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Best Breast-Cancer Care Eludes Older Women

Research highlights need to individualize treatment,,,,

SUNDAY, Oct. 21 (HealthDay News) -- As women live longer lives, the number of breast cancer cases among older patients is rising, too.

Yet many older women are being under-diagnosed and under-treated for the disease, studies show. Often, age -- rather than health status -- is the deciding factor in determining how to care for the 80-and-older set.

"I think that the biggest problem to this point has been physicians' and patients' attitudes toward treatments," said Dr. David A. Litvak, a general surgeon and surgical oncologist for the Permanente Medical Group in Southern California.

Patients, on one hand, often have misconceptions about what the treatment involves. "They think it's going to be too disruptive to their daily lives," Litvak said. On the other hand, a lot of physicians have biases about treating anyone over 80, he added. Their thinking is, "How much time could they possibly have left?" As a result, many doctors assume a "leave-them-alone sort of attitude," he said.

Litvak led a study examining the medical records of 354 women, 70 and older, who were diagnosed with breast cancer at a community hospital in Michigan between 1992 and 2002. The study was published recently in the Archives of Surgery.

In all, 46 percent of the women had breast cancer that doctors could detect during a physical examination. Even though 72 percent of the women had mammograms, those tests were given mainly to verify the physical exams.

Seventy percent of the women were diagnosed when their cancer was in the early stages. But 36 of the women overall, and 56 percent of those 80 and older, were never closely evaluated to see whether the cancer had spread to their lymph nodes.

The study also revealed lapses in treatment. About half of the women had breast-conserving surgery, but fewer than expected received chemotherapy, radiation and hormonal therapy after surgery, and the rates of treatment were lowest among the oldest women.

The findings add to a growing body of medical literature examining the under-treatment of older breast cancer patients.

Dr. Rebecca Silliman, a professor of medicine and public health at Boston University and chief of the geriatric section at Boston Medical Center, noted that she and others have been reporting on this gap in care for many years. As a co-author of a recent article in the journal Cancer, she and her colleagues have even linked under-treatment to a higher risk of breast cancer recurrence in older women.

"What is really needed is better evidence for treatment efficacy in this age group, plus more accurate strategies for identifying those at risk of bad outcomes and matching treatment intensity to risk," she said. "This isn't being done as well as we would hope."

Dr. Arti Hurria, director of the aging and cancer research program at City of Hope in Duarte, Calif., is leading an effort to develop a geriatric assessment tool to improve the ability to predict how an older breast cancer patient will tolerate certain treatments and what the benefits of treatment will be.

"We've developed a geriatric assessment that's feasible to do within daily practice, and now we're looking to see how does the assessment predict how an individual will do if they receive a certain treatment, or if they don't," she said.

The tool is simple enough that most patients can provide the information themselves and complete the survey in less than 30 minutes, Hurria said. It asks about a patient's activity level, medical problems, social support, nutritional status, and psychological state, among other things.

The assessment seeks to gather information about a woman's life expectancy, tolerance to treatment and access to support systems that may be necessary to get through therapy, Hurria said.

For example, she explained, "If they don't have social support, can we get a visiting nurse in? If they are feeling depressed and anxious, should we be getting some physiological support as part of the treatment plan?"

Litvak supports geriatric assessments as a way to get past age discrimination. "We should be changing our way of treating older patients and not have absolute cutoffs for age," he said.

More information

Read the American Geriatrics Society's position statement on breast cancer screening for older women.

SOURCES: David A. Litvak, M.D., general surgeon and surgical oncologist, Permanente Medical Group, Southern Calif.; Rebecca A. Silliman, M.D., Ph.D., professor of medicine and public health, schools of medicine and public health, Boston University, and chief of the geriatrics section, Boston Medical Center; Arti Hurria, M.D., director, aging and cancer research program, division of medical oncology and therapeutics research, and assistant professor, division of population sciences, City of Hope, Duarte, Calif.; October 2006, Archives of Surgery

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