ORIGINAL ARTICLE

Patterns of Surgical Treatment for Women with BreastCancer in Relation to Age

Jim Wang, PhD,* James Kollias, FRACS, MD,* Margaret Boult, BSc (Hons),*Wendy Babidge, BSc (Hons), PhD,*� Helen N. Zorbas, MB, BS, FASBP,�

David Roder, PhD� and Guy Maddern, FRACS, PhD*�

*National Breast Cancer Audit, ASERNIP-S, Royal Australasian College of Surgeons, Stepney;�Department of Surgery, Adelaide University, Queen Elizabeth Hospital, Adelaide, SA; and�National Breast and Ovarian Cancer Centre, Sydney, NSW, Australia

n Abstract: Although treatment recommendations have been advocated for all women with early breast cancer regard-less of age, it is generally accepted that different treatments are preferred based on the age of the patient. The aim of thisstudy was to assess the pattern of breast cancer surgery after adjusting for other major prognostic factors in relation topatient age. Data on cancer characteristics and surgical procedures in 31,298 patients with early breast cancer reported tothe National Breast Cancer Audit between 1999 and 2006 were used for the study. There was a close association betweenage and surgical treatment pattern after adjusting for other prognostic factors, including tumor size, histologic grade, num-ber of tumors, lymph node positivity, lymphovascular invasion (LVI), and extensive intraduct component. Breast ConservingSurgery (BCS) was highest among women aged £40 years (OR = 1.140; 95% CI: 1.004–1.293) compared to women aged51–70 years (reference group). BCS was lowest in women aged >70 years (OR = 0.498, 95% CI: 0.455–0.545). Signifi-cantly more women aged £50 years underwent more than one operation for breast conservation (20.4–24.8%) comparedwith women aged >50 years (11.4–17.0%). Women aged >70 years were more likely to receive no surgical treatment, 3.5%versus 1.0–1.3% in all other age groups (£40, 41–50 51–70 years). There is an association between patient age and thetype of breast cancer surgery for women in Australia and New Zealand. Women age £40 years are more likely to undergoBCS despite having adverse histologic features and have more than one procedure to achieve breast conservation. Olderwomen (>70 years) more commonly undergo mastectomy and are more likely to receive no surgical treatment. n

Key Words: age, breast cancer, surgery

Although treatment recommendations have been

advocated for all women with early breast cancer

regardless of age, it is generally accepted that different

treatments are preferred based on the age of the

patient. The National Breast and Ovarian Cancer

Centre (NBOCC, formerly NBCC) has developed the

Clinical Practice Guidelines for Younger Women with

Breast Cancer (1), in addition to Clinical Practice

Guidelines for the Management of Early Breast Can-

cer (2) to address younger women’s particular needs.

The outcomes of Breast Conserving Surgery (BCS)

may also differ for women of different age. Many

studies have demonstrated that young women have

worse outcomes following breast-conserving therapy

with an increased risk of locoregional recurrence (3

and other references). Other age-specific consider-

ations, such as sexuality, self-esteem, quality of fam-

ily ⁄ social life and fertility can often influence

treatment choices, treatment efficacy, and safety. The

decision making process is often shared by the patient

and her surgeon.

There are age disparities in breast cancer treatment

choices in addition to other factors such as education,

income status, insurance plan, functional status, and

comorbidity (4). Age-related breast cancer pathology

may simultaneously influence treatment decisions for

women with early breast cancer. There are conflicting

reports on the age pattern of breast cancer manage-

ment. One report suggested that the overall treatment

pattern was not affected by age, except for the small

group of patients aged >70 years who had no axillary

node biopsy or dissection (5). Rao et al. (6) concluded

that elderly patients receive less aggressive treatment

Address correspondence and reprint requests to: Dr. James Kollias,

FRACS, MD, Chair of the royal Australasian College of Surgeons, Section of

Breast Surgery, Chair of the Breast Surgeons Society of Australia, New

Zealand and Clinical Director of the National Breast Cancer Audit, PO Box

553, Stepney, 5069 SA, Australia, or e-mail: Jim.kollias@health.sa.gov.au.

