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Tailor survelliance mammography for older breast cancer survivors
Many older breast cancer survivors reported undergoing surveillance mammograms recently.
More than half of older breast cancer survivors with an estimated life expectancy of less than 5 years reported undergoing a surveillance mammogram in the prior year, according to study results published in Journal of Clinical Oncology.
“Our findings highlight the urgent need for more data on the risks and benefits of mammography among older breast cancer survivors with limited life expectancy so we can better inform patients,” Rachel A. Freedman, MD, MPH, assistant professor of medicine at Harvard Medical School and assistant professor of medical oncology at Dana-Farber Cancer Institute, and colleagues wrote.
Freedman and colleagues pooled data from the National Health Interview Study from 2000, 2005, 2008, 2010, 2013 and 2015 to assess surveillance mammography use among women aged 65 years and older with a history of breast cancer.
Investigators used multivariable logistic regression to assess the probability of mammography within the past year by 5- and 10-year life expectancy.
Researchers adjusted for survey year, region, age, marital status, insurance, educational attainment and indicators of access to care.
The analysis included 1,040 survey respondents, of whom 88.6% were white and 33.7% were aged 80 years or older.
Nearly 9% of respondents had an estimated life expectancy of 5 years or less, and 35.1% had an estimated life expectancy of 10 years or less.
Approximately 80% of women reported having undergone routine surveillance mammography in the prior year.
The number of women who reported undergoing mammography decreased as life expectancy decreased (P < .001). However, 56.7% of those with estimated life expectancy of 5 years or less, as well as 65.9% of those with an estimated life expectancy of 10 years or less, reported undergoing mammography during the previous year.
Of note, 14.1% of women with life expectancy greater than 10 years did not report undergoing mammography receipt in the prior year.
“Future studies should focus on developing strategies on how best to engage older women with a history of breast cancer in shared decision-making and how to best tailor surveillance mammography,” Freedman and colleagues wrote. “This will allow for evidence-based guidelines on use of surveillance mammography in older breast cancer survivors that emphasize who is unlikely to derive benet from mammography and who is more likely to experience potential harm. Such guidelines can help oncologists and primary care providers engage patients in decision-making and help focus our interventions on those that may better promote longevity and well-being.”
HemOnc Today spoke with Freedman about the study and their potential implications.
Question: What prompted this research?
Answer: I have been very interested in how older breast cancer survivors are followed in the long term in practice and what the right timing is to stop annual surveillance mammograms. We have no information about what providers are doing in practice but suspected that indefinite mammograms occur for many women, including those who are frail and who may no longer benefit from this testing. Older women are often left out of clinical trials studying important questions like this.
Q: Did the findings surprise you?
A: We were surprised at the proportion of women — more than half — with less than 5-year life expectancy who reported undergoing annual mammograms. We also were surprised by the approximately 14% of women with excellent life expectancy who did not have mammograms in the previous year.
Q: What are the potential clinical implications of the findings?
A: These results highlight the fact that we need to be doing better at tailoring who is getting — and not getting — this testing. We need to do better at tailoring our follow-up care.
Q: Can you discuss the need for guidelines to help standardize screening for this patient population? What is the most appropriate strategy for this group?
A: In my view, as women age, we should be regularly having conversations about our testing, such as what is appropriate for that patient, her preferences, etc. Women with limited life expectancy of less than 5 years likely will not benefit from mammograms, and focusing follow-up on other elements may be more beneficial than the knee jerk for indefinite annual mammograms.
Q: Do you have plans for future research in this area?
A: Yes, I am very interested in this topic and plan to study this topic further. I am working on ways we can come together to find consensus on these issues, and then explore how older breast cancer survivors feel about these conversations and decisions.
Q: Is there anything else that you would like to mention?
A: Although annual mammograms make sense for many women, the idea that mammograms will forever help women live longer should be questioned and discussed with patients over time. This does not mean we should not continue to examine and follow our elderly, more frail patients, but we should try to focus our efforts on other factors that — in many cases — might have more impact on their well-being than mammography. – by Jennifer Southall
Reference:
Freedman RA, et al. J Clin Oncol. 2017;doi:10.1200/JCO.2016.72.1209.
For more information:
Rachel A. Freedman, MD, MPH, can be reached at Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA 02215; email: rachel_freedman@dfci.harvard.edu.
Disclosure: Freedman reports no relevant financial disclosures.