Mammography Screening For Older Women Research Articles

Abstract IA021: Balancing act: cancer control and equity through implementation and de-implementation

Abstract Promoting evidence-based cancer prevention and control may require de-implementation strategies, aimed at reducing or removing interventions that have been shown as ineffective, potentially harmful, lacking in demonstrated effectiveness, or offering only limited health benefits. De-implementation involves a range of actions, including scaling back these interventions, narrowing their application to specific populations or settings, substituting them with more effective alternatives, or entirely discontinuing them without replacement. The evolving nature of scientific evidence and the shifting landscape of population health priorities, which contribute to changing guidelines over time, make de-implementation an important component of the broader implementation science to advance cancer prevention, control, and equity. While the field is expanding, there remains a research gap in empirical studies that elucidate the factors influencing de-implementation or effective strategies for facilitating it. Emerging data indicate that the drivers of implementation and de-implementation often differ, necessitating distinct or adapted strategies, frameworks, and outcomes. Implementation and de-implementation approaches also have varying implications and considerations for addressing health disparities. Breast cancer screening through mammography serves as a case study, exemplifying an evidence-based practice marked by both underuse and overuse — corresponding to lower and higher guideline-recommended participation, respectively — across different population groups and settings. In this educational session presentation, we will share the approaches and insights gathered from our efforts to promote appropriate screening mammography within racially and ethnically diverse and underserved communities. In this education presentation, we will highlight findings from our NIH-funded studies, focusing on two specific areas: breast density notification and mammography screening in older women. These areas represent current practices characterized by insufficient evidence regarding effectiveness, potential harms, and benefits, along with inconsistent clinical recommendations, illustrating the need for a more deliberate and well-informed approach to enhance breast cancer control and mitigate health disparities. Beyond illuminating some of the challenges at the policy, organizational, and provider levels, we emphasize the critical role that women or patients play in shaping the landscape of breast cancer screening. Their perspectives and experiences are crucial considerations when formulating de-implementation strategies aimed at optimizing breast cancer screening and promoting equity. Citation Format: Parisa Tehranifar, Nathalie Moise, Rachel C. Shelton. Balancing act: cancer control and equity through implementation and de-implementation [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr IA021.

Health benefits and harms of mammography screening in older women (75+ years)—a systematic review

BackgroundThere is little evidence on the balance between potential benefits and harms of mammography screening in women 75 years and older. The aim of this systematic review was to synthesise the evidence on the outcomes of mammography screening in women aged 75 years and older.MethodsA systematic review of mammography screening studies in women aged 75 years and over.ResultsThirty-six studies were included in this review: 27 observational studies and 9 modelling studies. Many of the included studies used no or uninformative comparison groups resulting in a potential bias towards the benefits of screening. Despite this, there was mixed evidence about the benefits and harms of continuing mammography screening beyond the age of 75 years. Some studies showed a beneficial effect on breast cancer mortality, and other studies showed no effect on mortality. Some studies showed some harms (false positive tests and recalls) being comparable to those in younger age-groups, with other studies showing increase in false positive screens and biopsies in older age-group. Although reported in fewer studies, there was consistent evidence of increased overdiagnosis in older age-groups.ConclusionThere is limited evidence available to make a recommendation for/against continuing breast screening beyond the age of 75 years. Future studies should use more informative comparisons and should estimate overdiagnosis given potentially substantial harm in this age-group due to competing causes of death.This review was prospectively registered with PROSPERO (CRD42020203131).

Effects by educational attainment of a mammography screening patient decision aid for women aged 75 years and older.

