Competing Risks and Treatment Benefits i n Elderly Patients

Breast cancer is the most frequent malignant tumor in women worldwide, with > 40 % of new cases every year found in women over the age of 65 years. As breast cancer incidence increases with age, worldwide changing demographics and increasing life expectancy are expected to further enlarge the absolute number of older women with breast cancer. However, elderly breast cancer patients are not treated to the same extent as younger patients and increasing age at diagnosis predicts deviation from guidelines for all treatment modalities. Evidence-based medicine in older patients is lacking as they are usually excluded from clinical trials often because of existing comorbidities and limited life expectancy. Accordingly, there is a higher competing risk of death from other causes than breast cancer compared with younger patients and this may have led to the false interpretation that prognosis of breast cancer in older patients is relatively good. However, every treatment modality should be evaluated during treatment decision making. Multimodal therapy should not be routinely withheld as data show that disease-specific mortality increases with age, probably due to under-treatment. Prognostic markers, fitness and comorbidities rather than chronological age should determine optimal, individualized therapy. It is recommended that treatment decisions should be discussed in a multidisciplinary setting, ideally in combination with any form of geriatric assessment, to improve breast cancer outcome in the older population.