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Objectives\ud \ud Approximately 20% of UK women aged 70+ with early breast cancer receive primary endocrine therapy (PET) instead of surgery. PET reduces surgical morbidity but with some survival decrement. To complement and utilize a treatment dependent prognostic model, we investigated the cost-effectiveness of surgery plus adjuvant therapies versus PET for women with varying health and fitness, identifying subgroups for which each treatment is cost-effective.\ud \ud \ud Methods\ud \ud Survival outcomes from a statistical model, and published data on recurrence, were combined with data from a large, multicenter, prospective cohort study of over 3400 UK women aged 70+ with early breast cancer and median 52-month follow-up, to populate a probabilistic economic model. This model evaluated the cost-effectiveness of surgery plus adjuvant therapies relative to PET for 24 illustrative subgroups: Age {70, 80, 90} × Nodal status {FALSE (F), TRUE (T)} × Comorbidity score {0, 1, 2, 3+}.\ud \ud \ud Results\ud \ud For a 70-year-old with no lymph node involvement and no comorbidities (70, F, 0), surgery plus adjuvant therapies was cheaper and more effective than PET. For other subgroups, surgery plus adjuvant therapies was more effective but more expensive. Surgery plus adjuvant therapies was not cost-effective for 4 of the 24 subgroups: (90, F, 2), (90, F, 3), (90, T, 2), (90, T, 3).\ud \ud \ud Conclusion\ud \ud From a UK perspective, surgery plus adjuvant therapies is clinically effective and cost-effective for most women aged 70+ with early breast cancer. Cost-effectiveness reduces with age and comorbidities, and for women over 90 with multiple comorbidities, there is little cost benefit and a negative impact on quality of life.

Background: In the UK there is variation in the treatment of older women with breast cancer, with up to\ud 40% receiving primary endocrine therapy (PET), which is associated with inferior survival. Case mix and\ud patient choice may explain some variation in practice but clinician preference may also be important.\ud Methods: A multicentre prospective cohort study of women aged >70 with operable breast cancer. Patient characteristics (health status, age, tumour characteristics, treatment allocation and decision-making\ud preference) were analysed to identify whether treatment variation persisted following case-mix\ud adjustment. Expected case-mix adjusted surgery rates were derived by logistic regression using the\ud variables age, co-morbidity, tumour stage and grade. Concordance between patients’ preferred and\ud actual decision-making style was assessed and associations between age, treatment and decision-making\ud style calculated.\ud Results: Women (median age 77, range 70e102) were recruited from 56 UK breast units between 2013\ud and 2018. Of 2854/3369 eligible women with oestrogen receptor positive breast cancer, 2354 were\ud treated with surgery and 500 with PET. Unadjusted surgery rates varied between hospitals, with 23/56\ud units falling outside the 95% confidence intervals on funnel plots. Adjusting for case mix reduced, but did\ud not eliminate, this variation between hospitals (10/56 units had practice outside the 95% confidence\ud intervals). Patients treated with PET had more patient-centred decisions compared to surgical patients\ud (42.2% vs 28.4%, p < 0.001).\ud Conclusions: This study demonstrates variation in treatment selection thresholds for older women with\ud breast cancer. Health stratified guidelines on thresholds for PET would help reduce variation, although\ud patient preference should still be respected.

Aims\ud Adjuvant chemotherapy is recommended as a treatment for women with high recurrence risk early breast cancer. Older women are less likely to receive chemotherapy than younger women. This study investigated the impact of chemotherapy on breast cancer-specific survival in women aged 70 + years using English registry data.\ud \ud Materials and methods\ud Cancer registration data were obtained from two English regions from 2002 to 2012 (n = 29 728). The impact of patient-level characteristics on the probability of receiving adjuvant chemotherapy was explored using logistic regression. Survival modelling was undertaken to show the effect of chemotherapy and age/health status on breast cancer-specific survival. Missing data were handled using multiple imputation.\ud \ud Results\ud In total, 11 735 surgically treated early breast cancer patients were identified. Use of adjuvant chemotherapy has increased over time. Younger age at diagnosis, increased nodal involvement, tumour size and grade, oestrogen receptor-negative or human epidermal growth factor receptor 2-positive disease were all associated with increased probability of receiving chemotherapy. Chemotherapy was associated with a significant reduction in the hazard of breast cancer-specific mortality in women with high risk cancer, after adjusting for patient-level characteristics (hazard ratio 0.74, 95% confidence interval 0.67–0.81).\ud \ud Discussion\ud Chemotherapy is associated with an improved breast cancer-specific survival in older women with early breast cancer at high risk of recurrence . Lower rates of chemotherapy use in older women may, therefore, contribute to inferior cancer outcomes. Decisions on potential benefits for individual patients should be made on the basis of life expectancy, treatment tolerance and patient preference.

