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Survival Outcomes of Early-Stage Hormone Receptor-Positive Breast Cancer in Elderly Women

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Elderly women (≥ 70 years old) form a significant proportion of patients affected by breast cancer (BC); however, the treatment decisions for this patient population are complicated, owing to the presence of comorbidities, limited life expectancy, reduced tolerability of therapy, and limited enrollment in clinical trials. A growing body of evidence suggests equivalent outcomes in elderly patients with hormone receptor-positive early-stage breast cancer receiving primary endocrine therapy only or surgery with subsequent endocrine therapy. Whether these results are reproduced in the larger BC population outside of a clinical trial currently remains unclear.

Patients and Methods

Women ≥ 70 years old diagnosed with early-stage invasive breast cancer between January 2008 and December 2013 with tumor size T1 or T2, minimal nodal involvement (N0 and N1), and estrogen and/or progesterone receptor positivity who started endocrine therapy within a year of diagnosis were identified using the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked datasets. Endocrine therapy was identified using outpatient prescription fills for anastrozole, exemestane, fulvestrant, letrozole, raloxifene, tamoxifen, and toremifene; the first fill date was used as the treatment initiation date. Surgical intervention included either breast-conserving surgery or mastectomy. Women who received chemotherapy were excluded. Trends in the use of primary endocrine therapy only were assessed using Poisson regression. Multivariable Cox proportional hazard regression was used to estimate the association between undergoing surgery within a year of diagnosis and 5-year all-cause mortality, after adjusting for patient demographics, comorbidities, and clinical cancer characteristics. Similar methods were used to assess 5-year cancer-specific mortality, where noncancer mortality was treated as a competing risk.

Results

Overall, 8784 women were included in the analysis: 8006 (91%) received surgery with endocrine therapy and 778 (9%) received primary endocrine therapy alone. The proportion of women not receiving surgery remained consistent between 2008 and 2013 (p = 0.10). The 5-year mortality was 11% (n = 619), and 19% of all deaths were due to cancer causes (n = 117). After adjustment, 5-year mortality was lower among women undergoing surgery (HR 0.59, 95% CI 0.47–0.74, p < 0.0001). Similar results were found when looking at 5-year cancer-specific mortality (HR 0.52, 95% CI 0.30–0.90, p < 0.0001).

Conclusions

Elderly breast cancer patients with early-stage hormone-receptor-positive disease receiving primary surgical intervention plus endocrine therapy may have significantly improved survival than those receiving primary endocrine therapy alone. This study suggests the importance of surgical intervention for elderly breast cancer patients and warrants further investigation and comprehensive geriatric assessment to identify subsets of elderly breast cancer patients who may benefit significantly from surgical intervention.

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Acknowledgements

The collection of cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the National Cancer Institute’s Surveillance, Epidemiology and End Results. Program under contract HHSN261201000140C awarded to the Cancer Prevention Institute of California, contract HHSN261201000035C awarded to the University of Southern California, and contract HHSN261201000034C awarded to the Public Health Institute; and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under agreement # U58DP003862-01 awarded to the California Department of Public Health. The ideas and opinions expressed herein are those of the author(s), and endorsement by the State of California Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their contractors and subcontractors is not intended nor should be inferred. The authors acknowledge the efforts of the National Cancer Institute; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database. The database infrastructure used for this project was funded by the CER Strategic Initiative of UNC’s Clinical and Translational Science Award (UL1TR001111) and the UNC School of Medicine. Additional funding for the SEER-Medicare data was provided by the UNC Lineberger Comprehensive Cancer Center’s University Cancer Research Fund (UCRF) via the State of North Carolina.

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Authors and Affiliations

  1. General Surgery Resident, Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52241, USA

    Apoorve Nayyar MBBS & Kristalyn K. Gallagher DO, FACOS, FACS

  2. Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Paula D. Strassle PhD, MSPH, Kathleen Iles MD, Danielle Jameison MD, Jihane Jadi BS & Kristalyn K. Gallagher DO, FACOS, FACS

  3. Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Paula D. Strassle PhD, MSPH

  4. Department of Surgery, VCU School of Medicine, Richmond, VA, USA

    Kandace P. McGuire MD, FACS

  5. Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA

    Kandace P. McGuire MD, FACS

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  1. Apoorve Nayyar MBBS
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  2. Paula D. Strassle PhD, MSPH
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Correspondence to Kristalyn K. Gallagher DO, FACOS, FACS.

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Nayyar, A., Strassle, P.D., Iles, K. et al. Survival Outcomes of Early-Stage Hormone Receptor-Positive Breast Cancer in Elderly Women. Ann Surg Oncol 27, 4853–4860 (2020). https://doi.org/10.1245/s10434-020-08945-1

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