Complex Multimorbidity and Breast Cancer Screening Among Midlife and Older Women: The Role of Perceived Need

Racial disparities in the screening mammography continuum within a heterogeneous health care system

BACKGROUND

Decreased mammography drives breast cancer disparities. Black women have lower rates of mammography completion than White women, and this contributes to disparities in outcomes. Points of disparity along the continuum for screening mammography remain underresearched.

METHODS

The authors compared mammography referrals for Black and White women aged 40-74 years at a heterogeneous academic medical center. Completion of steps of the screening mammography continuum was compared between Black and White women within two age cohorts: 40-49 and 50-74 years. Multivariable logistic regression was used to evaluate the association between race and mammogram completion.

RESULTS

Among 26,476 women, 3090 (12%) were Black, and 23,386 (88%) were White. Among Black women aged 50-74 years who were due for mammography, 40% had referrals, 39% were scheduled, and 21% completed mammography; the corresponding values for White women were 42%, 41%, and 27%, respectively. Similar differences in referral outcomes were noted for women aged 40-49 years, although Black women had lower rates of provider-initiated referrals (9% vs. 13%). Adjusted analyses for those aged 40-49 and 50-74 years demonstrated an association between Black race and lower rates of mammography completion (odds ratio [OR] for 40-49 years, 0.74; 95% CI, 0.57-0.95; p = .02; OR for 50-74 years, 0.85; 95% CI, 0.74-0.98; p = .02). In multivariable analyses, noncommercial insurance and higher comorbidity were associated with lower rates of mammography. Provider-initiated referral was positively correlated to mammogram completion.

CONCLUSIONS

Black race was associated with 15%-26% lower mammography completion (adjusted). Both groups experienced the highest attrition after scheduling mammograms, although attrition was more precipitous for Black women. These findings have implications for future interventions, including increasing provider-initiated referrals and decreasing barriers to attending scheduled mammograms.

Investigating the Influence of Periodontal Disease on the Association Between Complex Multimorbidity and Health: A Cross-Sectional Study

Aims and Objectives

The aim of this study was to evaluate whether periodontal disease (PD) moderates the association between complex multimorbidity (MM) and fair/poor general health in a US representative sample of older individuals.

Materials and Methods

This study identified 937 participants who were at least 60 years of age from the 2013-2014 National Health and Nutrition Examination Survey. A multivariable logistic regression model was used to estimate the association between complex MM (including chronic conditions, functional limitations, and geriatric syndromes) and self-reported fair/poor general health. Subsequently, we specified interactions between complex MM and PD to determine whether PD moderates the effect of complex MM on fair/poor general health.

Results

Nineteen percent of participants reported fair/poor general health. Complex MM was associated with 2.2 times greater odds of self-reported fair/poor health. However, PD was neither independently associated with fair/poor health nor an effect modifier for the association between complex MM and fair/poor general health. Age, white race, those with at least a high-school education level, a family income-to-poverty ratio of at least 2, former smoking status, and being married were significantly associated with fair/poor general health.

Conclusion

Complex MM, but not PD, was associated with greater odds to report fair/poor general health, and PD did not moderate the association between complex MM and fair/poor general health. People with complex MM are more likely to have worse general health; however, PD did not strengthen this association. Further studies are needed to evaluate whether treatment for PD for people vulnerable to the development of complex MM has a positive effect on their general health.

Women's experiences of age-related discontinuation from mammography screening: A qualitative interview study

INTRODUCTION

In Denmark, women are discontinued from mammography screening at age 69 due to decreased likelihood of benefits and increased likelihood of harm. The risk of harm increases with age and includes false positives, overdiagnosis and overtreatment. In a questionnaire survey, 24 women expressed unsolicited concerns about being discontinued from mammography screening due to age. This calls for further investigation of experiences related to discontinuation from screening.

METHODS

We invited the women, who had left comments on the questionnaire, to participate in in-depth interviews with the purpose to explore their reactions, preferences, and conceptions about mammography screening and discontinuation. The interviews lasted 1-4 h and were followed up with a telephone interview 2 weeks after the initial interview.

RESULTS

The women had high expectations of the benefits of mammography screening and felt that participation was a moral obligation. Following that, they perceived the screening discontinuation as a result of societal age discrimination and consequently felt devalued. Further, the women perceived the discontinuation as a health threat, felt more susceptible to late diagnosis and death, and therefore sought out new ways to control their risk of breast cancer.

CONCLUSION

Our findings indicate that the age-related discontinuation from mammography screening might be of more importance than previously assumed. This study raises important questions about screening ethics, and we encourage research to explore this in other settings.

