Lack of Care For Older Breast Cancer Patients
29 Mar 2007
Older women with breast cancer get a lower level of care than younger women, researchers at The University of Manchester have found.
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, the researchers report 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.
Dr Katrina Lavelle, who led the study at the University's School of Nursing, Midwifery and Social Work, explains: "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."
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.
The 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. 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."
Dr Katrina Lavelle is available for interview from 2pm today (Thursday 29th March 2007). To arrange an interview or for more information please contact Media Relations Officers Mikaela Sitford or Jo Nightingale on 0161 275 2111 or 8156.
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 team would like to thank the NW Cancer Intelligence Service (previously the North Western Cancer Registry) for computing and administrative support and the clinicians, administration staff and patients at the participating hospitals.
The University of Manchester developed the first nursing degree in England at its then School of Nursing Studies. Now the School of Nursing, Midwifery and Social Work, it has established an acclaimed national and international reputation and is committed to conducting high-quality applied research that provides the evidence to improve care and shape services. At the last Research Assessment Exercise (RAE) in the UK in 2001, the School achieved the maximum score of 5 for nursing and midwifery. It also had by far the largest research portfolio of the establishments receiving this accolade. Similarly, social work was assessed as a 5-rated subject at the RAE.
The University of Manchester's Faculty of Medical and Human Sciences boasts an annual research income of £51m, 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/