Publications

PURPOSE Few data are available on breast cancer characteristics, treatment, and survival for women age 80 years or older. PATIENTS AND METHODS We used the linked Surveillance, Epidemiology and End Results-Medicare data set from 1992 to 2003 to examine tumor characteristics, treatments (mastectomy, breast-conserving surgery [BCS] with radiation therapy or alone, or no surgery), and outcomes of women age 80 years or older (80 to 84, 85 to 89, > or = 90 years) with stage I/II breast cancer compared with younger women (age 67 to 79 years). We used Cox proportional hazard models to examine the impact of age on breast cancer-related and other causes of death. Analyses were performed within stage, adjusted for tumor and sociodemographic characteristics, treatments received, and comorbidities. Results In total, 49,616 women age 67 years or older with stage I/II disease were included. Tumor characteristics (grade, hormone receptivity) were similar across age groups. Treatment with BCS alone increased with age, especially after age 80. The risk of dying from breast cancer increased with age, significantly after age 80. For stage I disease, the adjusted hazard ratio of dying from breast cancer for women age > or = 90 years compared with women age 67 to 69 years was 2.6 (range, 2.0 to 3.4). Types of treatments received were significantly associated with age and comorbidity, with age as the stronger predictor (26% of women age > or = 80 years without comorbidity received BCS alone or no surgery compared with 6% of women age 67 to 79 years). CONCLUSION Women age > or = 80 years have breast cancer characteristics similar to those of younger women yet receive less aggressive treatment and experience higher mortality from early-stage breast cancer. Future studies should focus on identifying tumor and patient characteristics to help target treatments to the oldest women most likely to benefit.

CONTEXT: Despite increased focus on improving palliative care in the emergency department (ED), there is little research on how to best address the specific needs of this patient population.

OBJECTIVES: To better understand the experiences of acutely symptomatic patients seen in the ED.

METHODS: Using in-person semi-structured interviews, we explored the attitudes, experiences, and beliefs of 14 patients and seven family caregivers on the inpatient palliative care consult service, who had been admitted through the ED at two academic medical centers. We used a grounded theory approach to code responses. Transcripts were coded by a palliative medicine physician, an emergency medicine physician, and a general internist. Discrepancies were resolved by consensus. Coded sections were iteratively reviewed for interpretation, and concepts were collapsed into themes.

RESULTS: Five distinct themes emerged: 1) unprepared for managing symptoms at home; 2) uncertainty and anxiety; 3) communication is essential; 4) mixed experiences with symptom management; and 5) conflicting perspectives about the purpose of palliative care clinicians in the ED.

CONCLUSION: Patients and caregivers identified systems, communication, and clinical issues in ED care that should be a focus for future research.

BACKGROUND: Prognostic information is becoming increasingly important for clinical decision-making.

OBJECTIVE: To develop and validate an index to predict 5-year mortality among community-dwelling older adults.

DESIGN AND PARTICIPANTS: A total of 24,115 individuals aged >65 who responded to the 1997-2000 National Health Interview Survey (NHIS) with follow-up through 31 December 2002 from the National Death Index; 16,077 were randomly selected for the development cohort and 8,038 for the validation cohort.

MEASUREMENTS: 39 risk factors (functional measures, illnesses, behaviors, demographics) were included in a multivariable Cox proportional hazards model to determine factors independently associated with mortality. Risk scores were calculated for participants using points derived from the final model's beta coefficients. To evaluate external validity, we compared survival by quintile of risk between the development and validation cohorts.

RESULTS: Seventeen percent of participants had died by the end of the study. The final model included 11 variables: age (1 point for 70-74 up to 7 points for >85); male: 3 points; BMI <25: 2 points; perceived health (good: 1 point, fair/poor: 2 points); emphysema: 2 points; cancer: 2 points; diabetes: 2 points; dependent in instrumental activities of daily living: 2 points; difficulty walking: 3 points; smoker-former: 1 point, smoker-current: 3 points; past year hospitalizations-one: 1 point, >2: 3 points. We observed close agreement between 5-year mortality in the two cohorts; which ranged from 5% in the lowest risk quintile to 50% in the highest risk quintile in the validation cohort.

CONCLUSIONS: This validated mortality index can be used to account for participant life expectancy in analyses using NHIS data.

OBJECTIVES: To exfamine patient perceptions of physician discussions and recommendations about total joint arthroplasty (TJA).

