Use In Older Women Research Articles

Evaluation of the efficacy and toxicity profile associated with intraperitoneal chemotherapy use in older women

ObjectiveIntraperitoneal (IP) chemotherapy (CT) for treatment of epithelial ovarian cancer (EOC) has been shown to provide a substantial OS advantage. This study aims to compare the toxicity and benefits of IP CT in patients ≥70 with those <70. MethodsWe performed a single institution retrospective review of patients diagnosed with Stage IIA-IIIC EOC from 2000 to 2013 who received IP CT. Clinicopathologic characteristics were extracted, and survival was calculated. Results133 patients were included with 100 pts. <70years old and 33 pts. ≥70years old. Clinical trial enrollment was similar despite age. In trial enrolled patients, older patients received statistically fewer cycles of therapy (6.4 vs 5.8, p=0.002) but had similar dose delays (0.9 vs 0.7, p=0.72), and modifications (0.9 vs 0.36, p=0.11). Median PFS (27 vs 31months) and OS (71 and 62months) were not statistically different. Grade 3/4 neutropenia was significantly worse in the older patients (82% vs 100%, p=0.04). Neuropathy grade ≥2 and other non-hematologic toxicities were not different between age groups. ConclusionsDespite completing fewer cycles of IP CT, older EOC patients had comparable survival to younger patients. The population of older patients receiving IP CT in this study were on clinical trial and likely to be heartier than the general older population. IP CT appears well tolerated and effective among select older patients and is likely under-utilized outside of clinical trials.

C08-B Psychotropic and Narcotic Drug Use in Older Women Diagnosed with Breast Cancer Across the Cancer Care Trajectory

C08-B Psychotropic and Narcotic Drug Use in Older Women Diagnosed with Breast Cancer Across the Cancer Care Trajectory

Adjuvant radiation use in older women with early-stage breast cancer at Johns Hopkins.

In 2004, The National Comprehensive Cancer Network (NCCN) Guidelines incorporated omission of radiation therapy after breast-conservation surgery in women ≥70years old with stage I, estrogen receptor-positive breast cancer who plan to receive endocrine therapy. One study demonstrated wide variation in implementing this change across 13 NCCN institutions. We evaluated the practice pattern at our institution. We identified women ≥70years old treated at our institution from 2009 to 2014. We calculated radiation therapy omission rate in those meeting the guidelines. We explored associations between radiation therapy omission, year of diagnosis, and patient characteristics with Wilcoxon rank sum tests and Fisher's exact tests. A total of 667 women met the inclusion criteria, and 117 (18%) were candidates for radiation therapy omission. Mean age among the 117 was 76.3years (Range: 70-95). Overall radiation therapy omission rate was 36.8%, but varied greatly by year of diagnosis (Range: 7.7-54.5%). This variation persisted after excluding women who did not receive endocrine therapy (Mean: 39.0%, Range: 0.0-75.0%). Factors associated with higher radiation therapy omission rates included older age and not having pathological nodal evaluation. The radiation therapy omission rate did not vary by race, tumor type, grade, or size. The implementation of the NCCN guideline has not been consistent at our institution. Our data suggest that other tools should be considered to apply the guidelines more consistently. We have implemented a quality improvement protocol that incorporates life expectancy estimate and geriatric assessment in women meeting the NCCN guideline at our institution.

Impact of guideline changes on use or omission of radiation in the elderly with early breast cancer: practice patterns at National Comprehensive Cancer Network institutions.

Breast radiation therapy (RT) is a care standard after breast-conservation surgery that improves local control and survival in women. In 2004, a phase III trial demonstrated radiation after breast-conservation surgery provided no survival and limited local control benefit to women aged 70 years and older with stage I, estrogen receptor-positive cancers who receive endocrine therapy. This led to breast-conservation surgery and endocrine therapy alone being incorporated as a category I option in the National Comprehensive Cancer Network (NCCN) Guidelines for older women in 2004. We examined factors associated with change in radiation use in elderly patients at 13 NCCN centers. We identified women treated at NCCN centers meeting age and stage criteria during 2000 to 2009. Factors considered a priori potentially associated with RT use were evaluated in univariate and multivariable models, including year of diagnosis, tumor and patient characteristics, axillary surgery, and treating institution. Date of diagnosis was classified as 2000 to 2004 vs 2005 to 2009, reflecting when guidelines changed. Among 1,292 eligible cases, 78% received RT. In multivariable analysis, diagnosis after 2004 (p = 0.0003), older age (p < 0.0001), higher comorbidity score (p = 0.0006), smaller tumors (p = 0.0146), and omission of axillary surgery (p < 0.0001) predicted RT omission. Ninety-four percent of women aged 70 to 74 years received RT in 2000, compared with 88% in 2009. For the same times and age 80 years and older, RT use was 80% vs 41%. Finally, RT use was associated with treating institution (p < 0.0001). After guideline changes for RT use in older women, NCCN centers demonstrated wide variation in implementing change. This suggests other factors are also influencing guideline uptake.

