Review
Oncoplastic and reconstructive breast surgery in the elderly R. James1 , S. J. McCulley2 and R. D. Macmillan1 1 Nottingham Breast Institute and 2 Department of Plastic Surgery, Nottingham City Hospital, Nottingham, UK Correspondence to: Mr R. D. Macmillan, Nottingham Breast Institute, City Hospital, Nottingham NG5 1 PB, UK (e-mail: [email protected])
Background: The recommendations of the UK All Party Parliamentary Group on Breast Cancer (2013)
have been endorsed recently by the UK Association of Breast Surgeons and are in line with the 2007 Cancer Reform Strategy, which states that treatment in older British women should be equivalent to that in younger patients unless precluded by co-morbidity or patient choice. Oncoplastic and reconstructive techniques are increasingly available to women with breast cancer. A review of the literature was carried out to investigate use of these techniques in older patients. Methods: A MEDLINE search was conducted to identify studies relating to oncoplastic and reconstructive surgery in the elderly. Results and conclusion: Nine studies were identified and included in the review. Older patients undergoing reconstruction, particularly autologous reconstruction, have outcomes that are at least as good as those achieved in younger patients, yet are far less likely to be offered these techniques. Issues influencing oncoplastic and reconstructive surgery in the elderly include: lack of standard pathways of care, concerns regarding higher operative risk, lack of evidence regarding outcomes, preconceptions regarding body image and lack of engagement with the decision-making process. A minority of older women are likely to accept reconstruction, but those who do are pleased with the results and experience good quality of life. There is now a range of safe oncoplastic and reconstructive options that could be considered as an alternative to standard mastectomy or wide local excision in older patients. Paper accepted 3 November 2014 Published online 18 February 2015 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9733
Introduction
Despite the high profile of younger sufferers, breast cancer is increasingly a disease of older women. One-third of all breast cancers occur in women aged 70 years or more; around 340 000 women aged over 65 years and resident in the UK have been diagnosed with breast cancer and are living with the effects of their disease and of their treatment1 . The number of women aged 65 years and over in the UK is projected to rise by nearly 50 per cent in the next 20 years to greater than 8 million; if current trends continue, by 2083 one-third of the population will be over 60 years of age with the absolute number of patients diagnosed with breast cancer in the older age group increasing accordingly2 . Similar demographic and epidemiological shifts are being seen in other developed countries. In the UK the All Party Parliamentary Group on Breast Cancer1 published the recommendations from its inquiry into older age and breast cancer in July 2013. This inquiry focused on three specific aspects of care: breast cancer © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
risk and early detection, access to standard treatments, and access to information and support. The resulting recommendations were designed to promote equitable treatment for older patients. The Association of Breast Surgeons3 in the UK has endorsed the findings of the inquiry alongside those of the 2012 review by the International Society of Geriatric Oncology4 , which recommended that the same surgical options should be offered to patients aged over 70 years as are offered to younger women. The 2007 Cancer Reform Strategy5 in the UK states that the only acceptable reasons for not providing equivalent treatment for older patients would be co-morbidity or patient choice. The UK National Mastectomy and Breast Reconstruction Audit6 has demonstrated that rates of immediate reconstruction in patients of all ages have risen from 11 per cent during 2005–2006 to 21 per cent during 2008–2009, and are likely to continue to rise. Despite huge geographical variation in reconstruction rates, a woman’s age remains the single most important factor in determining whether or not she will be offered breast reconstruction6 . After the age BJS 2015; 102: 480–488
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Proportion of women offered and accepting reconstruction according to age in the UK National Mastectomy and Breast Reconstruction Audit 2009
Table 1
Age (years)
Offered reconstruction (%)
Accepted reconstruction (%)
60 60 53 45 18
43 35 20 8 2
< 40 50 60 70 80
of 70 years, the proportion of women offered reconstruction falls progressively. Acceptance rates decline after the age of 55 years, but a significant minority of older women still choose to undergo reconstruction: at age 50 years, 60 per cent of women are offered reconstruction, which is accepted by 35 per cent; at 70 years, 45 per cent are offered reconstruction, with 8 per cent accepting surgery (Table 1)6 . Many issues potentially influence the offer and uptake of oncoplastic and reconstructive surgery in fit elderly patients. These include lack of standard pathways of care, concerns about higher operative risk, lack of evidence regarding outcomes, preconceptions regarding body image and lack of engagement with the decision-making process. Oncoplastic and reconstructive techniques are increasingly being used as part of the range of surgical options open to women with breast cancer, and can result in significant benefit in terms of quality of life (QoL)6 . A review of the literature was conducted to investigate the use of oncoplastic surgery and breast reconstruction in the management of older patients with breast cancer. Methods
A MEDLINE search was carried out using combinations of the search terms ‘oncoplastic’, ’reconstruction’, ‘breast’, ‘older’ and ‘elderly’. The references of identified papers were scrutinized for further relevant studies. Only papers published in English-language journals up to December 2013 were included. Results
Literature search The initial MEDLINE search produced eight citations. Of these, a letter containing no original data was discarded. The remaining seven papers consisted of a review article and six original studies. The review article was also discarded as it contained no additional data. One of the original studies was reported in an abstract presented at the © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
481
Potential citations identified (no RCTs) n = 241 Excluded as either not relevant to the review or contained no new or additional information n = 235 Original studies included in review n = 6 Further original studies identified in references n=3 Original studies included in review n = 9
Flow diagram describing identification of studies included in the review. RCT, randomized clinical trial
Fig. 1
Plastic Surgery 2005 conference7 . No accompanying paper was identified but data from the abstract were included in the literature review. A further three papers containing original data were identified on review of references. Therefore, a total of nine studies were included in this review (Fig. 1).
Oncoplastic breast-conserving surgery in the elderly Only one paper8 directly mentioned oncoplastic techniques for breast conservation in elderly women. De Lorenzi and colleagues described a retrospective review of 63 women aged 65 years or older, 14 of whom had oncoplastic breast-conserving surgery, whereas 49 women underwent mastectomy and breast reconstruction. The indications for using oncoplastic techniques were poorly located tumours (lower pole), small breast size and T2–T3 tumours. Six procedures were bilateral, two of which were for bilateral cancers and the remaining four for symmetry. Ten of the 14 patients had co-morbidities, with six having an American Society of Anesthesiologists (ASA) fitness grade of I or II, and six a score of III or IV (ASA grade was unknown in the remaining patients). There were no systemic or medical complications of surgery. One patient had a wound infection, which resolved without any delay to radiotherapy. Two patients proceeded to mastectomy. The authors concluded that oncoplastic and reconstructive techniques are safe in the elderly, and suggested potential advantages for oncoplastic techniques in the older patient; older women are more likely to have fatty breasts and may have a better cosmetic result from a mammoplasty than from mobilization of breast tissue to fill the defect left by a wide local excision8,9 . www.bjs.co.uk
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Table 2
R. James, S. J. McCulley and R. D. Macmillan
Study details Year
Study type
Age (years)
August et Lipa et al.10
1994 2003
Case series Case series
≥ 60 ≥ 65
18 81
Stover et al.7 Selber et al.15 De Lorenzi et al.8
2005 2009 2010
Case series Case series Case series
> 65 ≥ 65 > 65
Howard-McNatt et al.13 Chang et al.14 Bowman et al.16 Girotto et al.11
2011 2011 2006 2003
Case series Case series Survey (QoL) Survey (QoL)
> 60 ≥ 60 60–77 > 65
132 55 49 + 2 from conservation group 89 122 75 24
Reference al.12
No. of patients
No. of procedures 22 (4 bilateral) 84 (66 unilateral,18 bilateral, 3 redo) 150 (18 bilateral) 69 (14 bilateral) 54 (3 bilateral + 2 from conservation group) 89 (bilateral cases n.r.) 156 (34 bilateral) 83 (15 bilateral)* 28 (4 bilateral)
Implant
Autologous + implant
Autologous
Control
Yes Yes
Yes Yes
Yes Yes
Yes Yes
Yes No Yes
No No Yes
No Yes Yes
No Yes No
Yes No Yes Yes
Yes No No No
Yes Yes Yes Yes
No Yes No Yes
*Procedures were carried out simultaneously in eight of 15 women with bilateral disease; seven of 15 bilateral cases were consecutive and therefore counted as a separate outcome. n.r., Not reported; QoL, quality of life.