DOI: 10.1111/j.1524-4741.2009.00828.x

� 2009 Wiley Periodicals, Inc., 1075-122X/09The Breast Journal, Volume 16 Number 1, 2010 60–65

when compared with their younger counterparts. On

a population basis, it is not clear whether age has an

independent effect on surgical treatment. In order to

determine the possible independent effect of age on

breast cancer surgery, the data relating to patient

characteristics and treatment need to be assessed using

a multivariate analysis method. To our best knowl-

edge, there has been no such study reported for an

Australian and New Zealand population. This study

aims to assess the pattern of breast cancer surgery

after adjusting for other major prognostic factors in

relation to patient age.

SUBJECTS AND METHODS

In this study, data was obtained from the National

Breast Cancer Audit (NBCA). The database from this

audit collects data on many aspects of breast cancer

diagnosis and treatment. The NBCA uses the defini-

tion of early breast cancer as stated in the NBCC

Clinical Practice Guidelines for the Management of

Early Breast Cancer, namely, invasive tumors of not

more than 5 cm in diameter with either impalpable or

palpable but not fixed lymph nodes (LN) and with no

evidence of distant metastases. This corresponds to

tumors that are T 1-2, N 0-1, and M0 (based on 1987

UICC classification). Cases of DCIS were excluded

from this study.

Between January 1998 to December 2006, 57,100

episodes of early breast cancer in this period were

reported to the NBCA. There were 31,298 patients

with key variables, age, type, size, and grade of the

main tumor and types of surgical treatment received,

available for the analysis and included in the subse-

quent analyzes. The following categorical data items

relating to early breast cancer diagnosis, surgery, and

adjuvant therapy were used in the analysis: age at

diagnosis in years (£40, 41–50, 51–70, >70), the prin-

ciple location of the main tumor (superior ⁄ lateral,

medial ⁄ inferior, central, >1 quadrant), method of

cytological ⁄ histologic diagnosis (fine needle aspiration,

core biopsy, open biopsy), invasive tumor size (1–10,

11–20, 21–30, 31–40, 41–50 mm), tumor grades (I, II,

III according to the modified Bloom and Richardson

criteria as described by Elston and Ellis) (7), LVI

(absent, present) LN status (positive, negative), exten-

sive intraduct component (EIC, absent, present), estro-

gen receptor (positive, negative), progesterone receptor

(positive, negative), type of surgical treatment (BCS,

mastectomy).

Statistical Methodology

The four age groups were analyzed for differences

in the various diagnostic, pathological, and surgical

treatment parameters previously described using the

chi-squared test (or Fisher’s exact test where the num-

ber of cases is <5 in one cell) and ANOVA where

appropriate. A statistical significance level of p < 0.05

was used. Multivariate analysis using logistic regres-

sion was used to determine the effect of age on the

use of surgical treatment. The odds ratio and its 95%

confidential interval from the analysis were shown.

RESULTS

The Relationship Between the Age and Method of

Preoperative Diagnosis

The number of patients was 2493 in the group aged

£40 years (mean ± SD: 35.9 ± 3.9), 6,863 in the group

aged 41–50 (46.1 ± 2.8), 15,842 in the group aged

51–70 (59.7 ± 5.6), and 6,100 in the group aged >70

(78.0 ± 5.3). Table 1 illustrates the methods of preop-

erative diagnosis using cytology, core biopsy, or open

biopsy. Fine needle aspiration cytology was the com-

monest method used for preoperative diagnosis. There

was a significantly higher use of core biopsy to obtain

a preoperative diagnosis in the 50–70 year age group

and a significantly greater use of open biopsy in

women aged £40 years.

