Abstract
There is insufficient evidence to recommend mammography for women >75 years. Guidelines recommend that older women be informed of the uncertainty of benefit and potential for harm, especially for women with short life expectancy. However, few older women are informed of harms of screening and many with short life expectancy are screened. Therefore, we aim to test whether a mammography screening decision aid (DA) for women >75 years affects their use of mammography, particularly for women with <10 year life expectancy. The DA is a self-administered pamphlet that includes information on screening outcomes, tailored information on breast cancer risk, health, life expectancy, and competing mortality risks, and includes a values clarification exercise. We are conducting a large cluster randomized controlled trial (RCT) of the DA with the primary care provider (PCP) as the unit of randomization to evaluate its efficacy. We plan to recruit 550 women 75-89 years from 100 PCPs to receive either the mammography DA or a pamphlet on home safety for older adults (control arm) before a visit with their PCP, depending on their PCP's randomization assignment. The primary outcome is receipt of mammography screening assessed through chart abstraction. Secondary outcomes include effect of the DA on older women's screening intentions, knowledge, and decisional conflict, and on documented discussions about mammography by their PCPs. We will recruit women from 5 Boston-based primary care practices (3 community-based internal medicine practices and 2 academic practices), and 2 North Carolina-based academic primary care practices. It is essential that we test the DA in a large RCT to determine if it is efficacious and to substantiate the need for broad translation into clinical practice. Our DA has the potential to improve health care utilization and care in a manner dictated by patient preferences.
Highlights
Women aged 75 and older are the fastest growing segment of the US population and are at the highest risk of breast cancer [1,2]
Our decision aid (DA) has the potential to improve health care utilization and care in a manner dictated by patient preferences
Data suggest that women need an approximate 10 year life expectancy to have a chance at a mortality benefit from being screened with mammography [11,12,13]
Summary
Women aged 75 and older are the fastest growing segment of the US population and are at the highest risk of breast cancer [1,2]. Among women 50-74 years, mammography is estimated to reduce breast cancer mortality by 15% to 25% [3,4,5,6] and screening is recommended every 1-2 years [7,8]. The reduced breast cancer mortality associated with mammography is likely smaller for older women due to shorter life expectancies, slower growing tumors, and competing illnesses [9,10]. There are immediate harms to screening older women including: pain, anxiety, complications from tests after a false positive mammogram (e.g., breast biopsy), and over diagnosis (finding cancers that otherwise would never have caused symptoms in one's lifetime) [10,14]. Over diagnosis is concerning since some older women experience significant complications from breast cancer treatment [15,16,17,18,19,20,21]
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