Old Age Affects Advanced-Stage Cancer Diagnoses Differently

Becky McCall

March 27, 2012

March 27, 2012 (London, United Kingdom) — The age-related pattern of advanced-stage diagnosis is strikingly different for breast and lung cancers, according to a study published in the March issue of the British Journal of Cancer.

A diagnosis of advanced breast cancer is more common in women older than 70 years than in women younger than 70 years. Conversely, a late-stage diagnosis of lung cancer is more common in people younger than 70 years than in people older than 70 years, the researchers report.

"If we better understand who is at risk of advanced stage diagnosis, then we will be able to better focus research and policies to achieve faster and greater gains in earlier diagnosis of cancer, leading to better survival outcomes," said lead author Georgios Lyratzopoulos, MD, clinical senior research associate at the University of Cambridge, United Kingdom. The study was conducted in collaboration with researchers from the Eastern Cancer Registration and Information Centre (ECRIC).

The researchers looked at cancer stage at diagnosis for breast and lung cancers, which together account for about 30% of all cancer diagnoses and cancer deaths in England.

For breast cancer, there was a marked trend for advanced stage (stage III/IV) at diagnosis as patient age increased. For women 70 to 74 years of age, compared with women 65 to 69 years, the odds ratio (OR) was 1.21; for women 75 to 79 years, the OR was 1.46; for women 80 to 84, the OR was 1.68; and for women older than 85 years, the OR was 1.78 (P < .001).

In contrast, older lung cancer patients had a lower chance of diagnosis at an advanced stage (OR, 0.82, 0.74, 0.73, and 0.66 for the same age groups; P < .001).

Data were drawn from the ECRIC, a population-based cancer registry covering a general population of approximately 5.7 million in the east of England, which contained complete information on stage at diagnosis for 16,460 (92%) breast cancer patients and 10,435 (79%) lung cancer patients. The data were for diagnoses made from 2006 to 2009.

For breast cancer, the researchers note that this study differed from previous similar studies because it adjusted for confounding factors such as tumor subtype and mode of diagnosis (screening or symptomatic presentation). However, they still found substantial age and socioeconomic differences in stage at diagnosis.

Because "the findings were adjusted for histological type, it is unlikely that differences in tumor types were responsible for the higher proportion of advanced-stage cancers in older women with breast cancer," Dr. Lyratzopoulos pointed out.

It is more likely that the findings reflect differences in awareness of breast cancer symptoms in older women and/or differences in healthcare-seeking behavior, he told Medscape Medical News.

Lower socioeconomic status was also associated with more stage III/IV diagnoses in women with breast cancer. "We believe [this reflects] differences in patient awareness of symptoms and signs and in healthcare-seeking behavior," Dr. Lyratzopoulos explained.

Different Story in Lung Cancer

For lung cancer, patterns of staging at diagnosis are in marked contrast to the patterns in breast cancer. As patients increased in age, they were less likely to be diagnosed with advanced-stage lung cancer.

"The inverse association between older age and chance of advanced-stage diagnosis for lung cancer provides a warning that we cannot assume that patient characteristics, such as old age, act in the same way for all cancers," said study author David Greenberg, PhD, who is from ECRIC. "We need to study the patterns for each cancer differently to develop the best earlier diagnosis strategies."

He noted that the reason older lung cancer patients appear to have a lower risk for late-stage diagnosis than their peers is unclear. "It is possible that older patients have a higher level of comorbidity or symptom burden, prompting investigation by a chest x-ray earlier in the disease process."

"Other research and qualitative studies to better understand the symptom signature of lung cancer in middle- and older-age groups, as well as physician behavior, would be valuable to identify mechanisms by which earlier diagnosis in younger age groups can be achieved," Dr. Greenberg told Medscape Medical News.

This study found that advanced stage at diagnosis of lung cancer was more frequent in men (OR, 1.14; P = .011). Unlike for breast cancer, there was no evidence of lower socioeconomic status being associated with an increase in advanced stage at diagnosis, but there was a trend (P = .236).

Although the records used in this study contained "complete" information on stage at diagnosis, the completeness of the information varied substantially, and missing stage information was more common in older patients.

"This may mean that some rather invasive investigations or treatments that enable accurate staging are not done as often because it is not judged appropriate by patients, their relatives, or doctors." Dr. Greenberg pointed out.

The researchers conclude that this study helps to define particular patient groups with substantial potential for improvements in early diagnosis. "Our research aims to help funders and policy makers prioritize early-diagnosis interventions and research to patient groups in which it is likely to matter most," said Dr. Lyratzopoulos.

"New and Robust Evidence"

Approached by Medscape Medical News for comment, Stephen Spiro, MD, deputy chair of the British Lung Foundation and honorary consultant physician at the University College London Hospital and The Royal Brompton Hospital in the United Kingdom, said that the prognosis for lung cancer in elderly patients is not likely to improve. Although it might "be encouraging that fewer elderly patients present with advanced, late-stage lung cancer, they are usually too old and frail to undergo radical surgery, which remains the best treatment for cure," he explained.

"The average age of patients who present with lung cancer is about 70 years, and the great majority (up to 70%) will have disease too far advanced for cure. Thus, the prognosis will remain poor for the majority of sufferers," Dr. Spiro concluded.

Lindsay Forbes, MD, codirector of the promoting early presentation group and of the cancer screening information team at King's College London, United Kingdom, also commented on the study for Medscape Medical News. She noted that breast cancer survival is poor in the United Kingdom, compared with other high-income countries with similar healthcare systems. "The international differences in cancer survival are most pronounced in 1-year survival — a marker of late stage at diagnosis — and in older women," she explained.

Dr. Lyratzopoulos and colleagues have provided new and robust direct evidence that, in the United Kingdom, older women are much more likely to be diagnosed with late-stage breast cancer than younger women, she said. "This is unlikely to be a result of differences in tumor biology between older and younger women, or missing data on stage."

"We already know that older women are more likely to delay presentation with breast cancer symptoms than younger women, and that they have lower breast cancer awareness," Dr. Forbes continued. "Equipping older women with the knowledge, skills, and confidence to present promptly with breast cancer symptoms may help downstage breast cancer in older women, and thereby improve their survival," she told Medscape Medical News.

Dr. Lyratzopoulos, Dr. Greenberg, Dr. Spiro, and Dr. Forbes have disclosed no relevant financial relationships.

Br J Cancer. 2012;106:1068-1075. Abstract

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