The Relationship Between Age and Breast Cancer

Pathology

Most of the cases (>95%) were unilateral breast

cancer. There was an increase in the proportion of

bilateral cancer with age (1.4% for the youngest

group, 2.2% for 41–50 group and 2.5% for 51–70

group, and 3.5% for >70 group).

No major difference was demonstrated between age

groups in their distribution of the location of the main

Table 1. Method of Preoperative Diagnosis UsingCytology or Histology

Method of

preoperative

diagnosis

Age (years)

p-value£40 (%) 41–50 (%) 51–70 (%) >70 (%)

Fine needle

aspiration cytology

60.2 54.4 50.0 59.1 <0.05

Core biopsy 43.4 48.6 52.7 40.3 <0.01

Open biopsy 15.9 14.9 13.7 8.8 <0.001

The Age Effect on Surgical Treatment Pattern of Breast Cancer • 61

tumor, particularly for those located superior ⁄ lateral

or medial ⁄ inferior (Table 2). In older patients, there

was a slight increase (p < 0.05) of tumors which were

centrally located and a decrease of tumors which were

in more than one quadrant.

A significant difference in histologic tumor grade

was demonstrated according to age groups (Table 3).

Over 50% of women aged £40 years had high-grade

cancers compared with approximately 25% aged

‡50 years. In women aged 41–50 years, 36% had

high-grade tumors. There was a corresponding lower

rate of low-grade tumors in the younger age group.

The size and number of the tumor varied signifi-

cantly across the age groups. There was a trend of the

reduction in tumor size and few tumors with the

increase of age up to 70-year old. There was a signifi-

cant reduction of LN+ tumor with age. Over 40% of

the younger women had LVI presence and the propor-

tion was nearly halved in the two older groups. There

was a significant reduction in cases with the presence

of EIC from the youngest group to the oldest group

(Table 4). There was a significant increase in the rate

of estrogen receptor positive breast cancer with

increasing age. The proportion of breast cancers with

positive progesterone receptor status was significantly

less in the youngest group (Table 4).

The Relationship Between Age and Use of Surgical

Procedures

A significantly higher proportion of women aged

51–70 years underwent BCS compared with other age

groups while younger women who underwent BCS

were significantly more likely to undergo more than

one surgical procedure to obtain tumor clearance. The

proportion of women underwent breast reconstruction

after mastectomy decreased significantly with the

increase of age. Most women underwent one or more

surgical procedures although a significantly higher

proportion of women aged >70 years received no sur-

gery at all (Table 5).

The multivariate logistic regression analysis

(Table 6) shows that age was significantly associated

with the likelihood of undergoing BCS in addition to

the following variables: histologic grade, number of

Table 2. The Distribution of Principle Location ofthe Main Tumor for Different Age Groups

Location

Age (years)

p-value£40 (%) 41–50 (%) 51–70 (%) >70 (%)

Superior ⁄ lateral 64.9 66.2 65.6 62.1 NS

Medial ⁄ inferior 23.9 22.8 24.1 23.6 NS

Central 9.2 9.3 9.2 13.2 <0.05

>1 quadrant 2.0 1.7 1.1 1.0 <0.05

Table 3. Histologic Grade of the Tumor for Differ-ent Age Groups

Histologic

grades

Age (years)

p-value£40 (%) 41–50 (%) 51–70 (%) >70 (%)

1 11.4 20.2 28.9 26.7 <0.001

2 36.5 44.2 43.9 46.9 <0.001

3 52.1 35.6 27.2 26.4 <0.001

Table 4. Tumor Characteristics forDifferent Age Groups (mean + SDand%)Variable

Age

p-value£40 41–50 51–70 >70

Tumor size (mm) 20.67 + 10.84 19.31 + 10.43 17.27 + 9.91 19.82 + 10.45 <0.01

No. tumors 1.58 + 1.11 1.50 + 1.05 1.35 + 0.89 1.28 + 0.78 <0.05

LN+ 48.4% 41.2% 32.5% 36.2% <0.001

LVI presence 41.3% 30.7% 22.0% 23.0% <0.001

EIC presence 29.2% 27.2% 19.9% 13.6% <0.001

ER+ 64.4% 74.8% 79.3% 82.6% <0.001

PR+ 59.6% 70.1% 66.3% 68.0% <0.05

LVI, lymphatic vascular invasion; EIC, extensive intraduct component; ER, estrogen receptor status; PR, progesteronereceptor status.

