Breast Cancer in Older Women

Locally Advanced Breast Cancer in the Elderly: A Major Challenge Requiring Effective and Appropriate Treatment

Aims and background

Breast cancer is the most common tumor in women. As the population above 65 years increases, breast cancer will be a more substantial problem for elderly patients. This work reports our experience in the management of stage III and IV locally advanced breast cancer.

Methods

Nineteen patients over 65 years of age (mean, 70.3 years) with stage III and IV breast cancers, treated between 1990 and 2000, are considered. The management and outcome are evaluated.

Results

Nine patients had stage IIIA breast cancer, 7 stage IIIB and 3 stage IV. Sixteen underwent Madden mastectomy and 3 simple mastectomy. Patients at stage HIB and 1 patient at stage IV with T4 tumor received neo-adjuvant chemotherapy. There were no significant postoperative complications. Sixteen patients were given tamoxifen and 10 patients adjuvant chemotherapy. Patients were followed for a median of 36.7 months (range, 6–72 months). In 8 patients with stage III disease, metastasis developed. Two patients had local recurrence of disease. Of the patients at stage IIIA, 6 were free from disease (one died from unrelated causes) and 3 had recurrent disease (2 died). Of the patients at stage IIIB, 2 are disease free and 5 had recurrent disease and died. Of the patients at stage IV, only one is alive.

Conclusions

Stage and individual characteristics of elderly women influence management. Patients should be managed adequately since most of them are fit enough to undergo treatment.

Purpose-in-Life and Breast Health Behavior in Hispanic and Anglo Women

Hispanic and Anglo women differ in their practice of breast health behavior. A likely factor is differences in purpose-in-life (PIL) that influence motivation to achieve goals. To determine the relationship between PIL and breast health behavior, the PIL Test was modified and translated into Spanish, and the Breast Health Behavior Questionnaire (BHBQ) was generated. Both Spanish and English versions of the PIL Test and the BHBQ were measured in 40 Spanish and 40 Anglo women ages 20 to 49. Cronbach’s alpha for the PIL Test were .86 for the English version and .72 for the Spanish; Cronbach’s alpha for the BHBQ were .78 for the English and .70 for the Spanish version. There was a significant relationship between PIL and breast health behaviors in Anglo women but not in Hispanic women. Findings suggest further study of PIL in Hispanic women and may indicate a need for teaching the benefits of self-regulation to maintain health.

A practical approach to geriatric assessment in oncology

More than half of new cancers are diagnosed in elderly patients, but data from randomized clinical trials do not represent the elderly population. Comprehensive geriatric assessment (CGA) can contribute valuable information to oncologists for risk stratification of elderly cancer patients. Functional impairments, frailty markers, cognitive impairments, and physical disabilities increase the risk for adverse outcomes during cancer treatment. Evidence is accumulating that selected elderly cancer patients benefit from CGA and geriatric interventions. However, perceived barriers to CGA include time, familiarity, cost, and lack of a well-defined procedure to interpret and apply the information. We present a model for rapid selection of elderly who would benefit from CGA using screening tools such as the Vulnerable Elders-13 Survey. We also define important geriatric functional risk factors, including mobility limitation, frailty, and dementia, and demonstrate how brief screening tests can make use of data realistically available to clinical oncologists to determine a stage of aging. Summary tables and a decision tree demonstrate how these data can be compiled to determine the risk for toxicities and to anticipate ancillary support needs.

Describing Elderly Women in Assisted Living’s Risk for Breast Cancer and Participation in Screening Behaviors

The purpose of this research was to provide descriptive information on elderly women’s breast cancer risk and their level of participation in breast cancer screening behaviors. Ninety-two women participated in the study; the mean breast cancer risk for five years was 2.4, and the lifetime mean risk was 4.4. An elevated five-year risk is a value greater than 1.7. The participants’ also provided information on their breast cancer screening behaviors. The modal response for participation in obtaining a medical checkup with a physician was six months or less. The modal response for obtaining a clinical breast examination was six months or less. These elderly women indicated a high rate of adopting breast cancer screening activities. Breast sonographers and mammographers have a unique opportunity to raise awareness with their elderly patients about breast cancer. Advocating screening measures and patient education are needed to assist elderly women in managing risk.

Older women and breast cancer screening: research synthesis

PURPOSE/OBJECTIVES

To identify the most beneficial ways to support older women as they make screening decisions using a systematic, epidemiologic, narrative review of research regarding benefits and burdens of breast cancer screening and treatment.

DATA SOURCES

Medical and nursing research databases emphasizing women aged 60 and older.

DATA SYNTHESIS

Older women can tolerate screening and treatment, yet they are underserved. The most frequently cited reason to explain this phenomenon is declining health status associated with aging. Research evidence does not support this claim. No evidence clearly describes relationships among health status, aging, and less screening or less aggressive treatment.

CONCLUSIONS

Older women experience varied health problems. However, indications that they are less able than their younger counterparts to tolerate screening or treatment for breast cancer do not exist.

IMPLICATIONS FOR NURSING

Further research in all aspects of breast cancer care in older women is required to define and describe risks and benefits of screening within a context of aging and changing health. Nurses should discuss the risks and benefits of screening with older women.

