Reducing Barriers and Strategies to Improve Appropriate Screening Mammogram Attendance in Women 75 Years and Older

Although breast cancer death rates have persistently declined over the last 3 decades, older women have not experienced the same degree in mortality reduction as younger women despite having more favorable breast cancer phenotypes. This occurrence can be partially attributed to less robust mammographic screening in older women, the propensity to undertreat with advancing age, and the presence of underlying comorbidities. With recent revisions to breast cancer screening guidelines, there has been a constructive shift toward more agreement in the need for routine mammographic screening to commence at age 40. Unfortunately, this shift in agreement has not occurred for cutoff guidelines, wherein the recommendations are blurred and open to interpretation. With increasing life expectancy and an aging population who is healthier now than any other time in history, it is important to revisit mammographic screening with advanced age and understand why older women who should undergo screening are not being screened as well as offer suggestions on how to improve screening mammogram attendance in this population.

Women 75 Years Old or Older: To Screen or Not to Screen?

Breast cancer is the most common cancer in women, with the incidence rising substantially with age. Older women are a vulnerable population at increased risk of developing and dying from breast cancer. However, women aged 75 years and older were excluded from all randomized controlled screening trials, so the best available data regarding screening benefits and risks in this age group are from observational studies and modeling predictions. Benefits of screening in older women are the same as those in younger women: early detection of smaller lower-stage cancers, resulting in less invasive treatment and lower morbidity and mortality. Mammography performs significantly better in older women with higher sensitivity, specificity, cancer detection rate, and positive predictive values, accompanied by lower recall rates and false positives. The overdiagnosis rate is low, with benefits outweighing risks until age 90 years. Although there are conflicting national and international guidelines about whether to continue screening mammography in women beyond age 74 years, clinicians can use shared decision making to help women make decisions about screening and fully engage them in the screening process. For women aged 75 years and older in good health, continuing annual screening mammography will save the most lives. An informed discussion of the benefits and risks of screening mammography in older women needs to include each woman's individual values, overall health status, and comorbidities. This article will review the benefits, risks, and controversies surrounding screening mammography in women 75 years old and older and compare the current recommendations for screening this population from national and international professional organizations. ^©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

All-Cause Mortality Risk Prediction in Older Adults with Cancer: Practical Approaches and Limitations

PURPOSE OF REVIEW

The prediction of all-cause mortality is an important component of shared decision-making across the cancer care continuum, particularly in older adults with limited life expectancy, for whom there is an increased risk of over-diagnosis and treatment.

RECENT FINDINGS

Currently, several international societies recommend the use of all-cause mortality risk prediction tools when making decisions regarding screening and treatment in geriatric oncology. Here, we review some practical aspects of the utilization of those tools and dissect the characteristics of those most employed in geriatric oncology, highlighting both their advantages and their limitations.

Evaluation of a mammography decision aid for women 75 and older at risk for lower health literacy in a pretest-posttest trial

OBJECTIVE

The evaluation of the effect of a mammography decision aid (DA) designed for older women at risk for lower health literacy (LHL) on their knowledge of mammography's benefits and harms and decisional conflict.

METHODS

Using a pretest-posttest design, women > 75 years at risk for LHL reviewing a mammography DA before and after their [B] primary care provider visit. Women were recruited from an academic medical center and community health centers and clinics.

RESULTS

Of 147 eligible women approached, 43 participated. Receipt of the DA significantly affected knowledge of mammography's benefits and harms [B] (pre-test (M = 3.75, SD = 1.05) to post-test (M = 4.42, SD = 1.19), p = .03). Receipt of the DA did not significantly affect decisional conflict (pre-test (M = 3.10, SD = .97) to post-test (M = 3.23, SD = 1.02), p = .71, higher scores = lower decisional conflict). The majority of the women (97%) indicated that the DA was helpful.

CONCLUSIONS

Women found a mammography screening DA helpful and its use was associated with these women having increased knowledge of mammography's benefits and harms.

PRACTICE IMPLICATIONS

With the shift toward shared decision-making for women > 75 years, there is a need to engage women of all literacy levels to participate in these decisions and have tools such as the one tested in this study.

Screening Tools Used by Clinical Pharmacists to Identify Elderly Patients at Risk of Drug-Related Problems on Hospital Admission: A Systematic Review

None of the models met the four key stages required to create a quality risk prediction model. Further research is needed to either refine the tools developed to date or develop new ones that have good performance and have been externally validated before considering the potential impact and implementation of such tools.

