At what age should breast cancer screening be stopped?

When to Stop Breast Cancer Screening

Breast cancer screening should be discontinued in women aged 75 years or older or in women with a life expectancy of 10 years or less, regardless of age. 1

Age-Based Recommendations for Stopping Breast Cancer Screening

• The American College of Physicians (ACP) recommends discontinuing screening mammography in average-risk women aged 75 years or older 1
• The American Cancer Society (ACS) recommends continuing screening mammography as long as a woman's overall health is good and she has a life expectancy of 10 or more years 1
• Most guidelines suggest discontinuing screening when, based on advanced age or comorbid conditions, a woman is unlikely to have a life expectancy long enough to benefit from screening—typically 10 years 1

Rationale for Stopping Screening at Age 75 or with Limited Life Expectancy

Time to Benefit Considerations

• It takes an average of almost 11 years before 1 death from breast cancer is prevented for every 1000 women screened 1
• The long time lag between mammography and reduction in breast cancer mortality means women with shorter life expectancy are unlikely to benefit 1

Risk-Benefit Analysis

• Older women face a higher probability of developing and dying from breast cancer but also have a greater chance of dying from other causes 1
• As women age, the potential harms of screening (false positives, overdiagnosis, unnecessary biopsies, and overtreatment) may outweigh the benefits 1
• Women with comorbid conditions that limit life expectancy (e.g., chronic obstructive pulmonary disease, heart failure, end-stage liver disease, end-stage renal failure, or dementia) are unlikely to benefit from screening 1

Life Expectancy Considerations

• Among women aged 70 years with no comorbid conditions, average life expectancy is approximately 19 years 1
• Among women aged 75 years with no comorbid conditions, average life expectancy is approximately 15 years 1
• Among 70-year-old women with serious comorbid conditions, average life expectancy is approximately 11 years 1
• Among 75-year-old women with serious comorbid conditions, average life expectancy is approximately 9 years 1

Decision-Making Algorithm for Stopping Breast Cancer Screening

1. Assess age:

   • If patient is ≥75 years old, consider discontinuing screening 1
   • If patient is <75 years old, proceed to step 2

2. Assess life expectancy:

   • If life expectancy is ≤10 years (due to age or comorbidities), discontinue screening 1
   • If life expectancy is >10 years, continue screening according to guidelines 1

3. Assess comorbidities that may limit life expectancy:

   • Serious conditions like end-stage renal disease, severe heart failure, dementia, or metastatic cancer 1
   • Multiple moderate comorbidities that collectively reduce life expectancy 1

4. Consider patient preferences:

   • Discuss the diminishing benefits and persistent harms of continued screening 1
   • Explain that the decision to stop screening should incorporate risk for cancer death, competing risks for other causes of death, and individual values 1

Common Pitfalls in Decisions About Stopping Breast Cancer Screening

• Continuing screening based on age alone: The decision to discontinue screening should not be based solely on age but should incorporate health status and life expectancy 1
• Overestimating benefit in elderly patients: The mortality benefit of screening takes approximately 11 years to manifest, which may exceed life expectancy in elderly patients or those with significant comorbidities 1
• Underestimating harms in older women: Older women are more susceptible to overdiagnosis and overtreatment of indolent cancers that would never become clinically significant in their lifetime 1
• Failing to reassess screening decisions periodically: As women age and develop new health conditions, the benefit-harm ratio of continued screening may change, requiring periodic reassessment 1

In conclusion, while breast cancer screening has proven benefits in appropriate populations, there comes a point where the potential harms outweigh the benefits. For most women, this occurs around age 75 or when life expectancy falls below 10 years due to comorbidities or advanced age.