Clinical Review

Breast Cancer Screening in Older Women

Clinician Reviews. 2011 April;21(4):29, 34-39

References

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• Patients with dementia or multiple comorbidities may find routine screening tests burdensome

• Screening decisions should be individualized rather than based on age alone

• Health care systems and insurance plans should not restrict coverage for screening tests in older adults based solely on age.⁵

Walter and Covinsky¹³ created a model to facilitate decisions about mammography for older women. They suggest first estimating life expectancy according to age and health status (see Arias²⁸ at www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_21.pdf). Factors considered in this decision model include a woman’s risk for dying of breast cancer, the effect of screening on this death rate, the potential risks involved with screening, and the woman’s preferences.

According to this model, Helen, at 82, would have had a life expectancy of 11.5 years. The annual breast cancer mortality rate for a woman of her age is 157/100,000.²⁹ Based on these data, Helen’s risk for dying of breast cancer is calculated to be 1.8%. The number of patients Helen’s age who would have to be screened to prevent one case of breast cancer is 240.

In Helen’s case, the risks involved with screening mammography would include a roughly 8% chance of her needing a subsequent diagnostic mammogram and/or breast biopsy. If Helen underwent biopsy, there would be a 75% chance that the suspicious mammogram would prove to be a false-negative result, possibly causing the patient undue anxiety. In Walter and Covinski’s model,¹³ these possibilities would be discussed with Helen in advance to help her clarify her own values and reach a screening decision.

By comparison, consider a hypothetical 70-year-old woman who is in the lowest quadrant of health status for her age; based on her age alone, the expert panels would agree that screening mammography is indicated. This patient has a life expectancy of 9.5 years and a 1.2% lifetime risk for dying of breast cancer. To prevent one case of breast cancer, 642 women of this age and health status would have to be screened. Thus, Helen would derive far more benefit from screening than would this hypothetical woman.

Life Expectancy, Health Status
In order to help an older woman make well-reasoned decisions about mammography screening, it is important for the clinician to evaluate her overall health status and life expectancy, as well as her risk for breast cancer and her long-term goals.

The potential benefit of any preventive health screening can be reduced in patients with a limited life span. Schonberg,²⁰ who created a nine-item tool to predict four-year mortality, demonstrated that women with a score higher than the cut-point of 14 were unlikely to benefit from mammography screening, based on their limited life expectancy.

According to Schonberg,²⁰ mortality risk increases with advancing age, male gender, and low BMI; a diagnosis of diabetes, cancer, or COPD; smoking, functional limitations, poor self-rated health, and a recent history of hospitalization. In Helen’s case, a BMI of 25, her nonsmoking status, an absence of significant comorbidities, and good functional status result in a score of 5 on the Schonberg tool. The associated life expectancy of greater than four years would have made mammography screening an advisable option for her.

Several easily administered tools are available to predict mortality or vulnerability. The Vulnerable Elders Survey (VES-13),^30,31 for example, is a 13-item tool developed by researchers from the RAND Health Project, the University of California–Los Angeles, and the Veterans Administration to predict vulnerability among older adults. Using a cut-point of 3, researchers who conducted this survey identified one-third of a cohort of 6,205 community-dwelling elders as vulnerable—that is, at four times the risk for functional decline or death, compared with the rest of the elderly population.³¹ Helen, with a VES-13 score of 0, would not have been considered vulnerable.

Additionally, risk for breast cancer can be calculated in the office setting with the National Cancer Institute’s Breast Cancer Risk Calculator³² (see www.cancer.gov/bcrisktool). Breast cancer risk factors for the older woman that are not included in the calculator but that may further influence decision making include:

• Use of hormone replacement therapy

• Obesity

• Increased bone mineral density.³³

It is important to determine a woman’s willingness to undergo mammography and any indicated follow-up procedures. Screening decisions can also be facilitated by discussions about the patient’s values regarding increased longevity, quality-of-life goals, pain and symptom management, and her available support systems.

Conclusion
Decisions about breast cancer screening for older women should be influenced by the health status and life expectancy of each patient, her goals for her remaining years, and her risk for breast cancer. Treatment decisions, when necessary, must take these factors, as well as severity of disease, into account. The reduction in quality of life that is inevitable with a diagnosis of advanced-stage metastatic breast cancer should be factored into the decision.