November 19, 2011

USA: Breast cancer advances miss the elderly

HOUSTON, Texas / The Houston Chronicle / News / November 19, 2011

Study finds drop-off by age despite overall improvements

By Todd Ackerman, Houston Chronicle

Dorothy Borel, 78, of Houston, says her fight against stage 3 breast cancer was "the hardest thing I've ever been through."
Photo: TODD SPOTH / Todd Spoth

Breast cancer care has improved dramatically in the past quarter-century, but a new Houston study suggests elderly women are barely benefiting from the advances.

Breast cancer patients 75 and older went from being the age group most likely to survive 10 years in 1980 to the least likely since the mid-1990s, according to the University of Texas M.D. Anderson Cancer Center study. The drop-off occurred even though tumors in older pa-tients tend to be the least aggressive.

"These numbers show differences in the outcomes of older women with breast cancer that certainly surprised me," said Dr. Benjamin Smith, an M.D. Anderson professor of radiation oncology and the study's lead author. "We found significant improvement in all other age groups over time, but in older women the improvement was minimal."

Smith said the graying of the population makes it more important for oncologists to develop better breast cancer strategies for elderly patients.

Women over 75 account for nearly 40,000 of the roughly 230,000 cases of breast cancer diagnosed every year. A woman's risk generally increases with age.

The study, published last week in the Journal of Clinical Oncology, didn't examine the cause of older women's lower survival rates.

But Smith hypothesized that reasons could include lower mammography rates resulting in later-stage diagnoses; chemotherapy regimens often too toxic to be tolerated; and limited knowledge of treatment options because older women are underrepresented in clinical trials.

Older women are the second group shown not to benefit from recent advances in breast cancer care. In 2007, an M.D. Anderson study found black women aren't faring any better now than two decades ago.

The new study confirmed that, finding black breast cancer patients' absolute death rate in 2006 was 38 percent higher than whites'.

Screening issues

One geriatric expert called the overall decrease in breast cancer deaths "an amazing success story," but acknowledged the smaller improvements in older women show "there is more work to be done."

"I agree that older women are less likely to get treatments generally considered optimal," said Dr. James Goodwin, director of the Sealy Center on Aging at the UT Medical Branch at Galveston. "We need to educate both cancer specialists and older women with breast cancer about the treatment choices and their implications."

Smith's team analyzed U.S. government data from more than 200,000 women ages 20 and older diagnosed from 1980 to 1997, looking at the rate of breast cancer death in the general population and the risk of breast cancer death in newly diagnosed patients. They compared the changes over time.

In 1980, the risk of death within 10 years of diagnosis was 24 percent among patients 75 and older; 28 percent among patients 65 to 74; and 32 percent among patients 55 to 64. In 1997, the risk was 17.4 percent among patients 75 and older; 15.4 percent among patients 65 to 74; and 16.6 percent among patients 55 to 64.

Between 1990 and 2007, the largest decrease in death rates was in women 20 to 49 - 2.4 percent per year. The smallest was in women 75 and older - 1.1 percent per year.

Surveys support the theory that less screening affects older women. About 50 percent of women over 75 get regular mammograms, compared to 80 to 90 percent of women under 65.

However, Harvard professor Mara Schonberg warned against just recommending more screening to solve the problem. A researcher on breast cancer prevention and treatment, she stressed the importance of life expectancy and expected quality of life in such decisions.

Tolerating treatments

Among those who opted for mammography and treatment was Dorothy Borel, a 78-year-old Houston woman, who says she's doing great after undergoing chemotherapy, a mastectomy and radiation therapy for stage 3 breast cancer. But she called it "the hardest thing I've ever been through."

"I was going to do whatever I need to do to keep living," said Borel, who previously had kidney cancer, open-heart surgery and thyroid disease. "But I can't begin to tell you how hard it was. I consider myself a very independent person, but I couldn't have done it without all the help I had."

Smith noted that some elderly people opt not to have chemotherapy because it can be so harsh and that some cannot undergo it because it's too toxic given other health problems.

The benefits of chemotherapy in older people have been controversial because of a lack of evidence, he said, but recent data show the therapy can make a difference.

Smith said much more research must be done to predict who can tolerate treatments and to develop better ones.

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