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American Geriatrics Society (AGS) Position Statement

BREAST CANCER SCREENING IN OLDER WOMEN

AGS Clinical Practice Committee

*Last Updated January 1, 1999*

BACKGROUND

Breast cancer screening guidelines have traditionally included monthly breast self-examination (BSE), periodic clinical breast examination (CBE) and periodic mammography. The latter has generated considerable controversy regarding the cost/benefit of screening women at younger ages (40-49 years).¹ At older ages the heat of contention is less but the guidelines for screening are not in agreement. The United States Preventive Services Task Force (USPSTF) currently recommends biennial mammography from age 50 to 70, citing the absence of clinical trial evidence to support the value of continued screening at older ages.² The American College of Physicians (ACP) recommends mammography screening until age 74 years, based on the oldest ages of clinical trial participants.³ The American Cancer Society (ACS) and the National Cancer Institute (NCI) currently advise annual mammography with no upper age cut-off.

Randomized clinical trials of mammography have established that early detection of breast cancer offers women ages 50-64 the best chance for longer survival and potential cure.¹ Nonetheless, nearly half of all incident breast cancers and more than half of breast cancer deaths occur among women over the age of 65.⁴ Recent cancer mortality statistics have shown promising declines in breast cancer mortality among women younger than 70 years, but no improvement in cancer mortality among the oldest women.^5,6 The lack of improvement in survival among women over age 70 reflects later stage at diagnosis and could reflect poorer host performance ⁷ or less than definitive therapy.⁸ Analysis of Surveillance, Epidemiology and End Results Program (SEER) data indicates that breast cancer cause-specific mortality in older women is associated with the stage of disease at first diagnosis and with the number of co-morbid conditions.⁹ Thus screening older women for early stage breast cancer offers the potential for longer survival and enhanced quality of life since treatment of early stage breast cancer is far less burdensome than that required to treat advanced disease.

Unfortunately, older women who are at greatest risk for breast cancer are less likely to be screened either by mammography or by clinical breast exam than are younger, lower risk women.¹⁰ The reasons for lesser screening of older women include patient, physician and system barriers. Surveys of older women indicate that physician recommendation is the major determinant of screening adherence.¹¹ Older women are more likely to visit physicians and to have Medicare coverage for primary and preventive care, including CBE and mammography, than are women under age 65. Therefore missed opportunities by primary care physicians clearly contribute to low screening rates among older women.¹² Physician barriers include age-biased anticipation of patient refusal,¹³ the tendency to "forget" prevention measures among the multiple conditions of geriatric patients, underestimating life expectancy of older women, and over-estimating physical and financial burdens of screening.¹⁴ There may be as well an element of therapeutic nihilism in the event of a clinically significant finding. Studies have found that physician characteristics (older, male, rural, internal medicine vs younger, female, OB-GYN) predict mammography referral and CBE performance.¹⁵ Patients’ race, education and social class are the best predictors of screening adherence for young, middle and early old aged women. But in late life, measures of social class recede in statistical importance, and old women regardless of social class are not being screened.^{16, 17}

In the past ten years great strides have been made with regard to quality of life for breast cancer patients that directly pertain to decision-making among geriatric women. First, with early stage local and regional disease, breast conserving surgery and selective approaches to axillary dissection are becoming more available. Second, tamoxifen is widely used and has relatively little toxicity. Recent advances in managing toxicities of adjuvant chemotherapy and radiation are also good news for older women with breast cancer.^18-20 The decision to accept or forgo adjuvant treatment or to seek breast conservation is a choice to be made by an informed patient and her oncologist. However, unless a diagnosis is made, older women will not have the range of choices available to younger patients.

Co-morbidity, performance status and life expectancy are routinely part of the oncologist’s calculation of therapeutic benefit vs cost in quality and duration of survival when discussing treatment options with patients. These considerations appropriately enter the decision to screen older women for breast cancer. For the population as a whole, a 75-year-old woman may expect on average 14.2 years of life, an 80-year-old 8.9 years and an 85-year-old 6.9 years of remaining life. ²¹ Important gerontological research has now allowed us to predict better which of these women is likely to continue in good health and which is more likely to fail in the nearer term. Two components, co-morbid conditions and functional status, appear to be independent predictors of relative survival. Several researchers have shown that progressive ADL dependence predicts mortality over the intermediate term.^22-26 Life expectancy in advanced malignancies, congestive heart failure and severe COPD can be predicted reasonably well. However, the number of co-morbidities has also been shown to have predictive value.⁹

There are two aspects of mammography screening which do differentially affect older women. First as rates of mammography have improved,²⁷ more "indolent" lesions, localized ductal carcinomas-in-situ (DCIS), are discovered. The best therapy for these lesions is controversial.^28,29 In an older woman who has not had previous regular mammography, DCIS on a first or long overdue mammogram may represent a neoplasm of many years’ duration and low metastatic potential. This is an area of active clinical research.

