Breast Cancer in the Balinese Elderly Population: Analysis of the Hospital-Based Cancer Registry
IGP Suka Aryana
1*, Putu A. T. Adiputra
2, Yulan Permatasari
3, Pande K. A. Prayudi
3, Hendra P. Setiawan
31 Geriatric Division, Internal Medicine Department, Sanglah General Hospital, Bali, Indonesia
2 Division of Surgical Oncology, Surgery Department, Sanglah General Hospital, Bali, Indonesia
3 Faculty of Medicine, Udayana University, Bali, Indonesia
*Corresponding author:
IGP Suka Aryana
Geriatric Division, Internal Medicine Department, Sanglah General Hospital, Bali, Indonesia [email protected]
INTRODUCTION
According to the data published by the Indonesian Ministry of Health, with the increase in life expectancy for the Indonesian population, the number of older populations will be continuously increasing over the next decades [1]. Following these demographic changes happening in Indonesia, the geriatric population will represent a special subgroup of the population because
of their special needs, social status, and health status which are distinct from other subgroups of the population.
Breast cancer accounts for 22.9% of all female cancers and is the leading cause of cancer death in females accounting for 13.7% of their cancer-related mortality [2]. Aging remains one of the most important risk factors for the development of new breast cancer, with the estimated risk of new breast cancer at 1 in 14 for women aged 60 to 79 compared with 1 in 24 A R T I C L E I N F O
Received : 28 November 2021 Reviewed : 22 December 2021 Accepted : 02 June 2022 Keywords:
breast cancer, descriptive, elderly
A B S T R A C T
Background: The elderly population in Indonesia will continue to increase over the next few decades. Breast cancer is 22.9% of all female cancers, and aging is one of the biggest risk factors.
The challenge in managing older cancer patients is the ability to accurately assess whether the expected benefits of treatment outweigh the risks. Epidemiological data is very important for research and the advancement of medical science in the future. Currently, the incidence of breast cancer in Indonesia is 26 per 100,000 population, but the incidence of breast cancer in the elderly is unknown.
Methods: This is a descriptive study of all breast cancer cases recorded in the cancer registry of Sanglah General Hospital, the largest cancer registry in Bali. Statistical analyses were conducted using descriptive statistics with the Statistical Package for the Social Sciences version 16.0 (SPSS).
Results: From 1997 until 2013, 1,020 cases of breast cancer among Balinese women of various ages were recorded, of which only 78 cases (7.6%) were attributed to the elderly (age ≥ 65 years).
At the time of diagnosis, distant metastasis was recorded for 28.9% of the elderly, compared with 24.4% for the younger group of patients (age < 65 years). Locally advanced breast cancer (LABC) was also recorded higher in the elderly (49.4% vs. 47.5%). A lower proportion of primary surgical treatment was recorded for the elderly than for the younger group of patients (69.7%
vs. 76.2%). A lower proportion of adjuvant therapy, either by chemotherapy or radiotherapy, was also recorded for the elderly (45.5% vs. 53.4% and 2.6% vs. 4.9%, respectively), but the proportion of adjuvant hormonal therapy was recorded higher in the elderly (1.3% vs. 0.7%). In contrast, palliative care was recorded higher in the elderly (7.7% vs. 5.7%). Unfortunately, no data about survival were available.
Conclusions: There is a tendency for older women in Bali to have more advanced disease at the time of diagnosis and receive less surgical treatment as the primary therapy, but they are more likely to receive adjuvant hormonal therapy and palliative care than their younger counterparts.
This information should be of major interest to clinicians.
women aged 40 to 59 and 1 in 228 women aged 39 and younger. As a result, an estimated 35% of women are over the age of 70 at the time of invasive breast cancer diagnosis. Almost 50% of women will be aged 65 or older at diagnosis [3]. Despite these statistics, surprisingly, little is known about how cancers develop and progress in older patients or what is the best way to treat them [4].
