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Queensbury, NY
What are the current recommendations for mammographic screening of elderly women? Is there an upper age cutoff?
University of Michigan Hospitals, Ann Arbor, MI 48109-0326
Breast cancer is a leading cause of cancer death in women older than 65 years. Both the incidence and mortality rates increase as a function of age. In the United States, approximately 45% of new breast cancers occur in women older than 65 years [1]. Although women over 65 account for only 13% of the adult population, an explosive growth of the aged is anticipated because of improvements in health care and the aging of baby boomers. By the year 2030, 20% of the population is expected to be older than 65 years [2].
Of the many misconceptions of the elderly, one of the most common is an underestimation of life expectancy. A woman who lives to age 65 can be expected to live an additional 18 years (age at death, 83 years). A 75-year-old woman can be expected to live 12 more years, and an 85-year-old woman, 7 more years [3].
Elderly patients present with breast cancer typically at a later stage than younger women in part because of the underutilization of physical examination and mammography. Treatment choices are more limited because of later detection. Survival is adversely affected even when cancer is diagnosed in women older than 75. Stage at the time of diagnosis remains the most important determinant of survival in the elderly from breast cancer [4].
Unfortunately, randomized controlled screening trials have not included sufficient numbers of women older than 69 years to provide a definitive answer regarding screening the elderly. We are left with inferential evidence based on case control studies and computer-modeling to make a rational decision regarding screening elderly patients. Because tumor size and stage have been shown to correlate with survival, several studies have assessed these parameters in elderly women who have undergone screening. In both women ranging in age from 65 to 75 years and women older than 75 years, smaller and lower stage tumors have been detected in screened women than nonscreened women [5]. Additionally, tumor size and stage in screened women over 65 are similar to tumor size and stage in screened women ranging in the 50-65 age group, a group known to benefit from screening mammography [3]. These lines of evidence support screening. Women screened annually have smaller tumors and lower stage than those screened at longer intervals [2]. Computer-modeling of screening mammography in elderly women has shown that lives can be saved at all elderly ages even in women with comorbid conditions [1]. The magnitude of the benefit decreases with increasing age, especially after age 80-85.
Screening mammography remains underused in the elderly, even in the age group for which there is consensus regarding screening [2]. Only a third of women in the 65-69 age group are undergoing routine screening mammography. This number declines to 21% in women in the 75-79 age group. Improvement in screening rates relies primarily on personal physician recommendation and the ability to improve access of elderly patients to screening.
Although survival benefit is the most common measure used to assess mammographic screening programs, quality of life and treatment options are also important considerations. Screened elderly women are much more likely to be eligible for breast conservation therapy than nonscreened women [6].
Potential negative factors involved in screening mammography in the elderly include problems inherent with mammography and financial cost. Call-back rates have been found to be similar in the elderly to those in younger women. The positive predictive value of mammography in women older than 65 is considerably better than that in younger women because of the increasing incidence of cancer and the decreasing incidence of fibrocystic change [5]. The discovery of biologically insignificant breast malignancies may occur. Analysis of financial cost per year of life saved shows a cost that is similar to that in younger screened women until after age 80 when moderate increases in cost occur [7]. Medicare now covers annual screening mammography without an upper age cutoff.
Many national organizations recommend annual screening mammography in the elderly without an upper age cutoff. These organizations include the American College of Radiology, the American Cancer Society, the American Medical Association, and the National Comprehensive Cancer Network. The American Geriatrics Society recommends that screening mammography continue until "at least the age of 80." The age to stop screening is best determined by the patient's physician who is aware of comorbid conditions as well as longevity factors that will influence an informed decision. Many consider it prudent to screen the healthy elderly through their 70s and in some women beyond.
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