Cancer Screening In Older Women Research Articles

A qualitative study of primary care clinician’s approach to ending cervical cancer screening in older women in the United States

The United States Preventive Services Task Force (USPSTF) recommends that cervical cancer screening end in average-risk patients with a cervix at 65 years of age if adequate screening measures have been met, defined as having 1) at least three normal consecutive cytology (Pap) tests, or 2) two normal cytology tests and/or two negative high-risk human papillomavirus tests between ages 55–65; the last test should be performed within the prior 5 years. Up to 60 % of all women aged 65 years and older who are ending screening do not meet the criteria for adequate screening. The objective of this study was to understand the process and approach that healthcare clinicians use to determine eligibility to end cervical cancer screening. In 2021 we conducted semi-structured interviews in San Francisco, CA with twelve healthcare clinicians: two family medicine physicians, three general internal medicine physicians, two obstetrician/gynecologists and five nurse practitioners. Thematic analysis, using inductive and deductive coding, was utilized. Three major themes emerged: following guidelines, relying on self-reported data regarding prior screening, and considering sexual activity as a factor in the decision to end screening. All interviewees endorsed following the USPSTF guidelines and they utilized self-report to determine eligibility to end screening. Clinicians’ approach was dependent in part on their judgement about the reliability of the patient to convey their screening history. Sexual activity of the patient was considered when making clinical recommendations. Shared decision-making was often utilized. Clinicians voiced a strong reliance on self-reported screening history to end cervical cancer screening.

Pap smear recommendations in older women, does the data support stopping?

To review the recommendations for cervical cancer screening in older women and to determine the evidence upon which the current and emerging recommendations are based on. To evaluate the possible consequences of stopping cervical cancer screening in older women. Recommendations are to space cervical cancer screening intervals for women aged 21-65 and stop in women older than 65. Cervical cancer incidence and mortality burden are significant in women over the age of 65. Human papillomavirus (HPV) vaccination rates are poor in older women. Advanced cervical cancer rates are increasing, including adenocarcinoma rates. Vulvar carcinoma rates are also increasing, and gynecological care and exams are less frequent when women are not getting routine pap testing. The current review shows that there is limited evidence on which to base the recommendation to stop screening. There is confusion among patients and physicians, and other healthcare providers over who to screen and when, and this is exacerbating the already known difficulty accessing healthcare among racial and ethnic minorities, underinsured, and rural populations, but rates of cancer are also rising most rapidly in white women. Recommendations to space or stop screening are often based on the perceived psychological distress of women undergoing testing and the cost of population screening.

Mammography and Decision Aid Use for Breast Cancer Screening in Older Women

Decision aids for breast cancer screening are increasingly being used by physicians, but the association between physician practice decision-aid use and mammography rates remains uncertain. Using national data, this study examines the association between practice-level decision-aid use and mammography use among older women. Physician practice responses to the 2017/2018 National Survey of Healthcare Organizations and Systems (n=1,236) were linked to 2016 and 2017 Medicare fee-for-service beneficiary data from eligible beneficiaries (n=439,684) aged 65-74 years. In 2021, multivariable generalized linear models estimated the association of practice decision-aid use for breast cancer screening and advanced health information technology functions with mammography use, controlling for practice and beneficiary characteristics. Overall, 60.1% of eligible beneficiaries had a screening mammogram, and 37.3% of physician practices routinely used decision aids for breast cancer screening. In adjusted analyses, advanced health information technology functions (OR=1.19, p=0.04) were associated with mammography use, but practice use of decision aids was not (OR=0.95, p=0.21). Beneficiary clinical and socioeconomic characteristics, including race, comorbidities, Medicare and Medicaid eligibility, and median household income were more strongly associated with mammography use than practice-level decision-aid use or advanced health information technology functions. Health information technology‒enabled automation of mammography reminders and other advanced health information technology functions may support mammography, whereas breast cancer decision aids may reduce patients' propensities to be screened through the alignment of their preferences and screening decision. More resources may be needed for decision aids to be routinely implemented to improve solicitation of patient preferences and targeting of mammography services.

