Observational cohort study to determine the degree and causes of variation in the rate of surgery or primary endocrine therapy in older women with operable breast cancer

Abstract

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.

Treatment choices for older women with primary operable breast cancer and cognitive impairment: Results from a prospective, multicentre cohort study

“…Reasons for lower rates of breast conserving surgery in the cognitively impaired groups may include clinicians offering PET due to a perceived risk of co-morbidities and age, patient and caregiver preferences for what is perceived as a lower risk/lower morbidity option in women with lower life expectancy, and a wish on the part of patients' caregiver to optimise quality of life. Another factor may be clinician preference [26] where cognitive impairment has been shown to be a significant clinician driver for non-surgical treatment [11].…”

“…Bridging the Age Gap in Breast Cancer was a prospective UK multicentre cohort study, which collected data on patient and cancer characteristics, treatment allocation, and survival outcomes in older women (>70) with primary operable breast cancer [24][25][26].…”

“…Where patients gave informed consent to participate, cognition status was ascertained through completion of the Charlson Index [27] form or the MMSE. The MMSE scored participants as having mild, moderate, or severe impairment according to standard scoring protocols (normal [27][28][29][30], mild CI [21][22][23][24][25][26], moderate CI [11][12][13][14][15][16][17][18][19][20], and severe CI (0−10)) [28]. The MMSE score always took precedence over Charlson Index categorisation if available, with participants re-categorised according to MMSE score.…”

“…Bridging the Age Gap is one of the largest prospective studies of treatment and outcomes in patients over 70, and has uniquely collected detailed data about cognitive status by permitting proxy consent of patients with cognitive impairment [26,45]. In addition, the study collected detailed baseline health and fitness status allowing us to tease out the contribution of impairment from other co-morbidities, frailty and older age, which often confound these analyses.…”

Process evaluation of the Bridging the Age Gap in Breast Cancer decision support intervention cluster randomised trial

“…In women over the age of 70, there is uncertainty about the benefits of adjuvant chemotherapy due to the lack of clinical trial data specific to this older age group [ 12 ]. There is also evidence that rates of both surgery [ 9 , 13 ] and chemotherapy [ 14 ] in this older age group vary widely both between units in the UK and across Europe [ 15 , 16 ]. Decisions about treatment in these contexts can therefore be challenging both for clinicians (we use this term to include all types of healthcare professionals) and patients and are often “preference sensitive” [ 17 ].…”