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| COMMENTARY |
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| Year : 2014 | Volume
: 60
| Issue : 3 | Page : 232 |
Breast cancer in the Geriatric population
Akshita Singh, Vani Parmar
Department of Breast Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| Date of Web Publication | 14-Aug-2014 |
Correspondence Address:
Dr. Vani Parmar
Department of Breast Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
How to cite this article:
Singh A, Parmar V. Breast cancer in the Geriatric population. J Postgrad Med 2014;60:232 |
With an estimated 1.67 million new cases of breast cancer being diagnosed globally annually [1] and its rising incidence and prevalence in women above the age of 70 [2] , we have an ever increasing challenge ahead of us for its management in the geriatric population. Therapeutic dilemma in the elderly stems from factors such as an advanced stage at presentation, a poorer prognosis despite a favourable biological phenotype with indolent ER positive tumours, co-morbidities that may preclude use of all available treatment options, and an inherent bias on the part of the physicians and patient/relatives in not initiating aggressive or toxic treatment [3] It is in the light of the above mentioned facts that we attempt to review the paper by Tan et al. [4] The authors have studied a cohort of 192 women with breast cancer above the age of 80. Most were low grade, ER positive tumours, less than five cms as seen in the study population with a majority undergoing a breast conservation surgery and axillary dissection in a single operative setting. While this study confirms some long held beliefs regarding tumour characteristics in the elderly, it is lacking in both a robust study methodology, and inferences issues inherent to retrospective studies.
As pointed out correctly by the authors, a retrospective analysis with small numbers, limited follow up, excluded data on neo adjuvant treatment and a selection bias inherent to the study design are the predictable shortcomings of the paper. A significant amount of missing information across all study variables also weakens the paper further. Groups with severe, non severe and no comorbidities, surprisingly failed to reveal a difference in median survival, attributable in part, to the short follow up and small numbers in the study. Attempts to compare the surgically and endocrine treated groups are erroneous in view of dissimilar comorbidity scores, median age at presentation and hormone receptor status as is expected in a retrospective audit. The median survival between the two groups did not show any difference and the authors justify their finding while referring to the Cochrane review [5] stating that surgery does not result in a better overall survival when compared to endocrine treatment. They have however failed to observe that the studies included in this review are also fraught with similar problems of being underpowered with inconsistencies in treatment regimens.
The paper however raises the extremely fundamental issue of geriatric oncology and the challenges associated therein The use of overall survival as an endpoint in studies involving the elderly population needs to be reconsidered and the need to find a surrogate marker is compelling. Tools to assess individual life expectancies and discovering biomarkers for toxicity are imperative to avoid underutilization of chemotherapy/radiotherapy in the elderly in adjuvant setting. Comprehensive geriatric training and randomized clinical trials will aid in accurate and appropriate decision making. Age should stop being a determinant and a deterrent while finalizing treatment options, making way for performance status instead. It is time our resources and funds are employed to address the pressing needs of oncological care in the geriatric population.
| :: References | |  |
| 1. | Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. 
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| 2. | Balducci L, Ershler WB. Cancer and aging: a nexus at several levels. Nat Rev Cancer. 2005;5:655-62.
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| 3. | Singh R, Hellman S, Heimann R. The natural history of breast carcinoma in the elderly: implications for screening and treatment. Cancer 2004;1;100(9):1807-13.
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| 4. | Tan LHM, Bate J, McNamara K, Carmichael AR. Outcome of surgically treated octogenarians with breast cancer. J Postgrad Med 2014;60;248-53.
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| 5. | Morgan J1, Wyld L, Collins KA, Reed MW. Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database Syst Rev 2014; 5: CD004272.
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