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PAPERS: Niels Kroman, Maj-Britt Jensen, Jan Wohlfahrt, Henning T Mouridsen, Per Kragh Andersen, Mads Melbye, Andrew Tutt, and Gillian Ross Factors influencing the effect of age on prognosis in breast cancer: population based study • Commentary: much still to learn about relations between tumour biology, prognosis, and treatment outcome in early breast cancer BMJ 2000; 320: 474-479 [Abstract] [Full text]

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Factors influencing the effect of age on prognosis in breast cancer

Richard Sainsbury   (20 March 2000)

Factors influencing the effect of age on prognosis in breast cancer 20 March 2000
Richard Sainsbury, Consultant Surgeon Royal Infirmary, Huddersfield Send response to journal: Re: Factors influencing the effect of age on prognosis in breast cancer	Dear Sir The paper by Kroman et al (1) has important implications for service delivery with increased amounts of chemotherapy required for young women. The authors imply, but do not state explicitly, that only women at high risk received adjuvant chemotherapy. 36.3% of their 867 patients under 35 fell into the low risk group and it was among them that the excess mortality associated with not receiving chemotherapy was seen. We used the Yorkshire Cancer Registry (now part of NYCRIS –Northern and Yorkshire Cancer Registration and Information Service) to see what the uptake of chemotherapy was for this group of patients over the 15 year period 1980 – 1994 and examined if this affected survival. We found data on 1534 patients under age 35 of whom only 304 (19.8%) received adjuvant chemotherapy. The 5-year overall survival for this group was 60% (95% confidence intervals 54.8-65.8) for those receiving chemotherapy and 63% (60.6-66.0) for those who did not. Forty one patients presented with overt metastatic disease, if they are excluded from the analysis the 5-year survival rates increased to 63% and 64% respectively. The paper from Denmark does not give 5-year survival rates and thus direct comparisons are not possible. There was no significant improvement in survival for those receiving chemotherapy for either the individual time cohorts or the group as a whole. A Wilcoxon (Breslow) test for equality of survivor functions showed no significant differences between the groups receiving chemotherapy and those who did not (p=0.31) The percentage of chemotherapy usage in this age group increased from 8% in the years 1980-84 to 17% in 1985-1989 and to 32% in 1999-1994. Reasons for the lower levels of chemotherapy in Yorkshire over this time can be related to the relative lack of surgical specialisation and lack of non-surgical oncology. The Danish patients were all included in trials where chemotherapy was used. We have previously shown large variations in chemotherapy and radiotherapy usage in Yorkshire (2) with a deleterious effect for the whole breast cancer population receiving suboptimal therapy (3). Chemotherapy may only have been given selectively to the under 35s with conventional poor prognostic features and thus no overall effect seen. With the end of high dose chemotherapy as an evidence-based option the optimum type of chemotherapy for this group of patients needs defining. 1. Kroman N, Jensen M-B, Wohlfahrt J et al. Factors influencing the effect of age on prognosis in breast cancer: a population based study. BMJ 2000; 320: 474-9 2. Does it matter where you live? Treatment variation for breast cancer in Yorkshire. Sainsbury JRC, Johnston C, Rider L and MacAdam WFA. Brit J Cancer 1995; 71: 1275-1278 3. Survival from breast cancer. Influence of clinician workload and patterns of treatment on outcome. Sainsbury JRC, Haward R, Rider L, Johnston C and Round C. Lancet 1995; 345: 1265-1270