Abstract
Objectives: With respect to breast cancer in the elderly, to define “old” in the context of comorbidity and physiologic rather than chronologic age. In addition, after discussion of factors influencing decisions regarding screening, stage at presentation and treatment decisions, to present an approach to the treatment of primary breast cancer in the elderly, taking into account quality of life, expected outcomes and cost-effectiveness.
Data sources: A review of the medical literature from 1980 to 1996, using the MEDLINE database and 2 relevant studies from The Henrietta Banting Breast Centre Research Programme at Women’s College Hospital, Toronto.
Study selection: A large number of breast cancer studies that might provide a better understanding of primary breast cancer in the elderly.
Data synthesis: The studies reviewed demonstrated that the annual incidence of breast cancer increases with age, along with a longer life expectancy for women. There appears to be a delay in presentation for elderly women with breast cancer, related in part to patient and physician knowledge. Biennial mammography and physical examination are effective in women aged 50 to 74 years, but compliance with screening recommendations decreases with age. Although treatment goals are the same for women of all ages, most treatment decisions are based on studies that seldom include women over 65 years of age. Physicians tend to underestimate life expectancy and older women are less likely to seek information. Breast conserving surgery, partial mastectomy and even axillary dissection can be carried out under local anesthesia with little physiologic disturbance, but unless axillary dissection is required to make a treatment decision, it may be foregone in clinically node-negative elderly women. The role of adjuvant radiotherapy in the elderly is not yet well established; tamoxifen is the usual adjuvant systemic therapy given to older women. For those who are truly infirm, tamoxifen alone can be considered. Studies to date do not clarify whether breast cancer in older women runs a more or less favourable course. However, locoregional recurrence appears to decrease with age. Deaths from competing causes are a confounding issue.
Conclusions: It is imperative to develop a coherent strategy for the treatment of primary breast cancer in the elderly that takes into account functional status and quality of life. Clinical trials must include older women and there must be good clinical trials designed specifically for older women.
If our concepts concerning breast cancer were derived solely from the cover picture in Time magazine or The New York Times, we would believe that breast cancer is solely a disease of the young and beautiful. However, data from the Surveillance, Epidemiology and End Results (SEER) study have given us a different and much more accurate perspective: the annual incidence of breast cancer increases with age, thus for a woman aged 65 years breast cancer is 3 times more likely to develop in the coming year than for a woman of 45 years.1 Thus, between the ages of 30 and 80 years, the annual incidence of breast cancer rises from 1:5900 to 1:290.2,3 It has been estimated that by the year 2030, almost two-thirds of the women in whom breast cancer is diagnosed will be 65 years of age or older.4
It has been stated5 that 18 600 cases of breast cancer will be diagnosed in Canada in 1996, and of these 10 900 (58.6%) will be in women 60 years of age and older, and 3500 (18.8%) in women between 50 and 59 years of age. With respect to the death rate, it is estimated that 5300 women will die of breast cancer in Canada in 1996; 3700 (69.8%) of these will be 60 years of age or older and 810 (15.3%) will be aged 50 to 59 years. The incidence of breast cancer in Canada has risen steadily over the past decade,5 attributed by many to increasing mammographic surveillance. However, a substantial proportion of this increase occurred in women above the age targeted in most breast cancer screening programs. There has been considerable interest in primary breast cancer in the elderly, and a number of investigators have addressed aspects of this problem.6–14
People are living longer: in an issue of Cancer Control devoted to various aspects of breast cancer in the elderly, the editors pointed out that in 1950 only 8% of the population was over 65 years of age, whereas by the year 2000 approximately 13% of the population would be over 65,3 and that the fastest growing group was the “over 80s.” Since age is the single most important risk factor for breast cancer,1,2,15 the appropriate management of breast cancer in the elderly should be a major concern in geriatric medicine.
Over the years there have been several recurring themes with respect to breast cancer in the elderly, and I would like to pose the following questions:
How do you define old?
What are the issues relating to comorbidity?
What factors influence the stage of presentation?
What are the issues around screening for breast cancer?
What factors play a role in treatment decisions for patients with primary breast cancer? — principles of management, deciding what constitutes “appropriate” treatment for breast cancer in the elderly, the role of clinical trials in decision-making around the treatment of breast cancer in the elderly, why data are relatively scarce, physician-related factors and patient factors important in treatment decisions.
