Improved prognosis of women aged 75 and older with mammography-detected breast cancer

USPSTF Recommendations and Overdiagnosis

Overdiagnosis is the concept that some cancers detected at screening would never have become clinically apparent during a woman's lifetime in the absence of screening. This could occur if a woman dies of a cause other than breast cancer in the interval between mammographic detection and clinical detection (obligate overdiagnosis) or if a mammographically detected breast cancer fails to progress to clinical presentation. Overdiagnosis cannot be measured directly. Indirect methods of estimating overdiagnosis include use of data from randomized controlled trials (RCTs) designed to evaluate breast cancer mortality, population-based screening studies, or modeling. In each case, estimates of overdiagnosis must consider lead time, breast cancer incidence trends in the absence of screening, and accurate and predictable rates of tumor progression. Failure to do so has led to widely varying estimates of overdiagnosis. The U.S. Preventive Services Task Force (USPSTF) considers overdiagnosis a major harm of mammography screening. Their 2024 report estimated overdiagnosis using summary evaluations of 3 RCTs that did not provide screening to their control groups at the end of the screening period, along with Cancer Intervention and Surveillance Network modeling. However, there are major flaws in their evidence sources and modeling estimates, limiting the USPSTF assessment. The most plausible estimates remain those based on observational studies that suggest overdiagnosis in breast cancer screening is 10% or less and can be attributed primarily to obligate overdiagnosis and nonprogressive ductal carcinoma in situ.

Tips for Addressing Screening Concerns: "Harms of Screening"

Early detection decreases deaths from breast cancer. Yet, there are conflicting recommendations about screening mammography by major professional medical organizations, including the age and frequency with which women should be screened. The controversy over breast cancer screening is centered on 3 main points: the impact on mortality, overdiagnosis, and false positive results. Some studies claim that adverse psychological effects such as anxiety or distress are caused by screening mammography. The purpose of this article is to address negative breast cancer screening concerns including overdiagnosis and overtreatment, effect on mortality, false positive results, mammography-related anxiety, and fear of radiation.

Reducing Barriers and Strategies to Improve Appropriate Screening Mammogram Attendance in Women 75 Years and Older

Although breast cancer death rates have persistently declined over the last 3 decades, older women have not experienced the same degree in mortality reduction as younger women despite having more favorable breast cancer phenotypes. This occurrence can be partially attributed to less robust mammographic screening in older women, the propensity to undertreat with advancing age, and the presence of underlying comorbidities. With recent revisions to breast cancer screening guidelines, there has been a constructive shift toward more agreement in the need for routine mammographic screening to commence at age 40. Unfortunately, this shift in agreement has not occurred for cutoff guidelines, wherein the recommendations are blurred and open to interpretation. With increasing life expectancy and an aging population who is healthier now than any other time in history, it is important to revisit mammographic screening with advanced age and understand why older women who should undergo screening are not being screened as well as offer suggestions on how to improve screening mammogram attendance in this population.

Health benefits and harms of mammography screening in older women (75+ years)-a systematic review

BACKGROUND

There is little evidence on the balance between potential benefits and harms of mammography screening in women 75 years and older. The aim of this systematic review was to synthesise the evidence on the outcomes of mammography screening in women aged 75 years and older.

METHODS

A systematic review of mammography screening studies in women aged 75 years and over.

RESULTS

Thirty-six studies were included in this review: 27 observational studies and 9 modelling studies. Many of the included studies used no or uninformative comparison groups resulting in a potential bias towards the benefits of screening. Despite this, there was mixed evidence about the benefits and harms of continuing mammography screening beyond the age of 75 years. Some studies showed a beneficial effect on breast cancer mortality, and other studies showed no effect on mortality. Some studies showed some harms (false positive tests and recalls) being comparable to those in younger age-groups, with other studies showing increase in false positive screens and biopsies in older age-group. Although reported in fewer studies, there was consistent evidence of increased overdiagnosis in older age-groups.

CONCLUSION

There is limited evidence available to make a recommendation for/against continuing breast screening beyond the age of 75 years. Future studies should use more informative comparisons and should estimate overdiagnosis given potentially substantial harm in this age-group due to competing causes of death. This review was prospectively registered with PROSPERO (CRD42020203131).