Breast reconstruction in the elderly Only eight published papers8,10 – 16 have addressed breast reconstruction in the elderly. A further study was presented at the Plastic Surgery 2005 conference by Stover and co-workers7 . The majority of these studies comprised small, heterogeneous, retrospective case series with variable definitions of older age (Tables 2 and 3). Complications in autologous versus implant reconstruction Six studies8,10 – 13,16 included patients with autologous and implant-based reconstructions. Lipa and colleagues10 reported significantly higher rates of complications for patients with implant-based reconstructions; complications were observed after 23 of 26 implant-based reconstructions, whereas there were ten complications among 24 latissimus dorsi (LD) flaps and 12 among 34 transverse rectus abdominis myocutaneous (TRAM) flaps in the autologous reconstruction group. Three of the complications in the autologous group were related to implants used to augment in these operations10 . Most patients with an implant-based reconstruction had minor, self-limiting early complications, but implant removal was necessary in 11 patients over the whole period of follow-up. The odds of breast-site complications were 80 per cent lower in patients undergoing an LD reconstruction and 91 per cent lower in patients undergoing a TRAM procedure than in patients who had implant-based reconstructions. Girotto et al.11 also found that patients with implant reconstructions had worse outcomes in terms of physical pain and role limitation than those with autologous reconstructions. August and colleagues12 commented that implant reconstructions were performed more frequently than tissue-based reconstructions in their series of elderly © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
patients. None of the other studies made a direct comparison of outcomes for implant-based versus autologous reconstructions. This may have been in part because of the very small numbers of autologous reconstructions in three of the studies8,12,13 . Chang and co-workers14 studied 650 patients who underwent a total of 818 free-flap procedures, 122 of whom were aged 60 years or more. The surgical complication rate was comparable to rates in other series at 21⋅8 per cent, and length of hospital stay, which was used as a surrogate for medical complications, was also acceptable at a mean of 4⋅3 days. Selber and colleagues’15 group of 55 patients all underwent free-flap reconstruction with low rates of complications. Overall, these studies suggest that autologous reconstructions may be safer in the elderly despite longer operating times and the more invasive nature of the procedure. Selber et al.15 suggested that elderly patients undergoing breast reconstruction may be encouraged to have implant rather than autologous reconstructions because of the perceived advantage of shorter operating times. However, complication rates may be higher with implant reconstructions and so autologous reconstructions should be regarded as low-to-intermediate risk operations with an acceptable risk profile for the older patient.
Complications in older versus younger patients Five studies10 – 12,14,15 compared outcomes in older and younger women. August and colleagues12 looked at 224 women aged under 60 years and 18 women aged 60 years and over who had undergone breast reconstruction. The older women had fewer complications than those in the younger group: seven with complications among 22 reconstructions (4 bilateral) versus 134 among 269 www.bjs.co.uk
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Table 3
483
Outcomes Age (years)
Implant
August et al.12
≥ 60
18
Lipa et al.10
≥ 65
26 (18 TEs) 13 (11 LDs, 2 TRAMs)
45 (13 LDs, 32 TRAMs)
Stover et al.7
> 65
150 (all TEs) 0
0
Selber et al.15
≥ 65
0
De Lorenzi et al.8
> 65
Howard-McNatt et al.13
Chang et al.14
Reference
Bowman et al.16
Girotto et al.11
Autologous + implant
Autologous
Complications
1 LD
3 TRAMs
Overall 7 of 22 Surgical 7 of 22 Implant loss 7 of 19 Medical 0 of 22 Overall 64 of 84§ Surgical 60 of 84 Implant loss 12 of 39 Medical 4 of 84 Overall 58 of 150¶ Surgical 46 of 150 Implant loss 11 of 150 Medical 1 of 150 Overall 22 of 69 Surgical 19 of 69 Inplant loss n.a. Medical 3 of 69 Overall 9 of 54 Surgical 9 of 54 Implant loss 6 of 49 Medical 0 of 54 Overall 10 of 89 Surgical 7 of 89 Implant loss 3 of 79 Medical 0 of 89 Overall n.r. Surgical 34 of 156 Implant loss n.a. Medical n.r.** Overall n.r. Surgical 42 of 83¶†† Implant loss n.r. Overall 5 of 28 Surgical 4 of 28 Implant loss n.r. Medical 1 of 28
0
69
48 (8 TEs)
1 LD
> 60
77#
2 LDs
5 (1 LD, 2 TRAMs, 2 local fasciocutaneous flaps) 10 (TRAMs, 1 DIEP)
≥ 60
0
0
156 free flaps (major TRAMs or DIEPs)
60–77
31
0
52 (43 TRAMs, 8 LDs, 1 local flap)
> 65
14 (TEs)
0
14 (7 TRAM of DIEP, 4 pedicled TRAMs, 3 LDs)
Reoperation for complications‡
Hospital stay (days)
Follow-up (months)*
6 of 22
n.r.
n.r.
n.r.
n.r.
50⋅4
13 of 150
2⋅8 (mean)
37 (2–120)
0 of 69
3⋅5
5⋅6(9⋅4)†
6 of 54
n.r.
43⋅1 (7⋅5–94⋅6)
4 of 89
n.r.
86
n.r.
4⋅3
n.r.
17 of 83
n.r.
45⋅6
n.r.
n.r.
n.r.
*Values in parentheses are range, except †s.d. ‡Includes implant loss. §Mostly minor and self-limiting. ¶Reported as incidence of each complication rather than as number of patients affected by complication. #Figures were given as percentages rather than absolute numbers and have been extrapolated. **Comparable to younger control group. ††Includes 25 minor self-limiting complications. LD, latissimus dorsi flap; TRAM, transverse rectus abdominis myocutaneous flap; n.r., not reported; TE, tissue expander; n.a., not applicable; DIEP, deep inferior epigastric perforator flap.
reconstructions (45 bilateral) respectively. This was particularly marked for patients undergoing implant-based reconstructions, among whom the older group had half the complication rate of the younger group; however, it is recognized that the number of patients in the older group was considerably smaller. This contrasts with the findings of Lipa and co-workers10 , who studied a cohort of 81 women aged over 65 years who had undergone implant and autologous reconstructions. They were compared with historical control data including patients of all ages from the same institution. Although complication rates were similar for autologous reconstructions, rates of complications related to implant reconstruction were significantly higher in the older patients; there were 20 complications (77 per cent) in 26 reconstructions among women aged over 65 years versus
218 (36⋅9 per cent) in 591 reconstructions among younger patients. Selber et al.15 compared 976 women aged less than 65 years with 55 patients aged 65 years and over, all of whom had undergone free-flap reconstructions. The older patients had higher ASA grades, a higher prevalence of hypertension and a higher average body mass index (BMI) than women in the younger group. However, there was no difference in length of stay, medical or surgical complication rates, reoperations or revisions between the older and younger patients. Chang and colleagues14 stratified patients undergoing free-flap procedures into four age groups: less than 50 years, 50–59 years, 60–69 years and 70 years or more. They found no significant differences between the four groups in rates of surgical complications, flap loss or length of stay. ASA grade and BMI were
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Percentage of women undergoing reconstruction stratified according to age
Table 4
Reference De Lorenzi et al.8 August et al.12 Stover et al.7 Lipa et al.10
Definition of older (years)
Older women undergoing reconstruction (%)
Younger women undergoing reconstruction (%)
> 65 ≥ 60 > 65 ≥ 65
17 7 11 9
n.r. 38 61 41
n.r., Not reported.
significant predictors of overall complications, but age was not a predictor of outcome.
