Journal of Surgical Oncology 41:19-21 (1989)

Treatment of Breast Cancer in Women Older Than 70 Years

EGON SVASTICS, MD, ZOLTAN SULYOK, MD, AND ISTVAN BESZNYAK, MD, FACS

From the Surgical Department, National Oncological Institute, Budapest, Hungary

Do age, associated diseases, general state, or the stage of tumor determine the operability of breast cancer in the elderly? Risk factors are studied on the basis of data on 465 patients over 70 years of age who had breast cancer surgery between 1977 and 1986. Operative mortality of patients is analyzed, and according to the results, the outcome of the surgery is mainly influenced by patients’ performance status (Karnofsky/Zubrod in- dex) and stage of disease and not by the associated diseases or patient age.

KEY WORDS: elderly patients, surgical risk

INTRODUCTION

As a result of better living conditions, the average age has been increasing all over the world. In Hungary, 10% of the female population is over 70 years of age and 2.9% over 80. Malignancies are the second most frequent dis- ease after circulatory diseases, which patients, doctors, and relatives have to face. Tumors in the elderly can be operated on with good results if they are discovered in an early stage. The same applies to breast cancer.

In the opinion of many doctors, elderly patients with breast carcinoma should not be treated surgically because of their assumed limited life expectancy and the slower growth rate of tumor in older age and also because even minor complications may endanger their lives. Are they correct in this outlook? This is the scope of the study.

MATERIALS AND METHODS

Data on 2,704 patients with breast cancer operated on at the Surgical Department of the National Institute of Oncology, Budapest, between September 1, 1977 and August 3 1, 1986 (9 years) have been processed. Of the 2,704, 465 (17%) patients were older than age 70 years. The oldest was age 91 years (Table I). The majority of the patients had stage I or I1 disease, but a few had locally ad- vanced cancer featuring ulceration, bleeding, or foul dis- charge. Some of them had distant metastases (stage IV).

RESULTS

As standard intervention, 299 patients had total mas- tectomy and axillary block dissection (64%) (Table 11).

Less radical operation (quadrantectomy + axillary block dissection) was carried out occasionally (9%) in patients with stage I disease [I], but its share has been increasing since Fisher’s [2] and Veronesi’s [3] publication of their results.

Associated Diseases

At the assessment of operative endurance, associated illnesses are to be considered. A significant number of patients (26%) had had medical treatment for certain symptoms of circulatory diseases. Several of them had been given antihypertensive therapy. For angina pecto- ris, 110 patients (22%) had had coronary-dilating treat- ment, but only five of them had gone through myocardial infarct. Forty-nine patients had complaints caused by de- creased cerebral blood perfusion. Thirty-two patients with diabetes mellitus received antidiabetic pills or in- jection (Table 111). Many patients suffered from two or even more of these disorders.

Total mastectomy and axillary block dissection were not suggested in cases of multiple associated diseases and low Karnofsky/Zubrod index. Thus, less radical op- erations were considered in most patients over age 80 years (Table IV).

Accepted for publication August 17, 1988. Address reprint requests to Egon Svastics, MD, National Oncological Institute, Rath Gyorgy 7, 1525 Budapest, Hungary.

0 1989 Alan R. Liss, Inc.

20 Svastics et al.

TABLE I. No. Elderly Breast Cancer Patients Treated Sureicallv

TABLE IV. Less Radical Surgery in Elderly Breast Cancer Patients

Age No. Percentage Age No./subtotal Percentage

70-79 years Over 80 Total

388 77

465

83.5 16.5

100.0

70-79 years Over 80 No ./Total

113/388 43/77

1561465

29 56 33

TABLE 11. Surgical Interventions in Elderly Breast Cancer Patients

TABLE V. Complications and Mortality in Elderly Breast Cancer Patients

Types of operations

Total mastectomy + Quadrantectomy + Wide excision Simple mastectomy Axillary block dissection" Total

axillary block dissection

axillary block dissection

No. Percentage

299 64

40 9 84 18 32 7 10 2

465 100

"This was performed in case of palpable axillary metastases in patients who had had simple mastectomy years before.