Duration and Toxicity of Adjuvant Trastuzumab in Older Patients With Early-Stage Breast Cancer: A Population-Based Study

Few data are available regarding adjuvant trastuzumab use in older women with early-stage breast cancer. We examined rates and predictors of adjuvant trastuzumab completion and cardiac events in this population. We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify patients age ≥ 66 years with stage I to III breast cancer diagnosed between 2005 and 2009 who received trastuzumab. Completion of trastuzumab was defined as receipt of more than 270 days of therapy. We used multivariable logistic regression to examine patient, clinical, and geographic characteristics associated with trastuzumab completion. We also examined rates of hospital admissions for cardiac events. Among 2,028 women, most (71.2%) were younger than age 76 years and had a comorbidity score of 0 (66.8%); 85.2% received trastuzumab with chemotherapy. Overall, 1,656 women (81.7%) completed trastuzumab. Older patients and those with more comorbidity had lower odds of treatment completion (odds ratio [OR], 0.40 [95% CI, 0.30 to 0.55] for age ≥ 80 years v age 66 to 70 years; OR, 0.65 [95% CI, 0.49 to 0.88] for comorbidity score of 2 v 0). During treatment, 73 patients (3.6%) were hospitalized for cardiac events (2.6% of those who completed trastuzumab v 8.1% of those who did not; P < .001). Most older patients who initiated adjuvant trastuzumab completed therapy. Age and comorbidity were among factors that were associated with treatment completion, and rates of significant cardiac events were higher in those who did not complete therapy. Further exploration of toxicities and optimal treatments for older women with human epidermal growth factor receptor 2-positive breast cancer are warranted.

Fertility in older women following removal of long-term intrauterine devices in the wake of a natural disaster

BackgroundIn order to evaluate the effect of long-term intrauterine device (IUD) use on female fertility, we interviewed 2301 women who lost children in the 2008 Wenchuan earthquake in China, which prompted IUD removal. Study DesignA clinical retrospective survey. ResultFive hundred and twenty-four women were lost to follow-up, and data from the remaining 1770 women were analyzed. The completed questionnaires revealed that 80.11% (1418/1770) became pregnant following IUD removal and about 88% (1256) of whom conceived within 1 year. Among women with different durations of IUD use, pregnancy rates and miscarriage rates were as follows: <5 years, 89.77% and 4.27%; 6–10 years, 81.10% and 10.19%; and >10 years, 75.20% and 12.98%, respectively. Age, duration of IUD use, a history of a previous miscarriage and abnormal menstruation before the earthquake were independently associated with reduced fertility, but a higher gravidity pre-earthquake was associated with a higher conception rate. ConclusionLong-term IUD use in older women had a high rate of pregnancy after removal of IUD, but with an increased risk of fertility problems.

Complementary/Alternative Therapy Use in Older Women with Arthritis

The purpose of this study was to describe the experiences of using complementary/alternative therapy (C/AT) in community-dwelling older women with arthritis. A descriptive qualitative approach using focus groups for data collection was conducted with a purposive sample of 27 older female C/AT users (mean age = 77.8, range = 65 to 93). Content analysis was used to identify themes, which included (a) acceptance of the incurable nature of arthritis, (b) high use of nutritional supplements, (c) use of multiple C/AT to manage symptoms, (d) physical symptoms and limited treatment options motivated C/AT use, (e) most C/AT were perceived as effective, (f) C/AT knowledge was limited among users, and (g) older women did not fully disclose their C/AT use to their primary care physician. Findings revealed that older women are motivated to use C/AT, particularly nutritional supplements, to manage arthritis symptoms without seeking medical advice from their physician. Strategies are needed to improve communication between health care providers and older patients on C/AT use for optimal management of arthritis and prevention of adverse events.

