of Cancer Screening
in Older Women Doubted
Women over 70 are having an increasing
number of mammograms and Pap smears despite a lack of scientific
evidence to support widespread testing of older women, a new study
Considering the "substantial"
societal costs of continuing to perform breast and cervical cancer
tests in the oldest age groups, extensive testing may not be justified,
argue researchers from Duke University Medical Center.
"We are questioning, is this
really a good use of health-care resources," says Dr. Truls
Ostbye, a professor in Duke's department of community and family
medicine and the lead author of the paper. "We're not necessarily
saying it is not, but certainly a lot of money is being spent."
Some 4.6 million screening mammograms
and 3.7 million Pap tests were performed in 2000 on women 70 and
older for a total cost of $507 million, the authors estimate.
That's up from an estimated 3.7 million mammograms and 2.8 million
Pap tests in 1996 at a cost of $411 million. The dollar estimates
do not include any follow-up evaluation and care that women may
The study, based on a review of
existing data, appears in the November/December issue of the Annals
of Family Medicine.
The Duke study fuels an ongoing
debate over the value of common cancer screenings in older women.
Some researchers say the benefits outweigh the cost, while others
see little value.
Ostbye and colleagues suggest early
detection isn't as lifesaving for older women as it is for younger
and middle-age women.
"As you get older, the number
of years that you have left is short and, unfortunately, there
are very many other diseases that are competing for your health,"
So it becomes "more doubtful"
that extensive screening among these women "can postpone
death," he adds.
Research as fresh as last week,
however, seems to contradict him. A study reported last week found
that, in general, the benefits of screening women over 65 for
breast cancer every two years outweigh the costs and possible
side effects. The exception may be women who suffer from serious
chronic health conditions or who aren't expected to live very
long, it said.
The debate rages on in part because
there are few rigorous studies involving older women. As a result,
clinical guidelines on cancer screening are "ambiguous and
inconsistent for elderly women," the Duke authors write.
The American Cancer Society, the
nation's leading voice on the war on cancer, recommends annual
mammograms beginning at age 40 and sets no upper age limit on
breast cancer screenings. It does say further research is needed
on the risks and benefits for women with serious chronic health
problems or short life expectancy.
As for Pap smears, it says women
70 years or older can choose to stop those screenings if they've
had at least three normal Pap tests in a row and no abnormal Pap
results in the last decade. The exceptions are women with a history
of cervical cancer, DES exposure before birth, HIV infection,
or a weakened immune system. These women should continue having
Pap tests as long as they are in good health, it recommends.
To assess the frequency of breast
and cervical cancer screenings, Ostbye and colleagues examined
data collected from two earlier studies funded by the National
Institute on Aging. The data covered the period from 1993 to 2000.
Among women aged 50 to 64, roughly
70 percent to 80 percent had a mammogram in the previous two years
and 75 percent had received a Pap smear over the same time frame.
Screening rates dropped for women 85 to 90 years of age, with
40 percent receiving mammograms and 25 percent having Pap smears.
Breast and cervical cancer testing
rates increased in all groups, including older women, from 1995-1996
Without specific cancer screening
guidelines, doctors are erring on the side of caution by testing
women who may not benefit, the paper notes. For example, according
to an earlier study cited in the paper, as many as 240 "very
healthy" 80-year-olds would need to have mammograms to prevent
one breast cancer death.
"This is the best-case scenario,"
Ostbye says. "You would have to screen many more 80-year-olds
because most aren't very healthy."
He and his Duke colleagues argue
that screening of the elderly "should be better and more
specifically addressed in national clinical guidelines."
But Robert Smith, director of cancer
screening at the American Cancer Society, defends national guidelines.
While some women who receive these
tests might not need them, he believes "under-screening"
is a larger problem than "over-screening," as physicians
start withholding or neglecting preventive care for older women.
"The fact of the matter is
there's no way to avoid some degree of waste because you inevitably
contribute to deaths that you otherwise would have wanted to avoid,"
he says. "There's always going to be a cost to reducing deaths
To learn more about screening for
cancer and cervical
Reference Source 101