Omission of surgery in older women with early breast cancer has an adverse impact on breast cancer-specific survival

Ward, Sue; Richards, Paul; Morgan, Jenna; Holmes, Geoffrey R.; Broggio, John; Collins, Karen; Reed, Malcolm; Wyld, Lynda

doi:10.1002/bjs.10885

Cited by 41 publications

(45 citation statements)

References 26 publications

(35 reference statements)

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“…We looked to examine treatment patterns for early, invasive ER+ breast cancer in older patients, in order to investigate whether the effect of age persists in the type of treatment. Older age seemed to correlate with less surgical treatment, which is in turn associated with worse breast cancer specific survival [12][13][14]. In order to assess whether non-operative treatment in the context of age is affected by the diagnosis (DCIS vs stage I&II invasive cancer), pooled effects from the previous studies were meta-analysed.…”

Section: Resultsmentioning

confidence: 99%

“…At the same time, the fact that a woman N80 y with DCIS is more probable to undergo surgery than a peer with invasive breast cancer, may be seen as a paradox, but it reflects the knowledge gaps on DCIS and the lack of acceptance for PET in this setting. Unfortunately, patient age in the setting of early breast cancer has repeatedly been shown to independently affect the decision of the physicians regarding the type of treatment that should be administered, whereas it is clear that it should not, as it has been shown that treatment de-escalation on this basis is related with worse survival [13,14,81]. All these data urge for change of attitude and clear delineation that de-escalation should not be a synonym for palliation.…”

Section: Discussionmentioning

confidence: 99%

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The challenge of avoiding over- and under-treatment in older women with ductal cancer in situ: A scoping review of existing knowledge gaps and a meta-analysis of real-world practice patterns

Karakatsanis

Markopoulos

2020

Journal of Geriatric Oncology

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

The challenge of avoiding over- and under-treatment in older women with ductal cancer in situ: A scoping review of existing knowledge gaps and a meta-analysis of real-world practice patterns

Karakatsanis

Markopoulos

2020

Journal of Geriatric Oncology

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“…43 Specifically, in women with ER-positive EIBC, surgery offers survival outcomes that are superior to primary endocrine therapy. 35 However, variation in the rate of primary surgery and survival, between older and younger women with ER-positive EIBC is widely reported. 1 2 35 44 The ability to distinguish between comorbidity and frailty is clinically relevant because these factors can be optimised, and potentially reversed (in the case of frailty), to improve rates of surgery and survival in women with EIBC.…”

Section: Discussionmentioning

confidence: 99%

“…Women who received surgery for ER-positive EIBC have better survival than women who did not. 35 Thus, the relationship between survival and surgery was explored by: (1) subgroups of women who did and did not have surgery and (2) using surgery as an explanatory variable in a Cox proportional hazards model for all women. The study specifically focused on 3-year survival because recommendations by the International Society of Geriatric Oncology and European Society of Breast Cancer Specialists for older women with breast cancer state that 'primary endocrine therapy (PET) should only be offered to elderly individuals with ER-positive tumours who have a short estimated life-expectancy (<2-3 years), who are considered unfit for surgery after optimization of medical conditions…'.…”

Section: Evaluation Of the Scarf Index's Performancementioning

confidence: 99%

Construction of the secondary care administrative records frailty (SCARF) index and validation on older women with operable invasive breast cancer in England and Wales: a cohort study

