Older Women and Breast Cancer Unmet Needs

By Dr. Paula Fletcher

Breast cancer has been widely recognized in Canada and elsewhere as an important threat to the health and well-being of women. According to the Canadian Cancer Society an estimated 1 in 9 women will develop breast cancer in her lifetime, while 1 in 27 will die from the disease. In addition, breast cancer is classified as the third leading cause of death and the second leading cause of all cancer deaths in women.

Despite these devastating statistics for women of all ages, younger women have been the primary thrust of research efforts into breast cancer. As such, the present paper examines the issues surrounding older women and breast cancer.

Magnitude of the Problem

Statistics show that women of all ages have an 11.2% lifetime probability of developing breast cancer and a 4.0% probability of dying from the disease. There is no other form of cancer that women are more likely to experience, and women are only more likely to die from lung cancer than breast cancer. The age-standardized incidence rate for breast cancer in women has risen consistently from 78.0 per 100,000 in 1969 to 106.6 per 100,000 in 1996. In that interval, the age standardized mortality rate has declined only modestly with a rate of 31.6 per 100,000 in 1969 and 29.4 per hundred thousand in 1996.3 In Canada alone, an estimated 20,500 will develop breast cancer in 2002;1 however, the incidence rate of breast cancer is increasing to the greatest extent among women over the age of 65.4 Combined with a general trend of population aging in Canada, this issue is expected to become an increasing concern.

Diagnosis and Treatment

Older women have a much higher probability of developing breast cancer, with probabilities of 0.4%, 3.8% and 9.3% in women aged 40, 60 and 80 years, respectively. Over 78% of new breast cancer cases appear in women over 50 years and more than 58% appear in women over 60 years of age. Likewise about 70% of breast cancer deaths occur in women over 60.3 Spirduso5 reports that the life expectancy of individuals almost doubled since the turn of the century, with women outliving men by 4 to 10 years.

Further, McPherson6 contends that “with declining birth rates and increased longevity, populations are increasingly moving from the “young” or “youthful” classification to the “mature” to the “aged” classification” (p. 100). Therefore, it is exceedingly important to address the unique concerns of older women with respect to breast cancer. An important implication of the rising incidence rate of breast cancer combined with no real change in mortality is that the number of women living with breast cancer is growing rapidly.

According to Muss7 and Masetti et al.8 breast cancer research has relatively neglected the elderly segment of the population, until recently, regardless of the fact that the risk of developing breast cancer increases with age, and over 33% of new cases occur in women over the age of 70. Therefore, it has been suggested that physicians may be lacking adequate scientific information needed to form treatment regimens for elderly women.9 Further, provision of less than optimal treatment may be provided to elderly women because of the unfounded view held by some physicians that cancer malignancies in the elderly are less aggressive.8,10 Masetti et al.8 also suggest that the following beliefs, although unsubstantiated (see, for example, Law et al.11), may add to the less aggressive approach to treatment for seniors: (1) the belief that elderly women initially present with breast cancer that is more locally advanced, (2) elderly women possess life expectancies that are limited, and (3) women of advanced age are not able to tolerate standard treatment, whether surgical or systemic. In addition, Love12 suggests that some physicians fail to provide elderly women with all of the treatment options, with the belief that “Well, they’re old; they don’t really want chemotherapy” (p.350).

Research studies that have included elderly women have revealed that seniors are less likely to undergo mammography, and further, are subjected to lesser and frequently inferior treatment for breast cancer.7 With respect to mammography, older women report that the lack of a physician’s recommendation constitutes one of the main reasons for not being screened.13,14

For example, in one study physicians reported completing less screening mammograms for older women between the ages of 75 to 84, in comparison to those aged 65 to 74. Further, advanced age, mild dementia, and living within nursing homes negatively affected doctor’s recommendations for mammography. Marwill et al.14 concluded that “physicians appear to be using implicit judgments about quality of life and age rather than life expectancy based on co-morbidity to determine breast cancer screening practices” (p.1210). In addition, McCool15 asserts that the higher mortality rates among older women with breast cancer are primarily the result of less screening among women of advanced age. Not only are older women less likely to be screened for mammography, there is some evidence to indicate that they are likely to be “nonpracticers” of breast self-examination.16

With regards to treatment, Fallowfield9 reported that many health professionals contend that older women with breast cancer that are subjected to surgery would experience poor quality of life. These contentions have often resulted in older women being treated with hormonal therapy solely, rather than surgical treatments.9,17 More importantly, clinical studies that have included older females, although few and far between, demonstrate that women of advanced age may benefit from and tolerate surgery, radiation and chemotherapy as much as their younger equivalents7, and that quality of life was not affected significantly among elderly women that received early surgery.9 Further, tamoxifen treatment alone, may be appropriate for initial treatment for early to late stage breast cancer,7 but appears to significantly decrease the effectiveness of local control of the disease over the long-term.9