Patient and physician decision styles and breast cancer chemotherapy use in older women: Cancer and Leukemia Group B protocol 369901.

PURPOSE Physician and patient decision styles may influence breast cancer care for patients ≥ 65 years ("older") because there is uncertainty about chemotherapy benefits in this group. We evaluate associations between decision-making styles and actual treatment. METHODS Data were collected from women treated outside of clinical trials for newly diagnosed stage I to III breast cancer (83% response) from January 2004 through April 2011 in 75 cooperative group sites. Physicians completed a one-time mailed survey (91% response), and clinical data were abstracted from charts. Patient decision style was measured on a five-point scale. Oncologists' preference for prescribing chemotherapy was based on standardized vignettes. Regression and multiple imputation were used to assess associations between chemotherapy and other variables. Results There were 1,174 women seen by 212 oncologists; 43% of women received chemotherapy. One-third of women preferred to make their own treatment decision. Patient and physician decision styles were independently associated with chemotherapy. Women who preferred less physician input had lower odds of chemotherapy than women who preferred more input (odds ratio [OR] = 0.79 per 1-point change; 95% CI, 0.65 to 0.97; P = .02) after considering covariates. Patients whose oncologists had a high chemotherapy preference had higher odds of receiving chemotherapy (OR = 2.65; 95% CI, 1.80 to 3.89; P < .001) than those who saw oncologists with a low preference. CONCLUSION Physicians' and older patients' decision styles are each associated with breast cancer chemotherapy use. It will be important to re-evaluate the impact of decision styles when there is greater empirical evidence about the benefits and risks of chemotherapy in older patients.

Use of bisphosphonate and risk of atrial fibrillation in older women with osteoporosis

Concerns have been raised among clinicians and patients whether or not bisphosphonates increase the risk of atrial fibrillation. In this large cohort study, increased risk of atrial fibrillation was not found to be associated with bisphosphonate. In fact, bisphosphonate even showed a protective effect against cardiac arrhythmia compared to other osteoporosis medications. Increased risk of atrial fibrillation among bisphosphonate users has been reported; however, the results from these studies are controversial. The purpose of this study was to evaluate the risk of atrial fibrillation associated with bisphosphonate use in older women. We used the Korean Health Insurance Review and Assessment Service claims database from May 1, 2005 to June 30, 2006. Retrospective cohort analysis was conducted on women 65 years or older with newly diagnosed cases of osteoporosis (ICD 10 code: M80, M81) who had not previously taken any medications for osteoporosis. Bisphosphonate-exposed and non-exposed patients were followed until they were either diagnosed with atrial fibrillation (ICD 10 code: I48) or until the end of the study. The Cox proportional hazards model was used to calculate hazard ratios and the 95% confidence intervals. Atrial fibrillation was reported in 626 of the 120,319 patients (0.52%) treated with bisphosphonates and 66 of 9,863 patients (0.67%) treated with other osteoporosis medications. Overall hazard ratio for developing atrial fibrillation in the bisphosphonate-treated group was 0.52 (95% CIs, 0.29-0.91). In patients with a medication possession ratio greater than 0.7, the hazard ratio was lower (HR 0.41, 95% CIs 0.23-0.75). In the subgroup analysis, alendronate showed a statistically significant protective effect against the risk of atrial fibrillation with a hazard ratio of 0.75 (95% CI, 0.58-0.97). Among older Korean women with osteoporosis, bisphosphonate was found to have a protective effect against atrial fibrillation.

Predictors of mammography use in older women with disability: the patients’ perspectives

To determine the factors associated with mammography use among Medicare beneficiaries and reasons for nonuse. Cohort of 4610 community-dwelling Medicare beneficiaries ≥ 65 years included in the 2004-2005 Medicare Current Beneficiary Survey. Regression models evaluated the association of disability with mammography use. Reasons for underuse are described. Women with disability were more likely than women with no disability to report lower mammography use (unadjusted, moderate disability OR = 0.76; 95% CI = 0.64, 0.91; severe disability OR = 0.46; 95% CI = 0.40, 0.54). Lower use was significant for women with severe disability (adjusted, OR = 0.67; 95% CI = 0.54, 0.83) and women with fair-poor self-rated health, no HMO enrollment and ≥ 3 comorbidities. No physician recommendation, no need, dislike/pain during the test and forget it were reasons for underutilization. Mammography use decreases with increasing level of disability. Common reasons for underutilization are no physician recommendation, no need, dislike/pain during the test and forgot it. Screening guidelines should be used to target women with disabilities who can benefit from mammography.

