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Home » Breast Cancer, EU Health, Health, Healthcare Policy

Elderly women with breast cancer have worse outcomes

Submitted by on 14 Jul 2017 – 09:20

Though almost half of women dying from breast cancer are aged 75 or above, the screening upper age in Europe never exceeds 75. Carole Mathelin, Vice President for Europe, International Society of Senology, et al, recommend that information campaigns on breast screening and examination must be strengthened to change the state of breast cancer care for the elderly

Breast cancer is the most common malignancy among women worldwide, particularly in developed countries. In 2012 in the European Union, it represented 30% of the newly diagnosed cancers and was responsible for 16% of the cancer mortality.

While it is well known that age is the largest risk factor of breast cancer – incidence grows with age, and the over-mortality among elderly women due to breast cancer is largely unknown. Indeed, the specific mortality associated with breast cancer increases with ageing. Almost half (45%) of the women who die from breast cancer are aged 75 or over.

Moreover, the difference between young and older women is spreading and epidemiological estimations show that after 65, both mortality and breast cancer incidence are constantly up, whereas before 65 they are starting to decrease. In this context, it is well known that Europe’s population is getting older. It is estimated that, between now and 2050, its population of over 65 is set to increase from about 19% to about 28%. It seems therefore clear that breast cancer, which right now is already a major public health concern, will become more important in the future and will therefore become more central in the medical practice of the future.

Yet an analysis of the international scientific literature reveals facts that are somewhat paradoxical. On the one hand, ageing appears to be associated with increased favorable biological and histological characteristics. On the other hand, the clinical data show that the disease is more advanced: tumors are larger in size, lymph nodes are more often affected and metastases are more frequently diagnosed. How can this apparent contradiction be explained?

It is well known that ageing leads to a decreased protection against cancer. Indeed, age is associated with a decreased immunological response – not only to infections but to cancers too – and this is called immunosenescence. The body’s tissues are more exposed to environmental carcinogens and the DNA reparation systems are less effective.

In addition to these general physiological modifications, with ageing some breast-specific modifications are observed. While older age is associated with lower levels of circulating estrogens, in the elderly breast epithelial cells become more sensitive to estrogens. Furthermore, with advancing age the mammary gland becomes “fattier” – i.e. breast tissue is progressively replaced with adipose and conjunctive tissue – leading to increased intra-mammary estrogens production.

Such “fatty” transformation of the breast allows for easier clinical and radiological examination. In addition, with advancing age the breast cancer micro-environment changes, which could also explain why less aggressive breast carcinomas spread more easily. The biological mechanisms essential for understanding this apparent paradox are at the moment the object of fundamental and translational research. However, society-related mechanisms also exist.

Today, the general population of most European countries undergoes screening for breast cancer as an established practice. The screening upper age varies in the different countries, however it never exceeds 75. Hence, none of the E.U. member states’ breast cancer screening programme includes elderly women.

Moreover, participation rates in such programmes – be them national or at the individual level – are heterogeneous, sometimes insufficient and decrease with advancing age. This leads to a huge discrepancy between breast cancer screening and the high incidence among elderly women.

Some – including health professionals – may mistakenly interpret the exclusion of the elderly from the screening as justified by a lower-risk situation, which is not. Similarly, clinical breast monitoring in elderly women is not performed sufficently. For example, only about half of physicians perform breast clinical examination on elderly women. This omission may lead to late diagnosis with more advanced local lesions and more likely tumour extension to lymph node or metastasis.

Furthermore, the common thinking can also be misleading; it is not uncommon to hear that in older patients “cancer progresses slowly” and “does not kill”. Such lingering dogmas contribute to aggravating the problem as they delay provision of the necessary medical care.

These ill-conceived assertions are easily contradicted by the documented scientific evidence. In addition, up until 85 years, the leading cause of mortality in elderly women with breast cancer is the cancer itself and not co-morbidity. In this respect it can be affirmed that a part of the medical community, patients and the society are generally either badly or not informed at all.

Epidemiological and societal data indicate that in most European countries breast cancer in elderly women is not always properly managed. Ideally, the physiological age should be considered rather than chronological age.

We suggest that information campaigns should be held and training on breast clinical examination for physicians and caregivers in general be strengthened. Also, women over the upper age limit for screening programmes should be not only allowed but also encouraged to undergo individual screening, both clinical and mammographic, if they so wish.

This article was co-authored by Massimo Lodi, Louise Scheer and Andrea Lodi.