Table 5. Utilization of the Surgical Procedures inDifferent Age Groups

Surgical procedures

Age

p-value£40 (%) 41–50 (%) 51–70 (%) >70 (%)

BCS* 53.9 56.7 62.9 53.0 <0.001

More than one BCS

procedures

24.8 20.4 17.0 11.4 <0.001

Mastectomy 44.9 42.0 36.1 43.5 <0.001

Reconstruction after

mastectomy

27.2 20.8 9.4 0.4 <0.001

No. surgical treatment 1.2 1.3 1.0 3.5 <0.001

*% BCS including one or more of the following procedures, open biopsy, CLE, re-exci-sion.

62 • wang ET AL.

cancers, tumor size, tumor location, the EIC presence

(yes or no), and LN status (+ or )). After adjusting

for these factors, compared with the group aged 51–

70 years (the reference group), the group aged

£40 years had a significantly increased likelihood of

receiving BCS (OR = 1.14, 95% CI: 1.004–1.293)

while the group aged >70 years had only half the

chance of receiving BCS (OR = 0.498, 95% CI:

0.455–0.545).

DISCUSSION

The results of this study demonstrate consistent dif-

ferences between the age groups in the early diagnosis,

cancer pathological characteristics, and the surgical

treatment received. After adjusting for cancer patho-

logical characteristics, age is independently associated

with the surgical treatment pattern in women with

breast cancer.

As expected, the breast cancers of younger women

had adverse histologic features including increased

tumor size, tumor number, higher histologic grades,

more LN involvement, more frequent LVI, and EIC.

These features suggest a higher rate of loco-regional

recurrence and worse survival for young women with

early breast cancer than older women which have

been confirmed by previous studies (8–11). There was

a significant increase in the rate of estrogen receptor

positive breast cancer in the older groups while the

proportion of progesterone receptor positive was sig-

nificantly higher only in the group aged >70 years. A

higher prevalence of simultaneous bilateral breast can-

cer was seen in women of older age groups. This

relates to the higher sensitivity of mammography for

older women (12,13). Another study reported that age

was a minor determinant of mammographic sensitivity

in women aged 40 years or older (14). There was no

difference between women aged 51–70 years and

those aged >70 years in tumor histologic grade, preva-

lence of LN+, and LVI although tumor size was signif-

icantly larger in women aged >70 years.

The clinical impact of the Breast Screen Australia

and Breast Screen Aotearoa Program in New Zealand

was demonstrated in the higher use of core biopsy in

the diagnosis of breast cancer in women aged 50–

70 years. Previous studies have demonstrated an

increase in preoperative cancer diagnosis with the use

of core biopsy compared with fine needle aspiration

(15,22 #1487). The use of open biopsy for breast can-

cer diagnosis was highest for women aged <40 years.

Although the reason for this may involve discrepant

results in the triple test, particularly in relation to

breast imaging, the increased use of core biopsy in this

group may lead to a reduced need for open biopsy.

The need to preserve the breast is more important

for young women. Higher rates of adjustment prob-

lems, body image issues, and depression have been

previously shown for younger women having mastec-

tomy (16). The preference of younger women for BCS

was also demonstrated by the strong age-related pat-

tern that they were more likely to undergo more than

one procedure to obtain resection margins or one or

two conservative procedures prior to mastectomy. In

the study population, one in four younger women

underwent more than one procedure. This may reflect

a more conservative approach by breast surgeons to

preserve breast aesthetic outcome with the first proce-

dure. Previous studies have shown that young women

tended to have smaller volumes of breast tissue

resected, more often extending to surgical margins at

re-excision (17).

