Delayed presentation of breast cancer in older women

Women in the UK have poorer survival rates for breast cancer than many other Western European countries even after taking into account differences in the age distribution of the population. (Berrino et al. 2007). So-called high resolution studies suggest that late stage at diagnosis is largely responsible for the differences in survival rates (Sant et al. 2003). Late stage at diagnosis is almost certainly due to a combination of late presentation by some women and delays in onward referral by some general practitioners. Most delay appears to be due to patient delay (Westcombe et al. 1999), which may be because of late discovery of symptoms or delayed presentation after discovering symptoms.

Delay in discovery or presentation with breast symptoms is particularly common in older women. Many clinicians can tell stories about elderly women presenting with apparently unmissable locally advanced breast cancer that must have been causing symptoms for a considerable period of time. While we know that very late presentation is associated with poor prognosis, what is more controversial is the extent to which less prolonged delays (of weeks to months) in presentation influence survival. This is important because at clinical and policy levels, we need to know how strong our message to check for symptoms and present early should be, and how that message should be delivered. The wrong message, delivered to the wrong audience, could lead to breast clinics crowded with the worried well, which would probably have little effect on breast cancer survival. More importantly, it would increase anxiety, unnecessary investigations, and would incur opportunity costs to health services.