Breast cancer in the Golden Girls

Prof Carol-Ann Benn discusses the treatment options for breast cancer in older women aka the Golden Girls.

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Seventy is the new 50; look at Helen Mirren and Cher. When I went on my runs through the vineyards recently, I felt my knees creak and thought I dislocated a hip while slip-sliding in mud, looking at the scenery. I realised that I needed to write on breast cancer in the elderly, with an understanding that elderly isn’t a number but rather a combination of physical, mental and psychosocial factors that make us be the age we are. No judging here.

Whilst many international congresses have defined elderly as those over 65, I think that maybe assuming a biological age as a definition isn’t fair. I have 20-year-old days, 70-year-old days and some 50-year-old days in between.

Today as people take more care of their bodies and minds, women over 70 are healthy, fit and still contributing to society and so they should be.

In fact, many women over 70 in SA are the primary caregivers for school-going children. Never mind my mom at 80 with teenage boys. My ‘monster-in-law’ (who absolutely is not) runs my house and Charl’s dad is the primary fetcher and carrier of a hulking teenage boy (forever grateful), as they were for Tia and Dom.

Genetic lotto

Awareness of the need to exercise, medical ability to diagnose and control cardiac disease, cholesterol, diabetes and osteoporosis has resulted in people living for longer and being healthy participants of all aspects of work and life in general. 

Unfortunately, longevity comes with the downside of the genetic lotto’s random ability to strike the wrong combination, which is becoming more frequent. More cancer is found in people over 70 more frequently (one in four people over 70 develop a cancer). 

What can one do about this statistic? Prevent (actually you can’t but you can decrease your risk); this involves exercise (45 minutes a day); little data exists on diet but moderation is the most sensible option; as well as not adopting an Ab Fab approach to social habits. Adding to prevention would be that of screening. 

Screening

It often concerns me that screening in older people is less frequent. This seems to be for a variety of factors from funding to a concept of “At my age if I get something, I’m not going for chemo or surgery; it can just develop and I’ll go to bed one night and die.” This only happens in movies.

Continuing to go for regular mammograms and ultrasound is imperative. If your breast tissue has involuted (less dense) and your previous mammograms have always been normal, the distance between the mammograms can be discussed with your doctor. 

You may only need to go every three years. If you’re not on hormone therapy (HRT) (and should you be at 70?), let the density of your breast and risk factors determine when you need screening.

Can I ask why you’re on HRT at 70? My understanding is that if you had a hectic menopause, you may need the crutch of HRT, but not for 20 years. Wean yourself off them slowly and deal will the issues of ‘dem bones’ and ageing gracefully with the many other options available.

Biopsy

The diagnosis of breast cancer in women over 70 is as for any woman,  and shouldn’t involve a surgically biopsy but a radiologically-guided core needle biopsy (gold standard). Sounding like a stuck record; when you have a mass or some small finding seen on your mammogram and ultrasound, you don’t need to rush into diagnosis or treatment. 

Prior to undergoing the core needle, remember that a biopsy isn’t an emergency. If you’re on cardiac aspirin or any form of blood thinners, this must be discussed with the radiologist. Cardiac aspirin can usually be stopped (two weeks is the safest), some blood thinners can’t be. Certain specialist radiologists will perform core biopsies whilst patients are on blood thinners (enquire which doctors can and will do this) and ask for costs and what is funded from your medical aid. 

If you don’t have funds, this biopsy can be done at a reputable government unit. Always check radiology’s T&Cs before agreeing to any procedure; and if you’re not clued up as to who pays for what, find a radiology navigator.

Gogo has a diagnosis, now what? 

Most importantly, does she have a support team? Part of being elderly sadly comes with kids in different places; less support structures which can be logistic (driving to reputable centres as opposed to the nearest local clinic); physical (is this person truly 75 or living in the twilight zone of dementia; a cardiac or arthritic cripple, or a go-getting exercise fanatic?).

I’m fascinated by the family dynamics in consults. “Mom is here to see you; we want to see you separately as she doesn’t know her diagnosis.” My general answer is let’s ask mom. “Mom, why do you think you’re here and why do you think a large needle was placed in your breast?” Answer: “Well because we think it’s cancer.” Unless mom is happily in the twilight zone, she probably has some idea. 

To consider all options, go for a second opinion. I tend to follow that trend in oncology of less is more and encourage opinions and time, so medicine, science, doctors and patients come to that five-star central concept of compromise. Changes in oncology care over the last 25 years and, more specifically, over the last 18 months of COVID-19 have resulted in clinicians understanding that individualising care is paramount.

Treatment

Treatment follows the same rules as for those younger with special care given to understanding biological age, logistics, life timelines and expectations. Should this not be something we do every day?

