New UK Study Finds Lack of Care for Older Breast Cancer Patients

March 29, 2007 - Compared to younger women, older women with breast cancer are less likely to be diagnosed via needle biopsy and triple assessment, less likely to undergo surgery and less likely to receive radiotherapy, say researchers in this week's British Journal of Cancer. Such management of older women is likely to lead to higher rates of local recurrence of the disease and higher than necessary mortality. A U.S. study in 2000 also found less aggressive treatment of elderly patients and another last year says elderly not being given breast exams.

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(See report on 2000 study below this report and report on lack of breast exams for elderly in sidebar.)

"We have found that older women from aged 70 and over are less likely to receive the same breast cancer care as younger women and that this is related to their age rather than differences in the biology of their tumour," says Dr Katrina Lavelle, who led the study at the University's School of Nursing, Midwifery and Social Work.

The highest incidence of breast cancer in England occurs in women aged 70 years and older. Older women also experience the worst survival - women aged 70-79 have a 76% five-year relative survival compared to 80% for all ages, and for women aged 80 plus this drops considerably to 61%, beyond what might be expected owing to an increase in age.

The team carried out a retrospective cohort study involving case note review based on the North Western Cancer Registry database of women aged 65 and over, resident in Greater Manchester with invasive breast cancer registered over a one year period.

The results of the study, funded by an NHS R&D Training Fellowship, may be generalized nationally as variation in survival between regions is lower for breast cancer compared to other cancers.

They found that, compared to women aged 65-69 years, women aged 80 plus with operable breast cancer have increased odds of not receiving triple assessment, not receiving primary surgery, not undergoing axillary node surgery and not undergoing steroid receptor tests (which indicate suitability for hormone therapy).

Compared with her 65-69-year-old counterpart, the odds of a woman aged 80 or older not receiving triple assessment for operable breast cancer are five-and-a-half times higher, and the odds of her not receiving surgery are more than 40 times higher.

Risk of Breast Cancer by Age in U.S.

Centers for Disease Control and Prevention: Breast Cancer

The risk of getting breast cancer increases with age. The table below shows the percentage of women (how many out of 100) who will get breast cancer over different time periods. The time periods are based on the person's current age.

For example, go to current age 60. The table shows 3.7% of women who are now 60 years old will get breast cancer sometime during the next 10 years. That is, 3 to 4 out of every 100 women who are 60 years old today will get breast cancer by the age of 70.

Percent of U.S. Women Who Develop Breast Cancer Over 10-, 20-, and 30-Year Intervals
According to Their Current Age, 2001–2003*

Current Age	10 Years	20 Years	30 Years
30	0.4	1.9	4.4
40	1.4	4.0	7.3
50	2.6	6.0	9.3
60	3.7	7.1	9.1
70	4.0	6.3	N/A

*Source: Data are from 17 Surveillance, Epidemiology, and End Results (SEER) registries covering 25% of the U.S. population. Age-specific data are not available for women over 95 years old. DevCan database, National Cancer Institute.

Deaths from Breast Cancer by Age

The risk of dying from breast cancer increases with age. The table below shows the percentage of women (how many out of 100) who will die from breast cancer over different time periods. The time periods are based on the person's current age.

For example, go to current age 60. The table shows 0.7% of women who are now 60 years old will die from breast cancer during the next 10 years. That is, about 1 woman out of 100 women who are 60 years old today will die from breast cancer by the age of 70.

Percent of U.S. Women Who Die from Breast Cancer Over 10-, 20-, and 30-Year Intervals
According to Their Current Age, 2001–2003*

Current Age	10 Years	20 Years	30 Years
30	0.1	0.3	0.7
40	0.2	0.6	1.3
50	0.4	1.1	1.9
60	0.7	1.5	2.2
70	0.9	1.8	N/A

*Source: Data are from National Center for Health Statistics (NCHS). Age-specific data are not available for women over 95 years old. DevCan database, National Cancer Institute.

Date last reviewed: 09/28/2006
Content source: Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion

Even women as young as 70-74 have over 7 times the odds of not receiving radiotherapy following breast conservation surgery compared to women aged 65-69 years.

In addition, the team discovered that the overall percentage of women in all the age groups not receiving steroid receptor tests was high at 41%, which resulted in treatment decisions being taken without this fundamental information.

Three quarters of the patients who did not receive steroid receptor tests were given the hormone therapy, tamoxifen: that is, prescribed a treatment without evidence that it would work.

In a survey of UK breast cancer surgeons in 2004, 75% reported that they would treat older breast cancer patients in a similar way to younger patients and 98% responded that the cut off point for breast cancer surgery was not age related.

Dr Lavelle says, "Clearly there is a difference in clinicians' perceptions of how older breast cancer patients should be treated and their actual practice.

"Standard management of breast cancer was infrequent in older women in Greater Manchester. The lack of diagnostic and steroid receptor testing resulted in older cancer patients having no effective treatment with 41% not undergoing a steroid receptor test, 32% of whom received tamoxifen as their sole form of treatment.