Quality of life Two studies11,16 investigated QoL, but used general health questionnaires rather than breast-specific ones. Both demonstrated good QoL for older patients after breast reconstruction. Bowman and colleagues16 surveyed 75 patients aged 60–77 years with regard to type of reconstruction, recovery time, complications, patient satisfaction, general health and QoL, with an 81 per cent response rate. The majority of patients who had implant reconstruction recovered within 4 weeks of surgery, whereas the majority who had autologous reconstruction recovered within 8 weeks. Some 70 per cent of patients thought that their results were good or excellent. There was no significant correlation between patient satisfaction and having experienced a complication. When asked if they would undergo the same treatment again, 89 per cent of respondent said they would. More than 90 per cent of patients felt that age should not determine whether or not reconstruction is offered. All respondents felt that reconstruction should have been discussed at diagnosis. Girotto et al.11 carried out a survey using Short Form 36 (SF-36®; QualityMetric, Lincoln, Rhode Island, USA) to investigate health-related QoL, body image and physical functioning in 24 patients aged over 65 years who had undergone breast reconstruction11 . The results were compared with age-matched general population norms, and those of patients who underwent mastectomy alone and a previously reported group of younger patients who had had mastectomy and reconstruction. There were no differences in complication rates between the older and younger groups. Older patients had better outcomes in terms of overall QoL after surgery than the age-matched general population and patients who had undergone mastectomy alone in all areas surveyed. They had better outcomes than younger patients who had undergone breast reconstruction in subscales influenced by mental health, but scored worse in areas relating to physical function. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
Proportion of elderly patients undergoing reconstruction after mastectomy De Lorenzi and co-workers8 identified 290 patients aged more than 65 years undergoing mastectomy over a 5-year interval. Almost all were offered reconstruction, but only 17 per cent accepted. August et al.12 found that over 11 years only 7 per cent of women aged 60 years or more had a breast reconstruction, compared with 38 per cent of younger women. Stover and colleagues7 reported a reconstruction rate of 11 per cent among women over 65 years of age, compared with 61 per cent in younger women. In a study of patients treated at M. D. Anderson Cancer Center, Lipa et al.10 found that 9 per cent of those aged 65 years and over treated during the study interval underwent breast reconstruction, compared with 41 per cent of those aged less than 65 years (Table 4). Discussion
The All Party Parliamentary Group on Breast Cancer’s 2013 report Age is Just a Number 1 makes it clear that older women with breast cancer should receive the most appropriate treatment given their condition and co-morbidities. National Institute for Health and Care Excellence guidelines for early and locally advanced breast cancer, and the National Health Service Constitution have stressed that management should not be dictated by age alone. In fact, it has been against the law to discriminate on the basis of age in health and social care since the 2010 Equality Act came into force in 2012. The lack of evidence in the literature with regard to reconstruction and oncoplastic breast-conserving surgery in the elderly reflects the underuse of these techniques in this group. The studies identified in this review suggest that complication rates in the elderly following reconstruction are comparable to those among younger groups, and that length of stay and recovery time are not significantly different. These studies have case selection bias and are based on small numbers, so their results cannot necessarily be extrapolated to all older women. However, QoL is improved with breast conservation or breast reconstruction in older patients, as in younger ones. Patients themselves feel that reconstruction is an option that should be considered at the time of diagnosis, and yet it is discussed in only a minority of instances. The results of the National Mastectomy and Breast Reconstruction Audit6 clearly demonstrate that older women are far less likely to be offered reconstruction than their younger counterparts. The reasons for failure to offer older women the same options as younger patients are varied. They include a tendency for older www.bjs.co.uk
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patients to be managed ‘off protocol’ and a reluctance to offer reconstructive techniques in a patient group where evidence is scarce. Age alone has been shown to be an independent risk factor for less than optimal treatment for breast cancer17,18 . A number of studies18 – 20 have shown that only around 50 per cent of older patients are treated according to national standards of care. Poor adherence to standard cancer management reflects the lack of level 1 evidence regarding optimal treatments for the elderly4 . Elderly women are under-represented in major trials, many of which excluded older patients altogether21 . Where they have been included, elderly patients usually form a small subgroup that is underpowered for statistical analysis22,23 . One of the nine recommendations made by the All Party Parliamentary Group on Breast Cancer1 was that data collection on outcomes for the elderly should be supported in order to create a firm evidence base for treatment options in this group. Establishing the absolute benefit of any treatment or procedure is essential in an elderly patient group as protecting QoL is of particular importance where life expectancy is more limited24 . There may be concern over presumed higher complication rates, and obviously older women are more likely to have co-morbidities. Assessment of function, rather than chronological age, has been found to be the most accurate method of predicting postoperative outcome25 . Proposed frailty index tools may help to identify patients at genuinely increased risk of complications and could result in an increase in the number of older patients being offered surgery. Failure to discuss reconstruction may also reflect a degree of prejudice within the medical profession, in which assumptions are made about older patients’ priorities regarding body image and QoL. This is compounded by a tendency among doctors to underestimate the life expectancy of older patients and to overestimate the likely impact of treatment toxicity26 . In fact, average life expectancy for a woman at 65 years in the UK is a further 21 years, with 11⋅6 years of good health2 . In addition, survival after treatment for breast cancer has improved substantially over recent years. Many older women can expect years of good health after a diagnosis of breast cancer. Lipa and colleagues10 reported a 10-year survival rate of 91 per cent for women aged 65 years and over who had undergone reconstruction with implants, and 88 per cent for those who had undergone a TRAM flap procedure. Issues around survivorhood are as relevant to many of these women as they are to younger patients. The National Mastectomy and Breast Reconstruction Audit27 has reported significant advantages for patients having reconstruction, in terms of satisfaction with appearance
(clothed and unclothed), confidence in social settings, emotional health, pain and sexual satisfaction. The studies in this review have demonstrated that older women undergoing reconstruction benefit significantly in terms of QoL. The limited evidence in the literature suggests that older women may regard body image differently to younger women, and find that it holds less significance for their QoL than other issues such as function28 – 32 . Acceptance rates remain low in series where all older patients have been offered reconstruction. Despite this, a significant minority of older women regard satisfactory body image as an important goal and choose to undergo reconstruction accordingly28 . Figueiredo and colleagues33 found that body image was highly significant in an investigation of the relationship between patient treatment preference, body image and mental health in 563 women aged 67 years or older. Body image was found to influence treatment preference in almost one-third of the patients studied and poor body image was a predictor of impaired mental health at 2 years. Function may also be facilitated by the use of some simple reconstructive techniques. Some of these may allow breast conservation, which can be the simplest option of all. Older women are less likely to be offered reconstruction than their younger counterparts, but are also less likely to accept it. This may reflect the fact that many older patients feel disenfranchised from the decision-making process. This is well documented and strategies should be adopted to enable older patients to participate fully in decisions regarding their treatment. It is, however, also highly likely that many older women simply do not wish to undergo more extensive surgery, and feel that a reconstruction will not make a substantial enough improvement to their QoL to justify the risks. It is important to establish priorities when discussing treatment. Mandelblatt and co-workers34 carried out a review of outcomes and QoL following treatment for breast cancer in older women. Older women who felt involved in the decision-making process, experienced good communication with medical staff, had treatments that took account of their views on body image and had a low perception of bias were more likely to have good QoL scores and higher levels of satisfaction. Oncoplastic breast-conserving surgery may offer oncological advantages as a result of the wider area of tissue excised and, importantly, margins are more likely to be clear with a reduction in the number of second operations required. In a survey of 11 studies35 – 45 with a total of 1532 patients undergoing therapeutic mammoplasty, a median of 7⋅4 (range 0⋅1–16) per cent underwent further surgery for close or involved margins. This compares with a re-excision rate of 20 per cent reported in a large cohort
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study of 55 297 women undergoing breast conservation in English hospitals46 . In some patients, wider margins may obviate the need for radiotherapy. Radiotherapy may have a detrimental impact on cosmesis and function, and can be omitted safely in selected groups of elderly patients. In a randomized clinical trial comparing quadrantectomy alone and quadrantectomy with radiotherapy, Veronesi et al.47 found that patients aged over 55 years who had not received radiotherapy had significantly lower local recurrence rates than their younger counterparts. Results of the PRIME 248 and CALGB 934349 trials have confirmed that older patients who receive hormone therapy after breast conservation treatment for low-grade, hormone receptor-positive, axillary node-negative cancers can avoid radiotherapy, with low rates of ipsilateral breast recurrence and equivalent overall survival, . The British Association of Surgical Oncology (BASO) II trial50 , while not an equivalence trial, suggested that tamoxifen is likely to be as effective as radiotherapy in reducing local recurrence among low-risk women undergoing breast conservation. Cancer care has focused increasingly on individualized treatment and patient choice17,24,25,51,52 . It should be recognized that elderly patients are a heterogeneous group with regard to fitness, function and expectations. Gennari and Audisio53 describe ageing as ‘a physiologic process characterized by loss of independence, co-morbidity and geriatric syndromes. Age 70 represents a milestone beyond which older people are found’. Suitability for oncoplastic or reconstructive procedures should not rest on chronological age alone.
