Decision‐Making Regarding Mammography Screening for Older Women

Abstract

The population is aging and breast cancer incidence increases with age peaking between ages 75–79. However, it is not known if mammography screening helps women ≥75 years live longer since none of these women were included in randomized controlled trials evaluating mammography screening. Guidelines recommend that older women with <10-year life expectancy not be screened since it takes approximately 10 years before a screen-detected breast cancer may impact an older woman’s survival. For women ≥75 years with ≥10 year life expectancy, guidelines recommend that clinicians discuss the benefits and risks of screening with older women to help these women elicit their values and preferences. It is estimated that 2 out of 1,000 women that continue to be screened biennially from ages 70–79 may avoid breast cancer death. However, 12–27% of these women will experience a false positive test and 10–20% of women that experience a false positive test undergo a benign breast biopsy. In addition, approximately 30% of screen-detected cancers would not otherwise have shown up in an older woman’s lifetime. Yet nearly all older women undergo treatment for these breast cancers and the risks of treatment increase with age. To inform decision-making, tools are available to estimate patient life expectancy and to educate older women about the benefits and harms of mammography screening. In addition, guides are available to help clinicians discuss stopping screening with older women with <10 year life expectancy. Ideally, screening decisions would consider an older woman’s life expectancy, breast cancer risk, and her values and preferences.

Use of Surveillance Mammography Among Older Breast Cancer Survivors by Life Expectancy

“…3,4 Recommendations for screening mammography in the United States have evolved in recent years, with increasing acknowledgment of the limitations in applying uniform screening guidelines to all women. 5,6 For average-risk women without a history of breast cancer, the American Cancer Society currently recommends cessation of screening mammography for women with , 10-year life expectancy. 6,7 Despite these guidelines, discussions surrounding cessation of screening mammography are challenging and happen infrequently.…”

“…5,6 For average-risk women without a history of breast cancer, the American Cancer Society currently recommends cessation of screening mammography for women with , 10-year life expectancy. 6,7 Despite these guidelines, discussions surrounding cessation of screening mammography are challenging and happen infrequently. [8][9][10][11] Likely as a result, screening mammography rates for women have remained stable over time, regardless of age, 12,13 even among those with limited life expectancy.…”

“…However, there are risks of screening that occur immediately, including anxiety and complications related to the evaluation of false-positive tests and overdiagnosis (detection of tumors that are of no threat). 6,14,[23][24][25][26][27] Therefore, older women with limited life expectancies who undergo surveillance mammography are unlikely to experience benefit and may instead place themselves at risk for harm.…”

Select Choices in Benign Breast Disease: An Initiative of the American Society of Breast Surgeons for the American Board of Internal Medicine Choosing Wisely® Campaign

“…The sensitivity of mammograms increases with age, but screening is not without risk; 12–27% women undergoing mammography will have a false-positive result, leading to a benign breast biopsy in 10–20% of women. 19…”

Supporting breast cancer screening decisions for caregivers of older women with dementia: study protocol for a randomized controlled trial

“…The risks, burdens, and harms of mammography screening for older women with ADRD are both physical and psychological and encompass medical interventions often referred to as the treatment cascade [26, 27]. Screening women with ADRD can potentially put them at risk of physical and psychological harm as a result of overdiagnosis, overtreatment, additional tests due to false positives, and the identification of a clinically unimportant cancer [4, 25, 28, 29]. Women with ADRD may also experience additional burdens because of their cognitive impairment.…”