Too old for BreastCheck: Are we neglecting older women?

Current screening is based on European guidelines but, given our increasing life expectancy, the age limit may be increased. Picture: iStock

Once women turn 70, they are no longer screened by BreastCheck, but 36% of breast cancer cases occur in women aged over 65, says Helen O’Callaghan

Any time national ICA president Josephine Helly was called for screening by BreastCheck she went. The screening kept the possibility of breast cancer on her radar. Now she’s 74 and she doesn’t get called anymore.

Josephine – well known as a mentor on RTÉ TV show ICA Bootcamp – says: “When you’re being called, you’re in the scheme of things. You don’t think about [breast cancer] when you’re not being called.”

Dr Janice Walsh, consultant medical oncologist at St Vincent’s University Hospital and at Tallaght Hospital, finds older women tend not to examine their breasts as much as younger women do. When she asks older patients who have breast cancer if they found the lump themselves, they often say ‘God, no! I never examine myself’.

Very often, as women get older, they focus more on heart disease, stroke, high blood pressure, diabetes, rather than on breast cancer. When I tell them women get breast cancer with no family history of it, they look at me in disbelief – they assume it must be in the family.

BreastCheck has been available nationally since 2007. An age extension implementation plan, which includes women aged 65 to 69, started in late 2015 and is currently being rolled out on a phased basis – by 2021, all women aged 50-69 will be invited for breast screening by the programme.

Breast cancer is the most commonly diagnosed cancer in women in Ireland. On average, over 3,000 women are diagnosed with invasive breast cancer and over 700 die each year from the disease according to National Cancer Registry Ireland (NCRI) 2018 figures.

To date, BreastCheck has provided over 1.9 million mammograms to more than 570,000 women and detected over 12,200 cancers.

Disease of increasing age

With 69 the cut-off age for BreastCheck screening, is there a danger women older than 69 may perceive themselves at less risk of getting breast cancer? Dr Walsh believes it’s a real concern.

“Advocacy groups need to highlight that cancer – and breast cancer – is a disease of increasing age. The older we get, the more likely we’ll be affected.”

NCRI (2018) data shows that 41% of new breast cancer cases are aged between 50-64 at diagnosis, while 18% are aged between 65 and 74 and 18% are aged 75 and over.

 “It’s like we drop off the cliff after we’re 69,” says 71-year-old Carmel Dawson, national PRO for the ICA, though she’s speaking to Feelgood in a personal capacity.

I went religiously to all of my BreastCheck appointments – and then to just cut you off! It’d be terrible to finish with BreastCheck at 69 and then, at 70 or 71, you have breast cancer and you’ve been missed. Why can’t they extend it after 69? I do believe it’s ageist.

 

A spokesperson for BreastCheck says the Department of Health chose age 50 to 69 for breast screening as there’s a greater proportion of women at risk of dying from the disease in this age group compared to women above or below this age category.

“Available medical evidence indicates there’s no discernible public health benefit in screening women outside of this age range. The benefit to public health is a key consideration when deciding to establish a population-based screening programme [like] BreastCheck.”

 A research paper on breast cancer screening programmes across the WHO European region states that as of July 2016, among high income OECD countries, 12 offer screening up to 69, four offer screening up to age 70, three (France, Emilia Romagna region of Italy and regions of Sweden) offer screening to age 74, while two (Netherlands and Piedmont region of Italy) offer screening to age 75. 

Screening across Europe 

Aisling Hurley, CEO, Breast Cancer Ireland. Picture: Moya Nolan
Aisling Hurley, CEO, Breast Cancer Ireland. Picture: Moya Nolan

Donal Buggy, Irish Cancer Society head of services, says there is certainty in the evidence that breast cancer screening in the 50-69 age group is effective in reducing deaths from breast cancer.

“And there is moderate certainty evidence exists that a programme is effective for women over 69. As a result of this, some countries in the EU provide screening up to age 74/75 but, in the majority, screening programmes are up to age 69.”

 He doesn’t believe making 69 the cut-off age is necessarily ageist.

 “BreastCheck is based on European guidelines that are based on science and research and expert interpretation of that research.”

However, Mr Buggy says the healthcare system will need to look at potentially screening in the older age group, particularly in light of increasing life expectancy.

In the overall context, we’re living longer – more and more people are healthier into their 70s, 80s and even 90s. Our cancer services and screening programmes need to be kept updated in the light of that, but it has to be based on sound research and evidence. The evidence doesn’t seem to be there for it now, though we are potentially moving there.

Breast Cancer Ireland set up to raise significant funding to support pioneering research programmes nationally, as well as to promote education/awareness on importance of breast health among women of all ages. A spokesperson says its remit doesn’t cover the national breast screening programme but the charity supports efforts to extend the age group. 

CEO Aisling Hurley comments: “Breast Cancer Ireland supports those advocating for a wider breadth of age profiles to be screened. We note in the US screening begins from age 40 and so we would hope to see this happen in Ireland in the future and that screening would be extended to women into their 70s.” 

Danger of over-diagnosis

But more research is needed regarding incremental benefits and harms of screening from age 70 onwards, points out Mr Buggy. He cites some of the ‘harms’ as over-diagnosis and false positives.

“Over-diagnosis could be around finding very small tumours that potentially wouldn’t have any impact on the woman for the duration of her natural life – she’d die with the tumour rather than of it. Cancer treatment itself is onerous and it might cause more harm than good.” 

The impact of false positives – ‘false alarms’ – is another consideration. A 2014 paper from the Harvard Health School that looked at ‘mammograms for older women’ points to the risks of mammography, mainly false positives.