Utilization of screening mammography in older women according to comorbidity and age: protocol for a systematic review

BACKGROUND

Approximately half of new invasive breast cancer cases diagnosed each year in the United States occur among women aged 65 years and older. The increasing life expectancy coupled with the attendant rise in breast cancer incidence and elimination of out-of-pocket expenses for screening mammography as a result of the Affordable Care Act could lead to higher utilization rates of screening mammography. Although research indicates that life expectancy should be a strong consideration when making screening decisions among older women, the extent to which screening mammography utilization is tailored to comorbidity and life expectancy is not well established.

METHODS/DESIGN

To identify relevant studies, a systematic search of the literature will be conducted using PubMed and EMBASE between January 1, 1991, and March 1, 2016. Additional studies will be found through citation review or by contacting experts in the field. The inclusion criteria will be any study design comprised of women aged 65 and older, assessing women's comorbidity, functional impairments, and/or health status, and reporting outcome measures that addressed mammography utilization within the last 1-5 years. For each study, two authors will independently abstract data regarding study eligibility and outcomes to determine relevance. Quantitative results will be extracted from text and tables, choosing preferably those adjusted for important confounders.

DISCUSSION

The review will provide evidence on the impact of comorbidity, functional limitations, and health status on screening mammography utilization in older women and inform decision aids in this area.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016032661.

Performance of the Breast Cancer Risk Assessment Tool Among Women Age 75 Years and Older

BACKGROUND

The Breast Cancer Risk Assessment Tool (BCRAT, "Gail model") is commonly used for breast cancer prediction; however, it has not been validated for women age 75 years and older.

METHODS

We used Nurses' Health Study (NHS) data beginning in 2004 and Women's Health Initiative (WHI) data beginning in 2005 to compare BCRAT's performance among women age 75 years and older with that in women age 55 to 74 years in predicting five-year breast cancer incidence. BCRAT risk factors include: age, race/ethnicity, age at menarche, age at first birth, family history, history of benign breast biopsy, and atypia. We examined BCRAT's calibration by age by comparing expected/observed (E/O) ratios of breast cancer incidence. We examined discrimination by computing c-statistics for the model by age. All statistical tests were two-sided.

RESULTS

Seventy-three thousand seventy-two NHS and 97 081 WHI women participated. NHS participants were more likely to be non-Hispanic white (96.2% vs 84.7% in WHI, P < .001) and were less likely to develop breast cancer (1.8% vs 2.0%, P = .02). E/O ratios by age in NHS were 1.16 (95% confidence interval [CI] = 1.09 to 1.23, age 57-74 years) and 1.31 (95% CI = 1.18 to 1.45, age ≥ 75 years, P = .02), and in WHI 1.03 (95% CI = 0.97 to 1.09, age 55-74 years) and 1.10 (95% CI = 1.00 to 1.21, age ≥ 75 years, P = .21). E/O ratio 95% confidence intervals crossed one among women age 75 years and older when samples were limited to women who underwent mammography and were without significant illness. C-statistics ranged between 0.56 and 0.58 in both cohorts regardless of age.

CONCLUSIONS

BCRAT accurately predicted breast cancer for women age 75 years and older who underwent mammography and were without significant illness but had modest discrimination. Models that consider individual competing risks of non-breast cancer death may improve breast cancer risk prediction for older women.

Predictive Mortality Index for Community-Dwelling Elderly Koreans

There are very few predictive indexes for long-term mortality among community-dwelling elderly Asian individuals, despite its importance, given the rapid and continuous increase in this population. We aimed to develop 10-year predictive mortality indexes for community-dwelling elderly Korean men and women based on routinely collected clinical data.We used data from 2244 elderly individuals (older than 60 years of age) from the southwest Seoul Study, a prospective cohort study, for the development of a prognostic index. An independent longitudinal cohort of 679 elderly participants was selected from the Korean Genome Epidemiology Study in Ansan City for validation.During a 10-year follow-up, 393 participants (17.5%) from the development cohort died. Nine risk factors were identified and weighed in the Cox proportional regression model to create a point scoring system: age, male sex, smoking, diabetes, systolic blood pressure, triglyceride, total cholesterol, white blood cell count, and hemoglobin. In the development cohort, the 10-year mortality risk was 6.6%, 14.8%, 18.2%, and 38.4% among subjects with 1 to 4, 5 to 7, 8 to 9, and ≥10 points, respectively. In the validation cohort, the 10-year mortality risk was 5.2%, 12.0%, 16.0%, and 16.0% according to these categories. The C-statistic for the point system was 0.73 and 0.67 in the development and validation cohorts, respectively.The present study provides valuable information for prognosis among elderly Koreans and may guide individualized approaches for appropriate care in a rapidly aging society.

