No Magic Age To Stop Performing Screening Mammograms

MedicalResearch.com Interview with:
Cindy S. Lee, MD

Department of Radiology and Biomedical Imaging
University of California, San Francisco, San Francisco
Now with Department of Radiology
NYU Langone Medical Center, Garden City, New York

MedicalResearch.com: What led you and colleagues to conduct this study?

Response: I am a breast imager. I see patients who come in for their screening mammograms and I get asked, a lot, if patients aged 75 years and older should continue screening, because of their age. There is not enough evidence out there to determine how breast cancer screening benefits women older than 75. In fact, all previously randomized trials of screening mammography excluded people older than 75 years.

Unfortunately, age is the biggest risk factor for breast cancer, so as patients get older, they have higher risks of developing breast cancer. It is therefore important to know how well screening mammography works in these patients.

MedicalResearch.com: What did the main findings suggest?

Response: We found encouraging results for screening older women. Screening mammography performs better when the patient is older. We relied on 4 measurements to evaluate how well screening works.

The first measure was recall rate, which is a ‘hot buzz word.’ Whenever people think of screening, they want to know how many women have been called back for additional imaging because recall rate is directly proportional to the rate of false positives.

A second measure was the cancer detection rate, or the number of cancers found per 1,000 screening exams.

The third and fourth measures used in this study were the positive predictive values (PPV) for biopsy recommended (PPV3) and for biopsy performed (PPV4). These two PPVs explained how many cancers were found among cases recommended for biopsy and among biopsied cases.

A good screening exam should have low recall rate, high cancer detection rate and PPVs, meaning that it has less false positives while catching more cancers. What we found was that with increasing age, cancer detection rate and the positive predictive value are both going significantly up. At the same time, the recall rate is going significantly down up until about age 90 years. So, screening mammography works better in older women.

MedicalResearch.com: Were you surprised by any of your findings? 

Response: We were surprised by how well screening works in older people. Knowing before we started that this is a disease that affects older patients, we expected to see more screening-detected cancers in older women. But what was surprising was the recall rate and the number of false positives (unnecessary workup) both decreased in older women. The difference is statistically significant and shows us that screening should not stop cold at age 75. Our results suggest that we should continue screening for as long as the patient can live for another 7 to 10 years and the patient would desire treatment if cancer was found.

MedicalResearch.com: What sort of clinical implications do the data have for practice?

Response: Our data support continued screening mammography in women aged older than 75 years and specifically it does not support a clear age cut-off. There is no magic age to stop screening mammography because the benefits appeared to continue to age 90. Decision to stop screening should be based on a discussion between each woman and her physician, because the individual patient preferences, comorbidities and health status are unique. We are promoting an individualized decision with screening in older women and it really does require a patient centered approach to care.

MedicalResearch.com: The USPSTF guidelines state there is not enough evidence to assess the balance of benefits and harms of mammography in women aged 75 and older. Randomized trials typically exclude this age group, too. Your findings showed that breast cancer detection rate and positive predictive values of mammography continued among women aged 75 to 90, so what should this mean for the clinical community going forward?  

Response: This study is the largest on the topic of screening in older woman. Moving forward, our results support a patient-centered approach to screening mammography. If a patient is over 75 years old, healthy with >5-7 years life expectancy and desires treatment for breast cancer if diagnosed, then she should have the access to screening mammogram. On the other hand, if the patient has limited life expectancy or does not desire breast cancer treatment, then it is appropriate to stop screening. All of this taken together tells us that we need to discuss with our patients their needs and preferences before making a personalized recommendation on breast cancer screening.

MedicalResearch.com: Is there anything else that you would like to mention that we have not already discussed?

Response: The specific database that we used, the National Mammography Database (NMD), is more than a research tool (2). NMD is designed as a practical quality improvement tool that any U.S. breast imaging facility can join to get periodic performance feedbacks with comparison to national benchmarks and its peers. Best part is that many facilities can now join the NMD for free. Go to https://www.acr.org/Quality-Safety/National-Radiology-Data-Registry/National-Mammography-DB for details. My hope is for more radiologists and more radiology facilities to take advantage of this, because NMD will help them see how well they compare to their peers as a facility and also as a physician in reading mammograms. It is a powerful tool that I hope more physicians will use.

Reference:  

  1. Lee CS, Sengupta D, Bhargavan-Chatfield M, Sickles EA, Burnside ES, Burleson J, Zuley M. Current Era Screening Mammography Outcomes from the National Mammography Database, Including over 6 Millions Exams. Scientific Presentation at 2016 Annual Meeting of RSNA. November 29, 2016.
  2. Lee CS, Bhargavan-Chatfield M, Burnside ES, Nagy P, Sickles EA. The National Mammography Database: preliminary data. AJR Am J Roentgenol. 2016;206(4):883-890. Available at https://www.ncbi.nlm.nih.gov/pubmed?term=Mammography+Database%3A+preliminary+data&TransSchema=title&cmd=detailssearch.

For more information:

Cindy Lee, MD, can be reached at the Department of Radiology, New York University Langone Medical Center, 765 Stewart Avenue, Garden City, New York, 11530. Cindy.Lee3@nyumc.org.

Disclosure: Lee reports no relevant financial disclosures.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community

Citation:

Lee CS, Sengupta D, Bhargavan-Chatfield M, Sickles EA, Burnside ES, Zuley ML. Association of Patient Age With Outcomes of Current-Era, Large-Scale Screening MammographyAnalysis of Data From the National Mammography Database. JAMA Oncol. Published online April 20, 2017. doi:10.1001/jamaoncol.2017.0482

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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