Reduced mammographic screening may explain declines in breast carcinoma in older women

A scoping review of ageism towards older adults in cancer care

INTRODUCTION

Ageism towards older adults with cancer may impact treatment decisions, healthcare interactions, and shape health/psychosocial outcomes. The purpose of this review is twofold: (1) To synthesize the literature on ageism towards older adults with cancer in oncology and (2) To identify interventions that address ageism in the healthcare context applicable to oncology.

MATERIALS AND METHODS

We conducted a scoping review following Arksey and O'Malley and Levac methods and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We conducted an exhaustive multi-database search, screening 30,926 titles/abstracts. Following data abstraction, we conducted tabular, narrative, and textual synthesis.

RESULTS

We extracted data on 133 papers. Most (n = 44) were expert opinions, reviews, and letters to editors highlighting the negative impacts of ageism, expressing the need for approaches addressing heterogeneity of older adults, and calling for increased clinical trial inclusion for older adults. Qualitative studies (n = 3) described healthcare professionals' perceived influence of age on treatment recommendations, whereas quantitative studies (n = 32) were inconclusive as to whether age-related bias impacted treatment recommendations/outcomes or survival. Intervention studies (n = 54) targeted ageism in pre/post-licensure healthcare professionals and reported participants' improvement in knowledge and/or attitudes towards older adults. No interventions were found that had been implemented in oncology.

DISCUSSION

Concerns relating to ageism in cancer care are consistently described in the literature. Interventions exist to address ageism; however, none have been developed or tested in oncology settings. Addressing ageism in oncology will require integration of geriatric knowledge/interventions to address conscious and unconscious ageist attitudes impacting care and outcomes. Interventions hold promise if tailored for cancer care settings. 249/250.

An age-period-cohort analysis of cancer incidence among the oldest old, Utah 1973-2002

We used age-period-cohort (APC) analyses to describe the simultaneous effects of age, period, and cohort on cancer incidence rates in an attempt to understand the population dynamics underlying their patterns among those aged 85+. Data from the Utah Cancer Registry (UCR), the US Census, the National Center for Health Statistics (NCHS), and the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) programme were used to generate age-specific estimates of cancer incidence at ages 65-99 from 1973 to 2002 for Utah. Our results showed increasing cancer incidence rates up to the 85-89 age group followed by declines at ages 90-99 when not confounded by the separate influences of period and cohort effects. We found significant period and cohort effects, suggesting the role of environmental mechanisms in cancer incidence trends between the ages of 85 and 100.

An investigation of the apparent breast cancer epidemic in France: screening and incidence trends in birth cohorts

BACKGROUND

Official descriptive data from France showed a strong increase in breast-cancer incidence between 1980 to 2005 without a corresponding change in breast-cancer mortality. This study quantifies the part of incidence increase due to secular changes in risk factor exposure and in overdiagnosis due to organised or opportunistic screening. Overdiagnosis was defined as non progressive tumours diagnosed as cancer at histology or progressive cancer that would remain asymptomatic until time of death for another cause.

METHODS

Comparison between age-matched cohorts from 1980 to 2005. All women residing in France and born 1911-1915, 1926-1930 and 1941-1945 are included. Sources are official data sets and published French reports on screening by mammography, age and time specific breast-cancer incidence and mortality, hormone replacement therapy, alcohol and obesity. Outcome measures include breast-cancer incidence differences adjusted for changes in risk factor distributions between pairs of age-matched cohorts who had experienced different levels of screening intensity.

RESULTS

There was an 8-fold increase in the number of mammography machines operating in France between 1980 and 2000. Opportunistic and organised screening increased over time. In comparison to age-matched cohorts born 15 years earlier, recent cohorts had adjusted incidence proportion over 11 years that were 76% higher [95% confidence limits (CL) 67%, 85%] for women aged 50 to 64 years and 23% higher [95% CL 15%, 31%] for women aged 65 to 79 years. Given that mortality did not change correspondingly, this increase in adjusted 11 year incidence proportion was considered as an estimate of overdiagnosis.

