Older Women Not Getting Proper Breast Cancer Treatment

Study cites need for better diagnoses and use of therapies

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By Steven Reinberg
HealthDay Reporter

WEDNESDAY, Oct. 18, 2006 (HealthDay News) -- Many older women with breast cancer are being under-diagnosed and under-treated, especially in community hospitals, researchers report.

The problem is taking on added urgency because breast cancer is becoming more common as the U.S. population ages. Almost 50 percent of women with breast cancer are 65 and older, and 35 percent are older than 70. And 77 percent of deaths from breast cancer involve women over 55, the researchers noted.

Yet many older women appear to be under-diagnosed and under-treated, perhaps because they may have other serious life-threatening medical conditions. In addition, there's confusion about when or if to screen older women for breast cancer. Some guidelines suggest that women stop having mammograms at 70, while others offer no upper limit.

In the report, published in the October issue of the Archives of Surgery, Drs. David A. Litvak and Rajeev Arora of Michigan State University looked at the medical records of 354 women aged 70 and older who were diagnosed with breast cancer in a community hospital between 1992 and 2002.

The doctors found that 46 percent of the women had breast cancer that could be detected during a physical examination. In addition, even though 72 percent of the women had mammograms, the tests were mostly administered to verify the results of the physical exam. In fact, mammograms found only 54 percent of undiagnosed breast cancers.

For 70 percent of the women, the cancer was in the early stages. But 36 percent of the women and 56 percent of those 80 or older were never examined to see if the cancer had spread to the lymph nodes.

In terms of treatment, the doctors found that about 50 percent of the women had breast-conserving surgery. However, the rates of women getting chemotherapy, radiation and hormonal therapy after surgery were lower than expected and lowest among the oldest women.

And many women who were candidates for adjuvant therapy, including those whose cancer had spread to lymph nodes, were not given this additional therapy. Of the 20 percent of women whose cancer had spread to the lymph nodes, only 29 percent received chemotherapy. Moreover, only 17 percent of the women 80 or older whose cancer had spread received chemotherapy. This rate was significantly lower than for women under 80, noted Arora and Litvak, who is now at the Kaiser Permanente Medical Center in Orange County, Calif.

"There are misconceptions by the public and the medical community that it's OK to omit certain diagnostic tests or treatments in older patients," Litvak said. "Older people are in a special category, which means that we have to be careful about how we treat them and how we approach their cancer."

Litvak and Arora believe that older patients should receive a geriatric assessment that would help estimate life expectancy and predict tolerance to cancer treatment. In addition, screening programs should be based on an individual geriatric assessment.

"The bottom line is that we really have to start individualizing the care of older patients," Litvak said. "It doesn't make sense to have a cap on mammograms for age. It should be based on the patient's overall health and their life expectancy. The same is true for treatment."

"Most older patients tolerate and benefit from the same treatments that younger patients get," Litvak added. "You just have to be careful about how you give it."

One expert thinks not enough is known about the risks and benefits of treating breast cancer in older women.

"This is not a surprising finding," said Dr. Alan Astrow, director of hematology/oncology at Maimonides Medical Center in New York City. "But we really don't know how best to treat older women with breast cancer."

For example, Astrow said, it's not known if withholding chemotherapy from older women shortens life. "Most oncologists feel that the side effects of chemotherapy in women over 80 would outweigh the benefits," he said.

Astrow thinks studies are needed to determine the value of breast cancer treatment for older women. "It could have an important public health impact," he said. "If, in fact, we are under-treating, and under-treating leads to worse outcomes, then that's something we really need to address because it affects a large number of women."

More information

The American Cancer Society can tell you more about breast cancer and older women.

SOURCES: David A. Litvak, M.D., Kaiser Permanente Medical Center, Orange County, Calif.; Alan Astrow, M.D., director, hematology/oncology, Maimonides Medical Center, New York City; October 2006 Archives of Surgery

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