01.05.10
Tackling age discrimination in breast cancer services
Jeremy Hughes , CEO of Breakthrough Breast Cancer, explains why the charity has launched its Every Chance campaign to open the debate around age equality in breast cancer and called for breast cancer treatment to be based on clinical need rather than age
Michael Marmot’s report Fair Society, Healthy Lives presents a challenging picture of the health inequalities which, despite massive increases in NHS funding, have remained doggedly intact. Whilst basic health provision and care for all has improved, the gap between top and bottom has not decreased. At the same time, the new equality legislation and the NHS Constitution make clear commitments to ending discrimination. The need for action is particularly true when we consider our ageing population and the growing number of older women who will be affected by breast cancer.
Breast cancer risk increases with age, and a third of all breast cancers occuring in women aged 70 and over. As life expectancy increases, we will see this proportion rise and the total number of breast cancers diagnosed each year in the UK will rise from 46,000 today to an estimated 57,000 in 2024.
The challenge of age discrimination in breast cancer starts even before diagnosis. The highly effective NHS breast screening programme is estimated to save at least 1,400 lives a year in England. Invitations to attend screening are sent to all women aged 50-70. This means as risk increases, screening invitations stop. The government has committed to extending the programme to invite women aged 47-73, but this is dependent on the introduction of digital mammography, which is happening painfully slowly. Although funding has been provided, it has not been ringfenced and the fact that only 31 of our 83 screening programmes in England had even one digital machine by September 2009, suggests the money is being spent elsewhere, thus delaying the extension of life-saving screening.
But even the extension to age 73 hardly solves the problem. Women over 70 can make their own screening appointments. However, a survey by Breakthrough Breast Cancer showed 98% of women over 70 did not attend screening and 97% did not realise they are at greater risk of developing the disease. We need to inform and empower these women and encourage trusted sources of information, such as GPs, to promote screening. Breakthrough’s survey also found that only19% of GPs inform a patient over 70 that she can request a free screening appointment.
Once diagnosed, treatment decisions can also depend on age and geographic location. Figures show that breast cancer patients over 80 are 40 times less likely to receive surgery, whilst data from the Breast Cancer Clinical Outcome Measures (BCCOM) Project, a pioneering audit of breast cancer treatment funded by Breakthrough Breast Cancer, suggests regional differences in breast cancer care. A recent study of ten hospitals in Eastern England alone showed wide variations in the treatment provided to women over 70.
The problem of chronological age rather than biological age determining treatment options also applies to access to radiotherapy. In 2006, only 74% of patients aged 70 and over with conservatively treated invasive breast cancer had radiotherapy treatment compared to 84% of those aged under 70.
Cases such as that of Daphne Cook who, ten years ago, was almost denied access to life-saving radiotherapy because the travel was judged as too difficult are still occurring today. Luckily for Daphne, her daughter, a health professional, was with her and questioned the reasoning of the consultant. Daphne, 87, a grandmother of seven and great-grandmother of six, said: “I didn’t understand the importance of radiotherapy treatment and I certainly wouldn’t have pushed for it. I feel lucky my daughter asked whether this was a clinical decision or one based on mode of transport. I’m glad to say I’ve had over 10 years of good health since my treatment to enjoy my family growing up.”
There are many barriers for older patients in accessing clinical trials of new treatments. All patients over 70 might be excluded because co-morbidities of some can change results and affect the success of the trial. This is turn means that clinicians do not have data on the efficacy of a treatment for that age group and may not prescribe it. In 2006, 41% of all patients with surgically treated invasive breast cancer were recorded as having received chemotherapy, but this was only 16% in patients aged 70 and over.
There is no doubt that frailty and fitness should be taken into account when considering appropriate treatment for breast cancer. Patients themselves should be empowered to make informed decisions, be given full information on the options available and support in assessing these. Feedback from patients received by Breakthrough shows that all too often the information and choice is not available to older patients. Supporting this decision-making is one of the vital roles played by clinical nurse specialists although they are facing very real threats as trusts review their budgets.
Breast cancer is the UK’s most common cancer. It is women’s greatest health concern. It is a disease where scientific advances have meant dramatic improvements in treatment and survival rates. Yet older women are not benefitting fully from these improvements and our performance remains behind much of Europe.
Breakthrough has a strong record of working with clinicians and managers to drive up service standards, for example through the acclaimed Breast Cancer Service Pledge. We will now extend our work with health care professionals and NHS leaders to tackle age discrimination in breast cancer services through our Every Chance campaign.
All patients should be given every chance to beat breast cancer, regardless of their age. From screening to surgery to radiotherapy and chemotherapy, we must stop age being used to deny women treatment and access. 12,000 women a year die from breast cancer. Some of these do so simply because they are judged too old.
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