title: Deviation from the Standard of Care for Early Breast Cancer in the Elderly: What are the Consequences?
abstract: BACKGROUND
  For elderly patients with early-stage breast cancer, the standards of care often are not strictly followed due to either clinician biases or patient preferences. The authors hypothesized that forgoing radiation and lymph node (LN) staging for elderly patients with early-stage breast cancer would have a negative impact on survival.
  
  
  METHODS
  From the Surveillance, Epidemiology, and End Results Program database, 53,619 women older than 55 years with stage 1 breast cancer who underwent breast conservation surgery were identified. Analyses were performed to compare the characteristics and outcomes of patients who received the standards of care with LN sampling and radiation and those of patients who did not, with control used for confounders. To account for selection bias from covariate imbalance, propensity score matching was performed. Survival was analyzed using the Kaplan-Meier method.
  
  
  RESULTS
  Older patients were less likely to receive radiation and LN sampling. These standards of care were associated with improved overall survival rates of 15.8 and 27.1 % after 10 years, respectively (p ≤ 0.0001). This survival advantage persisted after propensity score matching, with a 7.4 % higher survival rate for patients who received radiation and a 16.8 % higher survival rate for those who underwent LN staging (p < 0.0001). Lymph node sampling and radiation therapy also conferred a statistically significant improvement in breast cancer-specific survival, with 1.3 and 2.6 % lower mortality rates respectively in the radiated and LN biopsy groups (p < 0.0001).
  
  
  CONCLUSIONS
  As patients age, they are less likely to receive the standard of care for stage 1 breast cancer. Even after controlling for other factors, the study showed that failure to adhere to the standards of LN sampling and radiation therapy may have a negative impact in survival.
authors.affiliation: Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA.
authors.forename: Susie X
authors.initials: SX
authors.lastname: Sun
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Hollenbeak
authors.forename: Anna M
authors.initials: AM
authors.lastname: Leung
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000473:pathology* / Q000532:radiotherapy* / Q000601:surgery; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008198:Lymph Nodes / Q000473:pathology*; D008207:Lymphatic Metastasis; D015412:Mastectomy, Segmental; D008875:Middle Aged; D009367:Neoplasm Staging; D057240:Patient Preference; D010818:Practice Patterns, Physicians'; D057216:Propensity Score; D018426:SEER Program; D021701:Sentinel Lymph Node Biopsy; D059039:Standard of Care; D015996:Survival Rate