Is lack of surgery for older breast cancer patients in the UK explained by patient choice or poor health? A prospective cohort study

Abstract

Background:Older women have lower breast cancer surgery rates than younger women. UK policy states that differences in cancer treatment by age can only be justified by patient choice or poor health.Methods:We investigate whether lack of surgery for older patients is explained by patient choice/poor health in a prospective cohort study of 800 women aged ⩾70 years diagnosed with operable (stage 1–3a) breast cancer at 22 English breast cancer units in 2010–2013. Data collection: interviews and case note review. Outcome measure: surgery for operable (stage 1–3a) breast cancer <90 days of diagnosis. Logistic regression adjusts for age, health measures, tumour characteristics, socio-demographics and patient's/surgeon's perceived responsibility for treatment decisions.Results:In the univariable analyses, increasing age predicts not undergoing surgery from the age of 75 years, compared with 70–74-year-olds. Adjusting for health measures and choice, only women aged ⩾85 years have reduced odds of surgery (OR 0.18, 95% CI: 0.07–0.44). Each point increase in Activities of Daily Living score (worsening functional status) reduced the odds of surgery by over a fifth (OR 0.23, 95% CI: 0.15–0.35). Patient's role in the treatment decisions made no difference to whether they received surgery or not; those who were active/collaborative were as likely to get surgery as those who were passive, that is, left the decision up to the surgeon.Conclusion:Lower surgery rates, among older women with breast cancer, are unlikely to be due to patients actively opting out of having this treatment. However, poorer health explains the difference in surgery between 75–84-year-olds and younger women. Lack of surgery for women aged ⩾85 years persists even when health and patient choice are adjusted for.

6. Case mix does not fully explain variation in rates of non-surgical treatment of older women with operable breast cancer

“…The analysis demonstrates that increasing age at diagnosis is associated with a reduced likelihood of receiving surgical treatment which is consistent with other similar studies (5,15,(23)(24)(25)(26) . Deprivation level was also associated with treatment type, with the most deprived group being less likely to undergo surgical management, a finding also described by Lavelle and colleagues in their prospective cohort of 800 women (26) .…”

“…Deprivation level was also associated with treatment type, with the most deprived group being less likely to undergo surgical management, a finding also described by Lavelle and colleagues in their prospective cohort of 800 women (26) . This may be due to the fact that affluence is associated with lower levels of comorbidity and smoking, and greater longevity and education (27) , thereby promoting better health and discussion of treatment options.…”

Healthcare professionals' preferences for surgery or primary endocrine therapy to treat older women with operable breast cancer

“…Several studies have explored the issue of increasing age ei g asso iated ith u de t eat e t of older women with operable breast cancer [5,[23][24][25]. Our results show that whilst HCPs consider age one of the least important factors in determining which treatment options to offer, it remains important and several interview participants admitted to using age-specific cut-offs to determine who should be offered PET.…”

“…However, a recent study by Lavelle and colleagues [23] found that lower rates of surgical treatment are unlikely to be due to patient choice and these results suggest that UK HCPs agree with this, believing that patients would not choose non-operative management if given the option. Hamaker and colleagues [15] suggested that variation in treatment may reflect underlying clinician preference influencing communication of treatment options.…”

The Information and decision support needs of older women (>75 yrs) facing treatment choices for breast cancer: A qualitative study

“…It is possible that their view of the decision making process represents the lack of an imposed treatment by the doctor but may still reflect the preference of the doctors or other HCP [31]. The impact of patients' choice on surgical rates in older women was investigated by Lavelle and colleagues [32] who conclude that actively opting out of surgery is unlikely to be the reason fewer older women undergo surgery. This study found older women wish to be active decision makers with women frequently reporting making an instant decision about their treatment choice either before a confirmed diagnosis or immediately after.…”