A sad fact: None of the eight major clinical trials looking at whether regular mammograms reduce a woman's risk of dying from breast cancer has included women over age 75.
Older adults are frequently excluded from trials, a problem for those trying to treat them based on information, not hunches. This helps explain why the United States Preventive Services Task Force says the current evidence is "insufficient" to assess mammography's value for those over age 75, and why the American Geriatrics Society cautions against it for women with limited life expectancies.
Not only may mammograms not help, like any medical procedure, they may also harm. Mammograms can result in false positives that require additional tests, including biopsies, and bring anxiety. The scans may identify small tumors that wouldn't have caused problems for years — or at all, since older women are far more likely to die from other causes.
Yet once a mammogram detects even a non-invasive cancer, "it's very hard to decide not to be treated," said Dr. Mara Schonberg, an internist at Beth Israel Deaconess Medical Center in Boston. Since most women over age 75 still get mammograms, thousands of them undergo unnecessary surgery, radiation and medication every year.
What women need, she and several colleagues agreed, is a "decision aid," a tool that clarifies a medical procedure and its likely results. Once they understand the pros and cons of mammograms, "women can make better decisions based on realistic information about their risks," she said. Dr. Schonberg, who has investigated breast cancer screening among older women for years, noted that women don't hear much about the cons.
She and her colleagues decided to put together an 11-page pamphlet, written clearly at a sixth-grade reading level. It points out that doctors don't know whether mammograms lower mortality in this age group. (Indeed, there is wide disagreement over whether regular mammograms lower mortality in any age group.) The guide estimates that out of 1,000 women over 75, three of those who get mammograms will die of breast cancer and so will four of those who don't, a tiny difference.
Its charts show that heart disease, other cancers, stroke and dementia are far greater threats to elderly women. It even helps women calculate their life expectancy, to see whether a mammogram is likely to extend their lives.
Then the researchers tried a small pilot study, asking 45 women aged 75 to 89 who'd had a mammogram within two years to use the pamphlet.
Did it help? Maybe. Sort of.
Yes, the information did significantly improve their knowledge, results published in the journal JAMA Internal Medicine show. The women scored higher on a true-false test about the benefits and risks of breast cancer screening after they read the pamphlet than they had beforehand.
Yes, it did lead to more conversations about the decision with primary care doctors: In the five years before this experiment, patient medical records showed, only 11 percent had had such discussions. In the six months after reading the guide, 53 percent did.
And yes, the proportion of this small group who intended to continue screening dropped substantially, especially among those with a calculated life expectancy of nine years or less. In that group, 85 percent had earlier said they intended to get another mammogram; after the guide, 50 percent did. The guide didn't make a significant difference in the group with a longer life expectancy.
Women said they liked the pamphlet and found it useful. Their doctors said so, too.
And yet 60 percent of these older women went ahead and got another mammogram within 15 months, including more than half of those with a lower life expectancy.
It was tough to persuade women to start getting regular mammograms back in the 1970s, when the American Cancer Society and the former first lady Betty Ford began campaigning for annual screening. Decades later, it's tough to get older women to stop. Ditto for other cancer screenings — Pap tests, prostate tests, colonoscopies —among both older men and women.
These decisions involve more than a risk/reward calculation, clearly. When it comes to mammograms, "women go for reassurance, for affirmation of their health," Dr. Schonberg said. Her own studies show that "they felt this was the responsible thing to do," what Dr. Alexia Torke, associate director of the Indiana University Center for Aging Research, has termed "a moral obligation."
Some women don't recognize that there's a decision to be made at all. "Radiologists send you an annual reminder card," Dr. Schonberg said. "You're just told, 'go.'" (The Preventive Services Task Force recommendation is every two years, not annually, up to age 74.)
Still, this remains an individual decision. Women who see the whole picture and decide to continue with mammograms — Medicare pays for one each year — at least have reached an informed decision.
So I hope Dr. Schonberg's pamphlet gets widely circulated. She's about to test it with a much larger sample of about 500 women in Massachusetts and North Carolina, then report her findings.
And then we'll publish a link to the guide here, for anyone to use.
Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."
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