Breast cancer outcomes based on method of detection in community-based breast cancer registry

PURPOSE

The impact of opportunistic screening mammography in the United States is difficult to quantify, partially due to lack of inclusion regarding method of detection (MOD) in national registries. This study sought to determine the feasibility of MOD collection in a multicenter community registry and to compare outcomes and characteristics of breast cancer based on MOD.

METHODS

We conducted a retrospective study of breast cancer patients from a multicenter tumor registry in Missouri from January 2004 - December 2018. Registry data were extracted by certified tumor registrars and included MOD, clinicopathologic information, and treatment. MOD was assigned as screen-detected or clinically detected. Data were analyzed at the patient level. Chi-squared tests were used for categorical variable comparison and Mann-Whitney-U test was used for numerical variable comparison.

RESULTS

5351 women (median age, 63 years; interquartile range, 53-73 years) were included. Screen-detected cancers were smaller than clinically detected cancers (median size 12 mm vs. 25 mm; P < .001) and more likely node-negative (81% vs. 54%; P < .001), lower grade (P < .001), and lower stage (P < .001). Screen-detected cancers were more likely treated with lumpectomy vs. mastectomy (73% vs. 41%; P < .001) and less likely to require chemotherapy (24% vs. 52%; P < .001). Overall survival for patients with invasive breast cancer was higher for screen-detected cancers (89% vs. 74%, P < .0001).

CONCLUSION

MOD can be routinely collected and linked to breast cancer outcomes through tumor registries, with demonstration of significant differences in outcome and characteristics of breast cancers based on MOD. Routine inclusion of MOD in US tumor registries would help quantify the impact of opportunistic screening mammography in the US.

Women 75 Years Old or Older: To Screen or Not to Screen?

Breast cancer is the most common cancer in women, with the incidence rising substantially with age. Older women are a vulnerable population at increased risk of developing and dying from breast cancer. However, women aged 75 years and older were excluded from all randomized controlled screening trials, so the best available data regarding screening benefits and risks in this age group are from observational studies and modeling predictions. Benefits of screening in older women are the same as those in younger women: early detection of smaller lower-stage cancers, resulting in less invasive treatment and lower morbidity and mortality. Mammography performs significantly better in older women with higher sensitivity, specificity, cancer detection rate, and positive predictive values, accompanied by lower recall rates and false positives. The overdiagnosis rate is low, with benefits outweighing risks until age 90 years. Although there are conflicting national and international guidelines about whether to continue screening mammography in women beyond age 74 years, clinicians can use shared decision making to help women make decisions about screening and fully engage them in the screening process. For women aged 75 years and older in good health, continuing annual screening mammography will save the most lives. An informed discussion of the benefits and risks of screening mammography in older women needs to include each woman's individual values, overall health status, and comorbidities. This article will review the benefits, risks, and controversies surrounding screening mammography in women 75 years old and older and compare the current recommendations for screening this population from national and international professional organizations. ^©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

The Landmark Series-Addressing Disparities in Breast Cancer Screening: New Recommendations for Black Women

Randomized, clinical trials have established the efficacy of screening mammography in improving survival from breast cancer for women through detection of early, asymptomatic disease. However, disparities in survival rates between black women and women from other racial and ethnic groups following breast cancer diagnosis persist. Various professional groups have different, somewhat conflicting, guidelines with regards to recommended age for commencing screening as well as recommended frequency of screening exams, but the trials upon which these recommendations are based were not specifically designed to examine benefit among black women. Furthermore, these recommendations do not appear to incorporate the unique epidemiological circumstances of breast cancer among black women, including higher rates of diagnosis before age 40 years and greater likelihood of advanced stage at diagnosis, into their formulation. In this review, we examined the epidemiologic and socioeconomic factors that are associated with breast cancer among black women and assess the implications of these factors for screening in this population. Specifically, we recommend that by no later than age 25 years, all black women should undergo baseline assessment for future risk of breast cancer utilizing a model that incorporates race (e.g., Breast Cancer Risk Assessment Tool [BCRAT], formerly the Gail model) and that this assessment should be conducted by a breast specialist or a healthcare provider (e.g., primary care physician or gynecologist) who is trained to assess breast cancer risk and is aware of the increased risks of early (i.e., premenopausal) and biologically aggressive (e.g., late-stage, triple-negative) breast cancer among black women.