“[False positives] show abnormalities in breast tissue that require further testing, including biopsies, which can be painful, stressful and expensive. Of the abnormalities recommended for biopsy, 60% to 75% turn out to be normal,” according to Dr Phoebe Freer, radiologist at Harvard-affiliated Massachusetts General Hospital. 

Uptake rate for BreastCheck among eligible women during 2017/18 was 74% for 50-54 year olds, 74% for 55-59 year olds, 73% for 60-64 year olds and 75% for those aged 65 and over. Mr Buggy says a big challenge is getting those who don’t take up their BreastCheck appointment to attend.

One in four women aged 50 to 69, who are eligible for the programme, doesn’t avail of the option – that’s the biggest challenge.

“There are myriad reasons why they don’t: some don’t believe in it. There are also education and demographic issues – those from poorer backgrounds are less likely to be screened.” 

Better outcomes

Women older than 69 are not automatically screened for cancer so should be vigilant about any changes in their breasts.
Women older than 69 are not automatically screened for cancer so should be vigilant about any changes in their breasts.

Dr Walsh spotlights the positives when it comes to older women and breast cancer.

“As women get older, 80% of breast cancers tend to be a less aggressive type of cancer. After women become menopausal and as they get into their 60s and 70s, we see a higher level of hormone-sensitive breast cancer that tends to be less aggressive.”

And when older patients are told ‘your cancer isn’t aggressive, it’s likely you’ll do very well’, they really take that on board, says Dr Walsh, adding that older women can often react differently to diagnosis than younger women.

“Older women don’t have the same underlying anxiety that women in their 40s have, who really fear they’re going to die of the cancer. Younger women are at a different point in relation to having families – they may not have children or they may have young children or kids doing exams.

Older women are more philosophical. If they have daughters, they’re grateful that it’s themselves and not their daughters who have breast cancer. And they’re often grateful to have got to this point of life without getting cancer – if they have family history, they might have expected it sooner.

 Dr Walsh points to another advantage for older women in the cancer-fighting stakes: their breasts are less dense so it’s easier to clinically detect cancer.

“Pre-menopausal breast tissue is much more dense – they might have glandular or cystic changes – so sometimes it can be harder to detect breast cancer in that population. As breasts get less dense and fattier, it’s much easier to detect a breast lump in that older breast.” 

Dr Walsh is adamant older women must be as breast-aware as younger women. “Breast cancer is very much a disease of advancing age. But the good news is the outcomes are excellent, though early detection is key.” 

The big message? Women must continue to be cancer-vigilant even when the BreastCheck invitation no longer drops on the mat.

Visit www.cancer.iewww.mariekeating.ie; www.breastcancerireland.com

‘Age makes no difference’

Theresa Byrne, who is training for her 29th minimarathon, was diagnosed with secondary breast cancer at 71.
Theresa Byrne, who is training for her 29th minimarathon, was diagnosed with secondary breast cancer at 71.

Theresa Byrne, 74, from Leixlip, found the lump herself in 2007.

She was due for mammogram at the BreastCheck mobile unit but her GP got her an earlier appointment. “They gave me the all-clear,” says the mother of three and grandmother.

But Theresa, who was aged 63 at the time, knew things weren’t right. “The lump was really painful, the more I examined it. It was quite tender and all the veins were standing out in that area of the breast. I had stiffness under my right arm.”

She eventually went for another mammogram, which found the lump was cancerous.

Theresa had a lumpectomy, and 26 lymph nodes removed. She had 26 chemo sessions and radiotherapy, and was on medication for five years. In late 2015, aged 71, she was diagnosed with secondary breast cancer. She had a small tumour on her lung.

“I was told there was no cure but they could keep it at bay. It’s a lot to take in. I was put on oral chemo and it contained the cancer.

Just because you reach 69 or 70, it doesn’t mean you can’t get breast cancer. I have a friend, who had a breast removed at 80, at 83 she had the second one done. Age makes no difference.

“I always kept my appointments for mammogram and I say to women: please go. I’m a great believer in the checks you can have done. Also, the woman always knows her own body and knows when something isn’t right.”

Describing herself as “very strong-willed”, Theresa’s training to do the Dublin women’s mini-marathon this June — for the 29th time.

Breast screening is for women without symptoms and BreastCheck urges any woman who has any concerns — between or after screenings — to visit her GP immediately even if she has had a recent mammogram.

Regardless of age, women are encouraged to remain breast-aware and to check for any symptoms/changes in their breasts.

Helen Forristal, director of nursing services at Marie Keating Foundation, says no matter what your age, it’s really important to be vigilant about your health and to continue to do breast self-examinations so you’re aware of any changes.

    Forristal has the following advice:

    Save the date

  • If you’re menopausal or post-menopausal, pick the same date every month to check your breasts – perhaps your birthday date, so if your birthday’s August 3, pick the third of each month to self-examine.
  • Become very familiar with your own body and know the warning signs:

  • Any lumps, thickening or bumpy areas in the breast tissue itself or in the armpit where the lymph nodes are
  • Any change is size/shape of the breast
  • Changes in the nipple, e.g. crusting, ulceration, bleeding or change in direction of or shape of nipple; unusual discharge from one or both nipples
  • Veins protruding more than usual
  • Any puckering, dimpling or redness of the skin
  • Swelling in the armpit or around the collarbone
  • Pain or discomfort that’s new and lingering more than two weeks.
  • Know your risk factors:

  • Is there family history of breast cancer? If yes, you need to be more vigilant.
  • Pregnancy at later age or having a late natural menopause
  • Having greater body fat, drinking alcohol and smoking.
  • Reduce your risk of breast cancer:

  • Maintain healthy body weight.
  • Do 30 minutes of moderate exercise five times weekly.
  • Consider how much alcohol you drink – don’t drink too much.
  • Quit smoking.
  • If you notice changes, go to GP for clinical examination.

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