What treatment options are there for primary breast cancer in the elderly, including surgery, radiotherapy and adjuvant systemic therapy?
What modifications in treatment are appropriate for the truly infirm?
What are the cost considerations?
What is the impact of breast cancer on the quality of life of elderly women?
How fast does breast cancer progress, are outcomes better or worse and are prognostic factors any different in the elderly?
How should we define old?
Is old age reached at 60, 65, 70, 75, 80 (somewhat trendily referred to as old-old) or even 90 (oldest-old) years of age? Age means different things to different people at different times and in different contexts, so it is inadequate to designate a women as old solely on the basis of chronologic age. A more useful definition is the biologic or physiologic age, which relates to social, cultural, psychologic, mental and functional status.
Assessment of comorbidity
In considering age, one must also take into account factors relating to the concept of comorbidity. Overall health must play an important decision-making role for the optimal treatment of older women with primary breast cancer. The whole issue of multiple or comorbid conditions assumes greater significance in older women. Greenfield and colleagues16 have developed a measure of this, which they have termed a comorbidity index; it rates 11 system categories, including “circulation, respiration, neurological, mental status, urinary, feeding, ambulation, transfer, vision, hearing and speech.”16 Each individual condition is given a value. Complications and how they affect the functional status are also taken into account. These are rated for each category on a 3-point scale (0 represents no comorbid disease, 1 represents mild, controlled comorbid disease and 2 represents moderate to severe comorbid disease). Of considerable interest was the finding that the 3-year rate for death unrelated to the cancer per se was increased 28-fold in elderly patients with 3 or more comorbid conditions. Caron stated recently17 that although age influences the ultimate outcome as a result of the gradual decline in physiologic reserve of organ function, the increased presence and severity of concomitant disease appears to have an even greater effect on outcome.
Factors influencing the stage of presentation
There appears to be a significant delay in presentation in elderly women, as evidenced by more advanced disease (both regional and metastatic), fewer asymptomatic cases and a longer time between the onset of symptoms and presentation.6,18–21 The stage of any cancer at the time of diagnosis not only relates to the biologic characteristics of the tumour and the host but is also influenced by both patient and physician and patient knowledge and behavioural characteristics.22 The elderly may exhibit reduced homeostatic mechanisms and reserve capacity and are more subject to iatrogenic illness. They are also more likely to be widowed, poor or multiply dependent, all of which can have an impact on both detection and response to treatment.
Screening for breast cancer
It has been well-established that screening asymptomatic women aged 50 to 74 years for breast cancer using mammography and physical examination of the breast prevents deaths from breast cancer.21,23,24 However, a consistent observation has been an age-related decline in compliance with screening recommendations.25,26 This may relate to factors such as lack of information, poor accessibility, lack of transportation and lack of physician support.27 Mah and Bryant6 have shown that knowledge about breast cancer among women decreases with age. Also, problems relating to social support, cultural differences and functional status all have a bearing on whether or not older women are screened.
Organizations have made differing screening recommendations, which can be confusing to women and the professionals who care for them. One pragmatic recommendation is that if the woman is functional with a life expectancy estimated at 3 years or more, screening should be carried out.28 Cost may also be a barrier to screening. It has been estimated that to scan 25% of the female population between the ages of 55 and 75 years would cost $80 000 to $90 000 per year of life saved.28
Sterns7 has shown that the cancer detection rate actually increases with age for every mode of presentation (mass, nodularity, pain, skin and nipple changes and discharge). Also, breast masses are very likely to be malignant in older women.
Although there is no proof that screening offers secondary prevention in women over 75 years of age, early detection of breast cancer may improve quality of life.
Factors influencing treatment for breast cancer
Principles of management
There is a wide range of treatment options, but the basic principles of breast cancer management, such as attempting to control local disease, preventing metastatic spread and treating symptomatic disease, should be equally applicable to older and younger women.4 In deciding on the optimal treatment for breast cancer in the elderly, several questions must be answered: Is the treatment contemplated as effective in older women? Is the toxicity of a treatment different in elderly women from that in younger women? Is the treatment necessary? and Will the woman live long enough to benefit from the treatment?29
What constitutes “appropriate” therapy for breast cancer?
