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Journal of Clinical Oncology, Vol 23, No 21 (July 20), 2005: pp. 4800-4801 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.01.4241
Undertreatment of Breast Cancer in Elderly Women: Contribution of a Cancer RegistryHematology/Oncology Division, General Hospital of Annemasse, Annemasse, France To the Editor: I read with interest the article by Bouchardy et al in the October 1, 2003, issue.1 The authors reviewed 407 breast cancer patients aged at least 80 years, recorded at the Geneva Cancer Registry between 1989 and 1999, pointing to undertreatment in this population. For example, 12% of women received no treatment, 32% received tamoxifen only, and 7% were treated by breast-conserving surgery (BCS) only. Overall, only 2% received chemotherapy, and 14% received radiotherapy. In total, about half of the patients did not receive standard treatment. Compared with the nontreated group, the adjusted hazard ratio of breast cancer mortality was 0.4 (95% CI, 0.2 to 0.7) for tamoxifen, 0.4 (95% CI, 0.1 to 1.4) for BCS alone, 0.2 (95% CI, 0.1 to 0.7) for mastectomy, and 0.1 (95% CI, 0.03 to 0.4) for BCS plus adjuvant treatment. The first point is the long period of recording, which may cause heterogeneity. Although tendencies in terms of prognostic influence of undertreatment are suggested, many results do not reach statistical significance given the limited size of the subgroups. Above all, despite interesting results, this work suffers from imprecision regarding certain classical questions. Because poor general status was present in only 17% of the patients who were not operated on, misconceptions might be hypothesized, such as undervalued life expectancy, reputed indolent course of the tumor, or sufficient efficacy of monotherapy by tamoxifen. Moreover, confusing factors may have interfered since adequate treatments comprising surgery and adjuvant therapy also had a favorable impact on mortality from other causes. Patients older than 85 years or presenting with acute comordid conditions underwent surgery less frequently. BCS was more frequently realized in the private health care sector. Nevertheless, this study does not help in evaluating the relative contributions of misconceptions, center effect, or patients' selection. Like most studies, diagnostic circumstances have not been detailed. The relatively small proportion of 22% of stage I disease evokes insufficient participation of elderly women in mammographic screenings. In a study of 5,643 patients aged 75 years or older from 2,000 hospitals throughout the United States and diagnosed in 1990, self-examination, physician examination, and nipple discharge led to the diagnosis in 37%, 34%, and less than 3% of cases, respectively.2 In Québec in the early 1990s, discovery of the tumor was incidental or symptomatic in 12.5% and 83% of cases, respectively.3 On the other hand, uncontrolled comorbid conditions might have favored diagnosis in a subset of patients with poor prognosis. Data regarding treatment choice remain limited. The major role of the family circle has rarely been evaluated until now, and this work does not enlighten the question. Refusal of all or part of the treatment by 14% of the patients or their families would have deserved more precision as much as many alterations of the treatment such as delays, shortening, or dose reductions might be induced in another fraction of the patients. In an observational study, in patients older than 79 years with stage I or II breast cancer, concern with family preferences was declared by 30% of the patients, even though patients with either severe comorbidities or moderate cognitive impairment had been excluded.4 In this line, many baseline characteristics are imprecise, such as acute, subacute, or chronic comorbidities, as well as poor, moderate, or good general health status. The number of comorbidities may be more relevant in terms of life expectancy since patients with three or more comorbid illnesses among diabetes; other neoplasia; or diseases of the lung, liver, or cardiovascular system have a 20-fold higher mortality rate from causes other than breast cancer.5 Nevertheless, some other data support the hypothesis of inadequate treatment. Thus, strangely, only 60% of the patients received tamoxifen while statistically, 80% to 90% of these patients have estrogen positive tumors, and in the early 1990s, tamoxifen was given quite systematically to elderly patients, independent of their estrogen receptor status. Conversely, monotherapy by tamoxifen instead of surgery may have been influenced by some randomized studies comparing the two treatments and showing equivalent disease-free survival despite high relapse rates in both arms.6 Underuse of adjuvant radiotherapy despite acceptable physical tolerance is also a focus of debate that is not highlighted in the article. Obviously, the distances from radiotherapy facilities may not be invoked given the surface of the area of Geneva (282 km2). Although the authors separate surgery into either mastectomy or BCS, the reality is more complex in an elderly population. The surgical procedure may be varied, as illustrated by the designations in the literature, including total mastectomy, wedge mastectomy, partial mastectomy, segmental mastectomy, quadrantectomy, excision biopsy, wide local excision, lumpectomy, or even toilet mastectomy.6-8 Thus, conserving procedures that consist of partial mastectomy may not require additional radiotherapy. Because cosmetic result might be seen as a minor tool, conservative surgery may be different than that of younger patients. The mortality of surgery seems extremely low in elderly patients, from less than 1.7% during the 1980s, to 0% during the 1990s.8 No information about surgery under local anesthesia has been given, while its accuracy has been demonstrated by certain centers.9 Interestingly, when performed, surgery was of quality, as suggested by the low frequency (6.5%) of positive margins and the high mean number of 14 removed lymph nodes. The therapeutic decision of surgery alone, but also disparity in access to medical care, might be hypothesized. In conclusion, this work illustrates the necessary efforts in terms of education of all the protagonists, even in developed countries, but also demonstrates the necessity of detailed and updated registries. Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. REFERENCES
1. Bouchardy C, Rapiti E, Fioretta G, et al: Undertreatment strongly decreases prognosis of breast cancer in elderly women. J Clin Oncol 21:3580-3587, 2003 2. Busch E, Kemeny M, Fremgen A, Osteen RT, Winchester DP, Clive RE: Patterns of breast cancer care in the elderly. Cancer 78:101-111, 1996[CrossRef][Medline] 3. Hébert-Croteau N, Brisson J, Latreille J, et al: Compliance with consensus recommendations for the treatment of early stage breast carcinoma in elderly women. Cancer 85:1104-1113, 1999[CrossRef][Medline] 4. Mandelblatt JS, Hadley J, Kerner JF, et al: Patterns of breast carcinoma treatment in older women. Cancer 89:561-573, 2000[CrossRef][Medline] 5. Balducci L, Yates J: General guidelines for the management of older patients with cancer. Oncology 14:221-227, 2000[Medline] 6. Gazet JC, Ford HT, Bland JM, et al: Prospective randomised trial of tamoxifen versus surgery in elderly patients with breast cancer. Lancet 1:679-681, 1988 7. Kantorowitz DA, Poulter CA, Sischy B, et al: Treatment of breast cancer among elderly women with segmental mastectomy or segmental mastectomy plus postoperative radiotherapy. Int J Radiat Oncol Biol Phys 15:263-270, 1988[CrossRef][Medline] 8. Benhaim DI, Lopchinsky R, Tartter PI: Lumpectomy with tamoxifen as primary treatment for elderly women with early-stage breast cancer. Am J Surg 180:162-166, 2000[CrossRef][Medline] 9. Martelli G, DePalo G, Rossi N, et al: Long-term follow-up of elderly patients with operable breast cancer treated with surgery without axillary dissection plus adjuvant tamoxifen. Br J Cancer 72:1251-1255, 1995[Medline]
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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