To help inform screening decisions, a mammography screening decision aid (DA) for women aged 75years and older was tested in a cluster randomized clinical trial of 546 women. DA use increased women's knowledge of the benefits and harms of mammography and lowered screening rates. In the current study, the objective was to examine whether participants' views of the DA and/or its effects differed by educational attainment. A secondary analysis was conducted of 283 women who received the DA before a personal care provider (PCP) visit during the trial to examine the acceptability of the DA and its effects on knowledge of the benefits and harms of mammography, screening intentions, and receipt of screening by educational attainment. Adjusted analyses accounted for clustering by PCP. Of the 283 participants, 43% had a college education or less. Regardless of educational attainment, 87.2% found the DA helpful. Women with lower educational attainment were less likely to understand all of the DA's content (46.3% vs 67.5%; P<.001), had less knowledge of the benefits and harms of mammography (adjusted mean±standard error knowledge score, 7.1±0.3 vs 8.1±0.3; P<.001), and were less likely to lower screening intentions (adjusted percentage, 11.4% vs 19.4%; P=.01). Receipt of screening did not differ by educational attainment. A mammography DA for women aged 75years and older was helpful to women regardless of their educational attainment; however, those with a college degree or greater understood the DA and, possibly as a result, lowered their screening intentions. Future studies need to examine how to better support informed decision making around mammography screening in older women with lower educational attainment. The authors examined data from a previous study to learn the effects of a mammography decision aid (DA) for women aged 75years and older according to their level of education. Overall, women found the DA helpful, but women with lower educational attainment found it harder to understand the benefits and harms of mammography screening and were less likely to lower their screening intentions than women with a college degree. The findings suggest that women aged 75years and older who have lower educational attainment may need an even lower literacy DA and/or more support from health care professionals.

Association between Breast Cancer Screening Intention and Behavior in the Context of Screening Cessation in Older Women.

Breast cancer is the most common life-threatening cancer in women and mammography screening is an important intervention that can reduce breast cancer-related mortality and morbidity.1 Not surprisingly, numerous studies have aimed at promoting the adoption of breast cancer screening.2–7 Based on the Theory of Planned Behavior, which posits that intention is the most important and proximal predictor of behavior,8 studies have found moderate association between breast cancer screening intention and receipt of screening,2,3 and a number of interventions have targeted screening intention as the outcome.4–7 All of these studies focused on increasing screening rates. More recently, there is growing recognition that among women aged 75 and older, the harms and burdens of routine mammography screening may outweigh the benefits.9–11 Therefore, the National Cancer Institute and others have called for interventions to reduce overuse and address screening cessation in older women.12 Screening cessation after decades of participation is likely different than the decision to initiate screening and it is not known how older women’s screening intentions relate to screening behavior in the context of de-implementing screening. Given that it can take years and significant resources to learn if an intervention leads to a reduction in overuse of mammography screening in older women, we aimed to examine among women aged 75 and older if lower intentions to be screened predicts lower screening rates in the context of screening cessation.

The Evaluation of a Modified Decision Aid for Older Women With Low Health Literacy

Given the lack of evidence recommending mammography for women >75 years, guidelines recommend that older women be informed of the uncertainty of benefits and of potential harms. The objective for this study was to evaluate the effect of a mammography decision aid (DA) designed for older women with low health literacy (LHL) on their decisional conflict and knowledge of mammography’s benefits and harms in a pretest-posttest trial. Women, 75-89 years were eligible for this study if they had not had a screening mammogram in six months, a history of breast cancer/dementia and had LHL (defined as reporting difficulty completing medical forms on one’s own or obtaining < college education). Forty-four women participated. their mean age was 78, 74% had a high school degree or less, and 53% were non-Hispanic White. Overall, women reported that the DA helped them prepare to talk with their clinician quite a bit (Mean =3.6/5.0 on preparation for decision making scale) and 97% found the DA helpful. Using McNemar’s test, decisional conflict did not change and knowledge on a 10 item true/false test on mammography screening did not change; however, after receiving the DA women were correctly less likely to think that having a mammogram would prevent cancer. With the shift toward shared decision-making for women > 75 years, there is a need to engage women of all literacy levels to make these decisions and we have developed a DA on mammography screening for older women with LHL that these women perceive to be helpful.

Decision-Making Regarding Mammography Screening for Older Women.