PATIENT AND PUBLIC CONTRIBUTION

This study was conducted as a result of the women's unsolicited concerns about being discontinued from screening. This particular group contributed to the study with their own statements, interpretations and perspectives on the discontinuation of screening, and the initial analysis of data was discussed with the women during follow-up interviews.

Multi-Morbidity and Risk of Breast Cancer among Women in the UK Biobank Cohort

(Multi-)Morbidity shares common biological mechanisms or risk factors with breast cancer. This study aimed to investigate the association between the number of morbidities and patterns of morbidity and the risk of female breast cancer. Among 239,436 women (40-69 years) enrolled in the UK Biobank cohort who had no cancer history at baseline, we identified 35 self-reported chronic diseases at baseline. We assigned individuals into morbidity patterns using agglomerative hierarchical clustering analysis. We fitted Cox models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for breast cancer risk. In total, 58.4% of women had at least one morbidity, and the prevalence of multi-morbidity was 25.8%. During a median 7-year follow-up, there was no association between breast cancer risk (5326 cases) and either the number of morbidities or the identified clinically relevant morbidity patterns: no-predominant morbidity (reference), psychiatric morbidities (HR = 1.04, 95%CI 0.94-1.16), respiratory/immunological morbidities (HR = 0.98, 95%CI 0.90-1.07), cardiovascular/metabolic morbidities (HR = 0.93, 95%CI 0.81-1.06), and unspecific morbidities (HR = 0.98, 95%CI 0.89-1.07), overall. Among women younger than 50 years of age only, however, there was a significant association with psychiatric morbidity patterns compared to the no-predominant morbidity pattern (HR = 1.25, 95%CI 1.02-1.52). The other associations did not vary when stratifying by age at baseline and adherence to mammography recommendations. In conclusion, multi-morbidity was not a key factor to help identify patients at an increased risk of breast cancer.

Association of time intervals in cancer screenings and older participants' characteristics, in a nationally representative sample

INTRODUCTION

Health agencies and guidelines have proposed various recommendations regarding breast and prostate cancer screening intervals for older adults. However, there is limited data about factors that could impact older individuals' adherence to these guideline-based intervals. This study emphasized the differences in screening rates between men and women undergoing screening for breast (mammogram) and prostate (prostate-specific antigen [PSA] test) cancer. It also investigated the socio-demographic and emotional factors associated with screening time intervals.

MATERIALS AND METHODS

This cross-sectional design study used data from the National Social Life Health and Aging Project Wave 3 (NSHAP-W3, 2015). The outcome measures were screening time intervals (PSA test or mammogram). Individuals were asked, "About how long has it been since you last had a screening?" Response categories ranged from 1 = within the past year to 5 = never. Differences in screening time intervals were evaluated and displayed by age group (PSA vs. mammogram). The association between the outcome measures and participants' characteristics was evaluated via ordinal logistic regression.

RESULTS

There were 2320 participants included: 52% women and 48% men. They had a mean age of 66.9 years old, were mostly White (74%) and college graduates (68%). The average time interval between screenings was greater for PSA testing than mammography (mean [M] = 2.28 vs. M = 1.89, p < 0.001). The middle age groups (PSA: 60-79 and mammogram: 65-74), had significantly more frequent screenings compared to the youngest group (50-54). In contrast, older (80+) individuals did not display shorter screening time intervals compared to the youngest group. Furthermore, shorter time intervals between screenings were associated with higher household income (mammogram: odds ratio [OR] = 0.804; PSA: OR = 0.785, p < 0.05), African American descent (mammogram: OR = 0.458, p < 0.001), and higher frequency of physical activity (PSA: OR = 0.921, p = 0.030). Lastly, women who responded "yes" to skipping care due to lack of insurance reported longer periods between mammograms (OR = 1.784, p = 0.002).

DISCUSSION

Findings from this real-world US population representative database highlight the role of age, income, and insurance in the timing between screenings; participants aged between 60 and 79 years old, African American women, and physically active men are more likely to pursue earlier screening. These results emphasize the importance of socioeconomic and lifestyle factors when seeking to impact screening timing.

Comparing the association between multiple chronic conditions, multimorbidity, frailty, and survival among older patients with cancer

INTRODUCTION

The high prevalence of multiple chronic conditions (MCC), multimorbidity, and frailty may affect treatment and outcomes for older adults with cancer. The goal of this study was to use three conceptually distinct measures of morbidity to examine the association between these measures and mortality.

