Bridging the age gap in breast cancer. Impacts of omission of breast cancer surgery in older women with oestrogen receptor positive early breast cancer. A risk stratified analysis of survival outcomes and quality of life

Abstract

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.

Care Disparities Across the Health Care Continuum for Older Adults: Lessons From Multidisciplinary Perspectives

“…3). 87 The median age of this matched cohort was 82 to 83, with higher rates of frailty and comorbidity than the general population.…”

“…The key is to select older women with a predicted life expectancy of fewer than 3 to 5 years for primary endocrine therapy. The Age Gap observational cohort Reproduced with permission from Wyld et al 87 study attempted to define the health characteristics of women suitable for primary endocrine therapy by recruiting women older than age 70 with early breast cancer and adjusting for baseline health and fitness using detailed propensity score matching. The study found that when matched cohorts with similar health status treated with either surgery or primary endocrine therapy were compared, there was no survival advantage with surgery (Fig.…”

“…Abbreviations: BCS, breast cancer-specific survival; PET, primary endocrine therapy. Reproduced with permission from Wyld et al87…”

Does Breast Cancer Surgery Impact Functional Status and Independence in Older Patients? A Narrative Review

“…Bridging the age gap Phase 1 showed that older patients (70-95 years) undergoing breast cancer surgery experienced a long-term negative impact on QOL and independence up to 2 years [14] For ER? breast cancer, patients who underwent either S?ET or PET both exhibited a decline in global health status scores, with a sharper decline in the surgery group at 6 weeks and failure to return baseline [1] Nottingham Research Programme Updated findings were conflicting, showing areas of improvement related to FS and a decline in others. No clear pattern was identified [16] ALND.…”

“…Surgery is the recommended treatment option for primary breast cancer irrespective of age. Primary endocrine therapy (PET) may be an alternative in selected older patients with significant comorbidities, as the overall survival benefit observed with surgery in certain subtypes of breast cancer may prove to be minimal when life expectancy is limited by other comorbidities [ 1 , 2 ]. Furthermore, a survey involving surgical oncologists published by Ghignone et al [ 3 ] highlighted that quality of life (QOL) and recovery of functional status (FS) were considered the most pertinent outcomes in onco-geriatric surgery, rather than overall survival.…”