Is it time to give up your annual mammogram?

If you dread your annual mammogram, you’re not alone. For many women, this breast cancer screening examination can be painful, stressful, and just an overall hassle.

You may wonder, are you old enough to give it up? If you’re over age 75, the answer is: maybe or maybe not. The fact is, breast cancer screening isn’t right for all older adults, but there’s no expert consensus on the right age to stop. This is mostly because scientific evidence in this area is lacking, says Dr. Kathryn Rexrode, associate professor of medicine at Harvard Medical School and chief of the Division of Women’s Health at Brigham and Women’s Hospital. Each woman really needs to decide whether to continue mammography based on the risks and benefits of the procedure for her unique circumstances.

Weighing the decision

What is known is that breast cancer is a disease that disproportionately affects older women, says Dr. Rexrode. About half of the women diagnosed each year are over 60, and 20% are over 70. “However, the rate of new cancers does seem to decline slightly in women over the age of 75,” she says. A 2012 study in the European Journal of Public Health found that some 3.3% of women over 75 will be diagnosed with breast cancer. Of those women, one in three will die from the disease.

“Advantages of mammography include early detection of cancer, and this early detection may facilitate earlier access to treatments,” says Dr. Toni Golen, editor in chief of Harvard Women’s Health Watch. In addition, many breast cancers that occur in older women may be easier to treat than those that more typically occur in younger women. “Breast cancers in older women tend to be estrogen-receptor positive,” says Dr. Rexrode. This means that treatment won’t necessarily require chemotherapy, and doctors may be able to instead use hormone therapy, which is typically well tolerated by most. Hormone therapy can be carried out using a type of medication known as aromatase inhibitors, such as anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femara), which slow the body’s production of estrogen. Another option, tamoxifen (Genox, Istubal, Nolvadex, and Valodex), prevents estrogen from entering and fueling growth in cancer cells.

Drawbacks to consider

While there are certainly benefits to diagnosing and treating cancers in older women, there are risks to factor into the equation as well. These include:

• The risk of false positives. “Mammograms are screening tests and are designed to detect as many cancers as possible. Screening tests have a certain number of false positives on purpose in order to catch as many cancers as we can,” says Dr. Golen. False positives (mammograms that look abnormal but there’s no real cancer there) will trigger further testing or a biopsy, and this is a procedure that some older patients may opt to avoid, according to Dr. Golen. This additional workup may find that a woman doesn’t have cancer, but still causes her stress and physical discomfort from the additional procedures. “Healthy women should weigh the benefit of possible early detection versus the stress of a possible false positive. For women with risk factors, they should follow the advice of their own physician,” says Dr. Golen.
• The potential for overtreatment. Some early or precancerous conditions discovered by mammography may never actually be fatal to a woman, even if she lives with them for many years. “In some cases, you’re treating things that would never truly cause harm,” says Dr. Rexrode. This includes ductal carcinoma in situ, a noninvasive cancer that has not spread outside the milk ducts (which may or may not become a life-threatening cancer); a precancerous condition called atypical hyperplasia; or breast calcifications, which are calcium deposits inside the breast that can sometimes indicate cancer, she says. Many women could potentially die with these conditions, and never because of them, says Dr. Rexrode. But treatment is usually recommended because doctors don’t yet have the ability to distinguish between those that present a danger and those that do not.
• The creation of worry and stress. Mammography can be stressful, particularly when someone is called back to examine abnormal findings. In addition, these findings may prompt the need to undergo invasive diagnostic procedures, including biopsy procedures, unnecessarily.
• The physical stress and side effects of treatments. While breast cancer treatment in older women may be tolerable for some, in other instances it will require surgical procedures, such as a lumpectomy to remove a tumor, a mastectomy procedure to remove one or both breasts, and radiation or chemotherapy treatments. Some women may not be willing or physically able to endure these treatments. “That doesn’t mean that we should never treat cancers in people in their 80s. We definitely do. But we need to consider the balance of side effects and benefits so that the treatment isn’t worse than the condition,” says Dr. Rexrode.

How the decision looks in real life

Ultimately, each woman will need to make the decision regarding screening mammography that best suits her needs. A healthy 83-year-old woman who expects to live another 10 years, and is willing to undergo not only the mammogram but also follow-up and cancer treatments if needed, should continue to get mammograms as long as those factors don’t change. On the other hand, if you are in poorer health or just aren’t willing to endure screening and treatment, it may be time to stop your annual mammograms. It’s a discussion that you should have with input from your doctor.

But keep in mind, the decision to stop screening isn’t always an easy one from a psychological standpoint, even if there are numerous drawbacks. “Many women find mammograms painful, and they carry a negative connotation and they are more than happy to give them up. Others see it as part of taking care of themselves and don’t want to give it up,” says Dr. Rexrode. Even if you know that it’s the right decision intellectually, it may be a hard one to make emotionally.