The consequence of undertreating breast cancer in the elderly

BACKGROUND: Recent studies have noted that a large fraction of elderly pati ents do not receive conventional treatment for breast cancer. The consequen ces of undertreatment of the elderly have not been adequately assessed. STUDY DESIGN: The senior author's database (PIT) was used to identify women undergoing potentially curative operations for breast cancer between 1978 and 1998. Risk factors, presentation, pathologic findings, treatment, and o utcomes of 206 women aged over 70 years were compared with those of 920 you nger patients. In addition, conventionally treated and "undertreated" elder ly patients RESULTS: Older patients' cancers were more often visible on mammography, us ually as a mass; younger patients' mammograms were less frequently positive , presenting more often with calcifications (p = 0.002). Cancers of the eld erly were better differentiated (p < 0.001) and more likely ro be estrogen- and progesterone-receptor positive (p < 0.001; p = 0.007). Patients over 7 0 had fewer mastectomies (19% versus 33%; p < 0.001) and were also less lik ely to undergo axillary node dissection (71% versus 81%, p = 0.006), postop erative radiation (69% versus 92%, p < 0.001), and chemotherapy (18% versus 48%, p < 0.001). Fifty-seven percent of older patients were treated with t amoxifen compared with 36% of younger patients (p < 0.001). Elderly patient s' rates of local and distant recurrence were comparable to those of younge r patients after both mastectomy and breast conservation. Ninety-eight patients (54%) over 70 were undertreated by conventional crite ria. Undertreated elderly patients were significantly older (78 versus 76 y ears, p = 0.003), were diagnosed with excisional biopsy more often (69% ver sus 57%, p = 0.069) and with fine-needle aspiration less frequently (22% ve rsus 38%, p = 0.069), and were more likely to have breast conservation (90% versus 73%, p = 0.004). Local and distant disease-free survival rates of b oth groups were comparable. Tamoxifen treatment significantly reduced the c hance of developing distant metastasis in node-negative elderly patients wi th invasive tumors (p = 0.028). Omission of chemotherapy had no impact on d isease control in the elderly. Axillary node status and estrogen-receptor s tatus were significantly related to local disease-free survival, and axilla ry node status was significantly related to distant disease-free survival i n multivariate analysis in the elderly. CONCLUSIONS: Elderly breast cancer patients are frequently treated with bre ast conservation, omitting axillary dissection, radiation therapy, and chem otherapy. Despite undertreatment by conventional criteria, the rates of loc al recurrence and distant metastasis are not increased in comparison with c onventionally treated elderly patients. Tamoxifen should be administered to elderly breast cancer patients with invasive tumors because it significant ly improves distant control. (J Am Coil Surg 2001;132:698-707. (C) 2001 by the American College of Surgeons).