Breast Cancer Among the Oldest Old: Tumor Characteristics, Treatment Choices, and Survival

Boston University, Boston, Massachusetts, United States
Journal of Clinical Oncology (Impact Factor: 18.43). 03/2010; 28(12):2038-45. DOI: 10.1200/JCO.2009.25.9796
Source: PubMed

ABSTRACT PURPOSE Few data are available on breast cancer characteristics, treatment, and survival for women age 80 years or older. PATIENTS AND METHODS We used the linked Surveillance, Epidemiology and End Results-Medicare data set from 1992 to 2003 to examine tumor characteristics, treatments (mastectomy, breast-conserving surgery [BCS] with radiation therapy or alone, or no surgery), and outcomes of women age 80 years or older (80 to 84, 85 to 89, > or = 90 years) with stage I/II breast cancer compared with younger women (age 67 to 79 years). We used Cox proportional hazard models to examine the impact of age on breast cancer-related and other causes of death. Analyses were performed within stage, adjusted for tumor and sociodemographic characteristics, treatments received, and comorbidities. Results In total, 49,616 women age 67 years or older with stage I/II disease were included. Tumor characteristics (grade, hormone receptivity) were similar across age groups. Treatment with BCS alone increased with age, especially after age 80. The risk of dying from breast cancer increased with age, significantly after age 80. For stage I disease, the adjusted hazard ratio of dying from breast cancer for women age > or = 90 years compared with women age 67 to 69 years was 2.6 (range, 2.0 to 3.4). Types of treatments received were significantly associated with age and comorbidity, with age as the stronger predictor (26% of women age > or = 80 years without comorbidity received BCS alone or no surgery compared with 6% of women age 67 to 79 years). CONCLUSION Women age > or = 80 years have breast cancer characteristics similar to those of younger women yet receive less aggressive treatment and experience higher mortality from early-stage breast cancer. Future studies should focus on identifying tumor and patient characteristics to help target treatments to the oldest women most likely to benefit.

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Available from: Rebecca A Silliman, Apr 07, 2015
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    • "Comorbidity adversely impacts the treatment [1] [2] [3] [4] [5] [6] [7] and outcomes [1, 3, 6, 8–22] of breast cancer, especially in older patients. For instance, studies have shown that breast cancer patients with previously identified comorbidity are less likely to receive adjuvant chemotherapy [2] [4] [5] and have higher mortality [8]. "
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    ABSTRACT: Preexisting comorbidity adversely impacts breast cancer treatment and outcomes. We examined the incremental impact of comorbidity undetected until cancer. We followed breast cancer patients in SEER-Medicare from 12 months before to 84 months after diagnosis. Two comorbidity indices were constructed: the National Cancer Institute index, using 12 months of claims before cancer, and a second index for previously undetected conditions, using three months after cancer. Conditions present in the first were excluded from the second. Overall, 6,184 (10.1%) had ≥1 undetected comorbidity. Chronic obstructive pulmonary disease (38%) was the most common undetected condition. In multivariable analyses that adjusted for comorbidity detected before cancer, older age, later stage, higher grade, and poor performance status all were associated with higher odds of ≥1 undetected comorbidity. In stage I-III cancer, undetected comorbidity was associated with lower adjusted odds of receiving adjuvant chemotherapy (Odds Ratio (OR) = 0.81, 95% Confidence Interval (CI) 0.73-0.90, P < 0.0001; OR = 0.38, 95% CI 0.30-0.49, P < 0.0001; index score 1 or ≥2, respectively), and with increased mortality (Hazard Ratio (HR) = 1.45, 95% CI 1.38-1.53, P < 0.0001; HR = 2.38, 95% CI 2.18-2.60, P < 0.0001; index score 1 or ≥2). Undetected comorbidity is associated with less aggressive treatment and higher mortality in breast cancer.
    02/2014; 2014:970780. DOI:10.1155/2014/970780
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    • "Several retrospective studies already reported that increased patient age is independently associated with decreased guideline compliance (Giordano et al, 2005; Van Leeuwen et al, 2011; Kiderlen et al, 2012; van de Water et al, 2012). Aged populations are indeed subject to under-treatment when compared with standards of care (Lavelle et al, 2007; Hancke et al, 2010) with a negative impact on survival (Owusu et al, 2007; Schonberg et al, 2010). In this study, MTB clinicians decided to not follow the recommendations for surgery provided by OncoDoc2, choosing to undertreat elderly patients. "
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    ABSTRACT: Background: Despite multidisciplinary tumour boards (MTBs), non-compliance with clinical practice guidelines is still observed for breast cancer patients. Computerised clinical decision support systems (CDSSs) may improve the implementation of guidelines, but cases of non-compliance persist. Methods: OncoDoc2, a guideline-based decision support system, has been routinely used to remind MTB physicians of patient-specific recommended care plans. Non-compliant MTB decisions were analysed using a multivariate adjusted logistic regression model. Results: Between 2007 and 2009, 1624 decisions for invasive breast cancers with a global non-compliance rate of 8.3% were analysed. Patient factors associated with non-compliance were age>80 years (odds ratio (OR): 7.7; 95% confidence interval (CI): 3.7–15.7) in pre-surgical decisions; microinvasive tumour (OR: 5.2; 95% CI: 1.5–17.5), surgical discovery of microinvasion in addition to a unique invasive tumour (OR: 4.2; 95% CI: 1.4–12.5), and prior neoadjuvant treatment (OR: 4.2; 95% CI: 1.1–15.1) in decisions with recommendation of re-excision; age<35 years (OR: 4.7; 95% CI: 1.9–11.4), positive hormonal receptors with human epidermal growth factor receptor 2 overexpression (OR: 15.7; 95% CI: 3.1–78.7), and the absence of prior axillary surgery (OR: 17.2; 95% CI: 5.1–58.1) in adjuvant decisions. Conclusion: Residual non-compliance despite the use of OncoDoc2 illustrates the need to question the clinical profiles where evidence is missing. These findings challenge the weaknesses of guideline content rather than the use of CDSSs.
    British Journal of Cancer 08/2013; 109(5). DOI:10.1038/bjc.2013.453 · 4.82 Impact Factor
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    • "These results imply a survival disadvantage for mastectomy in patients with larger tumors, more comorbid illnesses, or advanced age. In another risk-adjustment study using SEER- Medicare data, Schonberg et al. found that mastectomy had a survival disadvantage relative to BCSR that increased with stage [10]. The risk-adjustment estimators used in both of these analyses only adjusted for measured covariates. "
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    ABSTRACT: Despite a 20-year-old guideline from the National Institutes of Health (NIH) Consensus Development Conference recommending breast conserving surgery with radiation (BCSR) over mastectomy for woman with early-stage breast cancer (ESBC) because it preserves the breast, recent evidence shows mastectomy rates increasing and higher-staged ESBC patients are more likely to receive mastectomy. These observations suggest that some patients and their providers believe that mastectomy has advantages over BCSR and these advantages increase with stage. These beliefs may persist because the randomized controlled trials (RCTs) that served as the basis for the NIH guideline were populated mainly with lower-staged patients. Our objective is to assess the survival implications associated with mastectomy choice by patient alignment with the RCT populations. We used instrumental variable methods to estimate the relationship between surgery choice and survival for ESBC patients based on variation in local area surgery styles. We find results consistent with the RCTs for patients closely aligned to the RCT populations. However, for patients unlike those in the RCTs, our results suggest that higher mastectomy rates are associated with reduced survival. We are careful to interpret our estimates in terms of limitations of our estimation approach.
    08/2012; 2012(2090-1402):127854. DOI:10.1155/2012/127854
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