Annals of Long Term Care

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?”