Breast Cancer in an Elderly Woman With Alzheimer’s Disease: Page 2 of 2
Breast cancer is the second leading cause of cancer deaths among women in the United States. The incidence of breast cancer increases with age, as does the incidence of Alzheimer’s dementia.1,2 The US Preventive Services Task Force recommends biennial mammographic breast cancer screenings for women aged 50 to 74 years.3 The American Geriatrics Society encourages offering screening mammography up to age 85 for healthy women who have an estimated life expectancy ≥5 years and for women >85 years who have excellent health and functional status and strongly believe in the benefits of screening.4 The American Cancer Society advises women to continue to receive breast cancer screening as long as they are in good health and a candidate for cancer treatment.5 Ideally, screening decisions should be individualized for each patient.4
The literature evaluating the relationship between dementia and breast cancer screening is limited, but it appears to indicate that women with dementia are less likely to receive screening and treatment. In addition, breast cancer tends to be diagnosed at later stages in dementia patients and is more likely to involve the lymph nodes.6 Breast cancer screening and treatment in older women with Alzheimer’s dementia presents an ethical dilemma: the risk of underdiagnosis and undertreatment is significant, as is the risk of overdiagnosis and overtreatment. As medical caregivers of patients with
dementia, we must often participate in making decisions about the need for breast cancer screening and treatment. How do we decide? To answer this question, we can weigh three decision-making approaches: an evidence-based one, an individualized one, or a patient- and family-centered decision-making approach (Table 1).7,8
The evidence-based approach allows research to guide recommendations, which are often detailed in published guidelines. At present, conflicting data have generated considerable controversy regarding breast cancer screening recommendations, and current guidelines generally identify age as the primary risk factor for this malignancy.9 Whereas the evidence demonstrates that routine mammography screening reduces breast cancer mortality for women aged 39 to 69 years, it does not indicate the same benefit for women aged ≥70 years.10 This suggests that routine screening may not be needed after age 69. The most recent survey on caregiver beliefs regarding breast cancer screening in older women with dementia found that screening was likely to continue following a dementia diagnosis, unless the dementia is severe, and decisions are influenced by physician recommendations and patient’s beliefs before the onset of dementia.11
The framework for an individualized decision-making approach to cancer screening for elderly patients involves carefully considering the benefits and risks to the woman and her comorbid conditions and life expectancy. A study of older women with breast cancer and comorbidities found no survival advantage associated with early cancer diagnosis; findings also suggested that cancer screening tests like mammography may not provide the same level of benefit as they do for women in average health.12
Patients with cancer and comorbid dementia have an increased mortality rate, but deaths among this demographic are mostly due to causes unrelated to cancer. For example, in patients with mild to moderate dementia, common causes of death are cardiovascular related, such as heart disease and stroke, and in patients with severe dementia, the most common cause of death is pneumonia.13,14 In general, cancer screening has only demonstrated a survival benefit in older patients with a life expectancy ≥5 years.15
Therefore, women with mild to moderate dementia whose life expectancy is ≥5 years may benefit from mammography screening, and the procedure should be offered (Table 2). Mammography screening is not recommended for women with mild to moderate dementia, significant functional dependency, and a life expectancy of <5 years, and is also not recommended for women with advanced dementia regardless of functional status and lifespan.16 The presence of comorbid conditions or short life expectancy do not appear to guide family caregivers’ screening decisions for women with mild and moderate dementia, and screening decisions for these women may need to be based on the patient’s and family’s/surrogate’s expressed wishes—a patient- and family-centered approach.
The patient- and family-centered approach is even more individualized and has at its core the concepts of dignity, respect, information sharing, participation, and collaboration. This approach might be most helpful when deciding the appropriateness of screening in difficult cases like ours. It is a shared decision-making process, in which the patient and family lie at the center. The physician outlines the benefits and risks of screening intervention, assesses the patient’s capacity to make her own decision, and ultimately coordinates the process with respect for the patient’s wishes and surrogates’ concerns.
When our patient’s daughter requested breast cancer screening for her mother, a discussion was held with the family regarding the possible benefits and harms of screening and treatment should cancer be found. It was explained that breast cancer screening in younger women may benefit this demographic but imposes a burden on older women with cognitive impairment. In women with moderate dementia and a life expectancy of <5 years, mammography screening would generally not be recommended; further, cancer screening is unnecessary unless intervention is anticipated. In patients with moderate to severe dementia, procedures such as screening mammography might be perceived as an assault, making the procedure impossible to be processed. In our patient’s case, when the mammogram came back suspicious for malignancy, she was cognizant enough to protest having a biopsy. Even incapacitated patients can express their wishes, and we should always respect them.
