Improving the Quality of Breast Cancer Care for Older Women: A Review of Research Across the Spectru

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Improving the Quality of Breast Cancer Care for
Older WomenA Review of Research Across the
Spectrum of Care
Jeanne Mandelblatt, MD, MPH Lombardi Cancer
Center
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Objectives

• Discuss demography of aging and cancer
• Review biology of aging and cancer
• Review data on
• Prevention and early detection
• Treatment
• Survivorship
• Highlight opportunities for future collaborations

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Doctors (need to be) skilled in the art as well
as the science of medicineto respond sensitively
to survivors individual sensibilities - their
different backgrounds, ..tolerance for pain..,
resources and family situations, and different
attitudes and beliefs about this world Natalie
Davis Spingarn 1922-2000
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Objectives

• Discuss demography of aging and cancer
• Review biology of aging and cancer
• Review data on
• Prevention and early detection
• Treatment
• Survivorship
• Highlight opportunities for future collaborations

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Demography of Aging and Cancer

• By 2030, 1 in 5 will be 65
• Median age of cancer patients 70 years
• Cancer is second leading causes of mortality
• Effective tools exist for prevention, early
  detection, and treatment

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Objectives

• Discuss demography of aging and cancer
• Review biology of aging and cancer
• Review data on
• Prevention and early detection
• Treatment
• Survivorship
• Highlight opportunities for future collaborations

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Biology of Aging and Cancer

• Time-length of carcinogenesis
• Increased vulnerability of aging tissues to
  carcinogens
• Environmental conditions favoring carcinogenesis
• Proliferative senescence
• Immune senescence

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Biology of Aging and Cancer - Dioxin
Dioxin exposure
Trieste, 1995
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Objectives

• Discuss demography of aging and cancer
• Review biology of aging and cancer
• Review data on
• Prevention and early detection
• Treatment
• Survivorship
• Highlight opportunities for future collaborations

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Cancer Prevention/Early Detection in Older
Persons - Pros
Increased

• Incidence, prevalence
• Test performance
• Risk of death
• Susceptibility to late-stage carcinogens
• Life span
• Healthier?

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Cancer Prevention/Early Detection in Older
Persons - Cons

• Competing mortality
• Complication risks
• Indolent tumors
• Effect of prior screen
• Costs ??
• Compliance

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Tamoxifen Effects by Age Risks
RR for Tamoxifen
NSABP-P1
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Tamoxifen Effects by Age Benefits
Benefits Risks if
Probability of death from breast cancer
Age
70 years
7
80 years
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Gail et al, 1999
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30 year old man starting on the 25,000 LB oat
bran muffin he must consume over 40 years to
significantly decrease his risk of death from
high cholesterol and cancer
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Effectiveness of Early Detection

• Several strategies exist
• Conflicting recommendations
• Uncertainty due to lack of RCT data
• Affected by heterogeneity in
• function, risk
• tumor biology
• preferences
• Affected by lead, length, and detection biases

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Barriers to Use of Early Detection by Older
Persons

• Provider-related
• Lack of MD recommendation
• Conflicting recommendations
• Communication
• Patient-related
• Lack of knowledge of risks, benefits
• Cultural attitudes
• Preferences

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Breast Cancer Screening - Upper Age Limits

• Should there be an upper age or life expectancy
  limit for screening based on
• Chronological age
• Breast cancer risk
• Functional status (physiological age)
• Costs

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Chronological Age and Upper Limits

• Incidence and sensitivity increase with age
• Screening beyond age 70
• Downstages disease
• May reduce death rate by 50-60
• Benefits women up to 84, even with HTN, mild
  CHF
• BUT positive predictive value of abnormal screen
  and false positives true positives
• Competing mortality increases with age

Mandelblatt et al, 1992 Nijmegen McCarthy et
al, 2000 Welch Fisher, 1998
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Physiological Age ADL Limits and Probability of
Death
Yabroff, Mandelblatt, Lawrence , et al, 2001.
NCI Grant RO1-CA72908
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• The view of the following economists are
  presented for entertainment purposes only

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Age of Cessation of Breast Cancer Screening -
Cost-Effectiveness
per LYS
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Objectives

• Discuss demography of aging and cancer
• Review biology of aging and cancer
• Review data on
• Prevention and early detection
• Treatment
• Survivorship
• Highlight opportunities for future collaborations

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Breast Cancer OPTIONS

• Outcomes and
• Preferences for
• Treatment
• In
• Older women
• Nationwide
• Survey

Funded by AHRQ, DOA, and DHHS
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Factors Associated with Treatment

• Patient preferences
• Illness burden
• MD practice style
• Communication
• Perceptions of ageism and racism

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Methods

• Longitudinal Cohort (n718)
• 29 Hospitals
• Baseline, 1 and 2 year Follow-up
• Data from Patient, MD, Chart, Claims
• Cross-sectional Sample (n3,851)
• Medicare Beneficiaries (over-sample of Blacks)
• 3,4, and 5 years Post-Surgery
• Data from MD, Chart, Claims, (Patient n1812)

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Treatment Patterns by Age
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Treatment Preferences

