Breast Cancer Surgery Could Be More Dangerous For Nursing Home Patients Than Cancer

Surgery is a mainstay of breast cancer treatment. For most women, it offers a good chance of a cure. But for frail nursing home residents, breast cancer surgery can harm health and even hasten death, researchers reported Wednesday in the journal JAMA Surgery.

Some experts are now questioning why patients who are fragile and advanced in age are screened for breast cancer, let alone given aggressive treatment. The researchers examined the records of nearly 6,000 nursing home residents who underwent inpatient breast cancer surgery the past decade. They found that 31 percent to 42 percent died within a year of the procedure.

That’s significantly higher than the 25 percent of nursing home residents who die in a typical year, said Dr. Victoria Tang, lead author and an assistant professor of geriatrics and hospital medicine at the University of California-San Francisco.

Tang’s study doesn’t include information about causes of death. But she said she suspects that many of the women died of underlying health problems or complications related to surgery, which can further weaken older patients.

Patients who were the least able to take care of themselves before surgery, for example, were the most likely to die within the following year. Dementia also increased the risk of death.

It’s unlikely that many of the deaths were due to breast cancer, which often grows slowly in the elderly, Tang said. Breast cancers often take a decade to turn fatal.

Study co-author Dr. Laura Esserman is director of the UCSF breast cancer center.

“When someone gets breast cancer in a nursing home, it’s very unlikely to kill them,” she said. “They are more likely to die from their underlying condition.”

Yet most patients in the study got sicker and less independent in the year following breast surgery.

Among patients who survived at least one year, 58 percent suffered a serious downturn in their ability to perform “activities of daily living,” such as dressing, bathing, eating, using the bathroom or walking across the room.

Women in the study, who were on average 82 years old, suffered from a variety of life-threatening health problems even before being diagnosed with breast cancer. About 57 percent suffered from cognitive decline, 36 percent had diabetes, 22 percent had heart failure, 17 percent had chronic lung disease and 12 percent had survived a heart attack.

Dr. Deborah Korenstein, chief of general internal medicine at New York’s Memorial Sloan Kettering Cancer Center, said the high mortality rate in the study is striking because breast surgery is typically considered a low-risk procedure.

The researchers provided an example of how a sick, elderly person can suffer from surgery.

An 89-year-old woman with dementia who underwent a mastectomy became confused after surgery and pulled off all her bandages. Health care workers had to restrain her in bed to prevent her from pulling off the bandages again.

The woman died 15 months later of a heart attack.

Surgery late in life is more common than many realize. One third of Medicare patients undergo surgery in the year before they die, a research team reported in The Lancet in 2011. Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week.

Nearly 1 in 5 women with severe cognitive impairment, such as Alzheimer’s disease, get regular mammograms, according to a study in the American Journal of Public Health.

The new study leaves some important questions unanswered.

The paper didn’t include healthier nursing home residents who are strong enough to undergo outpatient surgery, said Dr. Heather Neuman, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health. These women might fare better than those who are very ill.

Esserman and Tang said their findings suggest doctors need to treat breast cancer differently in very frail patients.

“People think, ‘Oh, a lumpectomy is nothing,’” Esserman said. “But it’s not nothing in someone who is old and frail.”

In recent years, doctors have tried to scale back breast cancer therapy to help women avoid serious side effects. In June, for example, researchers announced that sophisticated genetic tests can help predict which breast cancers are less aggressive – a finding that could allow 70 percent of patients to avoid chemotherapy.

The Medicare database used in the study didn’t mention whether any of the patients had chemotherapy, radiation or other outpatient care.

The researchers acknowledged that they can’t rule out the possibility that some of the women suffered complications due to these other therapies. But in general, they noted, only 6 percent of nursing home residents with cancer are treated with chemotherapy or radiation.

The authors said doctors should give very frail patients the option of undergoing less aggressive therapy, such as hormonal treatments. In other cases, they could offer to simply treat symptoms as they appear.

Korenstein, of the Sloan Kettering institute, said the study raises questions about the value of screening nursing home residents for breast cancer.

The American Cancer Society hasn’t set an upper age limit for breast cancer screening. It advises women to be screened as long as they’re in good health and expected to live at least another decade.

Residents of nursing homes generally can’t expect to live long enough to benefit from breast screening, Korenstein said.

“It makes no sense to screen people in nursing homes,” Korenstein said. “The harms of doing anything about what you find are far going to outweigh the benefits.”

Liz Szabo, Kaiser Health News
Kaiser Health News (KHN) is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.