Personalising therapy for early-stage oestrogen receptor-positive breast cancer in older women

Age is one of the most important risk factors for the development of breast cancer. Nearly a third of all breast cancer cases occur in older women (aged ≥70 years), with most cases being oestrogen receptor-positive (ER+). Such tumours are often indolent and unlikely to be the ultimate cause of death for older women, particularly when considering other comorbidities. This Review focuses on unique clinical considerations for screening, detection, and treatment regimens for older women who develop ER+ breast cancers-specifically, we focus on recent trends for de-implementation of screening, staging, surgery, and adjuvant therapies along the continuum of care. Additionally, we also review emerging basic and translational research that will further uncover the unique underlying biology of these tumours, which develop in the context of systemic age-related inflammation and changing hormone profiles. With prevailing trends of clinical de-implementation, new insights into mechanistic biology might provide an opportunity for precision medicine approaches to treat patients with well tolerated, low-toxicity agents to extend patients' lives with a higher quality of life, prevent tumour recurrences, and reduce cancer-related burdens.

Using Facebook Live to Advocate Breast Cancer Screening

With current conflicting and confusing screening mammography guidelines between major medical organizations, radiologists have an opportunity to educate and advocate for patients using the power of social media. The authors provide a brief overview on the impact of social media in radiology, in particular Facebook, as well as challenges encountered by radiologists as they establish an online presence, and how to effectively use Facebook Live to advocate for screening mammography.

Breast Cancer Screening Recommendations Inclusive of All Women at Average Risk: Update from the ACR and Society of Breast Imaging

Breast cancer remains the most common nonskin cancer, the second leading cause of cancer deaths, and the leading cause of premature death in US women. Mammography screening has been proven effective in reducing breast cancer deaths in women age 40 years and older. A mortality reduction of 40% is possible with regular screening. Treatment advances cannot overcome the disadvantage of being diagnosed with an advanced-stage tumor. The ACR and Society of Breast Imaging recommend annual mammography screening beginning at age 40, which provides the greatest mortality reduction, diagnosis at earlier stage, better surgical options, and more effective chemotherapy. Annual screening results in more screening-detected tumors, tumors of smaller sizes, and fewer interval cancers than longer screening intervals. Screened women in their 40s are more likely to have early-stage disease, negative lymph nodes, and smaller tumors than unscreened women. Delaying screening until age 45 or 50 will result in an unnecessary loss of life to breast cancer and adversely affects minority women in particular. Screening should continue past age 74 years, without an upper age limit unless severe comorbidities limit life expectancy. Benefits of screening should be considered along with the possibilities of recall for additional imaging and benign biopsy and the less tangible risks of anxiety and overdiagnosis. Although recall and biopsy recommendations are higher with more frequent screening, so are life-years gained and breast cancer deaths averted. Women who wish to maximize benefit will choose annual screening starting at age 40 years and will not stop screening prematurely.

Current controversies in breast cancer screening

Multiple large-scale, randomized controlled trials throughout the world have demonstrated screening mammography significantly reduces a woman's risk of dying from breast cancer. Despite the known mortality reduction, the perceived harms of mammography are weighed against the known value. Multiple national guidelines have moved away from recommending all women have annual screening mammograms beginning at age 40. Instead, many now encourage women at average risk for developing breast cancer to engage in shared decision-making with their providers, carefully weighing the perceived harms against the known benefits of mammography. These factors should be incorporated into the decision about when to begin and how often to screen. This paradigm shift has been particularly controversial as it relates to women in the 40-49-year age group, considering their incidence of breast cancer and therefore derived benefit of screening is lower, yet the breast cancers that do occur tend to be more aggressive and often require intensive therapy. Thus, debates ensue over the appropriate age at which to begin screening for breast cancer, how often screening should occur, and when to stop.

Current Guidelines and Gaps in Breast Cancer Screening

Breast cancer is the most common nonskin cancer in women and the second leading cause of cancer death for women in the United States. Mammography screening is proven to significantly decrease breast cancer mortality, with a 40% or more reduction expected with annual use starting at age 40 for women of average risk. However, less than half of all eligible women have a mammogram annually. The elimination of cost sharing for screening made possible by the Affordable Care Act (2010) encouraged screening but mainly for those already insured. The United States Preventive Services Task Force 2009 guidelines recommended against screening those 40 to 49 years old and have left women over 74 years of age vulnerable to coverage loss. Other populations for whom significant gaps in risk information or screening use exist, including women of lower socioeconomic status, black women, men at higher than average risk of breast cancer, and sexual and gender minorities. Further work is needed to achieve higher rates of screening acceptance for all appropriate individuals so that the full mortality and treatment benefits of mammography screening can be realized.

