Have you heard the joke about the old woman with the droopy breasts? If you haven't, you will. The cartoons and jokes making the rounds on the senior circuit about sagging breasts compete with jokes about forgetfulness and bad hearing.
Women who live long enough will find that their breasts sag. For women over seventy, dealing with sagging breasts is a small, but annoying problem. Making decisions about cancer screening and cancer treatment is a major one.
Sagging breasts. As women age, the connective tissue in their breast can stretch. Although breasts can be lifted surgically just as tummies can be tucked and double chins reduced, most women skip the pain and expense of cosmetic surgery and learn to live with their new shape. Medically, it's not a problem most of the time. Sometimes rubbing creates irritation, or excessive moisture leads to rashes. Using dusting powder in the fold under the breast or tucking a handkerchief in the band of the bra to absorb perspiration may be all that's needed. However, for a persistent rash, see a doctor to make sure you get the right kind of ointment or lotion to treat it. A heat rash requires different treatment from a fungal infection.
Cancer Screening. One study found that elderly women and their doctors often don't discuss whether they should continue annual mammograms. They just stay with an annual mammogram without thinking it through. Current guidelines say a mammogram every two years is sufficient to find breast cancers in older women, but that is a generalization, and each woman needs to talk about her own risks and benefits from mammography with her doctor.
Unfortunately, doctors can't offer women over age 75 solid data about mammography because randomized studies have excluded them. One way of thinking about the issue is to consider life expectancy. If a woman has a life expectancy of less than ten years, mammography may be of little benefit to her because the purpose of a mammogram is to catch a tiny cancer early before it has a chance to grow, and many of the cancers caught by mammography would not cause problems within that ten-year window.
The trick, of course, is to know what one's life expectancy is. On the average a 75 year old can expect to live ten more years, and an 85 year old can expect to live six more years. But these are averages. If everyone in your family was still active and hardy at age 98 and you don't have any health problems, your life expectancy is above those averages.
Another way to look at the issue is to think about what you would do if a screening test did find cancer. Some women know for sure that they would take any treatment and go to any lengths to extend their life. Others are pretty sure they would forego treatment even if cancer was discovered, so they prefer not to know. In her 80's, my mother was in this second group and decided there was no more point in getting a mammogram.
Because there are so many complex factors to take into account, there is no one right answer to whether an elderly woman should have a mammogram.
Cancer treatment. Age is a risk factor for breast cancer although it drops slightly after age 80. When I sat in the chemo room at age 50, I was usually the youngest by 20 years or so. Most of the people were elderly, and many of them seemed to me to be frail beyond a degree one might expect from their cancer. Yet studies show that the elderly are likely to be undertreated with chemotherapy because their doctors fear the effects of treatment.
Certainly this hesitation has some basis in fact. Few clinical trials have included the elderly, and it is well-known that age can affect how medications are metabolized in the body. Older patients are also likely to have other health issues like high blood pressure or diabetes that might make it harder for them to cope with treatment side effects. They are more likely to be taking other medications that might have interactions with chemo.
Age alone should not be the determining factor in what kind of treatment a patient receives. Dr. Noam VanderWalde argues that functional age is more important than chronological age when making decisions about cancer treatment in the elderly. He says, "I've met a 78-year-old who continues to win gold medals in the senior Olympics in swimming, and I've met a 72-year-old who can't walk more than 20 feet without getting short of breath. Many geriatric oncology clinics are using geriatric assessments to give a better understanding of the overall health and functional age of the patient to hopefully allow us to make better cancer treatment decisions. Although the data is still maturing and there are many questions that still need to be answered, this type of personalized therapy will hopefully lead to more effective therapy and better overall care of this population."
One study that looked at hormonal therapy for older breast cancer patients found that although frail women were less likely to start hormonal therapy, those that did were about as likely to continue it as the more robust patients.
Over the years, I've heard from many sons and daughters asking what they should do for their elderly mom who was just diagnosed with breast cancer. How can they convince a reluctant mother to get treatment? Can an 85 year-old woman get through chemotherapy and radiation? What should they do?
As gently as possible I tell them to respect their mother's choice. Unless she has dementia, she needs to be in charge. The role of the adult child can be to make sure the doctor explains all the options. A woman who has lived more than 70 years knows her own mind. She knows what she is willing to do to add more months or years to her life. She will know if she doesn't want treatment. Older women shouldn't be pressured into treatments that will diminish the quality of the end of their life. Nor should they be denied treatment no matter their chronological age if they have the stamina and determination to try it. My aunt who had breast cancer treatment in her 80's just celebrated her 100th birthday.
The woman who has lived past age 70 has the wisdom of life experience. She has watched her family and friends cope with illness and death. She has rejoiced in babies' births and laughed at toddlers' antics. She has even laughed at droopy breast jokes.
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