JANUARY
29, 2021 3:02 AM AEDT
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 the pros and cons of screening in survivors’
later years.
The
guidelines, published online today in a paper in JAMA Oncology, recommend
discontinuing routine mammograms for survivors with a life expectancy under
five years; considering stopping screening for those with a 5-10-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.
“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 tradeoffs associated with mammography should play,”
says Rachel A. Freedman, MD, MPH,
of Dana-Farber Cancer Institute, the first author of the new 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.”
To formulate
the new guidelines, Freedman recruited an 18-member panel of patients in
addition to breast cancer primary care, geriatrics, radiology, survivorship,
and nursing experts from around the country to review 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. (Designed to detect breast cancer at an
early stage, mammograms sometimes uncover growths that turn out not be
cancerous, or small, slow-growing tumors that won’t have an impact on an older
woman’s life expectancy. The detection of such growths often entails further
stress and anxiety, tests, and treatment.)
Reassuringly,
the literature review confirmed that most older breast cancer survivors had a
low risk for breast cancer in either breast – particularly for 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 (detection of growths that appear cancerous but turn out
not to be), 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 and by five clinician focus groups,
resulting in several revisions. After further review by the International
Society for Geriatric Oncology, the guidelines were refined and finalized.
Because of the
low risk that older survivors will develop a cancer in their breast, the
lengthy time needed for the small 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 age 75 or older
whose life expectancy is under five years. This holds even for those with a
history of higher-risk tumors such as triple-negative or ERBB2-positive. (Life
expectancy is 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.) The
guidelines call for consideration of stopping mammography when life expectancy
is five 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 five years, the guidelines recommend ceasing mammography unless
an individual is in extraordinary health and has a strong preference to
continue testing.
Freedman
emphasizes that the new guidelines are not prescriptive but should serve as a
starting point for older survivors of breast cancer in conversations with their
physician. “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 says.
The senior authors of the paper are Nancy L. Keating, MD, MPH,
of Brigham and Women’s Hospital, and Mara A. Schonberg, MD, MPH, of Beth Israel
Deaconess Medical Center. Co-authors are: Eric P. Winer, MD, Haley Gagnon,
Adriana Perilla-Glen, MBA, Nancy U. Lin, MD, and Anna C. Revette, PhD, of
Dana-Farber; Barbara K. LeStage, MHP, of Dana-Farber and the Alliance for
Clinical Trials in Oncology; Christina A. Minami, MD, MFA, MS, of Brigham and
Women’s Hospital; Monica Morrow, MD, and Stuart M. Lichtman, MD, of Memorial
Sloan Kettering Cancer Center; Alexander K. Smith, MD, MS, MPH, and Louise C.
Walter, MD, of Veterans Affairs Health Care System, San Francisco, Calif.; Mina
S. Sedrak, MD, MS, of City of Hope; Hans Wildiers, MD, of University Hospitals,
Leuven, Belgium; Tanya M. Wildes, MD, MDSI, of Washington University School of
Medicine; Kah Poh Loh, MBBCh, BAO, of University of Rochester School of
Medicine and Dentistry; Etienne G. C. Brain, MD, PhD, of Institut Curie,
Saint-Cloud, France; Pamela S. Ganschow, MD, of Rush University Medical College
and Cook County Health; Kelly K. Hunt, MD, of The University of Texas MD
Anderson Cancer Center; Deborah K. Mayer, PhD, RN, AOCN, of University of North
Carolina at Chapel Hill; Kathryn J. Ruddy, MD, MPH, of the Mayo Clinic; and
Reshma Jagsi, MD, DPhil, of the University of Michigan; Beverly Canin, of the
Cancer and Aging Research Group.
The study was supported by the National Cancer Institute (grants
R21CA227615-01A1 and P30 CA00874.8); Susan G. Komen (CCRCR18552788); the
American Cancer Society (MRSG-14-240-01-CPPB); and the National Institute on
Aging (P30 AG044281.
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