Screening Mammography in Older Women

Abstract

Importance Guidelines recommend individualizing screening mammography decisions for women 75 and older. However, little pragmatic guidance is available to inform this approach. Objective To provide an evidence-based approach to individualizing decision-making about screening mammography that considers older women's risk of breast cancer and the potential benefits and harms of screening in the context of varying life expectancies and preferences. Evidence Acquisition We searched PubMed for English-language studies in peer-reviewed journals published from January 1, 1990 to February 1, 2014 to identify risk factors for late-life breast cancer in women 65 and older and to quantify the benefits and harms of screening mammography for women 75 and older. Findings Age is the major risk factor for late-life breast cancer. In general, traditional breast cancer risk factors (e.g., age at first birth, age at menarche) that represent hormonal exposures in the distant past are less predictive of late-life breast cancer than factors indicating recent exposure to endogenous hormones (e.g., bone mass, obesity). None of the randomized trials of screening mammography included women over age 74, such that it is uncertain whether screening mammography is beneficial in these women. Observational data favor extending screening mammography to older women who have a life expectancy > 5-10 years. Modeling studies suggest approximately 2 fewer women per 1,000 die from breast cancer if women in their 70's continue biennial screening for 10 years, versus stopping screening at age 69. Potential benefits must be weighed with potential harms of continued screening over ten years, which include false-positive mammograms (~200 per 1,000 women screened) and overdiagnosis (~13 per 1,000 women screened). Providing these frequencies both verbally and graphically may help inform older women's decision-making. Conclusions and Relevance For women with less than a 5-10 year life expectancy, recommendations to stop screening mammography should be framed around increased harms and the need to refocus health promotion on interventions likely to be beneficial over a shorter timeframe. For women with a life expectancy > 5-10 years, the decision about whether potential benefits of screening outweigh harms is a value judgment that requires a realistic understanding of screening outcomes.

Increased Cancer Detection Rate and Variations in the Recall Rate Resulting from Implementation of 3D Digital Breast Tomosynthesis into a Population-based Screening Program

“…For some, potential risks of false-positive results, not detecting breast cancer, or overtreatment of small breast cancers have caused concern about the utility of 2D mammography, as with any imaging examination (6)(7)(8)(9).…”

Screening Mammography Use Among Older Women Before and After the 2009 U.S. Preventive Services Task Force Recommendations

“…The 2009 USPSTF recommendations generated intense debate about the questionable benefits and potential harms of screening mammography for women. [1][2][3][4][5][6][7][8][9][10] Recently, the USPSTF released a draft statement concerning screening mammography, but it did not change its 2009 recommendations. 11 Since the 2009 release, many studies have examined the impact of the recommendation changes on breast cancer screening.…”

Breast Cancer Screening: Updated Recommendations of the Brazilian College of Radiology and Diagnostic Imaging, Brazilian Breast Disease Society, and Brazilian Federation of Gynecological and Obstetrical Associations

“…Another factor that supports the use of mammography screening for this age group is the high sensitivity and specificity of the method. 22,23 Taking into account all these factors, many medical organizations recommend that the decision be made on a case-by-case basis after consulting with the patient. Therefore, the CBR, SBM and FEBRASGO recommend that this group of women with an expected survival rate of more than 7 years be included in breast cancer screening protocols in Brazil.…”