{"id":46143,"date":"2023-09-12T12:00:00","date_gmt":"2023-09-12T12:00:00","guid":{"rendered":"https:\/\/www.cancer.gov\/news-events\/cancer-currents-blog\/2023\/mammography-older-women-breast-cancer-overdiagnosis"},"modified":"2024-11-03T15:12:23","modified_gmt":"2024-11-03T15:12:23","slug":"study-adds-to-debate-about-mammography-in-older-women","status":"publish","type":"post","link":"https:\/\/ogkologos.com\/en\/study-adds-to-debate-about-mammography-in-older-women\/","title":{"rendered":"Study Adds to Debate about Mammography in Older Women"},"content":{"rendered":"

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A mammogram with arrows pointing to an asymmetry that was found to be an invasive ductal carcinoma.<\/p>\n

Credit: BMC Med Imaging. January 2019. https:\/\/doi.org\/10.1186\/s12880-018-0303-3.<\/p>\n<\/p><\/div>\n<\/figcaption><\/figure>\n<\/p><\/div>\n

It has become widely accepted that it\u2019s always best to find breast cancer as early as possible, when the cancer is less likely to have spread elsewhere in the body and less aggressive treatment may be needed.<\/p>\n

And studies have shown that routine screening mammography does reduce breast cancer deaths in women aged 40 to 75.<\/p>\n

But screening also comes with downsides, which include the risk of overdiagnosis<\/a> and overtreatment<\/a>. A new study suggests that the risk of overdiagnosis with routine screening mammography is substantial<\/a> for women in their 70s and older.<\/p>\n

And this overdiagnosis risk escalates with increasing age and other health problems, according to findings published August 8 in the Annals of Internal Medicine<\/em>.<\/p>\n

The concept of overdiagnosis is a tricky one. It doesn\u2019t refer to false positives\u2014test results that indicate that a suspicious mass is cancer when further tests show that it actually isn\u2019t. Instead, in overdiagnosis, a screening test does find a true cancer. But it\u2019s a cancer that will grow very slowly\u2014or not at all\u2014and would never cause problems during someone\u2019s lifetime.<\/p>\n

Treatment for such cancers would, by definition, be unnecessary. But since there is currently no way to tell which breast cancers found on screening mammograms will grow, and how fast, women who have such cancers almost always have surgery, and sometimes additional treatments.<\/p>\n

Because older or frail women are most likely to have a shorter remaining life span, the prospect of overdiagnosis has led to sometimes intense debate about whether it\u2019s appropriate to screen these women for breast cancer.<\/p>\n

\u201cThe suggestion that screening may not be helpful [for some people] is tricky,\u201d said Ilana Richman, M.D., from Yale School of Medicine, who led the new study. \u201cWe don\u2019t want our patients to think that we\u2019re giving up on them, when what we\u2019re really after is just the opposite\u2014focusing on care that improves quality of life by avoiding tests that are unlikely to be beneficial.\u201d<\/p>\n

\u201cIt can often take 10, 20, even 30 years for a slow-growing breast cancer to cause harm,\u201d added Mara Schonberg, M.D., from Beth Israel Deaconess Medical Center, who was not involved with the new study. \u201cSo, for older women with other health conditions, with frailty, … diagnosing breast cancer and treating it [may] only cause additional problems.\u201d<\/p>\n

Modeling screening mammography in older women<\/h2>\n

Rigorous clinical trials to evaluate the ability of cancer screening tests to save lives all follow a similar design, Dr. Richman explained. They enroll a large number of participants, who are randomly assigned to either undergo routine screening or not. These participants are then followed for many years, to see if there are fewer deaths from cancer in the screened group over time.<\/p>\n

Differences in the number of cancers detected don\u2019t provide information about the effectiveness of screening, because more cancers will always be found if one looks for them<\/a>. In fact, if a study finds many more cancers in people who are screened but no decrease in cancer deaths, that is more likely to be evidence of overdiagnosis than of any benefit for screening.<\/p>\n

