Introduction

It's been shown over and over again that chemotherapy is effective in prolonging the life of women with breast cancer. Yet it seems that not all women offered chemo accept it - possibly because they don't want to face the sometimes-brutal side effects. Doctors in New Mexico, USA, have studied just what proportion of women at different ages enters chemo programs.

What was done

In 1990 the National Institutes of Health (NIH) held a consensus development conference that recommended what they called 'adjuvant chemotherapy' for all women with lymph-node positive cancer, and for those with cancer confined to the breast but with a poor prognosis (outlook) for various reasons (e.g. a tumor over 1 cm in diameter).

The New Mexico Tumor Registry was used to collect information on women over 20 with a diagnosis of breast cancer and who were candidates for adjuvant chemotherapy, between 1991 and 1997. They found information on 5,101 such patients. Actual use of chemotherapy was detailed, and then sorted to allow analysis as to whether the patient had, or had not, received chemo. Different 5-year age groups were analyzed along these lines, after appropriate adjustments to neutralize the effects of race, actual tumor stage, the node status (positive or negative) and whether the tumor was found to be 'hormone-sensitive' or not.

What was found

Overall, only 29% of the women received chemotherapy. The use of chemo decreased substantially with increasing age:

This decrease with age was about the same, whatever the stage of tumor, etc.

Why is there increased refusal with age?

First, it's known that the effectiveness of adjuvant chemotherapy in prolonging life does decrease with age; this may influence how strongly physicians encourage chemo in older people.

Second, physicians and patients may think that the toxic effects of chemo are greater in older patients; in fact, however, this is not the case. Women of different ages, whose health is otherwise good, experience similar side-effect profiles with the commonly used chemo regimes.

Third, it's possible that 'community' oncologists, who practice away from large university and clinical hubs, assume that the recommendations are based on clinical trial patients in situations that are not typical for the general population. This assumption, of course, is also wrong.

Unfortunately, the New Mexico doctors didn't have information on the reasons given for patients not enrolling for chemo. Was the choice made by a well-informed patient, an ill-informed patient, or a doctor operating in what was thought to be the best interests of the patient? This remains a subject for another study.

Comment

There was clearly a big difference between the NIH recommendations and actual clinical practice, and this difference was much, much greater in older women. If we accept that chemo is somewhat less effective in women in the upper age groups, this may be an appropriate response by patients and their physicians. Good-quality life (i.e. free from the side-effects of chemo) is chosen over a longer, but more unpleasant, life. And, of course, the older the patient, the more likely they will opt for a more restful, chemo-free, existence.

Once again, the benefit-risk balance for one form of treatment is the question, and the answer will vary from one patient to the next. The way to get the best answer in each case is for both the patient and the doctor to be well informed of the benefits and risks of chemotherapy at all ages. It is likely that, in the future, adjuvant chemo courses will be tailored to suit the age of the patient, in order to maximize the benefit while minimizing the side-effects, on an individual basis.

Source

Discrepancy between consensus recommendations and actual community use of adjuvant chemotherapy in women with breast cancer.
XL. Du, CR. Key, C. Osborne,  et al., Ann Intern Med, 2003, vol. 138, pp. 90--97

Links

• Disease Digest: Breast Cancer
• Smashing Myths about Breast Cancer, Part I: Does Personality Play a Role?
• Review: The Cancer Patient's Workbook