In a study appearing Aug. 29, 2018, in JAMA Surgery, UCSF researchers found that 58 percent of women who resided in a nursing home for more than 90 days before breast cancer surgery experienced significant functional decline one year after surgery. The study found that women with functional impairment in their daily activities prior to treatment had the highest rates of one-year mortality and functional decline. Patients with prior cognitive impairment also had higher rates of functional decline after one year.
“Surgery often cures the cancer, but can have a negative impact on elderly patients’ everyday activities and worsen their quality of life,” said lead author Victoria Tang, MD, MAS, assistant professor of geriatrics and of hospital medicine at UCSF and the affiliated San Francisco VA Health Care System. “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.”
Breast cancer surgery is the most common cancer operation performed in nursing home residents, constituting 61 percent of procedures. More than half of nursing home physicians report encountering residents with suspected breast cancer, and about two-thirds of those are referred for diagnosis or treatment.
In the JAMA Surgery study, Tang and her colleagues used 2003-2013 claims from all U.S. Medicare nursing homes to review data for 5,969 women ages 67 and older who had lived in a nursing home for at least 90 days and who underwent inpatient breast cancer surgery. In this group (83 percent white, 57 percent cognitively impaired), 61 percent (3,661) of the patients received the most invasive treatment, known as axillary lymph node dissection with lumpectomy or mastectomy (ALND). Another 28 percent (1,642) received a mastectomy, and 11 percent (666) underwent the least invasive lumpectomy. Researchers examined 30-day and one-year mortality, hospital readmission rates, and functional status in activities of daily living, such as eating, dressing and using the bathroom.
The researchers noted that the rates were high for 30-day readmission (16 percent overall, 15 percent ALND, 14 percent mastectomy, 26 percent lumpectomy) and all-cause mortality at 30 days (3.2 percent overall, 2 percent ALND, 4 percent mastectomy, 8.4 percent lumpectomy) and one year (31 percent overall, 29 percent ALND, 30 percent mastectomy, 41 percent lumpectomy).
“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 co-morbidities 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.”
The researchers recommend that long-term nursing home residents with breast cancer consider hormonal therapy, such as endocrine therapy or radiotherapy, or symptom management only instead of surgery. Further studies should specifically evaluate this population in the outpatient setting and compare outcomes in those with and without the surgical intervention. Tools to support informed decision-making also are needed, they said.
The deferring of breast cancer surgery in frail elderly women is similar to prostate specific antigen (PSA) testing, Tang said. PSA testing is common in elderly men despite evidence that those without aggressive prostate cancer are unlikely to benefit from diagnosis and treatment and may face significant risks for quality of life if they undergo prostate surgery.
“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, professor of surgery, health policy and geriatrics, ad director of the Center for Surgery in Older Adults at UCSF.
Other UCSF contributors to the JAMA Surgery study were Shoujun Zhao, MD, PhD; W. John Boscardin, PhD; Rebecca Sudore, MD; Kenneth Covinsky, MD, MPH; Louise Walter, MD; Laura Esserman, MD, MBA; and Rita Mukhtar, MD. Funding was provided by a National Institute on Aging (NIA) UCSF Older Americans Independence Center grant (P30 AG044281), NIA Research Training in Geriatric Medicine grant (T32 AG000212), and National Institutes of Health UCSF Clinical and Translational Science Institute grant (KL2 TR001870).
UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises three top-ranked hospitals – UCSF Medical Center and UCSF Benioff Children’s Hospitals in San Francisco and Oakland – as well as Langley Porter Psychiatric Hospital and Clinics, UCSF Benioff Children’s Physicians and the UCSF Faculty Practice. UCSF Health has affiliations with hospitals and health organizations throughout the Bay Area. UCSF faculty also provide all physician care at the public Zuckerberg San Francisco General Hospital and Trauma Center, and the SF VA Medical Center. The UCSF Fresno Medical Education Program is a major branch of the University of California, San Francisco’s School of Medicine.