For 70+ women and their MDs, more reasons to rethink routine mammograms

mammographyus-300x240As Americans live longer, clinicians may need to reconsider whether they need to subject older patients to routine screenings that may trigger even more costly, invasive, painful, and unnecessary medical testing and procedures. For women 70 and older, for example, yet more new evidence raises doubts about mammograms designed to detect breast cancers.

As the New York Times reported, researchers in Boston examined 2000-2008 Medicare claims “to follow more than one million women, ages 70 to 84, who had undergone a mammogram.” Quoting Dr. Xabier Garcia-Albéniz, an oncologist and epidemiologist at RTI Health Solutions and lead author of a new observational study of their women subjects:

“They had never had breast cancer and had a ‘high probability,’ based on their medical histories, of living at least 10 more years. ‘That’s the population who will reap the benefit of screening,’ Dr. Garcia-Albéniz said, because it takes 10 years for mammography to show reduced mortality. The researchers divided the subjects into two groups: one that stopped screening, and another that continued having mammograms at least every 15 months. They found that mammograms provided a survival benefit, if a modest one, for women ages 70 to 74. In line with previous research, the study found that annually screening 1,000 women in that age group would result, after 10 years, in one less death from breast cancer. But among the women who were 75 to 84, annual mammograms did not reduce deaths, although they did, predictably, detect more cancer than in the group that discontinued screening. ‘You’re diagnosing more cancer, but that’s not translating to a mortality benefit,’ Dr. Garcia-Albéniz said.”

Why not? Dr. John Hsu, a health services researcher at Harvard Medical School and senior author of the new study, published in the Annals of Internal Medicine, told the newspaper: “The cancers themselves might be different at different ages. They might grow faster or slower or be more likely to spread.”

Dr. Otis Brawley, an oncologist and epidemiologist at the Johns Hopkins University School of Medicine, who wrote an editorial accompanying the study, told the New York Times, that treatments, too, may  be less effective at older ages, while seniors also experience “competing mortality.” As he explained, many cancers detected by mammography — tiny tumors that earlier technology wouldn’t have spotted — are unlikely to cause harm if untreated. But most older people have other diseases that will progress. “It’s very difficult to tell someone in her 70s or 80s that we’re going to modify your treatment, or not treat you, because of the likelihood that something else will kill you before this cancer will,”  he said.

Here’s another key point that the study and the doctors emphasized, according to the New York Times:

“That reluctance to discuss life expectancy and the limitations of screening also means that many women don’t recognize that, in addition to being inconvenient, expensive and a cause of discomfort or anxiety, mammograms can actually do harm. The tests often prompt unneeded surgery, radiation or drug regimens for cancers that would never have caused symptoms or shortened lives. Still, because life expectancy varies widely, some very healthy older women may live long enough to benefit and may indeed want screening. Mammograms could lead to treating an aggressive cancer earlier, and with less extensive surgery, for instance.”

If this evidence-based information makes women’s choices about mammography more complex and nuanced, this itself is an improved outcome, the researchers argued. They and other experts quoted said that cancer specialists and surgeons need to spend more time talking with patients to ensure they fully grasp treatments they may receive.

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care. This has become an ordeal due to the skyrocketing complexity, uncertainty, and cost of treatments and prescription medications, too many of which turn out to be dangerous drugs. Instead of helping patients and clarifying how their care might be optimized, over screening, over diagnosing, and over treating patients is a related and big problem in the U.S. health care system, leading not only to patient harms and even deaths but also an estimated $200 billion annually in wasted costs.

For women patients, mammography long has been held up as a gold standard of care in the detection and treatment of breast cancer, akin to what men have been told about the prostate-specific antigen screening or PSA test for prostate cancer. Over time, experts have been resetting their thinking on these most common cancers in women and men, trying to determine which types they detect are fast growing killers that need urgent care versus those that develop slowly and may not require aggressive treatment.  Early detection remains a key aspect of cancer care. But it has not proven a panacea with the disease. And experts slowly have been de-emphasizing both mammography and PSA testing.

And, as the New York Times article on the new mammogram research reported, specialists struggle now to ensure that patients understand how cancer care is changing, so they receive their fundamental right to informed consent. This means they are told clearly and fully all the important facts they need to make an intelligent decision about what treatments to have, where to get them, and from whom.

The newspaper reported that a Boston internist prepared special materials for seniors, “a brochure, written at a sixth-grade reading level, that uses research findings to explain the pros and cons [of late-life breast cancer screening.] A pilot study showed that, after reading it, women from [ages] 75 to 89 were more knowledgeable about mammography, more apt to discuss it with their doctors and less enthusiastic about continuing it. But they did continue. More than 60%, including those with lower life expectancies, had another mammogram within 15 months. A larger study with 546 participants, being readied for publication, will report similar results…”

The newspaper column noted that the specialist who researched and delivered to patients the fuller explanation of mammography had family experience with a senior making choices about the procedure — her grandmother. She underwent the test at age 78, leading to surgery and chemotherapy so unpleasant she halted it. She had yet another mammogram in her mid-80s, followed up with yet more surgery. The patient died at 88, not of breast cancer but smoking-related emphysema. Before her death, she told her spouse that among her life regrets was taking the multiple, late breast cancer screenings and treatments.

Illustration credit: Created for the National Institutes of Health / National Cancer Institute
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