Risks of breast cancer surgery may outweigh benefits for nursing home residents

Female nursing home patients who underwent breast cancer surgery experienced significant functional decline and high rates of 1-year mortality, according to a study published in JAMA Surgery.

“Although some practitioners, patients and caregivers believe breast surgery is necessary to prevent morbidity and mortality from breast cancer, the risks or harm may outweigh the benefit in this frail, vulnerable population, in which many have limited life expectancy,” Victoria Tang, MD, MAS, assistant professor in the division of geriatrics, department of medicine at University of California, San Francisco, and a physician at San Francisco VA Health Care System, and colleagues wrote.

Because data are lacking on breast cancer surgery outcomes among patients with high functional dependence and shorter life expectancy, researchers assessed OS and functional status changes after breast cancer surgery — stratified by surgery type — among nursing home residents.

“We were motivated to conduct this research because it was surprising for us to see that breast cancer surgery was the most common cancer surgery in this population,” Tang told HemOnc Today.

The researchers linked national Medicare inpatient files to the Minimum Data Set for nursing homes — a mandatory assessment of all nursing home residents who reside in facilities participating in Medicare or Medicaid — to identify 5,969 patients aged 67 and older (mean age, 82 years; 83.1% white) who underwent a breast cancer surgical procedure between 2003 and 2013. The data contained discharge information for all fee-for-service inpatient hospitalizations.

Researchers assessed rates of 30-day and 1-year mortality, as well as 1-year functional decline after surgery using the Minimum Data Set Activities of Daily Living (MDS-ADL) summary score, in which a higher score indicates greater dependence.

Of the residents, 3,661 (61.3%) underwent the most invasive type of surgery — lumpectomy or mastectomy with axillary lymph node dissection (ALND) — 1,642 (27.5%) underwent a mastectomy, and 666 (11.2%) underwent a lumpectomy.

“It was surprising that a large proportion of our cohort underwent the most invasive type of surgery — lumpectomy or mastectomy with ALND — and the least invasive surgery, lumpectomy, had the worst outcomes, but that was because the group that underwent that procedure was a sicker group to begin with,” Tang told HemOnc Today. “We think that lumpectomy may have been pursued in this sicker group because it is seen as a ‘less risky’ procedure or ‘low-risk’ procedure.”

Overall, 1,842 (30.9%) died within 1 year of surgery and, among those who survived 1 year, 3,478 (58.3%) experienced significant functional decline.

Researchers reported 30-day mortality rates of 8% after lumpectomy, 4% after mastectomy and 2% after ALND. At 1 year, mortality rates increased to 41% after lumpectomy, 30% after mastectomy and 29% after ALND.

In multivariate analysis, poor baseline MDS-ADL score — or a score from 20 to 28, indicating substantial functional dependence — appeared associated with a higher 1-year mortality risk after lumpectomy (HR = 1.92; 95% CI, 1.23-3), mastectomy (HR = 1.8; 95% CI, 1.35-2.39) and ALND (HR = 1.77; 95% CI, 1.46-2.15) compared with a MDS-ADL score from 0 to 7.

Mean MDS-ADL score increased 2.8 points following lumpectomy, 4.1 points following mastectomy and 4.8 points following ALND.

Worsening preoperative MDS-ADL score increase risk for 1-year functional decline following lumpectomy (subharzard ratio [sHR] = 1.59; 95% CI, 1.25-2.03), mastectomy (sHR = 1.79; 95% CI, 1.52-2.09) and ALND (sHR = 1.72; 95% CI, 1.56-1.91). Cognitive impairment prior to surgery also was associated with greater risk for 1-year functional decline following lumpectomy (sHR = 1.27; 95% CI, 1.03-1.56), mastectomy (sHR = 1.26; 95% CI, 1.09-1.45) and ALND (sHR = 1.14; 95% CI, 1.04-1.24).

Researchers noted several limitations, including a lack of information on outpatient services; endocrine therapy, chemotherapy or radiation therapy that may have been used on conjunction with or instead of inpatient surgery; staging of the breast cancer; anesthesia type and outcomes. Tang and colleagues also noted that a patient’s worsening function may or may not be attributable to surgery.

“This research should really be used to inform surgical decision-making conversations between the health care team and the patient and family members” Tang said, adding that other treatment options such as radiation and hormonal therapy can be considered.

Tang added that she would like to see further research “looking at the outcomes of nursing home residents with breast cancer surgery vs. those without surgery or other types of treatment.”

The study highlighted important issues that should be considered when caring for the elderly, Jessica Y. Liu, MD MS, surgeon at Emory University, and Karl Y. Bilimoria, MD, MS, associate professor of surgical oncology and medical social sciences at Feinberg School of Medicine of

Northwestern University, wrote in a related editorial.

Although screening guidelines generally recommend stopping screening at age 75 years, when patients have a palpable breast mass or nodal disease, “patient life expectancy, functional status, surgical risk and the natural history of breast cancer must be considered,” to determine appropriate treatment, Liu and Bilimoria wrote.

“There is an especially fine line between undertreatment and overtreatment when so much depends on forecasting the future, and simply performing these assessments will not result in a definitive answer about how to proceed, but these assessments can help guide decision-making,” they added.

Overall, the study reveals poor outcomes among the high-risk nursing home population for what is generally considered a low-risk procedure, they added.

“The study contributes momentum to ongoing initiatives promoting more individualized care with geriatric evaluation in the surgical decision-making of our aging population,” Liu and Bilimoria wrote. – by Trudi Gilfillian

For more information:

Victoria Tang, MD, MAS, can be reached at San Francisco Veterans Affairs Medical Center, 4150 Clement St., Room 181(G), San Francisco, CA 94121; email: victoria.tang@ucsf.edu.

Disclosures: Tang reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Liu and Bilimoria report no relevant financial disclosures.