Mammography screening for older women with and without cognitive impairment

No upper age limit exists for Medicare benefits for mammography screening, but benefits for women older than age 75 remain unclear. From a clinical perspective, it would be useful to know if there is an upper age limit for women beyond which screening for breast cancer will not extend life. Using a decision-analysis model, the author examined the utility of screening using cohorts of women age 75 to 79, 80 to 84, and 85 and older, with and without cognitive impairment. The analysis evaluated different scenarios of the benefit of biennial screening versus no screening for women who had no prior screening and women who had participated in a regular screening program. Screening increased Quality Adjusted Life Years (QALYs) at all ages. Marginal savings in life expectancy adjusted for quality of life for women with no prior screening ranged from 43.5 days for healthy 75 to 79-year-old women to 25.9 days for women older than age 85. Among cognitively impaired women who were never screened, savings ranged from 20 to 5.5 days for the three age cohorts. Biennial screening among women who had been screened continuously resulted in substantially smaller life expectancy savings, from 3.3 days for healthy individuals age 75 to 79 to less than 1 day for women older than age 85. Cost effectiveness analysis indicated the reduction in costs associated with managing recurrent disease gained by early diagnosis with mammography was greatest among the population with no prior screening. Although the increase in QALYs was consistently lower for cognitively impaired women than for their healthy counterparts, the presence of cognitive impairment did not alter the finding that screening increased QALYs.