Breast Cancer Research and Treatment

, Volume 145, Issue 1, pp 185–192 | Cite as

Impact of comorbidity on outcome of older breast cancer patients: a FOCUS cohort study

  • Mandy Kiderlen
  • Nienke A. de Glas
  • Esther Bastiaannet
  • Willemien van de Water
  • Anton J. M. de Craen
  • Onno R. Guicherit
  • Jos W. S. Merkus
  • Martine Extermann
  • Cornelis J. H. van de Velde
  • Gerrit-Jan Liefers


Older breast cancer patients often suffer from comorbid diseases, which may influence life expectancy. The aim of this study was to assess the impact of specific comorbidities on overall survival and distant recurrence free period (DRFP) of older breast cancer patients. Patients were included from the population-based FOCUS cohort which contains 3,672 breast cancer patients aged 65 years or older. The impact of comorbidity on overall survival and DRFP was analyzed using multivariable Cox proportional hazard models and Poisson regression models. Median follow-up time was 6.8 years (range 0–14.0). Irrespective of age; the number of comorbid diseases was significantly associated with worse overall survival [hazard ratio (HR) per increasing number of comorbid diseases: 1.20, 95 % confidence interval (CI) 1.13–1.27 and HR 1.09, 95 % CI 1.05–1.13 for age <75 and age ≥75, respectively]. Median follow-up time for DRFP was 5.7 years (range 0–14.0). An increasing number of comorbid diseases was associated with a decreasing risk of metastases among patients aged ≥75 (HR 0.94, 95 % CI 0.87–1.02), whereas an increasing risk was shown for patients aged <75 (HR 1.09, 95 % CI 1.01–1.19). This study shows that in older breast cancer, patients overall survival and DRFP are influenced by comorbidity. This reiterates that patient outcome is not only influenced by breast cancer, and non-cancer-related factors should be taken into account.


Breast cancer Geriatric oncology Comorbidity Overall survival Distant recurrence Epidemiology 

Supplementary material

10549_2014_2917_MOESM1_ESM.doc (41 kb)
Supplementary material 1 (DOC 41 kb)


