Skipping Chemo

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One of the most agonizing choices a patient with a life-threatening illness has to make is when to put quality of life ahead of length of life. Case in point: chemotherapy after breast-cancer surgery. Although the side effects of chemo (among them nausea, fatigue and hair loss) can be brutal, the treatment does work: patients who go through it will, on average, live longer. So I was surprised to read in the current issue of Annals of Internal Medicine that only 29% of breast-cancer patients actually take their doctor's advice and get chemotherapy after surgery. Even more striking was the breakdown by age. While 66% of women 45 and younger go in for chemo, the numbers drop to 12% for women 65 to 69.

The results are based on an examination of the medical records of more than 5,000 women who were diagnosed with breast cancer between 1991 and 1997. According to Dr. Xianglin Du, assistant professor of internal medicine and geriatrics at the University of Texas Medical Branch at Galveston and lead author of the study, there was "a clear divergence between recommendations from the National Institutes of Health and what is seen in clinical practice." The NIH guidelines, developed by experts in the field and released in November 2000, found "substantial" benefit from chemotherapy for both premenopausal and postmenopausal women up to age 70 and recommended post-surgical chemo in all cases in which tumors were greater than 1 cm in diameter.

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For the NIH, that's a rousing endorsement. So why are so many women ages 65 to 69 opting out?

I suspect there are a couple of reasons, one good and one not so good. The first probably stems from the definition of substantial benefit. While chemotherapy is typically thought of as life-prolonging (rather than lifesaving), its benefits definitely fall off with age. According to the Early Breast Cancer Trialists' Collaborative Group, women 50 and younger were 27% less likely to die within 10 years of surgery if they were also treated with chemo. By contrast, women 60 to 69 had their 10-year mortality rate reduced by only 8% with post-surgical chemotherapy.

The other reason seems to be a misconception about the risks and side effects of chemo. These can include impaired thought processes and increased risk of infections, and many older women believe they won't tolerate all of this as well as younger women do. That's a view not shared by many doctors. "For an otherwise healthy older woman," says Du, "the toxicities of chemotherapy should be no different than for a younger woman."

For patients and doctors alike, it's this balance of risk and benefit that ultimately decides. Dr. Alfred Chang, chief of surgical oncology at the University of Michigan Medical School, believes most women will do what their doctor recommends if the choice is properly presented. He suggests that oncologists need to be more aggressive in explaining chemotherapy's benefits. Having never had to go through it myself, I have difficulty imagining all the factors a woman — young or old — weighs when considering chemo. It's her life, and she has to make the call. All I would ask is that she arm herself with the facts before she decides.

Dr. Gupta is a neurosurgeon and a correspondent for CNN