The concept of “appropriate” therapy is an appealing one. The NIH Consensus Conference on the treatment of early stage breast cancer30 concluded that partial mastectomy with levels I and II axillary lymph-node dissection and the addition of adjuvant breast irradiation is the preferred form of treatment for the primary tumour regardless of age, with total mastectomy being reserved for multicentric or relatively large primary tumours. Systemic therapy in the form of tamoxifen or other chemotherapy may be recommended according to circumstances. The recommendations concerning surgery were based on 4 large randomized trials, which compared total mastectomy with breast conservation and postoperative breast irradiation.31–34 These trials showed no difference in disease-free survival or overall survival, but few of the women involved were older than 65 years. It may well not be valid to extrapolate recommendations derived from studies involving younger women to the elderly.
The role of clinical trials in treatment decisions
To determine how best to treat women with breast cancer, we rely on the results of properly conducted clinical trials. Unfortunately controlled trials of cancer therapy have failed to involve older women in sufficient numbers,29,35,36 perhaps for logistic reasons. It has also been stated that the relative difficulty in obtaining truly informed consent in the elderly can add to the difficulty of carrying out prospective randomized controlled clinical trials.37 Prospective cohort studies may be more feasible in elderly patients. In addition, comorbidity is a confounding factor in assessing outcomes of treatment and is not always easy to take into account. Nonetheless, it was encouraging to find a listing of clinical breast cancer research protocols in which older women took part. Fourteen were for, or included, postmenopausal women and 2 trials were specifically designed for women over 70 years of age.38
Factors relating to physicians that can influence treatment decisions
It is often stated that older women receive less than definitive treatment aimed at potential cancer control.16,39–44 It is true that a less aggressive treatment approach seems entirely reasonable for frail patients with recognizable comorbidity.43 However, in 1 study of women over the age of 70 years, all with a low comorbidity index, fewer patients received definitive potentially curative treatments than would have been provided for younger women,16 suggesting that physicians may treat according to chronologic rather than physiologic age, and this may translate into poorer outcomes.
Physicians tend to spend less time with their elderly patients and are less likely to involve them in decision-making, 43,45,46 and physical and social disabilities are frequently underestimated.47 Also, many physicians are not up to date on current life expectancy. 29,43,48 A women who is 75 years old has an average life expectancy of 12 years. In a group of physicians polled, approximately 40% estimated life expectancy for a 75-year-old woman to be 4 years or less and 85% underestimated it by at least 2 years.43,48 In addition, local customs for treatment can become entrenched. A study was done to assess the distribution of breast conserving therapy in Medicare patients over 65 years of age in the United States.49 In many states, breast conserving therapy was carried out in less than 10% of cases, and the highest rate was less than 22%.
Factors relating to the patient and her family that can influence treatment decisions
Some problems are related to the patient herself, who may even be older than the clinician and therefore less likely to seek information and to challenge. She may also tend to act on beliefs accumulated over years.3 The family can play a greater or lesser role in medical decision-making.
Treatment options for primary breast cancer
With respect to every modality of possible treatment for primary breast cancer in the elderly, there are controversies — regarding the extent of surgery on the breast, whether or not an axillary dissection should be carried out, if radiation to the breast should be given and regarding the role of adjuvant therapy.
Surgical treatment
With respect to surgical treatment, several authors have written over the years about the ability of older women to withstand even a radical mastectomy, 35,50 but should this, in itself, constitute a reason for such an aggressive surgical approach? Although, as mentioned before,30 partial mastectomy is the preferred surgical treatment to total mastectomy in most cases, the SEER data from Detroit showed that women over 55 years of age were actually much less likely to have had breast conserving surgery,51 although when women were 85 years or over, this trend was reversed.1,29 There are no data to suggest that older women should not undergo breast conserving surgery, and there is nothing to say that an older woman is not as upset as a younger woman by the sequelae of breast loss. However, the older woman herself may be part of the equation by choosing total mastectomy “just to be sure” or to obviate the need for radiotherapy.
Surgery for breast cancer, particularly partial mastectomy, does not usually result in a major physiologic disturbance, and if a patient poses a high anesthetic risk because of extensive comorbidity, partial mastectomy and even axillary dissection can be carried out under local anesthesia, with excellent sedation and relief of anxiety being achieved by neuroleptic agents.
