How to Treat Elderly Patients. Breast Cancer Guidelines

As with many cancers, breast cancer occurs more often in people who are older. As people age, their risk of developing breast cancer tends to increase.¹ In 2019, approximately 65% of people with breast cancer were 65 and older.²  While the rising risk with age may be disconcerting to some, it’s important to know that advances in technology and individualized care are improving the outcomes for seniors living with breast cancer.

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The best way to treat older patients with breast cancer is on an individual basis with plans to provide social and other supports. Your doctor can help you make treatment decisions based on your overall health, cancer type, and preferences. Your treatment plan should be a shared decision based on discussions with your doctor and other members of your medical care team.

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Generally speaking, older breast cancer patients with good overall health can be treated the same way as younger patients. This article will discuss some of the special considerations for treating breast cancer in older adults.

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How common is breast cancer among seniors, and when is it usually diagnosed?

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As of January 1, 2019, 8.3% of all females in the U.S. ages 65 and up were living with breast cancer (0.1% for males).²

Breast cancer is most often diagnosed in females ages 65-74. The median age at diagnosis for women is 63.³ This means that half of the women diagnosed were younger than 63, and half of them were older.

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What kinds of breast cancer are most common for older adults?

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As with younger people, invasive ductal carcinoma is the most commonly diagnosed cancer in older people.⁴ Invasive ductal carcinoma starts in the cells lining the milk ducts.⁵ The second-most commonly diagnosed cancer among people 70 and older is invasive lobular carcinoma,⁴ which starts in the milk glands (also called lobules).⁵ Both invasive ductal and invasive lobular cancer are known as invasive because they may spread from either the milk ducts or glands into the breast tissue or lymph nodes.⁵

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Most cancers diagnosed in people 70 and up are hormone receptor positive (HR-positive).⁴ This means that the tumor has receptors for either estrogen or progesterone (or both) on it. HR-positive cancers can be treated with endocrine therapy (also called hormone therapy).⁵ In HR-positive cancers, tumors tend to grow more slowly, which means that people diagnosed with this kind of cancer later in life generally have a good prognosis.⁴

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Cancer data has also shown that older women are more likely than younger women to have cancers negative for a protein called human epidermal growth factor receptor 2 (HER2).⁶ HER2-negative cancers can be treated with chemotherapy.⁵ In a study including women with HR-positive, HER2-negative tumors (the most common in older women), the survival rate after two years was 94.8% for women aged 70-79 and 85% for those over 80.
(Most of the people who died over the age of 80 died of non-cancer-related causes.) ⁷

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Although lower-risk cancers are more common, of course some older women have more aggressive forms of cancer.⁸ One such cancer is called triple-negative. Having triple-negative breast cancer means that the cancer does not have either of the two hormone receptors and is HER2 negative. A study of women 70 and older showed that chemotherapy significantly improved the chances of survival for women with triple-negative breast cancer.⁹ It’s important to remember that, if you are a healthy older person, you will benefit from chemotherapy to the same extent as younger people.

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Despite being diagnosed at an older age, many seniors with breast cancer have successful treatments. A study of invasive breast cancer in older women linked surgery, endocrine therapy, and chemotherapy to increased survival. As described above, most patients who later passed away died from causes unrelated to breast cancer.¹⁰

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What kinds of breast cancer are most common for older adults?Why does breast cancer affect older people more often than younger people?

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Genes control how the cells in your body grow and divide. Cancer is caused by damage to these genes. Damaged or abnormal cells may grow and multiply, forming tumors. In the case of cancer, these tumors can spread to other parts of the body.¹¹

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Many times, your body can repair cells with genetic damage.¹¹ But over time, there are more opportunities for your genes to become damaged. Over time, your body becomes less effective at repairing this damage,¹ and your immune system has a harder time fighting off the cancer cells.

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How does breast cancer affect older adults differently?

