Feb. 20, 2001 -- Whether or not a woman wins the battle against breast cancer depends on many things. Researchers have now found that, at least for a woman after menopause, age and the presence of other diseases may affect her chances for survival.
Breast cancer is the second leading cause of cancer deaths among women, and it is estimated that there will be nearly 200,000 new cases in 2001. While breast cancer occurs in all age groups, the hardest hit are postmenopausal women. More than three-quarters of all deaths from this disease occur in women over the age of 55, and as age goes up, the chances of survival decrease.
According to a study published in the Feb. 21 issue of the Journal of the American Medical Association, not only do older women have a higher death rate, but age and the presence of other diseases may influence both treatment decisions and overall assessment of the cancer.
Treating an older population needs to be more individualized, says study author Jerome W. Yates, MD. Factors involved in treatment may include both physical and, in some cases, social factors, which will help the physician determine the best method of treatment, he says. Yates is a senior vice president at Roswell Park Cancer Institute in Buffalo, N.Y.
The researchers looked at records of 1,800 postmenopausal women with breast cancer. Nearly three-quarters of them had been diagnosed with early stage cancer.
The National Institutes of Health (NIH) has a set of guidelines known as the NIH Consensus Statement for Treatment of Early Breast Cancer, which doctors use when deciding on therapy for their patients. While almost all of the women in the study had received treatment in accordance with these guidelines, therapy given to the older patients had been less consistent with the NIH consensus.
A procedure called axillary lymph node dissection is a common surgery used to determine the extent of disease in patients with early stage breast cancer. This involves removing underarm lymph nodes that drain fluids from the breast. Fewer axillary lymph node dissections were performed on women 70 and older.
And when the procedure was performed in this age group, the patients tended to receive more extensive surgery than younger women. Older women had a greater chance of having a modified radical rather than the less disfiguring partial mastectomy.
However, the authors do not specifically say that older patients were denied treatment because of their age, Christopher Benz, MD, tells WebMD. "What the article does not say is that patients who are over the age of 55 are being treated inappropriately," he says, "And that's a conclusion that some would read into this." Benz, who was not involved in the study, is a professor of medicine at the University of California, San Francisco, and a breast cancer specialist.
For example, Benz points out that the study doesn't tell us if the women were also receiving the drug tamoxifen, a common treatment for patients who have the type of breast cancer that responds to it. This cancer is very common in women over the age of 50, says Benz, and this type of therapy is often given regardless of what stage the cancer is in.
"So if you're going to treat someone with the same type of treatment regardless of the staging, do you have to take out their lymph nodes?" asks Benz, since the procedure itself can often produce complications.
"It is quite possible that many of them would have been put on tamoxifen, and the decision not to remove lymph nodes was based on that, rather than their age," he says.
Benz also adds that the decision to have a mastectomy rather than just removing the tumor may have also had to do with their other health problems and patient preference.
"When a partial mastectomy or lumpectomy is done," he explains, "the patient is generally treated with daily radiation therapy for a six-week period."
Older people may have problems getting to the hospital to have their daily radiation therapy. And with a mastectomy, they have their surgery and are done with it, he says, and cosmetic results may be less of a concern. "So the higher incidence of modified radical mastectomy in this population might be a combination of the patient's and doctor's choice -- of what will work better for the patient," he says.
Unfortunately, the study was not designed to be able to tell why patients did or did not get certain treatments, says Yates. "We don't know from this data what circumstances determined the treatment," he says.
But he agrees with Benz that it was probably a combination of many factors, including patient preference.
The older the women were, the more likely they were to have another medical condition in addition to their breast cancer. The presence of illnesses such as kidney disease, liver disease, and stroke lowered their chances of surviving their breast cancer. In fact, a number of the women died from causes other than breast cancer. It appeared that the older the women were, the more likely they were to die from an illness such as heart disease, rather than their breast cancer.
"The real message here is that we have all of these other competing problems, and we have to have some sort of objective way -- something other than age alone -- to be able to factor in for medical decision making in a 70-year-old," says Benz.
"It's important to find a doctor who has had experience treating patients with breast cancer," says Yates, "and who can discuss the different treatment options and what the advantages and disadvantages may be. The most important thing is that a woman sees someone who is prepared to sit down and discuss the options."