Undertreatment Is Common Among Elderly Patients With Early-Stage Breast Cancer and Non-Hodgkin’s Lymphoma

TAMPA, Florida—Giving suboptimal care, in terms of chemotherapy regimens and dose intensities, is "compromising survival" of elderly patients, according to a report by Julie Meyer, MPH, of a study involving close to 24,000 patients with early stage breast cancer and non-Hodgkin’s lymphoma. Ms. Meyer is a nurse practitioner in the Senior Adult Oncology Program at H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida.

The study examined records from 1,243 community oncology practices for 20,799 patients with early-stage breast cancer and for 3,165 with non-Hodgkin’s lymphoma. The researchers defined suboptimal treatment (or low planned dose on time) as less than 85% of the planned dose intensity for breast cancer and less than 80% for the non-Hodgkin’s lymphoma regimen.

Among the breast cancer patients, the percentages for those receiving suboptimal care was 27.8% of those over 65 vs 20.8% of younger patients receiving CMF (cyclophosphamide/methotrexate/fluorouracil) therapy, 28.1% of those over 65 vs 23.7% of younger patients receiving CAF (cyclophosphamide/doxorubicin/fluorouracil), and 14.7% of those over 65 vs 10.2% of younger patients receiving AC (doxorubicin/cyclophosphamide). Among the non-Hodgkin’s lymphoma patients receiving CHOP (cyclophosphamide [Cytoxan]/doxorubicin/vincristine [Oncovin]/prednisone), 42% of those over 65 were undertreated, compared to 23% of younger patients.

"Physicians say they’re giving [elderly patients] standard care, but they’re not," Ms. Meyer said. Because persons of differing ages who receive similar chemotherapy regimens experience similar survival rates, giving suboptimal treatment to elderly patients is thereby "compromising survival," she added.

Hematopoietic Growth Factors

Elderly cancer patients run a higher risk of treatment-induced myelosuppression, especially neutropenia, and suffer more infections and more severe infections than younger people. These conditions often cause reductions and delays in planned chemotherapy, Ms. Meyer said, but need not translate into dose-limiting toxicities when hematopoietic growth factors are used. Nonetheless, only 10% of elderly cancer patients receive growth factors proactively, she noted. Instead, among the great majority of physicians, the "attitude is ‘let’s just see if they need it,’" she said.

In addition, she said, when growth factors are prescribed, Medicare requires that patients come to a physician’s office for these daily shots, though insurance providers generally permit younger patients to give themselves the shots at home. The perceived inconvenience of these office visits, she suggested, encourages many physicians to forego prescribing proactive growth factors.

The "significant" discrepancies in treatment of older vs younger patients indicate that the elderly need hematopoietic growth factors from the beginning of their chemotherapy in order to assure that they can tolerate the full doses that they need, Ms. Meyer said. Nurses can play an important role by checking that doses are only reduced when truly necessary.