Background
In the UK there is variation in the treatment of older women with breast cancer, with up to 40% receiving primary endocrine therapy (PET), which is associated with inferior survival. Case mix and patient choice may explain some variation in practice but clinician preference may also be important.
Methods
A multicentre prospective cohort study of women aged >70 with operable breast cancer. Patient characteristics (health status, age, tumour characteristics, treatment allocation and decision-making preference) were analysed to identify whether treatment variation persisted following case-mix adjustment. Expected case-mix adjusted surgery rates were derived by logistic regression using the variables age, co-morbidity, tumour stage and grade. Concordance between patients’ preferred and actual decision-making style was assessed and associations between age, treatment and decision-making style calculated.
Results
Women (median age 77, range 70–102) were recruited from 56 UK breast units between 2013 and 2018. Of 2854/3369 eligible women with oestrogen receptor positive breast cancer, 2354 were treated with surgery and 500 with PET. Unadjusted surgery rates varied between hospitals, with 23/56 units falling outside the 95% confidence intervals on funnel plots. Adjusting for case mix reduced, but did not eliminate, this variation between hospitals (10/56 units had practice outside the 95% confidence intervals). Patients treated with PET had more patient-centred decisions compared to surgical patients (42.2% vs 28.4%, p < 0.001).
Conclusions
This study demonstrates variation in treatment selection thresholds for older women with breast cancer. Health stratified guidelines on thresholds for PET would help reduce variation, although patient preference should still be respected.
Background: In breast cancer (BC) management, age related practice variance is widespread with older women having lower rates of surgery, based on the premise of poor tolerance and reduced treatment benefit. Primary endocrine therapy (PET) may be appropriate in those who are unfit for surgery or with a limited life expectancy. This prospective multi-center study aimed to determine co-morbidity and frailty thresholds beyond which surgery is no longer beneficial.Methods: A multi-center, prospective observational study with propensity score matched analysis to determine thresholds for optimal allocation of surgery or PET in women over age 70 with operable breast cancer. Baseline comprehensive geriatric assessment was performed. Cancer stage, grade and biological subtype were recorded as were treatment details. Outcome measures (overall and breast cancer specific survival, quality of life and adverse events) were recorded at 6 monthly intervals for 2 years. Propensity score matching was performed in Stata.Results: The study recruited 3416 women from 56 UK breast units between 2013 and 2018.Of these, 2979 (88%) had ER+ BC, of whom 2354 had surgery and 500 PET. The median age was 77 (range 69-102), varying by treatment allocation: surgery: 76 years (69-94) versus PET: 84 years (70-102). Similarly Charlson co morbidity score (CCI) differed (median CCI surgery group: 4 (interquartile range IQR: 3-5) versus 6 (IQR 4-7)) and activities of daily living (ADL) scores differed by treatment allocation (median ADL surgery 100 (IQR 100-100) versus PET 95 (IQR 95-100). Un-adjusted all cause mortality (median 2 years) was 135/486 (28%) for PET and 212/2307 (9%) for surgery (P < 0.001). Un-adjusted BC specific mortality was 5% for PET patients, 3% for surgery patients. There were no deaths due to surgery
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