TUMOR DETECTION AND STAGING MODALITIES IN OLDER PATIENTS WITH BREAST CANCER: A PROFILE OF A GROUP OF ITALIAN WOMEN

Abstract

To the Editor: Breast cancer is the most common neoplasm in the industrialized world, and 50% of cases occur in women aged 65 and older. As the population ages, increased incidence can be expected. Breast cancer in older women is also frequently1,4 managed suboptimally. A review of 297 women aged 70 and older referred to our Institute between January 1980 and December 1989, could be a reflection of breast cancer management in Italy. None of these women was included in clinical trials of cancer prevention or cancer treatment. Patients who had undergone adequate clinical and pathological staging, including complete blood chemistries, chest X-ray, skeletal X-ray or radionuclide bone scan, and complete removal of the primary tumor plus dissection of at least level I and II axillary lym-phonodes, were eligible for the study. Of the 297 women 70 years or older with pathologically confirmed breast cancer, 226 were eligible for the study; 71 were excluded from the study because stage was incomplete in 48 cases, surgical resection of primary was inadequate in eight (simple mastectomy, 3; biopsy or nodulectomy, 4; no surgery, 1) and pathology was incomplete in 15. Characteristics of the 226 women are summarized in Table 1. The diagnostic modalities and the time that elapsed from original tumor detection to treatment were analyzed. Detection modality was classified according to (1) self exam (“patient diagnosis”), (2) family physician screening or symptoms related to the cancer (“physician diagnosis”), (3) part of diagnostic work-up for an unrelated condition (“incidental diagnosis”). Incidental diagnosis accounted for 59.9% of cases, patient diagnosis for 26.9%, and physician diagnosis for 13.2%. In 54.7% of cases, diagnostic and therapeutic interventions were instituted within 3 months of the initial detection. A delay in referral of 6 months or longer was seen in 23.6%. No difference among women aged 70 to 75 or 76 to 80 or greater than 80 was observed. Chi-square revealed no significant association between age and stage at diagnosis (P = .170), age and tumor detection modality (P = .105), or age and delay in referral (P = .405). Even if in slight contrast to the SEER data5 and data obtained by the Italian GIVIO group (Interdisciplinary Group for Cancer Care Evaluation),6 our results are comparable to those reported by other authors.7–11 Breast cancer in the older population presents with more benign biological characteristics than in premenopausal women: 76% of our patients had low or intermediate grade disease, and 73% had ER rich tumors. Moreover, 72.5% of patients had stage I or II disease, and axillary lymph nodes were pathologically negative in 50.2%. Staging was inadequate in 24% of this series. This percentage is higher than the 21.4% and 16.7% observed in the SEER series reported by Yancik et al.5 Among our fully staged women, the majority were amenable to curative treatment as all of our stage I or II tumors received radical or conservative surgery. These findings are similar to those reported by other authors.5,12 Among incompletely staged women, the majority did not receive a full evaluation of distant metastases because complete staging was performed only when cases were ment as all of our statge I or II tumors received radical or conservative surgery. These finding are similar to those reported by other authors.5,12 Among incompletely staged women, the majority did not receive a full evaluation of distant metasteses because complete staging was performed only when cases were symptomatic. The majority of our patients received definitive treatment within 3 months of diagnosis; however, a 6 months or greater delay was observed in one-fourth of the population. Noteworthy is the fact that one-fourth of patients detected their cancer through breast self-examination (BSE), and 60% of cases were detected during a physical examination for unrelated reasons. Whereas the value of BSE remains controversial, data document the benefits of routine examination of the breast by physicians taking care of older patients. Age determines an increased request for medical attention. Each physical examination is an occasion to screen older individuals for common conditions, including breast cancer. However the benefit of breast cancer diagnosis in women aged 70 or older may not be evident because of the high mortality observed for other medical conditions. Therefore, the value in terms of reduced morbidity and mortality of routine breast examinations in the older women must be considered cautiously. In conclusion, our experience from a single center shows the majority (54.7%) of older women with breast cancer are treated within 3 months from first diagnosis, and 72.5% present with early stage disease. Physical exam plays a major role in the diagnosis of breast cancer in older women, accounting for 60% of tumor detection in our series. The survival and quality of survival benefits remain to be defined.