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Breast Cancer in an Elderly Woman With Alzheimer’s Disease
The goal of cancer screening is to optimize outcomes by diagnosing cancer and initiating treatment earlier. Current breast cancer screening recommendations were established for women in average health at average risk for breast cancer. Their applicability to older, institutionalized patients with comorbidities, declining cognitive or functional status, and limited life expectancy is less clear. Based on our patient’s story, we explore the dilemma that cancer screening for patients with limited decision-making capacity represents.
Case Presentation
Our patient was an 80-year-old white woman with moderate Alzheimer’s dementia. She had moved to Michigan to live with her daughter. During her first geriatric evaluation in 2004, she had no complaints and expressed satisfaction with her new living arrangement and its closeness to her family. She was independent in basic activities of daily living.
The patient’s medical history included diabetes mellitus, hypertension, dyslipidemia, and osteoporosis. Her surgical history was significant for a hysterectomy in her 50s due to endometrial cancer. Her mother and sister had developed Alzheimer’s disease in their 80s.
Results of a physical examination were unremarkable. The patient’s capacity for making simple decisions, such as choosing what clothes to wear, was intact, but she was incapable of informed decision-making. Her daughter had requested that the patient undergo mammography for breast cancer screening, noting that the patient was receiving regular breast cancer screenings, including breast examination and mammography, up until 5 years ago. The daughter indicated that she wanted her mother screened so that she could get a more definitive assessment of her own risk for breast cancer. We discussed the benefits and risks associated with mammography screening with the patient and her family. The patient was unable to comprehend the discussion, so informed consent for the procedure was obtained from her son, who was the durable power of attorney for healthcare (DPOA-HC) decisions.
The mammography findings were suspicious for malignancy and further evaluation was recommended. The patient’s DPOA-HC decided to authorize the biopsy, but the patient was not sure she wanted one and asked, “What’s the difference how I will die?” She ultimately agreed with her family’s decision, concluding, “Whatever they want is good for me.”
A stereotactically-guided breast biopsy was scheduled, but the patient did not cooperate, precluding the biopsy from being performed. The radiologist discussed other diagnostic options in detail with the family, who decided to accept a watchful waiting approach.
Approximately 18 months later, the patient was hospitalized for acute confusion and an examination revealed a 2x2-cm left axillary lymph node. Due to progressive dementia and its burden on her caregivers, she was placed in a nursing home. Nearly 3 years after this, she developed a palpable left breast mass and left upper extremity lymphedema. Results of a mammography study were again highly suspicious for malignancy. The medical team discussed diagnostic and treatment options with the patient’s family, and her DPOA-HC decided on comfort care only because of her advanced dementia.
Over the next 6 months, the patient developed a painful, indurated, ulcerated lesion in her left breast and significant arm edema. Hospice was consulted for wound care, pain management, and family support. The patient died peacefully in her nursing home room. All the family members displayed full understanding and acceptance of the diagnosis, treatment plan, and supportive care provided. However, the physician and other medical caregivers were left with an ethical question: “Did we do the right thing for our patient?”
Discussion
Breast cancer is the second leading cause of cancer deaths among women in the United States. The incidence of breast cancer increases with age, as does the incidence of Alzheimer’s dementia.1,2 The US Preventive Services Task Force recommends biennial mammographic breast cancer screenings for women aged 50 to 74 years.3 The American Geriatrics Society encourages offering screening mammography up to age 85 for healthy women who have an estimated life expectancy ≥5 years and for women >85 years who have excellent health and functional status and strongly believe in the benefits of screening.4 The American Cancer Society advises women to continue to receive breast cancer screening as long as they are in good health and a candidate for cancer treatment.5 Ideally, screening decisions should be individualized for each patient.4
The literature evaluating the relationship between dementia and breast cancer screening is limited, but it appears to indicate that women with dementia are less likely to receive screening and treatment. In addition, breast cancer tends to be diagnosed at later stages in dementia patients and is more likely to involve the lymph nodes.6 Breast cancer screening and treatment in older women with Alzheimer’s dementia presents an ethical dilemma: the risk of underdiagnosis and undertreatment is significant, as is the risk of overdiagnosis and overtreatment. As medical caregivers of patients with
dementia, we must often participate in making decisions about the need for breast cancer screening and treatment. How do we decide? To answer this question, we can weigh three decision-making approaches: an evidence-based one, an individualized one, or a patient- and family-centered decision-making approach (Table 1).7,8
