Breast Cancer Over 70: How Much Treatment Is Enough?
Many women older than 70 can safely receive fewer treatments for early-stage breast cancer, a new study suggests.
Researchers found that adding lymph node removal or radiation to women's treatment did not seem to cut their risk of a breast cancer recurrence, which was low overall.
The findings, experts said, support existing recommendations to "de-escalate" those procedures for many older women.
The point is to spare them of side effects from treatments that are unlikely to bring benefits, said Adrian Lee, one of the researchers on the study.
In practice, though, many women continue to undergo the procedures, said Lee, an investigator with the Women's Cancer Research Center at the University of Pittsburgh Medical Center.
At issue are women aged 70 and up who have early-stage breast tumors that are estrogen-receptor positive -- meaning the hormone helps fuel their growth. Standard treatments include surgery to remove the tumor, followed by hormone therapy to reduce the chances of the cancer coming back.
"Our surgeries and hormone therapies today are very good," Lee said.
And that, he added, is likely one reason why those older women do not get added benefit from lymph node removal or radiation.
Beyond that, breast cancer after age 70 is often slow-growing, said Dr. Carla Suzanne Fisher, director of breast surgery at Indiana University School of Medicine, in Indianapolis.
Since older women's cancer is typically -- though not always -- less aggressive, additional therapies may be unnecessary, Fisher said.
Then there's the fact that women in their 70s and 80s commonly have other serious health conditions, like heart disease.
"These women generally aren't dying of breast cancer," Lee said. "They're dying of other causes."
The study was published online April 15 in JAMA Network Open.It included more than 3,300 women aged 70 and older diagnosed with breast cancer between 2010 and 2018. All had early-stage tumors positive for estrogen receptors. None had "clinical" signs that the cancer had spread to lymph nodes in the armpit, such as swelling.
Even with no such signs, it is possible that cancer cells have migrated to those lymph nodes. So doctors can check by doing a sentinel node biopsy, which involves removing the lymph node (or set of nodes) to which cancer cells are most likely to have spread.
But guidelines issued in 2016 recommend against routinely doing sentinel node biopsy in low-risk older women like those in the study. That's because of a lack of evidence it's helpful, and because the procedure can have side effects, like swelling, numbness and shoulder pain.
Yet, Lee's team found, 65% of their study patients underwent sentinel node biopsies, with no decline after the 2016 guideline.
Similarly, 54% of women underwent radiation, despite evidence from clinical trials that it can be safely skipped.
There was no evidence those procedures benefited women, the study authors noted.
Only a small percentage had a cancer recurrence in the five years after treatment. That happened in 3.5% of women who had a node biopsy, for example, versus 4.5% of those with no biopsy.
When Lee's team factored in other variables -- like women's overall health -- there was no evidence that node biopsies or radiation helped women avoid recurrences or live longer free of breast cancer.
Fisher, who is also with the American Society of Breast Surgeons, said she thinks the findings will help convince more doctors the procedures can be safely skipped.
"Omitting something can be difficult, for both doctors and patients," Fisher said. "It can be a difficult conversation when you're telling a patient, 'We used to do this, but we don't think it's necessary anymore.'"
Lee agreed that cutting back on common medical therapies is generally more challenging than adding new ones.
He and Fisher encouraged patients to ask questions about any recommended treatments, including whether they are necessary at all, and what the benefits and risks could be.
"We want to tailor treatment to individual patients," Fisher said. "So we need to keep going back to that two-way conversation."
The American Cancer Society suggests questions to ask your doctor about breast cancer treatment.
SOURCES: Adrian Lee, PhD, investigator, Women's Cancer Research Center, Hillman Cancer Center, University of Pittsburgh Medical Center, and director, UPMC/Pitt Institute for Precision Medicine, Pittsburgh, Pa.; Carla Suzanne Fisher, MD, MBA, associate professor, surgery, and director, breast surgery, Indiana University School of Medicine, Indianapolis, and incoming chair, communications committee, American Society of Breast Surgeons, Columbia, Md.; JAMA Network Open, April 15, 2021, online