Evidence
Alert

Breast cancer surgery is safer for older women than has been assumed

Surgeons in the UK vary significantly in their willingness to perform surgery on older women with breast cancer. Many assume that surgery on these patients is not safe. Now a study of over 3,000 women in the UK has shown that breast cancer surgery is a safe option for women over 70. However, the more breast tissue that is removed, the bigger the negative impact on quality of life.

This information could be used to help surgeons decide which of their patients could be offered surgery for breast cancer. It clarifies the risks associated with different types of surgery among different groups of patients.

A decision aid for surgeons has already been developed by researchers working on this project, to help them make evidence-based decisions with older patients.

What’s the issue?

Older women over 70 with breast cancer receive surgery less frequently than younger women in the UK. If they do have surgery, they are less likely to also have reconstructive surgery to restore the appearance of the breast. These older women also have worse survival rates than younger women with breast cancer.

The UK National Audit of Breast Cancer in Older Patients (NABCOP) has shown rates of surgery in older women vary considerably across breast units in the UK. This suggests that decisions are biased and not based on evidence. Surgery rates are also generally much lower in the UK than in some other European countries including Ireland and Poland.

Low rates of breast cancer surgery in the UK may be due to the assumption that surgery is not safe in older people. Low rates of reconstructive surgery following breast cancer surgery may be due to the assumption that loss of a breast (mastectomy) or loss of breast tissue will not lead to  poor body image and/or reduced quality of life as much in older as in younger patients.

There is little clear information on the outcomes of surgery for older women with breast cancer with different levels of frailty and other long term conditions (comorbidities). This makes it difficult for their healthcare providers to offer evidence-based information.

What’s new?

Between 2013 and 2018, researchers recruited 3,375 women aged over 70 with operable breast cancer. The women were being treated at 56 breast units across the UK, and most (83.4%) underwent surgery. They were followed up for two years.

Researchers found:

  • no deaths were attributable to surgery for breast cancer in this study. Fewer than one in five women (19.3%) had an adverse outcome, such as a dangerous blood clot (DVT) or wound pain.
  • a woman’s age predicted what surgery she would receive. The oldest women in the group were twice as likely to have a mastectomy than the youngest women (59.1% vs 29.9%). Younger women were more likely to have breast-conserving surgery, with less breast tissue removed. This may relate to the lack of screening in older women, so cancers tend to be found when they are bigger and women feel a lump.
  • older women were less likely to have lymph glands under the armpit removed (axillary surgery) than younger women (91.4% vs 98.6%). The aim of axillary surgery is to find out if the cancer has spread, and to remove any cancer in the axilla.
  • just 2.8% of the women in this study who had a mastectomy went on to have reconstructive sugery. This compares to one in five (20%) women overall in the UK.
  • quality of life was lower after surgery particularly for those who had more breast tissue removed as in mastectomy.
  • the risk of being unable to carry out some standard day to day tasks was higher after surgery.

Why is this important?

Older women are more likely to be diagnosed with breast cancer at a later stage, and to have complex health needs including frailty, dementia and other illnesses.

This study followed women after surgery and showed that breast surgery in women over 70 may be safer than is assumed. It provides data that will help surgeons to weigh up the risks and benefits of different types of surgery for older women with breast cancer, based on characteristics including age, dementia, frailty and other long term conditions. Surgeons may be able to consider more breast-preserving surgery to improve quality of life, for example.

What’s next?

This study was part of the Bridging the Age Gaps in Breast Cancer project which has already produced a decision tool called Age Gaps to help UK-based surgeons make evidence-based decisions. Further research by the group has shown that the characteristics of women selected for surgery varies substantially between surgeons and breast units, suggesting some bias.

Researchers plan to carry out further research into:

  • outcomes at ten years
  • the impact of surgery on quality of life
  • the characteristics of women who have reconstructive breast surgery
  • older womens’ desire for reconstructive surgery and their experience of it.

Findings will be used to further refine the Age Gaps tool to help surgeons avoid over- or under-treating older women with breast cancer.

There has been interest from groups in Canada, France and Holland who would like to test the usefulness of the tool in their own populations.

You may be interested to read

The full paper: Morgan JL, and others. Breast cancer surgery in older women: outcomes of the Bridging Age Gap in Breast Cancer study. British Journal of Surgery. 2020;107:1468-1479

Further information about the Bridging the Age Gap in Breast Cancer study can be found on the University of Sheffield website

The Age Gap Decision Tool can also be found on the University of Sheffield website

Lifford KJ, and others. Efficient development and usability testing of decision support interventions for older women with breast cancer. Patient Prefer Adherence. 2019;13:131-143.

Ward S, and others. Omission of surgery in older women with early breast cancer has an adverse impact on breast cancer‐specific survival. British Journal of Surgery. 2018;105:1454-1463

Funding

The study was funded via the NIHR Programme Grants for Applied Research.

Commentaries

Study author

It is important to note that some women may have been offered breast reconstruction and declined it. The study records the women who underwent breast construction but more may have been given the option. That being said, from my previous research on this subject, it is definitely a view held by many surgeons that older women are less interested in the cosmetic side of treatment than younger women.

Jenna Morgan, NIHR Clinical Lecturer, and Specialty Registrar in Breast Surgery, University of Sheffield Medical School

Member of the public

These findings suggest that the choice of treatment should be determined by a woman’s fitness not her age. The study makes a case for continuing routine breast screening beyond the age of 70. And it raises questions about excessive surgery of the axilla in women whose cancer has not spread.

Older women diagnosed with breast cancer, and their carers, need to know about these findings in order to understand the choices available. Occupational therapists, physiotherapists, care home staff and GPs also need to know so that they can help women assess the possible implications of surgery on their quality of life and on their independence. They may also come up with interventions, such as building up women’s fitness, to help manage the worst effects.

Cathie Joyce, Carer of elderly family members, Shrewsbury, Shropshire

Clinical researcher

This study allows clinicians to be confident in recognising the safety of surgery in some appropriate older women. However, it also suggests that we consider limiting more extensive surgery where it is not required because of the negative effects on quality of life reported.

Jane Macaskill, Honorary Senior Clinical Lecturer, School of Medicine, University of Dundee

Conflicts of Interest

None declared.