Screening Mammography: There is Value in Screening Women Aged 75 and Over Stamatia Destounis, MD, FACR, FSBI, FAIUM Elizabeth Wende Breast Care, LLC. Clinical Professor University of Rochester School of Medicine and Dentistry

Background: Screening Mammography in the Aging Population US guidelines unclear regarding when to stop screening Population over 74 years of age not included in RCTs – best available data from observational studies, and prediction models

Background – USPSTF Recommendation Insufficient evidence to assess the benefits and harms of screening mammography in women 75 years and older Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined Siu AL, et al. Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 20106; 164: 279-296.

Background- Society Recommendations American Cancer Society – continue as long as woman is in good health and is expected to live 10 more years or longer [Smith RA, et al. CA Cancer J Clin 2018; 68: 297-316.] American College of Radiology -  The age to stop screening should be based on each woman’s health status rather than an age-based determination [Monticciolo DL, et al. JACR 2017; 14: 1137-1143.]

Background- Breast Cancer in the Elderly Nearly 1/5 breast cancers occur in women 75 or older Cancer detection rates and PPV for biopsy are highest and recall rates are lowest in the 70-plus age group [Lee CS, et al. JAMA Oncol 2017], confirming screening efficacy in this group Elderly women who do not participate in screening more likely to present with higher stage cancers [Vyas et al. Breast Cancer Res Treat 2014; Badgwell et al. JCO 2008; McCarthy et al. J Am Geriatr Soc 2000], with reduced survival [McCarthy, Vacek et al. J Am Geriatr Soc 2014; McPherson et al. J Am Geriatr Soc 2002 ] REFS FROM ACR RECOMMENDATIONS ARTICLE Dijck JV, Verbeek AL, Beex LV, Hendriks JH, Holland R, Mravunac M, et al. Breast-cancer mortality in a non-randomized trial on mammographic screening in women over age 65. International journal of cancer. 1997;70(2):164-8.

Study Purpose To review outcomes of screening mammography performed in women 75 and over to determine the rate of cancer diagnosed and associated histology and surgical excision performed

Methods and Materials IRB approved retrospective review of medical records to identify patients with cancers diagnosed at screening mammography over 10-year period (2007-2017) 763,256 total screening appointments 3,716 patients diagnosed with 4,412 screen-detected malignancies (5.8 cancers/1000) during this time 4.9 patients/1000 76,885 (10%) screening mammograms were performed in women 75 and over 671 patients diagnosed with 751 malignancies identified for further evaluation

Results 645 malignancies diagnosed in 616 patients included in analysis Cancer detection rate: 8.4/1000 645/76885 26 excluded – found on US,

Results – Tumor Metrics Average size of invasive tumors – 1.4cm (range 0.07mm – 8cm) No residual disease in 11 cases 16 no surgery performed 14 no tumor size specified 84% of tumors were estrogen receptor (ER) positive 7% of patients had positive nodes at excision (46/616)

Results Overall, 98% of patients underwent surgical excision: 73% of tumors were treated with lumpectomy 24% mastectomy 3% no surgery performed 13 patients with 17 malignant tumors did not undergo surgical excision Avg. patient age = 85 years Comorbidities included: advanced patient age, overall poor health, metastatic disease Approx. 12 of these patients were treated with hormone therapy

82 year old presenting for screening mammogram

Grade 2 Invasive ductal carcinoma Stage IA Node negative ER/PR +, Her2Neu – Lumpectomy + radiation Stable follow-up

Discussion The goal of screening is to detect breast cancers when tumors are small and node negative lower stage and before metastasis The cancers detected in this study were largely invasive (82%), low stage (79%) and node negative (92.5%) There is a substantial cancer detection rate in this group (8.4/1000) - meeting ACR’s desired goals for medical audit data

Conclusions There are benefits of screening yearly after age 75 This age-group makes up a relatively small percentage of total screening population (10%), yet cancer diagnoses make up 16.6% of all patients diagnosed with screen-detected cancers High CDR= 8.4/1000 98% underwent surgical excision, suggesting that most women in this age group are in good health and do want to pursue surgical excision There are benefits of screening yearly after age 75

Thank You “The decision sdestounis@ewbc.com “The decision regarding when to stop screening should not be based on age alone” – ACR, SBI