Bridging the age gap in breast cancer. Improving outcomes for older women.

Title: Bridging the age gap in breast cancer. Improving outcomes for older women.Aims:Aim 1: To optimise the surgical treatment of older women with breast cancer.Workstreams 1 & 2. To provide an evidence-based, management algorithm to ensure older women (>70 years) with early breast cancer are offered optimal treatment with surgery & ensure that primary endocrine therapy (PET) is offered appropriately only to women who are sufficiently frail to derive little benefit from surgery. For these women we will develop a Decision Support Instrument (DSI) to facilitate informed choice.Aim 2: To optimise breast screening provision for older women.Workstream 3 & 4. To determine the optimal upper age limit at which continued mammographic screening is clinically and economically effective and to support older women in making an informed choice about ongoing screening and promoting early symptomatic presentation by the development of an information support toolBackground: Research plan.Breast cancer affects some 13 000 UK women >70 & causes the deaths of 6733 each year. Younger women with breast cancer have seen a 44% improvement in survival in the past 30 years compared to only a 19% improvement in the >70s. This relates to a combination of under-treatment & a lack of routine screening in this age group. Of concern is the widespread use of primary endocrine therapy (PET) where surgery is omitted & anti-oestrogens are used as the only treatment. Whilst this is effective in frailer older women, UK practice is highly varied, with a 4 fold variation in the rate of non-surgical treatment. Inevitably this means some women will be under treated, others over treated. This study will develop a clinical management algorithm to ensure that clinicians have easy access to the risk & benefit ratios of the choice of each treatment (surgery or PET) for each woman permitting tailored counselling. Older women themselves will be provided with decision support by the development of a DSI facilitating shared decision making.The second issue is that screening is not routinely offered to women >70. In the younger age group (50-70) screening is responsible for a 25-40% increase in breast cancer survival. Older women may self refer for screening but uptake rates are poor due to lack of screening awareness & a perception that screening unnecessary. The risk to benefit ratio of screening is less favourable with increasing age & at some point screening ceases to be beneficial. This study will develop an evidence base to inform decisions about the optimal age cut off for breast screening. In view of concerns about the lack of balanced information about the risks & benefits of screening it will also develop a tailored information support tool to facilitate screening decisions.Both projects will be based on direct data collection from cancer registries & from 22 UK Breast Units who will submit data for 2 comprehensive cohort studies. The potential for bias in cohort studies will be addressed by correction for patient health & disease state variance. These data will be used to develop 2 models to predict long term outcomes, health economic costs & Quality of Life (QoL) in screened versus non screened & surgically treated versus PET treated women.Using qualitative methods we will develop our DSI based on initial data collection from older women about their information needs & preferences. The DSI will be rigorously field tested before being made available to UK breast Units. Similarly, we will develop our screening information tool using mixed methods & then pilot & test the tool using well validated methods.Research team.The team comprises nationally & internationally recognised experts in the fields of elderly breast cancer care, health services modelling, elderly care, screening, decision support, cancer registry expertise, health services research & PPI.Research environment.The research will be led by the University of Sheffield with support from across the UK