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We’re still learning a lot about breast cancer in seniors. Generally speaking, the characteristics of tumors in younger patients may be different in older patients. Cancer may also respond differently to therapy for older patients.¹²

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Because many clinical trials in the past did not include older patients, we don’t have much evidence about the best treatments.^(6,13-14) Improvements in testing of the tumors for different mutations (different from genetic mutations we inherit from our parents) are helping us to make more personalized recommendations for seniors with breast cancer.⁴

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Because of our aging population in the U.S., geriatric oncology (the study of cancer in older people) is more important than ever. Today, researchers are trying to learn more about how cancer affects older people.⁸

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Here’s what we know so far:

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Cancer treatments like chemotherapy may be harder on older people. For example, older patients have a higher risk of side effects from treatment.⁸ Older patients are also more likely to have other health conditions that affect how their bodies react to treatment.^(12,14)

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Because of this, some doctors may be less likely to treat older patients with the standard treatments that younger patients receive.¹⁰ Sometimes, giving a patient less than the standard treatment can do more harm than good. This is called undertreating a patient. On the other hand, patients can also be overtreated— they receive harmful or unnecessary treatment.

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To avoid over- or undertreating, it’s important that your doctor considers your individual situation. The National Comprehensive Cancer Network (NCCN) 2022 guidelines recommend that doctors consider factors such as your goals, preferences, and overall health before deciding on treatment. Age should not be the deciding factor when considering whether to give a patient treatment that could improve quality of life or survival.¹²

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NCCN also recommends that doctors avoid treatment that may negatively impact your quality of life if it does not significantly improve survival.¹  You and your medical team can discuss whether the benefits of certain treatments outweigh the risks.

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Treatment considerations

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Before Treatment

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Before beginning treatment, a doctor may ask you questions or give you a series of simple tests that tell them more about you. These tests are important because a person’s age alone does not define what they are capable of or how they may respond to cancer treatment.¹² Two people of the same age may have very different needs depending on their life experiences, overall health, or other factors.

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The NCCN Older Adult Oncology Panel recommends that doctors give patients a Comprehensive Geriatric Assessment (CGA). This test helps the doctor learn more about things like:

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• any other health conditions you have
• your ability to get around
• your mental health
• any falls you may have taken
• your diet
• what your support system is like

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Learning these things may help your doctor come up with a treatment plan that is individualized for you and your needs.¹²

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Breast-conserving surgery (lumpectomy) or mastectomy

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Breast surgery has very low mortality rates in people of all ages, and it is considered the standard of care unless patients are not fit for surgery or do not want it. Surgery has been shown to improve survival rates for people in their 80s with early-stage breast cancer. However, breast surgery does not appear to improve survival rates for people 70 or older with locally advanced (Stage III) cancer. ¹³

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One study of women 70 and older demonstrated that having breast surgery is more effective at preventing breast cancer progression and recurrence than endocrine therapy alone. However, there was no data to suggest that either surgery or endocrine therapy benefits overall survival.¹⁵

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Sentinel lymph node biopsy

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A sentinel lymph node biopsy is a way to determine if cancer has metastasized (spread) from a tumor to the lymph nodes. If cancer were to spread, it would first reach the sentinel lymph nodes. If the biopsy shows that cancer has not spread to the sentinel lymph nodes, it is unlikely that it has spread to any other lymph nodes.¹⁶

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Although a sentinel lymph node biopsy is standard for most node-negative patients,¹⁶ the Society of Surgical Oncology (SSO) recommends that you do not have routine sentinel lymph node biopsies if you:

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• are 70 years old or older
• have early-stage, invasive breast cancer
• have node negative, HR positive, and HER2 negative cancer

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Studies have shown that for people who have non-palpable axillary lymph nodes and are receiving endocrine therapy, having a sentinel lymph node biopsy:

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• does not reduce the risk of cancer coming back near where it started
  (locoregionally)
• does not improve breast-cancer-related survival in the older population ¹⁷

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Radiation

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Some older patients may be able to avoid radiation therapy. For adults 70 years or older with HR-positive tumors, research shows that whole-breast radiation may reduce the risk of cancer recurrence but may not affect their chances of survival.¹⁸ For these patients, reducing the risk of cancer recurrence alone may not be enough to warrant the risks of receiving radiation therapy.

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The NCCN 2022 guidelines panel recommends that patients may consider receiving breast-conservation surgery only (without radiation) if you:

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• have negative margins
• are 70 years or older
• have node-negative, hormone receptor-positive cancer
• have a tumor less than 2 cm across
• commit to five years of endocrine (hormonal) therapy ¹⁸

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Your doctor can help you determine if you fall into this group.

