- The average lifetime risk of breast cancer for women in the United States:
- Is 12.9%
- Age is one of the most important risk factors:
- The median age of diagnosis is 63 years:
- With over 50% of breast cancer diagnoses occurring:
- Between the ages of 55 to 74 years
- With over 50% of breast cancer diagnoses occurring:
- Breast cancer diagnosis drops from 26.5% to 13.7% for women ages 75 years or older and to 5.2% for women aged 84 years or older
- The median age of diagnosis is 63 years:
- Mammogram:
- Remains the cornerstone for screening
- There is little guidance for continued screening recommendations for women aged 75 years or older:
- In 2009, the U.S. Preventive Services Task Force:
- Made official recommendations that women have biennial screening mammography:
- From aged 50 to 74 years
- For women aged 40 to 49 years:
- Screening should be done based on individual assessment and discussion with her health care providers
- The task force concluded that the data to evaluate the benefit and harms for mammography for women over age 75 years was insufficient to recommend continued screening
- Made official recommendations that women have biennial screening mammography:
- The American Cancer Society and the American Society of Breast Surgeons:
- Recommend continued screening:
- As long as a woman’s life expectancy is at least 10 years:
- There has been demonstrated survival benefit in this population without significant comorbidities as well as lower rates of false-positive biopsies
- As long as a woman’s life expectancy is at least 10 years:
- Recommend continued screening:
- In 2009, the U.S. Preventive Services Task Force:
- The Affordable Care Act includes coverage of screening mammography regardless of life expectancy
- The recommendation to stop screening mammograms based on advanced age or competing comorbidities is difficult for both patients and providers to approach and discuss
- Some patients think that stopping screening is a form of age discrimination and providers find it difficult to discuss or determine life expectancy
- Age is an unreliable indicator of mortality:
- The Lee Index was initially validated as a tool to estimate 4-year mortality
- This was recently re-evaluated and validated for 10-year mortality
- The index can be accessed through the ePrognosis website:
- Patients with a high 10-year mortality risk are more likely to be harmed by preventive interventions with “long lagtimes-to-benefits” such as screening mammograms
- The diagnosis of occult malignancy in elderly patients:
- Has the risk of causing harm related to diagnostic procedures, surgical procedures, and medical or radiation therapies
- It is estimated that approximately 30% of breast cancers are overdiagnosed cancers and almost one third of the women will experience a harm related to this overdiagnosis
- For older women with a life expectancy of greater than 5 to 10 years:
- It is unknown whether screening mammography actually decreases the risk of dying of breast cancer
- For elderly women with new symptomatic breast findings:
- Diagnostic imaging will guide diagnosis and treatment
- Mammography is more sensitive and specific for women over 80 years of age (sensitivity = 86% vs. 73% in 50-year-old; specificity = 94% vs. 92% in 50-year-old)
- Ultrasound is also a reliable imaging test and biopsy can be safely done with relative patient comfort for histologic and biologic/prognostic panel testing
- This information will then allow for an informed shared decision-making discussion with the patient and her provider
- References
- Cancer Stat Facts: Female Breast Cancer. National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Accessed March 3, 2023. https://seer.cancer.gov/statfacts/html/breast.html
- Nelson HD, Fu R, Cantor A, Pappas M, Daeges M, Humphrey L. Effectiveness of breast cancer screening: systematic review and meta-analysis to update the 2009 U.S. Preventive Services Task Force Recommendation. Ann Intern Med. 2016;164(4):244-255. doi.org/10.7326/M15-096
- The American Society of Breast Surgeons Official Statements. Accessed March 3, 2023. https://www.breastsurgeons.org/resources/statements
- Cruz M, Covinsky K, Widera EW, Stijacic-Cenzer I, Lee SJ. Accurately predicting 10-year mortality for older Americans: an extension of the Lee Index. JAMA. 2013;309(9):874-876. doi.org/10.1001/jama.2013.1184
- ePrognosis—Lee Index. University of California San Francisco. Accessed March 3, 2023. https://eprognosis.ucsf.edu/lee.php
- Walter LC, Schonberg MA. Screening mammography in older women: a review. JAMA. 2014;311(13):1336-1347. doi.org/10.1001/jama.2014.2834
Rodrigo Arrangoiz MS, MD, FACS, FSSO 