Breast Cancer After 60: Knowing Your Needs

Published in the Summer 2013 issue of LBBC's National Newsletter, Insight

After a routine mammogram in 2005, Marcia Messing, 81, received a message from her imaging center. Then 73 years old, Marcia didn’t think much of it, delaying a return call until the center reached out again and insisted on speaking with her. After follow-up appointments, she learned the radiologist saw what looked like a tumor in each breast.

“I never thought they’d tell me I had breast cancer,” says Marcia, of Los Angeles, who once managed an MRI center herself. “When you’re that age, you’re at a point in your life when you think you’ve made it through. And then, wham-o! I was totally shocked.”

Diagnosis at a Later Age

Most people diagnosed with breast cancer are older than age 60; the average age at diagnosis is 62. According to the National Cancer Institute, 1 in 28 American women will be diagnosed with breast cancer between ages 60 and 70. As we approach 80, this number drops to 1 in 26.

Despite the greater chance of diagnosis at a later age, many women are surprised. Some find the physical and psychological effects of a breast cancer diagnosis and treatment less bothersome than the more tiring or painful health-related issues they already face. Linda Cooper, LCSW, OSW-C, a licensed clinical social worker at Rocky Mountain Cancer Centers in Denver, says medical professionals should be aware of and prepared for the diversity of reactions older women have at diagnosis.

“Older women are not all the same,” Ms. Cooper explains. “In considering just women over age 60, there’s a spectrum from the ‘young-old’ to the ‘very old,’ and they each experience a diagnosis individually.”

Your overall health, family support, marital status, financial ability, health insurance coverage and role in your community all may impact your treatment decision-making. “[Often] an older woman isn’t just caring for herself; she’s caring for her grandchildren, her spouse or her siblings. It’s essential that for as long as possible, she remain vital and independent,” Ms. Cooper says.

As you undergo treatment or make decisions, consider the following issues you may face, and be sure to ask your providers questions. 

Health, Aging and Breast Cancer

When treated with standard therapies, early-stage breast cancer and ductal carcinoma in situ (DCIS) diagnosed in older women usually don’t shorten life. But you may have other health issues—what doctors call comorbidities—that may impact your treatment options. Trouble with everyday movement, for example, may impact treatment options and make treatments that require frequent trips to the hospital difficult; other chronic illnesses, like heart conditions, may limit cancer medicines that can be combined with those prescribed for the heart.

It’s important that all your providers communicate with one another and that you maintain a record of your medicines, including dose and frequency, to share with any new doctors.

Mara Schonberg, MD, MPH, assistant professor of medicine at Beth Israel Deaconess Medical Center, Harvard Medical School, says clear communication is key to getting the right treatment for you.

“Not many clinical trials include women who have comorbidities, so we often don’t conclusively know how effective or ineffective a treatment will be for someone who [has them],” Dr. Schonberg explains. “Treatment decisions should always be based on the question of ‘how will I benefit’?”

At the same time, breast cancer calls for many doctor visits, which means more care, more eyes on you, and sometimes, more underlying conditions found and treated.

“The screening level involved in a breast cancer diagnosis might distract you from symptoms of other illnesses, but breast cancer care by necessity means you’re getting more of everything, and that can be a good thing,” says Dr. Schonberg.

Gretchen Kimmick, MD, MS, associate professor of medicine and a medical oncologist at the Duke Cancer Institute in North Carolina, stresses the importance of screening for other syndromes before beginning treatment.

“There are new tools for physicians to use to determine risk of side effects from treatment and that help determine where other support services, such as physical therapy or nutrition counseling, or consultation with a doctor who specializes in geriatric syndromes, might be useful,” says Dr. Kimmick.

Making treatment decisions

After her diagnosis, Marcia met with a breast surgeon who recommended a double mastectomy. The treatment plan felt too aggressive to her. “He was very professional but not comforting in any way,” Marcia remembers. She decided to get a second opinion with a surgeon she knew, who agreed the tumors could be treated with lumpectomies.

“He scared me less, and I trusted him,” she says. “With my age and tumor size, I didn’t need chemo,just radiation.”

Not all women seek a second opinion. Dr. Schonberg notes a trend toward women following the first recommendation a doctor makes.

“There don’t seem to be very many conversations about the pros and cons of treatment, and what other treatment options are available,” she says. “But you should push your doctor and be informed. Ask your surgeon the challenging questions.”

More and more medical schools and facilities train doctors in shared decision-making that allows you to decide on treatment paths that suit your personal needs. It’s OK to let your oncologist know if you don’t understand a treatment path, or you think a certain treatment might disrupt your lifestyle. Being open and honest with your healthcare team is the best way to ensure you get the treatment you need, while living the life you want.

Balancing your specialists

Many people develop health issues with age, such as diabetes, high blood pressure and problems with mobility, the ability to move well. If you have age-related or other chronic conditions, you may see several specialists to manage them. You might even see your specialists more often than your primary care physician (PCP).

