Radiotherapy Issues in Elderly Breast Cancer Patients

Abstract

Breast cancer in the elderly is a rising health care chal lenge. Undertreatment is common. While the propor tion of older patients receiving adjuvant radiotherapy (RT) is rising, the proportion undergoing breastconserv ing surgery without irradiation has also risen. The evi dence base for locoregional treatment is limited, reflect ing the historical exclusion of older patients from randomised trials. The 2011 Oxford overview shows that the risk of first recurrence is halved in all age groups by adjuvant RT after breastconserving surgery, although the absolute benefit in older ‘lowrisk’ patients is small. There is level 1 evidence that a breast boost after breast conserving surgery and wholebreast irradiation reduces local recurrence in older as in younger women, although in the former the absolute reduction is modest. Partial breast irradiation (external beam or intraoperative or postoperative brachytherapy) is potentially an attractive option for older patients, but the evidence base is insuf ficient to recommend it routinely. Similarly, shortened (hypofractionated) dose fraction schedules may be more convenient for older patients and are supported by level 1 evidence. There remains uncertainty about whether there is a subgroup of older lowrisk patients in whom postoperative RT can be omitted after breastconserving surgery. Biomarkers of ‘low risk’ are needed to refine the selection of patients for the omission of adjuvant RT. The role of postmastectomy irradiation is well estab lished for ‘highrisk’ patients but uncertain in the inter mediaterisk category of patients with 1–3 involved axil lary nodes or nodenegative patients with other risk factors where its role is investigational.