Despite documented under-treatment, surgery and adjuvant treatment are well tolerated, effectively decrease relapse, and improve survival in many older patients with cancer, including women with breast cancer ≥ 80 years old. Studies show that older adults are willing to receive treatment for cancer just as readily as younger patients [5]. However, the challenge of managing older patients with cancer is the ability to accurately assess whether the expected benefits of treatment outweigh the risks. Because aging is a heterogeneous process, older patients with cancer need individualized management. The lack of comprehensive evaluation and efficacy data restricts the basis of treatment modifications to factors such as chronologic age and has retarded the development of interventions to optimize cancer treatment in older adults.
Currently, the incidence of breast cancer in Indonesia is 26 per 100,000 population, but none is known about the incidence among the elderly [6]. No study describes the trend in diagnosis and treatment of breast cancer among the elderly in Indonesia, especially among the elderly of Balinese population. Clinicians should try to address whether there is a significant discrepancy between the elderly and younger breast cancer population. This study aims to describe the diagnosis and treatment of breast cancer among older Balinese women above 60 years. Therefore, this study would provide an initial description of the treatment profile for elderly breast cancer.
METHODS
This study is a descriptive study of female breast cancer cases recorded in the hospital cancer registry of Sanglah General Hospital. Sanglah General Hospital’s registry is the largest hospital registry in Bali whose patients come from nine districts, including Denpasar, Badung, Tabanan, Negara, Gianyar, Bangli, Klungkung, Karangasem, and Buleleng. However, the registry also includes patients who reside outside the island of Bali since Sanglah General Hospital is the center of referral for the East and West Nusa Tenggara region. Thus, we exclude patients who reside outside Bali. There were 1,020 cases of primary breast cancer diagnosed between 1997 and 2013, among all ages. The elderly are defined as those aged 60 years and older.
The data analysis included the stages of diagnosis and the treatment received by the patients. We made
a cross-tabulation to compare the trend in diagnosis and treatment in elderly patients versus the younger group. We recorded the distant metastasis at the time of diagnosis and staging of breast cancer. The kinds of treatment are grouped whether the patient got initial/
main therapy, adjuvant therapy, or palliative care.
We used Statistical Packages for Social Science (SPSS) to aid the descriptive analyses. The rates for each character within each group of age were presented in percentages.
RESULTS
We collected 1,045 cases of breast cancer women of various ages, 25 of which were excluded due to incomplete data or referrals from other islands outside Bali. Of 1,020 cases included in this study, only 78 cases (7.6%) were attributed to the elderly (age ≥ 60 years).
At the time of diagnosis, distant metastasis was recorded for 28.9% of the elderly, compared with 24.4% for the younger group of patients (age < 60 years) (Table 1).
Staging is the most important determinant of prognosis in breast cancer. Therefore, it plays a key role in treatment planning. We describe the staging using the TNM system by the American Joint Committee on Cancer (AJCC). Locally advanced breast cancer (LABC) was also recorded higher in the elderly (49.4% vs.
47.5%). LABC is also known as stage III (III A, III B, and III C) in the TNM staging system. Table 2 shows the proportion of each stage in the elderly patients (≥ 60 years old) versus in the younger group of patients (<
60 years old).
Elderly patients with breast cancer frequently present with one or more comorbid conditions in addition to their cancer, and this can complicate clinicians’ treatment decisions. Moreover, older patients with cancer are seldom comprehensively evaluated. A patient can undergo more than one method of treatment: whether it’s initial therapy, adjuvant therapy, palliative care, or a combination of all three. As seen in Table 3, a lower proportion of primary surgical treatment was recorded for the elderly than for the younger group of patients (69.7% vs. 76.2%). A lower proportion of adjuvant therapy, either by chemotherapy or radiotherapy, was also recorded for the elderly (45.5% vs. 53.4% and 2.6%
vs. 4.9%, respectively), but the proportion of adjuvant hormonal therapy was recorded higher in the elderly (1.3% vs. 0.7%). In contrast, palliative care was recorded higher in the elderly (7.7% vs. 5.7%). Unfortunately, no data about survival were available.
