Treating nursing home patients with breast cancer
Today, breast cancer has a very high cure rate. The common treatment is surgery and usually a combination of hormone therapy, chemotherapy or radiation. Most patients go on to live long cancer-free lives, but one group of women doesn’t seem to fare as well.
A recent study published in JAMA Surgery found that for women who live in nursing homes, surgery and other aggressive treatments might not be the best option.
The 10-year study of Medicare records followed close to 6,000 women living in nursing homes who underwent inpatient surgery for breast cancer. The one-year mortality rate for patients in the study was 41 percent for those who had lumpectomies, 30 percent for those who had mastectomies and 29 percent for those who had axillary lymph node dissection.
In comparison, the American Cancer Society lists the following overall five-year survival rates:
- For Stage 0 or Stage I breast cancer, the survival rate is about 100 percent.
- For Stage II breast cancer, the survival rate is about 93 percent.
- For Stage III breast cancer, the survival rate is about 72 percent.
- For Stage IV or metastatic breast cancer, the survial rate is about 22 percent.
The other significant reveal of the study was that among one-year survivors, the functional decline rate of daily living activities such as eating, dressing, and using the bathroom was 56 to 60 percent. This is especially important because researchers reported that breast cancer surgery is the most common cancer operation for nursing home residents, accounting for 61 percent of procedures.
Researchers noted that the highest mortality rate occurred in the least invasive procedure, lumpectomy, which appeared to be the operation performed on the patients who were the sickest before surgery. Additionally, those who already had the highest rate of functional decline prior to surgery showed the worst decline afterwards. The fact that these patients were sicker before surgery indicated their outcomes were most likely tied to their prior health.
Breast cancer specialist Jill Oxley, MD, of Cape Cod Surgical Associates in Hyannis, said that studies like this show that it is important to make medical decisions about the treatment of breast cancer on a case by case basis, taking all the individual factors into consideration.
“It’s not just about age,” she said. “Their general health is so much more important than age. Life expectancy is also an important factor. If you have someone who is elderly and frail in a nursing home, they are not going to have the life expectancy of someone who is elderly and working or volunteering or golfing or gardening.”
If a frail elderly person in a nursing home has breast cancer that is not symptomatic, then the best thing to do could be nothing because they are most likely going to die from something else besides breast cancer, she said. This is especially true since other treatments such as medication and radiation carry their own risks and problems for this population.
“Some of the hormonal medications that are used can increase the risk of blood clots,” Dr. Oxley said. “Others can increase the rate of osteoporosis so, for an elderly woman who already has frail bones, a fall itself could be life threatening. Radiation means taking someone to the hospital from a nursing home five days a week for potentially six weeks. That’s a lot of back and forth to the hospital.”
With that in mind, for patients of any advanced age who are healthy enough, surgery can be the best option, she said. A lumpectomy can be done with local anesthesia and intravenous sedation as an outpatient. The surgery is minimally invasive and outcomes are usually excellent.
Dr. Oxley and her colleagues perform many such surgeries on healthy older people. Data from Cape Cod Hospital over the past 10 years shows that almost 15 percent of people diagnosed with breast cancer were over the age of 80, she said. Another 24 percent were in their 70s.
What About Mammograms?
Similar guidelines about health status can be used to determine whether to continue mammograms. The U.S. Preventive Services Task Force recommendation is to start at age 50 and have mammograms every other year until 75, Dr. Oxley said. That is not an opinion that breast cancer doctors agree with because it is a cost-saving recommendation rather than a life-saving one.
“The general consensus is there is no age to stop having mammograms, but the life expectancy should be 10 years,” she said.
The task force recommendation to stop at 75 short-changes women in this age group, according to Dr. Oxley, because a 75-year-old’s life expectancy is another 13 years. So a 75-year-old is expected to live to 88 and an 80-year-old is still expected to live to 90.
“If you have someone in their late 70s or 80s who is living independently and in good health, they are probably going to live another 10 years, and it’s very reasonable to keep getting mammograms. But if you have an 80-year-old who is a nursing home resident, that’s not the same patient. Most nursing home patients aren’t going to live another 10 years.”
Whether to have a mammogram at an older age is a decision that should be made in conjunction with your healthcare providers. Elderly patients need to consider what is most important to them and what treatments they would be willing to do if the mammogram results are not what they hope, she said.
“If they are healthy and they still would want to have a biopsy should their mammogram be abnormal, they can still have their mammograms,” Dr. Oxley said. “They will never be turned away because of age.”