Thursday, January 28, 2010

Mammograms in Women with Dementia: What's the Problem?


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 the most fundamental problems with ordering screening mammograms in women with dementia is that it suggests check box medicine is being provided, and therefore the real needs of the patient and her caregiver are not being attended to.

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.

4 comments:

Anonymous said...

[This comment dropped off, not sure why.]

I also see the advantages - disadvantages. Since dementia and AD are being diagnosed earlier, many women may survive 8-10 years.
That being said, breast cancer often metastasizes to bone, which is extremely painful. I am not in favor of aggessive treatments in general, but I have had many Alzheimer patients undergo successful lumpectomy without chemo or radiation, thus only involved an overnight hospital stay, but may have prevented cancer from spreading.

Eric Widera said...

Great summary Ken. I've been reading a lot of commentary on this issue and the one common denominator for people who argue for screening even in advanced dementia is the question - "what's the harm?"

Many people view medical technology such as screening tests as interventions that can only provide benefit to the consumer. They fail to realize that, as with any medical intervention, there are risks associated with them. I'm not sure why this is but it does seem pervasive.

Janice said...

In the patient with severe dementia frequently there is no thought given as to benefit versus harm. I have in my living will that if I am unable to speak for myself (e.g. advanced dementia) I am not to be put on a fluid restriction. As a nurse it kills me when these patients want a drink of water and can't have it and they don't remember why a minute after you explain it. There are so many things we do to this population that does not improve there QOL and has very little chance of improving their health.

Dan Matlock said...

I had to write this - I just received an automated "reminder" that one of my clinic patients doesn't have a pap/mammo documented.

She's 96 and just had a small CVA!

I suppose I'll get dinged again!