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Physical, Cognitive Function Should Be Considered When Making Breast Cancer Treatment Decisions for Nursing Home Residents

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Research has found that breast cancer surgery is the most common cancer operation among nursing home residents. About 61% of cancer surgeries in nursing homes are breast cancer surgeries.

A new study suggests that nearly 60% of frail women living in a nursing home for 90 days before breast cancer surgery lost more than half their physical and/or cognitive function. They also were were more likely to be readmitted to the hospital or die in the year after surgery. The researchers suggest that the physical and cognitive function levels of these women should be considered when making breast cancer treatment decisions.

The research was published online on Aug. 29, 2018, by the journal JAMA Surgery. Read “Functional Status and Survival After Breast Cancer Surgery in Nursing Home Residents.”

What makes a person frail?

Doctors define being frail as age-associated loss of function that makes it hard for a person to cope with everyday life. People who are frail have:

  • low energy
  • low grip strength
  • a slowed walking speed
  • low physical activity
  • unintentional weight loss

People who are frail are more likely to:

  • fall and hurt themselves
  • need help doing daily activities, such as eating, bathing, and using the toilet
  • be hospitalized
  • be disabled in some way
  • die from any cause

Using information from a Medicare database, the researchers looked at 5,969 women who had been diagnosed with breast cancer and had inpatient breast cancer surgery:

  • the women ranged in age from 67 to older than 85; the average age was 82
  • 666 of the women had lumpectomy
  • 1,642 women had mastectomy
  • 3,661 women had lumpectomy/mastectomy and also had axillary lymph node surgery
  • 4,960 of the women were white; 845 were Black
  • 3,396 women had cognitive problems
  • 1,324 women had heart failure
  • 2,175 women had diabetes
  • 1,055 women had chronic breathing problems
  • 1,608 had arthritis or other connective tissue problems
  • nearly 30% of the women had been hospitalized three or more times in the year before breast cancer surgery

What are the outcomes after breast cancer surgery in frail, older women?

The researchers looked at how many women were readmitted to the hospital and their physical and cognitive function levels after breast cancer surgery. They also looked at how many women died 30 days and 1 year after breast cancer surgery.

In the 30 days after breast cancer surgery, 16% of the women were readmitted to the hospital:

  • 26% of women who had lumpectomy were readmitted
  • 15% of women who had axillary lymph node surgery were readmitted
  • 14% of women who had mastectomy were readmitted

Of the women who were alive 1 year after breast cancer surgery, 55% to 60% had a decline in function.

In the 30 days after breast cancer surgery, 3.2% of the women died. Women who were older, had other conditions, and had a decline in function before surgery were more likely to die in the 30 days after breast cancer surgery.

In the year after breast cancer surgery, 31% of the women died. Women who had the lowest function and were considered the most frail were more likely to die in the year after surgery.

"Surgery often cures the cancer, but can have a negative impact on elderly patients' everyday activities and worsen their quality of life," said lead author Victoria Tang, M.D., assistant professor of geriatrics and of hospital medicine at University of California-San Francisco. "This study shows that for frail, elderly patients, breast cancer care should be individualized and goal-oriented, with the option of only providing hormonal therapy or symptom management, instead of surgery."

The researchers recommended that long-term nursing home residents diagnosed with breast cancer consider hormonal therapy, radiation, or only managing the symptoms of breast cancer instead of surgery.

Weigh the risks and benefits of all treatment options

They also recommended that future studies look specifically at breast cancer treatment in long-term nursing home residents and compare outcomes between women who have surgery and women who do not. The researchers also said that tools to support informed decision-making are needed.

"While some clinicians, patients, and caregivers believe breast [cancer] surgery is necessary to prevent morbidity and mortality from breast cancer, the risks of harm may outweigh the benefit in this frail, vulnerable population, in which many have a limited life expectancy," said senior author Emily Finlayson, M.D., professor of surgery, health policy, and geriatrics at the University of California-San Francisco.

If you are an older woman living in a nursing home who has been diagnosed with breast cancer or have a loved one who is in this situation, you may want to talk to your doctor (or your loved one’s doctor) about this study. Ask about a treatment approach that makes the most sense for your unique situation and considers a number of factors, including:

  • your preferences
  • your age
  • any other health problems you have
  • all the characteristics of the cancer
  • your level of physical and cognitive function

Together, you and your doctor can weigh the risks and benefits of each treatment and decide on a plan that makes the most sense for you.

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