Don’t Rule Out Breast Cancer Surgery for 90-Year-Olds

ORLANDO — Primary breast cancer surgery for nonagenarians in good physical shape was associated with improved survival compared with a non-surgical approach, retrospective data from a single center in Italy showed.

Among 123 breast cancer patients ages 90 and above, median overall survival from the time of diagnosis reached 54 months for those who underwent mastectomy or wide local excision as compared with 29 months for women treated conservatively (P<0.001), reported Massimo Ferrucci, MD, PhD, of Veneto Institute of Oncology in Padua, Italy.

And surgery was associated with a reduced risk of breast cancer-related death (P<0.01), according to findings presented during an oral session at the 25th annual meeting of the American Society of Breast Surgeons.

No significant survival differences were observed between the age-adapted and standard surgeries, Ferrucci said, but postoperative complications were higher with the standard approach. He concluded that the age-adapted approach should be the treatment of choice for this patient population.

“Nearly half of elderly patients with breast cancer receive suboptimal or unconventional surgical and systemic treatments,” said Ferrucci. “Despite pre-existing comorbidities and shorter life expectancy, 40% of women aged 80 or older with breast cancer die from cancer-related causes.”

The bottom line of the study is that “aging is not an illness,” he said, noting that despite their age the patient population still had good performance characteristics, with more than half having an (ECOG) Performance Status of 0-1.

“We don’t see many 90-year-old women in this good shape who are diagnosed with breast cancer,” session moderator Preeti Subhedar, MD, a breast surgeon who practices in Mount Kisco, New York, told MedPage Today.

“Nonagenarian women should also know that we do have very good non-surgical treatments for breast cancer that can help in controlling their disease,” said Subhedar, who was not involved in the research. “Of course, for women who are in good performance status, surgery should not be ruled out just because they are in their 90s.”

For their study, Ferrucci and his research team reviewed the medical records of nonagenarian patients treated at the Veneto Institute of Oncology and selected 123 consecutive patients that met the study criteria of having newly diagnosed stage I-IV oligometastatic breast cancer from January 2007 through December 2018. Their goal was to scrutinize the types of treatment the women received and determine which surgical strategy was associated with the best oncologic outcomes.

Patients included had a median age of 93 years (range 90-99), while 37% underwent standard surgery (n=45), 29% received age-adapted surgery (n=36), and 34% received no surgery (n=42). More than half had an ECOG Performance Status of 0-1 (53.6%) and a Karnofsky score of 80-100 (54.5%), while a little less than half had a Charlson Comorbidity Index score of 0-1 (47.1%). A majority had normal cognitive function (55.3%) and most had normal humoral status (70.7%).

The researchers determined that there was no statistically significant difference in overall survival (P=0.8) or in disease-free survival (P=0.4) between the standard and age-adapted surgeries. Among surgical patients, higher Charlson Comorbidity Index score was the only factor associated with worse survival (HR 1.21, 95% CI 1.01-1.44).

The majority of patients (58.6%) were diagnosed with stage II disease. Neoadjuvant hormone therapy was administered to 16% of patients, resulting in a partial response in 69.2% of cases and disease progression in the rest.

Of the 81 individuals who had some form of surgery, mastectomy was performed in 41% and the other 59% had a lumpectomy. In patients who underwent protocol-based surgery, 63% had mastectomy; 86.5% of patients having age-adapted surgery underwent a wide local excision.

Among standard-protocol surgery patients, sentinel lymph node biopsy was performed in 65.2% of cases, while direct axillary clearance was performed in 30.4%.

The overall postoperative complication rate was 53%, with breast seroma being the most frequent (24.7%).

For adjuvant therapy, about three-fourths received hormone therapy and while radiotherapy was recommended for 17% only about half of those patients received it, Ferrucci reported.

The overall recurrence rate among surgical patients was 12.3%, while the disease progression rate in the non-surgical group was 26.2%.

Limitations to the research included the single-center design and the possibility for selection bias.

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