Exploring hearing aid use in older women through narratives

This study explored experiences surrounding hearing aid use and non-use in older women with hearing loss. A narrative approach was used to gain an in-depth understanding of the meaning and contextual issues that impact upon the adaptation process of older adults and their transitions in using hearing devices. Four women over the age of sixty who were identified as being consistent hearing aid users took part in three face-to-face interviews. biographic-narrative-interview guiding framework was used to gather data in this study. Data were analyzed both holistically and thematically from a phenomenological perspective to identify the meaning and essence of the participants’ experiences. The results revealed an overarching theme of meaningful participation in life situations and events that were linked to purposeful use and non-use of hearing aids. Barriers and facilitators related to participation, which in turn affect hearing aid use and acceptance, were uncovered. The results of this study have implications for audiologic research, and practice.SumarioEste estudio exploró las experiencias alrededor del uso o no uso de auxiliares auditivos por ancianas con pérdidas auditivas. Se usaron las narraciones como enfoque, para lograr la comprensión exhaustiva del significado y de los aspectos contextuales que impactan el proceso de adaptación de los adultos mayores y su transición en el uso de instrumentos auditivos. Tomaron parte en tres entrevistas cara-a-cara, cuatro mujeres mayores de sesenta años, identificadas como usuarias consistentes de auxiliares auditivos. Se usó el marco guía de de entrevistas biográficas-narrativas para obtener los datos de este estudio. Estos datos fueron analizados tanto holística como temáticamente, desde una perspectiva fenomenológica para identificar el significado y la esencia de las experiencias de las participantes. Los resultados revelaron un tema enarcado de participación significativa en situaciones de vida y eventos ligados al uso propositivo o al no uso de auxiliares auditivos. Las barreras y los facilitadores relacionados con la participación, que afectan en sus momentos el uso y la aceptación del auxiliar auditivo, no fueron cubiertos. Los resultados de este estudio tienen implicaciones para la investigación y la práctica audiológica.

Sensitivity of Self-Report Mammography Use in Older Women

Recent survey evidence indicates a decline in mammography use among older women. The objective of this study was to detect sensitivity of self-reported mammography use and pose evidence-based suggestions to increase survey accuracy. Using the 1991-2006 Medicare Current Beneficiary Survey, 15,357 women, aged > or =65 years, were selected based on use of mammography services. The women were interviewed in the community setting at random periods after screening and asked, Have you had a mammogram or breast X-ray since [today's date or previous supplement round interview date] a year ago? Statistical analyses were conducted between March 11 and April 28 of 2008. This study tested whether sensitivity (i.e., probability of an affirmative response) was dependent on length of the recall period and on respondent demographic and socioeconomic characteristics. Overall, 90.4% of the older women self-reported use; however, sensitivity decreased as the recall period lengthened (90% at 6 months, 80% at 12 months). This time effect was significantly higher among older, economically disadvantaged women. Sensitivity also decreased an additional 13.8% if the event occurred in the previous calendar year, and 3.5% if conducted in a non-English language or by proxy. Greatest sensitivity occurred during the 6-month period after service without straddling calendar years. These findings may aid the tailoring of future surveys for older adults, improving the recall of preventive services.

Patient preference as a determinant of breast cancer adjuvant chemotherapy use in older women: CALGB #369901

