Patient Perspectives on Treatment Options for Older Women With Hormone Receptor–Positive Breast Cancer

Abstract

Key Points Question What are older women’s perspectives on recommendations for treatment de-escalation for low-risk, early-stage hormone receptor–positive breast cancer? Findings In this qualitative study of 30 participants aged 70 years or older, women expressed skeptical views regarding age-based treatment guidelines, difficulty interpreting the rationale for reducing low-value care to be a favorable rather than poor prognosis, and perceived benefit of some low-value therapies for peace of mind. Meaning Emphasizing an overall favorable prognosis and improving patient education on the risks vs benefits of adjuvant therapies may help reduce overtreatment in older women with early-stage, hormone receptor–positive breast cancer.

Peace of Mind: A Role in Unnecessary Care?

“…4 Another study analyzed the perspectives of older women on treatment options for hormone receptor-positive breast cancer given the guidelines recommending against routine axillary staging with sentinel lymph node biopsy because the potential harms outweigh the potential benefits. 6 This study found that 40% of older women reported that they would proceed with sentinel lymph node biopsy despite evidence suggesting that omission is safe because of reassurance if negative: "I know for my daughter they did the lymph node test, so I was glad for that because then she had peace of mind that nothing had spread. That's what I would like, peace of mind on that."…”

“…That's what I would like, peace of mind on that." 6 Peace of mind has also been implicated as a key patientcentered outcome driving the increased utilization of contralateral prophylactic mastectomy (CPM), 7 a procedure that offers no survival benefit. [8][9][10] A study of surgical decision making demonstrated that less knowledge about breast cancer and greater worry predicted patient interest in CPM, suggesting that in many cases, the decision for CPM is rooted in peace of mind.…”

Improved Survival after Breast-Conserving Therapy Compared with Mastectomy in Stage I-IIA Breast Cancer

“…Despite the many benefits observed with BCT, the rates of unilateral or bilateral mastectomies for patients with unilateral breast cancer, who are candidates for BCT, are on the rise [29,64]. Perceived risks such as a fear of developing a second breast cancer, a historical belief that mastectomy is a safer option, possible avoidance of long-term breast cancer surveillance imaging, and the inconvenience of daily radiotherapy treatments may all have contributed to increasing mastectomy rates, which is of concern [53,[65][66][67]. Nevertheless, it is important to note that different mastectomy and reconstruction techniques may lead to various amounts of remaining breast glandular tissue, potentially increasing the risk of breast cancer residual disease or recurrence [68].…”

De-escalation in breast cancer surgery

“…For example, patients and providers often dispute set age cutoffs in favor of assessment of an individual patient’s physiology. Finally, similar to the reasons underlying the continued use of CPM, the continued use of SLNB has been justified in terms of promoting patient peace of mind and allowing the determination of nodal involvement to confirm cancer staging 8 , 21 .…”