Age bias found in adjuvant therapy recommendations for women with early breast cancer
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Women aged 69 years who underwent surgery for high-risk breast cancer received recommendations for adjuvant radiation therapy nearly two times more often than women a year older undergoing the same procedure, study results showed.
Data from the retrospective analysis, published in International Journal of Radiation Oncology, Biology, Physics, revealed a precipitous year-over-year drop between ages 69 and 70 years that significantly lowered the odds of receiving radiation therapy after lumpectomy, suggesting clinicians are making decisions based on a guideline-concordant age cutoff rather than accounting for other patient-specific risk factors, the investigators wrote.
“We were surprised by the results,” Wesley J. Talcott, MD, MBA, a radiation oncologist with Northwell Health, told Healio. “The magnitude of the difference was surprising. ... You are twice as likely to not receive a standard-of-care treatment recommendation if you show up at your oncologist’s office a few days or a few months after your 70th birthday.”
Background
Investigators specifically targeted treatment choices starting after age 69 years knowing that guidelines — including those from National Comprehensive Cancer Network and Society of Surgical Oncology — define women aged 70 years or older as “older adults.”
“For certain subsets in cancer care, there are guidelines that say we can consider different treatment for patients with more advanced-stage disease vs. younger patients,” Talcott said. “This is somewhat arbitrarily set at age 70 in many guidelines, but obviously there's nothing magical about that number.”
Radiation oncologists who treat breast cancer have gotten used to this as the dividing line between treatment recommended for older and younger patients based on a combination of guidelines and previous studies showing use of adjuvant radiation does not improve outcomes in older patients with high-risk breast cancer. This mindset could affect treatment decisions for adults above age 70 years who have high-risk disease but are otherwise healthy enough to receive adjuvant radiation therapy.
Knowing this, Talcott and colleagues conducted a retrospective study to investigate whether a potential “age cutoff heuristic” among clinicians impacted treatment decision-making for women who underwent breast conserving surgery for higher-risk, early-stage breast cancer.
Methodology
The investigators divided the study into two cohorts of women considered strong candidates for adjuvant therapy who underwent lumpectomy for early-stage breast cancer between 2004 and 2017.
Cohort one (n = 160,990) comprised patients with high-risk disease features — including ER-negative disease — and no planned endocrine therapy who had been considered appropriate candidates for radiation therapy. Cohort 2 (n = 394,946) included patients with hormone receptor-positive disease and tumors greater than 5 mm determined appropriate for endocrine therapy.
Year-over-year age difference in likelihood of adjuvant therapy recommendation served as the study’s primary outcome measurement.
Key findings
Results from cohort 1 showed a marked decrease in recommendation for adjuvant radiation therapy from 90% to 92% among those aged 50 to 69 years to 81% among those aged 70 years.
Results from cohort 2 revealed a more modest decline in endocrine therapy recommendations year-over-year between ages 69 and 70 years. However, year-over-year age difference between 69 and 70 years remained a predictor of endocrine therapy recommendation (OR = 0.86; 95% CI, 0.74-0.99).
Multivariate analysis revealed that year-over-year age difference was an independent predictor of and had a significant impact on adjuvant radiation recommendation when comparing patients aged 69 years vs. 70 years (OR = 0.47; 95% CI, 0.39-0.57).
The investigators reported age 70 years at diagnosis to be associated with 53% lower odds of being recommended for and 39% lower odds of receiving radiation compared with patients aged 69 years when controlling for other variables.
Clinical implications
The study results are clinically meaningful due to the number of women aged 70 years with high-risk breast cancer who are not receiving appropriate standard of care for their disease, according to Talcott.
“Our key takeaway from the study is that physicians in breast oncology — in a very substantial and meaningful way — are treating age not as a continuous variable, as would be appropriate, but often dichotomizing it through what we are calling an age cutoff heuristic into bins of older vs. younger patients and using that mental shortcut to allocate care."
This mental shortcut can lead to inefficient allocation of health care resources, he added, noting that just a difference in age of a few months can lead to significantly different adjuvant treatment recommendations.
“The more cognitive biases you are aware of as a physician, the better off your decision making will be,” he told Healio. “We are all time-strapped to see as many patients in the clinic as possible ... and so we all use these heuristics. But we want to catch ourselves when they work against us and we make irrational decisions based on those heuristics.”
For more information:
Wesley J. Talcott, MD, MBA, can be reached at wesley.talcott@yale.edu.
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