Jordan is a middle-income country with an estimated total population of 10 million, the majority of them are the younger generation, and only 3.7% are 65years or older [15]. However, given the changing demographics and health care, this group is expanding rapidly.

Age is an important risk factor for breast cancer. However, data on whether patients age at diagnosis is also related to breast cancer treatment outcomes and survival in our region is lacking. Life expectancy for Jordanian females is significantly lower compared to Western societies [16].

Our data presented in this paper shows that chemotherapy and surgery were not aggressively used to treat a significant proportion of our patients, especially those with metastatic disease. Less than two-thirds of those with non-metastatic disease and only 14% of those with metastatic disease received chemotherapy. Similarly, surgical interventions were less aggressive. Less than a third had BCS while sLN biopsy was performed on 38.0% and axillary dissection was performed less often than younger patients [17]. Though breast reconstructive surgery is not commonly performed in our region, less than 5% of our older patients included in this study had it.

Avoidance of both surgery and chemotherapy in this age group was also reported in Western literature [18]. Hormonal therapy use as the sole therapy for breast cancer increases with age. One study at UK hospitals showed an increase from 2.8% in patients aged 6569years to 40.3% among patients aged 70years or older [19]. Furthermore, it has been shown in previous studies that older women are less likely to receive adjuvant radiotherapy [4, 20, 21].

Variation in the rate of surgery for breast cancer persists even in the same hospital. In one study that utilized data on over 17,000 women aged 70years or more with ER-positive operable breast cancer from two UK regional cancer registries demonstrated considerable variation in rates of surgery. Despite adjusting for case-mix, this variation persisted at the hospital level [10]. Utilizing the Charlsons Index of co-morbidity, Giordano and colleagues reported that among women aged 75years or older treated for breast cancer with clinical stage I-IIIa, the odds of having surgery in accordance with the guidelines were 0.32 (95% confidence interval (CI) 0.20 to 0.51) times lower than those of 5564-year-old [22].

Because treatment decisions for such older patients are based mostly on age rather than health status or potential benefit, objective tools that assess the fitness and functional status of older patients for the planned cancer treatment is highly needed [23, 24]. A study from Sweden that included 4453 women diagnosed with breast cancer in Malm University Hospital between 1961 and 1991 looked at the effect of age on breast cancer-specific mortality. When adjusted for potential confounders, including stage at diagnosis, age was a significant factor only for patients aged 80years or more [25].

Based on women diagnosed with breast cancer between 2008 and 2014, the 5-year OS rate, published by the American Cancer Society, based on SEER (Surveillance, Epidemiology, and End Results)-database, for patients with stage IV disease is 27% [26]. This number had increased from 22% in 2012 [27]. The SEER database, however, does not group cancers by the American Joint Committee on Cancer (AJCC) TNM stages, instead, it groups cancers into localized, regional, and distant stages. The 5-year OS rates for patients with regional disease is 85%. Our survival rates are a little lower. However, the two populations are not comparable. Several of the known poor prognostic pathological features, like positive axillary lymph nodes and high-grade tumors are more prevalent in our patient population compared to what was reported in Western literature. The prevalence of comorbidities among our population, in general, is high enough to explain our lower life expectancy and this obviously affect the aggressiveness of anticancer therapy for this population and may be another factor to explain this difference in OS.

Our study is not without limitations. This is a retrospective study with limited data on potentially important factors like performance status, detailed comorbidities and social support. Though our study is a single-institution one, our center treats over two-thirds of all breast cancer patients in the country.

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Tumor characteristics and treatment outcomes of older patients with breast cancer in Jordan - BMC Blogs Network

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