Surgical treatment decisions for older patients; the influence of tumour characteristics, patient health and choice.

Purpose:Women aged ≥70 years experience highest incidence and worse relative survival for breast cancer in England1,2. Substantial differences in breast cancer treatment by age have been demonstrated3. However, national UK policy/ guidelines indicate that management may justifiably differ for older patients on the basis of their tumour characteristics, health and choice4. We investigate whether the disparity in treatment for breast cancer by age persists once differences in these variables are adjusted for. The ability of a range of pre-treatment health measures to predict post surgical complications and HRQoL will also be tested with a view to developing accurate health measures into treatment decision making tools.Methods:Our previous studies investigated the role of tumour characteristics and health in age-related treatment differences. We undertook:(1) a retrospective case note review of women aged 65 years, resident in Greater Manchester with invasive breast cancer registered in 1999 (n = 480) adjusting for differences in tumour characteristics5(2) a pilot prospective study of patients diagnosed in 2002-3 (n = 76) adjusting for co-morbidity and general health (represented by Activities of Daily Living)6Results:Study 1: Older women were less likely to receive standard management compared to younger women for all indicators investigated. For example compared to women aged 65-69 years, women aged 80 years with operable (stage 1-3a) breast cancer had increased odds of not receiving primary surgery (OR = 43.0, 95% CI: 9.7-191.3).Study 2: The odds of patients aged ³80 years with operable breast cancer undergoing surgery were reduced by a factor of 44 (OR: 0.023, 95% CI: 0.001-0.361) compared to patients aged 65-79 years.Conclusions & Current Studies: These results indicate that older women in the UK are less likely to receive standard management for breast cancer, compared to younger women and this disparity is not explained by differences in tumour characteristics and general health. Our current studies investigate the role of patient choice in surgical treatment decisions for older breast cancer patients. The role of patient health is also being investigated in a larger sample and pre-treatment health measures which best predict post surgical complications and HRQoL for older breast cancer patients are being identified. In order to do this we have established large prospective cohorts of women aged ≥65 diagnosed with early stage invasive breast cancer in England from 2010-2012 (812 of our 900 overall target sample has currently been recruited). We are collecting data via pre- treatment interviews (with both patients and their surgeons), post surgical surveys and case note reviews. These cohort studies will establish the extent to which the difference in treatment for older breast cancer patients can be explained by patient choice, health and tumour characteristics. Health measures which accurately predict outcome for surgery in the cohorts will then be developed into a surgical treatment decision making tool in a first phase RCT of a complex intervention aiming to base surgical treatment decisions on patient health, choice and acceptable risk of adverse outcome.References:[1] Office for National Statistics. Cancer statistics registrations: Registrations of cancer diagnosed in 2008, England. Series MB1 No. 39. www.statistics.gov.uk . 2010. [2] Cancer Research UK. Breast Cancer Survival Statistics. http://info.cancerresearchuk.org/cancerstats/types/breast/survival/#age . 2009. [3] Lawrence, G, Kearins, O, Lagord, C, Cheung, S, Sidhu, J, and Sagar, C. The Second All Breast Cancer Report. 2011. National Cancer Intelligence Network.[4] Department of Health. Cancer Reform Strategy. 2007. London. [5] Lavelle K, Todd C, Moran A, Howell A, Bundred N, Campbell M (2007b) Non-standard management of breast cancer increases with age in the UK: a population based cohort of women ≥65 years. British Journal of Cancer 96: 1197-1203[6] Lavelle K, Moran A, Howell A, Bundred N, Campbell M, Todd C (2007a) Older women with operable breast cancer are less likely to have surgery. British Journal of Surgery 94: 1209-1215