A subtle and perhaps unconscious age bias among doctors may be depriving thousands of older women of aggressive therapy for breast cancer--perhaps needlessly shortening their lives--according to a new UCLA study.
The study, which examined breast cancer treatment given to 374 women at seven major Southern California hospitals, found women 70 and older received inappropriate treatment for their breast cancers four times as often as women 50 to 69. Nearly one of five of the older women received incorrect therapy.
In all, the older women received appropriate care 83% of the time while the younger group was correctly treated in 95.6% of all cases. Older women, said a member of the UCLA team, often did not have modern breast-saving surgery--such as the so-called lumpectomy--and their treatment less often included complete exploration of the lymph nodes in their armpits to determine whether their cancers had spread.
The conclusions focused on women with two of the most treatable types of breast cancer.
"We conclude that physicians may manage patients with this highly treatable (if found early) disease according to (chronological age alone) without regard for physiological condition," the UCLA team said, "and that this age bias may result in a less favorable prognosis than could be achieved using currently recommended therapy."
The finding allowed for such variables as the greater prevalence of serious health problems other than cancer in women over 70 and the possibility that cancer in the older women may have spread more by the time it was detected.
In the research, older women free of cancer and other serious disease were matched against members of the younger group in similar health.
The age-related difference in breast cancer therapy was seen beginning by age 65, but statistically significant disparities were not clear until age 70, the research team said.
Breast cancer was the only type studied in the UCLA investigation. Researchers suggested similar studies to identify possible age bias in other types of cancer.
According to American Cancer Society estimates, 48.5% of breast cancers diagnosed each year are in women between 50 and 69, with an additional 19.2% in women between 70 and 79. The society said 130,000 new cases are projected for 1987, of which 63,050 are projected to be in women 50 to 69 and 24,960 in women 70 to 79. After age 80, incidence declines markedly.
The researchers, from UCLA and the Sepulveda Veterans Administration Hospital, said the standardization of the two groups of women studied--stripping away factors that might medically justify less vigorous intervention with some older patients--was a unique feature of the new research. A report appears today in the Journal of the American Medical Assn.
The 374 cases studied were selected from among those treated at the seven hospitals, which Dr. Sheldon Greenfield, who headed the research team, declined to name because of confidentiality agreements. However, Greenfield confirmed that the group includes health centers in Santa Barbara, the San Fernando Valley, the Westside and the South Bay.
Greenfield said there was little variation among the hospitals in terms of the differences in treatment between the two age groups. He and Dr. Patricia Ganz, another researcher, agreed that the treatment decisions were made by individual physicians.
The women's health insurance status--including their reliance on Medicare and Medi-Cal--did not influence the choices.
"It was a rather universal thing," Greenfield said. "We uncovered something that's not very much related to the hospital. It's more of a doctor-related thing. I prefer to think it's something done unconsciously."
What apparently occurs, the research team said, is that physicians conclude that an older women may not be as concerned as a younger one with saving her breasts. Also, because of her age, doctors apparently do not order removal and study of lymph nodes to determine the extent of her disease in the belief that she will live only a few more years anyway.
Dr. Arthur Holleb, the American Cancer Society's senior vice president for medical affairs, agreed an unintentional age bias probably does color the therapeutic decisions of physicians.
"I suspect it's probably true," he said, "because most of us taking care of patients try to be as easy as possible on the older folks. We probably do have a tendency to do a little bit less than we normally would for a younger patient.
"I do think it needs to be rethought . . . to be sure that adequate therapy is being performed for all patients."
Good Chance of Recovery
Greenfield said that an otherwise healthy 70-year-old whose breast cancer is detected early can expect as good a recovery as a younger women. A statistically average 70-year-old women could expect to live another seven years, according to current American longevity rates.