Axillary dissection can undoubtedly be done, but should it? It provides staging information and, to a minor extent, may contribute to the control of regional disease. If the information will be used in decision-making concerning systemic therapy, then there is a clear indication for axillary dissection. However, the recent trend has been to treat all older women with tamoxifen regardless of nodal status or even estrogen-receptor status. Thus, it seems entirely reasonable to adopt a “wait and see” policy regarding axillary dissection. In the National Surgical Adjuvant Breast Project protocol B-04,52 which included women up to 70 years of age, one-third had total mastectomy only. Although 20% demonstrated nodal progression at the 15-year follow-up, there was no survival advantage in carrying out the axillary dissection prophylactically. There is some suggestion that axillary progression is even less common in older women.35
Adjuvant treatment
Radiotherapy
Radiation is the accepted treatment after lumpectomy,53,54 but, again, can studies in younger women be extrapolated to the elderly? There is no doubt that radiation can be tolerated,55 but there are certainly technical difficulties regarding such mundane matters as transportation that figure more prominently with advancing years.
One randomized study from Milan53 indicated that radiotherapy actually appears to confer less benefit in older women. A definitive answer would be extremely useful. There is a study underway in Toronto that has recently expanded to include the Province of British Columbia. Supported by the Ontario Ministry of Health, the study was initiated by Fyles and associates to assess the need for breast radiotherapy in women 50 years of age and over with nodenegative breast cancer (Dr. A.W. Fyles, Radiation Oncology, Princess Margaret Hospital, Toronto: personal communication, 1997). Women with T1 or T2 tumours receive lumpectomy, and attention is paid to achieving resection margins that are pathologically clear of malignant cells. Between the ages of 50 and 65 years, axillary dissection is done to confirm the node-negative status, but for women over 65 years of age, clinical node negativity is accepted. Accepting the hypothesis that tamoxifen alone can probably serve to keep local recurrence to an acceptable level, the researchers prescribe tamoxifen for 5 years for all women, and they are randomized to receive radiotherapy or no radiotherapy. The target for entry is 900 women and nearly 600 have been randomized to date (Dr. A.W. Fyles: personal communication, 1997).
Adjuvant systemic therapy
With respect to hormonal manipulation, it is true that breast tumours in the elderly are much more likely to be estrogen-receptor positive.20,35,56 One randomized, controlled study of surgery, with or without tamoxifen, carried out in 181 women 65 to 85 years of age by Cummings and associates, 57,58 showed that tamoxifen extends the time to treatment failure by 3 years and reduces recurrences, deaths and second breast cancers. Other studies have noted similar benefits with tamoxifen in postmenopausal women, but usually have only included women up to 70 years of age.59–63 An overview analysis by the Early Breast Cancer Trialists’ Collaborative Group,64 showed that tamoxifen caused a small but real improvement in disease-free survival in women 50 years of age and older. There are also potential benefits to women in this age group with respect to cardiovascular disease and osteoporosis.
Chemotherapy is a matter for more deliberation. Again an overview analysis was carried out and showed that chemotherapy, although effective in women under 50 years of age, resulted in only a 10% reduction in the annual odds of death in women aged 60 to 69 years and did not appear to be beneficial in women older than 70 years.65 The lack of effectiveness of adding conventional chemotherapy to tamoxifen therapy in postmenopausal women was suggested by the study of Pritchard and colleagues.66 Fisher and associates,67 on the other hand, studied women 50 years of age or older and noted a significantly better distant disease-free survival and overall survival for those treated with combination chemotherapy (tamoxifen with adriamycin plus cyclophosphamide or with melphalen plus 5-fluorouracil) as opposed to tamoxifen alone. Although 55% of these women were 60 years of age and older, the results for this group were not separated from those of women less than 60 years of age. In a trial conducted by the Ludwig Breast Cancer Study Group,68 a subset of patients 65 years of age and older (node-positive and estrogenreceptor positive) were randomized to receive 1 of the following 3 protocols: (1) cyclophosphamide, methothrexate and 5-fluorouracil plus prednisone plus tamoxifen; (2) prednisone plus tamoxifen or (3) no further treatment. Through 5 years of follow-up, no difference was noted between protocols (1) and (2). Some people have attributed the lack of effect in older women in this study to the fact that older women seldom received anthracycline-based chemotherapy regimens. However, there may be a trend toward less benefit from the adjuvant chemotherapy with advancing years rather than a “cut-off” effect at the time of menopause.
The elderly with extremely poor functional status
Special consideration should be given to the truly infirm. Margolese and Foster8 reported a pilot study in which nothing but tamoxifen was given to 30 patients who were infirm or refused surgery. The majority regressed or remained stable. Of importance is the fact that none subsequently suffered from uncontrollable locoregional disease.
