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Surveillance Mammography in Older Patients With Breast Cancer—Can We Ever Stop?A Review

Educational Objective
To learn the benefits and harms of mammographic surveillance in older patients with breast cancer.
1 Credit CME
Abstract

Importance  Approximately 4% to 5% of breast cancer survivors will develop a new ipsilateral or contralateral cancer (in-breast event) over the 5 years following diagnosis, and annual surveillance mammography is recommended for those with residual breast tissue. The risk for such in-breast events persists over time, though increasing age at cancer diagnosis and treatment with hormonal therapy are associated with lower risk, and most older survivors of breast cancer will ultimately die from nonbreast cancer–related causes. Specific guidelines for surveillance strategies in older patients are limited. Prospective data on the benefits and harms of surveillance mammography in this population are lacking, and most of the evidence is derived from observational, retrospective data, often in the general population.

Observations  We review the current recommendations for breast cancer screening and surveillance for older patients, the current evidence for ipsilateral and contralateral breast cancer risks in older survivors of breast cancer, and suggested approaches for discussions about surveillance mammography with older patients. We recommend individualized decision making for surveillance breast imaging in older survivors of breast cancer, with consideration of the following strategy for women 70 years or older: 1-time imaging 6 to 12 months after completion of local therapy followed by annual or biennial surveillance mammography for healthy women and cessation of mammography in patients whose life expectancy is less than 5 years to 10 years, regardless of age. Decisions on mammographic surveillance should also incorporate whether hormonal therapy is being administered, whether a patient’s anticipated life expectancy is extraordinary, and whether a patient’s individual risk for in-breast events is higher (or lower) than average risk for breast cancer survivors.

Conclusions and Relevance  We propose reframing discussions around surveillance mammography in older breast cancer survivors and to consider cessation while taking into account life expectancy, the estimated risk for subsequent in-breast events, and patient preferences.

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Article Information

Corresponding Author: Rachel A. Freedman, MD, MPH, Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215 (rafreedman@partners.org).

Published Online: November 17, 2016. doi:10.1001/jamaoncol.2016.3931

Author Contributions: Dr Freedman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors participated in the planning, review, and writing of this manuscript, and all authors approved the final submitted version.

Concept and design: Freedman, Partridge, Hurria, Winer.

Acquisition, analysis, or interpretation of data: Freedman, Keating, Muss, Hurria.

Drafting of the manuscript: Freedman, Muss.

Critical revision of the manuscript for important intellectual content: All Authors.

Administrative, technical, or material support: Freedman.

Study supervision: Freedman, Winer.

Conflict of Interest Disclosures: Dr Keating serves as a medical editor for the Informed Medical Decisions Foundation, now part of Healthwise, a nonprofit organization whose mission is to help people make better health decisions. Dr Hurria serves as a consultant for Seattle Genetics, OptumHealth Care Solutions, Inc, GTx, Inc, Boehringer Ingelheim Pharmaceuticals, Caregive, and Sanofi. She receives research-related funding from GlaxoSmithKline, Celgene, and Novartis. No other conflicts are reported.

Funding/Support: Dr Freedman is supported by the American Cancer Society and Susan G. Komen for the Cure. Dr Keating is supported by the National Cancer Institute (grant K24CA181510).

Role of the Funder/Sponsor: The funders/sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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