  1. 1.
    Wildiers H, Kunkler I, Biganzoli L et al (2007) Management of breast cancer in elderly individuals: recommendations of the International Society of Geriatric Oncology. Lancet Oncol 8:1101–1115PubMedCrossRefGoogle Scholar
  2. 2.
    Biganzoli L, Wildiers H, Oakman C et al (2012) Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA). Lancet Oncol 13:e148–e160PubMedCrossRefGoogle Scholar
  3. 3.
    Wildiers H, Mauer M, Pallis A et al (2013) End points and trial design in geriatric oncology research: a joint European organisation for research and treatment of cancer—Alliance for Clinical Trials in Oncology–International Society of Geriatric Oncology position article. J Clin Oncol 31:3711–3718PubMedCrossRefGoogle Scholar
  4. 4.
    Mell LK, Jeong JH, Nichols MA et al (2010) Predictors of competing mortality in early breast cancer. Cancer 116:5365–5373PubMedCrossRefGoogle Scholar
  5. 5.
    van de Water W, Markopoulos C, van de Velde CJ et al (2012) Association between age at diagnosis and disease-specific mortality among postmenopausal women with hormone receptor-positive breast cancer. JAMA 307:590–597PubMedGoogle Scholar
  6. 6.
    Schairer C, Mink PJ, Carroll L et al (2004) Probabilities of death from breast cancer and other causes among female breast cancer patients. J Natl Cancer Inst 96:1311–1321PubMedCrossRefGoogle Scholar
  7. 7.
    Yancik R, Wesley MN, Ries LA et al (2001) Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older. JAMA 285:885–892PubMedCrossRefGoogle Scholar
  8. 8.
    van de Water W, Seynaeve C, Bastiaannet E et al (2013) Elderly postmenopausal patients with breast cancer are at increased risk for distant recurrence: a tamoxifen exemestane adjuvant multinational study analysis. Oncologist 18:8–13PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Barnett K, Mercer SW, Norbury M et al (2012) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 380:37–43PubMedCrossRefGoogle Scholar
  10. 10.
    Al-Refaie WB, Vickers SM, Zhong W et al (2011) Cancer trials versus the real world in the United States. Ann Surg 254:438–442PubMedCrossRefGoogle Scholar
  11. 11.
    Hutchins LF, Unger JM, Crowley JJ et al (1999) Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med 341:2061–2067PubMedCrossRefGoogle Scholar
  12. 12.
    World Health Organization (2012) The international statistical classification of diseases and related health problems ICD-10Google Scholar
  13. 13.
    Conference communication: age categorization proposed at oral session, accessible for members only. Discussed at: International Society of Geriatric Oncology annual meeting; Berlin, Germany, 15–17 Oct 2009Google Scholar
  14. 14.
    Patnaik JL, Byers T, Diguiseppi C et al (2011) The influence of comorbidities on overall survival among older women diagnosed with breast cancer. J Natl Cancer Inst 103:1101–1111PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Land LH, Dalton SO, Jensen MB et al (2012) Impact of comorbidity on mortality: a cohort study of 62,591 Danish women diagnosed with early breast cancer, 1990–2008. Breast Cancer Res Treat 131:1013–1020PubMedCrossRefGoogle Scholar
  16. 16.
    Ording AG, Cronin-Fenton DP, Jacobsen JB et al (2013) Comorbidity and survival of Danish breast cancer patients from 2000–2011: a population-based cohort study. Clin Epidemiol 5:39–46PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Patnaik JL, Byers T, Diguiseppi C et al (2011) Cardiovascular disease competes with breast cancer as the leading cause of death for older females diagnosed with breast cancer: a retrospective cohort study. Breast Cancer Res 13:R64PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Siegelmann-Danieli N, Khandelwal V, Wood GC et al (2006) Breast cancer in elderly women: outcome as affected by age, tumor features, comorbidities, and treatment approach. Clin Breast Cancer 7:59–66PubMedCrossRefGoogle Scholar
  19. 19.
    Janssen-Heijnen ML, Houterman S, Lemmens VE et al (2005) Prognostic impact of increasing age and co-morbidity in cancer patients: a population-based approach. Crit Rev Oncol Hematol 55:231–240PubMedCrossRefGoogle Scholar
  20. 20.
    Janssen-Heijnen MLG, Szerencsi K, van de Schans SAM et al (2010) Cancer patients with cardiovascular disease have survival rates comparable to cancer patients within the age-cohort of 10 years older without cardiovascular morbidity. Crit Rev Oncol Hematol 76:196–207PubMedCrossRefGoogle Scholar
  21. 21.
    Houterman S, Janssen-Heijnen ML, Verheij CD et al (2004) Comorbidity has negligible impact on treatment and complications but influences survival in breast cancer patients. Br J Cancer 90:2332–2337PubMedCentralPubMedGoogle Scholar
  22. 22.
    Ring A, Sestak I, Baum M et al (2011) Influence of comorbidities and age on risk of death without recurrence: a retrospective analysis of the Arimidex, Tamoxifen alone or in combination trial. J Clin Oncol 29:4266–4272PubMedCrossRefGoogle Scholar
  23. 23.
    Harris EE, Hwang WT, Urtishak SL et al (2008) The impact of comorbidities on outcomes for elderly women treated with breast-conservation treatment for early-stage breast cancer. Int J Radiat Oncol Biol Phys 70:1453–1459PubMedCrossRefGoogle Scholar
  24. 24.
    Louwman WJ, Janssen-Heijnen ML, Houterman S et al (2005) Less extensive treatment and inferior prognosis for breast cancer patient with comorbidity: a population-based study. Eur J Cancer 41:779–785PubMedCrossRefGoogle Scholar
  25. 25.
    Pal SK, Katheria V, Hurria A (2010) Evaluating the older patient with cancer: understanding frailty and the geriatric assessment. CA Cancer J Clin 60:120–132PubMedCrossRefGoogle Scholar
  26. 26.
    Hamaker ME, Jonker JM, de Rooij SE et al (2012) Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review. Lancet Oncol 13:e437–e444PubMedCrossRefGoogle Scholar
  27. 27.
    Raji MA, Kuo Y-F, Freeman JL et al (2008) Effect of a dementia diagnosis on survival of older patients after a diagnosis of breast, colon, or prostate cancer: implications for cancer care. Arch Intern Med 168:2033–2040PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Robb C, Boulware D, Overcash J et al (2010) Patterns of care and survival in cancer patients with cognitive impairment. Crit Rev Oncol Hematol 74:218–224PubMedCrossRefGoogle Scholar
  29. 29.
    Ording AG, Garne JP, Nystrom PM et al (2013) Comorbid diseases interact with breast cancer to affect mortality in the first year after diagnosis—a Danish nationwide matched cohort study. PLoS One 8:e76013PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Hamaker ME, Hamelinck VC, van Munster BC et al (2012) Nonreferral of nursing home patients with suspected breast cancer. J Am Med Dir Assoc 13:464–469PubMedCrossRefGoogle Scholar
  31. 31.
    Lin TL, Kuo MC, Shih LY et al (2012) The impact of age, Charlson comorbidity index, and performance status on treatment of elderly patients with diffuse large B cell lymphoma. Ann Hematol 91:1383–1391PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Mandy Kiderlen
    • 1
    • 2
  • Nienke A. de Glas
    • 1
  • Esther Bastiaannet
    • 1
    • 2
  • Willemien van de Water
    • 1
    • 2
  • Anton J. M. de Craen
    • 2
  • Onno R. Guicherit
    • 3
  • Jos W. S. Merkus
    • 4
  • Martine Extermann
    • 5
  • Cornelis J. H. van de Velde
    • 1
  • Gerrit-Jan Liefers
    • 1
  1. 1.Department of SurgeryLeiden University Medical CenterLeidenThe Netherlands
  2. 2.Department of Geriatrics and GerontologyLeiden University Medical CenterLeidenThe Netherlands
  3. 3.Department of SurgeryBronovo HospitalThe HagueThe Netherlands
  4. 4.Department of SurgeryHaga HospitalThe HagueThe Netherlands
  5. 5.Department of Medical Oncology, Moffitt Cancer CenterUniversity of South FloridaTampaUSA

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