For Elderly Women with Breast Cancer

For Elderly Women With carcinoma, Surgery might not Be the simplest Option

Annie Krause moved into a home in Detroit in 2015, when she was 98 years old.

She had grown frail. Arthritis, recurrent infections, and hypertension had made it difficult for her to manage on her own.

When the facility’s doctor examined her, he found a mass in Ms. Krause’s breast and recommended a biopsy — a standing operating procedure to work out what kind of tumor this was and, if it proved malignant, what treatment to pursue.

Once diagnosed, carcinoma almost always results in surgery, even in older women.

“If she were a passive person, she would have had a lumpectomy,” said Ms. Krause’s granddaughter, Dr. Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston.

“But my grandmother was very strong-willed.

She said no, no, no, she didn’t want any procedure.”

That didn’t stop the doctor from recommending a biopsy, however.

Having spent years studying how best to tell older women about carcinoma, Dr. Schonberg said that patients’ decisions — about screenings and coverings — have proved stubbornly immune to change.

She told me about her family’s situation within the wake of a recent study by researchers at the University of California San Francisco.

Published in JAMA Surgery, it followed nearly 6,000 home residents who underwent inpatient carcinoma surgery over a 10- year period.

It’s the foremost common cancer operation for home residents, the researchers reported. Yet Medicare data showed that as a gaggle, these women didn't farewell.

“The trajectories for these patients tend to be poor, to start with,” said Dr. Victoria Tang, a geriatrician, and therefore the study’s lead author.

Almost by definition, women in nursing homes have serious health problems that already portend limited life expectancies.

The women within the study (average age 82) had high rates of diabetes, arthritis, heart failure, and stroke. They needed considerable help with everyday tasks.

overflow half were cognitively impaired.

Yet their surgeons attended to operate aggressively. Though about 11 percent had a lumpectomy, quite 1 / 4 underwent a mastectomy, removal of the whole breast.

in additional than 60 percent, surgeons also removed underarm lymph nodes, a procedure usually conducted to assist determine future treatment, but one which will cause pain and infection, with arm swelling that hampers mobility.

In younger and healthier groups, carcinoma surgery is taken into account a coffee risk. “A lumpectomy is seen as routine, no big deal,” Dr. Tang said

 “It are often done as an outpatient.” But for these women, “the surgery for carcinoma may are worse than the carcinoma itself,” said Dr. Rita Mukhtar, a carcinoma surgeon, and a co-author of the study.

Within a month after surgery, two to eight percent of the patients within the study had died, a very high death rate.

Those undergoing lumpectomy — perhaps, the authors hypothesize because those women were sicker and deemed less likely to survive more invasive surgery — were presumably to die.

Surgeons and hospitals (and Medicare) pay close attention to The 30-day death rate, but most patients and families expect more, months or years of extended life in exchange for the trials of surgery.

But within a year, 29 to 41 percent of those patients had died, counting on the sort of the surgery they’d had — another very high death rate.

Of those who survived a year, about 60 percent experienced a decline in function.

“A lymph node dissection might disable you and leave you in pain, so you’re less ready to dress or bathe or maybe feed yourself,” Dr. Tang said.

Of course, home residents do decline and die, with or without surgery. But that, Dr. Mukhtar said, was the purpose.

“We’re taking people that are more likely to die of something else, and putting them through hospitalization and surgery, with all those risks,” she said, citing those including infection falls and delirium.

“By operating on them, we could also, be diminishing their quality of life for his or her remaining days.”

Given a clearer sense of the risks, patients and families might choose less invasive treatments.

Hormone therapy, like tamoxifen or aromatase inhibitors are taken orally, slows the progression of certain sorts of tumors.

Radiation can also control tumors, with fewer dangers than surgery.

In cases where a tumor grows through the skin and causes pain or bleeding, of course, surgery becomes a palliative response.

But it takes quite 10 years after screening to stop one carcinoma death for 1,000 patients screened if they’re of average risk.

So researchers say mammograms (and carcinoma screening, which involves an identical time lag) are most useful for those with life expectancies greater than a decade.

Few women in nursing homes will live that long.

Many that develop the carcinoma will experience no symptoms, and would never have known that they had it without a physical exam or continuing mammograms.

Like any test or procedure, mammography involves risks: additional screenings, biopsies, complications of biopsies and treatment, and therefore the anxiety the entire process creates.

Us Preventive Services Task Force doesn’t recommend mammograms for women over 75 because there’s insufficient evidence to assess benefits and harms.

Older women have largely been excluded from clinical trials.

Since many older women are dutifully having mammograms for many years anyway, Dr. Schonberg developed a brochure called “Should I Continue Getting Mammograms?”

It explains procedures, helps women assess relevant health factors and points out that over age 75, screening 1,000 women prevent just one carcinoma death over 5 years, while generating 100 false positives.

(There’s also a version for ladies over 85.) Distributing the brochure to 45 women, Dr. Schonberg determined that it had some impact. After using it, women were more knowledgeable and more likely to debate the decision with their doctors.