Oncoplastic surgery and breast reconstruction in the elderly: an unsolved conundrum

Introduction

Breast cancer has become the most prevalent cancer in women in high income countries due to improved detection rates and more effective treatments. As of the end of 2020, there were worldwide 7.8 million women alive who were diagnosed with breast cancer in the past 5 years, making it the world’s most prevalent cancer (1). Additionally, a large increase in the aging population is directly proportional to an increase in the absolute number of breast cancer cases in higher age groups (2). Chronological age should not prevail in decision-making about treatment, and we should not forget that older patients are under-represented in clinical trials with the subsequent low evidence level supporting decisions in this age group (3).

Geriatric assessment and competing causes of death should be a mandatory part of the older breast cancer patient pathway (3).

Over and undertreatment are always a delicate balance, particularly in this age group. However, we should not forget that a 70-year-old fit woman has, nowadays, a median life expectancy of additional 15 years at least, in high income countries (4). This means that many 70 years old women can carry the burden of overtreatment without the benefit of improved overall survival or better quality of life (QoL), for a long period of time. On the other hand, older women experience higher mortality from early breast cancer when they are undertreated (5) This is particularly true, regarding locoregional treatment for women over the age of 80, who are less likely to receive any form of surgery or adjuvant radiation as compared to those less than 75 years old (6).

As previously considered, many factors should be taken into consideration when proposing breast cancer surgery in a woman in this age group. A geriatric screening can be quickly performed identifying women that will need a further comprehensive geriatric assessment and a life expectancy estimation using one of the multiple available tools (3).

Although staging is usually higher in older women due to the absence of population-based screening, early breast cancer is still the most common form of presentation, with the majority being stage I or II amenable to breast conserving surgery with good cosmetic outcomes (7).

However, in some cases, classic breast conserving surgery will not be feasible, and using oncoplastic breast conserving techniques or a mastectomy with reconstruction could be a good alternative, but both settings are frequently debated and underused in this older population (8).

The purpose of the current work was to review the most relevant literature analysing surgical strategies in older women trying to obtain some evidence to support the use of oncoplastic procedures and breast reconstruction in this specific age group.

Review process

Search was undertaken by authors C Mavioso and C Pereira using Medline and Scopus from 1990 until 2022 including all papers published in peer-reviewed journals with retrospective series and prospective cohort studies that would include breast cancer surgical treatment with some form of reconstruction, partial or total, immediate or delayed in older women with or without comorbidities.

Rarity and heterogeneity of available studies

Most studies published about reconstructive surgery in older women are retrospective and use different definitions for old age. This heterogeneity in the definition of old leads to difficulty in comparison of outcomes, mainly when chronological age is the only factor considered.

Using the recent updated recommendations from the EUSOMA-SIOG joint paper, old age should be defined as ≥70 years old (3). For every old breast cancer patient, a geriatric screening test should be undertaken before any treatment to determine if the patient is fit or frail. If frailty is diagnosed, a complete geriatric assessment should then follow, accompanied by a life expectancy calculation.

Regarding oncoplastic breast surgery, even the retrospective evidence in old age is almost non-existent (8-10). Even with large enough datasets like the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), the retrospective nature of the studies without correction for obvious bias (e.g., that women choosing to undergo oncoplastic breast surgery will be less frail than women who opt for having a classic breast conserving surgery) will have a striking impact on the conclusions (10).

The same happens in all studies regarding post mastectomy breast reconstruction (PMBR), where again, heterogeneity and selection bias are constantly reported (Table 1).

Oncoplastic surgery

The lack of evidence in the literature regarding oncoplastic surgery in the elderly reflects the underuse of these techniques in this age group (8).

Chronological age remains the most important factor in determining whether a patient will be offered an oncoplastic procedure including breast reconstruction (8,27,31,32).

The main reasons could be the lack of patient education about oncoplastic breast surgery and surgeon bias in selecting a procedure taking into account patient’s age. The risks of additional surgery, complications, longer hospital stays, further hospitalizations and uncertain outcomes may outweigh the potential benefits in terms of cosmesis and QoL in these patients. This may also reflect an attitude that body image is less important to this older population due to societal and cultural issues (27,31-34).