9544 Background: Decisions about use of breast cancer chemotherapy in women 65 and older (“older”) can be complex due to comorbidity, uncertain efficacy and limited data on patient preference. Methods: Older women diagnosed with invasive, non-metastatic breast cancer between 2004 and 2008 were recruited from 53 CALGB sites for an observational study of preferences and chemotherapy use. Data on preferences and other factors were collected from patient interviews and clinical data were abstracted from charts. Generalized estimating equation regression was used to assess associations between chart-reported chemotherapy and independent variables; associations were also evaluated in 2 subgroups: “chemotherapy indicated” (estrogen receptor [ER] negative and/or node positive) and “consider chemotherapy” (ER positive and node negative). Results: Among 935 eligible women registered, 815 (87.2%) completed interviews. The mean age of the cohort was 73 years (range 65–100); 38% were node positive, 82% were ER positive and all had tumors ≥ 1 cm (44% were AJCC stage 1, 44% stage 2 and 12% stage 3). Based on ER and nodal status, chemotherapy was “indicated” for 47% and could be “considered” for 53%. Crude chemotherapy rates were 70% in the “indicated” group and 17% in the “considered” group, for an overall rate of 42%. Women who would choose chemotherapy for an increase in survival of ≤12 months were 4.1 times (95% CI 2.5–6.7, p&lt;.0001) more likely to receive chemotherapy than women who would only choose chemotherapy if it added more than 12 months, controlling for age, tumor factors, comorbidity and other covariates. Stronger preferences were seen among women with “indications” for chemotherapy (OR 7.9, 95% CI 3.7–17.0, p&lt;.001) than in those where treatment might be “considered” (OR 1.8, 95% CI 0.9–3.4, p=.08). Higher patient rating of communication with providers was independently related to a decision to use chemotherapy among women where chemotherapy could be “considered” but not among those where chemotherapy was “indicated”. Conclusions: Beyond clinical indications, older women's preferences and communication with providers are important correlates of chemotherapy use. [Table: see text]

Screening Mammography in Older Women&lt;subtitle&gt;Effect of Wealth and Prognosis&lt;/subtitle&gt;

Wealthy women have higher rates of screening mammography than poor women do. Screening mammography is beneficial for women with substantial life expectancies, but women with limited life expectancies are unlikely to benefit. It is unknown whether higher screening rates in wealthy women are due to increased screening in women with substantial life expectancies, limited life expectancies, or both. This study examines the relationship between wealth and screening mammography use in older women according to life expectancy. A cohort study was performed of 4222 women 65 years or older with Medicare participating in the 2002 and 2004 Health and Retirement Survey. Women were categorized according to wealth and life expectancy (based on 5-year prognosis from a validated prognostic index). The outcome was self-reported receipt of screening mammography within 2 years. Overall, within 2 years, 68% of women (2871 of 4222) received a screening mammogram. Screening was associated with wealth (net worth, > $100 000) and good prognosis (< or = 10% probability of dying in 5 years). Screening mammography was more common among wealthy women than among poor women (net worth, < $10 000) both for women with good prognosis (82% vs 68%; P < .001) and for women with limited prognoses (> or = 50% probability of dying in 5 years) (48% vs 32%; P = .02). These associations remained after multivariate analysis accounting for age, race, education, proxy report, and rural residence. Poorer older women with favorable prognoses are at risk of not receiving screening mammography when they are likely to benefit. Wealthier older women with limited prognoses are often screened when they are unlikely to benefit.

Estrogen modifies arousal but not memory for emotional events in older women

Emotional arousal and the affective content of events influence memory. These effects shift with age such that older people find negative information less arousing and remember proportionately more positive events compared to the young. The emotional enhancement of memory is mediated by medial temporal lobe limbic structures and the prefrontal cortex, which are both affected by sex hormones. We examined whether hormone use (estrogen or estrogen and progesterone) in older women modulated perceptions of valence and arousal, and subsequent memory for emotional images or stories. Their performance was compared to younger women. Hormone use in older women resulted in higher arousal for negative images and stories but memory was not affected. We hypothesize that estrogen modifies the influence of the amygdala and the prefrontal cortex on emotion, but that age-related changes in the hippocampus prevent the enhancement of emotional memory in older women.

Fracture risk and antiresorptive medication use in older women in the USA

Risk of fragility fractures in older women appears to be under-recognized and under treated. Analysis of a national sample of older US women reveals that over 5 million are at high risk of fracture; only one third of these report being told they have osteoporosis and one quarter are receiving appropriate treatment. Substantial numbers of older women in the United States suffer fragility fractures each year. Although risk for these fractures can be readily identified from clinical characteristics, many women may not be receiving treatments demonstrated to reduce risk. Our objective was to estimate the extent of fracture risk among older white US women and assess patterns of use of pharmacologic agents in response to that risk. Cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) for 1999-2000 and 2001-2002 were combined to enumerate risk factors for fracture and use of antiresorptive prescription medications for all white women 65 years of age and older. The FRACTURE Index (FI), developed from the Study of Osteoporotic Fractures (SOF), which combines subjects' characteristics to estimate five-year fracture risk, was applied to these national data. Of more than 15 million US women in this age group almost 40% have one risk factor in addition to age that predisposes to fracture; 20% have two or more. More than 5 million women are in the highest category of FI risk; 26% of these will have a nonvertebral fracture and 10% will have a vertebral fracture in the next five years. Antiresorptive medications are being taken by less than 50% of women in most risk categories when all antiresorptives, including estrogen replacement, are included; only 17% of older women who have sustained a prior fracture and 13% in the highest category of FI risk are receiving agents specifically intended to reduce bone loss. Millions of older US women are at high risk for fragility fractures. Levels of treatment with antiresorptive medications are low and are not commensurate with fracture risk.

