IS SURGICAL-MANAGEMENT COMPROMISED IN ELDERLY PATIENTS WITH BREAST-CANCER

Objective The suggestion that breast cancer management is compromised in elderly patients had prompted our review of the results of policies regarding screening and early detection of breast cancer and the adeq uacy of primary treatment in older women (greater than or equal to 65 years of age) compared to younger women (40 to 64 years of age). Summa ry Background Data Although breast cancer in elderly patients is consi dered biologically less aggressive than similar staged cancer in young er counterparts, outcome still is a matter of stage and adequate treat ment of primary cancer For many reasons, physicians appear reluctant t o treat elderly patients according to the same standards used for youn ger patients. There is even government-mandated alterations in early d etection programs. Thus, since 1993, Medicare has mandated screening m ammography on a biennial basis for women older than 65 years of age co mpared to the current accepted standard of yearly mammograms for women order than 50 years of age. Using State Health Department and tumor r egistry data, the authors reviewed screening practice and management o f elderly patients with primary breast cancer to determine the effects of age on screening, detection policies (as reflected in stage at dia gnosis), treatment strategies, and outcome. Methods Data were analyzed from 5962 patients with breast cancer recorded in the state-wide Tumo r Registry of the Hospital Association of Rhode Island between 1987 an d 1995. The focus of the data collection was nine institutions with es tablished tumor registries using AJCC classified tumor data. Additiona l data were provided by the State Health Department on screening mammo graphy practice in 2536 women during the years 1987, 1989, and 1995. R esults The frequency of mammographic screening for all averaged 40% in 1987, 52% in 1987, and 63%. in 1995. In the 65-year-old and older pat ients, the frequency of screening was 34% in 1987, 45% in 1989, and 48 % in 1995, whereas in the 40- to 49-year-old age I group, the frequenc y of mammography was 47% in 1987, 61% in 1989, and 74% in 1995 (p < 0. 001). There was a lower detection rate of preinvasive cancer in the 65 -year-old and older patients, 8.8% versus 13.7% in patients within the 40- to 64-year-o1d age group (p < 0.001). There was a higher percenta ge of treatment by limited surgery among elderly patients with highly curable Stage IA and IB cancer with 26.6% having lumpectomy alone Vers us 9.4% in the younger patients. Five-year survival in that group was significantly worse (63%) than in patients treated by mastectomy (80%) or lumpectomy with axillary dissection and radiation (95%, p < 0.001) . A similar effect was seen in patients with Stage II cancer. Conclusi ons Breast cancer management appears compromised in elderly patients ( older than 65 years of age). Frequency of mammography screening is sig nificantly less in elderly women older than 65 years of age. Early det ection of preinvasive (curative cancers) is significantly less than in younger patients. The recent requirement by Medicare of mammography e very other year may further reduce the opportunity to detect potential ly curable cancers. Approximately 20% of patients had inferior treatme nt of favorable stage early primary cancer with worsened survival. Det ection and treatment strategy changes are needed to remedy these defic iencies.