Women with Limited Life Expectancy
Elderly Women
Young Women
Women with Thoracic Radiation
Race
Males

Women with Limited Life Expectancy

Achieving balance between the benefits and harms of screening is especially important for women with a life expectancy of no longer than 5 years. Such women might have end-stage renal disease, severe dementia, terminal cancer, or severe functional dependencies in activities of daily living. Early cancer detection and prompt treatment are unlikely to reduce morbidity or mortality within the woman's 5 years of expected survival, but the negative consequences of screening will occur immediately. Abnormal screening may trigger additional testing with attendant anxiety. In particular, the detection of low-risk malignancy would probably result in a recommendation for treatment, which could impair rather than improve quality of life, without improving survival. Despite these considerations, many women with poor life expectancy due to age or health status often undergo screening mammography.[1]

Screening mammography in women older than 65 years often results in additional diagnostic testing in 85 per 1,000, with cancer diagnosed in nine. The testing is often accomplished over many months, which may cause anxiety due to diagnostic uncertainty.[2] While screening mammography may yield cancer diagnoses in approximately 1% of elderly women, many of these cancers are low risk. A study of California Medicare beneficiaries aged 65 to 79 years demonstrated this clearly. The relative risk (RR) of detecting local breast cancer was 3.3 (95% confidence interval, 3.1–3.5) among screened women. Diagnosis of metastatic cancer was reduced among screened women (RR = 0.57), suggesting there may be benefit of mammography screening in elderly women, though it comes with an increased risk of overdiagnosis.[3]

One study examined the usefulness of mammography in evaluating breast complaints in 1,908 women aged 35 years or younger. Although 23 were found to have palpable cancers, none of the 1,908 mammograms contributed any information that affected patient management.[4]

Screening has been recommended for women exposed to therapeutic radiation, especially if exposed at a young age. Screening mammography and magnetic resonance imaging can identify early-stage cancers, but the benefits and risks have not been clearly defined.

Although age-adjusted breast cancer incidence rates are higher in white women than in black women, mortality rates are higher in black women. Among breast cancer cases diagnosed from 1995 to 2001, 64% of white women and only 53% of black women had localized disease. The 5-year relative survival rate for localized disease was 98.5% for white women and 92.2% for black women; for regional disease, it was 82.9% for white women and 68.3% for black women; and for distant disease, it was 27.7% for white women and 16.3% for black women. Both breast cancer incidence and mortality are lower among Hispanic and Asian/Pacific Islander women than among white and black women.[5]

Several explanations for these findings have been proposed, including lower socioeconomic status, lower level of education, and less access to screening and treatment services. Population-based studies demonstrate that, compared with other groups, Medicaid recipients and uninsured patients of all races have later-stage breast cancer diagnosis, and survival from the time of diagnosis is shorter. This difference is associated with socioeconomic status and may reflect lack of participation in screening activities.[6,7] Black women older than 65 years are less likely to undergo mammogram screening. Among regular users of mammography, however, cancer was diagnosed in black and white women at similar stages.[8]

Similar studies of Hispanic populations have been done. Breast cancer stage at diagnosis in San Diego County was more advanced for Hispanic than for white women, especially for those younger than 50 years. Low-income whites were more likely to have late-stage diagnosis than high-income whites. Among Hispanic women, there was no difference according to income, but all the Hispanic groups were at or below the lowest white income level.[9] In New Mexico, a population-based case-control study examined reproductive histories of 719 Hispanic and 836 white breast cancer patients, with half of each group having breast cancer. The Hispanic women had higher body mass index, higher parity, and earlier pregnancies.[10] Whereas reproductive factors such as age at first full-term birth, parity, and duration of lactation accounted for some of the ethnic differences in postmenopausal women, there was no evidence that these factors played a role in the differences in premenopausal patients. A study of mammography screening in a health maintenance organization in Albuquerque found that Hispanic women had consistently lower rates of screening than whites (50.6% vs. 65.5% in 1989, and 62.7% vs. 71.6% in 1996).[11] Predictors of more advanced stage at diagnosis included Hispanic race (odds ratio, 2.12) and younger age.

Approximately 1% of all breast cancers occur in males. Most cases are diagnosed during the evaluation of palpable lesions and treatment consists of surgery, radiation, and systemic adjuvant hormone therapy or chemotherapy. There are no data on the benefits or risks of screening.

References

1. Walter LC, Lindquist K, Covinsky KE: Relationship between health status and use of screening mammography and Papanicolaou smears among women older than 70 years of age. Ann Intern Med 140 (9): 681-8, 2004.  [PUBMED Abstract]
   
   
2. Welch HG, Fisher ES: Diagnostic testing following screening mammography in the elderly. J Natl Cancer Inst 90 (18): 1389-92, 1998.  [PUBMED Abstract]
   
   
3. Smith-Bindman R, Kerlikowske K, Gebretsadik T, et al.: Is screening mammography effective in elderly women? Am J Med 108 (2): 112-9, 2000.  [PUBMED Abstract]
   
   
4. Hindle WH, Davis L, Wright D: Clinical value of mammography for symptomatic women 35 years of age and younger. Am J Obstet Gynecol 180 (6 Pt 1): 1484-90, 1999.  [PUBMED Abstract]
   
   
5. Ries LAG, Eisner MP, Kosary CL, et al., eds.: SEER Cancer Statistics Review, 1975-2002. Bethesda, Md: National Cancer Institute, 2005. Also available online. Last accessed February 12, 2009. 
   
   
6. Roetzheim RG, Pal N, Tennant C, et al.: Effects of health insurance and race on early detection of cancer. J Natl Cancer Inst 91 (16): 1409-15, 1999.  [PUBMED Abstract]
   
   
7. Bradley CJ, Given CW, Roberts C: Race, socioeconomic status, and breast cancer treatment and survival. J Natl Cancer Inst 94 (7): 490-6, 2002.  [PUBMED Abstract]
   
   
8. McCarthy EP, Burns RB, Coughlin SS, et al.: Mammography use helps to explain differences in breast cancer stage at diagnosis between older black and white women. Ann Intern Med 128 (9): 729-36, 1998.  [PUBMED Abstract]
   
   
9. Bentley JR, Delfino RJ, Taylor TH, et al.: Differences in breast cancer stage at diagnosis between non-Hispanic white and Hispanic populations, San Diego County 1988-1993. Breast Cancer Res Treat 50 (1): 1-9, 1998.  [PUBMED Abstract]
   
   
10. Gilliland FD, Hunt WC, Baumgartner KB, et al.: Reproductive risk factors for breast cancer in Hispanic and non-Hispanic white women: the New Mexico Women's Health Study. Am J Epidemiol 148 (7): 683-92, 1998.  [PUBMED Abstract]
    
    
11. Frost FJ, Tollestrup K, Trinkaus KM, et al.: Mammography screening and breast cancer tumor size in female members of a managed care organization. Cancer Epidemiol Biomarkers Prev 7 (7): 585-9, 1998.  [PUBMED Abstract]
    
    

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