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Continuing Screening Mammography in Women Aged 70 to 79 Years
Impact on Life Expectancy and Cost-effectiveness
Karla Kerlikowske, MD;
Peter Salzmann, MD;
Kathryn A. Phillips, PhD;
Jane A. Cauley, DrPH;
Steve R. Cummings, MD
JAMA. 1999;282:2156-2163.
Context Mammography is recommended and is cost-effective for women aged 50 to 69 years, but the value of continuing screening mammography after age 69 years is not known. In particular, older women with low bone mineral density (BMD) have a lower risk of breast cancer and may benefit less from continued screening.
Objective To compare life expectancy and cost-effectiveness of screening mammography in elderly women based on 3 screening strategies.
Design Decision analysis and cost-effectiveness analysis using a Markov model.
Patients General population of women aged 65 years or older.
Interventions The analysis compared 3 strategies: (1) Undergoing biennial mammography from age 65 to 69 years; (2) undergoing biennial mammography from age 65 to 69 years, measurement of distal radial BMD at age 65 years, discontinuing screening at age 69 years in women in the lowest BMD quartile for age, and continuing biennial mammography to age 79 years in those in the top 3 quartiles of distal radius BMD; and (3) undergoing biennial mammography from age 65 to 79 years.
Main Outcome Measures Deaths due to breast cancer averted, life expectancy, and incremental cost-effectiveness ratios.
Results Compared with discontinuing mammography screening at age 69 years, measuring BMD at age 65 years in 10,000 women and continuing mammography to age 79 years only in women with BMD in the top 3 quartiles would prevent 9.4 deaths and add, on average, 2.1 days to life expectancy at an incremental cost of $66,773 per year of life saved. Continuing mammography to age 79 years in all 10,000 elderly women would prevent 1.4 additional breast cancer deaths and add only 7.2 hours to life expectancy at an incremental cost of $117,689 per year of life saved compared with only continuing mammography to age 79 years in women with BMD in the top 3 quartiles.
Conclusions This analysis suggests that continuing mammography screening after age 69 years results in a small gain in life expectancy and is moderately cost-effective in those with high BMD and more costly in those with low BMD. Women's preferences for a small gain in life expectancy and the potential harms of screening mammography should play an important role when elderly women are deciding about screening.
Author Affiliations: Departments of Epidemiology and Biostatistics (Drs Kerlikowske, Phillips, and Cummings), Medicine (Drs Kerlikowske, Phillips, and Cummings), Clinical Pharmacy, School of Pharmacy (Dr Phillips); and General Internal Medicine Section, Department of Veterans Affairs (Dr Kerlikowske), University of California, San Francisco; Stanford University Graduate School of Business, Palo Alto, Calif (Dr Salzmann); and Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pa (Dr Cauley).
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RELATED LETTER
Screening Mammography in Elderly Women
Jeanne Mandelblatt, K. Robin Yabroff, William Lawrence, Bin Yi, Grethen Orosz, Harrison G. Bloom, Clyde B. Schecther, Martine Extermann, Lodovico Balducci, William Satadano, Sarah Fox, Rebecca A. Silliman, Marianne C. Fahs, Peter Muening, for the Research on Breast Cancer in Older Women Consortium, Serge Rozenberg, Hamphrey Ham, Fabienne Liebens, David Seidenwurm, Jonathan Breslau, Karla Kerlikowske, Kathryn A. Phillips, Steve R. Cummings, Peter Salzmann, and Jane A. Cauley
JAMA. 2000;283(24):3202-3204.
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December 8, 1999
JAMA. 1999;282(22):2183-2184.
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