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5 6
7
8
9
10
11
12 13
14
Disclosure
The authors declare no conflict of interest. References 1 All Party Parliamentary Group on Breast Cancer (APPGBC). Age is Just a Number. The Report of the Parliamentary Inquiry into Older Age and Breast Cancer. APPGBC: London, 2013. 2 Office for National Statistics. Table A1-1, Principal Projection – UK Summary, 2010-Based; 2011. http://www. ons.gov.uk/ons/publications/re-reference-tables.html? edition=tcm%3A77-229866 [accessed 20 November 2014]. 3 Cawthorne S. All party parliamentary group on breast cancer: inquiry into older age and breast cancer. ABS Newsletter 2013: 1. 4 Biganzoli L, Wildiers H, Oakman C, Marotti L, Loibl S, Kunkler I et al. Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European
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21 Kiderlen M, Bastiaannet E, Walsh PM, Keating NI, Schrodi S, Engel J et al. Surgical treatment of early stage breast cancer in the elderly: an international comparison. Breast Cancer Res Treat 2012; 132: 675–682. 22 Hurria A, Leung D, Trainor K, Borgen P, Norton L, Hudis C. Factors influencing treatment patterns of breast cancer patients age 75 and older. Crit Rev Oncol Hematol 2003; 46: 121–126. 23 Smith BD, Jiang J, McLaughlin SS, Hurria A, Smith GL, Giordano SH et al. Improvement in breast cancer outcomes over time: are older women missing out? J Clin Oncol 2011; 29: 4647–4653. 24 Crivellari D, Aapro M, Leonard R, von Minckwitz G, Brain E, Goldhirsch A et al. Breast cancer in the elderly. J Clin Oncol 2007; 25: 1882–1890. 25 Muss HB, Busby-Whitehead J. Older women with breast cancer: slow progress, great opportunity, now is the time. J Clin Oncol 2011: 29: 4608–4610. 26 Diehl KM. Lack of knowledge is not the same as lack of benefit: it is time to stop undertreating our elderly breast cancer patients. J Surg Oncol 2009; 99: 129–130. 27 NHS Information Centre for Health and Social Care. National Mastectomy and Breast Reconstruction Audit. Fourth Annual Report. NHS Information Centre for Health and Social Care: Leeds, 2011. 28 Pusic AL, Thompson TA, Kerrigan CL, Sargeant R, Slezak S, Chang BW et al. Surgical options for early-stage breast cancer: factors associated with patient choice and postoperative quality of life. Plast Reconstr Surg 1999; 104: 1325–1333. 29 Kenny P, King LM, Shiell A, Seymour J, Hall J, Langlands A et al. Early stage breast cancer: costs and quality of life one year after treatment by mastectomy or conservative surgery and radiation therapy. Breast 2000; 9: 37–44. 30 Al-Ghazal S, Fallowfield L, Blamey RW. Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer 2000; 36: 1938–1943. 31 Engel J, Kerr J, Schlesinger-Raab A, Sauer H, Holzel D. Quality of life following breast conserving therapy or mastectomy: results of a 5-year prospective study. Breast J 2004; 10: 223–231. 32 Hopwood P, Haviland J, Mills J. The impact of age and clinical factors on quality of life in early breast cancer: an analysis of 2208 women recruited to the UK START trial (Standardisation of Breast Radiotherapy Trial). Breast 2007; 16: 241–251. 33 Figueiredo MI, Cullen J, Hweng Y-T. Breast cancer treatment in older women: does getting what you want improve your long term body image and mental health? J Clin Oncol 2004; 22: 4002–4009. 34 Mandelblatt JS, Figueiredo MI, Cullen J, Tallarico M, Barry WT, Cohen HJ. Outcomes and quality of life following breast cancer treatment in older women: when, why, how much and what do women want? Health Qual Life Outcomes 2003; 1: 45.
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35 Clough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Falcou M-C. Oncoplastic techniques allow extensive resections for breast conserving therapy of breast carcinomas. Ann Surg 2003; 237: 26–34. 36 Kaur N, Petit JY, Rietjens M, Maffini F, Luini A, Gatti G et al. Comparative study of surgical margins in oncoplastic surgery and quadrantectomy in breast cancer. Ann Surg Oncol 2005; 12: 539–545. 37 McCulley SJ, Macmillan RD. Therapeutic mammoplasty – analysis of 50 consecutive cases. Br J Plast Surg 2005; 58: 902–907. 38 Losken A, Styblo TB, Carlson GW, Jones GE, Amerson BJ. Management algorithm and outcome evaluation of partial mastectomy defects treated using reduction or mastopexy techniques. Ann Plast Surg 2007; 59: 235–242. 39 Rietjens M, Urban C, Rey PC, Mazzarol G, Maisonneuve P, Garusi C et al. Long-term oncological results of breast conservative treatment with oncoplastic surgery. Breast 2007; 16: 387–395. 40 Giacalone PL, Roger P, Dubon O, El Gareh N, Rihaoui S, Taourel P et al. Comparative study of the accuracy of breast resection in oncoplastic surgery and quadrantectomy in breast cancer. Ann Surg Oncol 2007; 14: 605–614. 41 Meretoja TJ, Svarvar C, Jahkola TA. Outcome of oncoplastic breast surgery in 90 prospective patients. Am J Surg 2010; 200: 224–228. 42 Fitoussi AD, Berry MG, Famà F, Falcou MC, Curnier A, Couturaud B et al. Oncoplastic breast surgery for cancer: analysis of 540 consecutive cases [outcomes article]. Plast Reconstr Surg 2010; 125: 454–462. 43 Caruso F, Catanuto G, De Meo L, Ferrara M, Gallodoro A, Petrolito E et al. Outcomes of bilateral mammoplasty for early stage breast cancer. Eur J Surg Oncol 2008; 34: 1143–1147. 44 Grubnik A, Benn C, Edwards G. Therapeutic mammoplasty for breast cancer: oncological and aesthetic outcomes. World J Surg 2013; 37: 72–83. 45 Schaverien MV, Raine C, Majdak-Paredes E, Dixon JM. Therapeutic mammoplasty – extending indications and achieving low incomplete excision rates. Eur J Surg Oncol 2013; 39: 329–333. 46 Jeevan R, Cromwell DA, Trivella M, Lawrence G, Kearins O, Pereira J et al. Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics. BMJ 2012; 345: e405. 47 Veronesi U, Luini A, del Vecchio M, Greco M, Galimberti V, Merson M et al. Radiotherapy after breast-preserving surgery in women with localised cancer of the breast. N Engl J Med 1993; 328: 1587–1591. 48 Kunkler I. Avoiding radiotherapy is an option for some older patients with breast cancer. San Antonio Breast Cancer Symposium 2013, San Antonio, 2013.
