Breast cancer treatment in older women

Trends in immediate breast reconstruction and early complication rates among older women: A big data analysis

BACKGROUND

Although approximately 57% of breast cancer (BC) diagnoses are in older patients (>60 years), only 4.1-14% receives breast reconstruction (BR). This has been attributed to physician concerns about operative complications. This paper aims to: 1) analyze the 30-day complication rates in the older patient population undergoing immediate breast reconstruction (IBR); and 2) analyze links between complication type and category of reconstruction.

METHODS

Using the ACS-NSQIP database (2005-2014), all women older than 60 years of age diagnosed with BC and DCIS were identified. IBR and complication rates were plotted for all ages. Patients were divided into those with and those without complications. Patient demographics and co-morbidities were compared. Complications within each type of reconstruction were analyzed.

RESULTS

Of the 4450 BC and 1104 DCIS patients, 22.3% (BC) and 20.9% (DCIS) had complications. IBR decreased significantly with increased age (P < 0.00 in both cohorts), while complication rates remained stable across all ages (P = 0.32 in BC, P = 0.69 in DCIS patients). Patients were well matched in terms of demographics.

CONCLUSIONS

The rates of breast reconstruction decrease with increasing age. Despite increasing age, associated complication rates in IBR patients remained stable.

Assessing the impact of a cooperative group trial on breast cancer care in the medicare population

PURPOSE

The Cancer and Leukemia Group B (CALGB) C9343 trial found that adjuvant radiation therapy (RT) provided minimal benefits for older women with breast cancer. Although treatment guidelines were changed to indicate that some women could forego RT, the impact of the C9343 results on clinical practice is unclear.

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare data set to assess the use of adjuvant RT in a sample of women ≥ 70 years old diagnosed with stage I breast cancer from 2001 to 2007 who fulfilled the C9343 inclusion criteria. We used log-binomial regression to estimate the relation between publication of C9343 and use of RT in the full sample and across strata of patient and health system characteristics.

RESULTS

Of the 12,925 Medicare beneficiaries in our sample (mean age, 77.7 years), 76.5% received RT. Approximately 79% of women received RT before study publication compared with 75% after (adjusted relative risk of receiving RT postpublication v prepublication: 0.97; 95% CI, 0.95 to 0.98). Although use of RT was lower after the trial within all strata of age and life expectancy, the magnitude of this decrease did not differ significantly by strata. For instance, among patients with life expectancy less than 5 years, RT use decreased by 3.7%, from 44.4% prepublication to 40.7% postpublication. Among patients with life expectancy ≥ 10 years, RT use decreased by 3.0%, from 92.0% to 89.0%.

CONCLUSION

The C9343 trial had minimal impact on the use of RT among older women in the Medicare population, even among the oldest women and those with shorter life expectancies.

Breast Cancer Reconstruction in the Elderly

Mastectomy is a surgical choice for breast cancer, yet breast reconstruction is underused in women older than age 60 years. Because of a paucity of information examining breast cancer reconstruction in the elderly, we sought to review our experience. By retrospective chart review, we evaluated 89 women older than 60 years having mastectomy and reconstruction from January 1998 to June 2008. Mean patient age was 65 years (range, 60 to 74 years). The majority (41%) had Stage 1 disease or Stage 2 (30%). Ductal carcinoma in situ comprised 25 per cent and Stage 3 totaled 2 per cent. Mastectomy for ipsilateral breast tumor recurrence after radiation therapy and lumpectomy comprised 11 per cent. Most underwent immediate breast reconstruction (89%). Reconstructive techniques included two-stage implant (58%), transverse rectus abdominus musculocutaneous (TRAM) flap (10%), latissimus dorsi musculocutaneous flap with implant (2%), or deep inferior epigastric perforator flap (1%). Complications included a 12 per cent infection rate, removal of two expanders resulting from exposure, one TRAM failure, and one TRAM required debriding. Four patients undergoing mastectomy with tissue expander had radiation resulting in one expander being removed. One local skin recurrence was treated with removal of implant and skin resection. Two patients have died from metastatic disease. Age should not be a contraindication for breast reconstruction in elderly women.