The population is aging, and breast cancer incidence increases with age, peaking between the ages of 75 and 79. However, it is not known whether mammography screening helps women aged 75 and older live longer because they have not been included in randomized controlled trials evaluating mammography screening. Guidelines recommend that older women with less than a 10-year life expectancy not be screened because it takes approximately 10 years before a screen-detected breast cancer may affect an older woman's survival. Guidelines recommend that clinicians discuss the benefits and risks of screening with women aged 75 and older with a life expectancy of 10 years or longer to help them elicit their values and preferences. It is estimated that two of 1,000 women who continue to be screened every other year from age 70 to 79 may avoid breast cancer death, but 12% to 27% of these women will experience a false-positive test, and 10% to 20% of women who experience a false-positive test will undergo a breast biopsy. In addition, approximately 30% of screen-detected cancers would not otherwise have shown up in an older woman's lifetime, yet nearly all older women undergo treatment for these breast cancers, and the risks of treatment increase with age. To inform decision-making, tools are available to estimate life expectancy and to educate older women about the benefits and harms of mammography screening. Guides are also available to help clinicians discuss stopping screening with older women with less than a 10-year life expectancy. Ideally, screening decisions would consider an older woman's life expectancy, breast cancer risk, and her values and preferences.

Incidence of breast cancer and estimates of overdiagnosis after the initiation of a population-based mammography screening program

There has been growing interest in the overdiagnosis of breast cancer as a result of mammography screening. We report incidence rates in British Columbia before and after the initiation of population screening and provide estimates of overdiagnosis. We obtained the numbers of breast cancer diagnoses from the BC Cancer Registry and screening histories from the Screening Mammography Program of BC for women aged 30-89 years between 1970 and 2009. We calculated age-specific rates of invasive breast cancer and ductal carcinoma in situ. We compared these rates by age, calendar period and screening participation. We obtained 2 estimates of overdiagnosis from cumulative cancer rates among women between the ages of 40 and 89 years: the first estimate compared participants with nonparticipants; the second estimate compared observed and predicted population rates. We calculated participation-based estimates of overdiagnosis to be 5.4% for invasive disease alone and 17.3% when ductal carcinoma in situ was included. The corresponding population-based estimates were -0.7% and 6.7%. Participants had higher rates of invasive cancer and ductal carcinoma in situ than nonparticipants but lower rates after screening stopped. Population incidence rates for invasive cancer increased after 1980; by 2009, they had returned to levels similar to those of the 1970s among women under 60 years of age but remained elevated among women 60-79 years old. Rates of ductal carcinoma in situ increased in all age groups. The extent of overdiagnosis of invasive cancer in our study population was modest and primarily occurred among women over the age of 60 years. However, overdiagnosis of ductal carcinoma in situ was elevated for all age groups. The estimation of overdiagnosis from observational data is complex and subject to many influences. The use of mammography screening in older women has an increased risk of overdiagnosis, which should be considered in screening decisions.

Primary Care Providers' Concerns and Recommendations Regarding Mammography Screening for Older Women

Morbidity and mortality from breast cancer increase with age; however, mammography screening does not reflect this increased risk for older women. Lack of provider recommendation is a major barrier to screening. This is a descriptive study of mammography screening recommendations of community primary care providers in North Carolina (N = 96) participating in a National Cancer Institute funded research project. Providers self-reported screening recommendations for typical patients of different ages and issues and concerns that might influence the decision. Chart reviews compared actual practices with policies stated. Of the providers, 51% recommended biannual, 45% annual for women ages 50 through 74; 4% recommended biannual, 80% annual, 5% did not recommend screening, and 10% had no general policy for women over 75. Cost, inconsistent guidelines, comorbidity, functional status, value of mammography, and patient resistance influenced screening recommendations. Chart review showed even lower rates of recommendation than self-reported figures. Although the use of screening mammography has increased over the past decade, older women are one of the last subgroups to derive benefit from this screening test. Our survey revealed lower rates for mammography referral in older women. The primary care provider appears to be essential to increasing participation for these older women in breast cancer screening.

Challenges in Mammography Screening for Older Women

Challenges in Mammography Screening for Older Women