Does health care end at age 80? The answer, clearly, is no. However, the extent and aggressiveness with which health care should be provided in this aging population is open to much debate. With the U.S. facing an ever aging population of baby boomers, defining this question and the shades of gray which surround it have become important priorities in health care.
An article in the Journal of Clinical Oncology last year, (Badgwell, et al. “Mammography before diagnosis among women age 80 years and older with breast cancer, JCO. 2008;28:2492-2498) focused on whether mammography was warranted in elderly women, defined as age 80 or older. The researchers noted that mammography in octogenarians is associated with diagnoses of breast cancer at earlier stages, making no assertions as to how this affected survival, but noting that those who underwent more frequent mammograms had a higher association with receiving breast conservation therapy. The study also identified that there is a paucity of research and published data on the diagnosis and treatment of breast cancer in the elderly population. Thus, while not clearly advocating for or against the use of mammography in octogenarians, based on inconclusive evidence to demonstrate a survival advantage, the study raised questions that would require further investigation to elucidate answers.
Ideologically, some arguments not to perform mammography in those patients age 80 and older include:
- 1. By this age, a person has a higher risk of dying of other co-morbidities rather than early stage breast cancer;
- 2. Patients at this age are not candidates for certain breast cancer therapies secondary to treatment-related complications or toxicities; and
- 3. Patients at this age are not interested in pursuing the chemotherapy, radiation and surgical therapies associated with treating breast cancer.
However, there are multiple arguments supporting mammography in the elderly. The first is that life expectancy in the last century has increased dramatically, so the notion that treatment for octogenarians already at death's door is futile no longer rings true. According to the CDC, life expectancy between 1960 and 2004 increased from 69.7 to 76.5 years (CDC Life Expectancy at Birth). But not only are people living longer, if someone reached the age of 85 (as of 2004), they could expect to live another 6.1 years. More and more people are living into their 90s, and what was once considered end-of-life, has now become the penultimate decade for many thanks to improved health care, technology and medication. This being said, increasing numbers of 80-year-olds are undergoing major operative procedures. Specifically for breast cancer, octogenarians diagnosed with breast cancer, treated with appropriate standard therapy, can be associated with 75% survival rates at more than 6 years. (Cancer. 2006; 106(8):1664-1668.)
The second argument for supporting mammography is that earlier diagnosis of breast cancer, regardless of age, provides survival benefit in terms of breast cancer risk. Schairer, et al. examined 430,510 women with breast cancer in the SEER database and calculated probabilities of death from breast cancer and other causes according to stage, race and age at diagnosis (JNCI. 2004;96:1311-1321.)
In the group of patients age 70 years and older, in situ and local disease were associated with higher probabilities of death from other causes, rather than breast cancer. However, the more advanced the disease stage at diagnosis, the higher the probability of dying from breast cancer than all other causes including heart, circulatory and respiratory disease. Therefore, the argument that women in their 80s have a higher risk of dying from causes other than their breast cancer can only be applied to those patients who are diagnosed with in situ or locoregional disease. An important limitation of the study is that it reviews an approximately 28-year span of treatment and specific treatments received were not well defined. Therefore changes in mortality due to changes in breast cancer treatment regimens over time were not well specified.
The third argument supporting mammography and earlier diagnoses of breast cancer in elderly is to refute the belief that octogenarians have no preference over mastectomy vs. breast conservation, so early diagnosis does not matter. Grube, et al. in 2001 discussed surgical management of breast care in the elderly (Am J Surg. 2001;182:359-364). In examining 1,006 patients in a prospectively collected database, and dividing them between those patients younger than age 70 and older than 70, there was no statistically significant difference in those that desired breast conservation therapy by age. Therefore, functional status as opposed to age should be the primary consideration in determining whether someone should undergo breast conservation therapy vs. mastectomy.
In the U.S., age 80 has become the new 70. And as the field of medicine advances, physicians will have to expand their comfort zone in adequately treating this population. The most important question to arise out of the whole controversy of who should be treated for what disease at which age is: “How important is age as a factor to consider?” Would you be more worried about treating breast cancer in a healthy 81-year-old with no medical co-morbidities and excellent functional status, or a 60-year-old with end-stage cardiac, pulmonary and/or renal disease? Perhaps age should not be the determining factor in deciding whether a patient should get a specific test but one of many considerations, such as functional status and co-morbidities, important in determining diagnostic or treatment options (JACS. 2007;205(6):729-734.)