Illustrative Case Series
An Older Patient with Newly Diagnosed Breast Cancer
By Gary Shapiro, MD, Medical Oncology, Johns Hopkins University. Dr. Shapiro reports no financial relationships relevant to this field of study.
The patient is an 82-year-old woman referred for management of newly diagnosed breast cancer. She had been well until approximately 10 years prior to this evaluation, when she sustained a myocardial infarction from which she recovered without complication. Subsequently, she was found to have moderate hypertension and hyperlipidemia, which has been managed medically.
Approximately five years prior to this evaluation, she began to notice impaired memory. Evaluation at that time included an MRI of the brain, which demonstrated small-vessel disease consistent with a clinical diagnosis of multi-infarct dementia. Her symptoms have gradually progressed to the point where she can no longer provide care for her husband, who has mobility impairment as a result of a cerebrovascular accident. She and her husband now reside in an assisted-living apartment.
Approximately one month prior to evaluation, a care provider, while assisting in bathing, noticed a breast mass and notified the patient's physician. MRI demonstrated a 3 cm x 4 cm mass, and a needle biopsy confirmed invasive ductal carcinoma. Tumor cells were positive for the expression of both estrogen and progesterone receptors but negative for HER-2-neu. The patient was referred to you to address questions regarding short-term and long-term management.
Deciding how aggressively to treat cancer in an older patient requires knowledge of both the natural history of the cancer and the patient's life expectancy, with and without the cancer. Will this patient's breast cancer end her life prematurely? Although the average 82-year-old woman is likely to live another eight years, this 82-year-old woman with progressive multi-infarct dementia, coronary artery disease, and hypertension has a five-year survival rate on the order of 40%. Unless she has metastatic disease, it is unlikely that she would die prematurely from a stage I or II cancer of the breast. On the other hand, she is quite likely to live long enough to experience significant symptoms (pain, skin breakdown, infection) from loco-regional progression of her breast cancer. Therefore, local treatment is advisable.
For the majority of older patients, early-stage breast cancer should be treated with the standard surgical procedures. Breast surgery is a relatively low-risk operative procedure, and advanced age alone should not compromise definitive surgery. Although our patient's coronary artery disease appears to be well controlled, older women with significant comorbid illnesses may tolerate surgery under local anesthesia better than general anesthesia. Older individuals undergoing general anesthesia may experience short-term cognitive impairment. Lighter sedation and peri-operative co-management by a geriatrician can decrease the impact of this acute problem, especially in patients who have pre-existing dementia.
Older women are just as concerned about body image and cosmesis as younger women and should be offered the option of breast conservation when medically appropriate. Older women with limited mobility or difficulties with transportation may prefer mastectomy to the frequent visits to the hospital required for post-lumpectomy radiation therapy. Partial-breast radiation may be another alternative.
Every elderly woman may not need adjuvant radiation therapy. If adjuvant tamoxifen is given after lumpectomy, it may be feasible to omit adjuvant radiation therapy in selected women 70 years and older who have small (< 2.0 cm), ER-positive, node-negative breast cancer. This is one reason why sentinel lymph node evaluation remains important, even in patients who are of advanced ages, or are otherwise frail.
Although breast MRI measurements overestimate tumor size in about one-third of the cases, the concordance between MRI and surgical pathology is generally quite good, and our patient probably does not fit into this low-risk group. Even if she did, one would need to carefully weigh the long-term risks of tamoxifen (especially the thromboembolic risk) against those of short-term radiation therapy. While cognitively impaired patients pose a unique challenge, they are frequently capable of participating in simple discussions about treatment side effects and logistics.
Primary hormonal therapy has an important role in elderly patients who refuse surgery, those expected to live only a few months, or those who have a significant surgical risk due to serious comorbid conditions. It can be quite effective and is usually well tolerated. However, primary hormonal therapy is no substitute for surgery. It produces inferior local control and significantly shorter survival.
Lymphedema from axillary dissection can be particularly debilitating in older women with arthritis and mobility problems. Sentinel-node biopsy techniques virtually eliminate this risk and should be used in all elderly women requiring lymph-node evaluation for staging and subsequent decisions regarding adjuvant radiation and systemic therapy.
Since our patient is likely to die of her comorbid illnesses before she suffers from metastatic disease, it may be reasonable to forgo the use of systemic adjuvant therapy, especially if her cancer has not spread to the lymph nodes. Although the benefit is only marginal, if her lymph nodes are involved, adjuvant therapy, with an aromatase inhibitor, should at least be discussed with her. Chemotherapy adds no benefit to her adjuvant regimen.
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