Breast Cancer Screening in Women Over 74 Years of Age

Breast Cancer Screening in Women Over 74 Years of Age

• Women over age 74:
  • Should be educated on the possible harms of screening mammogram:
    • Such as:
      • Overdiagnosis and false positives vs. the potential benefits
  • They should be offered the choice to stop or continue mammogram screening in the context of:
    • Their life expectancy
    • Comorbidities
    • Personal beliefs
• Controversy exists and data are limited for using screening mammogram in women over age 74:
  • Healthy women in this age group of women are likely to have a lifespan of 15 years or more
  • Using Medicare claims and Surveillance, Epidemiology, and End Results (SEER) program data:
    • Patients age between 69 to 84 who elected for annual mammograms in the four years prior to breast cancer diagnosis:
      • Had lower 5- and 10-year death rates compared to those who elect for irregular or no mammograms during that interval
• “Framing cancer screening conversations in terms of increasing harms in relation to decreasing benefits has been found to be most acceptable to older patients and may maintain or promote trust more than citing national guideline recommendations to stop screening based on age cutoffs for women with less than a 5 to 10 year life expectancy, recommendations to stop screening mammography should be framed around how a woman’s health problems increase the harms of screening (e.g., overdiagnosis) and shift the focus to interventions likely to be beneficial over a shorter time frame (e.g., falls prevention, depression screening).”
• No screening breast imaging:
  • Is required for asymptomatic patients with a normal breast exam who have a life expectancy less than 5 years
• Conversations regarding cessation of mammogram should be focused on risk of harm such as false positives and the significance of this in relation to the patient’s medical condition
  • Interestingly, the number of false positives actually decreases with age^:
    • However, the number of lives saved is 2 / 1000, compared to 39% of women harmed by overdiagnosis or false positives
• References
• Walter LC, Schonberg MA. Screening mammography in older women: a review. JAMA. 2014;311(13): 1336-1347.
• Sanderson M, Levine RS, Fadden MK, Kilbourne B, Pisu M, Cain V, et al. Mammography screening among the elderly: a research challenge. Am J Med. 2015;128(12):1362.e7-1362.e14
• Sharpe RE Jr, Levin DC, Parker L, Rao VM. The Effect of the Controversial US Preventive Services Task Force Recommendations on the Use of Screening Mammography.J Am Coll Radiol. 2016 Nov;13(11S):e58-e61.
• Oeffinger KC, Fontham ET, Etzioni R, Herzig A, Michaelson JS, Shih YC, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-1614.

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