Beware Mammograms for Elderly
The frail see more pain than gain
WEDNESDAY, May 30, 2001 (HealthDayNews) -- The idea that all older women benefit from yearly screenings for breast cancer ought to be re-examined, a San Francisco doctor contends.
In addition to a woman's age, says Dr. Louise Walter, a geriatrics fellow at the Veterans Affairs Medical Center, her overall health and life expectancy ought to be considered, as well.
That's because the burdens associated with annual mammograms, or breast X-rays, often outweigh the benefits for frail elderly women, Walter says.
The American Cancer Society recommends that all women over 40 have a screening mammogram every year. Screening mammograms are used to check for breast cancer in women who have no apparent symptoms of the disease.
But Walter says government agencies that regulate nursing homes and other care facilities for older people rely too heavily on such recommendations. In California, she says, when the state Division of Health Services rates a care facility, it uses the number of mammograms received by residents there as an indicator of the quality of care.
In other words, the more mammograms, the better the care.
But a new study by Walter claims that mammograms do not extend the life of most of these women and that the tests actually cause physical and psychological harm to many of them.
"I think quality of care is really indicated by whether there was thoughtful decision making," Walter says. "A doctor should be able to [say], 'Based on this patient's life expectancy, the burdens outweigh the benefits and we don't recommend this test.' "
"The bottom line is that screening decisions in frail older women should be individualized," she says.
With that, the cancer society agrees.
"We need to give physicians better tools to identify women who are not likely to benefit from additional care," says Dr. Robert Smith, the organization's director of cancer screening.
"If this is a numbers game, where everyone is driven to meet state health department requirements regardless of the likelihood that a patient really could benefit from mammography, then perhaps the state needs to temper those recommendations after a certain point," Smith says.
"On the other hand," he adds, "we really do provide a woman's physician with some sense of responsibility for knowing when preventive health care is not likely to be beneficial, not by virtue of the fact that they're 80 years old, but because they're not expected to live much longer."
"The challenge -- and it is a fairly complex one -- is knowing at what point and how you might reach [that] decision," he says.
But the study authors, Smith says, "are right to raise this issue."
Walter and her colleagues at the University of California, San Francisco, analyzed the cases of 216 elderly California women, with an average age of 81, who were enrolled in a program designed to care for people eligible for nursing homes but who want to stay at home. All received annual screening mammograms.
In 38 of the women, a positive result from a screening led to further testing or procedures, ranging from additional mammograms to ultrasound exams to biopsies, the study says.
However, only four of the women -- 1.8 percent -- ultimately were diagnosed with breast cancer, according to the study, and two of those women died from other causes not long after they'd been treated for cancer by having all or part of a breast removed. The findings were presented at a meeting of the American Geriatrics Society earlier this month in Chicago.
"In many of these cases, a frail older woman spends the last several months of her life dealing with the trauma of testing positive for breast cancer and being treated, when it turns out the disease wouldn't have affected her anyway because she already had a life-limiting illness," Walter says.
"Without a mammogram, they'd have lived their life out just fine," she says.
Most women don't see the benefits of screening mammograms for about five years, Walter says. "So if your life expectancy is less than five years, it's very unlikely you'd benefit."
In addition, she says, 42 percent of the women in the study who had some abnormality detected by the mammogram experienced anxiety, pain or psychological distress as a result, she says. And because almost half of the women had been diagnosed with dementia, "many of the psychological reactions were because they couldn't understand what was being done to them," Walter adds.
"That's angst that could have been avoided," she says.
However, Smith argues that it's probably better than the alternative.
"Additional imaging or ultrasound can make women nervous, but it's certainly preferable to dying from breast cancer," he says.
"A death from breast cancer is horrible," Smith adds.
What To Do
For more about breast cancer, check out the CancerNet.
To find out what clinical trials are being done on breast cancer, check Veritas Medicine.