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Guidelines help individualize surveillance for older early-stage breast cancer survivors

JAMA Oncology
Reuters Health - 02/02/2021 - New guidelines that lay out risks and benefits of surveillance mammography for older early-stage breast cancer survivors should be used to individualize management, researchers say.

"How and when to stop mammograms in older breast cancer survivors can be challenging for clinicians and their patients for many reasons, including a lack of guidelines to support these decisions," Dr. Rachel Freedman of the Dana Farber Cancer Institute in Boston told Reuters Health by email. "Without consensus on how to approach mammograms in the aging patient, there is tremendous variability in use of mammography across the US, even when one's anticipated life expectancy is limited because of medical conditions that are unrelated to their breast cancer history."

"We anticipate our guidelines will lead to better discussions with patients," she said, "better support for clinicians to guide patients in stopping mammography when the time is right, provide talking points for these discussions, provide education about the benefits and harms of testing, and allow clinicians and patients to feel empowered by acknowledging there is a decision to be made."

As reported in JAMA Oncology, after a literature review of the risk of ipsilateral and contralateral breast cancer events among breast cancer survivors and the benefits and harms associated with mammography, a multidisciplinary expert panel met to develop consensus guidelines on surveillance mammography for breast cancer survivors 75 years or older.

After critical review by the International Society for Geriatric Oncology, the guidelines were refined and finalized.

The literature review found a low risk for ipsilateral and contralateral breast cancer events in most older survivors. The guidelines emphasize taking into consideration a patient's risk for in-breast cancer events, age, life expectancy, and personal preferences. Recommendations include:

- Discontinuing routine mammography for all breast cancer survivors when life expectancy is less than five years, including those with a history of high-risk cancers;

- Considering discontinuing mammography when life expectancy is five to 10 years;

- Continuing mammography when life expectancy is more than 10 years; and

- Ongoing clinical breast examinations and diagnostic mammography to evaluate clinical findings and symptoms, with reassurance for patients that these practices will continue.

Dr. Freedman said, "If clinicians use the guidelines and talking points over time, we anticipate that mammogram use will decrease when it's appropriate, with all decisions being personal."

Dr. David Haggstrom of the Regenstrief Institute and Indiana University School of Medicine, commented in an email to Reuters Health, "The evidence of clinical benefit for mammography among breast cancer survivors is limited and some potential harms exist. Therefore, a tailored approach to surveillance mammography involving shared decision-making is appropriate. The clinical purpose of both screening and surveillance is to detect a breast cancer early enough to make a meaningful difference, not just to detect cancer."

"One of the clinical challenges of implementing this approach is estimating, as well as talking about, life expectancy," said Dr. Haggstrom, who is director of Regenstrief Institute's Center for Health Services Research. "Primary care or geriatric physicians might be more comfortable than oncologists discussing life expectancy with patients and the discontinuation of screening."

"Future research should consider the impact of these differences for clinical practice and patients' quality of life," he said. "Being transparent about the cost to the patient of tests is also appropriate to better inform patient decisions."

"That said, overall, the risk of breast cancer recurrence among breast cancer survivors older than 75 is relatively low," he affirmed. "Begin discussions about discontinuing surveillance with patients early. Having this dialogue in the context of a long-term, longitudinal relationship with the patient is ideal."

SOURCE: https://bit.ly/3pHcz44 JAMA Oncology, online January 28, 2021.

By Marilynn Larkin

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