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49 Hughes K, Schnaper L, Berry D, Cirrincione C, McCormick B, Shank B et al. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 2004; 351: 971–977. 50 Blamey RW, Bates T, Chetty U, Duffy SW, Ellis IO, George D et al. Radiotherapy or tamoxifen after conserving surgery for breast cancers of excellent prognosis: British Association of Surgical Oncology (BASO) II trial. Eur J Cancer 2013; 49: 2294–2302. 51 Beadle BM, Woodward WA, Buchholz TA. The impact of
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age on outcome in early stage breast cancer. Sem Radiat Oncol 2011; 21: 26–34. 52 Gennari R, Curigliano G, Rotmensz N, Robertson C, Colleoni M, Zurrida S et al. Breast carcinoma in elderly women: features of disease presentation, choice of local and systemic treatments compared with younger postmenopausal patients. Cancer 2004; 101: 1302–1310. 53 Gennari R, Audisio RA. Breast cancer in elderly women. Optimizing the treatment. Breast Cancer Res Treat 2008; 110: 199–209.
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Oncoplastic and reconstructive breast surgery in the elderly R. James1 , S. J. McCulley2 and R. D. Macmillan1 1 Nottingham Breast Institute and 2 Department of Plastic Surgery, Nottingham City Hospital, Nottingham, UK Correspondence to: Mr R. D. Macmillan, Nottingham Breast Institute, City Hospital, Nottingham NG5 1 PB, UK (e-mail: [email protected])
Background: The recommendations of the UK All Party Parliamentary Group on Breast Cancer (2013)
have been endorsed recently by the UK Association of Breast Surgeons and are in line with the 2007 Cancer Reform Strategy, which states that treatment in older British women should be equivalent to that in younger patients unless precluded by co-morbidity or patient choice. Oncoplastic and reconstructive techniques are increasingly available to women with breast cancer. A review of the literature was carried out to investigate use of these techniques in older patients. Methods: A MEDLINE search was conducted to identify studies relating to oncoplastic and reconstructive surgery in the elderly. Results and conclusion: Nine studies were identified and included in the review. Older patients undergoing reconstruction, particularly autologous reconstruction, have outcomes that are at least as good as those achieved in younger patients, yet are far less likely to be offered these techniques. Issues influencing oncoplastic and reconstructive surgery in the elderly include: lack of standard pathways of care, concerns regarding higher operative risk, lack of evidence regarding outcomes, preconceptions regarding body image and lack of engagement with the decision-making process. A minority of older women are likely to accept reconstruction, but those who do are pleased with the results and experience good quality of life. There is now a range of safe oncoplastic and reconstructive options that could be considered as an alternative to standard mastectomy or wide local excision in older patients. Paper accepted 3 November 2014 Published online 18 February 2015 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9733
Introduction
Despite the high profile of younger sufferers, breast cancer is increasingly a disease of older women. One-third of all breast cancers occur in women aged 70 years or more; around 340 000 women aged over 65 years and resident in the UK have been diagnosed with breast cancer and are living with the effects of their disease and of their treatment1 . The number of women aged 65 years and over in the UK is projected to rise by nearly 50 per cent in the next 20 years to greater than 8 million; if current trends continue, by 2083 one-third of the population will be over 60 years of age with the absolute number of patients diagnosed with breast cancer in the older age group increasing accordingly2 . Similar demographic and epidemiological shifts are being seen in other developed countries. In the UK the All Party Parliamentary Group on Breast Cancer1 published the recommendations from its inquiry into older age and breast cancer in July 2013. This inquiry focused on three specific aspects of care: breast cancer © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
risk and early detection, access to standard treatments, and access to information and support. The resulting recommendations were designed to promote equitable treatment for older patients. The Association of Breast Surgeons3 in the UK has endorsed the findings of the inquiry alongside those of the 2012 review by the International Society of Geriatric Oncology4 , which recommended that the same surgical options should be offered to patients aged over 70 years as are offered to younger women. The 2007 Cancer Reform Strategy5 in the UK states that the only acceptable reasons for not providing equivalent treatment for older patients would be co-morbidity or patient choice. The UK National Mastectomy and Breast Reconstruction Audit6 has demonstrated that rates of immediate reconstruction in patients of all ages have risen from 11 per cent during 2005–2006 to 21 per cent during 2008–2009, and are likely to continue to rise. Despite huge geographical variation in reconstruction rates, a woman’s age remains the single most important factor in determining whether or not she will be offered breast reconstruction6 . After the age BJS 2015; 102: 480–488
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Proportion of women offered and accepting reconstruction according to age in the UK National Mastectomy and Breast Reconstruction Audit 2009
Table 1
Age (years)
Offered reconstruction (%)
Accepted reconstruction (%)
60 60 53 45 18
43 35 20 8 2
< 40 50 60 70 80
of 70 years, the proportion of women offered reconstruction falls progressively. Acceptance rates decline after the age of 55 years, but a significant minority of older women still choose to undergo reconstruction: at age 50 years, 60 per cent of women are offered reconstruction, which is accepted by 35 per cent; at 70 years, 45 per cent are offered reconstruction, with 8 per cent accepting surgery (Table 1)6 . Many issues potentially influence the offer and uptake of oncoplastic and reconstructive surgery in fit elderly patients. These include lack of standard pathways of care, concerns about higher operative risk, lack of evidence regarding outcomes, preconceptions regarding body image and lack of engagement with the decision-making process. Oncoplastic and reconstructive techniques are increasingly being used as part of the range of surgical options open to women with breast cancer, and can result in significant benefit in terms of quality of life (QoL)6 . A review of the literature was conducted to investigate the use of oncoplastic surgery and breast reconstruction in the management of older patients with breast cancer. Methods
A MEDLINE search was carried out using combinations of the search terms ‘oncoplastic’, ’reconstruction’, ‘breast’, ‘older’ and ‘elderly’. The references of identified papers were scrutinized for further relevant studies. Only papers published in English-language journals up to December 2013 were included. Results
Literature search The initial MEDLINE search produced eight citations. Of these, a letter containing no original data was discarded. The remaining seven papers consisted of a review article and six original studies. The review article was also discarded as it contained no additional data. One of the original studies was reported in an abstract presented at the © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
481
Potential citations identified (no RCTs) n = 241 Excluded as either not relevant to the review or contained no new or additional information n = 235 Original studies included in review n = 6 Further original studies identified in references n=3 Original studies included in review n = 9
Flow diagram describing identification of studies included in the review. RCT, randomized clinical trial
Fig. 1
Plastic Surgery 2005 conference7 . No accompanying paper was identified but data from the abstract were included in the literature review. A further three papers containing original data were identified on review of references. Therefore, a total of nine studies were included in this review (Fig. 1).
