Does life expectancy affect treatment of women aged 80 and older with early stage breast cancers?☆
Introduction
The benefits of radiotherapy after breast conserving surgery (BCS) among women aged ≥ 80 with early stage breast cancer are not well understood even though radiotherapy after BCS is standard treatment for most younger women.1 No studies have demonstrated a mortality benefit of radiotherapy after BCS among women aged ≥ 80, although some studies suggest a small reduction in local recurrence.[1], [2], [3], [4] Most experts agree that older women in excellent health without comorbid disease limiting their life expectancy would be the most likely to benefit from radiotherapy after BCS.[2], [3], [4], [5]
A pooled analysis of data from several trials including women of all ages, (but few ≥ 70 years) found that radiotherapy after BCS resulted in 7% of women experiencing a local recurrence after 5 years compared to 26% of women who received BCS alone.6 This study also showed a 5.4% reduction in breast cancer mortality and a 5.3% reduction in overall mortality after 15 years among women who received radiotherapy after BCS. Breast cancer recurrence was less common among women aged ≥ 70 (3% among women who received radiotherapy after BCS compared to 13% among those who did not).6 Data were not presented on whether the mortality benefit of radiotherapy after BCS persisted among women ≥ 70 years. A randomized control trial (RCT) comparing mastectomy, BCS alone, and BCS plus radiotherapy including women of all ages after 20 years follow-up found that radiotherapy after BCS reduced rates of ipsilateral recurrence (39.2% to 14.3%).7 There were no significant differences in distant-disease free or overall survival in the three groups; however, radiotherapy after BCS was associated with a nearly significant increase in breast cancer survival.8 These studies suggest that radiotherapy after BCS for early stage breast cancer significantly reduces local recurrence and possibly reduces breast cancer mortality after 15–20 years follow-up, which is beyond the life expectancy of most women ≥ 80 years.8
Few studies examining radiotherapy after BCS have focused on older women. One RCT included 636 women aged ≥ 70 with stage I, estrogen receptor positive (ER +) breast cancer treated with BCS, and randomized women to treatment with tamoxifen plus radiotherapy or tamoxifen alone. After 5 years, the group that received radiotherapy experienced fewer local and regional recurrences (1% versus 4%, p < 0.001) but there were no significant differences in distant recurrence or survival.1 An observational study that included women with similar characteristics found that radiotherapy after BCS reduced breast cancer recurrence from 5.1% to 1.1%.2 Another RCT that included 769 women aged ≥ 50 (~ 40% ≥ 70 years) with node negative breast tumors, 5 centimeters (cm) or less, found that radiotherapy after BCS reduced local recurrence (7.7% to 0.6%, p < 0.001) but did not show significant differences in rates of distant relapse or overall survival after 5 years.3 A recent review recommended radiotherapy for all patients after BCS, except possibly women aged ≥ 70 with lymph node negative (LN–) tumors, 5 cm or less, being treated with hormonal therapy.9 Although not all investigators agree that elderly women with favorable tumor characteristics can forgo radiotherapy after BCS, nearly all concur that those with limited life expectancies are unlikely to benefit.[2], [6], [10], [11]
In this study, we examined initial treatment of women aged ≥ 80 with early stage breast cancers by life expectancy. We then examined characteristics associated with the use of radiotherapy after BCS among these women.
Section snippets
Methods
We used data from the National Cancer Institute's linked SEER-Medicare dataset. Since 1992, SEER has included 11 population-based tumor registries in the metropolitan areas of San Francisco/Oakland, Detroit, Atlanta, and Seattle; Los Angeles county; the San Jose-Monterey area; and the states of Connecticut, Iowa, New Mexico, Utah, and Hawaii.12 These areas cover approximately 14% of the US population.13 For this study, we included 9932 women aged ≥ 80 with continuous fee-for-service Medicare
Results
Of the 9,932 women aged ≥ 80 diagnosed with favorable breast cancers, 58.2% were aged 80–84, 29.7% were aged 85–89, and 12.1% were aged ≥ 90; 43% were regular users of mammography. The majority were diagnosed with stage I disease (61.8%, Table 1). Approximately half (55.4%) had a CCI of 0 and 8.7% had a CCI ≥ 3 (Table 2). Based on data from controls, women with a CCI ≥ 3 had a substantially higher probability of 5-year mortality (72.4%) than women with a CCI of 0 (36.1%). Despite this large
Discussion
We found that half (50.3%) of women aged ≥ 80 with ER+, LN − breast tumors ≤ 5 cm received radiotherapy after breast conserving surgery. We also found that treatment with radiotherapy after BCS was not limited to the oldest women in good health; 37% of women with a 72% probability (CCI ≥ 3) of mortality in five years and very little chance of benefit received radiotherapy after BCS. Increasing age and the presence of dementia, which are two factors strongly associated with decreased life expectancy,
Disclosures
The authors have no conflicts of interest to report.
Author Contributions
Concept and design: Schonberg, Marcantonio, Silliman, McCarthy Data collection: Schonberg, McCarthy Analysis and interpretation of data: Schonberg, Marcantonio, Ngo, Silliman, McCarthy Manuscript writing and approval: Schonberg, Marcantonio, Ngo, Silliman, McCarthy.
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Cited by (11)
Adjuvant Radiation Improves Survival in Older Women Following Breast-Conserving Surgery for Estrogen Receptor–Negative Breast Cancer
2016, Clinical Breast CancerCitation Excerpt :One could postulate that perhaps the slightly younger radiation cohort may have had fewer comorbidities, which could have influenced decision making toward radiation based on their performance status.21 A SEER analysis by Schonberg et al22 evaluated patients age 80 and older who were ER+ regarding the utilization of adjuvant radiation therapy after lumpectomy and found that treatment was not limited to women in good health with minimal medical comorbidities; in fact, their data suggested that women with significant high risk of 5-year mortality received radiation and, equally, up to 45% of women without morbidities affecting life expectancy did not receive radiation. Increased age was found to be predictive of radiation omission in these patients who were ER+, but only in patients aged 90 and older.
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Dr. Schonberg was supported by a Paul B. Beeson Career Development Award in Aging supported by the National Institute on Aging K23 [K23AG028584], The John A. Hartford Foundation, The Atlantic Philanthropies, The Starr Foundation, and The American Federation for Aging Research. Dr. McCarthy was supported by the American Cancer Society [RSGT-10-080-CPHSPS]. There are no financial disclosures.