A random initialization deep neural network for discriminating malignant breast cancer lesions

Breast cancer is one of the most common cancer in women, with more than 1,300,000 cases and 450,000 deaths each year worldwide. Recent studies show that early breast cancer detection, along with suitable treatment, could significantly reduce breast cancer death rates in the long-term. While the consequences of a false positive diagnosis can be psychologically and socioeconomically burdensome, the result of a false negative diagnosis can be devastating, especially in terms of health detriment. In this context, the false positive and false negative rates commonly achieved by radiologists are extremely arduous to estimate and control, and some authors have estimated figures of up to 20% of total diagnoses or more. Novel ideas in computer-assisted diagnosis have been prompted by the introduction of deep learning techniques in general and of convolutional neural networks (CNN) in particular. In this paper, we design and validate an ad-hoc CNN architecture specialized in breast lesion classification and heuristically explore possible parameter combinations and architecture styles in order to propose a model selection criterion which can pose the emphasis on reducing false negatives while still retaining acceptable accuracy. We achieve good classification performance on the validation and test set, demonstrating how an ad-hoc, random initialization CNN architecture can provide practical aid in the classification and staging of breast cancer.

Screening Mammography: There Is Value in Screening Women Aged 75 Years and Older

OBJECTIVE

Patient screening mammography records performed in women aged 75 years and older were reviewed to evaluate the value of screening in this population, by determining the incidence of cancer diagnosed and associated outcomes.

METHODS

Data from patients aged 75 years and older who presented for screening mammography and underwent biopsy with resultant malignant pathology were retrospectively collected and analyzed to record patient demographics and outcomes.

RESULTS

From 2007-2017, there were 763,256 screening mammography appointments in 130,232 patients, with 3716 patients diagnosed with 4412 screen-detected malignancies (5.8 per 1000 cancers). In women aged 75 years and older, 76,885 (76,885 per 130,232, 10.1%) screening mammograms were performed in 18,497patients, with 643 malignancies diagnosed in 614 women eligible for study inclusion (8.4 per 1000 cancers). Lesions frequently presented as a mass with or without calcifications (472 per 643, 73%). A majority (529 per 643, 82%) was invasive; 79% (507 per 643) stage 0 or 1, and 63% (407 per 643) grade 2 or 3. Lymph node-positive status was confirmed in 7% of patients (46 per 614). Surgical intervention was pursued by 98% of patients (599 per 614).

CONCLUSION

Screening mammograms in women aged 75 years and older comprise a small percentage of the total screening examinations; however, they represented a significant portion of all patients diagnosed with screen-detected cancers, showing a substantial cancer detection rate. Most tumors were low stage, intermediate to high grade, and invasive. The majority had treatment involving surgery, suggesting these women are in good health and want to pursue surgical intervention. Screening mammography should be performed in this age group.

An Ad Hoc Random Initialization Deep Neural Network Architecture for Discriminating Malignant Breast Cancer Lesions in Mammographic Images

Breast cancer is one of the most common cancers in women, with more than 1,300,000 cases and 450,000 deaths each year worldwide. In this context, recent studies showed that early breast cancer detection, along with suitable treatment, could significantly reduce breast cancer death rates in the long term. X-ray mammography is still the instrument of choice in breast cancer screening. In this context, the false-positive and false-negative rates commonly achieved by radiologists are extremely arduous to estimate and control although some authors have estimated figures of up to 20% of total diagnoses or more. The introduction of novel artificial intelligence (AI) technologies applied to the diagnosis and, possibly, prognosis of breast cancer could revolutionize the current status of the management of the breast cancer patient by assisting the radiologist in clinical image interpretation. Lately, a breakthrough in the AI field has been brought about by the introduction of deep learning techniques in general and of convolutional neural networks in particular. Such techniques require no a priori feature space definition from the operator and are able to achieve classification performances which can even surpass human experts. In this paper, we design and validate an ad hoc CNN architecture specialized in breast lesion classification from imaging data only. We explore a total of 260 model architectures in a train-validation-test split in order to propose a model selection criterion which can pose the emphasis on reducing false negatives while still retaining acceptable accuracy. We achieve an area under the receiver operatic characteristics curve of 0.785 (accuracy 71.19%) on the test set, demonstrating how an ad hoc random initialization architecture can and should be fine tuned to a specific problem, especially in biomedical applications.

