Breast cancer treatment in the elderly: Do treatment plans that do not conform to NCCN recommendations lead to worse outcomes?
Introduction
Aging remains one of the single greatest risk factors for the development of new onset breast cancer, with approximately one-half of all cases of new onset breast cancer occurring in women older than 65 years of age, and more than 30% occurring after the age of 75.1,2 Elderly patients with breast cancer often present with similar disease characteristics as their younger counterparts. In addition, the cancer stage at diagnosis is typically comparable to those in younger women, although some studies have shown elderly women to have advanced disease at the time of presentation.2 Breast cancer research in the elderly has generally been lacking, and until recently, women over the age of 70 have largely been excluded from breast cancer trials. It was assumed in the past that older cancer patients were unlikely to survive for a sufficient length of time to allow for local or systemic recurrence. However, research has since shown that most breast cancer octogenarians survive greater than six years following their cancer diagnosis with the 5-year survival rate for women 70–79 years of age noted to be 82.4%, and those 80 years and older noted to be 74%.3,4
Studies have also shown that in spite of favorable prognostic factors such as low-grade tumor types, lower incidence of axillary lymph node involvement and vascular invasion, estrogen receptor-positive disease, and less aggressive tumor biology, elderly breast cancer patients often receive less than the standard-of-care when compared to their younger counterparts.1,5 Reasons for under treatment of elderly women may be multifactorial, with physicians limiting treatment for elderly patients secondary to comorbidities and life expectancy. According to Hamaker et al.,6 physicians did not recommend therapy because of older age in 14% and comorbidities in 11%, but 31% of treatment omissions were as a result of patient preference.
Recent research has shown that elderly women who underwent lumpectomies were noncompliant with radiation and hormonal therapy, with noncompliance being even higher in women aged 80 years and older.7
There is a paucity of research evaluating how nonconformity to National Comprehensive Cancer Network (NCCN guidelines) affects outcomes in elderly breast cancer patients. The purpose of this study was to assess whether nonconformity to NCCN treatment guidelines in elderly patients has a negative impact with regards to local recurrence, metastatic disease, and disease-specific survival, compared to patients whose treatment conformed to NCCN guidelines.
Section snippets
Methods
This study was approved for implementation by the Institutional Review Board of Ascension Via Christi Hospitals Wichita, Inc. A retrospective chart review was conducted on women 70 years and older, who underwent treatment for newly diagnosed breast cancer between September 1, 2006 and July 31, 2013. The data was obtained from a single surgeon’s practice and included: age at diagnosis, comorbidities, tumor characteristics, nodal status, treatment received (surgery, hormonal therapy, and/or
Results
Initial records review yielded a total of 186 women older than 70 years of age that were treated for breast cancer. Of those, 7 were excluded due to the presence of metastatic disease at the time of diagnosis, leaving 179 patients for study inclusion (conforming n = 107, and nonconforming n = 72). Nonconforming patients were older than their conforming counterparts by 2.6 years (80.5 vs. 77.7 years, P = 0.001; Table 1). No differences were observed with regard to comorbidities between study
Comments
The incidence of breast cancer significantly increases with age, and in recent years the average age of a woman with newly diagnosed breast cancer has risen to 62 years.9 This data also shows that over 40% of breast cancers occur in women over the age of 65. While the average age at diagnosis has increased, survival is improving. According to SEER, the 5-year survival rate for breast cancer from 2009-20159 was 89.9%, compared to a 5-year survival rate of 87% from 2000 to 2013.4 Despite an
Conclusions
Data from our study showed that nonconformity to NCCN guidelines in elderly patients with breast cancer did not significantly affect their outcome (local recurrence, metastatic disease, and breast cancer related deaths). Nonconformity with hormonal therapy also did not significantly affect patient outcomes. Larger studies are required to confirm these findings. In addition, more research may be required to verify whether hormonal therapy is required in elderly patients, as this could
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