Objective Patients with cancer face difficult decisions regarding treatment and the possibility of trading quality of life (QoL) for length of life (LoL). Little information is available regarding patients' preferences and attitudes toward their cancer treatment and the personal costs they are prepared to exchange to extend their life. The aim of this review is to determine the complex trade‐offs and underpinning factors that make patients with cancer choose quality over quantity of life. Methods A systematic review of the literature was conducted using MeSH terms: cancer, longevity or LoL, QoL, decision making, trade‐off, and health utility. Articles retrieved were published between 1942 and October 2018. Results Out of 4393 articles, 30 were included in this review. Older age, which may be linked to declining physical status, was associated with a preference for QoL over LoL. Younger patients were more likely to undergo aggressive treatment to increase survival years. Preference for QoL and LoL was not influenced by gender, education, religion, having children, marital status, or type of cancer. Patients with better health valued LoL and inversely those with poorer physical status preferred QoL. Conclusion Baseline QoL and future expectations of life seem to be key determinants of preference for QoL versus LoL in cancer patients. In‐depth studies are required to understand these trade‐offs and the compromises patients are willing to make regarding QoL or LoL, especially in older patients with naturally limited life expectancy.

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Introduction Older patients with early breast cancer (EBC) derive modest survival benefit from chemotherapy but have increased toxicity risk. Data on the impact of chemotherapy for EBC on quality of life in older patients are limited, but this is a key determinant of treatment acceptance. We aimed to investigate its effect on quality of life in older patients enrolled in the Bridging the Age Gap study. Materials and methods A prospective, multicentre, observational study of EBC patients ≥70 years old was conducted in 2013–2018 at 56 UK hospitals. Demographics, patient, tumour characteristics, treatments and adverse events were recorded. Quality of life was assessed using the European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaires (EORTC-QLQ) C30, BR23 and ELD 15 plus the Euroqol-5D (eq-5d) over 24 months and analysed at each time point using baseline adjusted linear regression analysis and propensity score-matching. Results Three thousand and four hundred sixteen patients were enrolled in the study; 1520 patients undergoing surgery and who had high-risk EBC were included in this analysis. 376/1520 (24.7%) received chemotherapy. At 6 months, chemotherapy had a significant negative impact in several EORTC-QLQ-C30 domains, including global health score, physical, role, social functioning, cognition, fatigue, nausea/vomiting, dyspnoea, appetite loss, diarrhoea and constipation. Similar trends were documented on other scales (EORTC-QLQ-BR23, EORTC-QLQ-ELD15 and EQ-5D-5L). Its impact was no longer significant at 18–24 months in unmatched and matched cohorts. Conclusions The negative impact of chemotherapy on quality-of-life is clinically and statistically significant at 6 months but resolves by 18 months, which is crucial to inform decision-making for older patients contemplating chemotherapy. Trial registration number ISRCTN 46099296.

Background: Age-related breast cancer treatment variance is widespread with many older women having primary endocrine therapy (PET), which may contribute to inferior survival and local control. This propensity-matched study determined if a subgroup of older women may safely be offered PET. Methods: Multicentre, prospective, UK, observational cohort study with propensity-matched analysis to determine optimal allocation of surgery plus ET (SþET) or PET in women aged !70 with breast cancer. Data on fitness, frailty, cancer stage, grade, biotype, treatment and quality of life were collected. Propensity-matching (based on age, health status and cancer stage) adjusted for allocation bias when comparing SþET with PET. Findings: A total of 3416 women (median age 77, range 69e102) were recruited from 56 breast unitsd2854 (88%) had ERþ breast cancer: 2354 had SþET and 500 PET. Median follow-up was 52 months. Patients treated with PET were older and frailer than patients treated with SþET. Unmatched overall survival was inferior in the PET group (hazard ratio, (HR) 0.27, 95% confidence interval (CI) 0.23e0.33, P < 0.001). Unmatched breast cancerespecific survival (BCSS) was also inferior in patients treated with PET (HR: 0.41, CI: 0.29e0.58, P < 0.001 for BCSS). In the matched analysis, PET was still associated with an inferior overall survival (HR Z 0.72, 95% CI: 0.53e0.98, P Z 0.04) but not BCSS (HR Z 0.74, 95% CI: 0.40 e1.37, P Z 0.34) although at 4e5 years subtle divergence of the curves commenced in favor of surgery. Global health status diverged at certain time points between groups but over 24 months was similar when adjusted for baseline variance. Interpretation: For the majority of older women with early ERþ breast cancer, surgery is oncologically superior to PET. In less fit, older women, with characteristics similar to the matched cohort of this study (median age 81 with higher comorbidity and functional impairment burdens, the BCSS survival differential disappears at least out to 4e5 year follow-up, suggesting that for those with less than 5-year predicted life-expectancy (>90 years or >85 with comorbidities or frailty) individualised decision making regarding PET versus SþET may be appropriate and safe to offer. The Age Gap online decision tool may support this decision-making process (https://agegap.shef.ac.uk/). Trial registration number: ISRCTN: 46099296.