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    Sunday, May 3, 2009


    Many of my GI patients and friends retired to South Florida have asked me to research the use of Mammography in women past the age of 65 so they can make informed decisions with their personal and family doctors.

    First we should realize that more than half of the cases of breast cancer treated in the United States occur in women over age 65. Yet mammography screening for older women is controversial, because no good randomized trials [prospective evaluation of a control vs. an experimental population] of such screening have been conducted in older populations.
    This is what I researched for them.

    Bottom Line: Effectiveness was modest and false positives were common. But there are pros and cons which I present here to augment full and informed decisions with their personal physicians.

    In the one prospective cohort study from three outpatient clinics in Boston, [Published in Journal Watch General Medicine April 30, 2009[Schonberg MA et al. Weighing the benefits and burdens of mammography screening among women age 80 years or older also J Clin Oncol 2009 Apr 10; 27:1774], researchers tracked mammography screening and breast cancer outcomes in over 2000 women (age, 80 at the beginning of the observation period) and who were followed for 2 to 12 years (median, 5 years).

    Half the women underwent mammography (average, about 2.5 mammograms per screened patient), and half did not. Twenty-eight breast cancers (including 8 ductal carcinomas in situ) were diagnosed among mammography recipients, and 20 were diagnosed among women who did not undergo mammography (half by clinician exam and half by patient-reported symptoms or signs).

    Breast cancer that was diagnosed during the study interval caused one death in the mammography group and two deaths in the no-mammography group.

    According to the J Clin Oncol. 2009 Apr 10;27(11):1774-80. Epub 2009 Mar 2, among screened women, 11% have false-positive mammograms that results in additional imaging tests or biopsies. Conclusions reached by the authors are that the majority of women > or = 80 years are screened with mammography yet few benefit.

    Meanwhile, 12.5% experience a burden [extra tests, some invasive] from screening.
    Because this study was small and because these women were not randomized, it cannot serve as a general rule of mammographic screening in the older woman. But it does suggest that the effectiveness of mammography is modest at best among women in their 80s and that the false-positive rate is not trivial in this age group. False positives you know lead to more aggressive and sometimes dangerous follow-up tests.

    How about the issue of Mammography in older frail women?

    Walter and Covinsky [J Gen Intern Med. 2001 Nov;16(11):779-84.] concludes that screening mammography in frail older women frequently necessitates work-up that does not result in benefit. Encouraging individualized decisions may be more appropriate and may allow screening to be targeted to older women for whom the potential benefit outweighs the potential burdens.

    PRO Mammography in the Older Woman

    McCarthy EP, et al. from Harvard [J Am Geriatr Soc. 2000 Oct;48(10):1226-33.Mammography use, breast cancer stage at diagnosis, and survival among older women. ] showed that women age 65 years and older account for most newly diagnosed breast cancers and deaths from breast cancer. Older women the authors say who undergo regular mammography are diagnosed with an earlier stage of disease and are less likely to die from their disease. Their data support the use of regular mammography in older women at least those age 65 and suggest that mammography can even reduce breast cancer mortality in older women, even for women age 85 and older.

    [Cancer. 1996 Dec 15;78(12):2526-34.The influence of risk factors on breast carcinoma screening of Medicare-insured older women. National Cancer Institute Breast Cancer Screening Consortium.] Roetzheim R, et al selected women to undergo mammography based on risk factors in women age 65 years or older). These risk factors included women with a family history of breast carcinoma and women who have had incidental radiation exposure of breast tissue which significantly increases the risk of breast cancer. The authors concluded that older women with additional risk factors should more likely to undergo screening mammography and that interventions that target older women with risk factors and their physicians thus appear warranted.

    [J Clin Oncol. 2007 Jul 20;25(21):3001-6. Epub 2007 Jun 4. Mammography surveillance and mortality in older breast cancer survivors.] Lash TL et al. performed a large observational study which provides support for mammography in older women aged 65 and older and appears reduces the rate of breast cancer mortality in older patients diagnosed with early-stage disease.

    [Breast Cancer Res Treat. 2008 Oct;111(3):489-96. Epub 2007 Oct 24.Surveillance mammography and the risk of death among elderly breast cancer patients.]
    Schootman M et al examined the benefits of mammography for elderly breast cancer survivors in community settings. He found that among 1351 breast cancer deaths (cases) and 5,262 controls, women who had a mammogram during a one or two-year time interval were less likely to die from breast cancer than women who did not have any mammograms during this time period. Similarly, risk of all-cause mortality was reduced among women who had mammograms during one- or two-year intervals. They concluded that in community settings, mammography use during a one- or two-year time interval was associated with a small-reduced risk of breast-cancer-specific and all-cause mortality among elderly breast cancer survivors.

    My opinion about mammography in the older woman?

    Finally we should know this. There are attitudinal differences by medical providers in the diagnosis and treatment of breast cancer in women over 65.

    A retrospective review of all women with primary operable invasive breast cancer treated at the University of Michigan Breast Care Center over a 30-month period was reviewed in the [Ann Surg Oncol. 1994 Jan;1(1):45-52. Age-related differences in breast cancer treatment.August DA et al.from the Department of Surgery, University of Michigan, Ann Arbor 48109-0331.]
    This was a study of a total of 77 older patients aged > or = 65 years (median, 71; oldest patient, 92). Fifty-one similar younger patients aged 55-64 years (median, 59) were identified for comparison.

    Patients were classified as either having received standard treatment or non-standard treatment. When overall treatment (local/regional plus systemic) was assessed, proportionately fewer older patients received standard treatment. Overall, only 59 of 77 older patients versus 50 of 51 younger patients received standard local/regional care.
    Older patients were less likely to receive chemotherapy than younger patients (7% versus 50%; p < 0.001). “Interestingly,” say the authors, “explanations for decisions to deviate from standard treatment guidelines were often not identified.”

    These data demonstrate age-related variations in breast cancer treatment in a multidisciplinary breast care unit. Although good clinical judgment may have played a role in these differences, via age-related patient preferences and co-morbidity, “the age-related attitudes of caregivers must also be taken into account to fully explain these variations,” state the authors.

    In conclusion, after I go through a full discussion with patients listing all the pros and cons I’m then almost always asked this question? Dr. Hookman-That’s all well and good-but what would you suggest if I was your sister?

    My answer is always that each case has to be individualized to your medical history, your risk factors, you physical exam, you routine lab data-even your anxiety level etc.
    But all the above factors being considered and evaluated I would go ahead and recommend annual to biannual mammograms in patients over 65-especially with increased risk factors enumerated above, and be wary of any attitudinal difference in medical provider behavior towards older patients.

    Please remember, however, as with all our articles we provide information, not medical advice. For any treatment of your own medical condition you must visit your local doctor, with or without our article[s].
    These articles are not to be taken as medical advice for you.

    1 comment:

    1. I just want to thank Dr. Hookman for this thoughtful review. As a 66 year old woman with no family history, etc., I wondered why a biannual rather than annual mammography was preferred by my gynecologist when my internist thought it was unnecessary. Now I think I will risk the x-ray. Sincerest thanks.