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Variation in Cancer Treatment By Age
In many cases (though not all), older people are less likely to get effective cancer treatments than are younger people, despite evidence that the elderly can tolerate and benefit from them (Begg and Carbone, 1983). The underuse of aggressive treatment among older people is often assumed to be related to the presence of coexisting conditions, but even among those without potentially complicating conditions, treatment differences exist by age (Newschaffer et al., 1996). Physicians may underuse some cancer treatment for elderly patients because they do not know that the elderly can tolerate aggressive therapy, they make mistaken assumptions about patient preferences, or they underestimate life expectancy. Some evidence suggests that the elderly are as likely as younger patients to prefer aggressive, lifesaving treatment (McQuellon et al., 1995; Yellen et al., 1994). Several research studies have documented the underuse of cancer treatments among older patients:
Older patients with localized or regional non-small-cell lung cancer were less likely than younger patients to receive any therapy, and among those who did receive therapy, older patients were more likely to receive radiotherapy than the more aggressive surgical treatment (Smith et al., 1995).
The elderly are less likely to receive bone marrow transplantation for leukemia or lymphoma (Mitchell et al., 1997).
Among women with breast cancer, older women are less likely to receive BCS instead of mastectomy (Chu et al., 1987; Farrow et al., 1992; Mor et al., 1985; Newschaffer et al., 1996; Satariano, 1992), and among those getting BCS, older women have lower rates of adjuvant radiotherapy (Greenfield et al., 1987).
Use of adjuvant chemotherapy declines with age among women with localized breast cancer (Hillner et al., 1996).
Physicians deviate from recommended chemotherapy regimens more frequently when treating older patients with cancer (Schleifer et al., 1991).
In New Mexico between 1984 and 1986, 43 percent of women age 85 and older, 84 percent of women age 75-84, and 92 percent of women age 65-74 received definitive treatment for localized breast cancer (defined as lumpectomy or excisional biopsy followed by radiation therapy or mastectomy). Age remained significant when access to transportation, physical activity levels, income, social support, ability to perform activities of daily living, mental status, and the presence of other medical illnesses were taken into account (Goodwin et al., 1993).
In a comparable population of women in Virginia in 1985-1989, 66 percent of women age 65-69 and 7 percent of women age 85 and older received the appropriate radiation therapy after BCS. In addition, 44 percent of patients with positive lymph nodes received any adjuvant therapy, and 33 percent received hormone therapy (even though adjuvant therapy is recommended for all patients with node-positive disease) (Hillner et al., 1996).
Based on Surveillance, Epidemiology, and End Results Program (SEER) data, 76 percent of women age 65-69, 68 percent age 70-74, 56 percent age 75-79, and 24 percent age 80 years or older received radiation therapy after breast conserving surgery for Stage I or II cancer. Controlling for differences in comorbidity narrowed, but did not eliminate, the difference associated with age (Ballard-Barbash et al., 1996).