Published studies regarding oncoplastic surgery in the elderly suggest that these techniques are feasible and well tolerated despite patient age, although the available evidence is very scarce (9,35). Complication rates, length of stay and recovery time were comparable to younger patients and without any delay to adjuvant radiotherapy (RT). The risk of severe complications seems to be more related to patients’ co-morbidities and not to age itself (10).

Oncoplastic procedures may have a potential advantage in this population (8,9). Elderly patients have a higher prevalence of large tumors at presentation (36) and are more likely to have fatty breasts. For large and poorly located tumors (i.e., inferior quadrants) older patients may have a better cosmetic result from a mammoplasty than from mobilization of breast tissue to fill the defect left by a wide local excision (8).

Oncoplastic breast conserving surgery encompasses several techniques, from simple and small tissue transfer to larger mobilizations, local perforator flaps and therapeutic mastopexies and mammaplasties. Each of these very useful types have diverse complications rates that remain very low when compared to classic breast conservation (10). However, higher age was an independent predictor of overall 30-day complications in the large retrospective review of the ACS NSQIP by Angarita et al. in 2018 (17).

Given the limited evidence for specific use of oncoplastic techniques in older patients, clinicians need to individualize treatment options considering patients expectations and preferences as well as their overall status (acute and chronic medical conditions, nutritional status and level of activity), as co-morbidities, not chronological age, seem to be the determinant factor of 30-day morbidity rate (9,10,37).

PMBR

As expected PMBR is also less frequently performed in older patients than in younger women. As published in 2017 by Gibreel et al. from the retrospective analysis of the National Cancer Data Base (NCDB) there were 364,767 patients who underwent mastectomy, of whom 127,501 (35.0%) had immediate breast reconstruction (IBR). Among mastectomy + IBR (M + IBR) patients, 10.3% were age 65 or older and only 1.5% were 75 or older (20).

From the available literature based almost entirely on retrospective reviews, the conclusion is that PMBR should not be denied based on age, as the rate of complications and patient reported outcomes are not worse when compared to the ones observed in younger women (Table 1).

However, as previously referred, the heterogeneity of the before mentioned studies is obvious due to their retrospective nature and the consequent selection bias. Patients proposed for PMBR are more likely to be younger and fitter (16). Age comparators are also heterogeneous between published studies, but reconstruction rates drop dramatically above 75 years old, and the rate of complications raise accordingly (21,29).

From all the papers revised, none of them excludes patients based on age. In fact, a consensus emerges in not using chronological age as a contraindication and, still, it remains unclear the reasons why so few elderly patients undergo PMBR.

As life expectancy and QoL rises, with many elderly patients still vital and healthy with an active socio-economical life, the possibility of an increased demand of PMBR is expected (24). Older patients that have co-morbidities can also be candidates for reconstruction because available support and treatment to optimize these co-factors have also improved greatly.

The type of PMBR is not consensual or uniform in its application, neither in type of surgery nor on its timing.

PMBR can be performed in an immediate setting (IBR) or delayed [delayed breast reconstruction (DBR)], the reconstruction can either be autologous, implant-based or a combination of both.

Usually in elderly patients the most frequent reconstruction choice according to published retrospective studies is an implant-based choice, using one stage strategy or, more frequently, with multistep expander-implant and lower use of autologous reconstruction (24).

Several factors can determine the choice for reconstruction, the timing, and the technique to be used.

Patient factors like personal preference, age, demographics, co-morbidities, American Society of Anesthesiologists (ASA), physical status, body mass index (BMI), smoking status, contralateral breast appearance, tumor stage and biology, co- or neo-adjuvant therapies, type and timing of reconstruction influence the reconstruction decision in general, as well as in older patients (11,12,28).

No less important is the type of hospital facility patients have access to and the availability of PMBR (11,26). Surgeons’ factors like less experience can influence the presumption that older patients do not tolerate longer surgeries as much, the fear of increased of complications and poor outcome (13,26,38). In fact, maybe due to less access of other sources of information, elderly patients tend to rely more in their surgeon’s opinion, and the way the surgeons present the reconstruction options also positively or negatively influences the patient’s choice (27).

In one stage implant-based reconstruction, some authors recognize an oriented choice considering breast size, the use of skin or skin and nipple sparring mastectomy, implant pocket (sub-muscular or acellular dermal matrices), the need of adjuvant RT and contralateral breast appearance (24). The one factor that most influences surgeons to not choose implant-based IBR is the use of RT as adjuvant treatment (39).