Studies conducted over the past few decades have found that women ages 40 to 74 who are regularly screened for breast cancer have a small but meaningfully reduced risk of dying of the disease<\/a>. But rigorous trials have not included women over the age of 75, Dr. Richman said.<\/p>\n

To approximate such a trial, Dr. Richman and her colleagues used data from more than 50,000 women enrolled in Medicare whose records were linked to NCI\u2019s Surveillance, Epidemiology, and End Results (SEER) database<\/a>. All had undergone screening mammography in 2002. None had had breast cancer, and all were aged 70 or older by January 1, 2003.<\/p>\n

The researchers divided the women into two groups based on whether they\u2019d had another screening mammogram at some point during the next 3 years. This allowed them to mimic the way participants would be split up in a clinical trial, with half assigned to continue screening and the other half to have no further screening.<\/p>\n

They then compared how many women were diagnosed with breast cancer (incidence) and how many died from breast cancer over the remainder of their lives.<\/p>\n

Increasing age, increasing risk of overdiagnosis<\/h2>\n

The women were followed through 2017 or until they were diagnosed with breast cancer or died. Overall, women in the study aged 70 to 74 were followed for a median<\/a> of almost 14 years, those aged 75 to 84 for a median of 10 years, and those aged 85 and older for a median of about 5 and a half years.<\/p>\n

More cancers were found in women who continued screening\u2014for example, among women aged 70 to 74 years, cancers were detected in about 6 of 100 women during the follow-up period, whereas they were detected in about 4 of 100 women who weren\u2019t screened.<\/p>\n

But the researchers did not see differences between the groups in the number of cancers that were diagnosed at more advanced stages, which are more likely to be lethal, or in deaths from breast cancer. They did see a difference in the number of cancers detected at an earlier stage, but this didn\u2019t translate into a decrease in deaths from breast cancer.<\/p>\n

Based on the differences in diagnoses between the two groups, the researchers estimated that, among women aged 70 to 74 diagnosed with breast cancer on screening mammography, around 31% would be overdiagnosed. These overdiagnosis estimates rose to 47% for women aged 75 to 84 and more than 50% for some women who had a life expectancy of less than 5 years (based on their age and other health conditions).<\/p>\n

The study\u2019s main takeaway message shouldn\u2019t be the exact overdiagnosis percentages, since these can vary based on the methods used to estimate them, said Natasha Stout, Ph.D., of NCI\u2019s Division of Cancer Control and Population Sciences<\/a>, who wasn\u2019t involved in the study.<\/p>\n

\u201cAnd it\u2019s important to remember that overdiagnosis is only something you can measure looking back, at the population level. You can never say, for any one individual woman, whether overdiagnosis happened,\u201d Dr. Stout added.<\/p>\n

\u201cBut across studies, the [overdiagnosis] numbers are big enough to be pretty meaningful for women\u201d aged 70 and older overall, she said. \u201cWe need to be thinking about overdiagnosis as a potential harm from screening tests in general, and people need to be aware [of it].\u201d<\/p>\n

Having hard conversations about mammography<\/h2>\n

The new study\u2019s results highlight the need for conversations between older women and their health care providers about the potential benefits and harms of continuing screening mammography.<\/p>\n

\u201cThese are not easy conversations to have,\u201d said Dr. Stout. By nature, they include a discussion of life expectancy and death, she explained, which can be difficult to handle in a sensitive manner.<\/p>\n

\u201cBut [these conversations] aren\u2019t about giving up on people, in any way. It\u2019s about not doing harm when a test is unlikely to be helpful,\u201d said Dr. Richman.<\/p>\n

And the potential harms of overdiagnosis can be substantial.<\/p>\n

When cancer, even a very small one, is found on a screening mammogram, \u201cmost of these women have surgeries, some will have radiation therapy, a smaller percentage will have chemotherapy,\u201d explained Dr. Richman. \u201cEven after something like a [lumpectomy<\/a>], older women risk functional decline. It can set them back in terms of how much they\u2019re able to do for themselves.\u201d<\/p>\n