Objectives\ud \ud The presence of dementia co-existing with a diagnosis of breast cancer may render management more challenging and have a substantial impact on oncological outcomes. The aim of this study was to examine the treatment and outcomes of older women with co-existing cognitive impairment and primary breast cancer.\ud \ud \ud Materials and methods\ud \ud A prospective, multicentre UK cohort study of women aged 70 years or over with primary operable breast cancer. Patients with and without cognitive impairment were compared to assess differences in treatment and survival outcomes.\ud \ud \ud Results\ud \ud In total, 3416 women were recruited between 2013 and 2018. Of these, 478 (14%) had a diagnosis of dementia or cognitive impairment, subcategorised as mild, moderate and severely impaired. Up to 85% of women with normal cognition underwent surgery compared to 74%, 61% and 40% with mild, moderate, and severe impairment (p = 0.001). Among women at higher risk of recurrence, the uptake of chemotherapy was 25% for cognitively normal women compared to 20%, 22% and 12% for mild, moderate and severe impairment groups (p = 0.222). Radiotherapy use was similar in the subgroups. Although patients with cognitive impairment had shorter overall survival (HR: 2.10, 95% CI: 1.77–2.50, p < 0.001), there were no statistically significant differences in breast cancer specific or progression-free survival.\ud \ud \ud Conclusion\ud \ud Cognitive impairment appears to play a significant part in deciding how to treat older women with breast cancer. Standard treatment may be over-treatment for some women with severe dementia and careful consideration must be given to a more tailored approach in these women.

Background: The Bridging the Age Gap in Breast Cancer study is a multicentre retrospective cohort study examining the management of older patients with breast cancer. This study aimed to examine the selection criteria for breast cancer surgery in patients over 70 and the adverse events risk in this population. We present the adverse event risks for breast cancer surgery in women over age 70 in the UK according to surgical type. Materials and Methods: Baseline information on patient characteristics, surgery type and adverse events was collected across 56 UK breast units. Surgery was classified as major (mastectomy or axillary node clearance) or minor surgery (breast conserving surgery +/- sentinel node biopsy). Adverse events were recorded for 2 years following surgery and classified using the Common Terminology for Classification of Adverse Events system and designated as systemic or local/wound complications. Rates of adverse events were calculated and compared between surgical categories using Chi Squared. Results: Between 2013-2018, 3460 women with operable breast cancer were recruited; 2792 (80.7%) were treated surgically. There were 62 bilateral tumours, giving a total of 2854 surgical events (1321 major, 1533 minor). There were no surgical related deaths (30-day mortality). The overall rate of systemic complications was 59/2854 (2.1%) and local complications was 1072/2854 (37.6%) although 547 had only a seroma and these have been excluded from further analysis. Major surgery was associated with higher rates of local complications (22.7%) vs minor (14.7%; P

Background: The Bridging the Age Gap in Breast Cancer study is a multicentre retrospective cohort study examining the management of older patients with breast cancer. This study aimed to examine the selection criteria for breast cancer surgery in patients over 70 and the adverse events risk in this population. We present data on the impact of age, comorbidity, frailty and dementia on breast surgical choices. Materials and Methods: Baseline information on age, comorbidities (Charlson Comorbidity Index), frailty (activities of daily living, ADL and instrumental ADL) and cognitive function (MMSE) was collected across 56 UK breast units from women >70 with early breast cancer. These were correlated with breast and axillary surgery rates and types, using Chi squared. Results: Between 2013-2018, 3460 women with operable breast cancer were recruited; 2792 (80.7%) were treated surgically. There were 62 bilateral tumours, giving a total of 2854 surgical events. Median age was 76 (range 70-95). Age was a significant predictor of mastectomy (mastectomy rate 70-74 years: 29.9%, 75-79: 41.1%, 80-85: 50.4% and 85+: 59.9% P 5 7.5% P 5 6 44.7% P