"Mortality of elderly breast cancer patients is unlikely to improve where this pattern of management persists."

Research lead for the School of Nursing, Midwifery and Social Work, Professor Chris Todd, commented: "It would be wrong to conclude that ageism is to be found in the NHS on the basis of these results alone, as this study has not been able to take the preferences of older women themselves into account. This is something we intend to investigate in the next phase of our research."

Editor's Notes:

Women in England aged 70, 75 and 80 years old currently have life expectancies of 16.0, 12.2 and 9.0 respectively. Moreover, life expectancy is increasing.

The life expectancy of 80 year old woman is expected to rise to 11.0 years by the year 2027. Therefore, older women who survive their breast cancer can currently be expected to live for a considerable time and this will increase in the future.
See http://www.gad.gov.uk/Life_Tables/docs/2004/20045yrEngperiod1981web.xls

Women aged 80 years and older currently represent 5.7% of the female population in England (1.5 million people). As the proportion of older people in the population is increasing, the percentage of women in England aged 80 and over, is expected to rise to 7.6% (2.1 million people) by 2027 and more than double to 12.5% (3.8 million people) by the year 2071. We can therefore expect the number of cases of breast cancer in older people to increase over the next 60 years.
See http://www.gad.gov.uk/Population/2004/england/weng045y.xls

'Non-standard management of breast cancer increases with age in the UK: a population based cohort of women aged 65 years and above' is published in the British Journal of Cancer. The study received ethical approval from the NW Multicentre Research Ethics Committee (MREC/01/8/62).

The NW Cancer Intelligence Service (previously the North Western Cancer Registry) provided computing and administrative support and the clinicians, administration staff and patients at the participating hospitals.

The University of Manchester's Faculty of Medical and Human Sciences receives almost a third of the University's total research income. There are 7,600 undergraduate students and 1,600 postgraduates on award-bearing courses. More students graduate each year from the School of Medicine than from any other medical school in the UK. For more information see http://www.manchester.ac.uk/

U.S. Study Says Breast Cancer and Treatment Less Aggressive in Elderly Women

Read complete report at American Cancer Society, click here

The American Cancer Society reports on a study in 2000 that found older women tend to have less aggressive breast cancers than younger women. It found, too, that women with lymph-node negative breast cancer older than 70 survive as long as their contemporaries without breast cancer. But, they also found a lack of treatment for these elderly patients.

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The researchers found elderly patients were less likely to receive systemic chemotherapy and radiation therapy and that they undergo less extensive surgery than younger patients. Older patients were just as likely as younger patients to receive systemic hormone therapy but, because older patients are more likely to have tumors with steroid hormone receptors, the researchers suggest greater numbers of them might be expected to have adjuvant endocrine therapy.

"It is not clear whether age was a factor in the decision regarding adjuvant endocrine therapy," the researchers write. "It is unfortunate that the majority of clinical trials that addressed surgical, radiation and systemic therapies have not included older patients."

The study authors say more research is needed into treatment for elderly breast cancer patients. "The best approaches to local and systemic therapies in elderly patients and the impact of each modality in therapy on the natural history of the disease and the quality of life require evaluation in clinical trials," they write.

"Because older patients with small tumors are more likely to die of non-breast-cancer conditions and because screening mammography detects small tumors that are more likely to be lymph node negative, it is possible that screening mammography might have limited value in older patients," the authors write.

The American Cancer Society (ACS), however, still recommends annual mammography for these women.

"The American Cancer Society does not put an upper limit on its screening recommendations and advises all women older than 40 to have an annual screening mammogram," says Harmon Eyre, MD, chief medical officer for the ACS. "We would not change our guidelines based on the results of one study."

A women should consider her overall health when making a decision about having mammography, Dr. Eyre adds. "If an older patient has health problems that keep her from being a candidate for breast cancer treatment, then mammography may not have great value to her," he says. "However, if an elderly patient is otherwise in good health, then breast cancer could be easily detected with a mammography and treated."

"This study clearly demonstrates that breast cancer in the elderly has distinctive biologic and clinical characteristics," writes Sami G. Diab, MD, of the Rocky Mountain Cancer Centers in Aurora, Colo., and colleagues in the April 5, 2000 issue of the Journal of the National Cancer Institute.

The US population is aging, and the risk of breast cancer increases with age. Changing demographics will lead to more cases of breast cancer in women age 65 or older, according to the study.

The team found older patients tend to have tumors with features previously shown to correlate with less aggressive growth and spread. For example, both databases show the percentage of patients with tumors that have estrogen receptors increases with age. The older patients also tended to have tumors with favorable genetic characteristics ? including normal p53 and low or undetectable levels of epidermal growth factor receptor and c-erbB2.

The researchers reviewed the records of 50,828 patients with invasive breast cancer from San Antonio databases and 256,287 patients from the Surveillance, Epidemiology and End Results registry, which is a collection of nine US cancer registries that collect and submit data to the National Cancer Institute.

>> More about breast cancer at MedlinePlus

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