title: The use of surgery in the treatment of ER+ early stage breast cancer in England: Variation by time, age and patient characteristics.
abstract: OBJECTIVE
  To assess whether the proportion of patients aged 70 and over with ER+ operable breast cancer in England who are treated with surgery has changed since 2002, and to determine whether age and individual level factors including tumour characteristics and co-morbidity influence treatment choice.
  
  
  METHODS
  A retrospective cohort analysis of routinely collected cancer registration data from two English regions (West Midlands, Northern & Yorkshire) was carried out (n = 17,129). Trends in surgical use over time for different age groups were assessed graphically and with linear regression. Uni- and multivariable logistic regressions were used to assess the effects of age, comorbidity, deprivation and disease characteristics on treatment choice. Missing data was handled using multiple imputation.
  
  
  RESULTS
  There is no evidence of a change in the proportion of patients treated surgically over time. The multivariable model shows that age remains an important predictor of whether or not a woman with ER+ operable breast cancer receives surgery after covariate adjustment (Odds ratio of surgery vs no surgery, 0.82 (per year over 70)). Co-morbidity, deprivation, symptomatic presentation, later stage at diagnosis and low grade are also associated with increased probability of non-surgical treatment.
  
  
  CONCLUSIONS
  Contrary to current NICE guidance in England, age appears to be an important factor in the decision to treat operable ER+ breast cancer non-surgically. Further research is needed to assess the role of other age-related factors on treatment choice, and the effect that current practice has on survival and mortality from breast cancer for older women.
authors.affiliation: Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK. Electronic address: p.richards@sheffield.ac.uk.
authors.forename: P
authors.initials: P
authors.lastname: Richards
authors.affiliation: Department of Health Economics and Decision Science, School for Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK.
authors.forename: S
authors.initials: S
authors.lastname: Ward
authors.affiliation: Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2JF, UK.
authors.forename: J
authors.initials: J
authors.lastname: Morgan
authors.affiliation: Public Health England, Knowledge and Information Team (West Midlands), Floor 6, 5 St. Philip's Place, Birmingham, B3 2PW, UK.
authors.forename: C
authors.initials: C
authors.lastname: Lagord
authors.affiliation: Brighton and Sussex Medical School, BSMS Teaching Building, University of Sussex, Falmer, Brighton, BN1 9PX, UK.
authors.forename: M
authors.initials: M
authors.lastname: Reed
authors.affiliation: Centre for Health and Social Care Research, Sheffield Hallam University, Collegiate Crescent, Sheffield, UK.
authors.forename: K
authors.initials: K
authors.lastname: Collins
authors.affiliation: Academic Unit of Surgical Oncology, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2JF, UK.
authors.forename: L
authors.initials: L
authors.lastname: Wyld
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor / Q000378:metabolism; D001943:Breast Neoplasms / Q000453:epidemiology / Q000378:metabolism / Q000601:surgery*; D004739:England / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008408:Mastectomy / Q000706:statistics & numerical data*; D009017:Morbidity / Q000639:trends; D009367:Neoplasm Staging; D018579:Patient Selection; D011379:Prognosis; D011960:Receptors, Estrogen / Q000378:metabolism*; D012042:Registries; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors
chemical_list: D014408:Biomarkers, Tumor; D011960:Receptors, Estrogen
keywords: Breast cancer; Comorbidity; Elderly; Retrospective study; Surgery