Elderly patients with breast cancer who received care in a community hospital setting may have been under-diagnosed, under-staged and under-treated, according to a report in the October issue of Archives of Surgery, one of the JAMA/Archives journals.
The number of older breast cancer patients has increased along with overall elderly population, according to background information in the article. About half of breast cancer patients are older than 65 years and 35 percent are older than 70; 77 percent of breast cancer deaths occur in women older than 55. Choosing the appropriate treatment for older patients is a challenge, because many have other serious illnesses in addition to their cancer that may threaten their health and shorten their lives. Questions remain about the best screening protocols for elderly women, as well. Some current guidelines suggest that women stop having mammograms at age 70, while others provide no upper limit.
David A. Litvak, M.D., then of Michigan State University, Lansing, and now at Kaiser Permanente Medical Center, Orange County, Calif., and Rajeev Arora, M.D., used a tumor registry database to identify 354 women age 70 or older who were diagnosed with breast cancer between 1992 and 2002 at a community hospital. The researchers studied the group of women as a whole and also divided them into three age groups for analysis: ages 70 to 74 (136 patients), 75 to 79 (115 patients) and 80 or older (103 patients).
Overall, 46 percent of the patients came to their physician with breast cancer that could be felt during a physical examination. Although 72 percent of all the women and 60 percent of those age 80 and older had mammograms, they were mainly used to verify the results of the physical exam--mammograms uncovered previously undetected breast cancer in only 54 percent of the patients, including 38 percent of those 80 years or older. More than 70 percent of patients were in the early stages of cancer, stages I and II, at diagnosis, but evaluation of the lymph nodes to thoroughly assess the cancer's progression was omitted in 36 percent of the cases (56 percent of those in women 80 or older).
About half of the women received breast-conserving surgery; however, rates of chemotherapy, radiation and hormonal therapy were lower than would be expected and were lowest among the oldest women. For example, 12 percent of all patients, 19 percent of those age 70 to 74 and 5 percent of those older than 80 underwent chemotherapy. "We also noted omissions of treatment in patients with indications for adjuvant [combination] treatment," including those whose cancer had spread to the their lymph nodes or who had estrogen receptor-positive tumors, the authors write. "All together, 70 patients (20 percent) had positive lymph nodes. Of these patients, 29 percent received chemotherapy. Moreover, only 17 percent of patients age 80 years or older received chemotherapy in the presence of lymph node disease, significantly less than the 70- to 74-year age group."
Although the results of this study do not confirm that these diagnosis and treatment patterns in older women lead to worse health, other evidence suggests this is the case, they continue. "Contrary to many physicians' beliefs, the data suggest that fit older patients derive the same benefits from treatment as do their younger counterparts," the authors conclude. "The cornerstone of treatment of older breast cancer patients is an adequate geriatric assessment that helps estimate life expectancy and predict tolerance of treatment. Treatment strategies then ought to be individualized based on this assessment." Screening guidelines should also be customized to the patient; those who expect to live more than five additional years should continue having mammograms, they write.
(Arch Surg. 2006;141:985-990. Available pre-embargo to the media at www.jamamedia.org.)
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