DISCUSSION
Our study demonstrates that the elderly group tends to present with more advanced diseases and receive less surgical treatment than their younger counterparts.
Age at diagnosis
< 60 Years old (n=942) ≥ 60 Years old (n=78)
N % N %
Initial/Main Treatment
Surgery 717 76.2 54 69.7
Radiotherapy 2 0.2 0 0.0
Chemotherapy 136 14.4 17 22.4
Hormonal therapy 1 0.1 1 1.3
None 86 9.1 6 6.6
Adjuvant therapy
Radiotherapy 46 4.9 2 2.6
Chemotherapy 503 53.4 35 45.5
Hormonal therapy 6 0.7 1 1.3
None 387 41.0 40 50.6
Palliative care 53 5.7 6 7.7
Table 3. The treatment method according to age Table 2. Breast cancer staging according to age
Age at diagnosis
< 60 Years old (n=942) ≥ 60 Years old (n=78)
N % N %
Stage
I 25 2.6 2 2.6
IIA 100 10.6 11 14.3
IIB 118 12.5 3 3.9
IIIA 96 10.2 9 11.7
IIIB 331 35.1 29 36.4
IIIC 21 2.2 1 1.3
IV 246 26.1 22 28.6
Incomplete staging 5 0.5 1 1.3
Table 1. Breast cancer’s characteristic of all patients
Age at diagnosis
< 60 Years old (n=942) ≥ 60 Years old (n=78)
N % N %
In situ 20 2.2 1 1.3
Local 271 28.8 17 22.4
Local Extension 153 16.2 16 21.1
Regional Metastasis 86 9.1 5 6.6
Local extension with Regional Metastasis 182 19.3 16 19.7
Distant Metastasis 230 24.4 23 28.9
They also tend to receive less adjuvant chemotherapy or radiotherapy but are more likely to receive hormonal therapy. Moreover, older women with breast cancer are more likely candidates for palliative care.
According to Surveillance Epidemiology and End Results (SEER) database, patients aged 60 years and older constitute about 70% of breast cancer patients, and about 46% are 70 years old and older [7]. In the USA, approximately 50% of breast cancers occur in women 65 years of age or older and more than 30%
occur after the age of 70 [8]. The incidence of women 70 years or older diagnosed with breast cancer varied from 100 to 350 per 100,000 per year during 2000–2004 in Europe [9]. In Egypt, the peak incidence of breast cancer occurs in the age group of 40–59 years; with the increase in life expectancy, breast cancer among elderly Egyptians is expected to rise markedly in the future [8]. Based on 1,020 cases of breast cancer among Balinese women that were recorded during 1997–2013, only 78 cases (7.6%) were attributed to the elderly (age
≥ 60 years), of which 28.9% came with distant metastasis.
Staging is the most important determinant of prognosis in breast cancer and therefore plays a key role in treatment planning. The size of the primary tumor, the lymph node status, and the presence of distant metastases determine the breast cancer stage.
Early-stage breast cancer is generally defined as stage I or II, locally advanced as stage III, and metastatic as stage IV. Stage I, II, or III are considered curable with optimal therapy, and according to the Surveillance Epidemiology and End Results (SEER) database, 5-year overall survival for women of all ages is 94% for stage I and 80% for stages II and III together [10]. Furthermore, the SEER database demonstrates that the average 5-year survival for elderly patients is lower in each stage and decreases with advancing age. Age-specific 5-year overall survival for patients with stage I cancer is 88% for those aged 67, 74/84% for those aged 75 to 84, and 50% for those aged 85 and older; for subjects with stage II cancer, it is 79% for those aged 67 to 74, 62% for those aged 75 to 84, and 35% for those aged 85 and older [11]. In our study, older Balinese women are more likely to present at a later stage than younger women.
However, we could not determine the overall survival of these women since the data about their survival is still lacking in our registry.
