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Researchers examine age and race differences in treatment of breast cancer

By the late 1990s, breast cancer mortality rates began to decline for the first time in several decades. However, rates failed to decline for older women (age 65 or older), and mortality rates actually increased for older black women. Two studies supported by the Agency for Healthcare Research and Quality (HS08395) and led by Jeanne S. Mandelblatt, M.D., M.P.H., of Georgetown University School of Medicine, recently examined age and race differences in the treatment of breast cancer.

The first study found that older black women are less likely than older white women with localized breast cancer to receive breast conserving surgery (BCS) plus radiation, currently the preferred treatment over mastectomy (complete breast removal). The second study shows that women with localized breast cancer who are older, not functioning as well at the time of surgery, and whose surgeons are cancer specialists are less likely to undergo lymph node biopsy after BCS.

Mandelblatt, J.S., Kerner, J.F., Hadley, J., and others (2002, October). "Variations in breast carcinoma treatment in older Medicare beneficiaries." Cancer 95, pp. 1401-1414.

Older black women are less likely than older white women to receive recommended treatment for local breast cancer, according to this study. The researchers analyzed data from 984 black and 849 white Medicare-insured women 67 years of age or older diagnosed with local breast cancer in 1994 and a subset of 732 surviving women who were interviewed 3 to 4 years after treatment. The researchers used these data to calculate odds of treatment, adjusting for age, other coexisting medical problems, attitudes, geographic region, and area measures of socioeconomic status (SES) and health care resources. Overall, 67 percent of women underwent mastectomy and 33 percent received BCS. Radiation was omitted in one-third of women after BCS.

Black women were older, sicker, diagnosed with stage 2 cancer (vs. stage 1) more often, and lived in areas where the elderly were more impoverished than their white counterparts. Elderly black women were 36 percent more likely than elderly white women to receive mastectomy versus BCS and radiation, even after taking into account poverty and other factors. Also, when they did receive BCS, black women were 48 percent more likely than white women to not have radiotherapy, a practice that would increase their risk of local cancer recurrence, although the absolute number of women affected was small.

The odds of mastectomy were nearly eight times as high and the odds of not having radiation after BCS were over five times as high for women living in areas with the highest quartile of elderly residents living below the poverty level compared with areas with the lowest quartile of poverty, controlling for other factors. Higher levels of coexisting illness and greater distance from a cancer center increased the odds of having a mastectomy versus BCS plus radiation for blacks but not for whites. Older age was independently associated most strongly with omission of radiation after BCS. Black women interviewed perceived more discrimination based on age and race than white women, and higher perceived age-based discrimination was associated with greater odds of mastectomy and radiation omission after BCS.

Edge, S.B., Gold, K., Gerg, C.D., and others (2002, May). "Patient and provider characteristics that affect the use of axillary dissection in older women with stage I-II breast carcinoma." Cancer 94, pp. 2534-2541.

Surgical biopsy (dissection) of axillary lymph nodes (in the arm pit) is almost always done during mastectomy to rule out lymph node involvement for women with breast cancer. Lymph node biopsy after BCS requires an additional incision and general anesthesia compared with often-used local anesthesia for BCS. Women with local breast cancer who are older, not functioning as well at the time of surgery, and whose surgeons are cancer specialists are less likely to undergo axillary lymph node biopsy after BCS, according to this study.

The investigators examined patient, clinical, and surgeon characteristics associated with the non-use of axillary lymph node biopsy after BCS. They used medical record and survey data for 464 elderly women with stage 1-2 breast cancer who underwent BCS at hospitals in four U.S. regions, as well as survey data from their 158 surgeons.

Most (63 percent) women underwent axillary lymph node biopsy after BCS. Increasing age was strongly associated with decreasing odds of undergoing node biopsy, even after considering other factors. Independent of age and other factors, women in the lowest quartile of physical functioning were 37 percent less likely to undergo node dissection compared with women in the highest quartile. Women who were cared for by surgeons with subspecialty training in surgical oncology were 60 percent less likely to undergo node dissection than women who were cared for by other surgeons (52 vs. 87 percent). Other provider and institutional factors, including geographic location, were not significant.

Although axillary lymph node biopsy after BCS is a reasonable procedure, its omission may represent appropriate management since the procedure can cause substantial problems. For instance, other research has shown that one-third of women who undergo axillary dissection experience long-term burning or prickling sensations, limited range of motion, and permanent lymphedema (puffiness or swelling of the arms), which can interfere with tasks such as self-care, shopping, and cleaning. Recently introduced sentinel lymph node biopsy causes fewer problems than complete dissection. Nevertheless, until more data are available, physicians must help women balance the risks and potential benefits of axillary lymph node dissection in making treatment decisions, suggest the researchers.

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