Screening and Cognitive Impairment
Screening and Cognitive Impairment
Mammographic screening for breast cancer in cognitively impaired women poses significant ethical questions. Many woman with dementia should not be screened because of the greater harm than benefits and the difficulty in obtaining informed consent. This article reviews the current controversy about mammography and then suggests a risk/benefit analysis for this vulnerable population. Autonomy, decision-making capacity, and the roles of surrogates and physicians are considered, as are ageism and the risk of undertreatment. The harm of overdiagnosis and subsequent overtreatment for women who are cognitively impaired, have comorbidity and a limited life span are outlined. In these cases, the burdens of mammography outweigh the benefits. For women with early cognitive impairment and longer life expectancies, the potential benefits may outweigh the harms. A decision-making process by the patient, proxy, and practitioner that takes account of foreseeable risks and benefits, patient capacity and preferences, and the effect of this screening intervention on quality of life is outlined.
Although the benefits of screening mammography for women younger than 70 have provoked active debate in lay and professional journals, the utility of this intervention in older women has received less attention. Every day, clinicians, appreciating that screening interventions that may benefit populations can possibly impose a burden on the individual patient, must decide whether to recommend breast cancer screening to women aged 70 and older, some of whom are cognitively impaired. This article addresses the ethical challenges posed by mammographic screening in the cognitively impaired woman. The analysis will focus on the proportionality of burdens and benefits of this intervention and on the issue of patient preference and informed consent. Screening mammograms should not be ordered in many older women with dementia.
Addressing breast cancer screening in demented women is especially important because breast cancer is common in older women. More than 50% of breast cancer is diagnosed in women aged 65 and older. The probability of developing breast cancer increases from 1 in 225 in women younger than 39, to 1 in 24 from age 40 to 59, to 1 in 14 from age 60 to 79.
Furthermore, the prevalence of cognitive impairment also increases with age, to as high as 50% at age 85. This analysis includes women with mild cognitive impairment who may or may not understand the risk-benefit assessment, mild to moderately demented women who still have a life expectancy of 5 years, and women with advanced dementia. This intersection of breast cancer and dementia raises questions about goals of care such as the importance of maintaining function and quality of life without imposing additional harm.
Mammographic screening for breast cancer in cognitively impaired women poses significant ethical questions. Many woman with dementia should not be screened because of the greater harm than benefits and the difficulty in obtaining informed consent. This article reviews the current controversy about mammography and then suggests a risk/benefit analysis for this vulnerable population. Autonomy, decision-making capacity, and the roles of surrogates and physicians are considered, as are ageism and the risk of undertreatment. The harm of overdiagnosis and subsequent overtreatment for women who are cognitively impaired, have comorbidity and a limited life span are outlined. In these cases, the burdens of mammography outweigh the benefits. For women with early cognitive impairment and longer life expectancies, the potential benefits may outweigh the harms. A decision-making process by the patient, proxy, and practitioner that takes account of foreseeable risks and benefits, patient capacity and preferences, and the effect of this screening intervention on quality of life is outlined.
Although the benefits of screening mammography for women younger than 70 have provoked active debate in lay and professional journals, the utility of this intervention in older women has received less attention. Every day, clinicians, appreciating that screening interventions that may benefit populations can possibly impose a burden on the individual patient, must decide whether to recommend breast cancer screening to women aged 70 and older, some of whom are cognitively impaired. This article addresses the ethical challenges posed by mammographic screening in the cognitively impaired woman. The analysis will focus on the proportionality of burdens and benefits of this intervention and on the issue of patient preference and informed consent. Screening mammograms should not be ordered in many older women with dementia.
Addressing breast cancer screening in demented women is especially important because breast cancer is common in older women. More than 50% of breast cancer is diagnosed in women aged 65 and older. The probability of developing breast cancer increases from 1 in 225 in women younger than 39, to 1 in 24 from age 40 to 59, to 1 in 14 from age 60 to 79.
Furthermore, the prevalence of cognitive impairment also increases with age, to as high as 50% at age 85. This analysis includes women with mild cognitive impairment who may or may not understand the risk-benefit assessment, mild to moderately demented women who still have a life expectancy of 5 years, and women with advanced dementia. This intersection of breast cancer and dementia raises questions about goals of care such as the importance of maintaining function and quality of life without imposing additional harm.
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