The vast majority of women diagnosed with breast cancer are older; only 5% of breast cancer cases occur in women under age 40, while fully one-third of all breast cancers are diagnosed in women 70 or older.
If you’re at least 70 years old, your chance of developing breast cancer in the next 20 years is about 1 in 26; yet most research around treatment, including clinical trials, focuses on women much younger. Older women have special challenges and concerns around breast cancer treatment - including whether or not to have it. Find out what you (or your mom, or an elderly relative facing breast cancer) should consider when making treatment decisions.
Breast cancer treatment is vastly improved over what it was 30 years ago, both in effectiveness, and in management of side effects. But treatment can still be very difficult - even life-threatening. Thus, the first thing to consider is the overall health of the prospective patient.
A woman with advanced congestive heart failure, for instance, or diabetes, or an exceptionally frail woman will probably want to carefully pick and choose which treatments she has - if any. Breast cancer is generally slow-growing, especially in older women; if the woman’s reasonable life expectancy is 1 or 2 years, then breast cancer treatment might not make any sense at all, given its side effects.
That said, some treatments are easier on the system than others. And the bang for your buck for, say, a lumpectomy might be much greater than it is for chemotherapy. Let’s examine what the data says about breast cancer treatment in older women.
The problem is, there are few studies focusing on breast cancer treatment in women over 70, as mentioned above. Several large British trials - including one focusing on the effectiveness of aromatase inhibitors vs. tamoxifen; and another examining the efficacy of chemotherapy for women over 70 with hormone-negative breast cancer - never got off the ground due to lack of participants.
Still, there’s been research gathered and conclusions drawn from trials covering all ages of breast cancer survivors, trials large enough to have included a significant number of older women. The following information is based on those trials.
Surgery: yes or no?
Yes; having a cancerous tumor removed will decrease risk of recurrence - although in most cases, it won’t increase risk of survival.
Most breast cancers in older women are low-grade, less aggressive "early" cancers; and in most cases, breast conservation surgery (lumpectomy) is every bit as effective as mastectomy. The exception would be a particularly large tumor or aggressive cancer.
But sadly, most older women have a mastectomy - whether by personal choice, or due to advice from their surgeon or a family member. In addition, fewer older women are offered reconstructive surgery. This may be due to underlying health issues that would make this type of major surgery dangerous; but in some cases, the surgeon simply assumes the woman doesn’t care about cosmetic results. If you’re having a mastectomy and want a rebuilt breast, explore the possibility.
Latest studies show that most older women can probably skip radiation if they so choose. Their risk of local recurrence will be higher; but their survival rate will be the same, so long as they follow surgery with hormone therapy: either tamoxifen, or an aromatase inhibitor.
Why would a woman choose to skip radiation, since without it she’s more likely to have a recurrence?
Because the risk of recurrence within 5 years is low across the board: 2% with radiation, 9% without. And radiation can be tough on an older woman: the daily trek to the hospital, plus the fatigue and possible pain of treatment are much less well-tolerated in older women.
The exception is women with hormone-negative cancer. Since hormone therapy isn’t effective for this group, radiation is a must; latest studies show that women with hormone-negative breast cancer who have a lumpectomy, but not radiation, are over 90% more likely to die of breast cancer than if they’d received radiation.
Luckily, brachytherapy and other "accelerated" types of radiation, some lasting as little as 5 days, are becoming more commonly available. And studies show that, for women over 70, there’s no appreciable difference in results between these quicker treatments and a longer, 6-week regimen.
Researchers know that chemotherapy’s effectiveness declines with age; and common sense tells us that chemo’s difficult side effects are more easily tolerated at age 40 than age 80. Thus an older woman being offered a choice of chemo should think long and hard about accepting it. The Oncotype-DX test is a useful tool for any woman on the fence about chemo, but especially for an older woman trying to balance quality of life with difficult side effects.
For older women where chemotherapy is clearly indicated (e.g., the cancer has spread, is particularly aggressive, or is triple negative), a non-anthracycline type of chemo (e.g., Taxol/Taxotere + Cytoxan) is now thought to be more effective than the traditional Adriamycin + Cytoxan regimen. TC comes with far less serious side effects, and produces equally good results.
After breast-conservation surgery, taking tamoxifen or an aromatase inhibitor (Arimidex, Femara, or Aromasin) is probably the best thing an older woman can do to treat her hormone-positive breast cancer. These drugs have been proven to reduce the risk of recurrence, prolong survival - and they come with much less serious side effects than other forms of treatment.
While an AI is probably a bit more effective than tamoxifen, AIs also reduce bone mineral density. If the patient has osteoporosis, or is at risk, she might choose tamoxifen rather than an AI. She could take another drug, a bisphosphonate, to combat bone loss (Boniva, Fosamax, et. al.); but these drugs come with some pretty difficult side effects of their own.
So, bottom line, what’s the best treatment for older women with breast cancer?
Depends on the woman’s age and overall health. There’s no magic about age 70; researchers simply have to draw a line somewhere, and that’s the age they’ve chosen.
A healthy, active 85-year-old might choose a mastectomy and reconstruction, undergo chemotherapy and 5 years of an aromatase inhibitor, and sail through with no problems. A frail 71-year-old might struggle with even a lumpectomy and tamoxifen.
If you’re an older woman facing breast cancer treatment - or if you’re an older woman’s caregiver - look realistically at overall health; and at the effectiveness of any treatment offered, vs. its side effects. It may be a long, tough series of decisions; but in the end, it’s worth it to take the time to tailor treatment to your age and health - whatever those may be.