Effect of patient age on management decisions in breast cancer: consensus from a national consultation

The impact of age on physical functioning after treatment for breast cancer, as measured by patient-reported outcome measures: A systematic review

PURPOSE

This systematic review aims to explore the impact of age on physical functioning post-treatment for early-stage, locally advanced, or locally recurrent breast cancer, as measured by patient-reported outcome measures (PROMs), identify PROMs used and variations in physical functioning terms/labels.

METHODS

MEDLINE, EmBase, PsycINFO, CINAHL and AMED were searched, along with relevant key journals and reference lists. Risk of bias (quality) assessment was conducted using a Critical Appraisal Skills Programme checklist. Data was synthesised through tables and narrative.

RESULTS

28,207 titles were extracted from electronic databases, resulting in 44 studies with age sub-groups, and 120 without age sub-groups. Of those with findings on the impact of age, there was variability in the way findings were reported and 21 % found that age did not have a significant impact. However, 66 % of the studies found that with older age, physical functioning declined post-treatment. Comorbidities were associated with physical functioning declines. However, findings from sub-groups (breast cancer stage, treatment type and time post-treatment) lacked concordance. Twenty-eight types of PROM were used: the EORTC QLQ-C30 was most common (50.6 %), followed by the SF-36 (32.3 %). There were 145 terms/labels for physical functioning: 'physical functioning/function' was used most often (82.3 %).

CONCLUSIONS

Findings point towards an older age and comorbidities being associated with more physical functioning declines. However, it was not possible to determine if stage, treatment type and time since treatment had any influence. More consistent use of the terminology 'physical functioning/function' would aid future comparisons of study results.

Breast reconstruction in older patients: A literature review of the decision-making process

AIM

Women not undergoing breast reconstruction after mastectomy tend to be older. This review aims to aid in effective, evidence-based choices regarding breast reconstruction in an older population, appraising the influencing patient factors described in the literature and those directing the reconstructive surgeon. This may refute current misconceptions and ensure surgical decisions are made based on evidence without ageist assumptions. The review forms the basis of an evidence-based algorithm addressing each step of the decision-making process.

METHOD

A literature search was conducted using PubMed, Medline, Evidence.nhs.uk and the Cochrane database. Search terms initially were breast reconstruction, mastectomy, elderly, older, decision, reasons and rationale. A separate literature search was performed for each of the individual 'steps' in the decision-making process.

RESULTS

Overall, 44 papers were obtained. For each section of the decision-making process, titles and abstracts were screened for relevance. Only English language papers were included.

CONCLUSION

If reconstruction is oncologically plausible and co-morbidities and frailty formally assessed, older women should be actively informed about breast reconstruction, receive support and engage in 'shared decision-making'. The older patient is less likely to do research independently. Amongst other factors, body image, cancer fears, employment and carer responsibilities play a part in the decision. With adequate preoperative and frailty assessment and early involvement of the geriatrician and anaesthetist, microsurgical reconstruction is safe. Autologous reconstruction has better long-term outcomes than implant-based reconstructions in this age group, correlating with improved survival and longevity of reconstruction. Age alone should not be considered a contraindication to breast reconstruction.

Therapy preferences in melanoma treatment--willingness to pay and preference of quality versus length of life of patients, physicians and healthy controls

Background

New melanoma therapies, like e.g. ipilimumab, improve survival. However, only a small subset of patients benefits while 60% encounter side effects. Furthermore, these marginal benefits come at a very high price of €110’000 per treatment. This study examines attitudes towards melanoma therapy options of physicians, healthy individuals and patients, their willingness to pay and preference of quality versus length of life.

Methods

Based on findings from a focus group questionnaires were developed and pretested. After obtaining ethical approval and informed consent surveys were conducted in a total of 90 participants (n = 30 for each group). Statistical analyses were conducted using R.

Findings

Attitudes vastly differed between healthy participants, physicians and melanoma patients. Whereas melanoma patients show a high willingness to endure side effects despite very small survival gains (down to 1 extra week) or even only hope with no survival benefit, healthy controls are more critical, while physicians are the most therapy adverse. Consequently, if given €100’000 and the free decision what to spend the money on the willingness to pay for therapy was much higher in the patient group (68%) compared to 28% of healthy controls and only 43% of the physicians, respectively. When lowering the amount of cash that could be received instead of ipilimumab to €50’000 or €10’000 to test price sensitivity 69% (+1%) and 76% (+8%) of melanoma patients, respectively, preferred ipilimumab over cash. When judging on societal spending even melanoma patients opted for spending on ipilimumab in only 21%.

Conclusion

The judgment about the benefits of new treatment options largely differs between groups, physicians being the most critical against therapy. Price elasticity was low.

Non-small cell lung cancer therapy: safety and efficacy in the elderly

BACKGROUND

Our objective was to evaluate and review the current literature on the treatment of non-small cell lung cancer (NSCLC) in the elderly.

METHODS

We selected recent peer-reviewed articles addressing ageing, cancer treatment in the elderly, and lung cancer treatment in the elderly. We defined elderly as over the age of 70.

RESULTS

The population is ageing dramatically throughout most of the world. Given that situation, clinicians are seeing and being asked to treat more elderly patients that have NSCLC. Elderly patients are less likely to participate or be allowed to participate in prospective or retrospective studies of treatments for NSCLC. Elderly patients are also less likely to be staged appropriately for their advanced tumors, and are less likely to be referred for surgery or adjuvant therapy after surgery. When treatment is tailored to patient comorbidities but not to age, the data support survival and outcomes comparable to those of younger patients.

CONCLUSIONS

Data are limited on the treatment of elderly patients with NSCLC. No data exist to support limiting recommendations for treatment based on age alone. Treatments should be determined on an individual basis.

Impact of age on the cancer-specific survival of patients with localized renal cell carcinoma: martingale residual and competing risks analysis

Background

Age at diagnosis has been shown to be an independent prognostic factor of localized renal cell carcinoma (RCC) in several studies. We used contemporary statistical methods to reevaluate the effect of age on the cancer-specific survival (CSS) of localized RCC.

Methods and Findings

1,147 patients with localized RCC who underwent radical nephrectomy between 1993 and 2009 were identified in our four institutions. The association between age and CSS was estimated, and the potential threshold was identified by a univariate Cox model and by martingale residual analysis. Competing risks regression was used to identify the independent impact of age on CSS. The median age was 52 years (range, 19–84 years). The median follow-up was 61 months (range, 6–144 months) for survivors. A steep increasing smoothed martingale residual plot indicated an adverse prognostic effect of age on CSS. The age cut-off of 45 years was most predictive of CSS on univariate Cox analysis and martingale residual analysis (p = 0.005). Age ≤45 years was independently associated with a higher CSS rate in the multivariate Cox regression model (HR = 1.59, 95% CI = 1.05–2.40, p = 0.027) as well as in competing risks regression (HR = 3.60, 95% CI = 1.93–6.71, p = 0.001).

Conclusions

Increasing age was associated with a higher incidence of cancer-specific mortality of localized RCC. Age dichotomized at 45 years would maximize the predictive value of age on CSS, and independently predict the CSS of patients with localized RCC.