Cancer Treatment in the Oldest-Old: Evidence for an Age Bias Against the Use of Tamoxifen
Cancer Treatment in the Oldest-Old: Evidence for an Age Bias Against the Use of Tamoxifen
Abstract & Commentary
Synopsis: Breast cancer occurs with increasing frequency throughout the lifespan, and there is mounting evidence that when it occurs in the oldest-old (those older than 85 years of age), less cancer-directed treatment is provided. In this report, tamoxifen use was compared in patients 80-84 years and 85-92 years. The results indicate that there was a greater than 25% drop-off in tamoxifen prescriptions between the 2 groups. Doctors tend to prescribe less tamoxifen to the oldest-old and also to those with significant comorbidities (in both age groups) or those unmarried and without living children. With increasing life expectancy currently being observed in these age groups, this study raises the possibility that oncologists may be missing the opportunity to help the oldest breast cancer patients achieve therapeutic benefit from tamoxifen.
Source: Blackman SB, et al. Cancer. 2002;95:2465-2472.Adjuvant tamoxifen is currently recommended for estrogen receptor-positive breast cancer, regardless of patient age. Although there is quite substantial evidence that older patients are less likely to be treated with cytotoxic chemotherapy, little data exist with regard to tamoxifen treatment, particularly in those patients older than 80 years of age. Blackman and colleagues studied 92 patients diagnosed at 4 US sites with primary, early stage breast cancer by phone interview (on 2 occasions) and medical record review. They compared the proportion of patients treated with tamoxifen in the 80-84 age group with those aged 85-92 years.
Before adjustment for comorbidities, patients aged 85-92 years were 28% less likely to receive a tamoxifen prescription compared with patients 80-84 years of age (relative risk [RR] = 0.72; 95% confidence interval [CI], 0.57-0.91). In this sample, patients not prescribed tamoxifen had substantially more comorbidity, but even after adjusting for comorbidity, the RR was 0.74 (95% CI, 0.58-0.93). In addition, the oldest patients and those not treated with tamoxifen were significantly less likely to be married or have living children.
The data from this review indicate a reduction in the use of tamoxifen in the oldest age group of breast cancer patients. Blackman et al speculate that given the increasing longevity of the oldest-old, undertreatment with adjuvant tamoxifen may put older breast cancer patients at an increased risk of disease recurrence and breast cancer mortality.
Comment by William B. Ershler, MD
This study has some important limitations, primarily based upon its rather small size and the likely possibility that those agreeing to be included and proceeding through the 2 interviews might not be truly representative of the population of interest (the oldest subset of breast cancer patients). Nonetheless, to my knowledge, this is the first report examining tamoxifen use in the oldest-old, and the findings support the notion that patients in this age group may be undertreated.
Breast cancer occurs with increasing numbers with each advancing decade. For example, compared with women 50-54 years of age, women 80-84 years of age have a 1.8-fold greater incidence of breast cancer and a 3.2-fold greater likelihood of dying of this disease.1 Currently, women 80 years and older account for 13% of new breast cancer cases but 27% of breast cancer deaths2 and the absolute numbers will increase dramatically in the next few decades as this age group is the fastest growing of all aging subsets in the United States.
One reason the death rate is higher for older women may relate to the less aggressive treatment they receive, when compared to younger women.3,4 For example, women older than 80 years are about 3 times less likely to receive guideline primary tumor therapy by not receiving radiation therapy following breast conserving surgery (BCS), compared with women 67-79 years of age.5 Additionally, breast cancer patients with poor family support, including unmarried patients without living children, are at a greater risk of receiving less than guideline primary surgical therapies and have poorer survival outcomes when compared to married patients who have living children.6,7
One possible explanation for the reduced tamoxifen use in the oldest breast cancer patients is a perception by treating oncologists that the toxicity might be greater in this age group or that a limited life expectancy due to the patient’s advanced age minimizes the chance for realizing therapeutic benefit. However, there is no solid evidence that tamoxifen toxicity is greater in the elderly. In fact, vasomotor symptoms, such as night sweats and hot flashes, have been reported to decrease with age.8
With regard to limited life expectancy, it should be recalled that the average expectancy at age 85 is 9.6 years, and at age 90, life expectancy is 6.8 years. Thus, patients with early breast cancer may well have time to achieve a meaningful benefit from tamoxifen treatment.
Dr. Ershler, INOVA Fairfax Hospital Cancer Center, Fairfax, VA, is Editor of Clinical Oncology Alert and Director of the Institute for Advanced Studies in Aging, Washington, DC.
References
1. Ries L, et al. Seer Cancer Statistics Review 1973-1988. http://seer.cancer.gov.
2. American Cancer Society. Breast cancer facts and figures 2001-2002. http://www.cancer.org.
3. Silliman RA, et al. Cancer. 1997;80:1326-1334.
4. Hebert-Croteau N, et al. Cancer. 1999;l85:1104-1103.
5. Mandelblatt JS, et al. Cancer. 2000;89:561-573.
6. Neale AV, et al. Soc Sci Med. 1986;23:305-312.
7. Goodwin JS, et al. JAMA. 1987;258:3125-3130.
8. Powles T, et al. Lancet. 1998;352:98-101.
9. National Center for Health Statistics. http://www.cdc.gov/nchs/datawh/statab/unpubd/mortabs/lewk3.htm.
Doctors tend to prescribe less tamoxifen to the oldest-old and also to those with significant comorbidities (in both age groups) or those unmarried and without living children. With increasing life expectancy currently being observed in these age groups, this study raises the possibility that oncologists may be missing the opportunity to help the oldest breast cancer patients achieve therapeutic benefit from tamoxifen.
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