title: Older age predicts a decline in adjuvant chemotherapy recommendations for patients with breast carcinoma: evidence from a tertiary care cohort of chemotherapy-eligible patients.
abstract: BACKGROUND
  The appropriate use of adjuvant chemotherapy for elderly women with breast carcinoma remains controversial. Efficacy data in women age >/= 70 years are scarce, resulting in a lack of clear guidelines for patients in this age group. Although several studies have demonstrated decreasing use of chemotherapy with age, none specifically examined its use in an elderly cohort of patients who were deemed eligible for such therapy based on consensus guidelines, simultaneously examining the impact of comorbidity and previous history of malignant disease on these recommendations.
  
  
  METHODS
  The authors examined adjuvant chemotherapy use among chemotherapy-eligible patients age > or = 50 years who were evaluated in a tertiary care cancer center. Associations between patient age and 1) physician recommendation for adjuvant chemotherapy, 2) recommended treatment regimen, and 3) patient acceptance of the treatment plan recommended were examined, adjusting for the impact of aggressive tumor characteristics, medical comorbidity, previous history of malignant disease, and features of the treatment setting.
  
  
  RESULTS
  Of the 208 chemotherapy-eligible patients who were studied, 74% overall were recommended chemotherapy. Chemotherapy was recommended to 92% of women age 50-59 years compared with 77% of women age 60-69 years and 23% of women age > or = 70 years. Increasing age was associated strongly with a decreasing likelihood of receiving a recommendation in favor of chemotherapy. After adjusting for estrogen receptor status, previous history of malignant disease, comorbidity score, and prognostic group, the odds of receiving a recommendation in favor of chemotherapy fell by 22% per year or 91% per 10-year interval, and the rate of decline did not change significantly at age > or = 70 years. We found no age-related differences in either the drug regimens recommended or patient acceptance rates for adjuvant therapy.
  
  
  CONCLUSIONS
  Age was associated strongly and independently with physician recommendation for adjuvant chemotherapy among a group of older women who were eligible specifically for such therapy. Medical comorbidity and a history of previous malignant disease did not alter this correlation significantly, although the latter was a significant predictor of chemotherapy use. Further studies clearly are needed to determine the underlying reasons for this strong age effect and to explore strategies that will optimize the utilization of this potentially curative therapy in the elderly.
authors.affiliation: Division of Hematology/Oncology, Department of Medicine, and Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. dma@mail.med.upenn.edu
authors.forename: Angela
authors.initials: A
authors.lastname: DeMichele
authors.forename: Mary
authors.initials: M
authors.lastname: Putt
authors.forename: Yawei
authors.initials: Y
authors.lastname: Zhang
authors.forename: John H
authors.initials: JH
authors.lastname: Glick
authors.forename: Sandra
authors.initials: S
authors.lastname: Norman
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000627:therapeutic use*; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000378:metabolism / Q000473:pathology; D017024:Chemotherapy, Adjuvant; D015331:Cohort Studies; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008875:Middle Aged; D009367:Neoplasm Staging; D016017:Odds Ratio; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011960:Receptors, Estrogen / Q000378:metabolism; D012189:Retrospective Studies; D012307:Risk Factors
chemical_list: D000970:Antineoplastic Agents; D011960:Receptors, Estrogen