With our aging population, we are starting to see more and more elderly women in our clinics with early stage breast cancers. If you live long enough, these things are inevitable. Generally, for early stage breast CA, we offer breast conservation therapy--- lumpectomy + sentinel lymph node sampling/axillary dissection + whole breast radiation +/- adjuvant chemotherapy/hormonal therapy--- as an alternative to modified radical mastectomy. But what about when your patient is 81 years old? Do they really need whole breast radiation? Do the elderly in general need to be treated exactly the same way as a 55 year old with breast cancer?
This paper from Italy (Martelli et al) tries to answer that question. The authors followed over 350 patients over the age of 70 who were treated solely by wide excision and post operative hormonal therapy. Lymph node sampling/dissection and whole breast irradiation were omitted. Recurrence and survival outcomes were followed over a median of 15 years and results were noted to be nearly equivalent to published data on patients treated with the standard BCT. The key is to get a wide excision with clean margins and to make sure that all patients are treated with hormonal therapy.
This is one of those underrated, yet reassuring, papers that community surgeons like myself can use to support individualized therapy for their elderly patients. Whole breast irradiation can be a pain in the ass. You basically have to drive into the hospital every weekday for 6 weeks for treatment sessions. If you're 83 years old and maybe you don't drive so well or your grown children work during the day and can't chauffeur you around, this can be a major problem. Furthermore, axillary dissection amps up the complication rates of breast surgery. A paper like this allows a surgeon to reasonably offer simple wide excision and adjuvant hormonal therapy (assuming the tumor is ER/PR positive), knowing that he hasn't compromised the patient's potential outcome by failing to meet the "standard of care". More importantly, knowing that one may avoid an extended course of radiation therapy may make elderly patients more apt to seek treatment of small mammographically detected abnormalities. So...good job Italy!