More than half of a nationally representative sample of older breast cancer survivors in the United States with a life expectancy of less than five years received annual surveillance mammography despite the unknown benefits of screening in this age group, a survey study showed.
Analysis of data from the National Health Interview Study (NHIS) (2000 to 2015) revealed that 57% of women with a short life expectancy underwent regular breast cancer screening. At the same time, only 14% of those with an estimated life expectancy of 10 years or more received the same testing, Rachel A. Freedman, MD, MPH, of Dana-Farber Cancer Institute, in Boston, MA, and colleagues reported online in the Journal of Clinical Oncology.
"Our findings highlight the urgent need for more data on the risks and benefits of mammography surveillance among older women with limited life expectancy so we can better inform patients," the study authors wrote. "Future studies should focus on developing strategies on how best to engage older women with a history of breast cancer in shared decision making and how to best tailor surveillance mammography."
Evidence-based guidelines on the use of surveillance mammography in older breast cancer patients will help sort out the benefits and potential harms, they added. This will make it possible for oncologists and primary care providers to initiate discussions with patients that focus on interventions "that may better promote longevity and well-being," they said.
NHIS data from 2000, 2005, 2008, 2010, 2013, and 2015 were analyzed for women 65 and older who reported a history of breast cancer. Among 1,040 women, 9% and 35% had an estimated life expectancy of ≤5 and ≤10 years, respectively, and 79% reported having routine surveillance mammography in the last 12 months. One-third were 80 or older and 89% were white.
Freedman and colleagues assessed the probability of mammography within the last 12 months by 5- and 10-year life expectancy using the validated Schonberg index. Estimates were adjusted for survey year, region, age, marital status, insurance, educational attainment, and indicators of access to care.
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In adjusted analyses, lower life expectancy was significantly associated with lower odds of mammography with an odds ratio of 0.4 for both ≤5-year and ≤10-year life expectancy.
Previous trials indicated that screening mammography has little value beyond age 70. Still, many women in this age group continue routine mammographic screening without discussing the risks and benefits with a clinician.
"Many clinically important breast cancers will present by physical examination alone," Freedman and colleagues wrote, "and it remains unclear whether the addition of mammography over physical examination alone among the oldest and frailest women meaningfully improves outcomes."
More research is needed to determine whether the use of mammography in older women with shorter life expectancies has an actual benefit, agreed Richard J. Bleicher, MD, of Fox Chase Cancer Center in Philadelphia, PA. "This pattern of use tells us who is getting it, and that we need to study it further, but [the study] doesn't tell us who is served best or least by mammography," he told MedPage Today.
Many clinicians don't discuss the use of mammography with patients, "because of the strong public and medical perceptions about their benefits," explained Bleicher, who was not affiliated with the study. A mammogram can be booked by patients without a prescription, he noted, but even when a clinician orders the mammogram, there's often no follow-up visit.
In addition, recent negative publicity about mammography, and how it may not serve women as well as previously thought, has resulted in "too many women" refusing to undergo the screening test at all, Bleicher pointed out. "We must be very cautious," he warned.
Clinicians must come to the table fully armed with the right information, argued Catherine M. Appleton, MD, of Washington University in St. Louis. "These conversations require time and a deep understanding of an individual patient's personal risk, balanced against the potential benefits," she said.
"Tailored and patient-specific decisions are going to be more appropriate than sweeping guidelines," she emphasized. "There is not a 'one size fits all' solution." Radiologists should "make themselves available as a resource to primary care providers who seek additional guidance on appropriate screening and imaging of patients," suggested Appleton, who also was not affiliated with the study.
The need for personalized and risk-specific screening extends beyond older women, she pointed out, adding that better access and affordability of breast cancer screening should also be a key priority. "Additional research to identify and correct gaps in care delivery is needed."
Study limitations include the self-report nature of the survey and the fact that investigators didn't have information on the timing of breast cancer diagnosis in relation to mammography, tumor characteristics, or the use of mammography in metastatic disease.
This study was funded by the American Cancer Society, Susan G. Komen, the National Cancer Institute, and the National Institute on Aging. Freedman reported institutional relationships with Puma Biotechnology, Genentech, and Eisai. No other potential conflicts of interest were reported.
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