A second issue, which has been raised about increasing mammography adherence generally, is whether increased rates of false positives justify the societal cost of additional testing and the burden of fear placed on women who receive such reports. The matter of false positives has been most controversial for younger women for whom dense breast tissue is associated with a higher rate of false positives than among older women with atrophic breast tissue. The likelihood of false positives is also related to the regularity of screening. Thus for an older woman with no recent mammogram the risk of additional imaging may be higher initially. In recommending mammography then, physicians may want to counsel women about the meaning of radiographers’ recommendations for additional studies.

Hormone replacement therapy (HRT) is becoming more common among older women. Estrogenic effects on breast tissue density may also slightly increase the chance of false positive mammograms. However, prolonged exposure to exogenous estrogens may also increase the occurrence of breast malignancies.³⁰ Starting an older woman on HRT may stimulate growth of estrogen responsive tumors.³¹ For these reasons, periodic mammography is strongly recommended for women on HRT or for women who have had prolonged (>7 years) exposure to HRT. The availability of selective estrogen receptor modifiers (SERMs), which do not stimulate breast tissue, may offset this problem in the future.³² New imaging methods, such as MRI, which are less sensitive to breast density, may become available in the future.

The appropriate interval for screening has also not been established by randomized clinical trials. It is estimated that up to ten years may elapse from malignant transformation to first palpable mass.³³ Current mammography technology can image such tumors approximately four years before they are palpable. This indicates that a screening interval of four years could detect most slow-growing malignancies before they are clinically evident. The problem is the suggestion that interval tumors may represent histology of greater malignant potential, so that a four year interval may miss these tumors when they are pre-clinical. The suggestion that older women have more "indolent" tumors is not supported by SEER data that demonstrate no age-related shift in tumor histology.⁴ Since clinical trials of mammography in the elderly are unlikely, simulations of the cost/benefit of annual or biennial mammography offer a reasonable approach. One simulation indicates that annual mammography results in added days of life regardless of age. The benefit is approximately halved however in the presence of a life limiting condition such as CHF.³⁴

Recommendations

Mammography

Physicians should strongly consider recommending annual or at least biennial mammography until age 75 and biennially or at least every three years thereafter with no upper age limit for women with an estimated life expectancy of four or more years. The decision to undergo screening is ultimately each woman’s choice. The physician’s obligation is to offer screening in a positive manner, to explore women’s individual concerns about the test and jointly decide with her how to proceed. The following are important informational points to guide a decision to screen for breast cancer:

Although the single greatest risk factor for breast cancer is age alone, older women with a family history of breast cancer, ³⁵ or current or long-term (>7 years) exposure to HRT are at increased relative risk and many of these women will need to be encouraged to continue annual mammography. Before starting HRT, women, regardless of age, should be encouraged to receive a screening mammogram (and Pap smear).

Life expectancy is an important factor in screening decisions. Presence of co-morbid conditions which impose functional limitations⁹ and which may be expected to progress (e.g. NYFC III and IV CHF, diabetes²¹ with end-organ damage, steroid or oxygen dependent COPD,³⁶ a known terminal diagnosis e.g. concurrent malignancy) probably obviates the benefit of screening. Four year mortality is increased among women with moderately severe and severe dementia and among women experiencing progressive functional decline. The evaluation of these factors should enter decisions about screening. Nursing home residence per se is not a contraindication to mammography for women who possess the decisional capacity, functional and co-morbidity profiles to benefit.³⁷

Clinical Breast Examination

There is no new evidence on the efficacy of CBE, however clinical breast examination is covered by Medicare and costs little in terms of physician time and effort.³⁸ It is recommended to be performed annually. The physician or nurse may use the CBE as an opportunity to review examination technique and to encourage the woman’s practice of BSE.

Breast Self-Examination

There is no new research evidence on the benefit of BSE, however it at least increases women’s awareness of their breast health.³⁹ Breast self-examination may be difficult for women with arthritic hand deformity or neuropathy. For these women annual CBE is more important. However for women with the manual dexterity or a willing partner to perform it, BSE instruction with annual refreshers during CBE is recommended. The recommended interval for performing BSE is monthly.

References

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Developed by the AGS Clinical Practice Committee and approved November, 1999 by the AGS Board of Directors. Journal of the American Geriatrics Society, 48:842-844, 2000. AGS, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118.