Lack of knowledge is not the same as lack of benefit: It is time to stop undertreating our elderly breast cancer patients

Abstract

Ever since Dr. H. Muss’s presentation regarding the frequency of lymph node involvement and differences in chemotherapy administration between younger and older patients enrolled in CALGB trials at the Annual American Society of Clinical Oncology (ASCO) meeting in 2003, the question has appeared in the headlines of many journal articles and news reports ‘‘Are we undertreating elderly breast cancer patients?’’ [1] Strictly interpreted, the answer to this question is yes. Multiple reviews have shown that older breast cancer patients are less likely to receive breast-conserving therapy, reconstructive surgery after mastectomy, radiation therapy after lumpectomy, and chemotherapy even for lymph node positive disease, as compared to their younger counterparts. Beyond a doubt studies have shown that elderly breast cancer patients are less often treated in compliance with national breast cancer guidelines. However, the better question to ask ourselves is ‘‘Why are we undertreating elderly breast cancer patients?’’ Are physician’s ageists? They do tend to underestimate the life expectancy of older patients, and to be overly pessimistic about older patient’s ability to tolerate recommended treatment. Also, many physicians confuse normal age related changes in physiology with the increased risk of comorbid disease that accompanies aging. It is misleading to declare that it is not chronologic age, but underlying health that is important. There are changes in hepatic metabolism, renal function, volume of distribution of medications, and other organ function as individual’s age that must be understood by physicians treating geriatric patients. As individuals age there is an increased risk of comorbid conditions such as obesity, heart disease, diabetes, etc. There are deficiencies in the educational background of most physicians regarding normal and abnormal geriatric physiology and treatment. When considering undertreatment of geriatric breast cancer patients, these deficiencies in physician education and understanding of geriatric care are accentuated by the fact that many physicians do not feel that standard breast cancer treatment guidelines adequately reflect the best level of care for older breast cancer patients. A large number of experienced physician feel that these national breast cancer treatment guidelines are overly aggressive for many older patients, particularly those with multiple comorbidities. A large review of breast cancer patients using the SEER database evaluated death from breast cancer versus death from other causes in over 400,000 women treated in the United States between 1973 and 2000. For patients with early stage, localized, estrogen receptor positive breast cancer, only in patients less than 50 (T1 tumors), or 60 years of age (T2 tumors), was the risk of death from breast cancer more then the risk of death from other causes. In other words, for patients over 50–60 years old, the risk of death from other causes exceeded their risk of dying from breast cancer. Even in those patients who had lymph node metastasis, if they had estrogen receptor positive disease, only in those patients under 70 did the risk of breast cancer exceed the risk of dying from other diseases. This reinforces the underlying assumption of many physicians that aggressive treatment of breast cancer in older patients may do more harm then good, as breast cancer will not be their life limiting disease, particularly for those patients with multiple comorbidities. It is also important to note, however, that for those patients who were lymph node positive and estrogen receptor negative, the risk of dying from breast cancer was higher then the risk of dying from other diseases at any age, yet it has been shown in many reviews that even that subgroup of older patients are often undertreated with systemic therapy [2]. The tendency to not comply with national breast cancer guidelines for older patients because of the belief by many physicians that breast cancer treatment guidelines are overly aggressive for older patients is often further complicated by the heterogeneity in beliefs and desires of the patients themselves. Anyone who frequently treats older patients can confirm that for the same set of circumstances and comorbidities a recommended treatment plan will be seen by one patient as overly risky and aggressive and by another patient as not aggressive enough. So, although helpful, the general evidence from the SEER database regarding risk of death from breast cancer versus risk of death from other causes is not enough to guide a physician in making decisions in the treatment of an individual patient. Most physicians are not well trained to predict a patient’s life expectancy based on their comorbidities and age, and as mentioned above, often are overly pessimistic in predicting an individual’s mortality from other causes, and overly optimistic in predicting an individual’s mortality from