Investigators have found that undergoing an annual surveillance mammography may remain common among geriatric patients with breast cancer, even in those with only a small risk of developing a second primary tumor or with significant competing mortality risks as a result of advanced age and comorbidities. The new findings were presented by Berger et al at the 24th American Society of Breast Surgeons (ASBrS) Annual Meeting.
Background
Surveillance mammography refers to imaging performed to screen for cancer recurrence or new tumors in patients who have been treated for breast cancer in the past.
“Ongoing surveillance mammography in these patients may lead to overdiagnosis and overtreatment of cancers that potentially would not harm patients if left untreated,” explained lead study author Elizabeth Berger, MD, MS, FACS, Assistant Professor of Breast Surgical Oncology at the Yale University School of Medicine. “A positive or false-positive finding may unnecessarily erode patients’ quality of life and incur costs to the patients and health-care system without benefit. Our study is unique because it looked at surveillance patterns among [geriatric patients] grouped not by age but by estimated remaining life expectancy. This is an important factor in determining the ultimate benefits of this care,” she added.
The investigators noted that breast cancer in geriatric patients is often indolent and slow-growing, and the disease may have no impact on patients who have shorter life expectancies.
“If [a geriatric patient] is in poor health and has significant competing mortality risks compared to breast cancer, annual mammography may not be necessary,” Dr. Berger continued, indicating that false-positive results can create unnecessary stress and may prompt costly downstream procedures—including additional imaging and biopsies. “The risks and benefits of surveillance mammography, including its downstream effects, should be considered by both patients and their [physicians] together to create a shared decision plan,” she suggested, emphasizing that discontinuing surveillance mammography may be an important but often challenging conversation.
Study Methods and Results
In the new study, the investigators analyzed the cases of 44,475 geriatric patients (aged 67 or older) at diagnosis for their first, nonmetastatic breast cancer with the aim of characterizing current surveillance mammography practice patterns across the United States for geriatric patients treated for breast cancers—while also taking life expectancy into consideration. The investigators reported that the study participants were identified from the Surveillance, Epidemiology, and End Results registry as well as the Medicare registry from 2003 to 2007. Additionally, about 30% of the participants involved in the study were aged 81 or older.
The patients were followed from 1 year after diagnosis until development of a second breast cancer, death, or the study’s conclusion in 2017. The investigators based life expectancy estimates on age, sex, and comorbidities. They detailed that the primary endpoints included receipt of surveillance mammography and occurrence of a second primary breast cancer.
After concluding their analyses, the investigators discovered that 55% of the geriatric patients involved in the study had at least one comorbidity, and 16% of them had three or more. Among those with comorbidities, 26% of them had life expectancies of less than 5 years, 36% had life expectancies between 6 and 10 years, and 38% had life expectancies of more than 10 years.
Further, the incidence of developing a second primary breast cancer differed based on life expectancy—with an incidence rate of 3.7% among those who had less than 5 years, 4.9% among those with 6 to 10 years, and 7.6% among those with more than 10 years. Significantly, 51% of the patients with life expectancies of less than 1 year received at least one surveillance mammography within 12 months of death. In patients with 6- to 10-year life expectancies, 82% of them received at least one surveillance mamography, and 62% of them received five.
Conclusions
“For [geriatric patients] with significant competing mortality risks unlikely to die of breast cancer diagnosed at an older age, [surveillance] mammography brings little benefit,” underscored Dr. Berger. “Our study suggests the need for value-based and patient-centered stratification of [geriatric] patients considered for [surveillance] mammography and development of a tool for shared decision-making between patients and physicians,” she concluded.
Disclosure: For full disclosures of the study authors, visit breastsurgeons.org.
