Our study found that breast cancer surgery for extremely old patients is warranted. This conclusion is based on the finding that a series of surgically treated breast cancer patients aged 85 years or older had a better survival outcome than patients in the same age group who did not undergo surgery for breast cancer.
Although surgery led to a favorable outcome, it is doubtful that surgery is the only reason for the good outcome. Another reason accounting for the better outcome for the patients undergoing surgery is that quite a few patients who did not undergo surgery did not receive hormonal therapy, regardless of the high prevalence of estrogen receptor-positive breast cancer. Therefore, the low frequency of hormonal therapy administration to the patients who did not undergo surgery probably accounts for the apparent better outcome of the patients undergoing surgery. Another reason for the worse outcome of the patients not undergoing surgery is that performance status might have affected the physician’s and patient’s decision. Safely undergoing surgery requires a good performance status. Furthermore, a poor performance status may result in the avoidance of adequate treatments, including hormonal therapy, by both the physician and patient. More studies are needed to validate the findings of our investigation.
We believe that surgical treatment for elderly patients with breast cancer is extremely safe if their preoperative conditions are appropriately evaluated. In our series, there were no hospital deaths. Although some patients had wound infections and necrosis, none of those postoperative problems were severe. Results from other single-institution studies on postoperative mortality of elderly patients who undergo breast cancer surgery have been favorable [8, 10].
The evaluation of surgical safety is essential for elderly breast cancer patients. The level of safety depends on the balance between surgical invasiveness and the patient’s tolerance of surgery. Surgical treatment for breast cancer is less invasive than other general surgeries and is thus safely performed in many patients. On the other hand, tolerability depends on a patient’s comorbidities [11, 12], frailty , and physical activity . These 3 factors are closely associated with one another .
Considering the low tolerance of some elderly patients being treated for breast cancer, various essential treatments, including axillary surgery, radiation treatment, and adjuvant chemotherapy have been avoided [7, 9]. Several small studies investigated avoiding axillary dissection in clinically node-negative patients with small breast cancers, and reported that the absence of axillary dissection does not affect overall survival [15–17]. However, 5.8–9% of patients developed recurrence involving the axillary lymph nodes. We believe that concomitant axillary surgery is preferable for 2 reasons. One, axillary surgery is not very invasive, and sentinel lymph node biopsy is appropriate for clinically node-negative cases . The second reason is that comorbid diseases may weaken the general condition of an elderly patient during the interval between the initial surgery and potential axillary recurrence. This interval to recurrence has been reported to range from 7 to 157 months ; longer intervals can reduce the treatment options, including a second surgery.
Radiation therapy after partial mastectomy tends to be avoided for elderly patients with breast cancer , because they are required to visit the hospital every day for several weeks. Although radiation therapy after a partial mastectomy does not seem to affect overall survival , the risk of local recurrence is increased in patients who do not undergo radiation therapy [20–22]. Although mastectomy is related to a higher risk of postoperative hemorrhage than is partial mastectomy , mastectomy is preferred for patients who want to avoid radiation therapy.
Adjuvant chemotherapy improves the survival outcomes of patients with early breast cancer; however, maintenance of the relative dose intensity is difficult in elderly patients [24–27]. Furthermore, treatment-related mortality increases with age . We believe that adjuvant chemotherapy is not appropriate for patients aged 85 years or older.