On Breast Cancer Screening in Older Women

On Breast Cancer Screening in Older Women

Breast Cancer Screening Shared Decision-Making in Older African-American Women

BackgroundDiscussions about whether to continue breast cancer screening in older women are complex, particularly for African American women. Decision aids may be helpful in guiding these conversations; however, little is known about the feasibility and acceptability of using breast cancer decision aids in older African American women. This study explored African American women's knowledge of breast cancer screening guidelines in older adults, prior conversations with providers regarding continuation of screening, and their understanding/willingness to engage in discussions about individualized breast cancer screening decision-making using two versions of tested decision aids. MethodsTwenty-four African American women; (age m = 83) in urban geriatric practice. Interviews with African American women age 75+. Both DAs include age, health/functional status, and comorbidities questions to determine a BCS harms/benefit score. ResultsMost participants (75%) reported familiarity with current breast cancer screening guidelines. Twenty-nine percent reported prior discussions with providers about continuing breast cancer screenings. Sixty percent did not need assistance completing DAs while 40% did. 66.7% found the decision aids “very helpful” in reflecting their breast cancer screening thoughts; 58.3% had no preference regarding either decision aid version. 75% of participants were willing to complete the decision aid before a provider visit. Participants equally preferred a health educator or provider facilitating discussion of breast cancer screening harms and benefits and potential cessation. ConclusionsOlder African American women are willing to engage in discussions about whether or not to continue breast cancer screening and found decision aids helpful.

Three large scale surveys highlight the complexity of cervical cancer under-screening among women 45–65 years of age in the United States

BackgroundLarge scale United States (US) surveys guide efforts to maximize the health of its population. Cervical cancer screening is an effective preventive measure with a consistent question format among surveys. The aim of this study is to describe the predictors of cervical cancer screening in older women as reported by three national surveys. MethodsThe Behavioral Risk Factor Surveillance System (BRFSS 2016), the Health Information National Trends Survey (HINTS 2017), and the Health Center Patient Survey (HCPS 2014) were analyzed with univariate and multivariate analyses. We defined the cohort as women, without hysterectomy, who were 45–65years old. The primary outcome was cytology within the last 3years. ResultsOverall, Pap screening rates were 71% (BRFSS), 79% (HINTS) and 66% (HCPS), among 41,657, 740 and 1571 women, respectively. BRFSS showed that women 60–64years old (aPR=0.88, 95% CI: 0.85, 0.91), and in rural locations (aPR=0.95, 95% CI: 0.92, 0.98) were significantly less likely to report cervical cancer screening than women 45–49-years old or in urban locations. Compared to less than high school, women with more education reported more screening (aPR=1.20, 95% CI: 1.13, 1.28), and those with insurance had higher screening rates than the uninsured (aPR=1.47, 95% CI: 1.33, 1.62). HINTS and HCPS also showed these trends. ConclusionsAll three surveys show that cervical cancer screening rates in women 45–65years are insufficient to reduce cervical cancer incidence. Insurance is the major positive predictor of screening, followed by younger age and more education. Race/ethnicity are variable predictors depending on the survey.

Resistance to discontinuing breast cancer screening in older women: A qualitative study.

Screening mammography is associated with reduced breast cancer-specific mortality; however, among older women, evidence suggests that the potential harms of screening may outweigh the benefits. We used a qualitative approach to examine the willingness of older women from different racial/ethnic groups to discontinue breast cancer screening. Women ≥70years of age who reported having a screening mammogram in the past 3years and/or reported that they intended to continue screening in the future were recruited for in-depth interviews. Participants who intended to continue screening were asked to describe how the following hypothetical scenarios would impact a decision to discontinue screening: health concerns or limited life expectancy, a physician's recommendation to discontinue, reluctance to undergo treatment, and recommendations from experts or governmental panels to stop screening. Semi-structured, face-to-face interviews were audio-recorded. Data coding and analysis followed inductive and deductive approaches. Regardless of the scenario, participants (n=29) expressed a strong intention to continue screening. Based on the hypothetical physician recommendations, intentions to continue screening appeared to remain strong. They did not envision a change in their health status that would lead them to discontinue screening and were skeptical of expert/government recommendations. There were no differences observed according to age, race/ethnicity, or education. Among older women who planned to continue screening, intentions to continue breast cancer screening appear to be highly resilient and resistant to recommendations from physicians or expert/government panels.