Oncoplastic breast-conserving surgery in the elderly Only one paper8 directly mentioned oncoplastic techniques for breast conservation in elderly women. De Lorenzi and colleagues described a retrospective review of 63 women aged 65 years or older, 14 of whom had oncoplastic breast-conserving surgery, whereas 49 women underwent mastectomy and breast reconstruction. The indications for using oncoplastic techniques were poorly located tumours (lower pole), small breast size and T2–T3 tumours. Six procedures were bilateral, two of which were for bilateral cancers and the remaining four for symmetry. Ten of the 14 patients had co-morbidities, with six having an American Society of Anesthesiologists (ASA) fitness grade of I or II, and six a score of III or IV (ASA grade was unknown in the remaining patients). There were no systemic or medical complications of surgery. One patient had a wound infection, which resolved without any delay to radiotherapy. Two patients proceeded to mastectomy. The authors concluded that oncoplastic and reconstructive techniques are safe in the elderly, and suggested potential advantages for oncoplastic techniques in the older patient; older women are more likely to have fatty breasts and may have a better cosmetic result from a mammoplasty than from mobilization of breast tissue to fill the defect left by a wide local excision8,9 . www.bjs.co.uk
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Table 2
R. James, S. J. McCulley and R. D. Macmillan
Study details Year
Study type
Age (years)
August et Lipa et al.10
1994 2003
Case series Case series
≥ 60 ≥ 65
18 81
Stover et al.7 Selber et al.15 De Lorenzi et al.8
2005 2009 2010
Case series Case series Case series
> 65 ≥ 65 > 65
Howard-McNatt et al.13 Chang et al.14 Bowman et al.16 Girotto et al.11
2011 2011 2006 2003
Case series Case series Survey (QoL) Survey (QoL)
> 60 ≥ 60 60–77 > 65
132 55 49 + 2 from conservation group 89 122 75 24
Reference al.12
No. of patients
No. of procedures 22 (4 bilateral) 84 (66 unilateral,18 bilateral, 3 redo) 150 (18 bilateral) 69 (14 bilateral) 54 (3 bilateral + 2 from conservation group) 89 (bilateral cases n.r.) 156 (34 bilateral) 83 (15 bilateral)* 28 (4 bilateral)
Implant
Autologous + implant
Autologous
Control
Yes Yes
Yes Yes
Yes Yes
Yes Yes
Yes No Yes
No No Yes
No Yes Yes
No Yes No
Yes No Yes Yes
Yes No No No
Yes Yes Yes Yes
No Yes No Yes
*Procedures were carried out simultaneously in eight of 15 women with bilateral disease; seven of 15 bilateral cases were consecutive and therefore counted as a separate outcome. n.r., Not reported; QoL, quality of life.
Breast reconstruction in the elderly Only eight published papers8,10 – 16 have addressed breast reconstruction in the elderly. A further study was presented at the Plastic Surgery 2005 conference by Stover and co-workers7 . The majority of these studies comprised small, heterogeneous, retrospective case series with variable definitions of older age (Tables 2 and 3). Complications in autologous versus implant reconstruction Six studies8,10 – 13,16 included patients with autologous and implant-based reconstructions. Lipa and colleagues10 reported significantly higher rates of complications for patients with implant-based reconstructions; complications were observed after 23 of 26 implant-based reconstructions, whereas there were ten complications among 24 latissimus dorsi (LD) flaps and 12 among 34 transverse rectus abdominis myocutaneous (TRAM) flaps in the autologous reconstruction group. Three of the complications in the autologous group were related to implants used to augment in these operations10 . Most patients with an implant-based reconstruction had minor, self-limiting early complications, but implant removal was necessary in 11 patients over the whole period of follow-up. The odds of breast-site complications were 80 per cent lower in patients undergoing an LD reconstruction and 91 per cent lower in patients undergoing a TRAM procedure than in patients who had implant-based reconstructions. Girotto et al.11 also found that patients with implant reconstructions had worse outcomes in terms of physical pain and role limitation than those with autologous reconstructions. August and colleagues12 commented that implant reconstructions were performed more frequently than tissue-based reconstructions in their series of elderly © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
patients. None of the other studies made a direct comparison of outcomes for implant-based versus autologous reconstructions. This may have been in part because of the very small numbers of autologous reconstructions in three of the studies8,12,13 . Chang and co-workers14 studied 650 patients who underwent a total of 818 free-flap procedures, 122 of whom were aged 60 years or more. The surgical complication rate was comparable to rates in other series at 21⋅8 per cent, and length of hospital stay, which was used as a surrogate for medical complications, was also acceptable at a mean of 4⋅3 days. Selber and colleagues’15 group of 55 patients all underwent free-flap reconstruction with low rates of complications. Overall, these studies suggest that autologous reconstructions may be safer in the elderly despite longer operating times and the more invasive nature of the procedure. Selber et al.15 suggested that elderly patients undergoing breast reconstruction may be encouraged to have implant rather than autologous reconstructions because of the perceived advantage of shorter operating times. However, complication rates may be higher with implant reconstructions and so autologous reconstructions should be regarded as low-to-intermediate risk operations with an acceptable risk profile for the older patient.
Complications in older versus younger patients Five studies10 – 12,14,15 compared outcomes in older and younger women. August and colleagues12 looked at 224 women aged under 60 years and 18 women aged 60 years and over who had undergone breast reconstruction. The older women had fewer complications than those in the younger group: seven with complications among 22 reconstructions (4 bilateral) versus 134 among 269 www.bjs.co.uk
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Table 3
483
Outcomes Age (years)
Implant
August et al.12
≥ 60
18
Lipa et al.10
≥ 65
26 (18 TEs) 13 (11 LDs, 2 TRAMs)
45 (13 LDs, 32 TRAMs)
Stover et al.7
> 65
150 (all TEs) 0
0
Selber et al.15
≥ 65
0
De Lorenzi et al.8
> 65
Howard-McNatt et al.13
Chang et al.14
Reference
Bowman et al.16
Girotto et al.11
Autologous + implant
Autologous
Complications
1 LD
3 TRAMs
Overall 7 of 22 Surgical 7 of 22 Implant loss 7 of 19 Medical 0 of 22 Overall 64 of 84§ Surgical 60 of 84 Implant loss 12 of 39 Medical 4 of 84 Overall 58 of 150¶ Surgical 46 of 150 Implant loss 11 of 150 Medical 1 of 150 Overall 22 of 69 Surgical 19 of 69 Inplant loss n.a. Medical 3 of 69 Overall 9 of 54 Surgical 9 of 54 Implant loss 6 of 49 Medical 0 of 54 Overall 10 of 89 Surgical 7 of 89 Implant loss 3 of 79 Medical 0 of 89 Overall n.r. Surgical 34 of 156 Implant loss n.a. Medical n.r.** Overall n.r. Surgical 42 of 83¶†† Implant loss n.r. Overall 5 of 28 Surgical 4 of 28 Implant loss n.r. Medical 1 of 28
0
69
48 (8 TEs)
1 LD
> 60
77#
2 LDs
5 (1 LD, 2 TRAMs, 2 local fasciocutaneous flaps) 10 (TRAMs, 1 DIEP)
≥ 60
0
0
156 free flaps (major TRAMs or DIEPs)
60–77
31
0
52 (43 TRAMs, 8 LDs, 1 local flap)
> 65
14 (TEs)
0
14 (7 TRAM of DIEP, 4 pedicled TRAMs, 3 LDs)
Reoperation for complications‡
Hospital stay (days)
Follow-up (months)*
6 of 22
n.r.
n.r.
n.r.
n.r.
50⋅4
13 of 150
2⋅8 (mean)
37 (2–120)
0 of 69
3⋅5
5⋅6(9⋅4)†
6 of 54
n.r.
43⋅1 (7⋅5–94⋅6)
4 of 89
n.r.
86
n.r.
4⋅3
n.r.
17 of 83
n.r.
45⋅6
n.r.
n.r.
n.r.
