Older breast cancer patients are urged to avoid radiation

Elderly women undergoing treatment for early stage breast cancer may safely forgo radiation therapy that is expensive, inconvenient, and often difficult without substantially increasing the prospects of the disease returning, researchers report today.

The findings could change treatment recommendations for the estimated 40,000 women over the age of 70 diagnosed annually with small breast tumors, nearly one-fifth of the newly diagnosed breast cancer cases expected this year in the United States.

In two studies and an editorial in today's New England Journal of Medicine, doctors, including several from Massachusetts General Hospital and Dana-Farber Cancer Institute, challenge the long-accepted canon that patients with smaller breast tumors should routinely get radiation.

For older patients with smaller tumors, the scientists conclude, limiting treatment to surgery and the antiestrogen drug Tamoxifen has emerged as an option, with no effect on long-term survival and only a slight increase in the return of breast malignancies.

Conversely, the researchers report that radiation should continue to be a regular component of treatment for women younger than 70, whose cancers tend to grow more quickly and spread more frequently.

Their conclusions reflect continuing efforts in the field of oncology to tailor treatments to the specific medical and social profiles of patients. They are an explicit recognition that medical choices come with a cost, economically and to the lifestyles of patients.

A course of radiation for breast cancer patients can cost as much as $25,000, one surgical oncologist estimated, and require trips to the hospital every weekday for as long as seven weeks.

''The point of our study is not so much that radiation is bad," said Dr. Kevin Hughes, a Mass. General surgical oncologist and lead author of one of the studies. ''But when treating patients, you always look at the risk-benefit ratio. Up until now, we've routinely said patients must have radiation. Now, we can go in and say this is what your real risk is, and this is what your real benefit is."

Hughes's study tracked 636 women age 70 and older who had been diagnosed with small breast tumors, defined as malignancies less than an inch in diameter. All the women underwent a breast-conserving surgical procedure called lumpectomy and took Tamoxifen; about half received radiation as well.

After following the women for an average of five years, the scientists discovered there was no difference between the groups in survival rates or in metastases, in which the cancer spreads to other organs. The women who received radiation were slightly less likely to experience a return of cancer in the same breast: During the five-year period, 1 percent of the patients getting radiation developed a new breast tumor, compared with 4 percent who got no treatments.

That difference in recurrence is small enough, a leader of the American Cancer Society said yesterday, that doctors must weigh the physical and financial costs of radiation before embarking on that treatment in older women.

''You may be treating a lot of women unnecessarily with the radiation," said Dr. Jerome Yates, the society's national vice president for research.

Complications from radiation can result in skin redness, itching, swelling, and fatigue. The side effects generally subside a few months after treatments end, but researchers found that in a small number of patients, they persisted for months or even years.

''It can have significant effects on quality of life," said Dr. Anthony W. Fyles, a radiation oncologist at Princess Margaret Hospital in Toronto and lead author of the second study in today's New England Journal. ''You can't sleep on that side; bras don't fit comfortably."

Evelyn Whittle had endured two other forms of cancer and open-heart surgery before doctors this year discovered a malignant growth in her right breast. The 79-year-old Somerville woman underwent a lumpectomy and is taking Tamoxifen. But there will be no radiation, a decision she reached in consultation with her doctors, who include Hughes.

She'd had radiation treatments before for other tumors, and while she said the side effects were not taxing, the treatments had tried her patience. ''It's just that you have to get transportation into the Mass. General, and after the radiation, you have to wait for transportation to pick you up," she said. ''So if I can take a pill and not have to undergo radiation, that's great."

Not all specialists are convinced that women will rush to abandon radiation therapy. Some women, those specialists speculated, will still opt for radiation. ''It comes down to a patient's preference of dealing with the discomfort and the issue now, or potentially dealing with it later" if the cancer returns, said Dr. Janice Rothschild, a general surgeon who performs breast operations at Tufts-New England Medical Center. ''For the most part, patients will do whatever necessary to avoid dealing with this again."

In the second study, Canadian researchers examined a broader age group of women, with patients as young as 50. Overall, that study of 769 women with small tumors found that during a five-year period, fewer than 1 percent of the women who got radiation in conjunction with surgery and Tamoxifen developed a new breast tumor compared with nearly 8 percent of those not treated with radiation.

A more detailed analysis by the Canadian doctors indicated that, for older women, radiation treatments yielded little benefit, a finding that jibed with the US study of patients over 70.

''Faced with an older woman with significant health problems, this says it's really OK to think about leaving out radiation," said Dr. Eric Winer, director of the Breast Oncology Center at Dana-Farber and an author of the US study. ''Faced with a younger woman . . . I'd be more concerned about leaving out radiation."

Stephen Smith can be reached at stsmith@globe.com.