The role of the PCP in your breast cancer care varies depending on where you live, your health insurance plan and your familiarity with your doctor. In some rural areas, where cancer centers are farther away, PCPs may be more involved in coordinating your care. You might even choose to have your PCP coordinate your care simply because you’ve known the doctor for so long.

Oncologists, PCPs and other specialists such as social workers often need to communicate after assessing how to maintain your independence. In some cases they may ask you to sign a document that gives them permission to talk with other members of your healthcare team. A social worker or nurse navigator at your treatment center can help you find ways to facilitate communication among your providers.

If you want your family members or caregivers to have access to your doctors or medical records, ask for a copy of the Health Insurance Portability and Accountability Act (HIPAA) at your next appointment. HIPAA is a federal law that protects your privacy and gives you control over who can access your health information.

Your provider’s office may communicate with you by email between appointments. If you are comfortable using computers, this can be a quick and easy way to get your questions answered. But if you don’t have access to a computer or are uncomfortable using one, you have a right to get your questions answered over the phone or in person.

The Internet can be a great resource for medical information, but it can sometimes be unreliable. If you choose to research online, always check what you find with your doctors.

Health Insurance and Medicare

At any age, health insurance can be complex. It can be especially difficult if you are new to Medicare or have supplemental insurance, or both, and you are just learning how to manage your plans. If you or your spouse or partner continues to work, you may have several plans covering you, including private insurance through your employer, Medicare and supplemental insurance.

Understanding your benefits plans, and what medical expenses they cover, is an important part of managing your breast cancer care. Talk to your insurance companies and ask for details; your cancer center may also have a financial counselor who can help you. If managing your bills during treatment becomes too much, ask a trusted friend or family member to help you.

When you have private insurance through an employer, your plan may cover a significant portion of breast cancer expenses after you fulfill the deductible, a set amount of money you must pay out-of-pocket before your insurance starts to cover costs.

If you are over age 65, you are likely enrolled in Medicare, a federal healthcare program for older adults that covers hospital stays, doctor visits and some cancer medicines after a deductible. Some medicines may require you to pay for additional coverage through Medicare Part D. Changes to the government budget in 2013 may affect where you can get treatment and what prescriptions are covered. Visit medicare.gov, call (800) 633-4227 or talk to your healthcare team for more information.

Some women, especiallythose under 65, may be uninsured. Chris Schrader, 64, runs a daycare from her home in Indianapolis and didn’t have access to insurance though an employer. She and her husband were too young for Medicare, but they couldn’t afford private coverage, so they decided to go without health care.

“It was a tough decision, but we were the picture of health at the time,” Chris says.

Chris had her annual mammogram through Little Red Door Cancer Agency, an Indianapolis-based nonprofit. When cancer was found, Little Red Door referred Chris to Project Health of the Indianapolis Medical Society, which serves poor and uninsured residents.

“Project Health paid for everything and didn’t make us feel small about it,” says Chris. “It’s important to remember that no matter what, help is available.”

Chris could not go back to a private plan because at the time of her diagnosis, insurance companies could still deny coverage for preexisting conditions, health issues you had before you applied for health insurance coverage. Today, the Affordable Care Act prevents insurance companies from denying coverage if you already have breast cancer.

If you’ve been diagnosed and do not have health insurance, ask to speak with a patient navigator or social worker who can help you find and apply for affordable coverage.

Managing Your Relationships 

Support from family and friends may be strong; it can also be a source of stress and anxiety. You maybe the caregiver for a family member, or you may be caring for someone else with a chronic illness. The role you fill may impact your treatment decisions as you work to balance what you want for yourself with what others want for you.

“If a woman is a caregiver, she’ll often delay her own treatment to continue caring for her relative, or she’ll go with a more aggressive treatment option to ensure that she’ll continue to be able to care for them,” says Dr. Schonberg. “At the same time, some families push for the woman to take a more aggressive route because they want her to be OK. You have to take a step back and consider all sides.Don’t take everything at face value.”

Romantic relationships may also play a role in your decisions. If you aren’t partnered, you may consider how treatment could affect your future, or whether reconstruction is important to your intimate life.

Linda Timmons, 62, was diagnosed with stage I breast cancer in 2011. Divorced with adult children, she opted for reconstruction after a bilateral mastectomy. Soon after, complications from the surgery forced her to have the implants removed. Now she is having a second reconstruction.

“People might wonder why someone would go through extra surgeries for reconstruction, but I wanted to,” says Linda. “The hardest part is feeling confident enough to go out there and date.”

Though single, Linda’s children, as well as her ex-husband, cared for her during treatment and after the surgeries that followed. Beyond her family, she found support in her friends and Bosom Buddies, a group at the Cancer Support Community in her Miami hometown.

“Strong friendships are an important part of getting well,” she says. “And knowing other women with breast cancer is just as essential. If you’re only dealing with family, you don’t understand that there are people out there with you who have been through it, too.”

For peer support and information in a confidential setting, call our Breast Cancer Helpline toll-free at (888)753-LBBC (5222). Your call will be answered by a woman who has experienced breast cancer.