Improving Breast Cancer Care for Older Women

Rebecca Silliman, MD, PhD
Professor of Medicine and Public Health
Boston University Schools of Medicine and Public Health
Chief of the Geriatrics Section at Boston Medical Center
rsillima@bu.edu

What's the problem?

Earlier diagnosis, improved treatment, and the overall increase in average lifespan continue to expand the number of breast cancer survivors who are aged 65 and older. This population is already estimated to be one million of the total 2.3 million breast cancer survivors.

This group of older women represents 17% of all older cancer survivors, yet the impact of breast cancer and its treatment on survivorship in these women has been poorly understood. In 2002, NCI funded Dr. Rebecca Silliman and her research team at Boston University to conduct the Breast Cancer Treatment Effectiveness in Older Women (BOW I) study, whose aim was to learn about older cancer survivors with early stage breast cancer. BOW I, which studied 1,859 women aged 65 and older, provided strong evidence that variations in care have substantial consequences for older women. Specifically, less-than-standard treatment was associated with increased rates of recurrence and breast cancer-specific mortality, while mammography surveillance during the first 5 years after diagnosis was associated with a reduced rate of breast cancer mortality.

Important questions about older breast cancer survivors remained, however, especially with respect to the long-term effects of treatment.

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How will this research address the problem?

To answer these questions, NCI recently funded Dr. Silliman to conduct a follow-on study - BOW II - to collect additional information about the BOW I breast cancer cohort through 15 years after diagnosis. A comparison cohort of women, without breast cancer and matched on age, study site, and breast cancer diagnosis year, will be followed for the same period of time.

BOW II's specific aims are to: (1) Determine whether surveillance mammography beyond 5 years following diagnosis reduces breast cancer-specific mortality, and explore whether surveillance mammography is cost-effective; (2) Determine the cost-effectiveness of standard primary tumor therapy (breast conserving surgery followed by radiation therapy or mastectomy) and adjuvant (tamoxifen) therapy, compared with less-than standard therapy, for older women with breast cancer; and (3) Identify late effects of breast cancer and its treatment by comparing incident comorbidity in 5-year breast cancer survivors to a matched comparison cohort without breast cancer.

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Significance of the study & results

One particularly innovative aspect of the BOW studies is that they take advantage of the resources of the Cancer Research Network (CRN). CRN's consortium of 14 health maintenance organizations nationwide provides a unique resource for investigators to study all phases of the cancer care continuum, from prevention through treatment and survivorship to end-of-life care. By collecting medical record and electronic data from six of the CRN integrated health care systems, BOW II investigators will compile a detailed dataset that will allow them to explore the effectiveness of mammography surveillance for recurrence and second primary cancers beyond 5 years. These data also will provide insights about the cost implications associated with short-term and long-term survivorship care and about the risk of late treatment effects.

BOW II will provide much-needed evidence about the effectiveness of surveillance mammography and the occurrence of late treatment effects. Together with the project's cost analyses, this study will inform efforts to improve care systems and promote evidence-based survivorship care for older women with breast cancer.

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Recent publications of interest

Yood MU, Owusu C, Buist DS, Geiger AM, Field TS, Thwin SS, Lash TL, Prout MN, Wei F, Quinn VP, Frost FJ, Silliman RA. Mortality impact of less-than-standard therapy in older breast cancer patients. J Am Coll Surg 2008 Jan;206(1):66-75.

Owusu C, Buist DS, Field TS, Lash TL, Thwin SS, Geiger AM, Quinn VP, Frost F, Prout M, Yood MU, Wei F, Silliman RA. Predictors of tamoxifen discontinuation among older women with estrogen receptor-positive breast cancer. J Clin Oncol 2008 Feb 1;26(4):549-55.

Field TS, Doubeni C, Fox MP, Buist DS, Wei F, Geiger AM, Quinn VP, Lash TL, Prout MN, Yood MU, Frost FJ, Silliman RA. Under utilization of surveillance mammography among older breast cancer survivors. J Gen Intern Med 2008 Feb;23(2):158-63.

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