• Concerned about recurrence 87
• Concerned with body image 68
• Get treatment over with 27
• Concerned about familys preference 27
• Concerned about inconvenience 23
• Wants no rx post-surgery 21

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Adjusted Odds of Rx by Preference
Controlling for Age, Stage, Comorbidity, SES,
Insurance, Race, MD, Region
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Explanatory Power of Illness Burden

• Variance in Local Rx
• Life Expectancy 4.8
• Physical Function 3.6
• Self-Rated Health 2.2
• of Illnesses 1.3
• ICED 1.1
• Charlson 0.9
• Variance in chemotherapy
• Physical Function 1.0

Mandelblatt, Bierman, et al, HSR, 2002
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Practice Patterns - MD Propensities
Attitudes Towards Patient Participation in
Decision Making
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Practice Propensities and Actual Treatment
Controlling for Patient Age, Stage, Race,
Comorbidity 27 of variance 45 of
variance
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Communication and Treatment
Greater communication associated with

• A sense of choice
• Getting BCS RT
• High surgeon volume and specialty training
• 2 year satisfaction

Controlling for age, comorbidity, region, stage,
MD gender, etc Liang et al, JCO, 2002
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Race, Bias, and Treatment

• Black women 42 more likely to get MST than
  Whites
• Black women 60 more likely to have RT omitted
  after BCS
• Blacks perceived more ageism and racism
• Ageism associated with omission of RT and MST

Controlling for age, comorbidity, region, stage,
SES n732 Surviving, Interviewed, Cancer, 2002
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Objectives

• Discuss demography of aging and cancer
• Review biology of aging and cancer
• Review data on
• Prevention and early detection
• Treatment
• Survivorship
• Highlight opportunities for future collaborations

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Survivorship

• Does treatment affect outcomes?
• Physical Function
• Mental Health
• Satisfaction
• Body Image

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Physical Function Arm Problems 2 Years
Post-Surgery
8.6
3.6
Odds of Arm Problems
2.5
Arm problems include swelling, pain, limitations
in motion 34 have arthritis Controlling for
baseline arm function, age, treatment, stage,
recurrence, baseline health and function
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Mental Health

• Not related to type of surgery
• Better mental health predicted by
• Low perceived ageism
• Sense of choice
• Receiving treatment concordant with preference
• Better body image

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Satisfaction

• Not related to type of surgery
• Greater satisfaction predicted by
• Sense of choice
• Lower perceived ageism, racism
• Better patient-MD communication
• Greater social support

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Body Image

• Better body image predicted by
• BCS
• Treatment concordant with preferences

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Conclusions

• Prevention probably pays
• Screening cost-effective at least to age 79
• Treatment preferences matter
• Age and race biases may exist
• Process of care more important than actual
  therapy
• Communication
• Shared decision making/choice
• Concordance of therapy with preferences

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Acknowledgements Investigators
D Axelrod F Barr C Berg C Burnett A Cahan S
Edge L Eggert K Gold L Gray M Halper K Hughes Y
Hwang
J Dunmore-Griffith E Guadagnoli J Hadley M
Halper N Ibrahim C Isaacs J Kerner J
Lynch Mathematica N Meropol J Mitchell B Peterson
D Polsky J Rowland K Schulman R Senie R Seigel B
Shank R Silliman J Simmons T Tsangaris J Weeks R
Winn
Advisors J Baigis, MJ Gibson, B Hillner, A
Langer, J Lamphere, M Lippman, M Morrow, J
Petrek , J Smith (past S Hellman, E Larson, R
Muhammad, D Winchester) Ex Officio M Cummings,
P Mudrow, A Potosky, J Warren, S Wood
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Acknowledgements- Staff
Central Project Staff Lynne Eggert Kathy
Summers Theresa Jordan Sandy Fournier Statistics
Yi-ting Hwang Karen Gold Mathematica Susan
Sprachman Audrey MacDonald Ann Self Kim Zito
Site Project Coordinators Parisa
Tehranifar Kathy Cleghorn Marilyn Sarnie Joan
Pearson Joann Bistura Dana Benett Rita
Collins Rosemary Gladiano Barbara Deakins Elaine
Lagow Maria Karigan Elvira Medrano Kathy
Thomas Kathy Rose Karen Smith
Site Project Coordinators Robin
Westendorf Juliet Obropta Nancy Watroba Alex
Barriera Joyce Holley Linda Miller Project
Officers Mary Cummings DrPh Patricia Modrow,
PhD Investigators Jack Hadley Jon Kerner Kevin
Schulman
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New Research

• Only 11 of older women get chemotherapy
• Under use of chemotherapy identified as major
  quality issue by IOM
• New Project
• Determinates of chemotherapy use
• Long-term survivorship after chemotherapy
• Costs of caregiver support

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Objectives

• Discuss demography of aging and cancer
• Review biology of aging and cancer
• Review data on
• Prevention and early detection
• Treatment
• Survivorship
• Highlight opportunities for future collaborations

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Future Collaborative Opportunities

• Quality of care in older minority groups
• Beliefs
• Cultural factors
• Social networks
• Cognition and treatment and outcomes
• Shared decision making
• Ethical concerns in cancer care
• Caregiver impact

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