MATERIALS AND METHODS

Using Medicare claims data linked with the 2012-2016 Ohio Cancer Incidence Surveillance System we identified older adults with incident primary cancer sites of breast, colorectal, lung, or prostate (n = 29,140). We used claims data to identify their Elixhauser comorbidities, Multimorbidity-Weighted Index (MWI), and Claims Frailty Index (CFI) as measures of MCC, multimorbidity, and frailty, respectively. We used Cox proportional hazard models to examine the association between these measures and survival time since diagnosis.

RESULTS

Lung cancer patients had the highest levels of MCC, multimorbidity, and frailty. There was a positive association between all three measures and a greater hazard of death after adjusting for age, sex (colorectal and lung only), and stage. Breast cancer patients with 5+ comorbidities had an adjusted hazard ratio (aHR) of 1.63 (95% confidence interval [CI]: 1.38, 1.93), and those with mild frailty had an aHR of 3.38 (95% CI; 2.12, 5.41). The C statistics for breast cancer were 0.79, 0.78, and 0.79 for the MCC, MWI, and CFI respectively. Similarly, lung cancer patients who were moderately or severely frail had an aHR of 1.82 (95% CI: 1.53, 2.18) while prostate cancer patients had an aHR of 3.39 (95% CI: 2.12, 5.41) and colorectal cancer patients had an aHR of 4.51 (95% CI: 3.23, 6.29). Model performance was nearly identical across the MCC, multimorbidity, and frailty models within cancer type. The models performed best for prostate and breast cancer, and notably worse for lung cancer. The frailty models showed the greatest separation in unadjusted survival curves.

DISCUSSION

The MCC, multimorbidity, and frailty indices performed similarly well in predicting mortality among a large cohort of older cancer patients. However, there were notable differences by cancer type. This work highlights that although model performance is similar, frailty may serve as a clearer indicator in risk stratification of geriatric oncology patients than simple MCCs or multimorbidity.

Heath status, frailty, and multimorbidity in patients with emergency general surgery conditions

BACKGROUND

Although nearly 1 million older adults are admitted for emergency general surgery conditions yearly, the extent to which baseline health influences the development and treatment of emergency general surgery conditions is unknown. We evaluated baseline health and older patients with and without emergency general surgery conditions.

METHODS

We used the prospectively collected Medicare Current Beneficiary Survey with Medicare claims and 2 validated health frameworks: (1) Deficit Accumulation Frailty Score and (2) Complex Multimorbidity. Self-reported health and function items were used to derive pre-emergency general surgery conditions Deficit Accumulation Frailty Score and Complex Multimorbidity scores. Deficit Accumulation Frailty Score ranges from 0 (no frailty deficits) to 100 (all possible deficits present). Complex Multimorbidity is a 3-point categorical rank based on the presence of chronic conditions, functional limitations, and geriatric syndromes. Specific survey factors were also examined to determine association with development of emergency general surgery conditions or use of operative management.

RESULTS

Of 54,417 individuals, 1,960 had emergency general surgery conditions (median age 79 [interquartile range 73-84]). Patients with emergency general surgery conditions had significantly higher Deficit Accumulation Frailty Score (19 [interquartile range 11-31] vs 14 [8-24]) and were more likely to be in the most severe Complex Multimorbidity category (38% vs 29%). Emergency general surgery conditions patients had higher proportions of nearly every health category, with the most striking differences in functional limitations. Patients who were treated nonoperatively had the poorest overall baseline health.

CONCLUSION

Patients who developed emergency general surgery conditions had more severe health burden than patients who did not, particularly in functional status. Clinicians must better understand the interaction between baseline health vulnerability and emergency surgical disease to improve prognostication and ensure alignment of patient goals and treatment strategies.

Mammography use and breast cancer incidence among older U.S. women

PURPOSE

The death rate for female breast cancer increases progressively with age, but organizations differ in their mammography screening recommendations for older women. To understand current patterns of screening mammography use and breast cancer diagnoses among older women, we examined recent national data on mammography screening use and breast cancer incidence and stage at diagnosis among women aged ≥ 65 years.

METHODS

We examined breast cancer incidence using the 2016 United States Cancer Statistics dataset and analyzed screening mammography use among women aged ≥ 65 years using the 2018 National Health Interview Survey.

RESULTS

Women aged 70-74 years had the highest breast cancer incidence rate (458.3 cases per 100,000 women), and women aged ≥ 85 years had the lowest rate (295.2 per 100,000 women). The proportion of cancer diagnosed at distant stage or with unknown stage increased with age. Over half of women aged 80-84 years and 26.0% of women aged ≥ 85 years reported a screening mammogram within the last 2 years. Excellent/very good/good self-reported health status (p = .010) and no dependency in activities of daily living/instrumental activities of daily living (p < .001) were associated with recent mammography screening.

