Annie Krause moved into a nursing home in Detroit in 2015, when she was 98 years old. She had grown frail. Arthritis, recurrent infections and hypertension had made it difficult for her to manage on her own.
When the facility’s doctor examined her, he found a mass in Krause’s breast and recommended a biopsy — standard procedure to determine what sort of tumour this was and, if it proved malignant, what treatment to pursue. Once diagnosed, breast cancer almost always leads to surgery, even in older women.
“If she were a passive person, she would have had a lumpectomy,” said Krause’s granddaughter, Dr. Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston. “But my grandmother was very strong-willed. She said no, no, no, she didn’t want any procedure.”
That didn’t stop the doctor from recommending a biopsy, however.
Having spent years studying how best to inform older women about breast cancer, Schonberg said that patients’ decisions — about screenings and treatments — have proved stubbornly resistant to change.
She told me about her family’s situation in the wake of a recent study by researchers at the University of California San Francisco. Published in JAMA Surgery, it followed nearly 6,000 nursing home residents who underwent inpatient breast cancer surgery over a 10-year period.
It’s the most common cancer operation for nursing home residents, the researchers reported. Yet Medicare data showed that as a group, these women did not fare well.
“The trajectories for these patients tends to be poor to begin with,” said Dr. Victoria Tang, a geriatrician and the study’s lead author. Almost by definition, women in nursing homes have serious health problems that already portend limited life expectancies.
The women in the study (average age 82) had high rates of diabetes, arthritis, heart failure and stroke. They needed considerable help with everyday tasks. Well over half were cognitively impaired.
Yet their surgeons tended to operate aggressively. Though about 11 per cent had a lumpectomy, more than a quarter underwent a mastectomy, removal of the entire breast.
In more than 60 per cent, surgeons also removed underarm lymph nodes, a procedure usually conducted to help determine future treatment, but one that can cause pain and infection, with arm swelling that hampers mobility.
In younger and healthier groups, breast cancer surgery is considered low risk. “A lumpectomy is seen as routine, no big deal,” Tang said. “It can be done as an outpatient.”
But for these women, “the surgical treatment for breast cancer may have been worse than the breast cancer itself,” said Dr. Rita Mukhtar, a breast cancer surgeon and a co-author of the study.
Within a month after surgery, two to eight per cent of the patients in the study had died, a very high mortality rate. Those undergoing lumpectomy — perhaps, the authors hypothesise, because those women were sicker and deemed less likely to survive more invasive surgery — were most likely to die.
Surgeons and hospitals (and Medicare) pay close attention to the 30-day mortality rate, but most patients and families expect more, months or years of extended life in exchange for the rigours of surgery.
But within a year, 29 to 41 per cent of these patients had died, depending on the type of surgery they’d had — another very high mortality rate.
Of those who survived a year, about 60 per cent experienced a decline in function. “A lymph node dissection might disable you and leave you in pain, so you’re less able to dress or bathe or even feed yourself,” Tang said.
Of course, nursing home residents do decline and die, with or without surgery. But that, Mukhtar said, was the point.
“We’re taking people who are more likely to die of something else, and putting them through hospitalisation and surgery, with all those risks,” she said, citing those including infection, falls and delirium. “By operating on them, we may be diminishing their quality of life for their remaining days.”
INFORMATION AND CHOICE
Given a clearer sense of the risks, patients and families might opt for less invasive treatments. Hormone therapy, like tamoxifen or aromatase inhibitors taken orally, slows the progression of certain kinds of tumours. Radiation may also control tumours, with fewer dangers than surgery.
In cases where a tumour grows through the skin and causes pain or bleeding, of course, surgery becomes a palliative response.
But it takes more than 10 years after screening to prevent a single breast cancer death for 1,000 patients screened, if they’re of average risk. So researchers say mammograms (and colon cancer screening, which involves a similar time lag) are most useful for those with life expectancies greater than a decade.
Few women in nursing homes will live that long. Many who develop breast cancer will experience no symptoms, and would never have known they had it without a physical exam or continuing mammograms.
Like any test or procedure, mammography involves risks: additional screenings, biopsies, complications of biopsies and treatment, and the anxiety the whole process creates.
The U.S. Preventive Services Task Force doesn’t recommend mammograms for women over 75 because there’s insufficient evidence to assess benefits and harms. Older women have largely been excluded from clinical trials.
Since many older women have been dutifully having mammograms for decades anyway, Schonberg developed a brochure called “Should I Continue Getting Mammograms?”
It explains procedures, helps women assess relevant health factors and points out that over age 75, screening 1,000 women prevents only one breast cancer death over five years, while generating 100 false positives. (There’s also a version for women over 85.)
Distributing the brochure to 45 women, Schonberg determined that it had some impact. After using it, women were more knowledgeable and more likely to discuss the decision with their doctors. Yet 60 per cent still had another mammogram
She has since completed a broader study, being prepared for publication, involving 541 women over 75. Here, too, preliminary results show that the proportion who had another mammogram dropped only slightly after using the brochure, from 61 to 56 per cent — a modest drop that demonstrates women’s reluctance to discontinue screening.
These subjects were not nursing home residents, and it might make sense for them to use other yardsticks besides age in their decision-making.
Mukhtar has performed breast cancer surgery on patients in their 50s and 60s, for instance, who had serious medical problems beforehand, leading to troubling complications afterward. But she also operated on healthy patients in their 80s who recovered well.
Nursing home residents are already in poor health, however. “It’s likely the surgery didn’t help them live longer, and certainly not better,” Schonberg said.
As for her grandmother, Annie Krause, she declined the biopsy and Schonberg supported her decision.
“In a 98-year-old, it probably is breast cancer,” Schonberg said. “But she didn’t want any more medical interventions. She was focused on optimising her quality of life.”
Krause died two years later, after a stroke.