In this study, we performed a qualitative analysis to determine why older women with invasive breast cancer choose non-operative management. Treatment side effects, length of treatment, impact on quality of life, and minimal survival benefit strongly influenced women’s decisions to decline surgery. In addition, patients expressed that experience (both personal and from other patients), fear of general anesthesia, and a desire to maintain independence were important factors in treatment decision-making. Physicians reported that older women declined treatment because they did not perceive their cancer as life-threatening compared to other comorbidities. Breast reconstruction was often not discussed as it was considered unimportant to patients. Patients felt empowered to participate in the decision-making process but appreciated having support. They also valued independence and quality of life over quantity of life.
Within this study population, fear of general anesthesia was frequently reported as a reason to forego surgery. An American College of Surgeons National Surgical Quality Improvement Program study of 26,761 older women (≥ 70y) with invasive breast cancer showed that 88% of patients underwent surgery with general anaesthesia [25]. While the 30-day overall morbidity rate was not significantly different between young and elderly women (3.9% versus 3.8%, p=0.2), older women did have significantly higher rates of pulmonary, cardiac, venous thromboembolic, and neurological morbidity. All-cause 30-day mortality was higher in older women compared to younger women (0.2% versus 0.05%, p<0.001). These data suggest that perhaps alternative strategies for anesthesia should be better explored. Breast surgery can be effectively performed under local and regional anesthesia, particularly in patients who are unable to tolerate or are fearful of general anesthesia. For example, mastectomy under local anesthesia was successfully reported in a series of American Society of Anesthesiologists class IV patients [26]. This study reported no morbidity in the form of hematoma, wound infection or skin flap necrosis. A prospective observational series of patients undergoing breast conserving surgery under a paravertebral block and mild sedation reported successful outcomes, including no need for intraoperative or postoperative opioids [27]. A survey of breast surgeons noted that approximately two thirds of respondents considered breast surgery under local anesthesia to be well-tolerated amongst older women [28]. It is unknown whether patients in our study were offered alternative anesthetic strategies or would have accepted surgery if they had been offered local or regional options.
Another factor that patients frequently described as a reason to avoid surgery was the concern over the length of recovery from surgery. Most breast surgery represents a short-term inconvenience to patients, as the majority of breast surgeries are day surgeries with a minority staying one night in hospital for observation. However, the isolated short- and long-term effects of breast surgery compared to alternative treatment options on older women’s functional status is unknown. Preoperative function is a well-known predictor of postoperative function. Specifically, patients who experienced preoperative functional decline are at a higher risk of accelerated postoperative functional decline [30]. Patients experiencing frailty, a multifactorial state associated with poor nutrition, strength, mobility, depression, comorbidities, and cognitive impairment, also have worse functional outcomes [31,32]. Although these patient factors greatly impact how well a patient recovers from surgery, the procedure itself also influences their postoperative course. Physical functional recovery in older adults who have undergone major surgery is occasionally slower compared to younger women. For example, older adults who underwent major abdominal surgery took 6 weeks to 3 months to recover basic activities of daily living, but up to 6 months to recover their instrumental activities of daily living [33]. In contrast, most older women undergoing surgery for pelvic organ prolapse, including those with low preoperative functional status, return to their baseline functional status within 3 months of surgery [34]. Unfortunately, studies looking specifically at how breast surgery affects older women’s postoperative functional status are lacking. Future studies are needed to evaluate functional status after breast surgery, as the return to baseline function may be comparatively quicker compared to larger and more invasive surgery.
One of the major, but deliberate, biases in this study is that all women initially declined surgery as the primary treatment modality. It is unclear whether the patients included in this study had already decided to decline surgery prior to their surgical consultation or if patient decisions evolved over the course of actual discussions with multidisciplinary providers. However, it is clear that a fulsome discussion about the pros and cons of different treatment options is required. Non-surgical treatments such as PET) are not without difficulties. Prolonged use of endocrine therapy is associated with increased odds of developing cardiovascular disease, bone fractures, deep venous thrombosis, and endometrial cancer [35]. PET may be associated with long lasting side effects and multiple hospital visits. A disadvantage of PET is that it may be only effective for a limited period, after which the treatment must be changed, and surgery may still eventually be necessary. Additionally, adherence to PET is variable amongst older women. A systematic review reported an adherence rate of 52% to 100% amongst older women [36]. Adverse events and toxicity are generally the main reasons for discontinuation of endocrine therapy [37]. Furthermore, there are challenges when discussing the effectiveness of PET as an alternative to surgery. Trials focused on closing this knowledge gap have been met with a lack of recruitment. The British ESTEem trial was developed to compare aromatase inhibitors with surgery, but poor patient inclusion resulted in premature closure of the study. Additionally, although randomised trials comparing tamoxifen with surgery showed tamoxifen was associated with inferior local disease control but similar overall survival [38], these data have important limitations. In some of these studies, patients received tamoxifen regardless of hormone receptor status, and the quality of surgery and radiotherapy received by the surgical group may not meet modern-day standards. Aromatase inhibitors have now replaced tamoxifen in the management of breast cancer in postmenopausal women owing to proven superior efficacy in other clinical scenarios [39-42]. Given data on PET are ever evolving in this patient population, it is clear that a balanced discussion is required between patients and providers to examine the pros and cons of surgical treatments as well as non-surgical options.
Patients stressed their desire to maintain independence and quality of life over quantity of life when deciding on treatment. In a qualitative study of older women with operable breast cancer who underwent PET, patients stated their age was a marker that they were at the end of their lives [43]. While patients did not express the desire for an immediate end, they were not interested in prolonging their lives. Patients declined surgery as they were concerned about the impact of surgical therapy on their quality of their life. The thoughts articulated by these patients describe “a sense of completeness that life has run its course” [44]. Identifying similar points of view in patients through discussion and exploration is critical to understanding a woman’s wishes surrounding breast cancer therapy. Recognizing this, health care providers can hopefully guide patients towards treatment options that most closely follow their wishes.
A challenge that lies in managing older women with breast cancer is accurately estimating life expectancy as different comorbidities having variable impact on life expectancy. Additionally, impaired cognition, malnutrition, and dependency for activities of daily living are important contributors to one’s quality of life [45]. Although considered important to determine treatment options for older women with operable breast cancer [28], a recent study shows that surgeons often underestimate a patient’s life expectancy [46]. This is also exacerbated by that fact that both physicians and patients feel there is limited time available for adequate and objective clinical evaluations and counselling. Therefore, a formal geriatric assessment may be a useful adjunct to identify which patients are at the highest risk of surgery when counseling patients on treatment options and which patients may benefit from prehabilitation [47].
This study has both limitations and strengths. One of the strengths is that we incorporated both physician and older women’s opinions, which allowed us to identify areas where the two groups converged and diverged. Additionally, the qualitative nature of this study facilitated in-depth exploration of participant’s opinions. Moreover, older women were interviewed at different time points from the initiation of their treatment, which allowed for varying perspectives regarding side effects and long-term impact of treatment decision. A limitation of this study is the homogeneity of both physicians and patients. Physician were all from a single, urban, academic institution with a predominant breast practice. Physicians treating older women in other centres may have different opinions from the ones expressed by this group. Patients were predominantly independent, Caucasian, English-speaking women who lived in a large urban area. This limits the applicability of this study to older women of diverse ethnic backgrounds and those who live in rural settings. Furthermore, volunteer bias exists, as the women who participated in our study all declined surgical therapy and are more likely to have strong views about their care. As a retrospective study, there may also be recall bias of events and details. Nonetheless, several themes were consistently triangulated across several women and physicians, which bolsters the face validity of the data.