Diagnosis and treatment on primary breast cancer in older women

The global population is ageing and older age is a major risk factor for breast cancer. When our group describes our research programme aiming to personalise the management of primary breast cancer in older women, we highlight the importance of looking at tumour biology, which appears to differ due to age (1). In order to optimise the care of this population, it is paramount that we continue with our efforts in improving the diagnosis and treatment. It is with this vision in mind that we publish a series covering a number of less thought about areas under this theme.

Lemij and colleagues in the Netherlands describe the problem as a global challenge from an epidemiological perspective (2). Breast cancer is the most commonly diagnosed malignancy among women, with more than 30% of all patients being over 70 years at the time of diagnosis. The number of older women with breast cancer is expected to increase in the upcoming decades due to the ageing of the population worldwide. Unfortunately, this heterogeneous older population is under-represented in clinical trials. Most older women with breast cancer present symptomatically and mammographic screening remains debatable. Evans discusses its pros and cons, stressing that there is currently no conclusive evidence of a reduction in breast cancer mortality with screening (3). Definitive evidence may come from the AgeX trial in the UK which is due to report in 2026. Another area of interest seldom talked about in this population is genetic testing. Chang describes a 1% detection rate of BRCA1/2 mutations in women older than 65 years of age and highlights the lack of current guidelines on genetic testing and intervention, such as prophylactic mastectomy, in this population (4).

On the treatment front, there are three articles (5-7). One looks at the lack of literature in the subject of oncoplastic surgery, which has been increasingly performed in younger women undergoing breast conserving surgery. This is in keeping with a recent publication from our group identifying a lower uptake of oncoplastic surgery in the older population (8). We also have two important articles describing the role of the geriatrician and the perspective of the patient. Traditionally the treatment of cancer is looked after by the oncologist (surgical, radiation and medical) but in this specific population where frailty assessment, decision making, treatment goals (preservation of function and quality of life as opposed to prolongation of survival) all matter, and the help of geriatric assessment will become extremely useful (6). Turner’s article is extraordinary and thought-provoking (7). It is the only one in this series written by a patient, who also describes the experience of her mother-in-law when she was undergoing treatment for a triple negative breast cancer.

Finally, I would like to draw readers’ attention to the latest recommendations on the management of breast cancer in older women, published jointly by the European Society of Breast Cancer Specialists (EUSOMA) and the International Society of Geriatric Oncology (SIOG), another example of ‘co-management’ of an older cancer patient, by oncology and geriatrics (9). While we strive our efforts on research, we must continue to appraise available evidence and recommend what clinicians (and patients!) could do every day.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Breast Surgery for the series “Diagnosis and Treatment on Primary Breast Cancer in Older Women”. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://abs.amegroups.com/article/view/10.21037/abs-23-52/coif). The series “Diagnosis and Treatment on Primary Breast Cancer in Older Women” was commissioned by the editorial office without any funding or sponsorship. K.L.C. served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Annals of Breast Surgery from August 2022 to July 2024. K.L.C. has provided consultancy to Roche UK and received travel grant from Cancers. The author has no other conflicts of interest to declare.

Ethical Statement: The author is 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/.

References

1. Parks RM, Green AR, Cheung KL. The impact of tumour biology on the management of primary breast cancer in older women—based on a research programme in Nottingham. Ann Breast Surg 2021;5:5. [Crossref]
2. Lemij AA, Bastiaannet E, de Glas NA, et al. Breast cancer in the older population: a global challenge—an epidemiological perspective. Ann Breast Surg 2023;7:17. [Crossref]
3. Andy Evans A. The pros and cons of breast screening in older women. Ann Breast Surg 2024;8:10.
4. Chang YK, Kwong A. Does genetic testing have any role for elderly breast cancer patients? A narrative review. Ann Breast Surg 2022;6:34. [Crossref]
5. Mavioso C, Pereira C, Cardoso MJ. Oncoplastic surgery and breast reconstruction in the elderly: an unsolved conundrum. Ann Breast Surg 2023;7:37. [Crossref]
6. Festen S, de Graeff P, Rostoft S. The role of the geriatrician in the care of older patients with breast cancer: a review. Ann Breast Surg 2023;7:29. [Crossref]
7. Turner S. “The perspectives of the patient and her carer” for the upcoming series “Diagnosis and Treatment on Primary Breast Cancer in Older Women”. Ann Breast Surg 2023;7:10. [Crossref]
8. Chia Z, Lee RXN, Cardoso MJ, Cheung KL, Parks RM. Oncoplastic breast surgery in older women with primary breast cancer: a systematic review. Br J Surg 2023;110:1309-15. [Crossref] [PubMed]
9. Biganzoli L, Battisti NML, Wildiers H, et al. Updated recommendations regarding the management of older patients with breast cancer: a joint paper from the European Society of Breast Cancer Specialists (EUSOMA) and the International Society of Geriatric Oncology (SIOG). Lancet Oncol 2021;22:e327-40. [Crossref] [PubMed]

Kwok-Leung Cheung