Older women with breast cancer who live in nursing homes experience worse mortality rates and functional declines after cancer surgery, suggesting they should consider other methods of treatment, according to researchers.
Their study, “Functional Status and Survival After Breast Cancer Surgery in Nursing Home Residents,” was published in the journal JAMA Surgery.
Breast cancer surgery is very common among residents of nursing homes. In fact, it makes up 61% of all procedures that are performed on those who live in nursing homes.
However, most breast cancer clinical trials have excluded women that are older, frail, and cognitively impaired, leading to uncertainty regarding treatment outcomes in these patients.
While surgery is the standard treatment for this disease, some studies have shown that care for older individuals undergoing treatment should be more individualized.
“Surgery often cures the cancer, but can have a negative impact on elderly patients’ everyday activities and worsen their quality of life,” lead author Victoria Tang, MD, said in a press release.
Tang is assistant professor of geriatrics and of hospital medicine at University of California, San Francisco (UCSF) and the affiliated San Francisco VA Health Care System.
To better understand the factors that contribute to treatment outcomes, researchers set out to evaluate the overall survival and change in functional status after breast cancer surgery in female nursing home residents.
The study was conducted using Medicare claims from 2003-2013 to identify U.S. nursing home residents that underwent breast cancer surgery.
Specifically, the study examined preoperative and postoperative function and identified patient characteristics that were associated with 30-day mortality, one-year mortality, and one-year functional decline after surgery.
A total of 5,969 female nursing home residents underwent breast cancer surgery, among whom 666 underwent a lumpectomy (the least invasive procedure), 1,642 received a mastectomy (the most invasive procedure), and 3,661 underwent lumpectomy or mastectomy with axillary lymph node dissection (ALND).
The most striking finding was that the 30-day mortality rates were 8% after lumpectomy, 4% after mastectomy, and 2% after ALND.
“The highest mortality rate was associated with the least invasive procedure, lumpectomy, which appeared to be performed in the sickest patients,” Tang said. “A higher mortality rate is somewhat expected due to advanced age and increased comorbidities present in nursing home residents. However, a 30-day mortality of 8 percent is much higher than would be anticipated for a surgical procedure that is generally considered very low risk.”
Additionally, the one-year mortality rates were 41% after lumpectomy, 30% after mastectomy, and 29% after ALND.
Finally, among patients who survived the first year after surgery, the functional decline rate was 56-60%.
Due to the abysmal treatment outcomes discovered in this study, researchers recommend that long-term residents of nursing homes should consider treatment options other than surgery, such as endocrine therapy or radiotherapy. They can also consider symptom management as opposed to full surgery.
“This study shows that for frail, elderly patients, breast cancer care should be individualized and goal-oriented, with the option of only providing hormonal therapy or symptom management, instead of surgery,” Tang said.
“While some clinicians, patients and caregivers believe breast surgery is necessary to prevent morbidity and mortality from breast cancer, the risks of harm may outweigh the benefit in this frail, vulnerable population, in which many have a limited life expectancy,” said senior author Emily Finlayson, MD, MS, a professor of surgery, health policy and geriatrics, and director of the Center for Surgery in Older Adults at UCSF.