Cancer screening in the older adult: issues and concerns

Making individual recommendations for cancer screening in older adult patients may be difficult and time consuming, because of the need to incorporate complex issues of life expectancy, health status, risks and benefits, and individual values and wishes. In this article, current recommendations and related risks and benefits are summarized. Specific issues and concerns are addressed, with suggestions for strategies to assist older adults in making screening decisions.

The challenges of individualized care for older patients with localized breast cancer

Individualized care is achieved when the appropriate screening and/or evaluative tests are used, the treatment plan is driven by evidence-based data and the patient's functional ability, physical and mental health, preference and social situation are incorporated into treatment decisions. Breast cancer is a disease of aging; yet, the management of breast cancer in older women in most cases lacks evidence from prospective randomized clinical trials (i.e., level 1 evidence) to support treatment recommendations. Older women are underrepresented in therapeutic clinical studies, even though studies show that selected fit older women enrolled on clinical trials derive similar benefits as younger women. Very few studies have focused on the distribution and biological behavior of different molecular subtypes of breast cancer in older women making it difficult to conclude whether old age adds extra biological complexity. A comprehensive geriatric assessment that includes a multidimensional process designed to assess functional ability, physical health, cognitive and mental health, social issues and environmental situation of elderly person should be an integral part of individualized care for older patients with breast cancer. However, incorporation of this tool into standard oncology practice is very slow despite the expected steep increase in older individuals with cancer projected over the next 25 years. All of the factors mentioned above hinder progress in delivering individualized care to older patients with breast cancer. This article provides an overview on progress and challenges of individualized and personalized health care in older women with breast cancer.

Common curbsides and conundrums in geriatric medicine

Within the next 15 years, the population of adults 65 years and older in the United States will double to approximately 70 million. Physicians must be well prepared to care for this rapidly growing population. Senior adults comprise a large proportion of most primary care practices in the United States, and the unique needs of this population cannot be overstated. Although traditional preventive screening modalities and disease-specific care models are of great utility, these processes may not be appropriate or consistent with the health goals of many older patients with multiple chronic conditions and reduced functional capacity. This Concise Review highlights commonly encountered clinical scenarios important to the care of these older patients. The topics include diagnosis and management of mild cognitive impairment, assessment of the cognitively impaired driver, cancer screening in the older patient, and sarcopenia.

Breast cancer screening and the changing population pyramid of Japan

BACKGROUND

Breast cancer has been the most prevalent cancer in Japan since the 1990s. The mortality from breast cancer is increasing in Japan, whereas in other industrialized countries it has been decreasing since 1990. On the other hand, Japan faces unparalleled growth in its aging population. The aim of this study was to report the mammography screening among Japanese women and the related upcoming changes in the population pyramid of Japan.

DATA SOURCES AND METHODS

The reference data for our study were obtained from the Center for Cancer Control and Information Services, Japan Ministry of Internal Affairs and Communications, Ministry of Health, Labour and Welfare, the Japanese Cancer Society, and the National Institute of Population and Social Security. The survey data were obtained from breast cancer and mammography screenings in the Tokyo Prefecture in 2008. The following parameters were analyzed: annual breast cancer incidence, current screening rates, average life-span, and predicted demographic statistics.

RESULTS

Our results showed that breast cancer incidence and mortality have been increasing annually in Japan. The average age of breast cancer patients increased to 58.40 years in 2010. The incidence of breast cancer in women aged 65 years and older increased from 25.3 to 32.9 % in the last 10 years and is expected to continue to increase in the future. The check-up rate was 16.0-20.0 % for women aged 65-74 years and 43.0-46.0 % for women aged 40-54 years. According to our questionnaire survey, concerns about breast cancer and mammography screening were high in the young and low in the elderly women. The Japanese population aged 65 years and older was 30,740 (24.1 %) in 2012 and is estimated to increase by 40 % over the next 20 years despite Japan's declining population size.

CONCLUSION

Breast cancer incidence has increased in Japan, even among patients aged 65 years and older. Breast cancer has become increasingly prevalent in older Japanese women. As the population pyramid of Japan changes, women aged 65 years and older, who think that there is no longer need to receive mammography screening and are not educated regarding self-examinations, should be encouraged to receive regular check-ups for breast cancer.

