Variation in treatment and survival of older patients with non-metastatic breast cancer in five European countries: a population-based cohort study from the EURECCA Breast Cancer Group

Abstract

Background Older patients are poorly represented in breast cancer research and guidelines do not provide evidence based recommendations for this specific group. We compared treatment strategies and survival outcomes between European countries and assessed whether variance in treatment patterns may be associated with variation in survival. Methods Population-based study including patients aged ≥ 70 with non-metastatic BC from cancer registries from the Netherlands, Belgium, Ireland, England and Greater Poland. Proportions of local and systemic treatments, five-year relative survival and relative excess risks (RER) between countries were calculated. Results In total, 236,015 patients were included. The proportion of stage I BC receiving endocrine therapy ranged from 19.6% (Netherlands) to 84.6% (Belgium). The proportion of stage III BC receiving no breast surgery varied between 22.0% (Belgium) and 50.8% (Ireland). For stage I BC, relative survival was lower in England compared with Belgium (RER 2.96, 95%CI 1.30–6.72, P < .001). For stage III BC, England, Ireland and Greater Poland showed significantly worse relative survival compared with Belgium. Conclusions There is substantial variation in treatment strategies and survival outcomes in elderly with BC in Europe. For early-stage BC, we observed large variation in endocrine therapy but no variation in relative survival, suggesting potential overtreatment. For advanced BC, we observed higher survival in countries with lower proportions of omission of surgery, suggesting potential undertreatment.

The characteristics, management and outcomes of older women with breast cancer in New Zealand

“…Only 101 women (4.1%) with stage I-III cancer, and 7 women (3.8%) with metastatic disease received chemotherapy. Elderly women in the current cohort were significantly less likely to receive chemotherapy as age and level of co-morbidity increased, which is in accordance with other research [4,11,12,16,23,[35][36][37][38][39]. A number of valid reasons do preclude the provision of chemotherapy in older women; chemotherapy use typically decreases with increasing level of co-morbidity [38,40], physicians may prefer not to administer it due to toxicity [9,11,14] and the potential impact on fitness [10,18,41].…”

“…However, radiotherapy use declined with increasing age and level of co-morbidity. Declining rates of radiotherapy with advancing age have also been reported in a variety of countries [4,11,16,23,[35][36][37].…”

“…Lower use of radiotherapy in the elderly is in part due to the reduction in absolute benefit shown in older women [9,11], with competing risks for death. Risk of local recurrence generally tends to decrease with age, and this has to be weighed against the negative effects on quality of life [46] and difficulties in accessing care that may influence treatment decisions [16]. As with chemotherapy, older women were more likely to receive radiotherapy in Waikato and women treated in the private sector were also more likely to receive radiotherapy.…”

“…Management of breast cancer in the elderly faces a number of issues. Historically, women over 70 have been consistently excluded from clinical trials [6][7][8][9][10][11][12], and with limited data demonstrating the effectiveness of standard treatments in the older population [13][14][15], current treatment strategies are founded on clinical evidence derived from younger women [16]. However, older women represent a different population, have a more heterogeneous level of fitness [17] and commonly present with a higher level of co-morbidity [18] and tumours that differ in their biology [19]; all factors which impact on treatment.…”

Surgical treatment and prognosis of breast cancer in elderly – A population-based study

“…Also, treatment strategies of early breast cancer vary markedly both nationally and internationally. In two recent studies, elderly patient populations from European countries were compared [7,8]. These studies found a great variance in treatment: in the British population 47.8% of patients received surgery in comparison to 90.5% in the Dutch population [7].…”