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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #19

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LEARNING OBJECTIVES

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Learning Objectives

  • Describe the key principles with regard to breast cancer in the older patient, including epidemiology, screening, risk factors, presentation, and initial evaluation of disease.

  • Understand the basic local and systemic therapy approaches in the management of breast cancer in the older patient.

  • Understand the basic approaches with regard to treatment of the older patient with metastatic breast cancer.

  • Describe the usual surveillance recommended for patients with breast cancer.

  • Understand potential prevention strategies.

  • Become aware of special (understudied) populations with breast cancer, including men, racial/ethnic minorities, and those with advanced comorbidity.

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Key Clinical Points

  1. Breast cancer in the older patient is common and will become more common as our population ages.

  2. Although many older patients die from causes other than breast cancer, it remains a deadly disease for many, especially those with higher-risk cancers.

  3. Older patients typically benefit from treatments (such as hormonal therapy and chemotherapy) as much as younger patients do, but may experience more toxicity with chemotherapy.

  4. When discussing treatment, screening, and surveillance strategies with older patients, it is important to be mindful of each patient’s competing medical issues, risk for cancer recurrence and cancer-related death, and functional status.

  5. Older patients with breast cancer are often understudied. How to best optimize care with regard to treatment, comorbidity, functional status, and outcomes remains a priority for future research.

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DEFINITION

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The breast, or mammary gland, is a fibrofatty organ that produces all the necessary nutrients for a newborn. In women of childbearing age, the breast responds to cyclic hormone production and contains an abundance of epithelial structures and stroma that enable the production of milk. In postmenopausal women, declining ovarian function in late menopause leads to regression of these structures. The postmenopausal breast contains a ductal system, but the lobules shrink and collapse, leaving an organ that is composed primarily of fat. While a breast lump in a premenopausal woman is likely to be a benign problem related to cyclic hormonal changes, in a postmenopausal woman, a breast mass is a major concern and is likely to be breast cancer.

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EPIDEMIOLOGY

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Cancer is the leading cause of death in women aged 55 to 74 and is second to heart disease in women aged 75 and older. The incidence of cancer increases dramatically with age. In particular, breast cancer—the most common cancer in American women—is a major health concern. According to 2014 American Cancer Society estimates, breast cancer is the most common cancer in women, accounting for 29% (232,670 new cases) of all newly diagnosed malignancies and the second leading cause of cancer-related death (40,000 deaths—15%). Moreover, current US incidence and mortality data suggest that 12% of all women (one in eight) will be diagnosed with breast cancer during their lifetime and that 3.5% will die from it.

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