Several large studies on breast cancer demonstrate that elderly women receive less-aggressive primary therapy [12-14]. including lower overall surgical rates, fewer axillary dissections, higher rates of not receiving postoperative radiation or chemotherapy, and higher rates of adjuvant hormonal therapy used alone. In our study, older women also have lower rates of overall surgical therapy, adjuvant chemotherapy, or radiotherapy.
They also have a higher rate of hormonal therapy (7.7%
vs. 5.7%) and palliative care (1.3% vs. 0.7%). As many
large reviews have reported, treatment selection does correlate strongly with 5-year survival, in which patients who receive the least aggressive therapy have the worst prognosis. One large study reported that five-year overall survival was 46% for women receiving no therapy, 51%
for tamoxifen alone, 82% for mastectomy, and 90% for breast-conserving surgery with adjuvant therapy [15].
The primary therapy for early-stage breast cancer in elderly people should include surgery unless the patient has an absolute contraindication. Standard therapy for early-stage breast cancer involves local therapy (surgical mastectomy or lumpectomy with or without radiation) followed by adjuvant systemic therapy. Adjuvant therapy is given after a definitive surgical procedure to reduce the risk of future recurrence. This risk reduction is accomplished with systemic therapy by destroying potentially metastatic tumors that may have escaped the breast and lodged as microscopic niduses at distant sites [11]. Schonberg et al. [16] showed that women aged ≥ 80 years have breast cancer characteristics similar to younger women yet receive less aggressive treatment and experience higher mortality from early-stage breast cancer. Their study is corresponding to our result that fewer elderly undergo surgery procedures (69.7% vs. 76.2%), and there is a higher proportion of palliative care in the elderly (7.7% vs. 5.7%).
However, it is difficult to discern the reasons behind the observed under-treatment among the elderly in our study, whether it was physician bias, patient preference, or co-morbidity limiting the options of treatment. Since our study is an observational study that is based on a hospital registry, there is potential for residual confounding factors for which we do not have data, such as performance status, social support, educational background, and economic status which contribute to determining the choice of therapy. We suggest that access to health care is one of the most important determining factors in this under-treatment. The majority of the elderly in Bali still have low awareness of breast cancer screening due to low education levels, making them have more advanced diseases at diagnosis and less likely to receive more aggressive treatment. Their lower socioeconomic status also plays an important role since screening and treatment of breast cancer are still considered costly. Lack of family support may also affect the decision to treat. Even when the elderly are admitted to the hospital to receive treatment, they are sometimes not eligible to undergo surgery as most operative risk results from underlying comorbidity and the effects of anesthesia on their dysfunctional organ systems.
However, this issue can be addressed by optimizing preoperative care of underlying disease and individualization of anesthetic techniques (general, local, or spinal anesthesia) to minimize operative risk [17].
However, there are several limitations to our study.
This study is a descriptive study with a far smaller number of samples within the elderly group than the non-elderly group. This makes it rather difficult to make an exact correlation between age and stage at presentation or the kinds of treatment received. Since our registry is a hospital registry that relies on its data source solely from the admitted patients, it may not disclose the real data on Balinese population. Thus, Balinese women with breast cancer that are not admitted to Sanglah General Hospital will not be included in our registry. Further research is needed to treat breast cancer at an earlier stage, particularly in the elderly population. Studies on new and adjuvant treatments are also needed to make more options for the elderly.
CONCLUSIONS
Elderly women of Balinese ethnicity are more likely to present at a later stage of disease and receive less aggressive treatment. Our findings are following the global finding of breast cancer in the elderly in which there is a tendency for older women in Bali to have more advanced disease at the time of diagnosis and receive less surgical treatment as the primary therapy, but they are more likely to receive adjuvant hormonal therapy and palliative care than their younger counterparts. This information should be of major interest to clinicians. We suggest that part, if not all these disparities, might be a result of the low education and low socioeconomic support among the elderly population in Bali, and hence, restrict access to healthcare. Further studies with larger samples are needed to further enrich the understanding of breast cancer in elderly women.
