Importance: 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.
Observations: 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.
Conclusions and relevance: 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.