But people put different values on different potential health outcomes, she added. And there are gray areas in decisions about screening. Women in their 70s offer an ideal example, she said.<\/p>\n

\u201cWe have data that suggests that screening is helpful [for these women]. But overdiagnosis probably also exists,\u201d she said. So it\u2019s important for clinicians talking to their older patients to acknowledge that those two things can occur simultaneously, she continued, and that different people may make different choices about continuing or stopping screening.<\/p>\n

Can some women have less treatment?<\/h2>\n

Drs. Schonberg and Stout have been developing an online conversation aid to help doctors and older women have these difficult conversations.<\/p>\n

The tool is designed to be used within the limited amount of time allocated for a wellness visit, they explained, but in a way that still takes individual concerns and values into account. These include the fact that some women, because of risk factors like family history or breast density<\/a>, will have a higher likelihood of developing breast cancer than others.<\/p>\n

The conversation aid is currently undergoing testing, \u201cbut we hope that having this kind of tool will address some of the barriers to these conversations<\/a>,\u201d Dr. Schonberg said.<\/p>\n

Methods to determine which cancers found on screening may be very slow growing\u2014and can potentially be simply monitored, or treated with hormone therapy<\/a> alone\u2014are also needed, wrote Otis Brawley, M.D., and Rohan Ramalingam, M.D., of the Johns Hopkins School of Medicine, in an editorial that accompanied the new study<\/a>. That includes identifying potential molecular features of these slow-growing cancers, they wrote, similar to what is already done to identify which treatments are best for specific forms of breast cancer. <\/p>\n

If such biomarkers<\/a> can eventually be developed, \u201cwe might be able to move precision or personalized medicine<\/a> to the point that we can distinguish types of cancer that are a threat and need treatment versus those that are indolent<\/a> but merit observation,\u201d they explained.<\/p>\n

In the meantime, new studies are starting to test whether these more conservative approaches to treatment may be safe<\/a> for some women with small cancers found on screening mammograms.<\/p>\n

\u201cThere\u2019s a lot of interest in the oncology world in asking: Can we better predict which treatments are necessary and which are not, so that for some women, we can safely do less?\u201d said Dr. Richman.<\/p>\n

Source<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

September 12, 2023, by Sharon Reynolds A mammogram with arrows pointing to an asymmetry that was found to be an invasive ductal carcinoma. Credit: BMC Med Imaging. January 2019. https:\/\/doi.org\/10.1186\/s12880-018-0303-3. It has become widely accepted that it\u2019s always best to find breast cancer as early as possible, when the cancer is less likely to have […]<\/p>\n","protected":false},"author":2,"featured_media":46144,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"footnotes":""},"categories":[5137],"tags":[],"class_list":["post-46143","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-world-news"],"_links":{"self":[{"href":"https:\/\/ogkologos.com\/en\/wp-json\/wp\/v2\/posts\/46143","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ogkologos.com\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/ogkologos.com\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/ogkologos.com\/en\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/ogkologos.com\/en\/wp-json\/wp\/v2\/comments?post=46143"}],"version-history":[{"count":1,"href":"https:\/\/ogkologos.com\/en\/wp-json\/wp\/v2\/posts\/46143\/revisions"}],"predecessor-version":[{"id":46273,"href":"https:\/\/ogkologos.com\/en\/wp-json\/wp\/v2\/posts\/46143\/revisions\/46273"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/ogkologos.com\/en\/wp-json\/wp\/v2\/media\/46144"}],"wp:attachment":[{"href":"https:\/\/ogkologos.com\/en\/wp-json\/wp\/v2\/media?parent=46143"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/ogkologos.com\/en\/wp-json\/wp\/v2\/categories?post=46143"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/ogkologos.com\/en\/wp-json\/wp\/v2\/tags?post=46143"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}