Improvements in preoperative local staging to

determine the extent of cancer in the breast in younger

women is likely to improve surgical outcomes and

reduce the need for multiple operations. The relatively

low sensitivity of mammography in the dense breast is

a detriment to surgeons planning breast conserving

procedures in young women. Recent studies have

suggested that MRI has a much greater sensitivity and

can accurately assess the extent of breast cancer in

women with dense breasts (18–20). It is anticipated

that breast MRI will have a place in preoperative stag-

ing of breast cancer for young women in the near

Table 6. Multivariate logistic regression analyzesfor likelihood of BCS

OR 95% CI for OR p-value

Age (years) £40 1.140 1.004 1.293 <0.05

41–50 1.082 0.996 1.176 NS

51–70 1

>70 0.498 0.455 0.545 <0.01

Tumor size 0.942 0.939 0.946 <0.05

Histologic grade 1 1

Histologic grade 2 0.898 0.826 0.977 <0.05

Histologic grade 3 0.875 0.798 0.960 <0.01

No. tumors 1 1

No. tumors 2 0.329 0.293 0.370 <0.001

No. tumors 3+ 0.161 0.142 0.183 <0.001

EIC present, no 1

EIC present, yes 0.461 0.425 0.500 <0.01

LN) 1

LN+ 0.736 0.685 0.789 <0.01

EIC, extensive intraduct component; LN, lymph node.Significant values shown in bold.

The Age Effect on Surgical Treatment Pattern of Breast Cancer • 63

future. Diagnostic core biopsy can also accurately pro-

file the primary tumor in breast cancer patients

(21,22), and should be used more often in younger

women in order to provide more precise information

on breast cancer histologic characteristics.

Women aged >70 years were least likely to undergo

BCS compared to those aged 51–70 years despite

having histologic features that suggested suitability for

breast conservation. Furthermore, they were about

three times more likely to receive no surgical treat-

ment comparing with other age groups. Reasons for

this may include greater patient acceptance of mastec-

tomy, avoiding radiotherapy due to inconvenience and

radiation sequelae, simplifying treatment, and a differ-

ent understanding of information about treatment

efficacy of various surgical treatment options. Our

findings are consistent with recent studies regarding

the breast cancer treatment pattern in older women

(6). Older women (>70-year old) were less likely to

undergo axillary surgery (p < 0.001) (5). Another

study reported a lower frequency of adjuvant therapy

use among women over 65 years of age (23). The

guideline adherence was markedly lower for elderly

patients (24). The seemingly lower level of treatment

received by older women is an important issue requir-

ing further study. The complex interaction between

age, overall heath status, and living function compli-

cates the planning and outcomes of surgery. One

study in the USA population comprising Hispanic,

black, and non-Hispanic white women showed that

there are racial and age disparities in breast cancer

treatment in addition to the effect of education,

income status, insurance plan, functional status, and

comorbidity (4).

The inverse association between the use of BCS and

age is not fully consistent with the current recommen-

dation in the clinical guidelines in Australia and New

Zealand for breast cancer treatment and care. The

guidelines for all women stated: where appropriate,

women should be offered a choice of either BCS fol-

lowed by radiotherapy or mastectomy, as there is no

difference in the rate of survival or distant metastasis

(1). The guidelines also highlighted the need of

informing patients that body image is better preserved

with BCS (level I evidence). On the other hand, in the

guidelines for younger women with early breast can-

cer, it is noted that there are inadequate data about

optimal local treatment in the very young but limited

evidence suggests that age younger than 35 years is

associated with increased risk of recurrence after

breast conserving treatment, and also possibly follow-

ing mastectomy (2). It is possible that, either through

the zeal of the treating team or through patient

choice, preservation of the breast in younger women

may be used injudiciously and may jeopardize local

cancer control. Adequate surgery is fundamental to

the optimal treatment of breast cancer. A recent study

has demonstrated that the risk of death from breast

cancer was significantly higher if loco-regional treat-

ment was inadequate despite adjuvant treatments (25).

