Clinical teams urged to routinely assess frailty in older women with breast cancer

A leading surgeon has urged doctors and nurses to routinely assess frailty and cognition among women aged 70 and over with suspected breast cancer, to identify potential health care needs when considering future treatment options.

Professor Kieran Horgan is a consultant breast surgeon and the clinical lead for surgery on the National Audit of Breast Cancer in Older Patients (NABCOP).  He commented as the 2020 Annual Report from the NABCOP was published. This analysed the care and outcomes for 185,648 women, aged 50 years and over, who were diagnosed with breast cancer between 1 January 2014 and 31 December 2018, in England and Wales. The audit evaluated the care and outcomes for women with breast cancer aged 70 and over, and compared this to a younger cohort of women aged between 50 and 69.

It found that older women with oestrogen positive tumours (ER+ breast cancer) were less likely to have surgery for their breast cancer - and instead received primary endocrine treatment.  The audit revealed wide variations in rates of surgery across NHS organisations for older women with ER+ breast cancer for those women aged 75 and over, with the rate being under 50% at some NHS trusts and over 80% at others. Breast cancer among older patients has similar characteristics to that of younger patients, and the audit found that there is no evidence that invasive breast cancer is a more benign disease in older patients. Variations in practice are therefore concerning.

Professor Horgan said: “Worryingly, the audit showed that apparently fit older women were less likely to undergo surgery if they had an oestrogen positive breast cancer tumour. There could be valid reasons why some patients did not have surgery. If, for example, a patient had heart disease, it could increase the risks of them having complications from a general anaesthetic. However, it is vital that there is equity of care for older people, particularly with regards to assessing a person’s suitability for surgery. This must be done by examining an individual’s fitness and not purely be based on chronological age.”

NABCOP has introduced a new ‘fitness assessment form’ to be used for patients aged 70 and over when they are first seen in hospital for suspected breast cancer. This comprises the Clinical Frailty Scale, the Abbreviated Mental Test Score and screening questions on significant medical problems. The form enables information about fitness to be available at the multi-disciplinary meeting to aid decision making and to help ensure that older women are not denied an opportunity to have potentially beneficial and life prolonging surgery.

The NABCOP 2020 Annual Report recommends that women should receive all components of the triple diagnostic assessment (TDA) at their initial clinic visit for suspected breast cancer in line with the National Institute for Health and Care Excellence (NICE) recommendations.  The audit found that variation remained between NHS organisations with a number of breast units having less than 70% of patients recorded as having TDA in a single visit. 

Prof Horgan also appealed to NHS hospitals to submit data on the care of older patients with breast cancer to the national cancer registries.  He said: “Many women will have been offered alternative treatment in the form of an anti-hormone tablet, while they wait for surgery. However, it is vital that we track the care and outcomes of patients during this time so that we can ensure quality of care is maintained.  It is crucial that hospitals continue data submissions and sense check them. We need the full multi-disciplinary team to engage with this and ensure that they understand and know their hospital’s data. 

Notes to editors

The National Audit of Breast Cancer in Older Patients (NABCOP) can be read here https://www.nabcop.org.uk/reports/nabcop-2020-annual-report/

The audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP), and is being carried out by the Royal College of Surgeons of England and the Association of Breast Surgery. The audit evaluated the care provided to women aged 70 years or older by NHS breast cancer services in England and Wales. It examined the care pathway of breast cancer patients from their initial diagnosis to the end of primary treatment.

The Royal College of Surgeons of England is a professional membership organisation and registered charity, which exists to advance surgical standards and improve patient care. 

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