CONCLUSIONS

Breast cancer may be overdiagnosed because screening increases diagnosis of slowly progressing non-life threatening cancer and increases misdiagnosis among women without progressive cancer. We suggest that these effects could largely explain the reported "epidemic" of breast cancer in France. Better predictive classification of tumours is needed in order to avoid unnecessary cancer diagnoses and subsequent procedures.

Cancers: Progress and Challenges in the Elderly

Cancer is a growing concern in the long-term care facility. The most common cancers long-term staff are apt to encounter include breast, lung, bladder, prostate, brain, and colorectal. Each cancer subtype and its treatment options are reviewed; they will vary with patients' level of functioning and tolerability. Since treatment guidelines were developed for younger cohorts, issues and side effects unique to elders require an ongoing alliance with oncology specialists. Screening guidelines and end-of-life issues are discussed.

Routine screening mammography in women older than 74 years: a review of the available data

OBJECTIVE

The efficacy of population screening mammography for the age group of 50-74 years has been demonstrated. However, only limited data are available regarding women aged 75 and over, and recommendations for breast cancer screening in this age group vary in different countries. The aim of the current study is to review the evidence of the efficacy of breast cancer screening in women over the age of 74 years.

METHODS

Studies published in English were retrieved by systematically searching MEDLINE (for papers published until August 2006), and by manually examining the references of the original articles and reviews retrieved. All studies that dealt with screening mammography over age 74 years were included. The studies were reviewed according to their outcomes and study design, focusing on breast cancer mortality and stage of breast cancer at diagnosis.

RESULTS

Three studies focused on the relationship between breast cancer screening and mortality; in the 75-84 years age group, the risk of disease-specific mortality was approximately two-fold higher among women who did not perform screening mammography compared to women who did. Another four studies showed that women who underwent screening mammography had significantly smaller tumors and earlier disease stage at diagnosis.

CONCLUSIONS

Regular mammography screening in older women may be associated with an earlier-stage disease and lower breast cancer mortality. These data support the use of screening mammography above age 75 years based on individual evaluations, rather than setting an upper age limit for breast cancer screening.

Chronological changes of clinical characteristics in 31,115 new breast cancer patients among Koreans during 1996-2004

Breast cancer has emerged as the most frequent malignancy among Korean women. Its clinical features have become closer to those now observed in Western countries. We performed this study to evaluate the chronological changes in Korean breast cancer characteristics and reproductive factors from 1996 to 2004. A nationwide multi-center survey within the Korean Breast Cancer Society (KBCS) has been performed since 1996. We analyzed the chronological changes among newly diagnosed primary breast cancer patients recruited at 41 university- and 65 surgical training-hospitals. All participating hospitals provided the essential information, including sex, age, surgical method used, American Joint Committee on Cancer classification, and other information, including reproductive factors, etc. This study showed a continuous increase in: the incidence of breast cancer (154.3% increase from 3801 to 9667 patients); breast-conserving surgery (124.1% increase from 18.7 to 41.9%); breast reconstruction after operation (25.4% increase from 5.2 to 16.4%); the percentage of early cancer (128.6% increase for stage 0; a 64.8% increase for stage I); and the number of patients with reproductive factors, such as early menarche, late menopause, late first-delivery, and no breast feeding. These results suggest that the rate of breast cancer in Korea is expected to continuously increase in the future; and that the pattern of breast cancer is perhaps mirroring that observed in Western countries.

Decision Making in Medicine and Health Care

Decision making is central to health policy and medical practice. Because health outcomes are probabilistic, most decisions are made under conditions of uncertainty. This review considers two classes of decisions in health care: decisions made by providers on behalf of patients, and shared decisions between patients and providers. Considerable evidence suggests wide regional variation exists in services received by patients. Evidence-based guidelines that incorporate quality of life and patient preferences may help address this problem. Systematic cost-effectiveness analysis can be used to improve resource allocation decisions. Shared medical decision making seeks to engage patients and providers in a collaborative process to choose clinical options that reflect patient preferences. Although some evidence indicates patients want an active role in making decisions, other evidence suggests that some patients prefer a passive role. Decision aids hold promise for improving individual decisions, but there are still few systematic evaluations of these aids. Several directions for future research are offered.