DECLARATIONS
Ethics ApprovalThis study was approved by our Institutional Health Research Ethics Committee (337/UN.14.2/Litbang/2013).
Competing of Interest
The authors declare no competing interest in this study.
Acknowledgment
The authors would like to acknowledge the support of the management at Sanglah General Hospital, who gave us generous access to their data and particularly of the Division of Surgical Oncology, Surgery Department, which allowed us to discuss with their staff at length. The authors are also grateful to Made Utari Rimayanti who spent extra time to help us with grammar checking to achieve a better manuscript.
REFERENCES
1. Data and Information Center Indonesian Ministry of Health. Gambaran Kesehatan Lanjut Usia di Indonesia. Buletin Jendela Data dan Informasi Kesehatan. Jakarta: Bakti Usadha. 2013. pp.1–18.
2. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008 v1.2, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No.
10. Lyon, France: International Agency for Research on Cancer [online], http://www.globocan.iarc.fr/
factsheets/cancers/breast.asp; 2010 [accessed on 15.06.2014].
3. Holmes CE, Muss HB. Diagnosis and Treatment of Breast Cancer in the Elderly. CA Cancer J Clin 2003;53:227–244.
4. Grauer N. Advancing Cancer Care for the Older Adult-Geriatric. Johns Hopkins Medicine, The Johns Hopkins University, Sydney: The Sidney Kimmel Comprehensive Cancer Center [online], http://www.
hopkinsmedicine.org/kimmel_cancer_center/our_
center/contact/referral.html [accessed on 15.06.2014].
5. Clough-Gorr KM, Stuck AE, Thwin SS, Silliman RA.
Older Breast Cancer Survivors: Geriatric Assessment Domains Are Associated With Poor Tolerance of Treatment Adverse Effects and Predict Mortality Over 7 Years of Follow-Up. J Clin Oncol 2010; 28:380–386.
6. Dinas Kesehatan Nasional. Data penderita kanker payudara di Indonesia. http://www.depkes.go.id/
index.php/berita/press-release/1060-jikatidak- dikendalikan-26-juta-orang-di-dunia-menderita- kanker-.html. 2007. [accessed on 15.06.2014].
7. Ries LAG, Melbert D, Krapcho M, editors. SEER cancer statistics review, 1975–2004. Bethesda:
National Cancer Institute.
8. Zeeneldin AA, Ramadan M, Gaber AA, Taha FM.
Clinico-pathological features of breast carcinoma in elderly Egyptian patients: a comparison with the non- elderly using population-based data. Journal of the Egyptian National Cancer Institute 2013; 25: 5–11.
9. Downey L, Livingston R, Stopack A. Diagnosing and treating breast cancer in elderly women: a call for improved understanding. JAGS 2007; 55: 1636–1644.
10. McCarthy EP, Burns RB, Freund KM et al.
Mammography use, breast cancer stage at diagnosis and survival among older women. J Am GeriatrSoc 2000;48:1226–33.
11. Biganzoli L, Wildiers H, Oakman C et al. Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA). Lancet Oncol 2012; 13: e148–60
12. Wanebo HJ, Cole B, Chung M et al. Is surgical management compromised inelderly patients with breast cancer? Ann Surg 1997;225:579–89.
13. August DA, Rea T, Sondak VK et al. Age-related differences in breast cancer treatment. Ann Surg Oncol 1994;1:45–52.
14. Kessler HJ, Seton JZ. The treatment of operable breast cancer in the elderly female. Am J Surg 1978;135:664–66.
15. Bouchardy C, Rapiti E, Fioretta G et al. Undertreatment strongly decreases prognosis of breast cancer in elderly women. J Clin Oncol 2003;21:3580–87.
16. Schonberg MA, Marcantonio ER, Li D et al. Breast cancer among the oldest old: tumor characteristic, treatment choices, and survival. Journal of Clinical Oncology 2010; 28: 2038–45.
17. Samain E, Schauvliege F, Deval B et al. Anesthesia for breast cancer surgery in the elderly. Crit Rev OncolHematol 2003;46:115–20.
