25 year trends in cancer incidence and mortality among adults aged 35-69 years in the UK, 1993-2018: retrospective secondary analysis

To the Editor,

I was intrigued by the recent study published in BMJ, titled "25-year trends in cancer incidence and mortality among adults aged 35-69 years in the UK, 1993-2018" by Shelton et al. This study emphasized that, despite breast cancer's relatively modest increase in incidence rates compared to other cancers over the study period, breast cancer still maintains significantly higher incidence rates than any other type of cancer [1]. These results indicate that breast cancer is still a major concern in women's healthcare nowadays.

It should be noted that age remains the major and independent risk factor for the development of breast cancer in women [2]. In the UK, more than a third of new breast cancer cases occur in women over 70, with fewer than one in five diagnoses in women under 50 [3]. Shelton et al.'s study, which focused on the 35-69 age group, suggested that the incidence of breast cancer within this demographic has stabilized in recent years [1]. However, this focus overlooks the critical need to address breast cancer risk in older UK women. While screening improvements and advances in treatments have reduced breast cancer mortality rates among younger women (despite an increase in incidence) [1, 2], survival rates for older women diagnosed with breast cancer have not seen significant improvements. Nearly half of breast cancer deaths occur in women aged 70 or older [4], a statistic that can be attributed to advanced disease stages at diagnosis due to diagnostic delays [5].

Some evidence suggests that screening mammography could reduce breast cancer or all-cause mortality among older women [6]. Yet, healthcare providers may be less inclined to refer older women for screening mammograms [2], primarily because of the current lack of solid evidence to comprehensively evaluate the benefits and risks of such screenings in older women [2]. Given that most older patients will die from causes unrelated to breast cancer, the potential for overdiagnosis and overtreatment poses a greater risk of harm in elderly patients compared to younger ones [2]. Moreover, research indicates that older breast cancer survivors even who are Medicare beneficiaries are still less likely to proactively undergo routine follow-up breast imaging [7].

These insights highlight the necessity of adopting a more personalized approach to perform mammography screening and other diagnostic methods for older patients with an average risk of breast cancer. This approach could be informed by exploring new clinical guidelines to help clinicians tailor screening practices more effectively to an older patient's likelihood of benefiting from ongoing screening. This assessment should consider the patient's comorbidity burden, functional status, life expectancy, and the potential treatment risks [2], potentially leveraging machine learning to achieve this [8]. Additionally, enhancing breast cancer literacy (i.e., being ‘breast aware’) among the UK' elderly is crucial. Misconceptions or outdated beliefs about breast cancer can prevent them from early detection and appropriate treatment-seeking behaviour. Therefore, educating older populations about breast cancer's signs, symptoms, and risk factors is vital for empowering them to recognize potential warning signs promptly, leading to timely medical intervention and better health outcomes.

References
1. Shelton J, Zotow E, Smith L, Johnson SA, Thomson CS, Ahmad A, Murdock L, Nagarwalla D, Forman D: 25 year trends in cancer incidence and mortality among adults aged 35-69 years in the UK, 1993-2018: retrospective secondary analysis. Bmj 2024, 384:e076962.
2. Bagegni NA, Peterson LL: Age-related disparities in older women with breast cancer. Adv Cancer Res 2020, 146:23-56.
3. Wilkinson L, Gathani T: Understanding breast cancer as a global health concern. Br J Radiol 2022, 95(1130):20211033.
4. Orucevic A, Curzon M, Curzon C, Heidel RE, McLoughlin JM, Panella T, Bell J: Breast Cancer in Elderly Caucasian Women-An Institution-Based Study of Correlation between Breast Cancer Prognostic Markers, TNM Stage, and Overall Survival. Cancers (Basel) 2015, 7(3):1472-1483.
5. Turner N, Zafarana E, Becheri D, Mottino G, Biganzoli L: Breast cancer in the elderly: which lessons have we learned? Future Oncol 2013, 9(12):1871-1881.
6. Walter LC, Schonberg MA: Screening mammography in older women: a review. Jama 2014, 311(13):1336-1347.
7. Jiang M, Hughes DR, Appleton CM, McGinty G, Duszak R, Jr.: Recent trends in adherence to continuous screening for breast cancer among Medicare beneficiaries. Prev Med 2015, 73:47-52.
8. Ming C, Viassolo V, Probst-Hensch N, Dinov ID, Chappuis PO, Katapodi MC: Machine learning-based lifetime breast cancer risk reclassification compared with the BOADICEA model: impact on screening recommendations. Br J Cancer 2020, 123(5):860-867.