Inadequate Breast Cancer Care
Remarkably, a second major study has been published in the past two weeks that sounds an alarm about breast cancer patients receiving adequate care-especially older women. A report in the October 15th issue of the journal Cancer has determined that about a quarter of breast cancer patients receive a "less than definitive" prognosis or primary care and thus suffer a significantly greater risk of recurrence and mortality from the disease.
The researchers, led by Dr. Timothy Lash of the Boston University of Public Health, said that a "definitive prognosis" should include an axillary lymph node dissection (removing underarm lymph nodes to check for cancer spread), evaluation of a tumor's estrogen receptor status, and histologic (tissue) examination.
For women with local disease, "definitive primary care" meant having a mastectomy or breast-conserving surgery plus radiation therapy within 5 months of surgery. For women with regional disease, chemotherapy and/or hormonal therapy was required.
Lash's multicenter team evaluated the records of 494 breast cancer patients aged 45- to 90-years-old who were treated for their disease between 1984 and 1986. They determined that 24 percent of the patients "received less than definitive prognostic evaluation and 27 percent received less than definitive therapy." This resulted in the women having about twice the risk of either recurrence or of dying from their breast cancer within the first 5 years after diagnosis.
Unfortunately, this increased risk was concentrated among the oldest women in the study. Lash attributed this discrepancy for elderly women to stubborn perceptions about limited life expectancy. He said such perceptions were prevalent among physicians, the patients' families-and even among elderly patients themselves.
And yet, a 75-year-old woman has about a 12-year life expectancy, said Lash, which clearly calls for consideration of all possible treatment options. Furthermore, numerous studies have shown that breast cancer in older women tends to progress at slower rates than it does in younger women.
Lash's report comes on the heels of a similarly disconcerting study published in the September 30th issue of the British medical journal The Lancet. That study, by Dr. Ann Butler Nattinger of the Medical College of Wisconsin and colleagues, determined that thousands of American women who underwent breast-conserving surgery (lumpectomies) for early-stage breast cancer did not receive appropriate follow-up care, including axillary node dissection and postoperative radiation therapy.
According to the findings of Nattinger's team, the proportion of women who received these additional recommended procedures dropped from an average of 88 percent during the period 1983-1989 down to 78 percent by the end of 1995. They based their conclusion on an analysis of 144,759 records from the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute.
Thus, while more women were having lumpectomies, a declining percentage of them were having the "total package" of recommended procedures as specified in National Institutes of Health guidelines. (It should be noted that omitting radiation therapy in carefully designed clinical trials is an appropriate option.)
A recent report published in the Journal of the National Cancer Institute found that elderly women with early stage breast cancer have survival rates similar to women in the general population, partly because tumor growth in older patients is slower than in younger patients.
Dr. Sami Diab of Rocky Mountain Cancer Centers in Aurora, Colorado and colleagues reviewed the records of more than 300,000 breast cancer patients in the SEER registry and the San Antonio Breast Cancer database. They wrote that tumors appear to become less aggressive as a woman gets older.
According to another report published in the journal Cancer, women between the ages of 60 and 69 who are diagnosed with breast cancer have a higher rate of disease-free survival and a lower rate of local recurrence than younger women. Dr. Jonathan Golledge from Charing Cross Hospital in London evaluated 784 breast cancer patients and also found that the treatments being offered to them differed significantly depending on their age.
A study by the U.S. Agency for Healthcare Research Quality further highlighted a bias in the treatment of older patients. Dr. Jeanne Mandelblatt of the Georgetown University School of Medicine and colleagues studied 718 women aged 67 or older who were being treated for newly diagnosed localized breast cancer. They found that the oldest women, those aged 80 and older, were significantly less likely than women 67 to 79 years old to be referred to a radiation oncologist. They noted that women sent to a radiation oncologist were 20 times more likely to have breast-conservation therapy rather than other treatments.
Of those who did receive breast-conservation therapy, very elderly women were 70 percent less likely to receive chemotherapy than younger patients, and they were 3.4 times less likely to receive radiation therapy. The researchers suggested that part of the reason for this discrepancy in treatment was that "there remains substantial scientific uncertainty as to the most appropriate treatment for older women."
SOURCES:
Cancer, October 15, 2000; 89:1739-1747
The Lancet, September 30, 2000; 1124-1125, 1148-1153
Journal of Clinical Oncology, January 2000; 18:296-306
Cancer, August 1, 2000; 89:561-573
Journal of the National Cancer Institute, April 5, 2000; 92:550-556
"Health, United States: 2000," National Center for Health Statistics, U.S. Centers for Disease Control and Prevention
Cancer, May 1, 2000; 88:2054-2060
Cancer, January 15, 2000; 88:369-374
[Table of Contents] [Archived Issues / Search] [The Breast Center]