A qualitative study of factors affecting chemotherapy use in older women with breast cancer: barriers, promoters, and implications for intervention

The incidence of breast cancer increases with advancing age and yet women 65 and older (hereinafter referred to as 'older' women) do not always receive the most intensive treatments, such as adjuvant chemotherapy. The causes of underutilization of chemotherapy in this age group are poorly delineated. The purpose of the study was to explore older breast cancer patients' attitudes towards chemotherapy and factors that influenced their decisions to use or not use this treatment modality. Qualitative methods were used to conduct race/ethnicity-specific focus groups. A thematic analysis was performed using NVIVO. Drawn from the Washington, DC area, participants were 34 ethnically diverse older breast cancer survivors (18 Caucasians, 10 African-Americans, and 6 Latinas). Focus groups were conducted in a local church; a senior center, and the Lombardi Cancer Center. Results showed that many women felt they had no 'choice' and did what the doctor told them to do. For those who reported participation in the decision, time spent exchanging information with the woman's physician and the inclusion of family members promoted perceptions of optimum decision-making leading to the use of chemotherapy. Two barriers to using chemotherapy were negative expectations about side effects and lack of information specific to the woman's individuals' circumstances. Women of color reported less physician communication and information, in part due to language difficulties and perceived bias; these factors acted as barriers to chemotherapy. Physicians could provide specific and limited information to patients and family members to promote realistic expectations and optimum decisions about chemotherapy, given the risks involved in this treatment modality. Interventions should be developed and tested to enhance communication that is sensitive to older women's culture, family structure, illness experiences, preferences, and expectations.

Adjuvant Chemotherapy Use and Outcomes in Older Women With Breast Cancer: What Have We Learned?

In both the basic science and clinical trial worlds it is not uncommon for two or more research groups to make similar discoveries or the same discovery simultaneously, or for two similarly designed clinical trials to obtain similar or the same results. However, this phenomenon is less common in the clinical epidemiology/outcomes research world. As editorial board member/ reviewer (R.A.S.) and associate editor (P.A.G.) of the Journal of Clinical Oncology, we encountered this issue. We felt that the story, its outcomes, and the research and clinical implications would be of interest to the readership. In April 2005, Giordano et al submitted an article addressing temporal changes in adjuvant chemotherapy use in older women, including changing patterns of specific agent use. The article also focused on patient factors associated with the receipt of chemotherapy and with putative toxicities of these agents. The analyses presented relied on the Surveillance, Epidemiology, and End Results (SEER)-Medicare data set, with the strengths of large numbers of cases across 14 geographic sites and over time, and the weaknesses of reliance on administrative claims data (and therefore lack of clinical data) for comorbidity, chemotherapy use, and toxicities. Although the reviewers and editor were enthusiastic about the topic, the lack of linkage of treatment to outcomes and the limitations of the data sources for toxicity information dampened their enthusiasm. A revised article received in June 2005 addressed the relationship between adjuvant chemotherapy treatment and breast cancer-specific and all-cause mortality and deleted the toxicity analyses. However, several remaining concerns of the reviewers led to the request for additional revisions. While these revisions were underway, Elkin et al submitted an article addressing temporal changes in adjuvant chemotherapy use in older women, also focusing on patient factors associated with receipt of chemotherapy, relating receipt of chemotherapy to all-cause mortality. The authors also used propensity scores and sensitivity analysis to address the methodologic challenges of measured and unmeasured confounders in observational studies. The additional strengths associated with these analytic approaches, the fact that the striking similarity between the two articles was a result of the editorial process, and the fact that both articles were simultaneously under review led to the decision to publish them both. The tangible outcomes of this process are found elsewhere in the Journal of Clinical Oncology. To complicate things additionally, while both research groups were finalizing their articles, the Journal of Gerontology: Medical Sciences published a similar paper by Du et al, again based on analyses of the SEER-Medicare data set. For comparative purposes, the key features of all three articles are displayed in Table 1. As might be expected from experienced investigators using the same data, all three groups observed increasing use of adjuvant chemotherapy over time; substantial geographic variation in use (from a low in San Francisco to a high in Hawaii); decreasing use in patients with increasing age and comorbidity; and increasing use in patients with poor prognostic indicators. The varying association of race across studies may well be related to different strategies for socioeconomic status measurement which are known to not be comparable, and differences in tumor characteristics (eg, stage and receptor status) selected for sampling across the three studies. It is the differences in tumor characteristics coupled with differences in outcome that are most likely responsible for the apparent lack of consistency of findings across the three studies. Giordano et al were least restrictive in their initial sampling, including all women with stage I-III disease, both estrogen receptor (ER) –positive and –negative, who received either breastconserving surgery or mastectomy. However, in the end, after stratification by ER and lymph-node status, they identified lymph node–positive, ER–negative patients as the subgroup benefiting from chemotherapy (hazard ratio, 0.72; 95% CI, 0.54 to 0.96). In contrast, Elkin et al restricted their sample to all stage I-III women with ER–negative tumors. Their initial analyses considered both lymph node-positive and lymph node-negative patients, yielding a hazard ratio of 0.85 (95% CI, 0.77 to 0.95). In response to the Giordano paper, analyses restricted to the lymph node-positive group, but with the additional propensity score adjustment, yielded results very similar to those of Giordano: hazard ratio, 0.76; 95% CI, 0.65 to 0.88; suggesting that most of the overall observed effect was restricted to this subgroup. Both sets of investigators observed that the benefits of adjuvant chemotherapy did not vary by age, and specifically were similar for those women younger than 70 years of age versus those 70 years of age or older. This latter finding is of particular importance because the overview of trials JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 24 NUMBER 18 JUNE 2