The biological age of the patient should be the most important factor, determining care irrespective of chronological age. In most multi-disciplinary units, discussions around anaesthetic risks and the patient’s wishes are of paramount importance when deciding the treatment options.

Options should only be discussed once the details of the core needle biopsy, including the receptors (oestrogen, progesterone and HER2/neu) are received. Understanding the clothes the cancer is wearing is critical. Again biology, both of the patient and cancer, are key determinates of treatment.I grew up in oncology under the adage that most women diagnosed with breast cancer over the age of 70 had lazy luminal A cancers. Sadly, I can’t say the same now. I’m not sure why we see such diverse types of breast cancer in the elderly; whether it’s due to the numbers of cancers we see or whether more people over 70 are alive and thriving hence more different cancers?

The difference

Let’s remind ourselves of treatment principles and discuss what’s different in women over 70. The following points account for a more individualised method of breast cancer management: 

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 is needed, preferably a core needle biopsy. Incision and excision biopsies of breast masses for diagnostic purposes shouldn’t be done unless a failed needle biopsy in terms of pathological information is obtained. And in the elderly, less is more is often better.

Ultrasound should be offered in conjunction with mammography. Mammography should be digital, breast tomography is offered in specialist units in SA, and MRI should be used in elderly women and can be done with careful understanding of who has what pace makers and other metal bits.

The gold standard today is the triple assessment and while not new is still not used by certain clinicians. This can only change if, like with recycling, the tidal wave of change comes from the community.

MDT

A multi-disciplinary team (MDT) approach is considered the standard of care in all patients. All patients after being diagnosed should be presented to a MDT, consisting of an independent team of cancer surgeons, radiologists, pathologists, reconstructive surgeons, oncologists, radiation oncologists, psychologists, navigation specialists, administrative staff and data capturers. True inter-disciplinary care should involve a minimum of two specialists per discipline.

This is particularly true in women over 70, close patient-centred discussions should take place prior to starting any treatment. The concept of a geriatrician in helping with treatment choices is critical.

All patients should be encouraged to take time with decisions, go for second opinions, take a few days to discuss the options. Waiting a day or two, participating in discussions and understanding what treatment options are, will help ensure ultimate psychological, cosmetic and best cancer management with regards to their circumstances logistically and around cancer survivorship.

Which treatment when?

All this info is needed before starting down the road of which treatment when. Some frail ladies are only treated with tablets (there are many), and the type of treatment can’t be decided until all the data is analysed from the core needle biopsy.

Determining whether a cancer has spread elsewhere can often help a woman and her family decide what important treatment decisions should be made. If cancer is elsewhere, there is often decisions about how to treat, with what and if one should treat. When I hear the question, “What if the cancer has spread”, I counter with “If we find cancer elsewhere will this change your decisions?” If granny has cancer in her liver or lungs, are you going to upscale and give chemo? If not, to what extent should you look. There has to be a balance so if one is going to have surgery for a locally advanced cancer, without knowing if there is cancer elsewhere, this may result in pointless cutting without understanding that lobbing off a breast in this scenario is of little value. 

But understanding if someone complaining of pain in a hip, back or elsewhere is due to arthritis or cancer, thus understanding if it’s the C-word, can result in options of certain medication or a small local blast of radiation to provide relief with minimal intervention. I often see Golden Girls that for many reasons have failed to disclose a variety of frighteningly advanced cancers hiding under their brassieres. Did they know and not tell, not check the girls regularly, or just decided at their age screening and checking isn’t necessary?

Not every Golden Girl decides, chooses or needs to start with surgery. In many instances, starting with a variety of medications from hormonal to others is possible. So, my reason for discussing treatments in the order below isn’t based on priority of choices.

Surgery

Should you choose surgery at your ripe old age, what surgery should you choose? The concept of going under the knife is frightening for all of us. 

No one should undergo any operation unless all safety checks are assessed. These are like flying. Remember you can’t fly unless you have all your documents (passports over 70 involve a detailed list of previous surgeries and how those trips went), medical problems and medications; you can’t pass security without emptying these pockets. Has the physician spoken to the anaesthetist and surgeon?

Further pre-operative discussions require an understanding of what surgery entails. How much tissue is being excised; the basic rule is if over 5% is removed, repositioning the breast tissue is important so that no massive divets result. The length of time on the theatre table and hospital stay and the downsides of this (risk of clots) need to be addressed. How will surgery be performed and by whom? Sometimes not using techniques to reconstruct the defect results in years of misery and complaints of breast swelling and oedema and functional concerns. 

