Patterns of Care

Numerous studies have documented that there are significant treatment differences in older patients compared to younger patients. Elderly women with early-stage breast cancer are less likely to undergo breast-conserving surgery than younger women, despite the increase in breast conservation over recent years among all age groups. Older women are also more likely to have radiotherapy or lymph node dissection omitted after breast-conserving surgery. Concerning systemic therapy, older women are more likely to be treated solely with adjuvant tamoxifen and are much less likely to undergo chemotherapy than younger women.

Less aggressive care of elderly breast cancer patients may be associated with a poorer outcome. Studying 390 women ages 45 to 90, Lash et al. found that patients who received a less than definitive prognostic evaluation had an adjusted relative hazard of recurrence of 1.7 [95% confidence interval (CI), 1.0-2.7] and an adjusted relative hazard for breast carcinoma mortality of 2.2 (95% CI, 1.2-3.9).

Patients who received less than definitive therapy had an adjusted relative hazard of recurrence of 1.6 (95% CI, 1.0-2.5) and an adjusted relative hazard of breast carcinoma mortality of 1.7 (95% CI, 1.0-2.8). Women aged 75 to 90 were least likely to receive definitive care and had relative hazards associated with less than definitive care as great or greater than the relative hazards observed in the whole cohort. This finding has implications for older women with localized breast cancer who are not receiving standard evaluations and therapy, as they may be at excess risk for disease recurrence and mortality. Other authors have not found differences in survival between older women who receive standard treatment and those who receive less aggressive care, after controlling for age, stage, and other clinical factors. Because elderly patients have more comorbidity, as well as functional limitations, less aggressive care may represent appropriate clinical judgment. Several studies indicate, however, that comorbidity or functional impairment cannot always explain less aggressive care. Furthermore, there is significant geographic variation in the care received by older breast cancer patients that cannot be explained by differences in functional status or comorbidity. For example, Mandelblatt and colleagues found that, between 1995 and 1997, women with localized breast cancer from five regions in the United States were 3.3 times more likely to have a mastectomy if they lived in Texas than if they lived in Massachusetts.

Other studies have shown that elderly patients with metastatic disease also appear to receive less aggressive care. In a population-based study of the treatment of metastatic breast cancer, Fetting et al. evaluated 132 cases of women who died of metastatic breast cancer in Washington County, Maryland, from 1984 to 1991. Sixty percent of women aged 75 years and older were referred to a medical oncologist, in contrast to 68% of women aged 65 to 74 years and 89% of women under age 65. Seventy-four percent of patients less than 65 years old received chemotherapy, compared to 42% of patients aged 65 to 74 years and 12% of women aged 75 years or older, despite the fact the there is not evidence that metastatic breast cancer responds differently to chemotherapy by age. Adjusting for other medical conditions and whether or not the patient saw a medical oncologist, there was still a significant effect of age on whether patients received chemotherapy. Of note, the different patterns of chemotherapy utilization were not associated with survival differences. Radiation therapy was also utilized significantly less frequently in older patients; however, there was no age effect on the utilization of hormonal therapy in this study. Less frequent utilization of palliative chemotherapy and radiation in older patients may be caused by a combination of patient and physician factors and may result in less effective palliation for older patients.