Although young age is currently not considered to be

a contraindication to breast conserving treatment, it

may signify a higher risk of ipsilateral breast tumor

recurrence (26), and require more aggressive surgical

resection and careful attention to margin status. As an

isolated loco-regional recurrence is a potentially cur-

able condition, patients treated with breast conserva-

tion, and diagnosed with breast cancer at a young age

should be monitored closely to detect local recurrence

at an early stage. If breast conservation cosmetic

issues assume importance, oncoplastic methods of

breast volume replacement or breast volume displace-

ment are methods that surgeons may employ to

improve outcomes. Further research is required in this

area.

This study has used data submitted over the last

8 years by breast surgeons in Australia and New

Zealand. One previous study has shown that over

this period of time, the use of BCS has not changed

significantly either overall (27), or for younger

women using multivariate models (28). In the multi-

variate logistic regression analysis, we have checked

and ensured that assumptions underlying the logistic

modeling, such as a lack of co-linearity, were satis-

fied. The variables which were not statistically signifi-

cant in the model have been dropped. A major

drawback of the present study is the lack of data

relating to patient participating in decision-making

process. Therefore, using the currently available data

in assessing the link between age and treatment can-

not elucidate the reasons for different treatment pat-

terns in women of different age. This study can only

illustrate the treatment pattern rather than identify

age as a factor influencing treatment. Complex inter-

actions between patient preference, breast cancer pre-

sentation, and treatment options by the surgeon may

at least partially explain some of the results reported

in this study.

In conclusion, this study demonstrates that there is

an independent association between patient age and

64 • wang ET AL.

the type of breast cancer surgery received by breast

cancer women in Australia and New Zealand. Women

age £40 years are more likely to undergo BCS despite

having adverse histologic features and often have

more than one procedure to achieve breast conserva-

tion. Older women (>70 years) more commonly

undergo mastectomy and are more likely to receive no

surgical treatment.

REFERENCES

1. NBCC. Clinical Guidelines for the Management and Supportof Younger Women With Breast Cancer, ed. N.B.C. Centre.

Camperdown, NSW: NBCC, 2004.

2. NBCC. Clinical Practice Guidelines for the Management ofEarly Breast Cancer, 2nd edn, ed. N.B.C. Centre. Camperdown,

NSW: NBCC, 2001.

3. Oh JL, Bonnen M, Outlaw ED, et al. The impact of young

age on locoregional recurrence after doxorubicin-based breast con-servation therapy in patients 40 years old or younger: how young is

‘‘young’’? Int J Radiat Oncol Biol Phys 2006;65:1345–52.

4. Naeim A, Hurria A, Leake B, Maly RC. Do age and ethnicity

predict breast cancer treatment received? A cross-sectional urbanpopulation based study. Breast cancer treatment: age and ethnicity

Crit Rev Oncol Hematol 2006;59:234–42.

5. Koshy A, Buckingham JM, Zhang Y, Craft P, Dahlstrom JE,Tait N. Surgical management of invasive breast cancer: a 5-year

prospective study of treatment in the Australian Capital Territory

and South-Eastern New South Wales. ANZ J Surg 2005;75:757–61.

6. Rao VS, Garimella V, Hwang M, Drew PJ. Management ofearly breast cancer in the elderly. Int J Cancer 2007;120:1155–60.

7. Elston CW, Ellis IO. Pathological prognostic factors in breast

cancer. I. The value of histological grade in breast cancer: experi-

ence from a large study with long-term follow-up. Histopathology1991;19:403–10.

8. Horst KC, Smitt MC, Goffinet DR, Carlson RW. Predictors

of local recurrence after breast-conservation therapy. Clin BreastCancer 2005;5:425–38.

