Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts3Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Oncol. 2017 Mar 1;3(3):402-409. doi: 10.1001/jamaoncol.2016.3931.
Approximately 4% to 5% of breast cancer survivors will develop a new ipsilateral or contralateral cancer (in-breast event) over the 5 years following diagnosis, and annual surveillance mammography is recommended for those with residual breast tissue. The risk for such in-breast events persists over time, though increasing age at cancer diagnosis and treatment with hormonal therapy are associated with lower risk, and most older survivors of breast cancer will ultimately die from nonbreast cancer-related causes. Specific guidelines for surveillance strategies in older patients are limited. Prospective data on the benefits and harms of surveillance mammography in this population are lacking, and most of the evidence is derived from observational, retrospective data, often in the general population.
We review the current recommendations for breast cancer screening and surveillance for older patients, the current evidence for ipsilateral and contralateral breast cancer risks in older survivors of breast cancer, and suggested approaches for discussions about surveillance mammography with older patients. We recommend individualized decision making for surveillance breast imaging in older survivors of breast cancer, with consideration of the following strategy for women 70 years or older: 1-time imaging 6 to 12 months after completion of local therapy followed by annual or biennial surveillance mammography for healthy women and cessation of mammography in patients whose life expectancy is less than 5 years to 10 years, regardless of age. Decisions on mammographic surveillance should also incorporate whether hormonal therapy is being administered, whether a patient's anticipated life expectancy is extraordinary, and whether a patient's individual risk for in-breast events is higher (or lower) than average risk for breast cancer survivors.
We propose reframing discussions around surveillance mammography in older breast cancer survivors and to consider cessation while taking into account life expectancy, the estimated risk for subsequent in-breast events, and patient preferences.
在诊断后 5 年内，约有 4%至 5%的乳腺癌幸存者会出现同侧或对侧新发癌症（乳房内事件），对于仍有乳房组织的患者，建议每年进行乳房 X 线筛查。尽管随着年龄的增长和激素治疗的应用，这种乳房内事件的风险会降低，但此类风险会持续存在，而且大多数乳腺癌的老年幸存者最终会死于非乳腺癌相关原因。针对老年患者的监测策略具体指南有限。在该人群中，关于监测乳房 X 线摄影的益处和危害的前瞻性数据缺乏，并且大多数证据来自观察性、回顾性数据，且通常来自一般人群。
我们回顾了目前针对老年患者的乳腺癌筛查和监测建议、老年乳腺癌幸存者同侧和对侧乳腺癌风险的现有证据，以及与老年患者讨论监测乳房 X 线摄影的建议方法。我们建议对老年乳腺癌幸存者的监测性乳房成像进行个体化决策，对于 70 岁或以上的女性，可考虑以下策略：局部治疗完成后 6 至 12 个月进行 1 次成像，然后每年或每两年进行健康女性的监测性乳房 X 线摄影，对于预期寿命不足 5 年至 10 年的患者，无论年龄如何，停止进行乳房 X 线摄影。关于乳房 X 线摄影监测的决策还应考虑是否正在进行激素治疗、患者预期寿命是否非凡以及患者同侧乳房事件的个体风险是否高于（或低于）乳腺癌幸存者的平均风险。
我们建议重新构建针对老年乳腺癌幸存者的监测性乳房 X 线摄影讨论，并考虑停止监测，同时考虑预期寿命、随后同侧乳房事件的估计风险和患者偏好。
