Screening for Cancer in Elderly Fuels Fight

By RONI CARYN RABIN
9 july 2008--As with most cancers, the risk of breast cancer increases with age. Yet while doctors tell women to have annual mammograms after age 40, they often advise 85-year-olds to go two or even three years between scans.
The problem, doctors say, is too little data. Large clinical trials, including those that have found that mammography saves lives, tend to focus on younger people and exclude the very old.
A recent study that tried to assess the usefulness of mammography among 80- and 90-year-olds found that very few women in this age group, 22 percent, underwent regular screenings for breast cancer, but that those who did were more likely to find the cancer early enough to avoid a mastectomy and survive at least five years.
The finding is important, because the population of very old people is rising sharply, with a fourfold rise expected by 2050. According to the National Institute on Aging, two-thirds of those over 85 are women.
But the study may raise more questions than it answers. Some experts dispute any suggestion that all elderly women should have annual mammograms — an idea that raises the specter of frail women being dragged from nursing home beds to be screened for cancer when they are far more likely to die of heart disease or complications from a broken hip.
“It gets back to the question: What is the goal of preventive care in the elderly?” said Dr. Diana B. Petitti, vice chairwoman of the United States Preventive Services Task Force. “In my opinion, it’s to maximize quality of life and function.”
Dr. Petitti and other experts on care for the elderly say the focus on mammography could distract attention from more pressing problems, like high blood pressure, low mobility, depression, chronic pain, and impaired vision and hearing.
The task force’s guidelines do not set a cutoff age for mammography, but they do recommend taking a patient’s other illnesses into account when deciding on screening.
The mammography study, published in May in The Journal of Clinical Oncology, looked at the records of more than 12,000 patients aged 80 and older who were given diagnoses of breast cancer from 1996 to 2002. It found that among those who had a mammogram every year or two before their diagnosis, 68 percent found the cancer at an early stage, compared with 33 percent of those who skipped mammograms altogether.
Five years after the breast cancer diagnosis, 75 percent of the frequent screeners were alive, compared with only 48 percent of those who had not been screened for at least five years before their cancer was found.
But those who had frequent mammograms were not only more likely to survive breast cancer, the study’s authors said, they were more likely to survive other illnesses as well, meaning that they may simply have been healthier to begin with.
“They could be surviving because they’re healthier, and not because you did the screening,” said Dr. Gildy V. Babiera, the study’s senior author and an associate professor of surgical oncology at the University of Texas M. D. Anderson Cancer Center in Houston. “Healthy women were getting more mammograms, because they were able to go to a facility and undergo the procedure. And they could also withstand the cancer treatment.”
Dr. Babiera said she became interested in the subject when she realized that a growing number of patients in their 80s were coming to her for breast cancer treatment.
“When I see a patient with advanced cancer who is 80 or older and has a lot of other diseases, I think, ‘What if she had had a mammogram earlier?’ ” she said. “And then she could have had a lumpectomy, instead of a mastectomy and lymph-node dissection, which are very different in terms of surgery and recovery time.”
About 17 percent of breast cancers are diagnosed in women over 80. But because women over 74 have not been included in any randomized clinical trials of mammography, organizations setting guidelines for older women have had to extrapolate from studies of younger women, and the guidelines are inconsistent and even contradictory.
The Preventive Services Task Force recommends a mammogram every year or two, while the American Geriatrics Society recommends mammograms every two to three years for women over 75, if life expectancy is at least four years. The American Cancer Society recommends annual mammography for all women over 40 and in good health.
“A woman who’s 70 still has close to 19 years of life left on average,” said Robert A. Smith, the society’s director of cancer screening. “As long as she’s in good health and would be a candidate for treatment if she were diagnosed, she should continue to get mammograms.”
But some physicians who specialize in the care of elderly women are critical of such recommendations, arguing that screening tests should focus on women with a life expectancy of at least five years, who are most likely to benefit. Few women in their 80s actually die of breast cancer, which is generally believed to progress more slowly in elderly women.
“Less than 2 percent of women 80 and older die of breast cancer,” said Dr. Mara A. Schonberg, an instructor of medicine at Harvard who does research on mammography and preventive care for elderly women. “There is a time to start screening and a time to stop screening — you don’t start screening at birth, and you don’t continue until death.”
Dr. Schonberg added that the study should have had more to say about the drawbacks of screening, like anxiety over the tests, the possibility of false positives leading to unnecessary procedures, and the higher risk of complications for elderly patients from surgery and anesthesia.
A primary care physician’s limited time with older patients would be better spent, Dr. Schonberg said, encouraging them to exercise and get their immunizations, and discussing problems that can interfere with day-to-day life, like incontinence, falls and the need to keep up social ties.
Dr. Louise C. Walter, a staff physician at San Francisco Veterans Affairs Medical Center who does research on cancer screening in the elderly, agreed.
“The biggest potential harm is that a patient with dementia or congestive heart failure could have a mammogram, and then a biopsy or other procedure that has a high risk of complications, and they have all these things done to them,” she said. “And then, either because of all the distractions or because it was the natural course of events, they die of the disease they already had. And they spent the last year of their life getting all kinds of procedures, when we could have improved their quality of life.”