(WOMENSENEWS)–Earlier this year, my 75-year-old mother went to her doctor for her routine annual physical, followed by her regular mammogram. For her, like so many women, yearly mammograms are considered simply part of the norm. But maybe they shouldn’t be.
The American Cancer Society recently issued new guidelines, softening the mandate for women to receive annual mammograms. The organization now recommends that women should receive mammograms only "as long as their overall health is good and they have a life expectancy of 10 years or longer."
Why the shift? As Zeke Emmanuel explained in a recent piece in The Atlantic, for every individual, there is a time when one has to say "enough" — no more screening tests, no more toxic therapies — a time when one is happy to live his life in blissful ignorance of any precancerous lesions lurking in his body that may have no impact on his remaining quality or quantity of life if left undiagnosed or untreated.
As a physician, I think about the emotional and physical cost of radiation exposure and anxiety associated with all of the tests patients undergo, potentially for naught, not to mention the financial cost. We, as a nation, spend $962 million for breast cancer screening each year in the Medicare population, whose average age is 77. How many of them go through screening simply as a matter of rote, without considering if they would truly want to pursue treatment if a cancer is found?
My mom is healthy and vibrant at 75; but there are no data to demonstrate any improvement in survival associated with screening mammography in women this age.
But then the phone rang.
Mom called to let me know they had found something on her mammogram. She had gone for additional tests, and they were now scheduling a biopsy. The next call was from the radiologist. She had seen a tiny mass in my mom’s breast and the biopsy had confirmed a low grade cancer.
Opening a Pandora’s Box
In that moment, a myriad of contradictory thoughts went through my mind. On the one hand, this was good news, and I was grateful that she had gone for her screening mammogram; we caught this cancer early, and her prognosis was outstanding. On the other hand, I lamented that she had the test, thinking that this tiny cancer (had we not known about it) may never have bothered her over her lifetime. Now, however, it opened a Pandora’s box, and we would need to deal with the aftermath of the diagnosis; from the physical effects of the treatment to the emotional fear that the diagnosis incites.
I thought back to a 90-year-old patient of mine whose story was very similar. She had seen her family physician for a routine physical, and he sent her for a screening mammogram, just as he always had. They had seen some calcium spots on the mammogram, which set off a series of additional mammograms, ancillary tests and finally a biopsy that found a precancerous lesion in her breast. On the one hand, this was wonderful news; pre-cancers are almost always curable with surgical resection. But when she came to see me for a consultation, she asked "Don’t you think I’m a bit old for surgery?"
It’s not that screening doesn’t save lives – it does. Eight randomized controlled trials and a myriad of observational studies demonstrate that mammographic screening is associated with a reduction in breast-cancer mortality of between 15 percent and 30 percent, particularly in women ages 50-69. Most national and international guidelines concur that there is benefit to screening in this population.
That said, there has never been a trial evaluating the benefit in women over 75, and data in this subpopulation is sorely lacking.
To be clear, the lack of data does not necessarily imply a lack of benefit. Indeed, mammography in this population finds cancers in 6 of every 1000 women screened, and 26 percent of breast-cancer deaths occur in patients diagnosed after age 74.
Weighing the Benefits
One must keep in mind, however, that the benefit of screening mammography must be weighed against a loss of quality of life particularly in the elderly, where increasing rates of over-diagnosis lead to unnecessary testing and treatments for cancers that, in retrospect, would have had no impact on longevity.
Indeed, a recent study published in the Journal of the National Cancer Institute found that while the ratio of benefit-to-harm declines after age 75, the harms associated with screening mammography actually outweigh the benefits in women over 90.
Hence while some may argue that limiting mammography in the elderly is using ageist criteria to "ration" care, others may question the rationale behind screening in this population, given the financial, physical and emotional toxicity they may face without significant benefit.
My 90-year-old patient decided to have her pre-cancer removed, but stopped having routine mammograms, figuring she would not want further therapy if another lesion was found.
Meanwhile, my mom had surgery and finished radiation. She touts the benefits of early detection and continues to get screened annually. The new American Cancer Society guidelines, while called "confusing" by many, make one thing clear: there is no longer a "one size fits all" approach to breast cancer screening. Each patient is an individual, and screening decisions must be tailored to their personal values and state of health.
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