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Chemotherapy

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The decision to treat an older patient with chemotherapy is largely based on a patient’s life expectancy and any other medical conditions. For those with good overall health and a longer life expectancy, chemotherapy may benefit survival. Researchers recently conducted a study of women ages 70 and older with non-metastatic, invasive breast cancer. They found that older women with advanced disease had good five-year survival rates after chemotherapy.⁷

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Older people with HR-negative disease may benefit more from chemotherapy than those with HR-positive disease. In a study of women 65 years and older, patients who received standard chemotherapy had better recurrence-free survival than patients who received endocrine therapy alone. This was especially true for patients who had HR-negative disease.¹⁹

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It’s important to note that older people may be more likely to experience toxic effects of chemotherapy.¹³ Therefore, you and your doctor should consider all factors that may affect how your body responds to chemotherapy. Your doctor may be able to make adjustments that can reduce your risk of toxic effects, such as reducing the dosage of certain drugs.¹³ There are tools that doctors can use to estimate how chemotherapy may impact your survival and your risk of experiencing toxic effects.^(13,19)

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Endocrine Therapy

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Endocrine therapy, also called hormonal therapy, can be used in addition to breast surgery.²⁰ It’s also an option for people who have other major medical conditions that are related to shorter life expectancies.

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Endocrine therapy is given to patients whose tumors have hormone receptors (HR-positive). When hormones like estrogen or progesterone attach to these receptors, they can help the tumor grow.²¹ People with HR-positive tumors may receive drugs called tamoxifen or aromatase inhibitors.¹³ These drugs help stop tumor growth by preventing the hormones from attaching to the receptors.²¹

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• Tamoxifen is a drug that blocks estrogen. It can help reduce the risk of cancer recurrence and slow cancer growth.²¹ However, possible side effects of tamoxifen, including blood clots, cold sweats, or eye problems like cataracts, are important to consider.^(20-21) If you have a higher risk for blood clots, aromatase inhibitors may be a better option.¹³

• Aromatase inhibitors are drugs that stop the body from producing estrogen. They may cause hot flashes and bone or muscle pain. One concern in women who have gone through menopause is bone thinning. ²¹ If you have a higher risk of bone fractures, tamoxifen may be a better option.¹³ There are also medications that can help strengthen your bones if you have bone thinning.

• As with chemotherapy, there are tools that your doctor can use to predict what the benefits and risks of endocrine therapy may be for you based on your situation.¹³ Because endocrine therapy can be a long commitment, this should be a shared decision between you and your medical team. Treatment generally lasts between five and ten years, and your quality of life is important to consider. Some people do not complete their whole course of treatment due to side effects they experience. A shorter treatment period may benefit older patients.²⁰ Talk with your doctor about how long treatment may be and whether the benefits of endocrine therapy outweigh the risks for you.

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Social Support

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Having people to support you on your cancer journey can make a big difference. This might include friends, family, people in your community, and people on your care team. Research shows that social support can improve both your physical and emotional well-being.¹² Scientists believe that social supports may even improve cancer outcomes by protecting you from stress that can cause tumor growth. ²²

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Your doctor may ask you questions about caregivers, your living situation, and your overall support system. Your doctor may also refer you to a social worker who can help connect you with resources in your community. Patient navigation programs can help you find transportation, support groups, financial assistance, and other supports.²²

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Conclusion

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Breast cancer treatment for older people in good health may look very similar to that of younger people. Many older patients have success with standard treatments such as surgery or chemotherapy. In general, breast cancer is less aggressive in older women. More so than your age, the type of cancer you have, your overall health, and any other medical issues will inform what kind of treatment you may receive. Decisions about treatments should always take your preferences into account and be shared between you and your medical team.

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References

1. Age. Breastcancer.org. https://www.breastcancer.org/risk/risk-factors/age. Published June 29, 2022. Accessed October 6, 2022.

2. SeerExplorer. SEERExplorer Application. https://seer.cancer.gov/statistics-network/explorer/application.html. Published September 1, 2022. Accessed October 6, 2022.

3. Cancer Stat Facts: Female Breast Cancer. SEER.https://seer.cancer.gov/statfacts/html/breast.html. Accessed October 6, 2022.

4. Treating breast cancer in people age 70 and up. Johns Hopkins Medicine.https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/treating-breast-cancer-in-people-age-70-and-up. Published February 25, 2022. Accessed October 6, 2022.

