Of late there has been some debate around radiation as an effective breast cancer treatment for elderly patients.
The debate has developed as a result of a study1 published in January this year that said despite 2004 research2 that showed that surgery and tamoxifen alone are nearly as effective as when radiation is added to the mix, 61,7% of breast cancer patients between 2005 and 2009 were still treated with radiation. Which is not far from the 68% who were treated with radiation between 2000 and 2004 – before the study was released.
The 2004 study (published in the New England Journal of Medicine) also showed that five years after surgery, the women who received both tamoxifen and radiation had only a 1% greater chance of avoiding a mastectomy. And there was only a 1% greater chance of recurrence for women taking medication only (with no radiation). In terms of survival rate – the probability of being alive during the same time period was also only one percent higher with radiation than without.
It is worthwhile to note that the women in the 2004 study were 70 years of age or older. Their cancer was detected early. The tumours were small (2 cm or smaller) and they had not spread into the lymph nodes. The breast cancer was estrogen-receptor positive (which includes about 9 out of 10 breast cancers at that age. )
So why are elderly women still being treated with radiation? Are the doctors being overly cautious? Is this justifiable or are they unneccesarily adding to a stressful, expensive and physically trying process?
Side effects of radiation include armpit discomfort, fatigue (which can sometimes take up to a year to dissipate), heart and lung problems (especially if the site of the radiation is on the left, over the heart), chest pain and lowered white blood cell counts. There can also be scarring and discolouration of the breast area which can be permanent. In essence, while radiation is a vital and highly effective treatment for cancer, it is not something to be embarked on if it can be avoided.
As a surgeon who has worked in the field for 27 years, I truly believe that research is a guide and each patient needs to be seen as an individual case. We cannot treat everyone the same way. As we know, cancer treatment (success and side effects) can differ radically from person to person. Bodies react in their own way to the combination of treatments the doctors prescribe. Throw into that mix elements like the overall health of the patient, their medical history, their genetics and you really can see how treatment has to be individualized.
Risk of breast cancer increases with age and treating elderly patients can often be tricky when you take into account their physical well-being. A patient who has long life expectancy due to genetics and overall good health should be given all treatments that they can afford and that their bodies can handle – including radiation. If there is long life expectancy then the cancer should be treated aggressively (as we would do with much younger patients who have breast cancer). While a patient who is at greater risk for other ailments like heart disease or a stroke, who doesn’t have a very long life expectancy, should not be given radiation. In this case it would be unneccesary and could do more harm than good.
The side effects of the treatments can be detrimental to even the young and fit, making them that much harder to manage when the body is older. It’s an ongoing balance the patients have to manage closely with their doctors and factors to be considered over and above side effects are: the ability to self manage regular medications, support systems at home and, often whether they are fighting more than one major health issue at the same time.
Older women are at greater risk of developing breast cancer but with early detection and carefully managed treatment breast cancer therapy in the elderly can be particularly rewarding as good results are often easily obtainable with less aggressive therapy than in younger patients.
1 US National Library of Medicine: The use of adjuvant radiotherapy in elderly patients with early-stage breast cancer: changes in practice patterns after publication of Cancer and Leukemia Group B 9343. January 2015. http://www.ncbi.nlm.nih.gov/pubmed/25488523
2 New England Journal of Medicine: Lumpectomy plus Tamoxifen with or without Irradiation in Women 70 Years of Age or Older with Early Breast Cancer. September 2004 http://www.nejm.org/doi/full/10.1056/NEJMoa040587
By Dr Justus Apffelstaedt, specialist surgeon with an interest in breast, thyroid and parathyroid health as well as soft tissue surgical oncology.