*Values in parentheses are range, except †s.d. ‡Includes implant loss. §Mostly minor and self-limiting. ¶Reported as incidence of each complication rather than as number of patients affected by complication. #Figures were given as percentages rather than absolute numbers and have been extrapolated. **Comparable to younger control group. ††Includes 25 minor self-limiting complications. LD, latissimus dorsi flap; TRAM, transverse rectus abdominis myocutaneous flap; n.r., not reported; TE, tissue expander; n.a., not applicable; DIEP, deep inferior epigastric perforator flap.
reconstructions (45 bilateral) respectively. This was particularly marked for patients undergoing implant-based reconstructions, among whom the older group had half the complication rate of the younger group; however, it is recognized that the number of patients in the older group was considerably smaller. This contrasts with the findings of Lipa and co-workers10 , who studied a cohort of 81 women aged over 65 years who had undergone implant and autologous reconstructions. They were compared with historical control data including patients of all ages from the same institution. Although complication rates were similar for autologous reconstructions, rates of complications related to implant reconstruction were significantly higher in the older patients; there were 20 complications (77 per cent) in 26 reconstructions among women aged over 65 years versus
218 (36⋅9 per cent) in 591 reconstructions among younger patients. Selber et al.15 compared 976 women aged less than 65 years with 55 patients aged 65 years and over, all of whom had undergone free-flap reconstructions. The older patients had higher ASA grades, a higher prevalence of hypertension and a higher average body mass index (BMI) than women in the younger group. However, there was no difference in length of stay, medical or surgical complication rates, reoperations or revisions between the older and younger patients. Chang and colleagues14 stratified patients undergoing free-flap procedures into four age groups: less than 50 years, 50–59 years, 60–69 years and 70 years or more. They found no significant differences between the four groups in rates of surgical complications, flap loss or length of stay. ASA grade and BMI were
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Percentage of women undergoing reconstruction stratified according to age
Table 4
Reference De Lorenzi et al.8 August et al.12 Stover et al.7 Lipa et al.10
Definition of older (years)
Older women undergoing reconstruction (%)
Younger women undergoing reconstruction (%)
> 65 ≥ 60 > 65 ≥ 65
17 7 11 9
n.r. 38 61 41
n.r., Not reported.
significant predictors of overall complications, but age was not a predictor of outcome.
Quality of life Two studies11,16 investigated QoL, but used general health questionnaires rather than breast-specific ones. Both demonstrated good QoL for older patients after breast reconstruction. Bowman and colleagues16 surveyed 75 patients aged 60–77 years with regard to type of reconstruction, recovery time, complications, patient satisfaction, general health and QoL, with an 81 per cent response rate. The majority of patients who had implant reconstruction recovered within 4 weeks of surgery, whereas the majority who had autologous reconstruction recovered within 8 weeks. Some 70 per cent of patients thought that their results were good or excellent. There was no significant correlation between patient satisfaction and having experienced a complication. When asked if they would undergo the same treatment again, 89 per cent of respondent said they would. More than 90 per cent of patients felt that age should not determine whether or not reconstruction is offered. All respondents felt that reconstruction should have been discussed at diagnosis. Girotto et al.11 carried out a survey using Short Form 36 (SF-36®; QualityMetric, Lincoln, Rhode Island, USA) to investigate health-related QoL, body image and physical functioning in 24 patients aged over 65 years who had undergone breast reconstruction11 . The results were compared with age-matched general population norms, and those of patients who underwent mastectomy alone and a previously reported group of younger patients who had had mastectomy and reconstruction. There were no differences in complication rates between the older and younger groups. Older patients had better outcomes in terms of overall QoL after surgery than the age-matched general population and patients who had undergone mastectomy alone in all areas surveyed. They had better outcomes than younger patients who had undergone breast reconstruction in subscales influenced by mental health, but scored worse in areas relating to physical function. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
Proportion of elderly patients undergoing reconstruction after mastectomy De Lorenzi and co-workers8 identified 290 patients aged more than 65 years undergoing mastectomy over a 5-year interval. Almost all were offered reconstruction, but only 17 per cent accepted. August et al.12 found that over 11 years only 7 per cent of women aged 60 years or more had a breast reconstruction, compared with 38 per cent of younger women. Stover and colleagues7 reported a reconstruction rate of 11 per cent among women over 65 years of age, compared with 61 per cent in younger women. In a study of patients treated at M. D. Anderson Cancer Center, Lipa et al.10 found that 9 per cent of those aged 65 years and over treated during the study interval underwent breast reconstruction, compared with 41 per cent of those aged less than 65 years (Table 4). Discussion
The All Party Parliamentary Group on Breast Cancer’s 2013 report Age is Just a Number 1 makes it clear that older women with breast cancer should receive the most appropriate treatment given their condition and co-morbidities. National Institute for Health and Care Excellence guidelines for early and locally advanced breast cancer, and the National Health Service Constitution have stressed that management should not be dictated by age alone. In fact, it has been against the law to discriminate on the basis of age in health and social care since the 2010 Equality Act came into force in 2012. The lack of evidence in the literature with regard to reconstruction and oncoplastic breast-conserving surgery in the elderly reflects the underuse of these techniques in this group. The studies identified in this review suggest that complication rates in the elderly following reconstruction are comparable to those among younger groups, and that length of stay and recovery time are not significantly different. These studies have case selection bias and are based on small numbers, so their results cannot necessarily be extrapolated to all older women. However, QoL is improved with breast conservation or breast reconstruction in older patients, as in younger ones. Patients themselves feel that reconstruction is an option that should be considered at the time of diagnosis, and yet it is discussed in only a minority of instances. The results of the National Mastectomy and Breast Reconstruction Audit6 clearly demonstrate that older women are far less likely to be offered reconstruction than their younger counterparts. The reasons for failure to offer older women the same options as younger patients are varied. They include a tendency for older www.bjs.co.uk
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patients to be managed ‘off protocol’ and a reluctance to offer reconstructive techniques in a patient group where evidence is scarce. Age alone has been shown to be an independent risk factor for less than optimal treatment for breast cancer17,18 . A number of studies18 – 20 have shown that only around 50 per cent of older patients are treated according to national standards of care. Poor adherence to standard cancer management reflects the lack of level 1 evidence regarding optimal treatments for the elderly4 . Elderly women are under-represented in major trials, many of which excluded older patients altogether21 . Where they have been included, elderly patients usually form a small subgroup that is underpowered for statistical analysis22,23 . One of the nine recommendations made by the All Party Parliamentary Group on Breast Cancer1 was that data collection on outcomes for the elderly should be supported in order to create a firm evidence base for treatment options in this group. Establishing the absolute benefit of any treatment or procedure is essential in an elderly patient group as protecting QoL is of particular importance where life expectancy is more limited24 . There may be concern over presumed higher complication rates, and obviously older women are more likely to have co-morbidities. Assessment of function, rather than chronological age, has been found to be the most accurate method of predicting postoperative outcome25 . Proposed frailty index tools may help to identify patients at genuinely increased risk of complications and could result in an increase in the number of older patients being offered surgery. Failure to discuss reconstruction may also reflect a degree of prejudice within the medical profession, in which assumptions are made about older patients’ priorities regarding body image and QoL. This is compounded by a tendency among doctors to underestimate the life expectancy of older patients and to overestimate the likely impact of treatment toxicity26 . In fact, average life expectancy for a woman at 65 years in the UK is a further 21 years, with 11⋅6 years of good health2 . In addition, survival after treatment for breast cancer has improved substantially over recent years. Many older women can expect years of good health after a diagnosis of breast cancer. Lipa and colleagues10 reported a 10-year survival rate of 91 per cent for women aged 65 years and over who had undergone reconstruction with implants, and 88 per cent for those who had undergone a TRAM flap procedure. Issues around survivorhood are as relevant to many of these women as they are to younger patients. The National Mastectomy and Breast Reconstruction Audit27 has reported significant advantages for patients having reconstruction, in terms of satisfaction with appearance