Developing and testing a decision aid for use by providers in making recommendations: about mammography screening in older women

Breast cancer incidence increases with age, but many older women do not receive appropriate mammography screening. A tool to support provider decision making holds potential to help providers and patients reach the best-informed decisions possible. We developed and tested a decision aid (DA) for healthcare providers to use in mammography screening recommendations in older women. Literature review, expert opinion, focus groups, and pilot testing of the DA were conducted in a university ambulatory geriatrics practice. Provider evaluations of the DA after piloting were collected and analyzed. Geriatricians reported important factors in decision making included patient life-expectancy, preferences, cognitive function, and individualization. Geriatricians reported the DA would have helped them make recommendations for mammography screening in 66% of pilot cases. It was less helpful when there was more certainty regarding decision making.

"Knowing is better": preferences of diverse older adults for discussing prognosis

BACKGROUND

Prognosis is critical in individualizing care for older adults with late life disability. Evidence suggests that preferences for prognostic information may be culturally determined. Yet little is known about the preferences of diverse elders for discussing prognosis.

OBJECTIVE

To determine the preferences for discussing prognosis of a diverse sample of older adults with late-life disability.

DESIGN & PARTICIPANTS

We interviewed 60 older adults with mean age 78 and mean 2.5 Activities of Daily Living dependencies. Participants were recruited from San Francisco's On Lok program, the first Program of All-inclusive Care for the Elderly (PACE). Participants were interviewed in English, Spanish, and Cantonese, and responded to scenarios in which their doctors estimated they had 5 years and 1 year left to live. Open-ended questions explored the reasons for their responses. Results were analyzed qualitatively using grounded theory.

KEY RESULTS

Sixty-five percent of participants wanted to discuss the prognosis if their doctor estimated they had <5 years to live and 75% if the estimate was <1 year. Three themes were prominent among patients who wanted to discuss prognosis: to prepare, to make the most of the life they had left, and to make medical or health-related decisions. Those who preferred not to discuss prognosis described emotional difficulty, the uncertainty of prognosis, or that it would not be useful. Nearly all participants said that doctors should not make assumptions based on race or ethnicity, though differences between ethnic groups emerged.

CONCLUSIONS

Most patients in this diverse sample of disabled elders were interested in discussing prognosis, while a substantial minority was not. Among those participants who preferred to discuss prognosis, many said that prognostic information would be important as they made difficult medical and personal decisions in late-life. Clinicians should inquire about preferences for discussing prognosis before sharing prognostic estimates.

Breast cancer risk assessment in women aged 70 and older

Although the benefit of screening mammography for women over 69 has not been established, it is generally agreed that screening recommendations for older women should be individualized based on health status and breast cancer risk. However, statistical models to assess breast cancer risk have not been previously evaluated in this age group. In this study, the original Gail model and three more recent models that include mammographic breast density as a risk factor were applied to a cohort of 19,779 Vermont women aged 70 and older. Women were followed for an average of 7.1 years and 821 developed breast cancer. The predictive accuracy of each risk model was measured by its c-statistic and associations between individual risk factors and breast cancer risk were assessed by Cox regression. C-statistics were 0.54 (95% CI = 0.52-0.56) for the Gail model, 0.54 (95% CI = 0.51-0.56) for the Tice modification of the Gail model, 0.55 (95% CI = 0.53-0.58) for a model developed by Barlow and 0.55 (95% CI = 0.53-0.58) for a Vermont model. These results indicate that the models are not useful for assessing risk in women aged 70 and older. Several risk factors in the models were not significantly associated with outcome in the cohort, while others were significantly related to outcome but had smaller relative risks than estimated by the models. Age-related attenuation of the effects of some risk factors makes the prediction of breast cancer in older women particularly difficult.

Improving health for elderly people: an international health promotion and disease prevention agenda

Across the world, there are substantial but missed opportunities for promoting health of older persons and extending the healthy life span. Current approaches to health care rely on late detection and treatment of disease, and some of the most expensive systems of care have population health outcomes that are poor to mediocre. A majority of deaths and disability result from progression of preventable chronic diseases for which human behaviors are major contributing factors. An organized and aggressive agenda in health promotion and disease prevention emerges as an important part of the strategy to both promote health and control costs. After reviewing data on determinants of health and contribution of behavioral factors to morbidity and mortality, this paper presents the evidence for efficacy and effectiveness of specific behavioral and clinical interventions to reduce risk for many of the problems accounting for death and disability among elders. We address tobacco use, lack of exercise, inadequate nutrition, hypertension, delirium, obesity, falls, cancer screening, poor oral health, osteoporosis, immunizations and medication safety. Strategies for implementation of effective interventions present an international challenge.

