Elderly breast cancer patients risk treatment discrimination

Researchers led by Professor Christos Markopoulos from Athens University Medical School (Athens, Greece) used the population of the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial to examine competing causes of death in post-menopausal women with early breast cancer. Participants were treated with exemestane for five years or tamoxifen for 2.5 years followed by exemestane for 2.5 years. This use of the data was possible because, after five years, the trial had found no difference in outcomes between the two treatments it was comparing.

The 9,766 patients were classified by their age at diagnosis, separating those below 65 years of age, those between 65 and 75, and those above 75. All patients had hormone receptor positive tumours, 50% had node negative disease, 68% received radiotherapy, and 36% received chemotherapy.

An analysis of their progress over the 5.1 years of the trial found that although the risk of dying from causes other than breast cancer was much higher in elderly patients, the risk of dying of breast cancer also increased with age.

Applying a statistical method that takes into account the risk of competing causes of death in the elderly population, it was found that the risk of dying from breast cancer was indeed greater for those diagnosed later in age.

According to Prof. Markopoulos, who is also Chair of the Hellenic Society of Breast Surgeons, the higher absolute death rate amongst elderly women with breast cancer suggests they are not receiving standard treatment. "Our findings show that elderly breast cancer patients are more likely to die from something else other than from breast cancer -- for instance, age specific co-morbidities such as heart attack. However, for those not suffering from other conditions or those who have survived other conditions, deaths from breast cancer are higher compared to younger patients with the same tumour characteristics," he explains. "This probably means that old women with breast cancer are being under-treated as doctors think they will die from something else."

Several factors which can cause breast cancer mortality with increasing age, such as an age specific decrease in the function of the immune system on tumour progression, could potentially affect the results but cannot be easily assessed, says Prof. Markopoulos. "However, we observed that radiotherapy was administered less frequently and administration of chemotherapy sharply decreased with increasing age. Thus, it is most likely that under-treatment of the elderly may explain the worse age-specific breast cancer outcome found in our study," he says.

Underlying this situation is a false perception that the outlook for older women with breast cancer is relatively good, says Prof. Markopoulos. "This false impression is most likely due to deaths from other age-related conditions."

He goes on to say: "Several other studies have shown that elderly breast cancer patients have lower odds of receiving standard care, including deviations from guidelines for surgery, radiotherapy and chemotherapy. More work should be done to clarify the picture in the elderly population, as patients of this age group are usually excluded from major clinical trials."

ECCO president, Professor Michael Baumann, said, "Elderly patients have often been considered as being not fit for state-of-the-art cancer care. A host of recent studies have shown that it is not age per se, but rather the status of health that are important parameters for predicting how well an individual may tolerate treatments. All over Europe we see an increase in numbers of elderly patients and we more often see elderly patients who are fit and very good candidates for standard cancer treatments. Educational efforts, but also detailed research on predictors and supportive measures, are key to make sure that all cancer patients, irrespective of age, receive evidence based, best individual treatment approaches."

Commenting on the study, which he was not involved in, Dr. Etienne Brain from Hôpital René Huguenin of the Institut Curie, France, stressed that evaluating competing risks remained a key issue in older patients with cancer, although it could yield opposite conclusions according to tumour type. "It relies mostly on the assessment of comorbidities and functional status, two items that the Société Internationale d'Oncologie Gériatrique (SIOG) has been strongly advocating to consider for almost ten years when taking decisions about treatment for elderly cancer patients, and which might help to estimate individual life expectancy," he said.

"Although this study confirms that causes not related to breast cancer are the main reasons for death, it also suggests the likelihood that the diverse nature of the hormone-positive disease plays a role too. We need to improve the breast cancer prognostic classification in the elderly, developing specific tools or implementing those developed for younger patients, in order not to deprive those who might derive a real benefit from additional treatment including chemotherapy."

Dr. James Bellini, a leading futures analyst and broadcaster who will give the keynote lecture at the opening ceremony for the 2011 European Multidisciplinary Cancer Congress on Friday evening, will urge policymakers to prepare for demographic challenges of the kind highlighted by Prof. Markopoulos's study. "An ageing Europe with falling populations and major financial problems will pose a growing challenge for healthcare policies. Not only will conditions like cancer and diabetes rise sharply, but Europe will face an enormous and growing need for care -- both short and long term," he will say. "If the future care challenge is not to become a crisis we need a new kind of 'capitalism' built around purpose and not simply around economic gain. Human communities must be at the heart of this endeavour."