5. NCNN Guidelines for Patients: Invasive Breast Cancer. National Comprehensive Cancer Network. https://www.nccn.org/patients/guidelines/content/PDF/breast-invasive-patient.pdf. Published 2022. Accessed August 29, 2022

6. Fusco D, Allocca E, Villani ER, Franza L, Laudisio A, Colloca G. An update in breast cancer management for elderly patients. Translational Cancer Research. 2018;7(S3). doi:10.21037/tcr.2018.03.21

7. Castelo M, Lu J, Paszat L, Veitch Z, Liu K, Scheer AS. Long-term survival in elderly women receiving chemotherapy for non-metastatic breast cancer: A population-based analysis. Breast Cancer Research and Treatment. 2022;194(3):629-641. doi:10.1007/s10549-022-06646-9

8. Breast cancer in the elderly: Treating this growing patient population. Breast Cancer Research Foundation. https://www.bcrf.org/blog/breast-cancer-elderly-treating-growing-patient-population/. Published June 16, 2022. Accessed October 6, 2022.

9. Bath C. Significant survival benefit from chemotherapy for older women with triple-negative breast cancer. The ASCO Post. https://ascopost.com/issues/january-25-2021/significant-survival-benefit-from-chemotherapy-for-older-women-with-triple-negative-breast-cancer/. Published January 25, 2021. Accessed October 6, 2022.

10. Peng Y, Hu T, Cheng L, et al. Evaluating and balancing the risk of breast cancer-specific death and other cause-specific death in elderly breast cancer patients. Frontiers in Oncology. 2021;11. doi:10.3389/fonc.2021.578880

11. What is cancer? National Cancer Institute. https://www.cancer.gov/about-cancer/understanding/what-is-cancer. Published May 5, 2021. Accessed October 6, 2022.

12. NCCN Clinical Practice Guidelines in Oncology: Older Adult Oncology. NCCN. https://www.nccn.org/professionals/physician_gls/pdf/senior.pdf. Published July 12, 2022. Accessed October 6, 2022.

13. Glaser R, Marinopoulos S, Dimitrakakis C. Breast cancer treatment in women over the age of 80: A tailored approach. Maturitas. 2018;110. doi:10.1016/j.maturitas.2018.01.014

14. Cornell LF, Mclaughlin SA, Pruthi S, Mussallem DM. Special considerations of Breast Cancer Management in the elderly. Breast Cancer Management. 2020;9(4). doi:10.2217/bmt-2020-0023

15. Morgan J, Wyld L, Collins KA, Reed MW. Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database of Systematic Reviews. May 2014. doi:10.1002/14651858.cd004272.pub3

16. Rao R. The Evolution of Axillary Staging in Breast Cancer. Mo Med. 2015;112(5):385-388. 17 Sentinel node biopsy: Choosing wisely. Choosing Wisely. https://www.choosingwisely.org/clinician-lists/sso-sentinel-node-biopsy-in-node-negative-women-70-and-over/. Published July 12, 2016. Accessed October 6, 2022.

17. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. National Comprehensive Cancer Network. https://www.nccn.org/login ReturnURL=https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Published June 2022. Accessed August 29, 2022.

18. Muss HB, Polley M-YC, Berry DA, et al. Randomized trial of standard adjuvant chemotherapy regimens versus Capecitabine in older women with early breast cancer: 10-year update of the CALGB 49907 trial. Journal of Clinical Oncology. 2019;37(26):2338-2348. doi:10.1200/jco.19.00647

19. Depboylu Bengü. Treatment and patient related quality of life issues in elderly and very elderly breast cancer patients. Translational Cancer Research. 2019;9(S1). doi:10.21037/tcr.2019.07.08

20. Hormone therapy for breast cancer: Breast cancer treatment. American Cancer Society. https://www.cancer.org/cancer/breastcancer/treatment/hormone-therapy-for-breast-cancer.html. Published October 27, 2021. Accessed October 7, 2022.

21. Kadambi S, Soto-Perez-de-Celis E, Garg T, et al. Social support for older adults with cancer: Young International Society of Geriatric Oncology Review Paper. Journal of Geriatric Oncology. 2020;11(2):217-224. doi:10.1016/j.jgo.2019.09.005