Breast Cancer Research and Treatment

, Volume 40, Issue 1, pp 75–86 | Cite as

Variation in staging and treatment of local and regional breast cancer in the elderly

  • Bruce E. Hillner
  • Lynne Penberthy
  • Christopher E. Desch
  • M. Kathleen McDonald
  • Thomas J. Smith
  • Sheldon M. Retchin
Guest editor's introduction



Few studies of practice variation in the management of early breast cancer for elderly women have examined the process of care in depth. This study evaluated the effects of age and other factors on surgical staging techniques and treatment.


Virginia cancer registry data were linked with Medicare claims and 1990 census data. The sample included all newly diagnosed patients with pathologic confirmed local and regional breast cancer in 1985–1989 (n=3,361). Analyses included descriptive univariate statistics and multiple logistic regression analysis for staging and treatment alternatives. Process of care variables included tumor size determination, axillary lymph node dissection, use of adjuvant therapy, and radiation if breast conserving surgery (BCS) was performed.


About 75 percent of women had tumor size and axillary node dissection. Increasing comorbidity was associated with a lower likelihood of axillary node dissection. Nine percent of local compared to 44 percent of regional disease patients received adjuvant therapy. Hormonal therapy increased from 13 percent of women in 1985–1988 to 24 percent in 1989. Hormonal therapy did not vary with patient age. One-third of the patients with positive lymph nodes compared to 8 percent of node negative women received hormonal therapy. Blacks were more likely to present with advanced disease. A logistic regression model evaluated the multiple effects of patients and clinical characteristics: older women were more likely to present with larger tumors, were less likely to have axillary node dissections, and were less likely to receive chemotherapy or radiation.


Younger age was most consistently associated with staging and the use of chemotherapy in this cohort of elderly breast cancer patients. Based on the reported initial treatment plan, hormonal therapy was infrequently used and information from axillary lymph node assessment was used to stratify treatment. Although the low use of adjuvant hormonal therapy in elderly women may compromise survival, neither comorbid nor socioeconomic factors as measured in this study explained this practice pattern.