You can still be a goddess

If you’re over a certain age; don’t have a partner; aren’t sexually active doesn’t mean that a doctor should tell you that you don’t need a breast (think Blanche). Many women over a certain age have breast reconstructive procedures safely. My favourite story is of a 91-year-old I treated. Due to the Paget’s of the nipple diagnosis, a mastectomy was needed. She had one with an immediate prosthetic reconstruction. She told me that her husband was a breast man and she was going to cross the great divide in a flowing white gown with two breasts and a 24-year-old cleavage. When she died, she left me a beautiful painting of a goddess in a flowing gown.

Has anyone told you that if you have your breast off, you don’t need radiation (this may be misinformation)? However, not all ladies over 70 need radiation if they undergo even breast-saving surgery. In fact, they may not even need surgery to the axilla (armpit) where the lymph nodes live. Remember not everyone today needs lots of lymph nodes out. The sentinel lymph node biopsy is the gold standard, for assessment of clinical and ultrasound node negative tumours.

Reconstruction

Breast reconstruction is safe and offered in all fit women over 70. It thrills me to see how many women over 70 go through reconstruction. In our unit, due careful pre-operative planning, combined clinical and aesthetic assessments are done, thus have no increased complications compared to those under 70, and as in all specialised units this data is published. Most women over 70 who elect to undergo surgery have breast-saving surgery.

The safety rules remain the same. 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) and is offered immediately at the time of removal of the cancer (one procedure). Neither does it delay time to further treatment if needed.

Radiation

Today more mature ladies with certain cancers can have a single blast of radiation in theatre. The problem often with radiation is the inconvenience of distance and time. It’s usually done daily Monday to Fridays for about a six-week period but today can be done for shorter durations should your cancer have followed all the T&Cs. 

We are privileged in our unit to be able to offer radiation as a once-off in theatre. This amazing technology goes a long way to improve the inconvenience of travel and time, particularly as many elderly women are reliant on others for lifts. 

Omitting radiation in women over 70 can be considered in certain scenarios, but if the tumour biology or glands suggest necessary, omission is fool hardy, as radiation often prevents cancer coming back locally. And as someone ages, we would prefer not to have to treat again for omitting a treatment option.

Chemotherapy

That scary word, chemotherapy. A better term is cytotoxic drugs (cancer antibiotics that kill cells (the bad ones while occasionally affecting the good ones)).

A large number of women over 70, if not medically frail, cope extremely well with chemotherapy. Chemotherapy regimens can be tailored for elderly and less fit patients; there are oral treatments and other drip treatments with few side effects. 

The important rule is not to assume, that due to a woman’s age, she isn’t fit for treatment.

Target therapy

These are drugs that play PAC-MAN with cancer cells. These smart drugs can and should be used if needed in women over 70. Availability of more target therapies due to better understanding of the cell biology of tumours is resulting in longer disease-free survival in patients.

Endocrine therapy

Hormonal treatment is critical and plays a central character role in many episodes of treating breast cancer in older women. Often times 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 to shrink the tumour smaller. 

Endocrine therapy reduces the risk of recurrence and improves overall survival. Patients with ER/PR negative tumours shouldn’t get hormonal therapy

Cryo-surgery

Clearly if fit for surgery, operating is an option, but cryo-surgery plays a critical role as the endocrine medication used to shrink cancers only works for about two years then the cancer starts developing a resistance to the medication, and it needs to be changed.

Patient follow-up should be convenient in the frail, with careful attention to a good history and examination and less to multiple investigations. Differentiating arthritis from bone pain and, sensibly, not investigating every ache is critical.

Funding

Funding in all women is a crucial issue, as we get older and aren’t working, care must be taken to ensuring a balance between medical expenditure and use of savings. Access to good care in government units that offer multi-disciplinary care is always an option. Always check what the shortfalls are.

Breast cancer is a PMB. However, the amount and type of treatments covered tends to depend on the medical aid plan that the patient is on, and it may require registration for an oncology benefit after diagnosis. It’s important that the patient does this as soon as possible. Remind patients to check what type of treatments they are covered for when considering starting or changing medical aids.

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 aren’t allowed to refuse cover for a patient with a pre-existing condition and that includes cancer. But, they may impose a waiting period from three months to one year where they won’t cover a condition. The patient needs to be aware of this and reminded that cancer treatment shouldn’t 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 don’t have the resources for travelling to a hospital or manage treatments.

Breast specialists believe patients should have access to exactly the same standard of healthcare in public and in private: the same expertise, same research trials, same support groups and psychological care for cancer survivors. And all oncology specialists strive for this.

Specific support groups ensure age specific pairing and counsellors to help with all aspects of care. It’s easy for patients in our time and economically-constrained community to ‘fall through the gaps’ of cancer treatment, and the counsellors form an important safety-net to prevent this.

Remember all you Golden Girls, most of you won’t die from your breast cancer; so check your girls and ensure you walk the red carpet of spectacular care.