DESIGN: Prospective cohort study.

SETTING: One large academic medical center and four community affiliates in Boston.

PARTICIPANTS: One hundred seventy-four patients aged 65 and older with severe osteoarthritis of the hip or knee for at least 6 months not controlled with medications.

MEASUREMENTS: Patient perceptions of primary care physicians' (PCPs) and orthopedists' communication about TJA were assessed at baseline for all patients and at 12 months for those who did not undergo surgery.

RESULTS: Of the 174 patients, 49 were aged 80 and older, 82% were non-Hispanic white, and 69% had knee osteoarthritis. Eighty-seven percent of individuals with baseline interviews and a PCP (142/163) reported that they had discussed their hip or knee arthritis with their PCP at baseline, and 26% (42/163) reported that their PCP discussed TJA as a treatment option. Of the 128 patients who saw an orthopedist, 65% reported that their orthopedist recommended TJA. Only 29% (51/174) of patients underwent TJA. Those who reported discussing TJA with their PCP at baseline were more likely to undergo TJA (P<.01). Thirty-six percent (44/123) of the patients who did not undergo TJA reported that their PCP discussed surgery as a treatment option at baseline or at 12month follow-up.

CONCLUSION: Patients with severe osteoarthritis of their hip or knee who report discussing TJA as a treatment option with their PCP are more likely to undergo TJA within the next year, but few older adults report having these discussions. Improvement is needed in communication between PCPs and patients about TJA.

STUDY OBJECTIVE: Although the focus of emergency care is on the diagnosis and treatment of acute illnesses and injuries or the stabilization of patients for ongoing treatment, some patients may benefit from a palliative approach. Little is known about delivering palliative care in the emergency department (ED). We explore the attitudes, experiences, and beliefs of emergency providers about palliative care in the ED, using structured qualitative methods.

METHODS: We studied 3 focus groups with 26 providers, including 14 physicians (10 residents, 4 attending physicians), 6 nurses, 2 social workers, and 4 technicians, working in 2 academic EDs in Boston. We used a grounded theory approach to code responses, resolving discrepancies by consensus.

RESULTS: Six distinct themes emerged: (1) participants equated palliative care with end-of-life care; (2) participants disagreed about the feasibility and desirability of providing palliative care in the ED; (3) patients for whom a palliative approach has been established often visit the ED because family members are distressed by end-of-life symptoms; (4) lack of communication between outpatient and ED providers leads to undesirable outcomes (eg, resuscitation of patients with a do-not-resuscitate order); (5) conflict around withholding life-prolonging treatment is common (eg, between patient's family and written advance directives); and (6) training in pain management is inadequate.

CONCLUSION: Providers ranked improved communication and documentation from outpatient providers as their highest priority for improvement. Attitudinal and structural barriers may need to be overcome to improve palliative care in the ED. Despite targeted recruitment, attending physician participation was low.

PURPOSE: To examine outcomes of mammography screening among women > or = 80 years to inform decision making.

PATIENTS AND METHODS: We conducted a cohort study of 2,011 women without a history of breast cancer who were age > or = 80 years between 1994 and 2004 and who received care at one academic primary care clinic or two community health centers in Boston, MA. Medical record data were abstracted on all screening and diagnostic mammograms, breast ultrasounds and biopsies performed, all breast cancers diagnosed through December 31, 2006, and on sociodemographics. Date and cause of death were confirmed using the National Death Index.

RESULTS: The majority of patients (78.6%) were non-Hispanic white and 51.4% (n = 1,034) had been screened with mammography since age 80 years. Among women who were screened, eight were diagnosed with ductal carcinoma in situ, 16 with early stage disease (1.5%), two with late stage disease, and one died as a result of breast cancer. Many (110; 11%) experienced a false-positive screening mammogram that led to 19 benign breast biopsies, eight refused work-up, and three experienced a false-negative screening mammogram; 97 were screened within 2 years of their death from other causes. There were no significant differences in the rate, stage, recurrence rate, or deaths due to breast cancer between women who were screened and those who were not screened.

CONCLUSION: The majority of women > or = 80 years are screened with mammography yet few benefit. Meanwhile, 12.5% experience a burden from screening. The data from this study can be used to inform elderly women's decision making and potentially lead to more rational use of screening.

PURPOSE: We sought to determine how women aged 80 years or older value different preventive health measures compared to women aged 65 to 79 years.