Key words

breast neoplasms elderly practice patterns databases surgical therapy staging adjuvant therapies 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin JS: Geographic variation in the use of breast-conserving treatment for breast cancer [see comments]. N Engl J Med 326:1102–1107, 1992PubMedGoogle Scholar
  2. 2.
    Farrow DC, Hunt WC, Samet JM: Geographic variation in the treatment of localized breast cancer [see comments]. N Engl J Med 326:1097–1101, 1992PubMedGoogle Scholar
  3. 3.
    Hand R, Sener S, Imperato J, Chmiel JS, Sylvester JA, Fremgen A: Hospital variables associated with quality of care for breast cancer patients [see comments]. JAMA 266:3429–3432, 1991PubMedGoogle Scholar
  4. 4.
    Hynes DM: The quality of breast cancer care in local communities: Implications for health care reform. Med Care 32:328–340, 1994PubMedGoogle Scholar
  5. 5.
    Desch CE, Penberthy L, Newschaffer CJ, et al: Factors that determine the treatment for local and regional prostate cancer. Med Care (in press)Google Scholar
  6. 6.
    Newschaffer CJ, Penberthy L, Desch CE, Retchin SM: Co-morbidity and age-related treatment patterns for non-metastatic breast cancer in elderly women. Arch Intern Med (in press)Google Scholar
  7. 7.
    Silverberg E, Boring CC, Squires TS: Cancer statistics, 1990. CA-A Cancer Journal 40:9–26, 1990Google Scholar
  8. 8.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis 40:373–383, 1987PubMedGoogle Scholar
  9. 9.
    Malenka DJ, McLerran D, Roos N, Fisher ES, Wennberg JE: Using administrative data to describe case mix: a comparison with the medical record. J Clin Epidemiol 47:1027–1032, 1994PubMedGoogle Scholar
  10. 10.
    Consensus Conference: Adjuvant chemotherapy for breast cancer. JAMA 254:3461–3463, 1985Google Scholar
  11. 11.
    NIH Consensus Conference: Treatment of early-stage breast cancer. JAMA 265:391–395, 1991Google Scholar
  12. 12.
    Kassirer JP: The quality of care and quality of measuring it. N Engl J Med 329:1263–1265, 1993PubMedGoogle Scholar
  13. 13.
    Osteen RT: Breast Cancer.In: Steele GD, Winchester DP, Menck HR, Murphy GP (eds): National Cancer Data Base, 1992. American Cancer Society, Atlanta, 1992, pp 29–38Google Scholar
  14. 14.
    Johnson TP, Ford L, Warnecke RB, et al: Effect of a National Cancer Institute Clinical Alert on breast cancer practice patterns. J Clin Oncol 12:1783–1788, 1994PubMedGoogle Scholar
  15. 15.
    Eley JW, Hill HA, Chen VW, et al: Racial differences in survival from breast cancer. Results of the National Cancer Institute Black/White Cancer Survival Study. JAMA 272:947–954, 1994PubMedGoogle Scholar
  16. 16.
    Early Breast Cancer Trialists' Collaborative Group: Effects of adjuvant tamoxifen and of cytotoxic therapy on mortality in early breast cancer: an overview of 61 randomized trials among 28,896 women. N Engl J Med 319:1681–1692, 1988Google Scholar
  17. 17.
    National Cancer Institute: Clinical Alert. National Cancer Institute, Bethesda MD, May 16–18, 1988Google Scholar
  18. 18.
    Harris JR, Morrow M, Bonadonna G: Cancer of the breast.In: DeVita VT, Hellman S, Rosenberg SA (eds) Cancer: Principles and Practice of Oncology. Lippincott, Philadelphia, 1994, pp 1264–1332Google Scholar
  19. 19.
    Early Breast Cancer Trialists' Collaborative Group: Systemic treatment of early breast cancer by hormonal, cytotoxic, or immune therapy. Lancet 339:1–15,71–85, 1992Google Scholar
  20. 20.
    Castiglione M, Gelber RD, Goldhirsch A: Adjuvant systemic therapy for breast cancer in the elderly: competing causes of mortality. International Breast Cancer Study Group. J Clin Oncol 8:519–526, 1990PubMedGoogle Scholar
  21. 21.
    Cummings FJ, Gray R, Tormey DC, et al: Adjuvant tamoxifen versus placebo in elderly women with nodepositive breast cancer: long-term follow-up and causes of death [see comments]. J Clin Oncol 11:29–35, 1993PubMedGoogle Scholar
  22. 22.
    Harris JR, Lippman ME, Veronesi U, Willett W: Breast cancer (2). N Engl J Med 327:390–398, 1992PubMedGoogle Scholar
  23. 23.
    Fisher B, Redmond C, Fisher ER, et al: Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med 312:674–681, 1985PubMedGoogle Scholar
  24. 24.
    Kantorowitz DA, Poulter CA, Sischy B, et al: Treatment of breast cancer among elderly women with segmental mastectomy or segmental mastectomy plus postoperative radiotherapy. Int J Radiation Oncology Biol Phys 15:263–270, 1988Google Scholar
  25. 25.
    Veronesi U, Luini A, Del Vecchio M, et al: Radiotherapy after breast-preserving surgery in women with localized cancer of the breast [see comments]. N Engl J Med 328:1587–1591, 1993PubMedGoogle Scholar
  26. 26.
    Jollis JG, Ancukiewicz M, DeLong ER, Pryor DB, Muhlbaier LH, Mark DB: Discordance of databases designed for claims payment versus clinical information systems. Ann Intern Med 119:844–850, 1993PubMedGoogle Scholar
  27. 27.
    Roos LL, Sharp SM, Cohen MM: Comparing clinical information with claims data: some similarities and differences [see comments]. J Clin Epidemiol 44:881–888, 1991PubMedGoogle Scholar
  28. 28.
    Greenfield S, Blanco DM, Elashoff RM, Ganz PA: Patterns of care related to age of breast cancer patients. JAMA 257:2766–2770, 1987PubMedGoogle Scholar

Copyright information

© Kluwer Academic Publishers 1996

Authors and Affiliations

  • Bruce E. Hillner
    • 1
  • Lynne Penberthy
    • 1
  • Christopher E. Desch
    • 1
  • M. Kathleen McDonald
    • 1
  • Thomas J. Smith
    • 1
  • Sheldon M. Retchin
    • 1
  1. 1.Massey Cancer CenterVirginia Commonwealth UniversityRichmondUSA

Personalised recommendations