(clothed and unclothed), confidence in social settings, emotional health, pain and sexual satisfaction. The studies in this review have demonstrated that older women undergoing reconstruction benefit significantly in terms of QoL. The limited evidence in the literature suggests that older women may regard body image differently to younger women, and find that it holds less significance for their QoL than other issues such as function28 – 32 . Acceptance rates remain low in series where all older patients have been offered reconstruction. Despite this, a significant minority of older women regard satisfactory body image as an important goal and choose to undergo reconstruction accordingly28 . Figueiredo and colleagues33 found that body image was highly significant in an investigation of the relationship between patient treatment preference, body image and mental health in 563 women aged 67 years or older. Body image was found to influence treatment preference in almost one-third of the patients studied and poor body image was a predictor of impaired mental health at 2 years. Function may also be facilitated by the use of some simple reconstructive techniques. Some of these may allow breast conservation, which can be the simplest option of all. Older women are less likely to be offered reconstruction than their younger counterparts, but are also less likely to accept it. This may reflect the fact that many older patients feel disenfranchised from the decision-making process. This is well documented and strategies should be adopted to enable older patients to participate fully in decisions regarding their treatment. It is, however, also highly likely that many older women simply do not wish to undergo more extensive surgery, and feel that a reconstruction will not make a substantial enough improvement to their QoL to justify the risks. It is important to establish priorities when discussing treatment. Mandelblatt and co-workers34 carried out a review of outcomes and QoL following treatment for breast cancer in older women. Older women who felt involved in the decision-making process, experienced good communication with medical staff, had treatments that took account of their views on body image and had a low perception of bias were more likely to have good QoL scores and higher levels of satisfaction. Oncoplastic breast-conserving surgery may offer oncological advantages as a result of the wider area of tissue excised and, importantly, margins are more likely to be clear with a reduction in the number of second operations required. In a survey of 11 studies35 – 45 with a total of 1532 patients undergoing therapeutic mammoplasty, a median of 7⋅4 (range 0⋅1–16) per cent underwent further surgery for close or involved margins. This compares with a re-excision rate of 20 per cent reported in a large cohort
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study of 55 297 women undergoing breast conservation in English hospitals46 . In some patients, wider margins may obviate the need for radiotherapy. Radiotherapy may have a detrimental impact on cosmesis and function, and can be omitted safely in selected groups of elderly patients. In a randomized clinical trial comparing quadrantectomy alone and quadrantectomy with radiotherapy, Veronesi et al.47 found that patients aged over 55 years who had not received radiotherapy had significantly lower local recurrence rates than their younger counterparts. Results of the PRIME 248 and CALGB 934349 trials have confirmed that older patients who receive hormone therapy after breast conservation treatment for low-grade, hormone receptor-positive, axillary node-negative cancers can avoid radiotherapy, with low rates of ipsilateral breast recurrence and equivalent overall survival, . The British Association of Surgical Oncology (BASO) II trial50 , while not an equivalence trial, suggested that tamoxifen is likely to be as effective as radiotherapy in reducing local recurrence among low-risk women undergoing breast conservation. Cancer care has focused increasingly on individualized treatment and patient choice17,24,25,51,52 . It should be recognized that elderly patients are a heterogeneous group with regard to fitness, function and expectations. Gennari and Audisio53 describe ageing as ‘a physiologic process characterized by loss of independence, co-morbidity and geriatric syndromes. Age 70 represents a milestone beyond which older people are found’. Suitability for oncoplastic or reconstructive procedures should not rest on chronological age alone.
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Disclosure
The authors declare no conflict of interest. References 1 All Party Parliamentary Group on Breast Cancer (APPGBC). Age is Just a Number. The Report of the Parliamentary Inquiry into Older Age and Breast Cancer. APPGBC: London, 2013. 2 Office for National Statistics. Table A1-1, Principal Projection – UK Summary, 2010-Based; 2011. http://www. ons.gov.uk/ons/publications/re-reference-tables.html? edition=tcm%3A77-229866 [accessed 20 November 2014]. 3 Cawthorne S. All party parliamentary group on breast cancer: inquiry into older age and breast cancer. ABS Newsletter 2013: 1. 4 Biganzoli L, Wildiers H, Oakman C, Marotti L, Loibl S, Kunkler I et al. Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European
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35 Clough KB, Lewis JS, Couturaud B, Fitoussi A, Nos C, Falcou M-C. Oncoplastic techniques allow extensive resections for breast conserving therapy of breast carcinomas. Ann Surg 2003; 237: 26–34. 36 Kaur N, Petit JY, Rietjens M, Maffini F, Luini A, Gatti G et al. Comparative study of surgical margins in oncoplastic surgery and quadrantectomy in breast cancer. Ann Surg Oncol 2005; 12: 539–545. 37 McCulley SJ, Macmillan RD. Therapeutic mammoplasty – analysis of 50 consecutive cases. Br J Plast Surg 2005; 58: 902–907. 38 Losken A, Styblo TB, Carlson GW, Jones GE, Amerson BJ. Management algorithm and outcome evaluation of partial mastectomy defects treated using reduction or mastopexy techniques. Ann Plast Surg 2007; 59: 235–242. 39 Rietjens M, Urban C, Rey PC, Mazzarol G, Maisonneuve P, Garusi C et al. Long-term oncological results of breast conservative treatment with oncoplastic surgery. Breast 2007; 16: 387–395. 40 Giacalone PL, Roger P, Dubon O, El Gareh N, Rihaoui S, Taourel P et al. Comparative study of the accuracy of breast resection in oncoplastic surgery and quadrantectomy in breast cancer. Ann Surg Oncol 2007; 14: 605–614. 41 Meretoja TJ, Svarvar C, Jahkola TA. Outcome of oncoplastic breast surgery in 90 prospective patients. Am J Surg 2010; 200: 224–228. 42 Fitoussi AD, Berry MG, Famà F, Falcou MC, Curnier A, Couturaud B et al. Oncoplastic breast surgery for cancer: analysis of 540 consecutive cases [outcomes article]. Plast Reconstr Surg 2010; 125: 454–462. 43 Caruso F, Catanuto G, De Meo L, Ferrara M, Gallodoro A, Petrolito E et al. Outcomes of bilateral mammoplasty for early stage breast cancer. Eur J Surg Oncol 2008; 34: 1143–1147. 44 Grubnik A, Benn C, Edwards G. Therapeutic mammoplasty for breast cancer: oncological and aesthetic outcomes. World J Surg 2013; 37: 72–83. 45 Schaverien MV, Raine C, Majdak-Paredes E, Dixon JM. Therapeutic mammoplasty – extending indications and achieving low incomplete excision rates. Eur J Surg Oncol 2013; 39: 329–333. 46 Jeevan R, Cromwell DA, Trivella M, Lawrence G, Kearins O, Pereira J et al. Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics. BMJ 2012; 345: e405. 47 Veronesi U, Luini A, del Vecchio M, Greco M, Galimberti V, Merson M et al. Radiotherapy after breast-preserving surgery in women with localised cancer of the breast. N Engl J Med 1993; 328: 1587–1591. 48 Kunkler I. Avoiding radiotherapy is an option for some older patients with breast cancer. San Antonio Breast Cancer Symposium 2013, San Antonio, 2013.
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49 Hughes K, Schnaper L, Berry D, Cirrincione C, McCormick B, Shank B et al. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 2004; 351: 971–977. 50 Blamey RW, Bates T, Chetty U, Duffy SW, Ellis IO, George D et al. Radiotherapy or tamoxifen after conserving surgery for breast cancers of excellent prognosis: British Association of Surgical Oncology (BASO) II trial. Eur J Cancer 2013; 49: 2294–2302. 51 Beadle BM, Woodward WA, Buchholz TA. The impact of
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Snapshot quiz
Snapshot quiz 15/4 Answer: An otherwise fit 34-year-old man presented with acute appendicitis. He was taken to theatre for laparoscopic appendicectomy. A 23-cm mildly inflamed and faecolith-laden appendix was found in the retrocaecal position with some periappendiceal inflammation. The procedure had to be converted to open operation owing to technical difficulty resulting from the length of appendix. The patient made an uneventful postoperative recovery. The Guinness Book of Records informs that the longest appendix recorded was removed at autopsy from a 72-yearold Croatian man: 26 cm. http://www.guinnessworldrecords.com/world-records/1000/largest-appendix-removed
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