CONCLUSION

Breast cancer incidence rates and stage at diagnosis vary by age. Many women aged ≥ 75 years receive screening mammograms. The results of this study point to areas for further investigation to promote optimal mammography screening among older women.

Physical multimorbidity and cancer prevalence in the National Health and Nutrition Examination Survey

OBJECTIVES

As the US population ages, both cancer and multimorbidity become more common and pose challenges to the healthcare system. Limited studies have examined the association between multimorbidity and cancer prevalence in the US adult population. To help address this gap, we evaluated the associations between individual chronic conditions and all-site cancer, multimorbidity and all-site cancer, and multimorbidity and site-specific cancers.

STUDY DESIGN

This is a cross-sectional study.

METHODS

Data from 10,731 adults aged 20 years or older who participated in the 2013-2016 National Health and Nutrition Examination Survey were used in our study. Self-reported demographics, smoking status, sedentary behavior, body mass index, individual chronic conditions, multimorbidity status, cancer history, and cancer sites were assessed.

RESULTS

In our sample, the prevalence of having any type of cancer or multimorbidity was 9% (N = 861) and 38% (N = 4248), respectively. Respiratory conditions (multivariable-adjusted odds ratio [OR]: 1.3; 95% confidence interval [CI]: 1.1-1.6) and arthritis (multivariable-adjusted OR: 1.5; 95% CI: 1.2-1.8) were observed to be statistically significantly associated with having all-site cancer after adjusting for potential confounders. Having multimorbidity was also statistically significantly associated with having all-site cancer (multivariable-adjusted OR: 1.4; 95% CI: 1.2-1.7), cervical cancer (multivariable-adjusted OR: 2.6; 95% CI: 1.2-5.4), and bladder cancer (multivariable-adjusted OR: 2.8; 95% CI: 1.0-7.6).

CONCLUSIONS

Multimorbidity was associated with all-site cancer, cervical cancer, and bladder cancer. The present study provides new evidence of the potential relationships between multimorbidity and cancer. Future longitudinal studies are warranted to clarify the temporality and potential biological mechanisms of the associations between multimorbidity and cancer.

Cancer Risk Among Older Adults: Time for Cancer Prevention to Go Silver

Over two-thirds of all new cancers are diagnosed among adults aged ≥60 years. As the number of adults living to older ages continues to increase, so too will the number of new cancer cases. Can we do more as a society to reduce cancer risk and preserve health as adults enter their 60s, 70s, and beyond? Cancer development is a multi-step process involving a combination of factors. Each cancer risk factor represents a component of cancer causation, and opportunities to prevent cancer may exist at any time up to the final component, even years after the first. The characteristics of the community in which one lives often shape cancer risk-related behaviors and exposures over time, making communities an ideal setting for efforts to reduce cancer risk at a population level. A comprehensive approach to cancer prevention at older ages would lower exposures to known causes of cancer, promote healthy social and physical environments, expand the appropriate use of clinical preventive services, and engage older adults in these efforts. The collection of articles in this supplement provide innovative insights for exciting new directions in research and practice to expand cancer prevention efforts for older adults. This brief commentary sets the stage for the papers that follow.

Highlights From an Expert Meeting on Opportunities for Cancer Prevention Among Older Adults

This paper provides highlights from an expert meeting to explore opportunities to reduce cancer risk and promote health at older ages. Factors that increase cancer risk among older adults include exposure to carcinogens from multiple sources, chronic conditions such as obesity and diabetes, and unhealthy behaviors. Emerging research points to chronic social stressors - social isolation, loneliness, and financial hardship - as being linked to accelerated biological aging and increased cancer risk later in life. Older adults may disproportionately encounter these stressors as well as barriers to preventive health care services, accurate health information, and environments that promote health. Researchers can use existing cohort studies of older adults to deepen our understanding of the relative benefit of modifying specific behaviors and circumstances. The evidence points to the value of comprehensive, transdisciplinary approaches to promote health and reduce cancer risk across the entire lifespan, extending through older adulthood. Clinical encounters with older adults provide opportunities for psychosocial and behavioral screening and counseling. In the presence of multiple morbidities, preventive health services may offer greater health benefits than cancer-screening tests. Strategies that involve families and caregivers, promote positive attitudes about aging, and engage many different community sectors have the potential to prevent or delay the development of cancer at older ages.