et al. 2020

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ObjectivesStudies that use national datasets to evaluate the management of older women with breast cancer are often constrained by a lack of information on patient fitness. This study constructed a frailty index for use with secondary care administrative records and evaluated its ability to improve models of treatment patterns and overall survival in women with breast cancer.DesignRetrospective cohort study.ParticipantsWomen aged ≥50 years with oestrogen receptor (ER) positive early invasive breast cancer diagnosed between 2014 and 2017 in England.MethodsThe secondary care administrative records frailty (SCARF) index was based on the cumulative deficit model of frailty, using International Statistical Classification of Diseases, Injuries and Causes of Death, 10th revision codes to define a set of deficits. The index was applied to administrative records that were linked to national cancer registry datasets. The ability of the SCARF index to improve the performance of regression models to explain observed variation in the rate of surgery and overall survival was evaluated using Harrell’s c-statistic and decision curve analysis. External validation was performed on a dataset of similar women diagnosed in Wales.ResultsThe SCARF index captured 32 deficits that cover functional impairment, geriatric syndromes, problems with nutrition, cognition and mood, and medical comorbidities. In the English dataset (n=67 925), the prevalence of frailty in women aged 50–69, 70–79 and ≥80 years was 15%, 28% and 47%, respectively. Adding a frailty measure to regression models containing age, tumour characteristics and comorbidity improved their ability to: (1) discriminate between whether a woman was likely to have surgery and (2) predict overall survival. Similar results were obtained when the models were applied to the Welsh cohort (n=4 230).ConclusionThe SCARF index provides a simple and consistent method to identify frailty in population level data and could help describe differences in breast cancer treatments and outcomes.

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“…The Bridging the Age Gap in Breast Cancer research programme sought to improve treatment decisionmaking for older women (≥70 years) with breast cancer by: 1) conducting an observational cohort study assessing breast cancer outcomes of older women, 2) developing decision support interventions (DESIs) to predict treatment outcomes and support shared decision-making, 3) testing the DESIs in a cluster randomised trial.…”

Section: Introductionmentioning

confidence: 99%

Process evaluation of the Bridging the Age Gap in Breast Cancer decision support intervention cluster randomised trial.

Burton

Lifford

Wyld

et al. 2020

Preprint

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Abstract BackgroundThe Bridging the Age Gap in Breast Cancer research programme sought to improve treatment decision-making for older women with breast cancer by developing and testing, in a cluster randomised trial, two decision support interventions (DESIs). One DESI supported the decision to have either primary endocrine therapy (PET) or surgery with adjuvant therapies and the second supported the decision to have adjuvant chemotherapy after surgery or not.MethodsSixteen sites were randomly selected to take part in the process evaluation. Multiple methods of data collection were used. Medical Research Council (MRC) guidelines for the evaluation of complex interventions were used.ResultsEighty-two patients, mean age 75.5, (range 70–93) provided data for the process evaluation. Seventy-three interviews were completed with patients. Ten clinicians from six intervention sites took part in telephone interviews. Dose: Ninety-one members of staff in the intervention arm received intervention training. Reach: The online tool was accessed on 324 occasions by 27 clinicians. Reasons for non-use of the online tool were commonly that the patient had already made a decision or that there was no online access in the clinic. Of the 32 women for whom there were data available, fifteen from the intervention arm and six from the usual care arm were offered a choice of treatment. Fidelity: Clinicians used the online tool in different ways, with some using it during the consultation and others checking the online survival estimates before the consultation. Adaptation: There was evidence of adaptation when using the DESIs. A lack of infrastructure, e.g. internet access, was a barrier to the use of the online tool. The brief decision aid was rarely used. Mediators: Shared decision-making: Most patients felt able to contribute to decision-making and expressed high level of satisfaction with the process. Participants’ responses to intervention: Six patients reported the DESIs to be very useful, one somewhat useful and two moderately useful.ConclusionsClinicians were mainly supportive of the interventions and had attempted some adaptations to make the interventions applicable, but there were practical and engagement barriers that led to sub-optimal adoption in routine practice.Trial Registered11th August 2016 - Retrospectively registered, http://www.isrctn.com/(ISRCTN: 46099296)

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Omission of surgery in older women with early breast cancer has an adverse impact on breast cancer-specific survival

Cited by 41 publications

References 26 publications

The challenge of avoiding over- and under-treatment in older women with ductal cancer in situ: A scoping review of existing knowledge gaps and a meta-analysis of real-world practice patterns

The challenge of avoiding over- and under-treatment in older women with ductal cancer in situ: A scoping review of existing knowledge gaps and a meta-analysis of real-world practice patterns

Construction of the secondary care administrative records frailty (SCARF) index and validation on older women with operable invasive breast cancer in England and Wales: a cohort study

Process evaluation of the Bridging the Age Gap in Breast Cancer decision support intervention cluster randomised trial.

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