How to survive and thrive as a new breast imager: what they don't teach in fellowship

PURPOSE

To provide practical tips to assist new breast imagers succeed in their first job after fellowship training.

METHODS

Transitioning from fellowship to a practicing breast radiologist is daunting for the new radiologist. There is a void in the literature addressing this transition. Practical tips are described based on various roles a new breast radiologist must navigate and highlights skills that can help ensure a successful transition and career.

RESULTS

Proficiency in clinical acumen may be assisted by becoming familiar with sentinel works and feedback based on the medical outcome audit. Noninterpretive skills that can assist the transition include communication skills, delegation of tasks, and implementing hanging protocols. Depending on the practice, skills in research, education, administration, teamwork, and community engagement may also assist the successful transition.

CONCLUSION

Practical strategies can assist the new breast radiologist to become proficient at essential skills that will assist the radiologist to survive and thrive in clinical practice.

Breast cancer in elderly women and altered clinico-pathological characteristics: a systematic review

PURPOSE

Breast cancer is the most common malignancy in women in terms of incidence and mortality. Age is undoubtedly the biggest breast cancer risk factor. In this study we examined clinical, histological, and biological characteristics and mortality of breast cancer in elderly women along with their changes with advancing age.

METHODS

We reviewed 63 original articles published between 2006 and 2016 concerning women over 70 years with breast cancer.

RESULTS

Compared to patients 70-79 years, patients aged 80 and over had larger tumor size with fewer T1 (42.9% vs 57.7%, p < 0.01) and more T2 lesions (43.5% vs 33.0%, p < 0.01). Lymph nodes and distant metastases were more frequent, with more N + (49.5% vs 44.0%, p < 0.01) and more M1 (8.0% vs 5.9%, p < 0.01). Infiltrating mucinous carcinomas were more frequent (4.3% vs 3.7%, p < 0.01). Tumors had lower grades, with more grade 1 (23.2% vs 19.8%, p = 0.01) and fewer grade 3 (21.5% vs 25.5%, p < 0.01), and were more hormone-sensitive: PR was more often expressed (72.6% vs 67.3%, p < 0.01). Lympho-vascular invasion was less frequent in the 80 years and over (22.9% vs 29.7%, p = 0.01). Breast cancer-specific mortality was higher both at 5 years (25.8% vs 17.2%, p < 0.01) and 10 years (32.7% vs 26.6%, p < 0.01).

CONCLUSION

Clinico-pathological characteristics, increased incidence, and mortality associated with aging can be explained on one hand by biological changes of the breast such as increased estrogen sensitivity, epithelial cell alterations, immune senescence, and tumor microenvironment modifications. However, sociologic factors such as increased life expectancy, under-treatment, late diagnosis, and insufficient individual screening, are also involved.

White-Black Differences in Cancer Incidence, Stage at Diagnosis, and Survival among Adults Aged 85 Years and Older in the United States

BACKGROUND

Increased life expectancy, growth of minority populations, and advances in cancer screening and treatment have resulted in an increasing number of older, racially diverse cancer survivors. Potential black/white disparities in cancer incidence, stage, and survival among the oldest old (≥85 years) were examined using data from the SEER Program of the National Cancer Institute.

METHODS

Differences in cancer incidence and stage at diagnosis were examined for cases diagnosed within the most recent 5-year period, and changes in these differences over time were examined for white and black cases aged ≥85 years. Five-year relative cancer survival rate was also examined by race.

RESULTS

Among those aged ≥85 years, black men had higher colorectal, lung and bronchus, and prostate cancer incidence rates than white men, respectively. From 1973 to 2012, lung and bronchus and female breast cancer incidence increased, while colorectal and prostate cancer incidence decreased among this population. Blacks had higher rates of unstaged cancer compared with whites. The 5-year relative survival rate for all invasive cancers combined was higher for whites than blacks. Notably, whites had more than three times the relative survival rate of lung and bronchus cancer when diagnosed at localized (35.1% vs. 11.6%) and regional (12.2% vs. 3.2%) stages than blacks, respectively.

CONCLUSIONS

White and black differences in cancer incidence, stage, and survival exist in the ≥85 population.

IMPACT

Continued efforts are needed to reduce white and black differences in cancer prevention and treatment among the ≥85 population. Cancer Epidemiol Biomarkers Prev; 25(11); 1517-23. ©2016 AACR.