Three European randomized trials37,69,70 of tamoxifen therapy versus surgery have been carried out in elderly women, and although the results of the studies were not that dissimilar, the conclusions differed. Gazet and associates69 reasoned that because tamoxifen was as effective as surgery in many ways, surgery should be reserved for those who do not respond or whose disease progresses. Robertson and colleagues70 noted that with surgery, 70% were free of local disease, whereas with tamoxifen therapy alone, only 47% remained free of local disease. Therefore, they concluded that primary treatment should include surgery. It has been said that most elderly patients will accept surgery, as the fear of cancer is greater than that of surgery, and leaving the cancer is equated with inoperability and a painful end. Bates and associates37 on behalf of the Elderly Breast Cancer Working Party showed no difference in survival or quality of life between optimal surgery and tamoxifen therapy, but those treated with tamoxifen alone more frequently had a subsequent change in management — usually surgery for local treatment failure. However, it is clear that for elderly women who are infirm, tamoxifen therapy alone may be the optimal form of management.
Cost and quality-of-life considerations
Cost-effectiveness is an important consideration. The costs related to screening have been mentioned. If radiotherapy or axillary dissection prove to be unessential, why generate extra costs or submit the patients to the morbidity inherent in these treatment modalities? Surgery in the form of partial mastectomy usually deals definitively with the primary cancer and may well be less expensive than prolonged treatment with tamoxifen to which surgery may ultimately have to be added. A partial mastectomy alone may be as efficacious for patients with limited life expectancy and possibly more cost-effective.
Although elderly women can tolerate adjuvant polychemotherapy for breast cancer,71 the benefit is extremely modest and the costs are relatively high.72 The greater morbidity of conventional chemotherapy compared with tamoxifen therapy is also a quality-of-life factor that must be taken in to account, particularly in a women with limited life expectancy.
Therapy for metastatic disease is only palliative and quality-of-life issues assume even greater importance in patients with systemic spread of disease. Except in patients with rapidly progressing visceral involvement, endocrine therapy is usually the first approach, even in estrogen-receptor-negative tumours.73 When tamoxifen therapy was compared to conventional chemotherapy (cyclophosphamide, methotrexate and 5-fluorouracil) and combination therapy (conventional chemotherapy plus tamoxifen) in postmenopausal women, the response rate to tamoxifen therapy alone was lower, but when the response to subsequent chemotherapy was taken into account, the results were virtually identical in the 3 treatment groups.74 In another study of women over 65 years of age,75 similar results were seen. Patient preference should be an important factor, for what seems worth-while to one woman may not be to another with a different value system.
Quality-of-life studies have suggested that adjustment to a diagnosis of breast cancer is no worse in older than in younger women with respect to measurable parameters such as somatization, obsessions/compulsions, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism and the Global Severity Index.76 Psychologic distress in older women studied correlated positively with life stressors such as financial, family or health problems experienced in the year before diagnosis. Much of the psychologic literature is focussed on the loss of the breast as the central theme,77 but a more important consideration is the threat to life and functional status that a diagnosis of breast cancer may represent. Adjuvant treatment and regular follow-up surveillance may be a constant reminder. Also, there are a number of questions concerning the cost-effectiveness of extensive follow-up in patients with breast cancer aside from routine mammography.78 On the positive side, the older woman may be less likely to have dependent children and financial problems and has had many life experiences to prepare her to cope with illness. However, a more limited social situation and functional status, and comorbid conditions, may affect quality of life more adversely in the older woman.
Prognostic factors and outcome in relation to age
With respect to outcome, it has often been stated that breast cancer in the elderly tends to be more well differentiated35,79 and to exhibit a lower growth rate as assessed by the thymidine labelling index or flow cytometry. 80,81 Tumours in older women are more likely to be estrogen-receptor positive.20,35,56
It has been claimed that older women with stage I or II disease have slightly better survival than younger women.35,82 However, this finding is counterbalanced by the fact that older women tend to present with more advanced disease.10,18,20,83 The view that breast cancer runs a more favourable course in older than in younger women has been challenged.10,84 In a large Swedish study of 57 068 women whose breast cancer was diagnosed between 1960 and 1978 (98% of total cases in Sweden), in order to get a measure of the breast-cancer-specific death rate, the authors assessed the relative survival rate (the ratio of the observed to the expected rate of survival). They found that there was a decline in the relative survival rate in women 50 years of age and older and also in women under 35 years. This was consistent with findings in another study comparing outcomes in 169 women 35 years of age and younger with 169 women 75 years of age and older.85 No significant difference in outcome was noted between these 2 groups.
