Published on February 8, 2021
New Mammogram Guidelines for Breast Cancer Survivors Over 75
A multidisciplinary panel has developed the first mammography guidelines for older breast cancer survivors, providing a framework for discussions between doctors and patients about the pros and cons of continued screening.
The guidelines, published in JAMA Oncology last month, recommend: discontinuing mammograms for survivors 75 and older who have a life expectancy of less than five years (even for those with a history of higher-risk tumors such as triple-negative); considering stopping screening for those with a five-to-10-year life expectancy; and continuing mammography annually or biannually for those whose life expectancy is greater than 10 years.
For women age 85 and older, whose life expectancy is often under five years, the guidelines recommend stopping mammography unless the individual is in extraordinary health and has a strong preference to continue testing. The recommendations are based on findings that most older breast cancer survivors have a low risk for breast cancer in either breast — particularly for those who have been treated with hormone-blocking therapy for hormone receptor-positive tumors — and that mammography offers little to modest clinical benefit for many older women.
“The standard recommendation for mammography in breast cancer survivors of all ages has been annual screening,” said Dr. Rachel A. Freedman of Dana-Farber Cancer Institute in Boston, the first author of the paper, in a press release. “The result is that the use of mammography for older survivors has been highly inconsistent.” She added: “With the number of older women who will be diagnosed with breast cancer expected to increase in the coming years, it’s important that we find ways to individualize decisions for each patient’s circumstances and preferences.”
Experts Develop Mammography Guidelines
To develop the guidelines, Dr. Freedman recruited an 18-member panel of experts in breast cancer primary care, geriatrics, radiology, survivorship and nursing — along with patients — to review the scientific literature on the risk of ipsilateral (the same breast) or contralateral (the opposite breast) cancer among older breast cancer survivors. The panel considered the subtype of cancer, the treatment patients received, their age and their health status.
A parallel review on the benefits and downsides of mammography found that mammograms sometimes uncover growths that turn out not to be cancerous, or small, slow-growing tumors that won’t have an impact on an older woman’s life expectancy. The panel concluded that the detection of such growths often entails further stress, anxiety, tests and treatment.
The panel used the results of both reviews to develop the mammography guidelines, which were reviewed by patient advocates and five clinician focus groups. While they are not prescriptive, the hope is that the guidelines will “offer clinicians support for having these conversations with patients and to make a shared, individualized decision for each woman,” Dr. Freedman said.
The guidelines will be complemented by printed materials to help survivors gauge their risk of cancer recurring and discuss the potential benefits and drawbacks of mammography with their doctor.
At What Age Is It Possible to Discontinue Mammograms?
Current evidence is insufficient to assess the balance of benefits and harms of screening mammography for women 75 and over, according to the U.S. Preventive Services Task Force, an independent group of national experts in prevention and evidence-based medicine.
Still, an estimated 52% of women aged 75 years and older undergo screening mammography in the United States, according to a study published last year in Annals of Internal Medicine. The research team found that continuing annual breast cancer screening past 75 did not result in substantial reductions in breast cancer mortality compared with stopping screening.
An article in the newsletter Harvard Women’s Health Watch noted that most breast cancers detected in older women are slow-growing and easily treated. A mammogram might detect a cancer that would not spread or metastasize for several years; however, the percentage of women who survive to that point decreases with each passing year, the article said.
"For women with a 10-year life expectancy, I recommend continued mammography screening," Dr. Nancy Keating, a professor of health care policy and medicine at Harvard Medical School and a physician at Brigham and Women's Hospital, told the newsletter. She was a senior author of the JAMA Oncology study. "For those with less than a 10-year life expectancy, I explain that studies suggest that mammography screening is unlikely to find a cancer that would change their life expectancy and is more likely to find a cancer that would never become evident otherwise during this time."
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