Factors Associated with Functional Decline in Elderly Female Breast Cancer Patients in Appalachia

Abstract

BackgroundFunctional status has been previously shown in the elderly cancer population to predict both mortality as well as treatment tolerance. The goal of this study was to determine if there are certain subsets of the elderly breast cancer population that are at higher risk of experiencing functional decline following treatment.MethodsPatient charts from the Edwards Comprehensive Cancer Center in Huntington, West Virginia, from January 2006 – January 2016 were reviewed. Relevant inclusion criteria included patients of 65 years of age and older with a new diagnosis of Stage 0-III breast cancer. Functional decline was defined as an increase of at least one point in Eastern Cooperative Oncology Group (ECOG) scores within one year of diagnosis. ECOG performance status was subjectively determined by the physician. Fisher’s exact test and Pearson’s Chi-squared test were initially utilized to assess potential factors associated with functional decline such as pretreatment ECOG score, age at diagnosis, stage, hormone receptor status, type of surgery received, whether radiation therapy, chemotherapy, or hormonal therapy was received, medical comorbidities, body mass index (BMI), complaints of weakness at diagnosis, and ambulatory status. Factors that were found to be significant were further assessed via multivariate logistic regressions.ResultsThree-hundred and fourteen patients were identified as meeting inclusion criteria. At one-year follow-up, 45 patients (14.3% of the cohort) had documented functional decline. On initial analysis, factors associated with functional decline included Stage III disease (p=0.002) and complaints of weakness at diagnosis (p=0.004). Following multivariate analysis, Stage III disease (p = 0.02), complaints of weakness at diagnosis (p = 0.04), and bilateral mastectomy (p = 0.03) were significantly associated with functional decline.ConclusionPatients who were diagnosed with Stage III breast cancer, had complaints of weakness at time of diagnosis, or had bilateral mastectomies were more likely to have a decline in functional status at one-year follow-up. Awareness of factors associated with functional decline in the elderly Appalachian population with Stage 0-III breast cancer will be useful during discussions regarding patient expectations, treatment, and goals of care. Elderly breast cancer patients for whom bilateral prophylactic mastectomies are not indicated may be better served by lumpectomy alone (based on patient age, hormone receptor status, and tumor size), lumpectomy followed by radiation therapy, or unilateral mastectomy to maximize the likelihood of functional preservation following treatment.

Does Breast Cancer Surgery Impact Functional Status and Independence in Older Patients? A Narrative Review

“…Of the residents, 55–60% exhibited functional decline at 1 year post-surgery, with an average drop in MDS-ADL score of 2.8 points following lumpectomy, 4.1 points after mastectomy and 4.6 points post-axillary lymph node dissection (ALND). In support of this, Singh et al [ 5 ] showed that bilateral mastectomies in 314 older Appalachian women aged ≥ 65 years were associated with poorer functional preservation ( p = 0.03) when compared to patients who underwent a unilateral mastectomy or lumpectomy, demonstrating the more apparent decline in FS outcomes after more extensive surgery. A systematic review on the subject [ 6 ], which included 10 studies, further summarised how patients post-ALND experienced appreciable impairment in their autonomy in carrying out their ADLs.…”

“…Several studies [5][6][7][8][9][10][11] have reported the negative impact of elective cancer treatment on subsequent FS trajectories by examining how it affects the broad areas of ADL and QOL.…”

“…Functional decline is noted after breast cancer surgery and is more apparent after extensive surgery [5,9] Cancer diagnosis and treatment, along with older age, are important predictors of decline in both ADL and IADL [12] Quality of life Long-term arm problems post-breast cancer surgery disrupted upper body function and were the main determinants for reductions in both physical and mental performance [9,10] Following post-mastectomy reconstruction, older patients (65-77 years) showed poorer outcomes in physical function compared to younger patients (25-64 years), but demonstrated better social functioning and mental health outcomes [11] Pre-existing factors influencing FS outcomes Pre-existing patient factors such as advanced age, multiple comorbidities, obesity, lower educational attainment and smoking are possible predictors of subsequent functional decline [6] Higher stage breast cancer (p = 0.02) and weakness at time of diagnosis (p = 0.04) were significantly associated with FS decline [5] Pre-operative declines in ADL and cognitive impairment prior to surgery were significantly linked to deteriorating functional trajectories at 1 year in breast cancer patients who underwent a lumpectomy, mastectomy and ALND [9] Examples of UK-based prospective studies…”

“…These include advanced age, multiple comorbidities, obesity, lower educational attainment and smoking [ 6 , 7 ]. Singh et al [ 5 ] describe functional decline as an increase of at least one point on the Eastern Cooperative Oncology Group (ECOG) score within one year of breast cancer diagnosis. Their study reported that higher stage disease ( p = 0.02) and feeling of physical weakness ( p = 0.04) at time of diagnosis were significantly linked to subsequent FS decline.…”

“…Baseline level of functioning should be considered when weighing up the risks and benefits of surgery for breast cancer, as it may serve to predict poor post-operative QOL outcomes [5]. Functional status refers to an individual's physical and cognitive capability to perform their usual activities of daily living (ADL), allowing for the maintenance of personal health and well-being [5][6][7][8][9]; however, this definition is quite broad, and actual domains of FS can vary between users. Commonly considered domains include physical and psychological functioning, cognition, social activity and independence with ADLs [6,9].…”