Screening Older Women

1
Screening Older Women

• Risk Factors
• Exercise
• US Governments Womens Health Initiative
• 1993-1998
• 74,171 women ages 50-79
• Brisk walking for 1-2 hrs/week can reduce risk
  of breast cancer by nearly 20, even with HRT
• (smh.com.au)

2
Screening Older Women

• Risk Factors
• Bone Density
• University of Pittsburgh
• Published 2001
• 8,905 women ages 65
• No history of breast cancer
• Monitored for 6.5 yrs
• 315 women developed breast cancer

3
Screening Older Women

• Bone Density
• Women with highest bone density were 3X
  more likely to develop breast cancer (also
  slightly older and heavier)
• Implications
• Indication of high estrogen level
• Better to maintain bone mass through diet
  medications other than HRT (OBGYN.net)

4
Screening Older Women

• Physician Recommendations
• According to American Geriatrics Society (last
  updated 1999)
• United States Preventive Services Task
  Force recommends biennial mammography from
  age 50-70.
• American College of Physicians recommends
  mammograms until age 74 (based on oldest ages
  of clinical trial participants)
• However, nearly 50 of all breast cancers and
  more than 50 of all breast cancer deaths occur
  among women over age 65

5
Screening Older Women

• Physician Recommendations
• Recent mortality rates show promising declines in
  women under 70 yrs. old
• However, no improvement or less improvement in
  older women
• Later stage of diagnosis
• May reflect more co-morbid conditions /or less
  definitive therapy
• OR less stringent screenings
• Older women screened less because of patient,
  physician, and system barriers

6
Screening Older Women

• Barriers to Screening
• Physician factors
• Age biased anticipation of patient refusal
• Tendency to forget prevention measures among
  the multiple conditions of geriatric patients
• Underestimating life expectancy of older women
• Over-estimating physical and financial burdens of
  screening
• Younger, female, OB-GYN doctors refer for
  mammograms more than older, male, rural
  internal medicine doctors

7
Screening Older Women

• Patient issues
• Type number of co-morbidity conditions
• Functional status (transportation may become an
  issue)
• Life expectancy issues
• 75-yr-old can expect 14.2 more yrs.
• 80-yr-old can expect 8.9 more yrs.
• 85-yr-old can expect 6.9 more yrs.

8
Screening Older Women

• System barriers
• Better mammography has led to identification of
  more indolent lesions (localized ductal
  carcinomas-in-situ (DCIS) that may have low
  metastatic potential.
• Increased rates of false positives higher
  societal cost of additional testing and burden of
  fear on women

9
Screening Older Women

• System barriers
• Few randomized trials of benefits of
  mammograms in older women (only 2 of 8
  randomized trials included women 60.
  None included women 75 (UCSF.edu)
• Controversy over whether older womens tumors are
  less lethal.

10
Screening Older Women

• UCSF Study (Jan 92-Dec93)
• 690,003 California Medicare beneficiaries aged
  66-79
• Of 300,000 screened, rates of advanced breast
  cancer were 43 lower than women not regularly
  screened.
• In CA, between 1989-1993
• Age 70-79 10 decrease in breast cancer
  mortality
• Age 50-60 19 drop in breast cancer mortality
• Probably related to less screening

11
Screening Older Women

• Screening Recommendations
• American Cancer Society National Cancer
  Institute recommend annual screenings with no
  upper age cut-off
• American Geriatrics Society recommends every 1-2
  years until 75, and then every 2-3 years in women
  with at least 3 years life expectancy.

12
Treating Older Women with Breast Cancer

• Another issue
• Breast Cancer Treatment Recommendations
• From website, What you Need to Know About.Breast
  Cancer
• According to researchers, screening for and
  treating breast, colon, and cervical cancer after
  age 75 may add only days to the average womans
  life (breastcancer.about.com)

13
Treating Older Women with Breast Cancer

• Breast Cancer Treatment Recommendations
• According to the American College of Physicians
• Screening for breast cancer starting at age 50
  has a maximum potential life expectancy benefit
  of
• 43 days for breast cancer
• (vs. 28 days for colon cancer)
• Stopping at age 70 maximum of 9 days lost
• Stopping at age 80 maximum of 5 days lost

14
Treating Older Women with Breast Cancer

• Breast Cancer Treatment Recommendations
• Therefore
• 80 of the benefit is achieved before 75 years
  of age for breast cancer.The small benefit of
  screening may be outweighed by the harms
  anxiety, additional testing, and unnecessary
  treatment
• (acponline.org, Effective Clinical Practice,
  March/April, 2000)

15
Treating Older Women with Breast Cancer

• Breast Cancer Treatment Recommendations
• POTENTIAL PROBLEMS
• Research turns statistical charts into
  recommendations for patient care
• Healthy 80 year olds get put into the same
  category as women with severe health issues
• Arbitrary groupings and economic concerns
  affect individual physician recommendations

16
Treating Older Women with Breast Cancer

• Under treatment of older women with breast cancer
• Women over 65 have a 6X greater risk of
  developing breast cancer and a 7X greater chance
  of dying from breast cancer than younger women.
  (epi.hss.state.ak.us)

17
Treating Older Women with Breast Cancer

• Under treatment of older women with breast cancer
• National Institute on Aging Study
• 1800 postmenopausal women age 55
• Found significant inverse relationship between
  the age of patients and the likelihood that they
  received NIH-consistent therapy. (older women
  less likely to receive all recommended Rx)
• (JAMA 2001285885-892)

18
Treating Older Women with Breast Cancer

• Under treatment of older women with breast cancer
• Georgetown University School of Medicine
• Assessed treatments offered to 718 women aged 67
• Oldest women (aged 80) were significantly less
  likely to be referred to a radiation oncologist
• 20 times less likely to have breast conservation
  surgery
• 70 less likely to receive chemotherapy
• 3.4 times less likely to receive radiation
  therapy
• (Cancer, January 15, 2000 88369-374)

19
Treating Older Women with Breast Cancer

• Under treatment of older women with breast cancer
• Ohio State University Medical Center
• 480 women with breast cancer
• Found that receiving chemotherapy was solely a
  matter of age (not stage, tumor size, lymph node
  involvement, or type of breast cancer)
• 80 of women under 50 got chemo
• 75 age 50-65
• 50 age 65
• RESEARCHERS QUESTIONS
• ?? Whether patients choice or doctor
  recommendation
• ?? Risks outweigh benefits
• ?? Whether effects decline with increased age
• (healthscout.com)

20
Treating Older Women with Breast Cancer

• Under treatment of older women with breast cancer
• New Mexico Tumor Registry
• 1991-1997 with breast cancer who were candidates
  for adjuvant chemo
• Neutralized for effects of race, actual tumor
  stage, node status, hormone-sensitive or not.