A study in the American Journal of Public Health examining mammogram use in older persons found that 18% of women with severe cognitive impairment had received a screening mammogram in the prior 2 years. These women had an average life expectancy of 3.3 years. Since one needs to live at least 5 years to benefit from screening mammography, most of these women had no chance of benefiting from mammography, but were subjected to all the potential harms.
The authors of this study, which included our UCSF colleagues Kala Mehta and Louise Walter, describe this as a good news-bad news finding. The good news was that women with severe cognitive impairment were much less likely to get mammograms. So doctors are to some extent individualizing screening decisions. The bad news is that this still represents a very large number of potentially harmful mammograms.
On the Newsweek website, Sharon Begley provides an excellent commentary on this study. This commentary was a pleasure to read. It explained complex issues in clear terms. It was a refreshing change compared to the simplistic discussion from much of the press during the recent mammogram controversy. It is instructive to read some of the comments on Ms. Begley's piece. It appears that there is often an instinctual reaction to any recommendation not to do a cancer screening test to assume the motivation is rationing, or a desire to save money. However, the reason not to do mammograms in women with dementia is that they are likely to do harm. The fact that this harm also costs money is just an added insult.
In order to help our patients avoid care that is more likely to hurt them than help them, it is important all of us be able to explain to our colleagues why mammograms are not a good idea in women with dementia. Here is a brief outline of that explanation:
- Mammography frequently finds abnormalities that are not cancer and need further evaluation. The fear caused by these findings, and the stress from the evaluation can be debilitating for healthy women. For women with dementia, the anxiety and stress can be debilitating. And with dementia, this stress is also felt by overworked caregivers.
- However, contrary to common perceptions, the most serious harm from mammography in women with dementia is not false positives, but actually finding a clinically insignificant cancer. The concept of clinically insignificant cancer is not understood by the public. A clinically insignificant cancer is a tumor that if undiagnosed would never cause symptoms in the patient's lifetime. The type of tumors for which mammograms are beneficial will generally be clinically insignificant in women with dementia. Without mammography they will go undetected and not cause problems. But if found, these women will often be given surgery and other invasive therapy. To subject someone with dementia to invasive therapy that has little chance of benefiting them is very unfortunate. Dr. Walter has previously shown that in some cases, this treatment leads to devastating complications, including one case report of a non healing wound infection, and another case of a post-operative stroke.
- Perhaps most concerning is that time spent focusing on nonhelpful care diverts focus from the type of care women with dementia really need. At GeriPal, we have previously discussed how primary care physicians are uncomfortable caring for patients with dementia. It is well established that the quality of care for people with dementia is poor. Interventions that could improve functioning and quality of life are often not done. As we have also discussed, the needs of caregivers get ignored.
Our health system fails frail elders with dementia. There is so much more that needs to be done for them. Contrary to those who raise the Rationing charge when it is suggested that women with dementia not get mammograms, this is actually about doing more for these patients, not less. We can start by not doing tests that are more likely to hurt our patients than help, and focusing on what these patients and their caregivers really need.