Age-Based Inequities Found in Breast Cancer Diagnosis, Staging, and Treatment

LANSING, Mich., Oct. 16 -- Women older than 70, who represent one in three breast cancer patients, are "underdiagnosed, understaged, and undertreated" compared with younger women, researchers here asserted.

A review of 354 breast cancer patients ages 70 and older found that 55% of the women who had breast-conservation surgery did not receive radiation, and only 29% of the women with positive lymph nodes received chemotherapy, according to findings reported in the Oct. 17 issue of the Archives of Surgery.

Moreover, the evidence suggested that mammography was underused as a screening modality. It detected occult disease in only 54% of all patients and 38% of patients ages 80 years and older (P<0.001), wrote David A. Litvak, M.D., and Rajeev Arora, M.D., of Michigan State University. Forty-six percent of women presented with palpable masses.

The investigators reviewed records from women treated at a community hospital from 1992 through 2002. The authors analyzed data from three prospectively chosen subgroups (women ages 70 to 74, 75 to 79, and 80 or older).

They assessed size, grade, and histologic type of tumor as well as estrogen receptor status and type of surgical procedure and type of adjuvant therapy. They also collected data on use of mammography, presence of a palpable mass, pathologic staging of tumor and lymph nodes, and comorbidities.

Among the findings:

• Lymph node evaluation was omitted in 36% of all patients and was significantly less likely to occur in women older than 80 (56% P<0.001).
• Only five women had sentinel node biopsy.
• Estrogen receptor status was unknown in 38% of the women.
• Adjuvant therapies were underused in all three age groups, but the likelihood of adjuvant chemotherapy was significantly less in women ages 75 or older than in the youngest age group (P<0.007).
• Comorbidities increased along with age so that the women older than 75 had significantly more documented comorbidities than women younger than 75 (P=0.001).

In an invited critique, Karen Lane, M.D., of the University of California at Davis pointed out that although the authors delineated what appeared to be age-based treatment differences, some treatments-including sentinel node/axillary dissection-- remain controversial in older women.

In a woman with significant comorbidity, who is not a good candidate for adjuvant therapy, Dr. Lane cautioned that "adding the morbidity of a sentinel node/axillary dissection under general anesthesia may not be warranted."

The Michigan State authors wrote that the "appropriate treatment of this group of patients remains difficult to define."

They concluded that the "cornerstone of treatment of older breast cancer patients is an adequate geriatric assessment that helps estimate life expectancy and predict tolerance of treatment."

To that end, they wrote, better use of mammography screening was in elderly women who are "considered to have a life expectancy of greater than five years."