Stage and treatment variation with age in postmenopausal women with breast cancer: compliance with guidelines

Abstract

Breast cancer-specific mortality is static in older women despite having fallen in younger age groups, possibly due to lack of screening and differences in treatment. This study compared stage and treatment between two cohorts of postmenopausal women (55-69 vs >70 years) in a single cancer network over 6 months. A total of 378 patients were studied (>70: N=167, 55-69 years: N=210). Older women presented with more advanced disease (>70: metastatic/locally advanced 12%, 55-69 years: 3%, P<0.01). Those with operable cancer had a worse prognosis (Nottingham Prognostic Index (NPI) >70: median NPI 4.4, 55-69 years: 4.25, P<0.03). These stage differences were partially explained by higher screening rates in the younger cohort. Primary endocrine therapy was used in 42% of older patients compared with 3% in the younger group (P<0.001). Older women with cancers suitable for breast conservation were more likely to choose mastectomy (>70: 57.5% mastectomy rate vs 55-69 years: 20.6%, P<0.01). Nodal surgery was less frequent in older patients (>70: 6.7% no nodal surgery, 55-69 years: 0.5%, P<0.01) and was more likely to be inadequate (>70: 10.7% <4 nodes excised, 55-69 years: 3.4%, P<0.02). In summary, older women presented with more advanced breast cancer, than younger postmenopausal women and were treated less comprehensively.

Figure 1

Prognostic group according to age in patients treated surgically for breast cancer. Graph shows percentage of patients in both age groups who were treated with surgery, including some form of axillary surgery for those with invasive carcinoma. These data exclude those in whom axillary staging was omitted or inadequate. DCIS: ductal carcinoma in situ. Nottingham Prognostic Index is the sum of the grade (1–3), the nodal status (no nodal disease=1, up to three nodes involved=2, four or more nodes involved=3) and the size of the tumour in cm divided by 5). The higher the score, the worse the prognosis.

Figure 2

Type of surgery by age group. Graph showing the number of patients in each age group who underwent surgery as their primary treatment. The number of patients suitable for breast-conservation surgery (BCS) was determined by assessing the size of the primary cancer relative to breast size, multifocality, position of tumour relative to the nipple and suitability for adjuvant radiotherapy. The number having mastectomy includes those unsuitable for breast-conservation therapy and those who were suitable but chose mastectomy.