Quality Indicators for the Care of Breast Cancer in Vulnerable Elders

Abstract

B reast cancer is the most common cancer diagnosed in women 1,2 and the second highest cause of cancer mortality in the United States. 3,4 Although approximately half of the women diagnosed with breast cancer are older than 65, 5 older patients are frequently underrepresented in oncology clinical trials. 6-8 Consequently, the risks and benefits of treatments is not well understood in older women. Some studies suggest that elderly patients with breast cancer are undertreated and thus have higher mortality then their younger counterparts. 9 This monograph discusses the relationship between processes and outcomes of care for breast cancer, identifies potential quality indicators (QIs) that may be used to assess the treatment of vulnerable elders (VEs) with breast cancer, and reviews the available evidence in support of these indicators. METHODSA total of 1,294 articles were considered in this review: 38 were identified using a Web search and 1,256 through Assessing Care of Vulnerable Elders (ACOVE)-3 literature searches. One limitation in developing this QI set was that, for some topics, previous studies and analyses had limited data on older patients. An effort was made to denote data specific to an older population within the text when they were available and relevant. RESULTSOf the 24 potential QIs, 21 were judged valid using the expert panel process (see the QIs on pages S464-S487 of this supplement), three were rejected, and two were added, for a total of 23 in the final set. The literature summaries that support each of the indicators judged to be valid in the expert panel process are described.Mammogram 1. IF a female VE is younger than age 70, THEN she should be offered mammographic screening for breast cancer every 2 years, BECAUSE mammography decreases breast cancer mortality. Supporting EvidenceThree meta-analyses reported a statistically significant reduction in risk of death from breast cancer in women who received screening mammography (relative risk (RR) 5 0.70, 0.71, and 0.74). 10-12 Two randomized, controlled trials (RCTs) of screening mammography 13,14 reported statistically significant reductions in the risk of death due to breast cancer in women younger than 70 but not in women aged 70 and older, whereas two case-control studies provided inconclusive evidence as to whether mammography reduced breast cancer mortality in women aged 65 and older. 15,16 Finally, a retrospective analysis demonstrated that women aged 65 to 74 benefited from screening mammography, 17 and a retrospective cohort study using population data from the National Cancer Institute (NCI)'s Surveillance, Epidemiology, and End Results (SEER) program demonstrated that women aged 67 and older who did not receive mammography were more likely to be diagnosed with breast cancer Stage II or greater and also more likely to die from breast cancer than women of the same age range who were regular users of mammography. 18 An evidence-based review of the literature by the U.S. Preventive Services Task Force (USPSTF) in 1996 recommended the us...

Health Maintenance in Older Adults: Combining Evidence and Individual Preferences

“…Screening mammography reduces breast cancer mortality in women,96,103–105 and this has been demonstrated in women up to age 70 years 96,106. Evidence is less clear for women age ≥80 years; in this group, harms may outweigh benefits 107.…”

“…The USPSTF recommends biennial screening mammography for women age 50–74 years and finds insufficient evidence to assess screening mammography in those age ≥75 years 104. The ACOVE investigators state that in women age <70 years, mammographic screening should be offered because it decreases breast cancer mortality 103. Medicare provides coverage for an annual screening mammogram for all female beneficiaries age ≥40 years; there is no age limit 26…”

Oncologists' Recommendations for Adjuvant Therapy in Hormone Receptor—Positive Breast Cancer Patients of Varying Age and Health Status

“…16 Supplementing this, the Assessing Care of Vulnerable Elders (ACOVE)-derived guidelines suggest that life expectancy should strongly inform the decision to administer chemotherapy in locally advanced breast cancer. 17 Both publications underscore the need to carefully evaluate health status and co-morbidities in the older adult. However, the lack of a standardized approach to stratify and assess the older patient renders critical importance to the attitudes of the oncologist in the determination of treatment choice.…”