Rachel Freedman, MD, MPH, is a medical oncologist in the breast oncology center in the Susan F. Smith Center for Women’s Cancers at Dana-Farber Cancer Institute (DFCI). She is also Associate Professor in Medicine at Harvard Medical School, a clinical researcher, and Medical Director of the DFCI Cancer Care Collaborative. She researches disparities in breast cancer treatment and outcomes for minority patients and older patients. She is a member of the Cancer.Net Editorial Board’s geriatric oncology advisory panel.
For women with no history of cancer, U.S. screening guidelines recommend that all women start receiving mammograms when they turn 40 or 50 and to continue getting one every 1 or 2 years. This routine continues until they turn about 75 years of age or if, for whatever reason, they have limited life expectancy. At that point, whether a woman continues to have mammograms depends on thoughtful discussion between the woman and her health care team about what is appropriate for her specific situation.
However, after an older woman is treated for breast cancer, it is less clear when mammography can safely stop as women age. Follow-up care guidelines for breast cancer survivors from the American Society of Clinical Oncology (ASCO) and American Cancer Society recommend that women have a mammogram on any intact breast every year. The goal of these mammograms is to find cancer that comes back in the affected breast, called a recurrence, or to detect a new breast cancer in either breast that may occur over time.
However, there are questions about how long breast cancer survivors should continue to receive mammograms if they are older than 75 or if other medical conditions may shorten their lives. Older patients have not been well represented in breast cancer research, and this has led to recommendations that are applied to all women with breast cancer. Because these guidelines have not addressed older women specifically, they often continue having these tests as a habit, without much discussion about the risks and benefits of mammograms.
But in 2021, mammography guidelines for breast cancer survivors age 75 and older were published in JAMA Oncology. These guidelines were developed by a panel of U.S. experts and recommend having discussions with women about their breast cancer history and treatment, their other medical history and concerns, the benefits and harms of mammography, and their personal preferences. The guidelines offer general guidance for the following:
Stop mammography for breast cancer survivors age 75 and older if they are expected to live less than 5 years.
Consider stopping mammography for breast cancer survivors age 75 and older who are expected to live between 5 and 10 years.
Continue mammography for breast cancer survivors age 75 and older who are expected to live more than 10 years.
Most women will benefit from mammograms for many years after they are diagnosed with breast cancer. But there are also women who will not benefit as much and can consider stopping mammograms. Stopping mammograms does not mean that women will not continue to receive proper care, follow-up with their providers, or physical examinations, but it does mean that mammograms may not lead to better outcomes for certain women. These guidelines are meant to serve as a support tool for clinicians and patients to promote shared decision-making, acknowledging that mammograms will not provide indefinite improvements in longevity and do have downsides.
In addition to the guideline recommendations above, here are 2 situations in which a woman might want to stop having mammograms:
If a woman is older and has other significant medical conditions, like heart disease or stroke, particularly when these conditions affect one’s physical function and mobility. In older patients previously treated for breast cancer, these other medical conditions often pose a greater risk of dying. So for patients who face significant medical challenges, it is not clear that continuing mammography forever makes sense. This is because there may not be clear benefits of mammography in this setting, but the downsides of mammography will continue over time.
Women treated for a lower-risk breast cancer who are on medications to help prevent additional cancers from forming. These medications, such as tamoxifen or aromatase inhibitors, lower the risk that there will be another breast cancer, sometimes to a risk level that is even lower than the general population of older women who have never had breast cancer. Here, the role of mammograms may be less important as well.
Mammograms also have harms that are important to consider when making a decision. There can be mild discomfort during the testing. Based on a mammogram’s result, there is also the chance that women will undergo a biopsy that finds no cancer, called false positives. There is also a risk for something called “overtreatment.” This is when mammography finds a cancer that would not affect a woman’s life span but may result in her getting treatments that she may not have needed.
In the end, you should ask your doctor about how mammograms may or may not help you and what the recommendations are for your situation. This is a very personal decision, and you and your health care team should work together to make this decision so that it feels right for you.
This post was updated February 19, 2021.
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