A nationwide panel of experts has developed the first mammography guidelines for older survivors of breast cancer, providing a framework for discussions between survivors and their physicians on screening in survivors’ later years. The guidelines, published today by Rachel A. Freedman, MD, MPH, and colleagues in JAMA Oncology, recommend discontinuing routine mammograms for survivors with a life expectancy less than 5 years; considering stopping screening for those with a 5- to 10-year life expectancy; and continuing mammography for those whose life expectancy is greater than 10 years.
The guidelines will be complemented by printed materials to help survivors gauge their risk of cancer recurring in the breast and weigh the potential benefits and drawbacks of mammography with their health-care team.
Rachel A. Freedman, MD, MPH
“The standard recommendation for mammography in breast cancer survivors of all ages has been annual screening. There has been little guidance on how to tailor screening for older survivors—what role life expectancy, risk of recurrence, patient preferences, or the trade-offs associated with mammography should play,” said Dr. Freedman, of Dana-Farber Cancer Institute and the first author of the paper. “The result is that the use of mammography for older survivors has been highly inconsistent. With the number of older women who will be diagnosed with breast cancer expected to increase in the coming years, it’s important that we find ways to individualize decisions for each patient’s circumstances and preferences.”
Creation of the Guidelines
To formulate the new guidelines, Dr. Freedman recruited an 18-member panel of patients in addition to experts specializing in breast cancer primary care, geriatrics, radiology, survivorship, and nursing from around the country. The panel reviewed the scientific literature on the risk of in-breast cancer among older breast cancer survivors, taking into account the subtype of cancer, the treatment patients received, their age, and health status. The group conducted a parallel review of research on the benefits and downsides of mammography.
The literature review confirmed that most older breast cancer survivors had a low risk for breast cancer in either breast—particularly those who had been treated with hormone-blocking therapy for hormone receptor–positive tumors. The panel estimated older survivors’ risk of developing cancer in the breast over a 10-year period and organized their results by cancer type and treatment.
The review of mammography studies found that although the benefits of screening in older women are not well-defined, research suggests mammography offers little to modest clinical benefit for many older women. The main downsides of mammography were false positives, anxiety associated with diagnostic testing, and overtreatment.
Combining the results of these reviews, the panel formulated a series of mammography guidelines for survivors of breast cancer. The guidelines were considered by a group of clinicians and patient advocates, as well as five focus groups made up of clinicians, resulting in several revisions. After further review by the International Society for Geriatric Oncology, the guidelines were refined and finalized.
Life expectancy was estimated by factors such as an individual’s medical history, their degree of functional independence, whether they smoke cigarettes, had a fall in the previous year, and whether they were recently hospitalized.
Due to the low risk that older survivors will develop a cancer in their breast, the time needed for the potential benefits of mammography to be realized, and the persistence of the negative effects of mammography, the new guidelines recommend discontinuing mammography for breast cancer survivors aged 75 or older whose life expectancy is under 5 years. This holds even for those patients with a history of higher-risk tumors, such as triple-negative or HER2-positive.
The guidelines call for consideration of stopping mammography when life expectancy is 5 to 10 years, and continuing annual or biennial mammography when life expectancy exceeds 10 years. For women age 85 and older—whose life expectancy is often under 5 years—the guidelines recommend ceasing mammography unless an individual is in extraordinary health and has a strong preference to continue testing. The authors also noted, “The panel also recommends ongoing clinical breast examinations and diagnostic mammography to evaluate clinical findings and symptoms, with reassurance for patients that these practices will continue.”
Dr. Freedman emphasized that the new guidelines are not prescriptive but should serve as a starting point for older survivors of breast cancer in conversations with their physicians. “The purpose of the guidelines is to offer clinicians support for having these conversations with patients and to make a shared, individualized decision for each woman,” she concluded.
Disclosure: The study was supported by the National Cancer Institute, Susan G. Komen, the American Cancer Society, and the National Institute on Aging. For full disclosures of the study authors, visit jamanetwork.com.The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.