The first mammography guidelines for older survivors of breast cancer have been developed by a nationwide panel of experts, providing a framework for discussions between survivors and their physicians on the pros and cons of screening in survivors’ later years.

The guidelines recommend discontinuing routine mammograms for survivors with a life expectancy under 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. These guidelines will be complemented by printed materials to help survivors scale 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,” said study author Rachel A. Freedman, MD, MPH, of Dana-Farber Cancer Institute, in a press release. “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 create the new guidelines, Freedman recruited an 18-member panel of patients in addition to experts in breast cancer primary care, geriatrics, radiology, survivorship, and nursing from around the country to review the scientific literature on the risk of in-breast cancer among older 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 review confirmed that most older breast cancer survivors had a low risk for cancer in either breast, particularly for those who had been treated with hormone-blocking therapy for hormone receptor-positive tumors. The panel then estimated older survivors’ risk of developing cancer in the breast over a 10-year period and organized their results by cancer type and treatment, according to the study authors.

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 downsides of mammography were false-positives, anxiety associated with diagnostic testing, and overtreatment.

The panel formulated a series of mammography guidelines for survivors of breast cancer using the results of these reviews. Several revisions were made, since the guidelines were considered by a group of clinicians and patient advocates and by 5 clinician focus groups. The guidelines were finalized after the review by the International Society for Geriatric Oncology.
The new guidelines recommend discontinuing mammography for breast cancer survivors 75 years of age and older whose life expectancy is under 5 years due to the low risk that older survivors will develop a cancer in the breast, the time needed for the small benefits of mammography to be realized, and the persistence of the negative effects of mammography, according to the study authors.

Further, 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 85 years of age 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.

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,” Freedman said in a press release.

REFERENCE
First mammography screening guidelines issued for older survivors of breast cancer. Dana-Farber Cancer Institute. https://www.dana-farber.org/newsroom/news-releases/2021/first-mammography-screening-guidelines-issued-for-older-survivors-of-breast-cancer/. Published January 28, 2021. Accessed January 29, 2021.