Doctors may be steering older women away from certain breast cancer treatments due to “well-meaning but misplaced beliefs” about their preferences and fitness to undergo surgery, a study suggests.
Breast cancer is the most common cancer in the UK, with about 56,000 people diagnosed and 11,500 dying from it each year. Although survival rates have almost doubled over the past 40 years, the greatest gains have been in younger patients. Since the 1970s there has been a 44% reduction in 65- to 69-year-olds, a 50% reduction in 50- to 64-year-olds and a 57% reduction in patients aged 25 to 49, versus a 27% reduction in 70- to 79-year-olds and a 6% increase for those aged 80-plus.
One potential reason for this survival gap is lower rates of surgery, chemotherapy or radiotherapy among older breast cancer patients, and a greater reliance on primary endocrine therapy (PET) using tamoxifen – a drug that blocks oestrogen receptors on cancer cells, inhibiting their growth – compared with younger patients.
“In the UK, up to 40% of older breast cancer patients are treated with PET alone, despite evidence that elective surgery in many of these patients is safe,” said Prof Malcolm Reed, an expert in breast cancer management in older women at Brighton and Sussex medical school.
Concerned that clinicians might be inadvertently steering women away from additional treatments, Reed and his colleagues asked 31 UK breast surgeons and specialist breast care nurses to complete a series of tests and questionnaires to assess their implicit biases towards older and younger women, and assumptions about breast cancer treatment in different age groups. They also interviewed clinicians to better understand the rationale behind their treatment decisions.
“We found that there are age biases amongst doctors, just like there are across the whole of society,” said Reed, whose research was published in the European Journal of Surgical Oncology.
“Some of it is unconscious, but a lot of it is based on what [clinicians] genuinely feel is best for these patients, but is not necessarily completely in line with the evidence. It is due to attitudes, which may be well-meaning but misplaced, about older people and their preferences for treatment or fitness for treatment.”
For instance, some specialists assumed that older patients were more afraid and less able to cope with information that gives a poor prognosis, or to understand treatment options.
According to data from the National Audit of Breast Cancer in Older Patients, whereas 98% of 50- to 69-year-olds with early invasive breast cancer who were considered “fit” received surgery within 12 months, just 68% of patients aged 80 or older did. For those with “mild-moderate frailty” 96% of patients aged 50 to 69 had surgery, compared with 51% of those aged 80-plus.
“For 10 or more years, the official Nice guidance has said that people should be treated the same for breast cancer, regardless of their age – unless they choose not to have an operation, or they are unfit [to undergo one],” Reed said.
“The problem is, it is rare for patients, particularly older ones, to tell their doctor what they want and don’t want when they’ve just been diagnosed with something like cancer, making them heavily reliant on advice from their medical team. The question is, are doctors aware of that influence?”
Caroline Abrahams, the charity director of Age UK, said: “This month is the 10-year anniversary of the Equality Act’s application to health services, which outlawed age discrimination in healthcare for the first time. Around then, the problem of older people being excluded from cancer treatment was well-documented. It is really worrying and depressing that, a decade on, these issues persist.”
Reed called for greater input from geriatricians to assess whether older patients are fit to undergo surgery, as well as the use of an algorithm called the Age Gap Decision Tool, which was recently developed to help doctors compare breast cancer treatments for older women.
Leena Chagla, the president-elect of the Association of Breast Surgery (ABS) and a consultant breast surgeon, stressed that the study was based on a small number of doctors and breast care nurses, and was not necessarily representative of the UK as a whole. However, she agreed there may be pockets of the country where improvement was needed, and said that efforts to raise awareness and improve education continued.
“It’s not because the doctors in these pockets don’t care – it could be due to a variety of things. But we want patients to ask questions such as ‘What are my chances with surgery?’, ‘What are my chances with this drug?’, ‘What is my risk of dying from the complication?’, because it may prompt them to [re-examine or re-explain things]. There are tools out there, such as the Age Gap Tool, which can help patients to jointly make decisions with their clinicians.”
Other reasons for lower breast cancer survival rates among older people are that they tend to be diagnosed later, with routine mammograms only offered to women up to the age of 71. Older patients also tend to be excluded from trials of new drugs, meaning evidence to support their use in this age group may be lacking.