DESIGN AND METHODS: We surveyed 107 women aged 80 years or older and 93 women aged 65 to 79 years; we randomly selected all of them from a large academic primary care practice. We measured perceived importance and priority placed on different preventive health measures, including screening tests; counseling on healthy lifestyle and geriatric health issues; immunizations; and recommendations for over-the-counter prevention medications.

RESULTS: Of the 200 women, 28.5% were aged 80 to 84 and 25.0% were aged 85 years or older. The majority of the women were non-Hispanic White (65.5%), had private insurance (82.0%), and were in good health condition (52.0%). Women aged between 65 and 79 were more likely than women aged 80 or older to consider screening tests and exercise counseling essential or very important to maintaining their health. Women aged 80 or older did not value any preventive health measure more highly than did younger women. Women who were 65 to 79 years of age ranked mammography screening as their most valued preventive health measure, with five of their top six measures being screening tests. Women who were 85 years of age or older prioritized flu shots, recommendations for aspirin, and then mammography screening.

IMPLICATIONS: Screening tests and exercise counseling are more highly valued by women aged 65 to 79 years than by women aged 80 years or older. Regardless of age, mammography screening is prioritized over other preventive health measures. Understanding how older women value different preventive health measures may help clinicians improve their preventive health counseling.

PURPOSE: We sought to examine the use of preventive health services among older women and to assess how age and illness burden influence care patterns.

METHODS: The charts of 299 women aged > or =80 and 229 women aged 65-79 years who did not have dementia or terminal illness at 1 academic primary care practice in Boston were reviewed between July and December 2005 to determine receipt of screening tests (e.g., mammography), counseling on healthy lifestyle (e.g., exercise), and/or geriatric health issues (e.g., incontinence), and immunizations. Illness burden was quantified using the Charlson Comorbidity Index (CCI).

RESULTS: Women aged > or =80 were more likely than women aged 65-79 to have a CCI of > or =3 (24.0% vs. 16.7%) and were less likely to receive all screening tests. However, receipt of mammography (47.8%) and colon cancer screening (51.2%) was still common among women aged > or =80 and was not targeted to older women in good health. Women aged > or =80 were less likely to be screened for depression (adjusted relative risk [aRR] 0.6; 95% confidence interval [CI], 0.5-0.8), osteoporosis (aRR, 0.6; 95% CI, 0.5-0.9), or counseled about exercise (aRR 0.8; 95% CI, 0.6-0.9) than younger women, but were more likely to receive counseling about falls (aRR 1.9; 95% CI, 1.4-2.6) and/or incontinence (aRR 1.8; 95% CI, 1.2-2.6). However notes documenting discussions about mood (28.6%), exercise (40.0%), falls (28.8%), or incontinence (20.8%) were low among all women.

CONCLUSION: In a comprehensive review of preventive health measures for elderly women, many in poor health were screened for cancer. Meanwhile, many older women were not screened for depression or counseled about exercise, falls, or incontinence. There is a need to improve delivery of preventive health care to older women.

BACKGROUND: Experts recommend that clinicians target mammography and colon cancer screening to individuals with at least 5 years life expectancy. Generally, immunizations and exercise counseling are recommended for all women aged > or =65 years, while Pap smears are generally not encouraged for these women.

METHODS: We used the 2005 National Health Interview Survey to examine receipt of several preventive health measures simultaneously among community dwelling US women aged > or =65 years by age and health status. We used functional status, significant diseases, and perceived health to categorize women into those most likely to be in above-average, average, or below-average health status. We used age and health status to estimate life expectancy.

RESULTS: Of 4683 participants, 25.8% were > or =80 years; 81.8% were non-Hispanic white; 21% were in above-average and 20% were in below-average health status. Receipt of mammography and colon cancer screening decreased with age and was not associated with health status for women aged > or =80 years. Nearly half (49%) of women aged > or =80 years in below-average health received mammography screening, while 19% of women aged 65-79 years in above-average health did not report receiving mammography. Nearly half of women aged 65-79 years (49%) in above-average health did not report receiving colon cancer screening. Pap smear screening was common among older women. Few (34%) reported receiving exercise counseling. Many did not report receiving pneumococcal (43%) or flu vaccinations (40%).

CONCLUSIONS: In our comprehensive review of preventive health measures for older women, we found evidence to suggest a need to improve delivery and targeting of preventive health services.