We found large and clinically relevant absolute survival differences disfavoring women aged 70–84 y as compared to women aged 50–69 y. Due to the Swedish mammography screening policies, the stage distribution was more unfavorable among the older, but an adjustment for stage could only partly explain the survival differences. Looking at relative survival stage by stage, the prognosis was worse in stage IIB and higher among women over 70 y as compared to those 50–69 y. Consistently over the stages we found less diagnostic activity, less use of breast conservation, considerably less use of chemotherapy, higher “low activity index,” and more often treatment in local hospitals in older women. Adjusting for these factors in models largely explained the differences by age group, except for women in stage IIB. Our large population-based register lends further strong support to previous reports [
] that there is an age bias in management of older women.
We used a population-based database with high coverage and little misclassification of the variables used in this analysis. Another strength is that relative survival provides a measure of the excess mortality experienced by breast cancer patients, irrespective of whether excess mortality is directly or indirectly attributable to cancer [
]. Therefore, we could study the excess mortality adjusting for the expected survival in the background population and thereby largely compensate our comparisons for mortality due to co-morbidity. However, a drawback of the study is the lack of information on co-morbidity. Co-morbidity may have provided rational reasons for withholding diagnostic measures or specific treatments. One recent study has, however, found non-rational differences in treatment among older women even after controlling for co-morbidity [
]. It would also have been interesting to know whether socioeconomic status is a determinant for survival, but in essence this would not have justified an eventual age bias in management.
An important explanation for the poorer survival among the elderly was the unfavorable stage distribution due to considerably less mammography screening activity after 70 y and no screening taking place after 74 y. This explanation points to an important health policy issue as the population ages. In many Western countries today, a 70-y-old woman has a life expectancy of 12–16 y.
In stages IIB and higher, radiotherapy was less often used in older women, and this could not be explained only by the less frequent use of breast conservation in the elderly. Radiotherapy in itself, although very effective in reducing relapses also among elderly [
] and generally well tolerated in higher age groups [
], will not have a major impact on mortality. However, the use of radiotherapy upon adequate indications may, in register data, be a proxy variable of the use of multidisciplinary management and compliance to clinical recommendations.
Only a very small proportion of the older women received chemotherapy. This is a consequence of the fact that the guidelines during this time period often have suggested upper age limits of 65–70 y for recommending chemotherapy. The evidence base for effectiveness of chemotherapy in the elderly is considered weaker than for younger women and only a few studies of the effect of chemotherapy have included women over 70 y [
]. A few studies have shown both that older women (≥65 y) have a higher treatment-related mortality than do younger women [
], and that older women in reasonably good health derive similar benefits (in relation to disease-free survival and overall survival) from more chemotherapy as the younger patients [
]. We only found an effect of modification of treatment in stage III, and not in stage IIB and unstaged, strengthening these findings. Moreover, co-morbidity has been found not to be an adequate explanation for why clinicians decide to use chemotherapy [
], and age alone seems to be an important indicator of the likelihood to receive adjuvant chemotherapy [
]. The survival differences by age group found in our study and studies by others point also to the importance of further investigating effective adjuvant systemic treatments in the elderly.
Tamoxifen was widely used in older women in our study. One possible reason for the difference in use (to the disadvantage of the younger patients) is that during the first half of the 1990s, tamoxifen was considered to have a negligible effect in younger patients and was therefore not given to those who received chemotherapy. However, we also found that with higher age, an increasing proportion of women with receptor-negative tumors were treated inappropriately with tamoxifen. A possible interpretation of this finding is that clinicians felt that some treatment activity is warranted in women perceived to have a moderate or high risk of recurrence, but that, in the absence of guidelines regarding chemotherapy, the clinician took the chance that tamoxifen would provide some benefit but little harm.
In summary, elderly women were disfavored in several ways: less use of mammography screening, lower diagnostic activity, and lower treatment activity, leading to a lower relative survival. This is a very distressing finding, since around 30% of all breast cancer patients are above the age of 70 y. There is an acute need for more empirical evidence about the effectiveness and tolerability of different treatments in elderly women. Likewise, it is probable that better structured guidelines for elderly women would be a means to improve the situation.
Breast cancer is the most common cancer in women in much of the developed world; for example, there are 41,000 new cases in the UK per year. In 2003, 6,869 women were diagnosed with breast cancer in Sweden. Survival has improved greatly; in the past ten years in the UK, the risk of dying of the disease has fallen by one-fifth. The disease is rare in women under 30 years, but the risk of breast cancer increases with age. Although there are a number of treatments for breast cancer, previous work has suggested that certain factors may affect whether a woman gets treatment. For example, older women are less likely than younger women to be entered into trials of treatment for breast cancer, and therefore treatment guidelines are not as clear for older women. They may also be less likely to receive breast cancer screening.
Why Was This Study Done?
The researchers wanted to look at whether the age of women affected both their survival rate and the treatment they were likely to receive for breast cancer.
What Did the Researchers Do and Find?
They studied 9,059 women aged 50–84 years, diagnosed with primary breast cancer between 1992 and 2002 in one health-care region in Sweden. The researchers found that relative survival over five years of women between 70 and 84 years of age was up to 13% lower compared to women aged 50–69 years. The difference in survival was most pronounced in women who had been shown to have more advanced disease or in whom no assessment of the stage of the disease had been made. There were significant differences in disease management found; older women had larger tumors, had fewer lymph nodes examined, and did not receive treatment by radiotherapy or chemotherapy as often as the younger women.
What Do These Findings Mean?
In older women, the diagnosis of breast cancer was often made later than in younger women. Once diagnosed, older women were less likely to be fully investigated for their cancer, and had less aggressive treatment. It is possible that other illnesses (co-morbidities) in these women may have meant that they were less likely to survive the cancer, but this cannot be the main cause of the differences, and diagnosis in older women is associated with poorer survival. The large differences in treatment of older women are difficult to explain by co-morbidity alone. Even in a country such as Sweden with good health care, age results in great differences in the diagnosis and care of women with breast cancer, with older women faring much worse than younger women.
Where Can I Get More Information Online?
The US National Cancer Registry has a page with many links to information on breast cancer, including prevention and treatment:
Cancer Research UK, a large UK charity that funds research into breast cancer, has many pages of patient information:
Swedish Cancer Registry:
Regional Oncologic Centre in Uppsala/Örebro Region:
Swedish Cancer Society: