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Decision support aids helped older women with newly diagnosed breast cancer understand the likely consequences of their treatment options. In a new study, the aids helped women come to an informed decision. The research found that using the tool, and incorporating the women’s priorities, often meant they chose less aggressive treatment.

Surgery is recommended for most women with breast cancer and chemotherapy for those with aggressive disease. But some women who are frail and older may choose to prioritise quality of life over length of life. This may mean deciding not to have surgery and having only hormone therapy; or choosing not to have chemotherapy after surgery. These treatments might help them live a little longer but can be demanding to go through.

New research explored the impact of decision aids among women over 70 who were diagnosed with breast cancer. The women either had a consultation using the decision aid or without it (standard care). Researchers found women in the centres using the decision aids were less likely to have surgery or chemotherapy.

The women were followed for an average of 3 years. Using the decision aid had little impact on their chances of being alive at 3 years. This suggests that the decision aids were well-targeted and used with women for whom the treatment choice would make least difference to their length of life.

The study found women who used decision aids were better informed about their treatment options. There was little difference in quality of life between women who used the decision aids and those who did not.

Further information on breast cancer treatment is available on the NHS website.

What’s the issue?

As the population ages, more people aged 70 and over are being diagnosed with cancer. But research into treatment for older age groups has been lacking.

Some doctors offer older women treatment that is likely to prolong their life as much as possible; others may offer less aggressive treatment. Key decisions around treatment for breast cancer in this age group are:

  • whether to have surgery to remove the cancer plus hormone treatment, or just hormone treatment
  • after surgery, whether or not to have chemotherapy.

Not every woman needs to make this decision. For some types of breast cancer, there is a clear best approach. Most women aged under 70 will be recommended surgery. Those with high-risk breast cancer will be recommended chemotherapy because it has been shown to improve the chances of living longer.

However, if a woman is frail and unwell, the life years gained by treatment may be short. Some women may prefer to accept the chance of a slightly shorter life and avoid the demands of surgery or chemotherapy.

Part of the difficulty in making treatment recommendations for women in their 70s is the variation in their fitness levels, other illnesses, and likely life expectancy. Women also vary in their own priorities and wishes about treatment.

This study is part of a programme to help determine the best way to treat older women with breast cancer. It tested decision aids designed for women over 70. They received a leaflet along with information from a computer algorithm, which uses information on women’s fitness, frailty, cancer stage and biology to calculate their  chances of survival with each treatment choice. The algorithm is based on national data on cancer survival.

The aim of decision aids is to help women make decisions based on their own situation and priorities. Researchers wanted to see whether having this extra information changed women’s decisions about treatment. They wanted to know whether this affected their quality of life, and how likely they were to be alive 3 years after diagnosis.

What’s new?

The study included 46 hospitals treating women for breast cancer. Staff at half the hospitals were trained to use two decision aids (one for whether to have surgery, the other for whether to have chemotherapy). These staff were encouraged to use the decision aids when discussing treatment options with women over 70 with breast cancer. In total, 1,339 women were included in the study.

Women who used decision aids were less likely to choose to have surgery or chemotherapy. However, they were not more likely to die from their cancer during the 3 years of follow-up. The study found women who used decision aids were better informed about their treatment options. There was little difference in quality of life between women who used the decision aids and those who did not.

The study found that:

  • more women (21%) chose not to have surgery and had hormone therapy alone at hospitals using decision aids, compared with those (15%) at hospitals not using decision aids
  • fewer women (10%) had chemotherapy at hospitals using decision aids, compared with those (15%) at hospitals not using decision aids
  • most (90%) women in hospitals in both groups were still alive after 3 years; there was no meaningful difference
  • more women (94%) at hospitals using decision aids said they knew about their treatment options, compared with those (74%) at hospitals not using decision aids; women who had used decision aids got higher scores in a test of their knowledge of treatment options.

Why is this important?

The aim of a decision aid is to support people’s autonomy and help them make informed decisions based on their own priorities. These results suggest that older women may be more conservative than their doctors when making treatment choices for breast cancer. They prioritised quality of life and independence over length of life.

The results suggest that – in the short term at least – using the decision aid did not reduce length of life. Longer follow-up of these women will reveal how treatment choice affects older women’s length of life. But the results suggest that some women over 70 can safely be offered a choice of treatment. Using a decision aid may help them to make the choice that is right for them.

Fewer women than expected used a decision aid when it was offered.  In addition, staff changes, their preferences, a lack of IT in consulting rooms and security firewalls in some Trusts’ IT systems contributed to low use. The researchers say that introducing decision aids will be challenging.

What’s next?

The online tools – which include leaflets that can be downloaded and printed – have been approved by the UK Medicines and Healthcare products Regulatory Agency (MHRA). They are freely available and have already been used more than 10,000 times. They are intended to be used by clinicians and patients together.

This study is part of a wider project on older women with breast cancer. Other studies in the project have found, for example, that chemotherapy reduced the chances of a cancer recurring but only increased length of life in some groups of older women (those with cancers not stimulated by the hormone oestrogen, called ER-negative cancers). Having chemotherapy reduced quality of life at 6 months but this had resolved after 18 months. This sort of information informs women’s decision-making.

The research team is now refining the decision aids, using results from their other research projects. They are adding information about how treatments affect women’s long-term survival and quality of life. They then want to test the decision aids to see whether this makes a further difference to the choices women make.

You may be interested to read

This NIHR Alert is based on: Wyld L, and others. Bridging the age gap in breast cancer: cluster randomized trial of two decision support interventions for older women with operable breast cancer on quality of life, survival, decision quality, and treatment choices. BJS 2021;108:5

A research paper about the impact of chemotherapy on quality of life in women with breast cancer: Battisti N.M.L, Reed M.W.R, Herbert E. and others. Bridging the Age Gap in breast cancer: Impact of chemotherapy on quality of life in older women with early breast cancer. European Journal of Cancer 2021;144:269e280

A research paper about the impact of omitting surgery in breast cancer treatment: Wyld L, Reed M.W.R, Morgan J. and others. Bridging the age gap in breast cancer. Impacts of omission of breast cancer surgery in older women with oestrogen receptor positive early breast cancer. A risk stratified analysis of survival outcomes and quality of life. European Journal of Cancer 2021;142:48e62

The Age Gap website includes the decision support aids and links to all publications from the project.

Support and information is available from expert nurses on Breast Cancer Now’s free Helpline. Call 0808 800 6000.

Breast cancer surgery is safer for older women than has been assumed: a previous NIHR Alert on a wide study which looked at the overall safety of breast surgery for older women.

 

Funding: This research was funded by the NIHR Programme Grants for Applied Research programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Commentaries

Study author

We know from other research that older women value being able to stay independent. They don’t want to go into a nursing home or be looked after by relatives. They want to hold on to their independence as long as possible. A few extra months of life at the expense of their independence isn’t worth it.I thought more people would be going for more aggressive treatment. Our most interesting finding was that people given the choice were choosing less aggressive treatment. That’s counter to the medical model. All the scenarios in the decision aid show a slight survival disadvantage for less aggressive treatment. But they saw the data and went for the less aggressive treatment.I was pleased there was no meaningful survival disadvantage, although we only have 36 months follow up; we will need to look at it again later. I was reassured that the tool was safe to use; the clinicians selected appropriate patients.Lynda Wyld, Professor of Surgical Oncology, Department of Oncology and Metabolism, University of Sheffield 

Breast Cancer Now

We’ve long voiced our concerns that many older women with breast cancer are offered limited treatment options due to assumptions around their frailty and a sole focus on quality of life, when we believe decisions must also be based on which treatment could be most effective for them. Multiple factors must inform the development of any treatment plan. In addition to age, other medical conditions, physical health and social circumstances must all be considered, as well as each individual’s personal preference.Decision-making tools can equip patients with the necessary information about the most effective treatments and what is involved for them to jointly decide on a treatment plan with their healthcare professionals, to best meet their needs. We therefore hugely welcome this research highlighting that a ‘one size fits all’ approach does not work when it comes to making treatment decisions for older women.Kotryna Temcinaite, Senior Research Communications Manager, Breast Cancer Now

Member of the public

This research has a potentially significant part to play in older women's decision making. Because surgery is a well-established treatment for breast cancer, any departure from the "norm" will be seen as less effective and the patient will need support to agree to the new approach.Breast scans are not automatic for this age group, and this is an important issue in an aging society.Annabel Dawson, Public Contributor, Houghton-le-Spring 

Clinician and researcher 

This research paper should encourage the use of decision aids in information exchange and decision-making. It will inform discussions with patients and these findings can be considered in future audit and research activities. This is a well written paper reporting a well conducted major research endeavour in a very difficult area.David Dodwell, Professor of Clinical Oncology and Consultant Clinical Oncologist, Leeds Cancer Centre; Lead Oncologist on National Breast Cancer Audits 
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