Herbal, Prescribed, and Over-the-Counter Drug Use in Older Women: Prevalence of Drug Interactions

Older adults are at particular risk for drug and herbal interactions because they have multiple health problems that require treatment and are generally more susceptible to adverse drug effects. This study used a database containing self-reported herbal, prescription, and over-the-counter (OTC) drugs concurrently taken by a sample of 58 women who were aged 65 years or older. Drug-drug interactions (DDIs) were identified using a Web-based pharmaceutical program. At least 1 moderate or high-risk DDI was identified in 74% of participants, with 136 total DDIs identified. Fifty-two percent (71) of total DDIs were between prescribed and OTC or herbals, with 63% (45) of these involving nonsteroidal antiinflammatory drugs (NSAIDs). It is imperative that health care providers identify all prescribed, OTC, and herbal drugs taken by their patients and assess all interactions in order to avoid the possibility of adverse drug effects.

Unfortunate Impact of Age on the Management and Outcomes of Unstable Angina and Non-ST Elevation Myocardial Infarction (The GUARANTEE Registry)

Few data are available from the registries on the impact of age and gender on treatment and outcomes of patients admitted for unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI). We examined the clinical characteristics, differences in management and outcomes, associated with age in 2948 consecutive patients with UA/NSTEMI. Prospectively collected data from the Global Unstable Angina Registry and Treatment Evaluation (GUARANTEE) registry were analyzed, comparing patients older than 75 years of age and those 75 years and younger. Patients presenting at a younger age, both men and women, were more likely to have a family history of coronary artery disease, to be current smokers, and to have hypercholesterolemia (P < 0.001). Older patients more commonly had a prior history of stroke, angina, myocardial infarction (MI), and congestive heart failure (P < 0.05), and had more diffuse disease on angiography (P < 0.001). Although older women more often "ruled-in" for MI on admission, they were less likely to be cared for by a cardiologist (P < 0.05). A gradient in the use of cardiac catheterization was seen, with greatest use in younger men, 54.2% versus 47.4% for younger women, 43.1% for older men, and the lowest use in older women, 34.5% (P < 0.01). An opposite gradient of in-hospital mortality was seen, with 0.7%, 0.7%, 0.9%, and 3.2% across the 4 groups, respectively, with older women having worse outcomes (P = 0.008). Unfortunately, a "reverse targeting" of procedures to patient risk was seen among elderly, even when stratified by gender, with older patients being higher risk, but less likely to receive appropriate procedures. To improve the outcomes of elderly men and women with UA/NSTEMI, they should be managed more aggressively.