Older women with breast cancer must be offered treatments that will give them the best possible outcome, a leading surgeon has said, as new data suggests women over 70 are less likely to undergo surgery, radiotherapy and chemotherapy than women aged 50 to 69.
The figures were published today by the National Audit of Breast Cancer in Older Patients (NABCOP), which is carried out by the Royal College of Surgeons and the Association of Breast Surgery. The audit evaluated the care given to women diagnosed with breast cancer between 1 January 2014 and 31 December 2016, in NHS hospitals in England and Wales.
Breast cancer is the most common female cancer in the UK. Around 45,000 new cases are diagnosed in women each year in England and Wales and about a third of these are in women aged over 70 years.
The audit found that there is variation among the proportion of women of different ages who receive surgery, radiotherapy and chemotherapy for early breast cancer. Specifically, among women aged 70+ years, 76 per cent had surgery to remove the cancer, compared with 96 per cent of women aged 50–69 years. In addition, a smaller proportion of women underwent breast conserving surgery, as opposed to mastectomy.
Surgery is the primary treatment for early breast cancer. However, other therapies may be preferable for some older women if they suffer from existing conditions, such as heart disease, or are considered too medically frail to survive surgery. A woman’s age, however, is not a good indicator of how fit they are, or how they would respond to certain treatments.
Prof Kieran Horgan, the lead surgeon on the audit, said: “This audit provides the clearest picture yet of the treatments that older women with breast cancer receive at NHS hospitals in England and Wales. It also highlights a number of differences in the type of treatments that older women undergo, compared to younger women.
“In some instances, it is not appropriate for an older women to have surgery, radiotherapy or chemotherapy. However, all women should be offered treatment that is tailored to their type of tumour, general state of health, and individual preferences.
“The results of the audit should remind every NHS hospital in England and Wales to ensure that all their patients are being offered the most effective breast cancer treatment for them, regardless of their age.”
The audit shows that for patients with early breast cancer:
- Among women who had breast conserving surgery1, 84 per cent had postoperative radiotherapy (RT) to the breast. Rates varied modestly by age: 85 per cent of women aged 50–69 years had postoperative RT, compared with 80 per cent of women aged 70+ years and 72 per cent of women aged 80-89 years. 36 per cent of women aged 90+ received postoperative radiotherapy.
- Among women who had a mastectomy, 35 per cent had postoperative radiotherapy to the chest wall. Rates decreased by age, from 41 per cent for women aged 50–59 years to 15 per cent for women aged 90+ years (37 per cent for 50–69 years vs 31 per cent for 70+ years).
The audit shows that the pattern of chemotherapy use for women diagnosed with early invasive breast cancer is broadly consistent with clinical recommendations, in particular:
- There was greater use of both adjuvant (given after surgery) and neo-adjuvant chemotherapy (given before surgery) among women with higher stage early invasive disease.
- However, rates also varied between the age groups. Use of chemotherapy was more common among women with:
- ER-negative disease2 (61 per cent for 50–69 years; 23 per cent for 70+ years).
- HER2-positive disease3 (60 per cent for 50–69 years; 28 per cent for 70+ years).
Prof David Dodwell, the oncology lead for the audit, said: “Older women often have different needs to younger patients as they may be less suitable for surgery, radiotherapy and chemotherapy. However, we still need to find out more about the reasons why some older women are not undergoing these treatments.
“Crucially, this audit will provide information to breast cancer services, which will help them to ensure care is delivered more consistently to older women across the country.”
The audit makes a number of recommendations for clinicians, NHS trusts and commissioners, which re-enforce NICE guidance. It recommends treating patients with early invasive breast cancer, irrespective of age, with surgery and appropriate systemic therapy, unless a patient also suffers from chronic conditions that preclude surgery. Among the other recommendations the audit makes are:
All NHS trusts and local health boards must ensure that:
- Chronological age alone is not a dominant factor in the decision to offer chemotherapy to women at high risk of recurrence, especially if their breast cancer is ER-negative3 (the absence of oestrogen receptors on breast cancer indicates those cancers will not benefit from anti-oestrogen therapies) or HER2-positive, in line with guidelines.
NHS trusts and local health boards must ensure that:
- Radiotherapy is considered for all women who receive breast-conserving surgery for cancer cells within the ducts of a breast (non-low risk DCIS 4) or early invasive breast cancer after breast-conserving surgery, in line with guidelines, regardless of age.
- All women at higher risk of local recurrence with early invasive breast cancer who undergo mastectomy should be considered for adjuvant (post-surgery) radiotherapy.
Commissioners (in England) and Welsh health boards should review the results for the organisations within their regions to assure themselves of the quality of care provided to their patients. They should work with NHS providers to:
- Develop strategies for addressing areas of variation.
- Ensure local providers are able to submit complete and accurate data to the national cancer registration services.
Source: Royal College of Surgeons
- Breast-conserving surgery (BCS) is a procedure to remove a discrete lump or abnormal area of tissue from the breast, without the removal of all breast tissue.
ER status – Oestrogen receptor status. Breast cancers can grow in response to the sex hormone oestrogen. Approximately 70% of invasive breast cancers are ‘ER positive’ as they have receptors for oestrogen. These receptors (often termed molecular markers) are targets for endocrine therapy. Cancers without oestrogen or progesterone receptors will not benefit from antioestrogenic treatment.
HER2 is human epidermal growth factor protein. This is a receptor that is present on normal breast cells. It is involved in the signalling and the promotion of cell growth, and may be described as HER2/neu gene as this gene is responsible for the overproduction of HER2 protein in each cell. Breast cancer cells with higher levels of HER2 receptors (HER2 positive) are more aggressive and may grow more quickly
The report distinguishes between three main groups of breast cancer:
- Ductal carcinoma in situ (DCIS), the most common type of non-invasive tumour
- Early invasive disease (defined stage 1 to 3A)
- Advanced disease (stage 3B, 3C and 4).