There is no reason why women over 70 cannot have safe surgery, reconstruction and other aspects of breast cancer treatment.
As people take more care of their bodies and minds today, women over 70 are often healthy, fit and still contributing immensely to society. In fact, in many South African households, women over 70 are the primary care givers for school going children.
Awareness of our need to exercise, our medical ability to diagnose and control cardiac disease, cholesterol and diabetes has resulted in people living longer, healthier lives.
Unfortunately, longevity does increase the downside of the genetic lotto’s random ability to strike the wrong combination. This means that more cancers are found in people over the age of 70.
What can you do about this?
In terms of breast cancer screening, continuing to go for regular mammograms and ultrasounds is imperative. If your breast tissue has involuted (become less dense) and your previous mammograms have always been normal, the time between your mammograms should be discussed with your doctor.
The diagnosis of breast cancer in women over 70 is as traumatic for any women, and calls for a radiologically guided core needle biopsy. Prior to undergoing the procedure, remember that a biopsy is not an emergency; if you are on cardiac aspirin (or any form of blood thinners), discuss this with your radiologist. Cardiac aspirin can usually be stopped two weeks prior, however some blood thinners cannot be stopped. Certain specialist radiologists will perform core biopsies whilst patients are on blood thinners (you need to enquire about which doctors can and will do this).
Treatment for breast cancer in women over 70 follows the same rules as for younger women, with certain special care being given to general medical conditions.
The biological age of the patient should be the most important factor in determining the type of care.
In most multi-disciplinary units discussions around anesthetic risks and the patients’ wishes are of paramount importance when deciding the treatment options for women over 70.
Treatment options should only be discussed once the details of the core needle biopsy, including the receptors (those for estrogen, progesterone and Her 2 neu ) are received.
Let’s remind ourselves of treatment principles and then discuss what is different for women over 70.
The following key practical points account for a more individualised method of breast cancer management:
1. TRIPLE ASSESSMENT
• Following a detailed history and examination, all patients should have an ultrasound and mammogram depending on their age and if
a suspicious finding is documented, a needle biopsy (preferably a core needle biopsy) should be performed.
• Incision and excision biopsies of breast masses for diagnostic purposes should not be done unless a failed needle biopsy, in terms of pathological information is obtained.
• Ultrasound examinations should be offered in conjunction with mammography.
• Mammography should be digital, breast tomography is offered in specialist units in this country, and MRI should be used in select circumstances.
The gold standard today is the triple assessment and while not new it is still not used by certain clinicians
2. TEAM APPROACH
• A multi-disciplinary team approach is considered the standard of care in all patients.
• After being diagnosed with a breast cancer, all patients should be presented to a multi-disciplinary team consisting of a cancer surgeon, radiologist, pathologist, reconstructive surgeon, oncologist, radiation oncologist, psychologist, nursing sister, administrative staff and data capturer.
• True inter-disciplinary care, should involve a minimum of 2 specialists per discipline.
This is particularly true in women over 70, close patient-centered discussions should take place prior to starting any treatment in women over 70.
3. PATIENT FACTORS
• All patients should be encouraged to take time to make their decisions, to go for second opinions and to take a few days to discuss the different treatment options.
• Waiting a day or two, participating in the discussions and understanding what the different treatment options are, will help ensure ultimate psychological, cosmetic and best cancer management.
The diagnosis of breast cancer in women over 70 should not be made by surgical biopsies… but by a specialist radiologist.
All this information is needed before starting down the road of which treatment when. Some frail ladies are only treated with tablets, and the type of treatment cannot be decided until all the data is analyzed from the core needle biopsy.
Determining whether a cancer has spread elsewhere, can often help a women and her family decide what important treatment decisions should be made. If cancer is elsewhere, there is often a decision about how and where one should treat.
Surgical Rules
1. Pre-operative discussions with a patient prior to surgery, should involve issues around family history, breast size, tumour size and location, and indications for radiation therapy.
2. Sentinel lymph node biopsy is the gold standard for an assessment of clinical and ultrasound node negative tumours.
3. Sentinel lymph node biopsy should be done in all patients prior to definitive surgery, should the possibility of the patient deciding on a skin sparing mastectomy and prosthetic reconstruction be considered.
4. The above is of value in women over 70 who elect to undergo surgery and reconstruction.
5. Unit guidelines as to cancer free margins should be decided on and adhered to at all times.
6. Should more than 5% of the breast tissue be removed, use of oncoplastic techniques is advised.
7. Clipping of the surgical bed is essential in all patients undergoing breast conserving surgery.
Reconstruction
Breast reconstruction is safe and is offered to all fit women over 70. It thrills me to see how many women over 70 go through breast reconstruction in our unit, due to our careful pre-operative planning and combined clinical and aesthetic assessments. It definitely helps that there are no increased complications for women over 70.
Regardless of age, reconstruction rules are:
1. Breast reconstruction is considered vital to the patient’s rehabilitation and an intrinsic part of breast cancer treatment (if this is the patient’s desire).
2. Immediate reconstruction is and should be available to most patients’ with breast cancer.
3. Reconstruction should not delay time to adjuvant therapy.
Chemotherapy
A large number of women over 70, if not medically frail, cope extremely well with chemotherapy. Chemotherapy regimes can also be tailored for elderly and less fit patients.
An important rule is not to assume that given a woman’s age – she is not fit for treatment.
1. To ensure optimal care for all patients a multi-disciplinary approach should be utilised for all patients to develop an optimal treatment plan.
2. Primary chemotherapy is the gold standard for all patients with locally advanced breast cancer.
3. Systemic chemotherapy can improve survival in patients with metastatic breast cancer.
4. Systemic chemotherapy produces durable remission in some patients with metastatic breast cancer.
5. Amplification of the Her2/neu is associated with increased aggressiveness of breast cancers – Trastuzumab should be utilised in these patients.
