Breast Cancer in the Elderly

*Agnieszka Jagiello-Gruszfeld and Agnieszka Mlodzinska*

#### **Abstract**

Breast cancer is a serious health problem in the elderly female population. The approach to treating healthy women aged 65–70 years should be similar to treating younger patients with a similar stage and biological subtype of breast cancer. Greater individualization of treatment is necessary in the case of patients with worse parameters of functional efficiency and features of the frail syndrome. It should also be emphasized the need for closer cooperation with geriatricians, especially when defining the management plan and conducting systemic treatment in this group of patients. There is also a great need for research into the proper selection of treatment in elderly breast cancer patients. This is especially important in groups of patients with early and locally advanced breast cancer.

**Keywords:** breast cancer, elderly, frailty syndrome, comprehensive geriatric assessment

### **1. Introduction**

Cancer is age-related. Increased life expectancy means that cancers in the elderly are becoming ever more common. More than three-quarters of cancer deaths are among those aged 65 years and older, and more than half among those are aged 75 years and older [1].

This poses a challenge, especially for clinical oncologists, when choosing systemic therapy, due to the specificity of this group of patients. Unfortunately, the group of elderly patients is still underrepresented in clinical trials evaluating new cancer therapies. As a result, there is much less evidence-based information to guide proposed medical management.

Many publications emphasize that older patients are less likely to receive the most effective forms of systemic therapies. This can lead to poorer treatment outcomes and negatively affect patients' survival rates [2].

An important problem for the clinical oncologist is the comorbidities, which occur much more frequently in the elderly versus the younger population. Regrettably, comorbidities happen to be treated suboptimally, especially in people with no family support or care, which can cause additional problems complicating decisions about systemic therapy [3].

It should be pointed out that access to systemic therapy in the elderly population can be significantly hampered for social and economic reasons, especially for patients who live a considerable distance from oncological centers and find it difficult to come to regular visits. This factor is less important when it comes to other types of oncological therapies, namely surgery and radiation therapy, as both are not stretched over time and, if necessary, a patient may be hospitalized until the completion of therapy. In the case of systemic therapy, patients need to visit the oncological center regularly (e.g. once a week or once a month), but they usually do not need to stay at the hospital for more than a few hours [4].

The primary risk factor for breast cancer is age. The median age of onset of this type of cancer is about 60 years. Over 40% of women with newly diagnosed breast cancer are 65 years and older. Since the population is clearly aging, the number of breast cancer patients may be expected to increase significantly in the coming years [1].

At present, the screening in most countries does not cover the population of 70 + − year-old women, mostly because this procedure is less cost-effective in comparison with the population of younger women. This is mainly due to the presence of concomitant diseases which reduce life expectancy, as well as the higher cost of treating breast cancer in elderly women. Besides, elder women are much less likely to report regularly for screening mammography. As a consequence, breast cancer detected in women at the age of 70 plus years is often at more advanced stages than in the case of younger women. According to some sources, over 40% of patients aged over 65 years are diagnosed with breast cancer only when distant metastases are already present [5].

Another very important problem in elderly breast cancer patients is systemic perioperative therapy. Although it is not a major problem to assess such patients eligible for endocrine therapy, a decision to assess a patient eligible for chemotherapy in many cases already raises many doubts among oncologists. The problem is even more compounded by the fact that older patients rarely consent to participate in clinical trials or they meet the exclusion criteria. As a result, elderly patients' therapy is suboptimal, usually not intensive enough, or they are sometimes assessed eligible for therapies that are too toxic for them; both options lead to a situation where the ultimate outcomes of treating older patients are worse.

The work published in 2011 by Smith et al. indicates that although the mortality rate from breast cancer in the <75-year-old population in the US declined by 2.5% per year from 1990 to 2007, breast cancer mortality in women aged 75+ years declined by only 1.1% per year [4]. In Europe, breast cancer mortality declined by 13% from 2000 to 2004 compared with the years 1990–1994; however, this decline was much more pronounced among women aged 35–64 years (17%) compared to only 6% for patients aged 65 years and older [5].
