Walter L C, Eng C, Covinsky K E
Division of Geriatrics, San Francisco VA Medical Center and the University of California-San Francisco 94121, USA.
J Gen Intern Med. 2001 Nov;16(11):779-84. doi: 10.1111/j.1525-1497.2001.10113.x.
The potential benefits and harms of screening mammography in frail older women are unknown. Therefore, we studied the outcomes of a screening mammography policy that was instituted in a population of community-living nursing home-eligible women as a result of requirements of state auditors. We focused on the potential burdens that may be experienced.
Between January 1995 and December 1997, we identified 216 consecutive women who underwent screening mammography after enrolling in a program designed to provide comprehensive care to nursing home-eligible patients who wished to stay at home. Mammograms were performed at 4 radiology centers. From computerized medical records, we tracked each woman through September 1999 for performance and results of mammography, additional breast imaging and biopsies, documentation of psychological reactions to screening, as well as vital status. Mean follow-up was 2.6 years.
The mean age of the 216 women was 81 years. Sixty-three percent were Asian, 91% were dependent in at least 1 activity of daily living, 49% had cognitive impairment, and 11% died within 2 years. Thirty-eight women (18%) had abnormal mammograms requiring further work-up. Of these women, 6 refused work-up, 28 were found to have false-positive mammograms after further evaluation, 1 was diagnosed with ductal carcinoma in situ (DCIS), and 3 were diagnosed with local breast cancer. The woman diagnosed with DCIS and 1 woman diagnosed with breast cancer were classified as not having benefited, because screening identified clinically insignificant disease that would not have caused symptoms in the women's lifetimes, since these women died of unrelated causes within 2 years of diagnosis. Therefore, 36 women (17%; 95% confidence interval [CI], 12 to 22) experienced burden from screening mammography (28 underwent work-up for false-positive mammograms, 6 refused further work-up of an abnormal mammogram, and 2 had clinically insignificant cancers identified and treated). Forty-two percent of these women had chart-documented pain or psychological distress as a result of screening. Two women (0.9%; 95% CI, 0 to 2) may have received benefit from screening mammography.
We conclude that screening mammography in frail older women frequently necessitates work-up that does not result in benefit, raising questions about policies that use the rate of screening mammograms as an indicator of the quality of care in this population. Encouraging individualized decisions may be more appropriate and may allow screening to be targeted to older women for whom the potential benefit outweighs the potential burdens.
筛查性乳腺钼靶检查对体弱老年女性的潜在益处和危害尚不清楚。因此，我们研究了一项筛查性乳腺钼靶检查政策的结果，该政策因州审计员的要求而在符合入住养老院条件的社区居住女性群体中实施。我们关注的是可能经历的潜在负担。
在1995年1月至1997年12月期间，我们确定了216名连续的女性，她们在参加一个旨在为希望居家的符合入住养老院条件的患者提供全面护理的项目后接受了筛查性乳腺钼靶检查。乳腺钼靶检查在4个放射中心进行。从计算机化医疗记录中，我们追踪了每位女性直至1999年9月，以了解乳腺钼靶检查的执行情况和结果、额外的乳房影像学检查和活检、对筛查的心理反应记录以及生命状态。平均随访时间为2.6年。
这216名女性的平均年龄为81岁。63%为亚洲人，91%至少在一项日常生活活动中存在依赖，49%有认知障碍，11%在2年内死亡。38名女性（18%）的乳腺钼靶检查结果异常，需要进一步检查。在这些女性中，6人拒绝进一步检查，28人在进一步评估后被发现乳腺钼靶检查结果为假阳性，1人被诊断为导管原位癌（DCIS），3人被诊断为局部乳腺癌。被诊断为DCIS的女性和1名被诊断为乳腺癌的女性被归类为未受益，因为筛查发现的是临床上无意义的疾病，在这些女性的一生中不会引起症状，因为这些女性在诊断后2年内死于无关原因。因此，36名女性（17%；95%置信区间[CI]，12至22）因筛查性乳腺钼靶检查而承受负担（28人因假阳性乳腺钼靶检查结果接受了进一步检查，6人拒绝了对异常乳腺钼靶检查结果的进一步检查，2人被发现并治疗了临床上无意义的癌症）。这些女性中有42%因筛查而有病历记录的疼痛或心理困扰。两名女性（0.9%；95%CI，0至2）可能从筛查性乳腺钼靶检查中受益。
我们得出结论，体弱老年女性的筛查性乳腺钼靶检查常常需要进行一些并无益处的进一步检查，这引发了对将筛查性乳腺钼靶检查率用作该人群医疗质量指标的政策的质疑。鼓励个体化决策可能更为合适，并且可以使筛查针对那些潜在益处超过潜在负担的老年女性。