Abstract P6-02-01: Perceived life expectancy, multimorbidity, and breast cancer screening in older women

Abstract Objective: Screening mammography (SM) benefits are maximal in women who have a several years' life expectancy. Perceived life expectancy (PLE), however, can be compromised by older age, and/or poor health. Prior studies have shown low rates of SM in younger and/or healthier women, while women who are older and/or those presenting with multimorbidity (MM) continue to undergo screening. The resulting under/overuse of SM causes an imbalance in the use of finite resources that should be rectified as we prepare for population aging. In this study, we investigate the use of SM in women 50 years of age or older in the context of age, PLE, MM, and other social determinants of health. Methods: This is a cross-sectional study using the nationally-representative 2012 U.S. Health and Retirement Study (n= 8934 women). In addition to demographics, we examined a broad range of variables on social determinants of health; as well as conditions constituting MM, including self-reported chronic conditions (e.g., heart disease), functional limitations (e.g., strength, and mobility limitations), and geriatric syndromes (e.g., low cognitive performance). We defined MM0-MM3 as gradients of MM, based on the occurrence/co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. PLE was calculated based on respondent's age-specific assessment of the chance they would live another 10-15 years. The outcome variable was self-reported mammography in the past 2 years. We conducted logistic regression analysis to evaluate the independent and interactive association between each of PLE and MM relative to SM, adjusting for potential confounders. Results: The median age was 65.7 years; 10.5% were Non-Hispanic Black (NHB), 7.8% were Hispanic, and 3.2% were Other Race. The percent of women with SM was 71.5% in the total population. The median assessment of PLE was a 50% chance of living another 10-15 years. 71.9% of women presented with chronic conditions, 36.8% with functional limitations, and 58.2 with geriatric syndromes. Adjusting for confounders, receipt of mammogram was positively associated with greater certainty of PLE (AOR for an increase of 10% –1.03 (1.01, 1.05)). Compared to those with no conditions (MM0), the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes was also positively associated with SM (AOR MM1– 1.48 (1.19, 1.84); AOR MM2– 1.35 (1.09, 1.69); and AOR MM3– 1.29 (1.02, 1.62)). In addition, PLE further strengthened the association between MM and SM. Although age was negatively associated with SM, this interacted with PLE such that the likelihood of having a mammogram was unrelated to age among women 100% certain they would live another 10-15 years. Conclusion: Both multimorbidity (MM) and perceived life expectancy (PLE) are independently and interactively associated with increased screening mammography (SM), suggesting overuse. Indeed, even among women 75 years of age or older, when SM may be least beneficial, receipt of SM in the past two years was 59.6% in the presence of highest MM gradient, and 68.1% when they were at least 75% certain they will live 10-15 years. A more detailed examination of the basis for PLE is warranted to understand the context in which screening recommendation is made. Citation Format: Koroukian SM, Warner DF, Schiltz NK, Cooper GS, Owusu C, Stange KC, Berger NA. Perceived life expectancy, multimorbidity, and breast cancer screening in older women [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-02-01.

Breast Cancer Screening in Older Women—Current Evidence and Future Perspectives

As populations of developed countries are aging, the number of older women with breast cancer will strongly increase. Randomized controlled trials in breast cancer screening rarely included patients over the age of 68. As a consequence, there is no solid evidence for beneficial effects of breast cancer screening in older women. In a recent observational study, we showed that the implementation of screening in women aged 70–75 in the Netherlands resulted in a strong increase of the incidence of early-stage breast cancer, while the incidence of advanced stage breast cancer barely decreased. Hence, current data do not support population-based screening in women over the age of 70.

