Case Recap
The patient is an 80-year-old woman with type 2 diabetes and hypertension well controlled with diet and medication. She has a C-cup breast size and no previous exogenous hormone exposure. She reports that she is physically active and takes long daily walks without any difficulties.
A routine screening mammogram reveals a 1.5 cm spiculated mass in the left breast within a 2 cm segment of microcalcifications. Breast exam is negative for any suspicious findings. Stereotactic core needle biopsy reveals invasive ductal carcinoma with associated DCIS; estrogen receptor positive.
This case raises several issues regarding the management of breast cancer in the elderly, including the relevance of advanced age and health status when determining axillary staging procedures; the appropriateness of breast conserving surgery versus mastectomy and whether adjuvant chemotherapy and/or radiation improves survival or jeopardizes quality of life in older patients.
Survey Results
A self-selected response pool of ASBD members completed an online survey with the following results. Of respondents, 62% were breast surgeons, 18% were surgical oncologists, 10% radiation oncologists, 8% medical oncologists, and 2% radiologists.
Figure 1 demonstrates that age is more than a factor of years of life. More than one-quarter of respondents reported that they consider a patient to be elderly based on the patient's health and not their chronological age. Of those who measured age in years, nearly 30% considered a patient elderly at age 80.
When asked whether patient age influences treatment decisions, nearly 60% of respondents indicated that it is sometimes or frequently a factor. On the other hand, more than one-third reported that they seldom or never consider age in making treatment decisions (Figure 2).
The vast majority of respondents (92%) recommended image-guided wire localization lumpectomy (to achieve negative margins and to clear all microcalcifcations) followed by breast XRT. If the patient had been 45 years of age, 100% of respondents would have made this recommendation.
The consensus, however, does not hold when asked whether the patient receive an ALND if intraoperative lymphatic mapping was performed, but failed to identify a sentinel lymph node. Here 45% of respondent said yes, 39% said no, 8% would do an axillary sampling, and 8% were unsure.
