Stage and treatment variation with age in postmenopausal women with breast cancer: compliance with guidelines

Abstract

Breast cancer-specific mortality is static in older women despite having fallen in younger age groups, possibly due to lack of screening and differences in treatment. This study compared stage and treatment between two cohorts of postmenopausal women (55 -69 vs 470 years) in a single cancer network over 6 months. A total of 378 patients were studied (470: N ¼ 167, 55 -69 years: N ¼ 210). Older women presented with more advanced disease (470: metastatic/locally advanced 12%, 55 -69 years: 3%, Po0.01). Those with operable cancer had a worse prognosis (Nottingham Prognostic Index (NPI) 470: median NPI 4.4, 55 -69 years: 4.25, Po0.03). These stage differences were partially explained by higher screening rates in the younger cohort. Primary endocrine therapy was used in 42% of older patients compared with 3% in the younger group (Po0.001). Older women with cancers suitable for breast conservation were more likely to choose mastectomy (470: 57.5% mastectomy rate vs 55 -69 years: 20.6%, Po0.01). Nodal surgery was less frequent in older patients (470: 6.7% no nodal surgery, 55 -69 years: 0.5%, Po0.01) and was more likely to be inadequate (470: 10.7% o4 nodes excised, 55 -69 years: 3.4%, Po0.02). In summary, older women presented with more advanced breast cancer, than younger postmenopausal women and were treated less comprehensively.

Healthcare professionals' preferences for surgery or primary endocrine therapy to treat older women with operable breast cancer

“…With dementia predominantly affecting the elderly, this represents a significant problem in this population. Studies show that older patients with dementia are less likely to receive standard cancer therapies [12] and that this is often stated as a reason for selecting PET over surgery [6,39]. However, there are currently no guidelines for the treatment of operable breast cancer in this complex group of patients which may reflect the lack of consensus amongst HCPs surveyed here.…”

“…Consequently, older patients with operable breast cancer may be offered alternative treatment modalities, such as primary endocrine therapy (PET) [5,6], where oestrogen receptor (ER) positive disease is treated with endocrine therapy alone. A meta-analysis comparing PET with surgery found no difference in survival, although rates of local control were inferior with PET [7], which may necessitate a change in management [8,9].…”

What influences healthcare professionals' treatment preferences for older women with operable breast cancer? An application of the discrete choice experiment

“…Furthermore a recent study demonstrated a lack of consensus among HCPs regarding the optimal way to treat this group [12]. Older patients with dementia are less likely to receive standard cancer therapies [28] and this is often stated as an explanation for selecting PET over surgery [5,29].…”

“…Older patients have higher rates of comorbidity and frailty so that the risk of death from breast cancer is relatively reduced, with only 23% deaths due to breast cancer for patients diagnosed in their mid-80s compared to 73% for patients diagnosed in their 50s [3]. Older patients with operable breast cancer may be offered alternative treatment modalities, such as primary endocrine therapy (PET) [4,5], wherein oestrogen receptor (ER) positive disease may be treated with endocrine therapy alone.…”

Surgery, with or without tamoxifen, vs tamoxifen alone for older women with operable breast cancer: Cochrane review

“…In the UK, its use is widespread, with up to 42% of all women over 70 being treated in this way, regardless of whether co-morbidity is documented (Wyld et al, 2004).…”