In newly diagnosed breast cancer, screening MRI of the contralateral breast detects mammographically occult cancer, even in elderly women: the mayo clinic in Florida experience

The role of magnetic resonance imaging (MRI) in patients with newly diagnosed breast cancer is somewhat controversial. The purpose of this study was to evaluate the prevalence of synchronous, occult contralateral breast cancer detected by MRI but not by mammography or clinical breast examination in women with newly diagnosed breast cancer, including those aged 70 years or older at our institution. MRI results for women with newly diagnosed breast cancer who underwent bilateral breast MRI after negative mammography and clinical examination between February 2003 and November 2007 at Mayo Clinic in Florida were reviewed. The prevalence of pathologically confirmed contralateral carcinoma diagnosed solely by MRI was determined and analyzed in the context of age, family history, menopausal status, breast density, and primary-tumor characteristics. Logistic regression was used to explore the association between contralateral carcinoma and potential patient risk factors. A total of 425 women were evaluated, of whom 129 (30%) were aged 70 years or older. A contralateral biopsy was recommended and performed solely on the basis of MRI in 72 of the 425 women (17%). Sixteen of these 72 women (22%) had pathologically confirmed carcinoma, including seven in the older subgroup. The prevalence of clinically and mammographically occult contralateral carcinoma detected by MRI was 3.8% (16/425) overall and 5.4% (7/129) in the group of older women. When potential risk factors for contralateral breast cancer were evaluated, postmenopausal status was the only significant predictor of contralateral cancer detected by MRI (p = 0.016). We concluded that contralateral breast screening with MRI should be considered in postmenopausal women with newly diagnosed breast cancer, even those aged 70 years or older at diagnosis.

Weighing the benefits and burdens of mammography screening among women age 80 years or older

PURPOSE

To examine outcomes of mammography screening among women > or = 80 years to inform decision making.

PATIENTS AND METHODS

We conducted a cohort study of 2,011 women without a history of breast cancer who were age > or = 80 years between 1994 and 2004 and who received care at one academic primary care clinic or two community health centers in Boston, MA. Medical record data were abstracted on all screening and diagnostic mammograms, breast ultrasounds and biopsies performed, all breast cancers diagnosed through December 31, 2006, and on sociodemographics. Date and cause of death were confirmed using the National Death Index.

RESULTS

The majority of patients (78.6%) were non-Hispanic white and 51.4% (n = 1,034) had been screened with mammography since age 80 years. Among women who were screened, eight were diagnosed with ductal carcinoma in situ, 16 with early stage disease (1.5%), two with late stage disease, and one died as a result of breast cancer. Many (110; 11%) experienced a false-positive screening mammogram that led to 19 benign breast biopsies, eight refused work-up, and three experienced a false-negative screening mammogram; 97 were screened within 2 years of their death from other causes. There were no significant differences in the rate, stage, recurrence rate, or deaths due to breast cancer between women who were screened and those who were not screened.

CONCLUSION

The majority of women > or = 80 years are screened with mammography yet few benefit. Meanwhile, 12.5% experience a burden from screening. The data from this study can be used to inform elderly women's decision making and potentially lead to more rational use of screening.

Development and validation of a multidimensional prognostic index for one-year mortality from comprehensive geriatric assessment in hospitalized older patients

