Treatment Bias Against Older Patients
A report just published in The Journal of the American Medical Association adds further evidence to the growing body of research showing a marked bias against older women in regard to breast cancer treatment.
Dr. Rosemary Yancik of the National Institute on Aging in Bethesda, Maryland and colleagues reviewed the cases of 1,800 postmenopausal women with breast cancer, all of whom were age 55 or older. Just under three-quarters of the women had stage I or stage II disease; 10 percent had stage III or IV disease; the balance were not classified.
Yancik's team found a direct relationship between a patient undergoing axillary lymph node dissection-a key diagnostic procedure to determine if breast cancer has spread-and the age of the patient. Women aged 70 and older were "significantly less likely" to undergo this important procedure, which is a key component of National Institutes of Health guidelines for appropriate breast cancer care.
Another report, issued by the U.S. Agency for Healthcare Research Quality and simultaneously published in the journal Cancer, found that elderly women with early-stage breast cancer are not being offered the same range of treatment options as their younger counterparts.
Dr. Jeanne Mandelblatt of the Georgetown University School of Medicine and colleagues studied 718 women aged 67 or older who were being treated at 29 hospitals across the country 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 (lumpectomy) rather than mastectomy.
Of those who did receive breast-conservation therapy, very elderly women were still 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 age discrepancy in treatment is that "there remains substantial scientific uncertainty as to the most appropriate treatment for older women."
This is unfortunate, however, because a report published in The Journal of the National Cancer Institute concluded that elderly women with early 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 Surveillance, Epidemiology and End Results (SEER) registry and the San Antonio Breast Cancer database. They wrote that tumors appear to become less aggressive as a woman gets older. It therefore makes a difference, they said, whether the patient is 50 or 60 or 80 years old.
The researchers found that when breast cancer in elderly patients is detected early, when tumor size is less than 2 cm, and when the lymph nodes are not involved, their survival rate is similar to that of women in the general population.
This should encourage physicians to treat their older patients as consistently and with as many treatment options as they do their younger ones, Diab said. He further suggested that treatments could also be better tailored to older patients because their tumors are less aggressive.
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.
Golledge wrote that younger women were nearly twice as likely as older women to experience local relapse. Among women aged 60 and older, the recurrence rate at 3 years was 2.4 percent, versus 8.5 percent in younger women. He also noted that women 70 years or older experienced better 3-year disease-free survival when treated with standard therapy (72 percent) than when treated with tamoxifen alone (58 percent).
And yet, women over age 60 whose cancer had not spread to their lymph nodes were less likely to receive standard chemotherapy (1 percent) or radiation therapy (45 percent) than were younger women (18 percent and 68 percent, respectively). On the other hand, older women were more likely to receive tamoxifen (94 percent, versus 73 percent for younger women).
A study published in the New England Journal of Medicine looked at how many patients 65 years of age and older were involved in 164 Southwest Oncology Group (SWOG) cancer treatment trials between 1993 and 1996. Dr. Laura Hutchins of the University of Arkansas for Medical Sciences in Little Rock and colleagues analyzed treatment trials for 15 types of cancer and found that older patients are "substantially underrepresented."
"Patients who were 65 years of age or older accounted for 25 percent of patients in SWOG trials, as compared with 63 percent in the U.S. population of patients with cancer," they wrote.
They added that the underenrollment of older patients was "particularly striking" for breast cancer studies. In those trials, only 9 percent of participants were 65 years of age or older, versus 49 percent of patients in the general population with breast cancer.
Hutchins echoed what many other researchers have also concluded: Far too many doctors-and even patients themselves-assume that older patients would not be able to tolerate or benefit from many of the most promising treatments under study.
However, given that the number of people over the age of 65 is expected to double in the coming decades, such assumptions could be disastrous.
SOURCES:
The Journal of the American Medical Association, February 21, 2001; 285:885-892
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, January 15, 2000; 88: 369-374
Cancer, May 1, 2000; 88: 2054-2060
New England Journal of Medicine, December 30, 1999; 341: 2061-2067
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