Autologous reconstructions are less frequent despite the fact that they usually have better aesthetic outcomes and less complication rates, when considering only chronological age and not associated comorbidities (11,14) The use of local flaps fascio cutaneous flaps, Goldilocks technique, latissimus dorsi (LD) flap and transverse rectus abdominis myocutaneous (TRAM) flaps are the most commonly used (30). Very scarce literature is published concerning free flaps, Dejean et al. (40) published the experience of deep inferior epigastric perforator (DIEP) flaps, finding similar results in success and complications comparing young and older patients. The limited literature including free flaps in old age as similar conclusions, attributing however greater satisfaction scores to the latter in most of the articles consulted (13,18,19,27,38).

A systematic review published by Oh et al. (22) about PMBR in general included 10 studies reporting complication rates in women over 60 years old. In this review, the overall rate of complications varied between 6.8% and 54.8%, values possibly related to the heterogeneity of the included patients and the different definitions of old age.

In most published studies, older patients have comparable outcomes to younger women with no significant differences in 30-day morbidity rates (9,13,22,33,41,42).

Although complication rates do not seem to be related with chronologic age alone, there have been reported higher rates of postoperative events including bleeding requiring reoperation, and higher unplanned readmission rates in elderly women submitted to breast reconstruction compared to younger patients, particularly when co-morbidities are taken into consideration (13,15,23,30).

Patient reported outcomes in oncoplastic and reconstructive breast surgery

In older breast cancer patients, the most valued driver of choice in breast cancer surgery regarding reconstruction options should be patient preference, after a careful geriatric assessment and life expectancy calculation. Most of the women who deny breast reconstruction surgery, make this decision based on more than one reason. Fear of undergoing a more complex with more pain and higher complication rate are the most frequently described reasons for the refusal of breast reconstruction (25).

Few studies focused on the QoL and body image of older breast reconstruction patients using patient-related outcome measures (PROMs) (33,41,43). These studies are limited because the authors tend to use a broad QoL score to measure multidimensional concepts such as mental health and body image. Nevertheless, body image seems to be important to breast cancer patients regardless of age and concerns about body image that are exacerbated in women who receive mastectomies without reconstruction (7). Breast-related psychosocial well-being and satisfaction with the outcome of breast reconstruction seems to be independent of age (43).

Concerning the type of reconstruction, Girotto et al. assessed outcomes with the use of a self-reported questionnaire (SF-36) addressing health-related QoL, body image and physical functioning (41). The authors observed that elderly patients reconstructed with autologous tissues had better outcomes than patients reconstructed with implant-based techniques due mainly to physical pain and role limitations (41).

To achieve better patient-related outcomes, the treatment of older patients must be individualized. Figueiredo et al., in a study that included a longitudinal cohort of 563 women with 67 years old or older, concluded that if women’s preferences about appearance were discordant with the type of treatment they received, they had poorer body image, mental health and QoL outcomes (44).

Conclusions

Due to the retrospective nature of all the analyzed studies, and its inherent selection bias, it is difficult to conclude that oncoplastic surgery and PMBR are safe alternatives to classic breast conservation and mastectomy without reconstruction.

We can conclude, however, from the reviewed publications, that the indication for the use of oncoplastic surgery or PMBR in older patients, should not be based in chronological age alone but in a comprehensive evaluation including geriatric assessment, life expectancy calculation and patient preference.

It is true that we lack prospective randomized trials in older women, but it is highly unlikely that these trials will happen with a traditional design due not only on to the difficulty in recruiting the necessary number of patients that will allow a meaningful result but also because some treatment options are no longer ethically susceptible to randomization. Large and well-structured prospective cohorts could be a valuable alternative to retrospective analysis.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Kwok-Leung Cheung) for the series “Diagnosis and Treatment on Primary Breast Cancer in Older Women” published in Annals of Breast Surgery. The article has undergone external peer review.

Peer Review File: Available at https://abs.amegroups.com/article/view/10.21037/abs-21-137/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://abs.amegroups.com/article/view/10.21037/abs-21-137/coif). The series “Diagnosis and Treatment on Primary Breast Cancer in Older Women” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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