In The Henrietta Banting Breast Centre at Women’s College Hospital in Toronto, we examined a cohort of 196 women 70 years of age and older with primary invasive breast cancer.12 At 10 years, with a median follow-up of 5.7 years, the disease-specific death rate was 26% and the overall death rate was 54%. Although the single largest cause of death was related to breast cancer, the sum total of deaths from competing causes was even greater. Factors predictive of distant disease and local recurrence in a multivariate analysis included tumour size, number of involved nodes and estrogen-receptor status. In terms of treatment, total mastectomy did not appear to result in better outcome than did partial mastectomy. Radiotherapy did not appear in the best Cox stepwise model. The local recurrence rate without radiotherapy was approximately 12%.
McCready and colleagues13,14 have studied the question of local recurrence in what could be termed a “pure” group of 366 patients. Primary treatment consisted of partial mastectomy alone, unadulterated by radiotherapy or adjuvant systemic treatment. Relapse was significantly less in patients 65 years of age or older. Assessment of prognostic factors (including age, axillary node status, tumour size, estrogen- and progesterone-receptor status, histologic and nuclear grades, vascular and lymphatic invasion and the presence and percentage of in situ carcinoma) was carried out on a cohort of 293 patients treated by partial mastectomy alone and followed up prospectively for a median of 8 years. With use of Cox stepwise multivariate model building, the factors that proved to be important in local recurrence in the whole cohort were determined. Decreased local recurrence was associated with absence of tumour emboli in vascular and lymphatic spaces, increase in age, minimal or no in situ carcinoma and the absence of nodal metastases. Similar findings were reported by Veronesi and colleagues53 who studied 273 women who underwent quadrantectomy alone. Local recurrence was significantly lower in women 50 years of age and older than in the group 50 years of age and younger.
It should be noted that most of the patients in these studies were treated at a time when the use of adjuvant systemic therapy was much less common than it currently is, particularly in the older age groups. Although it is not clear whether breast cancer itself pursues a more or less lethal course in older as opposed to younger patients, there is no doubt about the confounding issue of death from competing causes in older women, which does impact on overall survival.
Recommended therapy
A schema for an approach to the primary treatment of breast cancer in the elderly (70 years and older) derived from studies cited in this review is presented in Table I. In patients who are healthy, with a low comorbidity index (CI), and who have small node-negative tumours, a partial mastectomy is recommended; axillary dissection should be reserved for those who are clinically node-positive. Women with larger tumours should undergo total mastectomy, with axillary dissection if they are clinically node-positive. In patients with several comorbid conditions, partial mastectomy and even axillary dissection or total mastectomy can be carried out, if necessary, under local anesthesia with sedation. Those with extremely poor functional status (multiple and severe comorbid conditions) should be disturbed as little as possible; however, tamoxifen might provide some benefit and is associated with few side effects. Radiation should be given after partial mastectomy to control local disease, although, with increasing infirmity, this may be impractical. It is hoped that the completion of the study to determine the need for breast radiation in addition to tamoxifen therapy in older women with node-negative breast cancer, will identify at least a subgroup of women in whom radiotherapy is not necessary. In women 70 years of age or older, there is probably little place for adjuvant chemotherapy.
It has been stated,86 “In determining individualized therapy for older patients, physicians should weigh the risks and benefits of treatment, evaluate the patient’s biologic, psychological, and social systems; assess the quality and quantity of life possible, and base decisions on individual patient information not age.”
Conclusions
It is imperative that we identify coherent strategies for the treatment of primary breast cancer in the elderly, taking into account outcomes that address not only survival time but also the quality of that time gained. Our knowledge on how best to treat the elderly woman with breast cancer should come from clinical trials including older women and from good clinical trials designed specifically to study primary breast cancer in older women.
Footnotes
Presented, in part, at a joint symposium on primary breast cancer in the elderly sponsored by the Canadian Association of Medical Oncologists, the Canadian Association of Radiation Oncology, the Canadian Oncology Society and the Canadian Society of Geriatric Medicine, in conjunction with the 63rd annual meeting of the Royal College of Physicians and Surgeons of Canada, Toronto, Ont., Sept. 17, 1994
- Accepted February 18, 1997.