Surgery Best for Controlling Breast Cancer in Elderly Women
Although women over age 70 are rarely offered surgery to treat their breast cancer, a new review of recent studies suggests surgery works better than hormone therapy to stop the progression of breast cancer in older women with operable tumors.
Although there was no significant difference in how long the women lived after having either surgery or first-line hormone therapy such as tamoxifen only, two of the studies found that women can go longer without their breast cancer becoming worse if they have surgery.
In fact, older women who had surgery alone or surgery combined with hormone therapy were half as likely to see their cancer progress over the course of the study as those who opted for hormone therapy only, say Daniel Hind of the University of Sheffield in England and colleagues.
"Surgery controls breast cancer better than tamoxifen alone in women aged 70 years and over but does not extend survival," the researchers concluded.
The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
Hind and colleagues examined seven studies of 1,571 women age 70 and older who had operable breast cancer, or cancers where the main tumor was mostly limited to breast tissue with little spread to other parts of the body. Study lengths ranged from three years to 12 years.
The studies included tumors that were sensitive and insensitive to estrogen receptor therapy, the primary drug treatment for breast cancer. Tamoxifen, the primary hormone treatment in all of the studies, blocks the activity of estrogen in the body.
Hind acknowledged that results could have been different if estrogen-insensitive tumors had been excluded from the review. However, "it is unlikely that the considerable local control advantage conferred by surgery would be overcome," he said.
While younger women with breast cancer often get hormone therapy in addition to surgery, women over 70 are usually prescribed tamoxifen only, "based on the premise that older patients are less likely to be fit for surgery," Hind said.
On average, the hormone therapy tamoxifen shrinks or slows the growth of tumors for only 18 months to 24 months. This could leave elderly patients even older when they need to turn to other hormonal therapies or surgical options.
Newer breast cancer drugs such as Femara and Arimidex, which lower the amount of estrogen produced by the body, may be useful treatments for older women who are unfit for surgery, but more rigorous testing of the therapies is needed, Hind and colleagues conclude.
Other studies suggest a bias against surgery in older patients that may not be warranted by the data. Several recent studies suggest elderly people are not treated as aggressively as their younger counterparts, although many of them respond well to more-invasive treatment.
Denise Uyar, M.D., a professor of obstetrics and gynecology at the Medical College of Wisconsin in Milwaukee, recently completed a study that found elderly women were less likely to have surgery or certain types of chemotherapy for ovarian cancer, although they were often suitable candidates for these treatments.
"However, it is difficult to determine one's 'fitness' for undergoing intensive treatment for cancer whether it is surgery or chemotherapy," Uyar says.
"The elderly are an increasingly diverse population and unfortunately there is no single assessment tool able to identify patients who are not only elderly, but frail," and at risk of dying from treatment complications, she adds.
The study was supported by the North Trent Cancer Research Network, UK.