The evidence-based approach allows research to guide recommendations, which are often detailed in published guidelines. At present, conflicting data have generated considerable controversy regarding breast cancer screening recommendations, and current guidelines generally identify age as the primary risk factor for this malignancy.9 Whereas the evidence demonstrates that routine mammography screening reduces breast cancer mortality for women aged 39 to 69 years, it does not indicate the same benefit for women aged ≥70 years.10 This suggests that routine screening may not be needed after age 69. The most recent survey on caregiver beliefs regarding breast cancer screening in older women with dementia found that screening was likely to continue following a dementia diagnosis, unless the dementia is severe, and decisions are influenced by physician recommendations and patient’s beliefs before the onset of dementia.11
The framework for an individualized decision-making approach to cancer screening for elderly patients involves carefully considering the benefits and risks to the woman and her comorbid conditions and life expectancy. A study of older women with breast cancer and comorbidities found no survival advantage associated with early cancer diagnosis; findings also suggested that cancer screening tests like mammography may not provide the same level of benefit as they do for women in average health.12
Patients with cancer and comorbid dementia have an increased mortality rate, but deaths among this demographic are mostly due to causes unrelated to cancer. For example, in patients with mild to moderate dementia, common causes of death are cardiovascular related, such as heart disease and stroke, and in patients with severe dementia, the most common cause of death is pneumonia.13,14 In general, cancer screening has only demonstrated a survival benefit in older patients with a life expectancy ≥5 years.15
Therefore, women with mild to moderate dementia whose life expectancy is ≥5 years may benefit from mammography screening, and the procedure should be offered (Table 2). Mammography screening is not recommended for women with mild to moderate dementia, significant functional dependency, and a life expectancy of <5 years, and is also not recommended for women with advanced dementia regardless of functional status and lifespan.16 The presence of comorbid conditions or short life expectancy do not appear to guide family caregivers’ screening decisions for women with mild and moderate dementia, and screening decisions for these women may need to be based on the patient’s and family’s/surrogate’s expressed wishes—a patient- and family-centered approach.
The patient- and family-centered approach is even more individualized and has at its core the concepts of dignity, respect, information sharing, participation, and collaboration. This approach might be most helpful when deciding the appropriateness of screening in difficult cases like ours. It is a shared decision-making process, in which the patient and family lie at the center. The physician outlines the benefits and risks of screening intervention, assesses the patient’s capacity to make her own decision, and ultimately coordinates the process with respect for the patient’s wishes and surrogates’ concerns.
When our patient’s daughter requested breast cancer screening for her mother, a discussion was held with the family regarding the possible benefits and harms of screening and treatment should cancer be found. It was explained that breast cancer screening in younger women may benefit this demographic but imposes a burden on older women with cognitive impairment. In women with moderate dementia and a life expectancy of <5 years, mammography screening would generally not be recommended; further, cancer screening is unnecessary unless intervention is anticipated. In patients with moderate to severe dementia, procedures such as screening mammography might be perceived as an assault, making the procedure impossible to be processed. In our patient’s case, when the mammogram came back suspicious for malignancy, she was cognizant enough to protest having a biopsy. Even incapacitated patients can express their wishes, and we should always respect them.
When the breast mass was found 3 years later, the family decided that hospice care, with comfort measures only, was the best approach for their mother. At the end of life, even if screening offers no perceived benefit to the patient’s quality of life, it is important to address the family’s concerns and provide them comfort—particularly if the family is the designated decision-maker. Decision-makers often change previously held positions regarding treatment if screening reveals a potentially fatal disease. We believe honoring patients’ wishes and addressing the concerns of their families are especially important during end-of-life care, and we feel that was accomplished in this case.
Conclusion
No definitive breast cancer screening and treatment recommendations exist for patients with Alzheimer’s dementia. Current guidelines refer to women at average risk for breast cancer and in average health and are not appropriate for patients with mild, moderate, or severe dementia. When considering the benefits versus risks of breast cancer screening and treatment in women with Alzheimer’s dementia, other values need to be weighed, such as preferences of the patient and her family, the stage of dementia, comorbidities, and the patient’s life expectancy. Breast cancer screening and treatment in patients with dementia who have limited decision-making capacity remains a complex medical, ethical, and legal issue that requires shared decision-making and, more importantly, necessitates patient- and family-centered care.
Drs. Kusz and Smith are associate professors of medicine, Michigan State University, East Lansing, MI. Dr. Kusz is director of geriatric education, and Dr. Smith is program director, Internal Medicine Residency Program, McLaren Regional Medical Center, Flint, MI.
The authors report no relevant financial relationships.
Acknowledgments
We would like to thank Diane Kallas, RN, BA, for sharing her clinical impressions, experience, and written commentaries as a nurse, director of case management, and member of the Bioethics Committee, McLaren Regional Medical Center, Flint, MI.
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