New cases of breast cancer among women under 50 are on the rise – a troubling trend that has generated widespread media attention along with awareness initiatives targeting younger women. But the fact remains that older people are far more likely to be impacted by breast cancer.
“Sometimes we get the idea that breast cancer is a disease of young people, and there's a lot of information about that. But the truth is that the face of breast cancer is the face of an older adult,” says the University of Colorado Anschutz Cancer Center’s associate director of global oncology, Enrique Soto Pérez de Celis, MD, PhD, a geriatric oncologist with a clinical and research interest in breast cancer among older adults.
Between 2019 and 2023, 71.8% of new diagnoses of female breast cancer in the United States were among women ages 55 and older, according to the National Cancer Institute. The highest U.S. breast cancer incidence rates are among women ages 65-74.
The American Cancer Society estimates that women have a one-in-46 probability of developing breast cancer before turning 50, based on 2019-2022 data. That probability rises to one in 25 between ages 50 and 64, and to one in 14 between ages 65 and 84. The probability of death from breast cancer also rises steadily as a woman ages, the ACS says.
Yet there is a disparity between breast cancer’s disproportionate impact on older people and how breast cancer after age 50 is treated and studied, says Soto, an associate professor in the CU Anschutz Department of Medicine’s Division of Medical Oncology.
“Often we don’t see age as a disparity, but it is,” he says.
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A big disconnect
Soto says older women are less likely to receive standard-of-care treatment or have easy access to high-volume cancer centers best suited to treat them, in part because of distance, transportation obstacles, and economic circumstances.
They’re also less likely to be represented in clinical trials and other studies that could lead to new therapies better suited to people in their age group, he says.
“Some trials have enrollment cutoffs based on age. Most trials require excellent performance status” – how well a person with cancer can perform ordinary daily tasks and handle self-care – “so they immediately exclude people who may be more vulnerable or frail.”
As a result, “although older people are the largest population of people with breast cancer in the U.S., it’s also a population for which we don't have a lot of data, so there's a big disconnect between where we're getting our information and how we are applying it for our patients.”
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Not precise enough
What’s more, Soto says, outcomes for older people with breast cancer can be worse than for younger people, for a variety of reasons.
For one thing, older patients “often have other issues that are going on at the same time as the breast cancer that are sometimes not appropriately factored into treatment plans and interventions that are designed for them,” he says.
Other factors that might lead to poorer outcomes for 50-and-older breast cancer patients include side effects from treatment that disproportionally impact their age group, as well as under- or overtreatment driven partly by age-based assumptions, Soto says.
“They may be treated with protocols and therapy choices that are not necessarily built for them. If they’re undertreated, that leads to adverse outcomes, of course. And when some people get overtreated, they may be given treatments they don't need, or that lead to toxicity, or even to shortened survival or decreased quality of life. We talk a lot about personalized medicine, and yet, in this large population of older people who are so common in our clinical practice, we are not being precise enough.”
Sometimes, obstacles to effective treatment “come from the older patients themselves,” Soto says. “There’s the idea that because they are older, treatment is not worth pursuing, or they can’t get good treatments, or they say, ‘This is too hard for me.’”
Challenges facing older people with breast cancer are even more pronounced for minority communities, Soto says. “We see many older women who come here from other countries – they don’t speak the language, they may have less than a primary-school education, and they’re facing our health care system, which is super-complicated under any circumstances. And a number of other issues – gender, race, sexual orientation, disability, financial status – are compounded by age.”
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Truly personalized
Soto calls for “a change in mindset across the board” when it comes to older people with cancer.
“Older people should feel empowered to participate in research and to get the latest treatments, as long as those treatments are designed for them,” he says. “Older people should understand that they are the main demographic affected by breast cancer.”
Providers should take into account an older breast cancer patient’s entire picture, including the nature of their cancer, their life expectancy, and their preferences, he says. Sometimes, that means the decision could be no treatment.
“Older people are more likely to have breast cancer, but that cancer is also more likely to have a favorable biology – smaller tumors or less aggressive tumors. Sometimes we end up finding that a tumor has a very small probability of causing harm or death in older people, and that we would be subjecting them to treatment that they might not need. It’s possible that an 85-year-old woman could have a small breast cancer that she can’t feel, and that she could go with no treatment at all, live the rest of her life with perfect quality of life, and then die because of something else. After a certain age, interventions that we do offer less and less return, and the probability of harm from surgery or hormone therapy also increases.”
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A contentious topic
Current screening recommendations for breast cancer call for mammograms to end after age 74. Whether the upper age limit should be changed is a “contentious topic” in oncology, Soto says.
“We need to make sure that in the future, our screening guidelines become more personalized, particularly for our aging population,” he says. “And for breast cancer in particular, older people should have conversations with their providers about when to stop screening, which doesn’t mean we’re not caring about your breasts anymore. After mammograms stop, older people still need a clinical examination every year.”
Soto says the CU Anschutz Cancer Center has made caring for older people with breast cancer and other cancers a priority. He leads a new geriatric oncology multidisciplinary clinic, and has been caring for older people with breast cancer since his arrival at CU Anschutz two years ago.
“We start by doing a geriatric assessment, a type of clinical evaluation that includes factors that change as we age, such as nutrition, function, independence, cognition, and psychological and social issues,” he says. “Also, we make sure that we are offering care that takes into account other things going on in people's lives, the things that they value the most, so that we can not only help them get control of their cancer, but also help them lead a better life. We consider all of those things to create a treatment pathway that is truly personalized and holistic for older people with breast cancer.”
Soto says he always tells his older patients: “If the treatment for breast cancer prevents you from doing the things you love, the things you value the most, then that treatment is wrong.”