Reconstruction Issues

As life expectancy increases with improving medical care, it is imperative that physicians re-evaluate their management of treatment. For example, conservation of the breast is rarely considered an issue or a priority for women of advanced age,12,17 despite the fact that older women also have issues about disfigurement after mastectomy.18 Love12 interjects that “a woman who’s lived with her breast for 85 years often wants to keep it till she dies - it’s part of her, and she’s used to it” (p. 350). In fact, Smyth et al.18 report that elderly married women were more apprehensive about the potential disfigurement that may have occurred after mastectomy. Sandison et al.19 suggest that elderly women may be more willing to consent to mastectomy because they grew up in an era in which mastectomy was the primary form of treatment; however, these women would still prefer to conserve their breasts, even if treatment procedures may impose some form of inconvenience (i.e., travel to distant locations for radiation therapy).19 As such, older women should be provided with the same options for breast preservation,7 as those offered to younger women.

Additional Needs of Older Women

Aside from the relatively larger size of the population of older women with breast cancer, this group also has distinct needs from other breast cancer age groups. Muss7 contends that aside from physical and psychosocial problems associated with breast cancer, these issues may be compounded in older women by co-morbidity, obstacles to transportation, decreased support, and potentially, physician bias,7,20 factors that have the potential to aggravate adjustment to recovery and play a role in diagnosis and treatment. For example, older women tend to experience a greater degree of comorbid illnesses, in conjunction with breast cancer, primarily because aging is associated with an increased incidence of a variety of conditions including heart disease, diabetes, osteoporosis, sensory and functional impairments.

In addition, the prevalence of activity limitations due to chronic conditions also increases with advancing age,5 potentially affecting diagnosis, treatment and recovery from breast cancer. Satariano and Ralgland21 studying the effect of co-morbidity on 3- year survival among women with early stage breast cancer between the ages of 40 to 84, reported that the number of co-morbid conditions significantly increased with age. As such, co-morbidity should be taken into account during the treatment and prognosis of women experiencing breast cancer.7

The positive effects that social support has on women with breast cancer is noteworthy, particularly support from the family and friends of women with breast cancer. Evidence indicates that a woman’s partner significantly affects her adaptation to a diagnosis of breast cancer.22 Conversely, Silliman et al.23 contend that absence of social support has been associated with poorer health outcomes, notably among women of advanced age.

Given that older women are more likely to be widowed than younger women, they may not have access to the same types of social supports from their spouses (i.e., assistance with caregiving, tasks around the house, transportation to health care facilities for treatment). For example, McPherson6 reports that 32% of older women that are between the ages of 65 to 74 live alone.

A diagnosis of breast cancer may also affect older women psychologically. For example, the impact of breast cancer on older women (e.g., in terms of body image) may be magnified by a pre-existing societal bias against aging in women. Knobf24 asserts that not only is the breast “an important part of feminine body image” (p. 214), but a woman’s “self-concept is tightly meshed into body image and is generally affected when any bodily changes occur” (p.214). Therefore, the changes associated with the body and body image, as a result of the alterations induced by breast cancer, may act to compound the myriad of other age-related changes older women have to experience as they age. Together these changes may intensify the negative feelings associated with changes in the appearance of the body.

Fallowfield9 stresses the importance of monitoring quality of life among this group of cancer survivors, primarily because of the other age-related issues with which these women have to cope (i.e., bereavement among family, limited mobility, social problems, becoming a burden to family). One study reported that seniors feared the treatment of cancer more than the disease itself, because physicians failed to clearly explain the process of the treatment, thus creating unnecessary fear and anxiety.25 This issue provides further support for the fact that older women may need to access different services or supports, in order to deal with the issues specific to aging, that younger women would not have to experience.

In addition, there is some evidence to suggest that older women experience less distress with respect to their cancer diagnosis and treatment;26,27 however, Pasacreta28 warns that this conjecture warrants caution. Older women receive significantly less chemotherapy and undergo reconstructive surgery to a lesser extent, thus suggestive of less aggressive treatment regimens for the elderly,28 in conjunction with lower levels of distress. Further, Trief and Donohue-Smith27 suggest that the differences may also be attributed to generational differences in willingness to report levels of distress, with younger women being more open about their feelings. More information is needed about the distress levels that older women feel about their illness; however, given the unlevel playing field between older and younger women with respect to diagnosis and treatment, applying the same strategies for increasing wellness and promoting recovery does not seem feasible.

Concluding Remarks

Overall, breast cancer research treats women as a homogeneous group, regardless of age, even though evidence indicates that the needs of women of advanced age may differ from younger women, and that the information needed by women changes across the age continuum.29 Smyth et al.18 contend that within research studies, the age range of women generally consist of women in their twenties to their eighties.26 Given that women are able to survive from a diagnosis of breast cancer,30 enhancing their quality of life is paramount. Thus, it would seem essential to focus on specific age ranges of women with respect to diagnosis, treatment, and support needs in order to avoid generalizing results from diverse age samples of women, and in the process enhance quality of life as women deal with a diagnosis of breast cancer. Further research efforts and support should focus on the unmet needs of this group of breast cancer survivors - women of advanced age.

References

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