The effect of under-treatment of breast cancer in women 80 years of age and older

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Abstract

Background

Several authors have demonstrated a trend toward the under-treatment of elderly and very elderly women with breast cancer. This study was undertaken to determine the impact of under-treatment of breast cancer in women age 80 and older.

Methods

A retrospective chart review of all patients 80 years and older with a newly diagnosed breast cancer at the MD Anderson Cancer Center, Houston, TX, between September 1, 1989 and September 1, 2004 was performed. Data extracted from charts included patient demographics, comorbidity, treatments recommended, treatments received, complications of therapy, disease recurrence and disease related death. Treatments undertaken were analyzed in the context of accepted therapy at the time of diagnosis.

Results

Two hundred twelve patients were identified. The median age was 83.5 years (range 80–97). Overall survival in the entire cohort was 7.28 years with a median follow up of 4 years for patients still alive at the end of the study period. Fifty seven percent of patients were under-treated according to institutional and national guidelines. Women who underwent hormonal therapy only demonstrated decreased disease specific survival (P < 0.001 respectively) compared with patients who received multi-modality therapy. Women who underwent partial mastectomy without radiation treatment experienced a significant increase in local regional recurrence (P = 0.045). There was an association of increased disease specific survival in patients who had surgical lymph node evaluation compared to those who did not (P = 0.04).

Conclusions

Outcomes are compromised in very elderly women with breast cancer in whom less than complete combined modality treatment is undertaken. With the previously demonstrated safety of radiation therapy, hormonal therapy and surgery in the very elderly population, multi-modality therapy should not be routinely withheld in patients in this age category.

Section snippets

Background

The average life expectancy in the United States has been rising nearly continuously since 1900. In 2005, the mean life expectancy of a woman at birth was 80 years [1]. This aging of the population is projected to continue; in the next 25 years the number of American women over the age of 65 years is expected to increase 104% and the number of women 85 years and older is also projected to double [2], [3].

As with most cancers, the risk of developing breast cancer increases with age from 1 in 209

Methods

After obtaining Institutional Review Board approval a retrospective analysis was performed on data collected from the medical records of newly diagnosed breast cancer patients 80 years and older evaluated at the MD Anderson Cancer Center between September 1, 1989 and September 1, 2004. Any patient who received breast cancer counseling (and ultimately refused care) or any component of multi-modality breast cancer treatment in our institution was included. Patients presenting with a recurrent

Results

Two hundred twelve patients were identified from our institutional database, patient demographics and treatment are described in Table 1. The median age was 83.5 years (range 80–97). Overall survival in the entire cohort was 7.28 years with a median follow up of 4 years for patients still alive at the end of the study period. Ninety-two (48.4%) patients were diagnosed with stage 1 disease, ten patients presented with stage IV disease. Forty three percent of patients received all treatment

Discussion

This study shows that the majority of very elderly women are still offered less than standard and unimodality instead of multi-modality treatment, resulting in unnecessary local regional recurrence as well as an increased possibility of risk of disease related death.

Several factors have been named in the literature as a basis for substandard treatment: older patients have a higher prevalence of comorbidities and lower life expectancy compared to younger patients [11], treatment may be perceived

Conflict of interest

None declared.

Reviewer

Professor Riccardo Audisio, Consultant Surgeon; Surgical Oncologist, Whiston Hospital, Department of Surgery, Warrington Road, Prescot, Merseyside L35 5DR, United Kingdom.

B.L. Van Leeuwen, M.D., Ph.D. is a surgeon with the elderly patient as main interest. She was employed by the Dutch Cancer Foundation 2007–2009 as a clinical and research fellow in “cancer in the elderly”. As such she gained valuable working and research experience in Uppsala University Hospital, Sweden, Whiston Hospital in Liverpool and the MD Anderson Cancer Center in Houston, USA. Since 2007 she has been the primary investigator of a project financed by the Dutch Government (ZonMw) entitled;

References (31)

  • I. Jatoi et al.

    Breast cancer mortality trends in the United States according to estrogen receptor status and age at diagnosis

    J Clin Oncol

    (2007)
  • New classification of physical status. American Society of Anesthesiologists

    Anesthesiology

    (1963)
  • A. Goldhirsch et al.

    Meeting highlights: international consensus panel on the treatment of primary breast cancer

    J Natl Cancer Inst

    (1995)
  • Life course perspectives of coronary heart disease, stroke and diabetes. Ageing and Life Course. Department of...
  • C. Bouchardy et al.

    Older female cancer patients: importance, causes, and consequences of undertreatment

    J Clin Oncol

    (2007)
  • Cited by (67)

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    B.L. Van Leeuwen, M.D., Ph.D. is a surgeon with the elderly patient as main interest. She was employed by the Dutch Cancer Foundation 2007–2009 as a clinical and research fellow in “cancer in the elderly”. As such she gained valuable working and research experience in Uppsala University Hospital, Sweden, Whiston Hospital in Liverpool and the MD Anderson Cancer Center in Houston, USA. Since 2007 she has been the primary investigator of a project financed by the Dutch Government (ZonMw) entitled; “A controlled trial of geriatric liaison intervention in frail surgical oncology patients.” She started work in the University Medical Center Groningen in September 2008 and was rewarded a tenure track fellowship by the University. She is a member of the research taskforce of Gerionne (Geriatric Oncology in the Netherlands) and the surgical taskforce of the International Society of Geriatric Oncology (SIOG). Together with Professor R.A. Audisio (University of Liverpool) she is co-investigator of an international study investigating the predictive value of several preoperative screening instruments in frail elderly patients.

    1

    Tel.: +1 603 650 9479; fax: +1 603 650 8030.

    2

    Tel.: +1 713 7451563; fax: +1 713 4044572.

    3

    The Department of Surgical Oncology, MD Anderson Cancer Center includes Feig B, Ames F, Hwang R, Lucci A and Meric-Bernstam F.

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