The caregiver effect on treatment decisions for the elderly
The proper management of the axilla in all patients with breast cancer has been an area of active investigation. Although involvement of the axillary nodes remains an important prognostic factor, the approach to gathering this information has changed dramatically.
Axillary lymph node dissection (ALND), long a standard component of the management of early stage breast cancer, remains the standard approach only for patients with clinically palpable axillary nodes or many positive axillary nodes confirmed by sampling techniques. For women with early stage breast cancer with a clinically negative axilla, ALND is no longer a routine part of the surgical treatment of breast cancer, having been replaced with the less invasive sentinel lymph node biopsy (SLNB). In patients with clinically node negative breast cancer, SLNB identifies patients without axillary node involvement, sparing themthemorbidity of ALND. Several studies have shown that SLNB is associatedwith lower rates of arm morbidity, including lymphedema, sensory loss, and range of motion deficits when compared to a standard ALND. Older women with breast cancer should stand to particularly benefit from this therapeutic shift. Breast cancer is the most common cancer among older women, and nearly one half of new cases of female breast cancer in the United States are diagnosed in women age 65 or older.8 Some data suggest that older women may suffer from greater arm morbidity following ALND than younger women, particularly if they have preexisting arthritis, a common age-related condition.9 Older women tolerate SLNB well, and it is associated with lower rates of arm morbidity than ALND. SLNB may be particularly appropriate for older women as it may be performed without the use of general anesthesia. In addition, because axillary node sampling is a staging procedure, some authors suggest that selected older women do not require any axillary lymph node assessment as the knowledge will not change treatment or outcome. This is particularly true for those individuals whose comorbidities preclude consideration of chemotherapy or radiotherapy.
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