When the breast mass was found 3 years later, the family decided that hospice care, with comfort measures only, was the best approach for their mother. At the end of life, even if screening offers no perceived benefit to the patient’s quality of life, it is important to address the family’s concerns and provide them comfort—particularly if the family is the designated decision-maker. Decision-makers often change previously held positions regarding treatment if screening reveals a potentially fatal disease. We believe honoring patients’ wishes and addressing the concerns of their families are especially important during end-of-life care, and we feel that was accomplished in this case.
No definitive breast cancer screening and treatment recommendations exist for patients with Alzheimer’s dementia. Current guidelines refer to women at average risk for breast cancer and in average health and are not appropriate for patients with mild, moderate, or severe dementia. When considering the benefits versus risks of breast cancer screening and treatment in women with Alzheimer’s dementia, other values need to be weighed, such as preferences of the patient and her family, the stage of dementia, comorbidities, and the patient’s life expectancy. Breast cancer screening and treatment in patients with dementia who have limited decision-making capacity remains a complex medical, ethical, and legal issue that requires shared decision-making and, more importantly, necessitates patient- and family-centered care.
Drs. Kusz and Smith are associate professors of medicine, Michigan State University, East Lansing, MI. Dr. Kusz is director of geriatric education, and Dr. Smith is program director, Internal Medicine Residency Program, McLaren Regional Medical Center, Flint, MI.
The authors report no relevant financial relationships.
We would like to thank Diane Kallas, RN, BA, for sharing her clinical impressions, experience, and written commentaries as a nurse, director of case management, and member of the Bioethics Committee, McLaren Regional Medical Center, Flint, MI.
1.American Cancer Society. Breast Cancer Facts & Figures, 2007-2008. www.cancer.org/acs/groups/content/@nho/documents/document/bcfffinalpdf.pdf. 2007. Accessed September 7, 2011.
2.Thies W, Bleiler L; Alzheimer’s Association. 2011 Alzheimer’s disease facts and figures. Alzheimers Dement. 2011;7(2):208-244. www.alz.org/downloads/Facts_Figures_2011.pdf. Accessed September 7, 2011.
3.US Preventive Services Task Force. Screening for breast cancer. www.uspreventive
servicestaskforce.org/uspstf/uspsbrca.htm. Published November 2009. Updated July 2010. Accessed September 7, 2011.
4.Schonberg M. Breast cancer screening: at what age to stop? Consultant. 2010;50(5): 196-205.
5.American Cancer Society. American Cancer Society Guidelines for the Early Detection of Cancer. www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/america.... Updated June 23, 2011. Accessed October 28, 2011.
6.Gorin SS, Heck JE, Albert S, Hershman D. Treatment for breast cancer in patients with Alzheimer’s disease. J Am Geriatr Soc. 2005;53(11):1897-1904.
7.Albert RH, Clark MM. Cancer screening in the older patient. Am Fam Physician. 2008;78(12):1369-1374.
8.Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001; 285(21):2750-2756.
9.Schousboe JT, Kerlikowske K, Loh A, Cummings SR. Personalizing mammography by breast density and other risk factors for breast cancer: analysis of health benefits and cost-effectiveness. Ann Intern Med. 2011;155(1):10-20.
10.Nelson DH, Tyne K, Naik A, et al; US Preventive Services Task Force. Screening for breast cancer: an update for the US Preventive Services Task Force. Ann Intern Med. 2009;151(10):727-737, W237-W242.
11.Smyth KA. Current practices and perspectives on breast cancer screening and treatment in older women with dementia. J Am Geriatr Soc. 2009;57(suppl 2):S272-S274.
12.Satariano WA, Ragland DR. The effect of comorbidity on 3-year survival of women with primary breast cancer. Ann Intern Med. 1994;120(2):104-110.
13.Kukull WA, Brenner DE, Speck CE, et al. Causes of death associated with Alzheimer disease: variation by level of cognitive impairment before death. J Am Geriatr Soc. 1994;42(7):723-726.
14.Raji MA, Kuo YF, Freeman JL, Goodwin JS. Effect of dementia diagnosis on survival of older patients after a diagnosis of breast, colon, or prostate cancer: implications for cancer care. Arch Intern Med. 2008;168(18):2033-2040.
15.Spalding MC, Sebasta SC. Geriatric screening and preventive care. Am Fam Physician. 2008;78(2):206-215.
16.Raik BL, Miller FG, Fins JJ. Screening and cognitive impairment: ethics of forgoing mammography in older women. J Am Geriatr Soc. 2004;52(3):440-444.