TABLE 111. Elderly Breast Cancer Patients' Associated Diseases

Tvoes of diseases No. Percentage

Hypertension Decompensation Coronary disease Cerebrosclerosis Diabetes mellitus Arteriosclerosis

obliterans Glaucoma Myocardial infarct Parkinsonism Other Total

131 133 110 49 32

27 6 5 4 4

501

26 27 22

Complications

It is also important to mention the operative morbidity. Although it is not an implicit complication, serum accu- mulation for more than a week was observed in 50 pa- tients (1 l %). Marginal or wide skin necrosis associated with superficial wound infection occurred in 11 cases (2%). Wound hematoma that needed evacuation devel- oped in three patients. With more emphasis on early postoperative mobilization, less thrombophlebitis and pneumonia would develop (Table V).

Mortality Only five patients (1 %) died because of various com-

plications (Table VI). All but one had locally advanced or metastatic cancer, and the type of surgical intervention was appropriate. One patient had mastectomy and axil- lary block dissection for her stage I1 breast carcinoma;

Complications No. Mortality

Long-lasting wound seroma Skin necrosis-wound infection Hematoma Thrombophlebitis Bronchopneumonia Renal failure Arteria cerebri media thrombosis Deep vein thrombosis-

Other Total

pulmonaIy embolisation

50 11 3 7 6 Death 1 1 Death 1 1 Death 1

2 Death 2 4

35 Death 5

insufficient suction drainage initiated a series of compli- cations that finally led to death.

DISCUSSION It is well known that the age-specific incidence of

breast cancer increases steeply after a perimenopausal plateau. Decreased immunosurveillance and cumulated exposure to carcinogens seem to be the most important factors in the elderly. Dietary fats, hormonal changes, and relative shortage of vitamins may also contribute to this higher incidence 141.

As life expectancy continues to increase, more and more elderly patients with breast carcinoma will be seen. Therefore, more attention should be given to this issue in the future. In elderly patients, due to negligence, breast cancer is often first diagnosed when it is in an advanced stage. However, development of tumor in elderly pa- tients is slower 151, estrogen and progesterone receptors tend to be positive, and the histopathological grading is often favorable [6 ] .

Life expectancy of elderly women according to Hun- garian statistical data is more than 10 years at age 70 and more than 5 years at 80; in the United States, the respec- tive data are 14.4 and 8.7 years 171.

Thus, surgical therapy should not be ruled out in elder- ly patients with cancer. The operative risk always has to be determined individually on the basis of the associated diseases, performance status, and stage of carcinoma, rather than simply on the number of years of life. After all, the "biological age" of the organism is of greater importance than is the chronological age. High-risk pa-

Treatment of Breast Cancer in Women 21

TABLE VI. Short Descriptive History of Deceased Elderly Breast Cancer Patients

85

83

71

83 Stage IV ulcerated tumor, bony metastases, toilet mastectomy, pneumonia, death on the 5th postoperative day

Stage IV locally advanced breast cancer + satellites, mastectomy + axillary block dissection, pneumonia, death on the 22nd postoperative day- thrombosis of the middle cerebral artery

Stage 111 ulcerated, bleeding tumor, simple mastectomy, died 3 weeks later in progressing renal failure

postoperative day thrombosis of the femoral vein, pulmonary embolization

hematoma, evacuation, wound infection, thrombosis of the femoral vein, pulmonary embolization, death on the 24th postoperative day

76

Stage 111, simple mastectomy, on the 18th

Stage 11, mastectomy + axillary block dissection,

tients should be screened out for more conservative sur- gery or, rarely, for nonsurgical therapy [7,8].

Wide excision of the primary tumor seems to be suf- ficient in high-risk patients with serious cardiovascular disease, diabetes, or impaired mobility due to obesity or limited contact with their surroundings, for example, be- cause of loss of hearing and/or vision. In case of bleed- ing, ulcerated, foul-discharging breast carcinoma, toilet mastectomy can be performed even if distant metastases are obvious.

Decision on treatment is usually made at the outpatient clinic after the first examination. During the 9 years of the present study, although 465 patients had operative treatment, surgery was withheld only in two cases. The operative mortality generally was not higher than 1% in this series, and some papers report even a zero operative mortality [7,9]. We lost only one stage I1 patient; her wound hematoma suppurated and an onsetting deep vein

thrombosis resulted in pulmonary embolism and led to death.

The other four deceased patients with stages I11 and IV disease had surgery for hygienic indication to avoid ul- ceration or for ulcerated, foul, bleeding breast carci- noma. Limited postoperative mobilization, and de- creased immune defense [lo] partly due to advanced cancer, may contribute to the development of complica- tions.

An operation not performed in stages I and I1 can be performed later only by taking higher risks. Surgical de- cision making in advanced cases therefore requires more attention.

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