A study led by Professor Christos Markopoulos from Athens University Medical School in Athens, Greece presented at the 2011 European Multidisciplinary Cancer Congress, shows that women diagnosed with breast cancer late in life have a higher risk of mortality from the disease compared with younger patients, assuming they survive other age-related conditions.

The results indicate shortcomings in patient care for elderly women along with differences in the progress of the disease.

Researchers used the population of the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial for their study to investigate competing causes of death in post-menopausal women with early breast cancer. They were able to use this data, because after five years, the trial had found no difference in outcomes between the two treatments it was comparing.

The study involved a total of 9,766 patients who were categorized according to their age at diagnosis, separating those below 65 years of age, those between 65 and 75, and those above 75. All patients were diagnosed with hormone receptor positive tumors, with 50% of patients having node negative disease, 68% receiving radiotherapy, and 36% undergoing chemotherapy.

Participants either received exemestane for five years or tamoxifen for 2.5 years followed by exemestane for 2.5 years.

The analysis of the participants progress over the 5.1-year trial period revealed, that even though the mortality risk due to causes other than breast cancer was significantly higher in elderly patients, the risk of dying of breast cancer also increased with age.

The researchers applied a statistical method that includes the risk of competing causes of death in the elderly population and discovered that the risk of dying from breast cancer was definitely greater for those who were diagnosed later in age.

Prof Markopoulos, Chairman of the Hellenic Society of Breast Surgeons, believes that the higher absolute death rate amongst elderly women with breast cancer suggests they are not receiving standard treatment.

He explains:

“Our findings show that elderly breast cancer patients are more likely to die from something else other than from breast cancer – for instance, age specific co-morbidities such as heart attack. However, for those not suffering from other conditions or those who have survived other conditions, deaths from breast cancer are higher compared to younger patients with the same tumor characteristics. This probably means that old women with breast cancer are being under-treated as doctors think they will die from something else.”

According to Prof Markopoulos other various factors that can cause breast cancer mortality with increasing age, such as an age specific decrease in the function of the immune system on tumor progression could potentially influence the results but cannot be easily assessed. Markopoulos continues:

“However, we observed that radiotherapy was administered less frequently and administration of chemotherapy sharply decreased with increasing age. Thus, it is most likely that under-treatment of the elderly may explain the worse age-specific breast cancer outcome found in our study. Underlying this situation is a false perception that the outlook for older women with breast cancer is relatively good. This false impression is most likely due to deaths from other age-related conditions.

Several other studies have shown that elderly breast cancer patients have lower odds of receiving standard care, including deviations from guidelines for surgery, radiotherapy and chemotherapy. More work should be done to clarify the picture in the elderly population, as patients of this age group are usually excluded from major clinical trials.”

According to ECCO president, Professor Michael Baumann:

“Elderly patients have often been considered as being not fit for state-of-the-art cancer care. A host of recent studies have shown that it is not age per se, but rather the status of health that are important parameters for predicting how well an individual may tolerate treatments. All over Europe we see an increase in numbers of elderly patients and we more often see elderly patients who are fit and very good candidates for standard cancer treatments. Educational efforts, but also detailed research on predictors and supportive measures, are key to make sure that all cancer patients, irrespective of age, receive evidence based, best individual treatment approaches.”

Dr Etienne Brain from Hôpital René Huguenin of the Institut Curie, in France, who was not involved in the study, stressed in a comment that evaluating competing risks remained a major issue in older cancer patients, although it could yield opposite conclusions according to tumor type.

He said:

“It relies mostly on the assessment of comorbidities and functional status, two items that the Société Internationale d’Oncologie Gériatrique (SIOG) has been strongly advocating to consider for almost ten years when taking decisions about treatment for elderly cancer patients, and which might help to estimate individual life expectancy. Although this study confirms that causes not related to breast cancer are the main reasons for death, it also suggests the likelihood that the diverse nature of the hormone-positive disease plays a role too. We need to improve the breast cancer prognostic classification in the elderly, developing specific tools or implementing those developed for younger patients, in order not to deprive those who might derive a real benefit from additional treatment including chemotherapy.”

Dr James Bellini is a leading futures analyst and broadcaster who will give the keynote lecture at the opening ceremony for the 2011 European Multidisciplinary Cancer Congress on Friday evening. He is going to urge policymakers to prepare for demographic challenges of the type pointed out by Prof Markopoulos’s study.

His lecture includes the statement that:

“An ageing Europe with falling populations and major financial problems will pose a growing challenge for healthcare policies. Not only will conditions like cancer and diabetes rise sharply, but Europe will face an enormous and growing need for care – both short and long term. If the future care challenge is not to become a crisis we need a new kind of ‘capitalism’ built around purpose and not simply around economic gain. Human communities must be at the heart of this endeavor.”

Written by Petra Rattue