Screening mammography for frail older women
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OBJECTIVE: The potential benefits and harms of screening mammography in frail older women are unknown. Therefore, we studied the outcomes of a screening mammography policy that was instituted in a population of community-living nursing home-eligible women as a result of requirements of state auditors. We focused on the potential burdens that may be experienced.
METHODS: Between January 1995 and December 1997, we identified 216 consecutive women who underwent screening mammography after enrolling in a program designed to provide comprehensive care to nursing home-eligible patients who wished to stay at home. Mammograms were performed at 4 radiology centers. From computerized medical records, we tracked each woman through September 1999 for performance and results of mammography, additional breast imaging and biopsies, documentation of psychological reactions to screening, as well as vital status. Mean follow-up was 2.6 years.
RESULTS: The mean age of the 216 women was 81 years. Sixty-three percent were Asian, 91% were dependent in at least 1 activity of daily living, 49% had cognitive impairment, and 11% died within 2 years. Thirty-eight women (18%) had abnormal mammograms requiring further work-up. Of these women, 6 refused work-up, 28 were found to have false-positive mammograms after further evaluation, 1 was diagnosed with ductal carcinoma in situ (DCIS), and 3 were diagnosed with local breast cancer. The woman diagnosed with DCIS and 1 woman diagnosed with breast cancer were classified as not having benefited, because screening identified clinically insignificant disease that would not have caused symptoms in the womenśs lifetimes, since these women died of unrelated causes within 2 years of diagnosis. Therefore, 36 women (17%; 95% confidence interval [CI], 12 to 22) experienced burden from screening mammography (28 underwent work-up for false-positive mammograms, 6 refused further work-up of an abnormal mammogram, and 2 had clinically insignificant cancers identified and treated). Forty-two percent of these women had chart-documented pain or psychological distress as a result of screening. Two women (0.9%; 95% CI, 0 to 2) may have received benefit from screening mammography.
CONCLUSION: We conclude that screening mammography in frail older women frequently necessitates work-up that does not result in benefit, raising questions about policies that use the rate of screening mammograms as an indicator of the quality of care in this population. Encouraging individualized decisions may be more appropriate and may allow screening to be targeted to older women for whom the potential benefit outweighs the potential burdens.
- Suzman RM. The Oldest Old. New York: Oxford University Press; 1992.
- Tabar L, Gunnar F, Chen H, et al. Efficacy of breast cancer screening by age: new results from the Swedish Two-County Trial. Cancer. 1995;75:2507–17. CrossRef
- Kerlikowske K, Grady D, Rubin SM, Sandrock C, Ernster VL. Efficacy of screening mammography: a meta-analysis. JAMA. 1995;273:149–54. CrossRef
- Satariano WA, Ragland DR. The effect of comorbidity on 3-year survival of women with primary breast cancer. Ann Intern Med. 1994;120:104–10.
- Mandelblatt JS, Wheat ME, Monane M, Moshief RD, Hollenberg JP, Tang J. Breast cancer screening for elderly women with and without comorbid conditions: a decision analysis model. Ann Intern Med. 1992;116:722–30.
- Welch HG, Albertsen PC, Nease RF, Bubolz TA, Wasson JH, Estimating treatment benefits for the elderly: the effect of competing risks. Ann Intern Med. 1996;124:577–84.
- Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001;285:2750–6. CrossRef
- Smith RA, Mettlin CJ, Davis KJ, Eyre H. American Cancer Society guidelines for the early detection of cancer. CA Cancer J Clin. 2000;50:34–49.
- Eng C, Pedulla J, Eleazer GP, McCann R, Fox N. Program of All-inclusive Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing. J Am Geriatr Soc. 1997;45:223–32.
- Tabar L, Fagerberg G, Duffy SW, Day NE, Gad AG, Grontoft O. Update of the Swedish Two-County program of mammographic screening for breast cancer. Radiol Clin N Am. 1992;30:187–210.
- Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V. Positive predictive value of screening mammography by age and family history of breast cancer. JAMA. 1993;270:2444–50. CrossRef
- Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illnesses in the aged: the index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–9.
- Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23:433–41.
- Fonseca R, Hartmann LC, Peterson IA, Donohue JH, Crotty TB, Gisvold JJ. Ductal carcinoma in situ of the breast. Ann Intern Med. 1997;127:1013–22.
- Cassel CK. Breast cancer screening in older women: ethical issues. J Gerontol. 1992;47:126–30.
- Brauner DJ, Muir JC, Sachs GA. Treating nondementia illnesses in patients with dementia. JAMA. 2000;283:3230–5. CrossRef
- Welch HG, Fisher ES. Diagnostic testing following screening mammography in the elderly. J Natl Cancer Inst. 1998;90:1389–92. CrossRef
- Beam CA, Layde PM, Sullivan DC. Variability in the interpretation of screening mammograms by US radiologists: findings from a national sample. Arch Intern Med. 1996;156:209–13. CrossRef
- Ries LAG, Kosary CL, Hankey BF, Miller BA, Clegg L, Edwards BK, eds. SEER Cancer Statistics Review, 1973–1996. Bethesda, Md: National Cancer Institute; 1999.
- Costanza ME. The extent of breast cancer screening in older women. Cancer. 1994;74:2046–50. CrossRef
- Sox HC. Screening for disease in older people (editorial). J Gen Intern Med. 1998;13:424–5. CrossRef
- VA National Center for Health Promotion. Health Promotion and Disease Prevention Program: VHA Handbook 1120.2. 1999 Available at: http://vaww.va.gov/publ/direc/health/handbook/1120-2hk.doc, accessed on 12/15/00.
- Harris R. What is the right cancer screening rate? (editorial). Ann Intern Med. 2000;132:732–4.
- Screening mammography for frail older women
Journal of General Internal Medicine
Volume 16, Issue 11 , pp 779-784
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- screening mammography
- frail elderly
- Industry Sectors
- Author Affiliations
- 1. the Division of Geriatrics, San Francisco VA Medical Center and the University of California, San Francisco
- 2. the Division of Geriatrics, University of California-San Francisco and On Lok Senior Services, San Francisco, Calif