First Mammography Guidelines Released for Older Breast Cancer Survivors

Life expectancy should be the driving force behind whether older breast cancer survivors continue with screening mammography.

At least that is the push behind the first screening mammography guidelines published Thursday, Jan. 28, for this patient group. A national panel of experts shared their recommendations in JAMA Oncology.

The group, led by Rachel A. Freedman, M.D., MPH, medical director of the Dana-Farber Cancer Institute Cancer Care Collaborative, noted that these guidelines are not prescriptive, but they are an excellent starting point for discussing mammography plans and options with older patients.

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“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 said, noting that printed materials designed to help patients gauge their recurrence risk and weigh the up- and downsides of mammography will be available.

The current standard-of-care with mammography for all breast cancer survivors is annual screening. But, little direction exists, she added, for how providers should tailor services for older women and whether life expectancy, recurrence risk, patient preferences, or tradeoffs associated with the exam should play a role in any decisions.

“The result is that the use of mammography for older survivors has been highly inconsistent,” Freedman said. “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 individualizer decisions for each patient’s circumstances and preferences.”

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Those are the questions a group of representatives from breast cancer primary care, geriatrics, radiology, survivorship, and nursing groups sought to answer. They were joined by an 18-member patient panel to review existing literature around the risks of breast cancer in older women. They also considered the pros and cons of continuing mammography in these older patients.

From their discussion, the group drafted these guidelines, which were reviewed by the International Society for Geriatric Oncology:

• Discontinue mammography for breast cancer survivors over age 75 who have a life expectancy under five years, even for those who have a history of higher-risk tumors, such as triple-negative or ERBB2-positive.
• Consider foregoing mammography for survivors with a five-to-10-year life expectancy.
• Continue annual or biennial mammography in survivors who have a life expectancy greater than 10 years.
• Cease mammography for women over age 85 with a life expectancy under five years unless the woman is in extraordinary health or wants to continue screening.

Based on their literature review, the team determined mammography offers older women little-to-moderate benefit, and it can produce false positives that can lead to anxiety, unnecessary testing, and over-treatment. Fortunately, they said, older breast cancer survivors have a low risk of breast cancer in either breast, especially those women who have previously received treatment with hormone-blocking therapy for hormone receptor-positive tumors.

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