6. Today chemotherapy is more individualised and less reciped as more combinations of drugs become available.
Radiation
The problem with radiation treatment is the inconvenience of the distance and time required to be at the appointments. Radiation is usually done daily Monday to Fridays, for a 6 week period.
Omitting radiation in women over 70 (should it be needed), is generally fool hardy, as radiation usually prevents the cancer from coming back locally. And as someone ages, we would prefer not to have to treat again for simply omitting a treatment option.
All patients with invasive carcinoma should receive radiation therapy as part of breast conservation therapy.
Endocrine therapy
Often, in frail ladies we may elect to start treatment with tablets only, this allows time for women to come to terms with the diagnosis and allows time to shrink the tumour. If fit for surgery, operating is always first prize, as the endocrine medication used to shrink cancers only works for about two years and then the cancer starts developing a “resistance” to the medication.
1. All patients with hormone receptor-positive tumours are candidates for endocrine therapy.
2. Endocrine therapy reduces the risk of recurrence and improves overall survival.
3. Patients with ER/PR negative tumours should not get hormonal therapy.
A three-month period on Tamoxifen often makes the prospect of breast cancer treatment less daunting for the medically frail.
Target therapies
These smart drugs can and should be used, if needed in women over 70.
1. Over-expression of the Her-2/neu protein is associated with poor prognosis and can be used to select patients for Trastuzumab (Herceptin) therapy.
2. Availability of more target therapies due to better understanding of the cell biology of tumours is resulting in longer disease free survival in patients.
Patient follow-up
Patient follow-up should be convenient for the frail, with careful attention paid to a good history and examination and less attention paid to multiple investigations. Differentiating arthritis from bone pain and sensibly not investigating every ache is critical.
1. History taking, eliciting symptoms and physical examinations should be done every 3-6 months for 3 years, then 6-12 months for 3 years, and then annually with special attention paid to long term side-effects (such as osteoporosis).
2. Ipsilateral and contralateral radiology every year.
3. Not routinely recommended for asymptomatic patients: blood counts; chemistry, chest Xrays, bone scans, liver ultrasounds, chest scans of chest or abdomen.
4. Any tumour markers (such as CA 153, CEA) are not recommended.
Specifics around who gets what treatment when is always an issue in women over 70.
FUNDING ISSUES
Funding for women, regardless of age is a crucial issue. Especially since as we get older, we are less likely to be working. Care must be taken to ensuring a balance between medical expenditure and the use of savings.
Access to good care in government units that offer multi-disciplinary care, is always an option. Always check what shortfalls and pay-ins may be required.
Breast cancer is a Prescribed Minimum Benefit (PMB), however the amount and type of treatment covered tends to depend on the medical aid plan that the patient is on. You may be required to register for a cancer scheme after your diagnosis. It is important that the patient does this as soon as possible. Patients need to check when considering starting or changing medical aids,
what type of treatments they will be covered for.
A cancer diagnosis may result in a person deciding that this is the time for them to start contributing towards a medical aid. Fortunately, medical aids are not allowed to refuse cover for a patient with a pre-existing condition (including cancer), but they may impose a waiting period from three months to one year, where they will not cover the condition. It is important that you are aware of this and reminded that cancer treatment should not be delayed during this timeframe.
There are many excellent public hospitals and superb academic cancer specialists who work in government hospitals. There are also many organisations that wish to help patients who do not have the resources to travel to a hospital or manage their treatments.
Breast specialists believe patients should have access to exactly the same standard of healthcare in public and in private hospitals: the same expertise, the same research trials, the same support groups and psychological care for cancer survivors. And all oncology specialists strive for this.
CANCER SUPPORT GROUPS
Specific support groups ensure age-specific pairing and counsellors to help with all aspects of care.
There is a strong connection between many public breast units and the Breast Health Foundation of South Africa. Counsellors are available to guide and support patients through diagnosis, treatment and recovery, allowing for seamless care and follow-ups. It is easy for patients in our time- and economically-constrained community to ‘fall through the gaps’ of cancer treatment, and these counsellors form an important safety-net to help prevent this.
A variety of support groups are available to all patients, and all patients should be encouraged to access these support groups.
ACCESSING CARE
This applies to women of all age groups
Integral to the central functioning of a specialist breast unit (whether in public or private care) is ensuring appropriate clinical assessment of women presenting with breast health concerns is achieved throughout the country. This allows correct referrals to be made to appropriate screening and diagnostic facilities. Clinics without specialist-based supervision often result in inappropriate patient management. This is not just a problem of an under-resourced state system but the same for public and private surgeons. That is what makes a specialist and why specialist multi-disciplinary units tend to manage patients in a more holistic way. In each province in South Africa there is access to a specialist breast unit, and even if it is far from your area, they can give advice on how to manage or refer patients appropriately.
There are a number of specialist breast units in South Africa in both public and private hospitals, which treat patients and manage breast cancer without leaving the patient in debt or difficulty.
The Breast Health Foundation helpline (0860 buddie) is one way to get advice on how to find the nearest specialist breast unit.
One in seven women over 70 are diagnosed with breast cancer. Care should be taken to:
• not rush into treatment
• assess medical conditions
• understand chronological age vs. physiological age,
• respect the patients’ wishes and
• provide sensible medical care.
There is no reason why women over 70 cannot have safe surgery, reconstruction and other aspects of breast cancer treatment.
Individualising each patient is the secret to good
treatment outcomes and to ensuring a healthy life post-diagnosis. Remember: almost all women in their 70s survive breast cancer!
MEET THE EXPERT