Breast cancer screening in older women

Breast cancer screening in older women

Cervical Cancer Screening in Older Women: New Evidence and Knowledge Gaps

Anne Rositch and colleagues discuss the study by Peter Sasieni and colleagues on cervical cancer screening in older women and describe the further information needed to help inform decisions about whether to extend screening programs beyond 65 years for women with adequate negative screening. Please see later in the article for the Editors' Summary

Response to Counterpoint: Efficacy of Cervical Cancer Screening in Older Women

We appreciate the perspective of Drs. Isidean and Franco (1). We agree with them that there are indeed costs (financial, physical, psychological) associated with cervical screening of older women, and that the decision to continue screening beyond a given age needs to weigh these costs against the benefits of screening. The purpose of our commentary (2) was to suggest that the recently formulated guidelines had not adequately considered those benefits. There are good reasons to believe that even a series of negative screens for cervical neoplasia predicts a low risk of subsequent cervical malignancy only for so long (3–5). Contrary to Isidean and Franco's assertion (1), it is possible that precursor lesions that develop in a woman aged 65 years or older—even a woman who was previously adequately screened—can progress to cervical cancer within her remaining life expectancy. Indeed, this is the main finding from the studies documenting a reduced incidence of invasive cervical cancer associated with receipt of screening among women in this age group (3, 4, 6, 7).

Efficacy of screening in preventing cervical cancer among older women

Although the effectiveness of cervical cancer screening has been firmly established in reproductive-age women, its usefulness in older women is unclear. We sought to evaluate the efficacy of cervical cancer screening in older women. We conducted a case-control study within two integrated health care systems in the northwestern United States. Cases (n = 69) were women aged 55-79 years who were diagnosed with invasive cervical cancer during 1980-1999. Controls (n = 208) were women with an intact uterus and no diagnosis of cervical cancer, but otherwise similar to cases in terms of age and length of enrollment in the health plan. We reviewed medical records to ascertain screening history during the 7 years prior to reference date. Compared to cases, controls were more likely to have received a Pap test. After adjustment for age and current smoking status, screening prior to an estimated 1-year duration of the occult invasive phase of cervical cancer was associated with a substantial reduction in risk [odds ratio (OR) 0.23; 95% CI 0.11-0.44]. Similar results were obtained using different estimates of the duration of the occult invasive phase. Analysis of the relative incidence of invasive cervical cancer in relation to the time following a negative screening test suggested a large reduction during the first year (OR 0.09; 95% CI 0.03-0.24). The incidence remained low for several years thereafter, returning to the incidence among unscreened women after 5-7 years. Cervical cancer screening by means of cytology is highly efficacious in older women. Our findings also suggest that five-yearly screening is approximately as efficacious as more frequent screening.

Determinants of Cancer Screening Practices of Women Over Age 55: What are the Perceived Barriers and Benefits of Breast Cancer Screening in Older Women?

Determinants of Cancer Screening Practices of Women Over Age 55: What are the Perceived Barriers and Benefits of Breast Cancer Screening in Older Women?

Cervical Cancer Screening Efficacy in Older Women

Abstract Although the effectiveness of cervical cancer screening, by means of the Pap smear, has been firmly established in reproductive-age women, the usefulness of cytologic screening in older women is unclear. We sought to assess the degree to which such screening in older women can reduce the incidence of cervical cancer. We conducted a case-control study to evaluate the efficacy of cervical cancer screening in older women enrolled in one of two large health maintenance organizations in the northwestern United States. Cases (n = 69) consisted of those women, 55 to 79 years of age, who were diagnosed with invasive cervical cancer during 1980 to 1999 as enumerated by regional cancer registries. Controls (n = 208) were women sampled from among enrollees who had not previously had a hysterectomy and were similar to cases in terms of age and length of enrollment in the health plan. We reviewed medical records to ascertain demographic, reproductive, and cervical screening history information during the 7 years before the reference date. Only tests which occurred during the presumed detectable preinvasive phase (DPP) of the disease, when screening could be beneficial, were considered and we evaluated results for a series of plausible estimates of this interval. Compared to cases, controls were more likely to have had a Pap test during the DPP, regardless of the estimate used. After adjustment for age and current smoking status, screening was associated with a substantial reduction in the risk of invasive cervical cancer (DPP = 72 months: OR, 0.23; 95% CI, 0.11–0.44). We observed only small differences in the odds ratio across the various estimates of the DPP that were employed. Analysis of the relative incidence of invasive cervical cancer in relation to the time following a negative screening test suggested a large reduction during the first year (OR, 0.09; 95% CI, 0.03–0.24). The incidence remained low for several years thereafter, returning to the incidence among unscreened women after 5 to 7 years. Cervical cancer screening is highly efficacious in older women. This needs to be explicitly considered in weighing the benefits and costs of such screening beyond the reproductive years.

