**2. Factors affecting the choice of a course of action**

In most developed countries, 65 is the chronological age assumed to define the elderly. However, there is no doubt that this is a conventional limit, and the chronological age does not coincide with the biological one. Women aged 65 years are frequently individuals with no functional limitations under the conditions of most developed countries; nonetheless, in developing countries, this limit should be perhaps set much lower. The differences between communities can be very clear, e.g. for those born in 2011, the life expectancy is estimated at 48 to 82 years depending on the region of residence [6, 7].

Therefore, when assessing the eligibility for therapeutic management of an elderly breast cancer patient, not only do we need information about the biological features of breast cancer and its progress but also about comorbidities, received medications and most of all, the patient's biological age, as this information should crucially

#### *Breast Cancer in the Elderly DOI: http://dx.doi.org/10.5772/intechopen.110293*

determine further action to be taken. Most geriatric oncologists agree that the key element is to divide the elderly patients into those who are completely stable, with no co-existing medical conditions, i.e. so-called fit patients, and ailing patients with multiple co-existing internal diseases, i.e. frail patients. Thus, the suggested course of action should be based primarily on the patient's biological age.

Generally speaking, advanced age is associated with reduced tolerance to physiological stress, more frequent occurrence of comorbidities, more intense cognitive disorders, and decreased social support. A patient over the age of 70 years can be expected to suffer on average from three comorbidities. It has been shown that most comorbidities such as renal failure, liver failure, and cerebrovascular disease are mostly associated with an increased risk of death from causes other than breast cancer. The occurrence of any serious and chronic comorbidities is assumed to play a major role in determining the predicted survival time in older patients aged 50–79 years and diagnosed with breast cancer.

This is to some extent confirmed by the study results published in 2011 by Schonberg et al. This study evaluates mortality from the cause of death in 66,000 women aged over 67 years after a breast cancer diagnosis compared to a properly selected group of women without breast cancer [8]. Women with ductal carcinoma in situ (DCIS) or stage I invasive breast cancer had a lower risk of death than the controls, and the most common cause of death was cardiovascular disease. Patients with a diagnosed stage II breast cancer had greater mortality than controls but among women aged 80 years and older, cardiovascular disease was still the prevailing cause of death. In contrast, for stage III or IV breast cancer, breast cancer itself was the commonest cause of death, even with the oldest patients.

Undoubtedly, the biggest decision-making problem is the eligibility assessment or the decision to abandon perioperative chemotherapy.

It seems that the most significant factor to take into account when making that decision should be an assessment of the patient's functional status, which is defined as an individual's ability to perform normal daily activities. In their work, Braithwaite et al. studied a cohort of 2200 women with breast cancer who received adjuvant therapy. Functional limitations in this group were associated with older chronological age, lower education level, and obesity. It has been shown that during the median followup of 9 years in patients with functional limitations, the risk of death increased from all causes but not from breast cancer (HR 0.90; 95% CI 1.03–1.92) [9].

Ideally, all elderly patients with indications for perioperative chemotherapy according to the generally applicable guidelines should have a comprehensive geriatric assessment (CGA) or at least a functional status assessment, which, unfortunately, is not possible in most cancers, mainly due to lack of time and qualified medical staff [10].

#### **3. Screening procedures**

For over 30 years, the main determinants of improved survival rates for cancer patients have been considered early detection of the disease, i.e. the screening tests that make this possible (namely screening mammography) and the introduction of adjuvant therapy. Most randomized studies evaluating the value of mammography screening did not include women aged 75 years or older. Therefore, the epidemiological benefits of screening in this age group are unknown. Observation studies suggest that older women with a life expectancy of 10 years plus should be taken into account in screening tests. The breast cancer mortality is estimated to be reduced by about 0.2% if active mammography screening is extended beyond the age of 70 years. However, in each case, a decision to continue mammography screening in 70 + − year-old women should be made on a case-by-case basis unless other guidelines are developed [11].
