Impact on Functionality
In all surgery classes, among surviving patients, 1-year functional decline was significant, based on changes in mean MDS-ADL scores, which increase as independence decreases. MDS-ADL scores for patients who underwent mastectomy alone increased an average of 4.1 points, scores after lumpectomy increased an average of 2.8 points, and after either procedure with ALND scores increased an average of 4.6 points. Preoperative ADL and cognitive status were also associated with declines in postoperative scores.1
The functional decline seen in these patients following breast cancer surgery occurred at a rate similar to that found in a study that investigated outcomes in 6822 nursing home residents who underwent colectomy for colon cancer from 1999 to 2005. The average increase in MDS-ADL in that study was 3.9 points 1 year after surgery, and the 1-year mortality rate was 53%.2
Preoperative MDS-ADL scores also correlated with an increased risk of mortality 1 year after surgery; hazard ratios for this analysis were 1.80 (95% CI, 1.35-2.39; P<.001) for mastectomy alone, 1.92 (95% CI, 1.23-3.00; P=.004) for lumpectomy alone, and 1.77 (95% CI, 1.46-2.15, P<.001) for a procedure with ALND.1
Commenting on these results, Jessica Y. Liu, MD, MS, Emory University in Atlanta, and Karl Y. Bilimoria, MD, MS, Northwestern University in Chicago, noted that these findings “highlight the poor outcomes in the high-risk nursing home geriatric population for what is generally considered a low-risk procedure.”3
These study findings suggest that risk of 1-year mortality and functional decline are higher for elderly female nursing home residents compared with younger community-dwelling women who undergo breast cancer surgery. These data for provide cautionary information to consider when offering breast cancer surgery to frail older women with cognitive and significant functional impairment. Although surgery is often considered as a curative treatment, it can lead to worse and more life-limiting postoperative issues for frail, elderly nursing home residents. Therefore, multimodality therapy may be an appropriate alternative therapy in this population.
1. Tang V, Zhao S, Boscardin J, et al. Functional status and survival after breast cancer surgery in nursing home residents [published online August 29, 2018]. JAMA Surg. doi: 10.1001/jamasurg.2018.2736
2. Finlayson E, Zhao S, Boscardin WJ, Fries BE, Landefeld CS, Dudley RA. Functional status after colon cancer surgery in elderly nursing home residents. J Am Geriatr Soc. 2012;60(5):967-973.
3. Liu JY, Bilimoria KY. Surgical decision making in elderly, impaired nursing home patients [published online August 29, 2018]. JAMA Surg. doi: 10.1001/jamasurg.2018.2737