Quality of life among older survivors of breast cancer

This study investigated the relation among perceived social support, uncertainty, and quality of life in older survivors with breast cancer. Proposed hypotheses predicted a significant positive correlation between perceived social support and quality of life, and a significant negative correlation between uncertainty and quality of life. It also was hypothesized that perceived social support and uncertainty, considered together, could explain more quality-of-life variance than either variable considered independently. A sample of 103 breast cancer survivors older than 50 years completed the Social Support Questionnaire, the Mishel Uncertainty in Illness Scale - Community Form, and the Ferrans and Powers Quality-of-Life Index - Cancer Version. Data were analyzed using Pearson product-moment correlation, t tests, analysis of variance, and stepwise multiple regression. All the hypotheses were supported. Additional findings showed significant positive correlations between age and uncertainty, and between support network size and social support. Significant negative correlations were found between age and perceived social support, and between age and size of support network. Uncertainty increased in the presence of other diseases, which were associated with poorer quality of life. The study results underscore the importance of social support in reducing illness uncertainty and improving the quality of life for older survivors of breast cancer.

Hormone receptors and proliferation in breast carcinomas of equivalent histologic grades in pre- and postmenopausal women

Breast cancers in younger, premenopausal women are more likely to exhibit an adverse prognostic profile (including negative steroid hormone receptors and a high rate of cellular proliferation) and poor outcome than breast cancers in postmenopausal women. It has been hypothesized that this adverse prognostic profile is a result of the higher histologic grade of breast cancers in pre- compared with post-menopausal women. To assess the association of expression of steroid hormone receptors and indicators of proliferation while controlling for histologic grade, we identified 100 infiltrating ductal carcinomas from premenopausal women 45 years of age or younger and 100 from postmenopausal women 65 years of age or older. The carcinomas were selected so that the histologic grades (low versus high) were distributed equally between the 2 groups. Estrogen receptors (ER), progesterone receptors (PR), p27(Kip1) and Ki-67 (to measure rate of proliferation) were assessed by immunohistochemistry and compared between groups. Clinical information and survival data were also analyzed. ER content was lower and proliferation was higher in carcinomas in premenopausal women (p = 0.048 and p = 0.005, respectively). By univariate analysis, p27(Kip1) and PR were not different between the groups; however, in multivariate analysis, p27(Kip1) was higher in postmenopausal women, but only in a subgroup with highly proliferative carcinomas. Overall survival was similar in the pre- and postmenopausal women. Furthermore, low p27(Kip1) and African-American ethnicity predicted a poorer overall survival in the premenopausal, but not in the postmenopausal, women in our study. After controlling for histologic grade, a lower expression of ER and a higher proliferative index were detected in breast carcinomas in premenopausal women. Therefore, some prognostic indicators, such as ER and proliferative rate, may be more closely associated with menopausal status than histologic grade. Our data also suggest that some prognostic factors are not equally effective as predictors of survival in pre- and postmenopausal women.

Psychosocial stages and quality of life of women with breast cancer

Certain issues are universal for all women with breast cancer, irrespective of age, ethnic group, or stage of disease. Yet, along with common concerns, experiences, and anxieties, each woman may encounter a unique set of problems. Ultimately, each woman's adaptation and choices will be strongly influenced by her personal history, her psychosocial stage, and her life-cycle concerns. Changes in the criteria norms for the psychosocial stages of women's lives and their subsequent influence on quality of life are issues that have substantial implications for nursing and other healthcare professions. Younger and older women have different needs, concerns, and quality of life issues in a context of psychosocial life stages that have changed significantly across the post-World War II generations. The experience of breast cancer is perceived differently by women of distinct psychosocial life stages. At each critical life stage, the unique emerging problems require specific psychosocial supports that can reduce or avert the ensuing emotional distress. The planning and implementation of care must be tailored to address the differences demonstrated by age and psychosocial life stage, and to enhance quality of life outcomes for survivors of breast cancer, both young and old.

Cancer screening in the elderly population

This article reviews the current state of knowledge regarding cancer screening in the geriatric population. Care of the elderly requires knowledge of underlying physiologic changes, comorbidities, quality-of-life factors, and life expectancies. There is always the danger that ageism may prevent elderly cancer patients from receiving the proper treatment. On the other hand, overzealous treatment can lead to adverse results if elderly patients are not properly targeted based on current evidence of the benefits and risks of specific screening practices.

Pain, cancer, and older adults

Pain is the most common symptom associated with cancer. Despite the fact that appropriate pain management exists, cancer pain often is inadequately controlled. Sixty percent to 85% of individuals with advanced cancer have either severe or chronic pain. Issues associated with cancer pain and pain management in later life include the effect of pain on the person, friends, and family; the influence of hope; the perception that older adults are less sensitive to painful stimuli; the special problems of drug management in older adults; and the unique issues of older women affected by cancer. This article concludes with implications for nurses. Future research needs to be directed to pain management at home, the ethics of pain management, pain in the cognitively impaired person, and the specific needs of older women.