For Elderly Women with Breast Cancer, Surgery May Not Be the Best Option
Annie Krause moved into a nursing home in Detroit in 2015, when she was 98 years old. She had grown frail. Arthritis, recurrent infections in addition to hypertension had made in which difficult for her to manage on her own.
When the facility’s doctor examined her, he found a mass in Ms. Krause’s breast in addition to recommended a biopsy — standard procedure to determine what sort of tumor This kind of was in addition to, if in which proved malignant, what treatment to pursue. Once diagnosed, breast cancer almost always leads to surgery, even in older women.
“If she were a passive person, she would likely have had a lumpectomy,” said Ms. Krause’s granddaughter, Dr. Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston. “yet my grandmother was very strong-willed. She said no, no, no, she didn’t want any procedure.”
in which didn’t stop the doctor via recommending a biopsy, however.
Having spent years studying how best to inform older women about breast cancer, Dr. Schonberg said in which patients’ decisions — about screenings in addition to treatments — have proved stubbornly resistant to change.
She told me about her family’s situation inside wake of a recent study by researchers at the University of California San Francisco. Published in JAMA Surgery, in which followed nearly 6,000 nursing home residents who underwent inpatient breast cancer surgery over a 10-year period.
in which’s the most common cancer operation for nursing home residents, the researchers reported. Yet Medicare data showed in which as a group, these women did not fare well.
“The trajectories for these patients tends to be poor to begin with,” said Dr. Victoria Tang, a geriatrician in addition to the study’s lead author. Almost by definition, women in nursing homes have serious health problems in which already portend limited life expectancies.
The women inside study (average age 82) had high rates of diabetes, arthritis, heart failure in addition to stroke. They needed considerable help with everyday tasks. Well over half were cognitively impaired.
Yet their surgeons tended to operate aggressively. Though about 11 percent had a lumpectomy, more than a quarter underwent a mastectomy, removal of the entire breast. In more than 60 percent, surgeons also removed underarm lymph nodes, a procedure usually conducted to help determine future treatment, yet one in which can cause pain in addition to infection, with arm swelling in which hampers mobility.
In younger in addition to healthier groups, breast cancer surgery is usually considered low risk. “A lumpectomy is usually seen as routine, no big deal,” Dr. Tang said. “in which can be done as an outpatient.”
yet for these women, “the surgical treatment for breast cancer may have been worse than the breast cancer itself,” said Dr. Rita Mukhtar, a breast cancer surgeon in addition to a co-author of the study.
Within a month after surgery, two to eight percent of the patients inside study had died, a very high mortality rate. Those undergoing lumpectomy — perhaps, the authors hypothesize, because those women were sicker in addition to deemed less likely to survive more invasive surgery — were most likely to die.
Surgeons in addition to hospitals (in addition to Medicare) pay close attention to the 30-day mortality rate, yet most patients in addition to families expect more, months or years of extended life in exchange for the rigors of surgery.
yet within a year, 29 to 41 percent of these patients had died, depending on the type of surgery they’d had — another very high mortality rate.
Of those who survived a year, about 60 percent experienced a decline in function. “A lymph node dissection might disable you in addition to leave you in pain, so you’re less able to dress or bathe or even feed yourself,” Dr. Tang said.
Of course, nursing home residents do decline in addition to die, with or without surgery. yet in which, Dr. Mukhtar said, was the point.
“We’re taking people who are more likely to die of something else, in addition to putting them through hospitalization in addition to surgery, with all those risks,” she said, citing those including infection, falls in addition to delirium. “By operating on them, we may be diminishing their quality of life for their remaining days.”
Given a clearer sense of the risks, patients in addition to families might opt for less invasive treatments. Hormone therapy, like tamoxifen or aromatase inhibitors taken orally, slows the progression of certain kinds of tumors. Radiation may also control tumors, with fewer dangers than surgery.
In cases where a tumor grows through the skin in addition to causes pain or bleeding, of course, surgery becomes a palliative response.
yet in which takes more than 10 years after screening to prevent just one breast cancer death for 1,000 patients screened, if they’re of average risk. So researchers say mammograms (in addition to colon cancer screening, which involves a similar time lag) are most useful for those with life expectancies greater than a decade.
Few women in nursing homes will live in which long. Many who develop breast cancer will experience no symptoms, in addition to would likely never have known they had in which without a physical exam or continuing mammograms.
Like any test or procedure, mammography involves risks: additional screenings, biopsies, complications of biopsies in addition to treatment, in addition to the anxiety the whole process creates.
The United States Preventive Services Task Force doesn’t recommend mammograms for women over 75 because there’s insufficient evidence to assess benefits in addition to harms. Older women have largely been excluded via clinical trials.
Since many older women have been dutifully having mammograms for decades anyway, Dr. Schonberg developed a brochure called “Should I Continue Getting Mammograms?”
in which explains procedures, helps women assess relevant health factors in addition to points out in which over age 75, screening 1,000 women prevents only one breast cancer death over 5 years, while generating 100 false positives. (There’s also a variation for women over 85.)
Distributing the brochure to 45 women, Dr. Schonberg determined in which in which had some impact. After using in which, women were more knowledgeable in addition to more likely to discuss the decision with their doctors. Yet 60 percent still had another mammogram
She has since completed a broader study, being prepared for publication, involving 541 women over 75. Here, too, preliminary results show in which the proportion who had another mammogram dropped only slightly after using the brochure, via 61 to 56 percent — a modest drop in which demonstrates women’s reluctance to discontinue screening.
These subjects were not nursing home residents, in addition to in which might make sense for them to use different yardsticks besides age in their decision-producing.
Dr. Mukhtar has performed breast cancer surgery on patients in their 50s in addition to 60s, for instance, who had serious medical problems beforehand, leading to troubling complications afterward. yet she also operated on healthy patients in their 80s who recovered well.
Nursing home residents are already in poor health, however. “in which’s likely the surgery didn’t help them live longer, in addition to certainly not better,” Dr. Schonberg said.
As for her grandmother, Annie Krause, she declined the biopsy in addition to Dr. Schonberg supported her decision.
“In a 98-year-old, in which probably is usually breast cancer,” Dr. Schonberg said. “yet she didn’t want any more medical interventions. She was focused on optimizing her quality of life.”
Ms. Krause died two years later, after a stroke.