Introduction : Primary endocrine therapy (PET) is an alternative treatment to surgery for oestrogen receptor (ER) positive operable breast cancer in older women. However, there is variable use of PET in the UK, with up to 40% of patients aged over 70 receiving PET instead of surgery in some regions. Treatment options offered to patients rely heavily on healthcare professional (HCP) assessment and opinion on which treatments are appropriate.\ud \ud Materials and methods : This was a mixed methods study combining semi-structured interviews with HCPs working in high and low PET regions in the UK, followed by a postal questionnaire survey distributed via the Association of Breast Surgery (ABS).\ud \ud Results : Thirty-four HCPs (20 breast surgeons; 13 nurse specialists; 1 geriatrician) were interviewed from 14 sites across the UK and 252/641 questionnaires returned (39%). There was an overriding view that PET is not suitable for patients under the age of 80 unless there are significant comorbidities. Opinion was split regarding the best way to treat patients with dementia. Patient preference was generally stated to be the most important factor when considering treatment, however only around a quarter 65/244 (26.6%) felt that all patients over the age of 70 should be offered PET as an alternative treatment option.\ud \ud Conclusions : Opinions differ on the best way to treat women over 70 with operable breast cancer, especially if they have co-existing dementia, as well as whether they should be offered PET as a treatment option. This may be a significant cause of treatment variation in the UK.\ud Keywords : Breast cancer; \ud Primary endocrine therapy; \ud Surgery; \ud Elderly; \ud Older; \ud Mixed methods.

Introduction: One third of all breast cancers occur in women over the age of 70. Primary endocrine therapy (PET) is used in some women to minimise morbidity in a population with higher rates of comorbidity and frailty. In the UK up to 40% of women over 70 are treated with PET although there is a high rate of variability of practice between centres reflecting a lack of guidance about case selection. Methods: A systematic review of the literature was performed to try and establish if this form of treatment is still valid in modern breast practice. Results: Six randomised controlled trials (RCTs) and 31 non-randomised studies were deemed eligible. Available data demonstrate an advantage for surgery over PET in terms of disease control and a likely survival benefit in patients with a predicted life expectancy of five years or more. Patients treated only with aromatase inhibitors (AIs) had superior rates of disease control when compared to Tamoxifen. Conclusions: Guidelines to aid selection are needed but PET should be reserved for patients with reduced predicted life expectancy (e.g. less than five years), with AIs being preferable over Tamoxifen.

Malpractice litigation involving the delivery of breast care has been evaluated in the United States of America (USA) but is a relatively new area of study in the United Kingdom (UK). We sought to study and evaluate the emerging trends in litigation claims in relation to breast disease with the National Health Service Litigation Authority (NHSLA) over the last 15 years, up to December 2010.

Background: Oesophageal carcinoma is the ninth most common malignancy in the UK with five year survival rate of only 8%. Most patients with dysphagia present at an advanced stage. Endoscopic stent insertion is a valid method of palliation. We present the outcomes of patients stented at a district general hospital. Method: This is a retrospective study of patients presenting to a district general hospital with inoperable oesophageal obstruction resulting in stent insertion from December 2000 to September 2006. Case notes were reviewed for demographics, diagnosis, treatment, complication and outcome. Results: Fifty-seven patients were stented endoscopically by a single surgeon during the study period for incurable oesophageal obstruction. Forty were male and 17 female (mean age 71.9 range 39–92). Most common causes were advanced adenocarcinoma (34; 60%) and squamous cell carcinoma (16; 28%). Other rarer causes were benign stricture of the oesophagus, lung carcinoma, non-Hodgkin's lymphoma and salivary gland tumour. Of the 50 patients with oesophageal carcinoma, strictures were in the lower third (in 68%), middle third (in 30%) and proximal third (in 2%). Twenty-four (42%) patients developed a complication, including overgrowth (14; 25%), migration (8; 14%), tracheo-oesophageal fistula (2; 4%) and perforation (1; 2%). There was an overall improvement in dysphagia in 41 (72%). Conclusion: Endoscopic stenting for advanced oesophageal obstruction is a well-tolerated procedure, which is acceptable to patients. Despite a significant complication rate, it allows the relief of dysphagia in most patients and therefore should be considered for all patients in this category.