Breast cancer adjuvant chemotherapy decisions in older women: the role of patient preference and interactions with physicians

Abstract

Purpose: Breast cancer chemotherapy decisions in patients > or = 65 years old (older) are complex because of comorbidity, toxicity, and limited data on patient preference. We examined relationships between preferences and chemotherapy use.

Methods: Older women (n = 934) diagnosed with invasive (> or = 1 cm), nonmetastatic breast cancer from 2004 to 2008 were recruited from 53 cooperative group sites. Data were collected from patient interviews (87% complete), physician survey (93% complete), and charts. Logistic regression and multiple imputation methods were used to assess associations between chemotherapy and independent variables. Chemotherapy use was also evaluated according to the following two groups: indicated (estrogen receptor [ER] negative and/or node positive) and possibly indicated (ER positive and node negative).

Results: Mean patient age was 73 years (range, 65 to 100 years). Unadjusted chemotherapy rates were 69% in the indicated group and 16% in the possibly indicated group. Women who would choose chemotherapy for an increase in survival of < or = 12 months had 3.9 times (95% CI, 2.4 to 6.3 times; P < .001) higher odds of receiving chemotherapy than women with lower preferences, controlling for covariates. Stronger preferences were seen when chemotherapy could be indicated (odds ratio [OR] = 7.7; 95% CI, 3.8 to 16; P < .001) than when treatment might be possibly indicated (OR = 1.9; 95% CI, 1.0 to 3.8; P = .06). Higher patient rating of provider communication was also related to chemotherapy use in the possibly indicated group (OR = 1.9 per 5-point increase in communication score; 95% CI, 1.4 to 2.8; P < .001) but not in the indicated group (P = .15).

Conclusion: Older women's preferences and communication with providers are important correlates of chemotherapy use, especially when benefits are more equivocal.

Fig 1.

Sampling frame for older women with newly diagnosed breast cancer. Flow chart of patient status. Women were registered to the study. Registered women completed interviews, refused, could not be contacted, were found to be ineligible (eg, as a result of cognitive screen failures or being outside of stage criteria), or were lost for administrative reasons. (*) Among the 814 women interviewed, nine had missing data as a result of a computer failure, and four had missing information on chemotherapy status, so that 801 women are included in the final data set. Other reasons for ineligibility included having recurrent cancer or another primary cancer or being beyond 20 weeks of last definitive surgery.