petrakis IE, Paraskakis S. Breast cancer in the elderly. Arch Gerontol Geriatr. 2010;50(2):179-184. 2. DeSantis C, Ma J, Bryan L, Jemal A. Breast cancer statistics, 2013. CA Cancer J Clin. 2014;64(1):52-62. 3. Cancer of the Breast (Invasive): SEER Incidence and U.S. Death Rates, Age Adjusted and Age Specific Rates by Race and Sex. In: Surveillance E, and End Results (SEER) Program, ed. SEER Cancer Statistics Review 1975-2012. 4. U.S. Census Bureau CPS, Annual Social and Economic Supplement, 2012. 5. Hurria A, Wildes T, Baumgartner J, Browner IS. NCCN Clinical Practice Guidelines in Oncology: Older Adult Oncology, version 1.2016. 2016. 6. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233-1241. 7. Gradishar WJ, Anderson BO, Balassanian R, Blair SL. NCCN Clinical Practice Guidelines in Oncology: Breast cancer, version 3.2015. 2015:110. 8. Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013;31(19):2382-2387. 9. Sierink JC, de Castro SM, Russell NS, Geenen MM, Steller EP, Vrouenraets BC. Treatment strategies in elderly breast cancer patients: Is there a need for surgery? Breast. 2014;23(6):793-798. 10. Cutuli B, De Lafontan B, Vitali E, et al. Breast conserving treatment (BCT) for stage I-II breast cancer in elderly women: analysis of 927 cases. Crit Rev Oncol Hematol. 2009;71(1):79-88. 11. Montroni I, Rocchi M, Santini D, et al. Has breast cancer in the elderly remained the same over recent decades? A comparison of two groups of patients 70years or older treated for breast cancer twenty years apart. J Geriatr Oncol. 2014;5(3):260-265. 12. Walton L, Ommen K, Audisio RA. Breast reconstruction in elderly women breast cancer: a review. Cancer Treat Rev. 2011;37(5):353-357. 13. Javid SH, He H, Korde LA, Flum DR, Anderson BO. Predictors and outcomes of completion axillary node dissection among older breast cancer patients. Ann Surg Oncol. 2014;21(7):2172-2180. 14. Martelli G, Boracchi P, Ardoino I, et al. Axillary dissection versus no axillary dissection in older patients with T1N0 breast cancer: 15-year results of a randomized controlled trial. Ann Surg. 2012;256(6):920-924. 15. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305(6):569-575.
Users are free to download and distribute Geriatric Fast Facts for informational, educational and research purposes only. See Term of Use for additional information.
Disclaimer: Geriatric Fast Facts are for informational, educational and research purposes only. Geriatric Fast Facts are not, nor are they intended to be, medical advice. Health care providers should exercise their own independent clinical judgment when diagnosing and treating patients. Some Geriatric Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.
Terms of Use: Geriatric Fast Facts are provided for informational, educational and research purposes only. Use of the material for any other purpose constitutes infringement of the copyright and intellectual property rights owned by the specific authors and/or their affiliated institutions listed on each Fast Fact. By using any of this material, you assume all risks of copyright infringement and related liability. Geriatric Fast Facts may not be reproduced or used for unauthorized purposes without prior written permission, which may be obtained by submitting a written request to: Medical College of Wisconsin, Dept. of Medicine, Division of Geriatrics and Gerontology, 8701 Watertown Plank Road, Milwaukee, WI 53226. Note the Geriatric Fast Facts may contain copyrighted work created under contract with government agencies, foundations, funding organizations and commercial companies, etc. If a particular author places further restrictions on the material, you must honor those restrictions regardless of whether such restrictions are described in this mobile app.