Think Twice About Breast Cancer Surgery in Frail Elderly

Fran Lowry

September 03, 2018

Frail female nursing home residents who undergo breast cancer surgery suffer high rates of mortality and hospital readmission, as well as loss of functional independence, a study of US nursing home data that spans more than a decade has revealed.

These new results should give pause for thought as to whether surgery is the best option for these patients, say the researchers.

The study was published online August 29 in JAMA Surgery.

The results show that for many of these frail elderly women "their outcomes are often not good," lead author Victoria Tang, MD, San Francisco Veterans Affairs Medical Center, University of California, told Medscape Medical News.

"Many are left with poor functional outcome, losing their ability to care for themselves. Doing their activities of daily living like dressing and bathing are impaired as a result of their surgery," Tang said.

She agrees that age should not be a barrier to treatment; however, the decision to undergo breast cancer surgery should take into account not just the disease but the patient's goals.

"What is important to the person? Are we going to potentially cause more harm than good with this treatment that we are offering? For example, I have a patient who says she just wants to go to church. And then she undergoes some procedure that leaves her debilitated and she can't go to church anymore. We need to stop and think about what this may mean for the patient if we do the surgery," Tang said.

In one instance, an 89-year-old woman with angina and dementia who was functionally dependent in two areas of daily living — bathing and dressing — was diagnosed with invasive ductal carcinoma. She underwent a mastectomy with axillary node dissection. The night after surgery, the patient pulled off all her bandages and required restraints. She died a year later of a heart attack.

"Let's put a pause in this breast cancer treat with surgery reflex action," Victoria Tang, MD

"In that situation, was surgery really worth it? If my patient thinks that it's worth it and wants to go through with it, then we will support her the best we can. But in this article, we're trying to say, let's put a pause in this breast cancer treat with surgery reflex action. That's our aim," Tang said.

Most Common Cancer Surgery in Nursing Homes

Breast cancer surgery is the most common cancer operation performed among nursing home residents, accounting for 61% of procedures, Tang said.

The surgery is considered low risk, but how well do elderly patients with functional dependence issues such as dementia and Alzheimer's disease, not to mention limited life expectancy, fare if they undergo breast cancer surgery?

In the current study, Tang and her group identified 5969 female nursing home residents from Medicare claims data between 2003 and 2013 who had undergone inpatient breast cancer surgery.

The researchers used the Minimum Data Set Activities of Daily Living (MDS-ADL) summary score to examine preoperative and postoperative function and identified patient characteristics associated with 30-day and 1-year mortality and 1-year functional decline after surgery.

The women were a mean age of 82 years (standard deviation, 7 years), most (83%) were white, and 57% were cognitively impaired.

Most of the women, 61% (n = 3661), received axillary lymph node dissection (ALND) with lumpectomy or mastectomy, the most aggressive treatment. Another 28% (n = 1642) received a mastectomy, and 11% (n = 666) underwent lumpectomy, the least aggressive treatment.

Thirty-day mortality was highest (at 8%) in the lumpectomy group, followed by 4% in the mastectomy group, and 2% in the ALND group.

One year after surgery, mortality was again highest in the lumpectomy group, at 41%, followed by 30% after mastectomy and 29% after ALND.

Those who survived of breast cancer surgery paid a price, however, suffering greater functional decline.

Survivors' overall rate of functional decline ranged from 56% to 60%.

The functional dependency score on the MDS-ADL increased by 3 points for lumpectomy, 4 points for mastectomy, and 5 points for ALND.

Patients who had greater functional dependency at baseline had the highest risk of mortality at 1 year.

For lumpectomy, the hazard ratio (HR) for death was 1.92 (P = .004); for mastectomy, the HR was 1.80 (P = .001), and for ALND, the HR was 1.77 (P = .001).

"The women who had a lumpectomy were probably sicker to begin with, and that is why we think the mortality was higher with the least invasive procedure," Tang said. "A higher mortality rate is expected in nursing homes. Usually it is around 20% a year. But a 30-day mortality rate of 8% is much higher than would be expected for a surgical procedure considered very low risk."

Tang would like to see more benign management options be considered for these frail, vulnerable patients.

"We could consider radiation or hormonal therapy. Deferring breast cancer surgery in these women is like prostate-specific antigen testing in men. We know prostate cancer tends to be a slower, nonaggressive type in the elderly, and work by Louise Walter, one of our study authors, has shown there are a lot of harmful effects from screening in this population," she said.

First of all, frail patients may not benefit from screening to begin with because screening itself can set-off a cascade of medical procedures and effects.

"They may find a blip on screening, so now we've got to work it up, now we've got to take it out, and then you have incontinence and these downstream issues just from screening," Tang said.

The study findings highlight the poor outcomes in this high-risk population for what is generally considered to be a low-risk procedure, write Jessica Y. Liu, MD, Emory University, Atlanta, Georgia, and Karl Y. Bilimoria, MD, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, in an invited commentary.

These results give momentum to finding and promoting individualized care that incorporates geriatric evaluation into the surgical decision-making of an aging population.

It may not be necessary to screen patients in nursing homes at all, the editorialists suggest.

They point out that guidelines generally recommend ceasing screening at age 75 years, and that more recent guidelines recommend continued screening past age 75 years if the patient is in good health and has a life expectancy longer than 10 years.

"Given that nursing home patients are unlikely to meet these criteria, there is the question of whether they should undergo any screening for breast cancer," the editorialists write.

Breast cancer management in the very elderly should include a geriatric evaluation such as the comprehensive geriatric assessment, they also suggest.

The expected natural history of untreated breast cancer must be weighed against the risks, they add.

"There is an especially fine line between undertreatment and overtreatment when so much depends on forecasting the future, and simply performing these assessments will not result in a definitive answer about how to proceed," Liu and Bilimoria conclude. "But these assessments can help guide decision-making."

The study was funded by grants from the National Institute on Aging and National Institutes of Health. Tang, Liu, and Bilimoria have reported no relevant financial relationships.

JAMA Surg. Published online August 29, 2018. Full Text, Editorial

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