9. Kollias J, Elston CW, Ellis IO, Robertson JF, Blamey RW.

Early-onset breast cancer – histopathological and prognostic consid-

erations. Br J Cancer 1997;75:1318–23.10. Pendlebury SC, Ivanov O, Renwick S, Stevens GN. Long-

term review of a breast conservation series and patterns of care over

18 years. ANZ J Surg 2003;73:577–83.

11. Zhou P, Gautam S, Recht A. Factors affecting outcome foryoung women with early stage invasive breast cancer treated with

breast-conserving therapy. Breast Cancer Res Treat 2007;101:51–7.

12. Kolb TM, Lichy J, Newhouse JH. Comparison of the

performance of screening mammography, physical examination,and breast US and evaluation of factors that influence them: an

analysis of 27,825 patient evaluations. Radiology 2002;225:

165–75.

13. Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V.Effect of age, breast density, and family history on the sensitivity of

first screening mammography. JAMA 1996;276:33–8.

14. Rosenberg RD, Hunt WC, Williamson MR, et al. Effects ofage, breast density, ethnicity, and estrogen replacement therapy on

screening mammographic sensitivity and cancer stage at diagnosis:

review of 183,134 screening mammograms in Albuquerque, New

Mexico. Radiology 1998;209:511–8.15. Litherland JC. Should fine needle aspiration cytology in

breast assessment be abandoned? Clin Radiol 2002;57:81–4.

16. Metcalfe KA, Esplen MJ, Goel V, Narod SA. Psychosocial

functioning in women who have undergone bilateral prophylacticmastectomy. Psychooncology 2004;13:14–25.

17. Vrieling C, Collette L, Fourquet A, et al. Can patient-, treat-

ment- and pathology-related characteristics explain the high local

recurrence rate following breast-conserving therapy in youngpatients? Eur J Cancer 2003;39:932–44.

18. Boetes C, Veltman J. Screening women at increased risk

with MRI. Cancer Imaging 2005;5:S10–5.19. Beatty JD, Porter BA. Contrast-enhanced breast magnetic

resonance imaging: the surgical perspective. Am J Surg 2007;193:

600–5; discussion 605.

20. Hoisington LA, Scherer DL, Berger KL. Breast MR imaging:applications and pitfalls. Radiol Technol 2007;78:367–77.

21. Cahill RA, Walsh D, Landers RJ, Watson RG. Preoperative

profiling of symptomatic breast cancer by diagnostic core biopsy.

Ann Surg Oncol 2006;13:45–51.22. Garg S, Mohan H, Bal A, Attri AK, Kochhar S. A compara-

tive analysis of core needle biopsy and fine-needle aspiration cytol-

ogy in the evaluation of palpable and mammographically detectedsuspicious breast lesions. Diagn Cytopathol 2007;35:681–9.

23. Balasubramanian BA, Gandhi SK, Demissie K, et al. Use of

adjuvant systemic therapy for early breast cancer among women

65 years of age and older. Cancer Control 2007;14:63–8.24. Schaapveld M, de Vries EG, Otter R, de Vries J, Dolsma

WV, Willemse PH. Guideline adherence for early breast cancer

before and after introduction of the sentinel node biopsy. Br JCancer 2005;93:520–8.

25. Kingsmore DB, Hole DJ, Gillis CR, George WD. Inadequate

treatment of symptomatic breast cancer. Br J Surg 2005;92:422–8.

26. Komoike Y, Akiyama F, Iino Y, et al. Ipsilateral breasttumor recurrence (IBTR) after breast-conserving treatment for early

breast cancer: risk factors and impact on distant metastases. Cancer2006;106:35–41.

27. Cuncins-Hearn AV, Boult M, Babidge W, et al. Nationalbreast cancer audit: overview of invasive breast cancer management.

ANZ J Surg 2006;

76:745–50.

28. Wang J, Boult M, Tyson S, et al. Trends in surgical treat-ment of younger patients with breast cancer in Australia and New

Zealand. ANZ J Surg 2008;78:665–9.

The Age Effect on Surgical Treatment Pattern of Breast Cancer • 65