Should Women Over 75 be Screened for Breast Cancer?
Our Aging Population
Currently, about 12% of the population is 65 years or older. By the year 2030, that figure is expected to reach 21%. The fastest growing age group in the United States is the population age 80 and over. Life expectancy data from the National Vital Statistics Reports from the Centers for Disease Control and Prevention (CDC) released in 2003 showed that females at age 70 have an average life expectancy of 15 years if they are relatively healthy and a life expectancy of 7 years for those over 85 years old.
One of the challenges in dealing with the elderly is the significant variability within an age group, with frail 70 year olds and robust 80 or even 90 year olds. It is important to consider the patient’s functional status and comorbidities in determining appropriate screening and health maintenance.
As the population ages, there is an increase in the number of patients diagnosed with breast cancer. Increasing age remains the greatest risk factor in developing the disease. Studies have shown that around 50% of patients diagnosed with breast cancer are older than 65 years of age and that approximately 35% are older than 70 years. Additionally, most women who die of breast cancer are over the age of 65. The dilemma that forms as patients advance in age is that the incidence of cancer increases, but so does the incidence of significant medical comorbidities.
Screening mammography enables detection of smaller and earlier stage tumors. Cancer stage at diagnosis determines treatment options and has a strong influence on the length of survival. The earlier breast cancer is caught, the better chance a person has of surviving five years after being diagnosed. For breast cancer, approximately 61% of women are diagnosed at the localized stage. The 5-year survival for localized breast cancer is 98.5%.
Overall, female breast cancer survival is good. However, women who are diagnosed at an advanced age are more likely than younger women to die of the disease. This is likely due to a combination of medical comorbidities, treatment inequalities and decreased screening leading to more advanced disease at the time of discovery. Elderly women with breast cancer are often underdiagnosed and undertreated, and this adversely affects their overall survival. Frequently, the bigger issue is not whether or not to find the cancer, but rather how to treat it once it is discovered as the disease and other comorbidities have to be managed together.
To date, there is no consensus as to when regular screening mammography should stop. One of the main reasons for the lack of a comprehensive guideline is because older patients are not very well represented in clinical trials. There are very few retrospective and prospective studies looking specifically at cancer screening in the elderly. Annual mammographic screening leading to early detection has significantly improved breast cancer survival in women age 40 to 69 years, but there is limited data with respect to benefits in women age 70 years and older and even less information for women age 75 years and older. Of note, a very recent retrospective study looking at over twenty years of data showed that mammography screening in women ages 75 to 89 led to cancers being detected at a statistically significantly lower stage and led to a 10% increase in 5 year survival. Randomized trials in this older age group are needed, however are unlikely to be performed.
The American College of Radiology (ACR) screening mammography guidelines state that there is no defined upper age limit at which mammography may not be beneficial. And that screening with mammography should be considered as long as the patient is in good health and is willing to undergo additional testing, including biopsy, if an abnormality is detected. The American Cancer Society Guidelines for the Early Detection of Cancer recommend yearly mammograms starting at age 40 and continuing for as long as a woman is in good health.
The decision as to when to stop mammography screening needs to be made on an individual basis. Women ages 70 and older with significant comorbidities may consider cessation of regular screening due to their poor overall health, especially if they have a remaining life expectancy of five years or less. However, women who are in good health and could benefit from treatment (if breast cancer were found) should continue to get mammograms.
Although there are clear guidelines as to what age to begin screening, there is less guidance concerning when it may be appropriate to stop screening. This is becoming more of an issue as average life expectancy continues to rise. As of now the American College of Radiology and Society of Breast Imaging recommend yearly screening for as long as a woman is in good health. The decision to stop screening must take into account each individual patients' age, overall health, life expectancy and their willingness to have any subsequent testing and/or treatment.
Wade C. Hedegard, M.D.
Elizabeth Wende Breast Care, LLC
Study published in Radiology (August 5, 2014)
Mammography-detected breast cancer is associated with a shift toward earlier-stage diagnosis in women 75 years and older, subsequently reducing the rate of more advanced, difficult-to-treat cases, according to a new study published online in Radiology.