Oldest old 'hanging in the balance'?

Washington, DC -- A lack of clear-cut, scientific evidence illustrating the benefits of mammography screening in women over 80 has created a trail of controversy leading to a disturbing conclusion about cancer care in America. "We are ill-prepared from a scientific knowledge perspective to provide cancer health care rationally, ethically, equitably and humanely to the 'booming' older population," say two leading cancer researchers.

In an editorial published online today in the Journal of Clinical Oncology (JCO), Jeanne S. Mandelblatt , MD, MPH, of Georgetown's Lombardi Comprehensive Cancer Center, and co-author Rebecca Silliman, MD, MPH, PhD, of Boston University Medical Center, address the lack of scientific evidence available regarding cancer screening interventions for older Americans – an issue at the heart of a controversial breast cancer screening study published in the JCO earlier this year.

This study used observational data to provide evidence about the effectiveness of mammography screening in older women, in the absence of clinical trials.

In the current editorial, Mandelblatt and Silliman explore the study's biases, all of which make screening seem more beneficial than it may actually be. If, as the editorial authors conclude, reduction in mortality is the appropriate metric to determine the effectiveness of screening then "at this time, we are left with the fact that there is no evidence that screening women 80 and older with mammography results in reductions in mortality."

Mandelblatt and Silliman commend the study's authors for raising difficult questions in gero-oncology especially when the answers are imperfect, but the authors draw attention to the broader problem related to care of older people.

"With continued gains in life expectancy and increases in cancer incidence with age, clinicians will be caring for an ever-increasing number of older individuals including the oldest old."

Mandelblatt and Silliman recommend an investment in clinical trials specifically to assess cancer screening and treatment for older individuals, in order to strengthen the empirical data available to the medical community when making screening recommendations.

"Without a major shift in emphasis in clinical trials and new investments in understanding the impact of technology and downstream therapy on older populations, we will continue to practice in the context of limited trial evidence."

Mandelblatt is associate director for population sciences at Lombardi Comprehensive Cancer Center. Silliman is chief of the geriatrics section at Boston University Medical Center.

The Lombardi Comprehensive Cancer Center, part of Georgetown University Medical Center and Georgetown University Hospital, seeks to improve the diagnosis, treatment, and prevention of cancer through innovative basic and clinical research, patient care, community education and outreach, and the training of cancer specialists of the future. Lombardi is one of only 41 comprehensive cancer centers in the nation, as designated by the National Cancer Institute, and the only one in the Washington, DC, area. For more information, go to http://lombardi.georgetown.edu.

Georgetown University Medical Center is an internationally recognized academic medical center with a three-part mission of research, teaching and patient care (through our partnership with MedStar Health). Our mission is carried out with a strong emphasis on public service and a dedication to the Catholic, Jesuit principle of cura personalis -- or "care of the whole person." The Medical Center includes the School of Medicine and the School of Nursing and Health Studies, both nationally ranked, the world-renowned Lombardi Comprehensive Cancer Center and the Biomedical Graduate Research Organization (BGRO), home to 60 percent of the university's sponsored research funding.