The impact of mammographic screening on the surgical management of breast cancer

BACKGROUND AND OBJECTIVES

Mammographic screening has been shown to result in downward stage migration, reflected by smaller tumor sizes and less extensive nodal involvement. National guidelines restrict screening recommendations in women age 40-49. The purpose of this study is to evaluate the specific impact of mammographic screening patterns on the surgical management of breast cancer in women aged 40-49.

METHODS

The study is a population-based retrospective review of the Vermont Breast Cancer Surveillance System of women aged 40-49 with a diagnosis of breast cancer. Tumor stage and related characteristics at the time of diagnosis, as well as the type of surgical intervention performed were recorded for women presenting with screen-detected versus non-screen-detected breast cancer.

RESULTS

Screen-detected breast cancers in women aged 40-49 were associated with a greater incidence of DCIS, smaller invasive tumor size, fewer cases of positive nodes, and higher rates of breast conservation compared to non-screened women presenting with symptomatic disease.

CONCLUSIONS

Mammographic screening is associated with less aggressive surgical treatment of breast cancer including higher rates of breast conservation. The observed changes in surgical management should factor into individual decision-making regarding screening mammography. J. Surg. Oncol. 2016;113:496-500. © 2016 Wiley Periodicals, Inc.

Non-attendance of mammographic screening: the roles of age and municipality in a population-based Swedish sample

Background

Inequality in health and health care is increasing in Sweden. Contributing to widening gaps are various factors that can be assessed by determinants, such as age, educational level, occupation, living area and country of birth. A health care service that can be used as an indicator of health inequality in Sweden is mammographic screening. The non-attendance rate is between 13 and 31 %, while the average is about 20 %. This study aims to shed light on three associations: between municipality and non-attendance, between age and non-attendance, and the interaction of municipality of residence and age in relation to non-attendance.

Methods

The study is based on data from the register that identifies attenders and non-attenders of mammographic screening in a Swedish county, namely the Radiological Information System (RIS). Further, in order to provide a socio-demographic profile of the county’s municipalities, aggregated data for women in the age range 40–74 in 2012 were retrieved from Statistics Sweden (SCB), the Public Health Agency of Sweden, the National Board of Health and Welfare, and the Swedish Social Insurance Agency. The sample consisted of 52,541 women. Analysis conducted of the individual data were multivariate logistic regressions, and pairwise chi-square tests.

Results

The results show that age and municipality of residence associated with non-attendance of mammographic screening. Municipality of residence has a greater impact on non-attendance among women in the age group 70 to 74. For most of the age categories there were differences between the municipalities in regard to non-attendance to mammographic screening.

Conclusions

Age and municipality of residence affect attendance of mammographic screening. Since there is one sole and pre-selected mammographic screening facility in the county, distance to the screening facility may serve as one explanation to non-attendance which is a determinant of inequity. From an equity perspective, lack of equal access to health and health care influences facility utilization.

Mammography interval and breast cancer mortality in women over the age of 75

The purpose of this study is to evaluate the relationship between mammography interval and breast cancer mortality among older women with breast cancer. The study population included 1,914 women diagnosed with invasive breast cancer at age 75 or later during their participation in the Women's health initiative, with an average follow-up of 4.4 years (3.1 SD). Cause of death was based on medical record review. Mammography interval was defined as the time between the last self-reported mammogram 7 or more months prior to diagnosis, and the date of diagnosis. Multivariable adjusted hazard ratios (HR) and 95 % confidence intervals (CIs) for breast cancer mortality and all-cause mortality were computed from Cox proportional hazards analyses. Prior mammograms were reported by 73.0 % of women from 7 months to ≤2 year of diagnosis (referent group), 19.4 % (>2 to <5 years), and 7.5 % (≥5 years or no prior mammogram). Women with the longest versus shortest intervals had more poorly differentiated (28.5 % vs. 22.7 %), advanced stage (25.7 % vs. 22.9 %), and estrogen receptor negative tumors (20.9 % vs. 13.1 %). Compared to the referent group, women with intervals of >2 to <5 years or ≥5 years had an increased risk of breast cancer mortality (HR 1.62, 95 % CI 1.03-2.54) and (HR 2.80, 95 % CI 1.57-5.00), respectively, p trend = 0.0002. There was no significant relationship between mammography interval and other causes of death. These results suggest a continued role for screening mammography among women 75 years of age and older.