Does Patient Health and Hysterectomy Status Influence Cervical Cancer Screening in Older Women?

Decisions to screen older patients for cancer are complicated by the fact that aging populations are heterogeneous with respect to life expectancy. To examine national trends in the association between cervical cancer screening and age, health and hysterectomy status. Cross-sectional data from the 1993, 1998, 2000, and 2005 National Health Interview Surveys (NHIS) were used to examine trends in screening for women age 35-64 and 65+ years of age. We investigated whether health is associated with Pap testing among older women using the 2005 NHIS (N = 3,073). We excluded women with a history of cervical cancer or who had their last Pap because of a problem. The dependent variable was having a Pap test within the past 3 years. Independent variables included three measures of respondent health (the Charlson comorbidity index (CCI), general health status and having a chronic disability), hysterectomy status and sociodemographic factors. NHIS data showed a consistent pattern of lower Pap use among older women (65+) compared to younger women regardless of hysterectomy status. Screening also was lower among older women who reported being in fair/poor health, having a chronic disability, or a higher CCI score (4+). Multivariate models showed that over 50% of older women reporting poor health status or a chronic disability and 47% with a hysterectomy still had a recent Pap. Though age, health and hysterectomy status appear to influence Pap test use, current national data suggest that there still may be overutilization and inappropriate screening of older women.

Cervical Cancer Screening in Older Women

Cervical Cancer Screening in Older Women

Breast Cancer Screening in Older Women

There is currently an epidemic of breast cancer in women 65 years of age and older. The purposes of this paper are to explore the breast cancer screening behaviors of older women and to identify some of the determinants of screening in these women.Data were analyzed from the 1987 National Health Interview Survey, a continuous nationwide household interview survey of the U.S. civilian, noninstitutionalized population.As in other studies, the utilization of breast cancer screening by older women was less in older women than in younger women. This was true for both mammography and clinical breast examination. A number of determinants of screening in older women were identified here. Women with a usual source of care and/or no activity limitation, as well as high school graduates, were the ones most likely to have received a screening mammogram and/or a screening clinical breast exam during the past year.The failure of older women to receive adequate breast cancer screening is an important concern which should be reevaluated, given the breast cancer epidemic in this population. This study identified a number of determinants of breast cancer screening in older women. For the most part, these determinants point to the primary care physician as the key to breast cancer screening in these women. Therefore, the primary care physician must be informed of, and encouraged to follow, the recommendations for periodic breast cancer screening in older women.

Uptake of breast cancer screening in older women

Uptake of breast cancer screening in older women

Uptake of breast cancer screening in older women.

to determine breast screening uptake in older women and to ascertain from previous non-attenders whether they would accept screening if invited. a random sample of older women randomly selected from three Family Health Service Authorities were interviewed in their homes. 1604 women aged 65 years and over living at home, a response rate of 94%. 120 respondents (8%) had previously been screened. Rates were higher among those who were married, separated or divorced than those who were single (P < 0.01). Of those who had not previously been screened, 742 (50%) reported that they would attend if invited. Age influenced potential attendance: 67% of those aged 65-69 would accept compared with 27% of those aged 80 and over (P < 0.0001). Future attenders were significantly more likely to belong to the upper social class and to be currently married, and were significantly less likely to be disabled or depressed, but more likely to be anxious (P < 0.05). it is unjustifiable to exclude women over 65 from breast screening on the basis of assumed low uptake rates. Certain categories of women--such as those who were physically disabled, depressed, single or from lower social classes--could be targeted to achieve maximum uptake rates.