Our objective was to construct and validate a Multidimensional Prognostic Index (MPI) for 1-year mortality from a Comprehensive Geriatric Assessment (CGA) routinely carried out in elderly patients in a geriatric acute ward. The CGA included clinical, cognitive, functional, nutritional, and social parameters and was carried out using six standardized scales and information on medications and social support network, for a total of 63 items in eight domains. A MPI was developed from CGA data by aggregating the total scores of the eight domains and expressing it as a score from 0 to 1. Three grades of MPI were identified: low risk, 0.0-0.33; moderate risk, 0.34-0.66; and severe risk, 0.67-1.0. Using the proportional hazard models, we studied the predictive value of the MPI for all causes of mortality over a 12-month follow-up period. MPI was then validated in a different cohort of consecutively hospitalized patients. The development cohort included 838 and the validation cohort 857 elderly hospitalized patients. Of the patients in the two cohorts, 53.3 and 54.9% were classified in the low-risk group, respectively (MPI mean value, 0.18 +/- 0.09 and 0.18 +/- 0.09); 31.2 and 30.6% in the moderate-risk group (0.48 +/- 0.09 and 0.49 +/- 0.09); 15.4 and 14.2% in the severe-risk group (0.77 +/- 0.08 and 0.75 +/- 0.07). In both cohorts, higher MPI scores were significantly associated with older age (p = 0.0001), female sex (p = 0.0001), lower educational level (p = 0.0001), and higher mortality (p = 0.0001). In both cohorts, a close agreement was found between the estimated mortality and the observed mortality after both 6 months and 1 year of follow-up. The discrimination of the MPI was also good, with a ROC area of 0.751 (95%CI, 0.70-0.80) at 6 months and 0.751 (95%CI, 0.71-0.80) at 1 year of follow-up. We conclude that this MPI, calculated from information collected in a standardized CGA, accurately stratifies hospitalized elderly patients into groups at varying risk of mortality.

Mammography before diagnosis among women age 80 years and older with breast cancer

PURPOSE

Screening mammography guidelines for patients age 80 years and older are variable. We determined the effect of mammography use on stage at breast cancer diagnosis and survival among women of this age range.

PATIENTS AND METHODS

We used the linked Surveillance, Epidemiology, and End Results-Medicare database to evaluate 12,358 women >or= 80 years of age diagnosed with breast cancer between 1996 and 2002. Patients were grouped according to number of mammograms during the 60 months before diagnosis: nonusers (0 mammograms), irregular users (one to two mammograms), and regular users (three or more mammograms). Effects of mammography on disease stage (I to IIa v IIb to IV) and survival were determined by logistic regression and Cox proportional hazards analyses.

RESULTS

Percentages of women with nonuse, irregular use, and regular use of mammography during the 5 years preceding diagnosis were 49%, 29%, and 22%, respectively. On multivariate analysis, patients were 0.37 times less likely to present with late-stage cancer for each mammogram obtained (odds ratio, 0.63; 95% CI, 0.63 to 0.67). Breast cancer-specific 5-year survival among nonusers was 82%, that among irregular users was 88%, and that among regular users was 94%. However, survival from causes other than breast cancer was also associated with mammography use, suggesting a bias for healthier patients to undergo mammography.

CONCLUSION

Regular mammography among women >or= 80 years of age was associated with earlier disease stage, although improved survival remains difficult to demonstrate. Health care providers should consider discussing the potential benefits of screening mammography with their older patients, particularly for those without significant comorbidity.

Factors influencing elderly women's mammography screening decisions: implications for counseling

Background

Although guidelines recommend that clinicians consider life expectancy before screening older women for breast cancer, many older women with limited life expectancies are screened. We aimed to identify factors important to mammography screening decisions among women aged 80 and older compared to women aged 65–79.

Methods

Telephone surveys of 107 women aged 80+ and 93 women aged 65–79 randomly selected from one academic primary care practice who were able to communicate in English (60% response rate). The survey addressed the following factors in regards to older women's mammography screening decisions: perceived importance of a history of breast disease, family history of breast cancer, doctor's recommendations, habit, reassurance, previous experience, mailed reminder cards, family/friend's recommendations or experience with breast cancer, age, health, and media. The survey also assessed older women's preferred role in decision making around mammography screening.

Results

Of the 200 women, 65.5% were non-Hispanic white and 82.8% were in good to excellent health. Most (81.3%) had undergone mammography in the past 2 years. Regardless of age, older women ranked doctor's recommendations as the most important factor influencing their decision to get screened. Habit and reassurance were the next two highly ranked factors influencing older women to get screened. Among women who did not get screened, women aged 80 and older ranked age and doctor's counseling as the most influential factors and women aged 65–79 ranked a previous negative experience with mammography as the most important factor. There were no significant differences in preferred role in decision-making around mammography screening by age, however, most women in both age groups preferred to make the final decision on their own (46.6% of women aged 80+ and 50.5% of women aged 65–79).

Conclusion

While a doctor's recommendation is the most important factor influencing elderly women's mammography screening decisions, habit and reassurance also strongly influence decision-making. Interventions aimed at improving clinician counseling about mammography, which include discussions around habit and reassurance, may result in better decision-making.

The influence of aging on the early detection, diagnosis, and treatment of breast cancer

Patterns of care for women with breast cancer vary substantially with patient age. Older patients with breast cancer frequently receive less than standard management, resulting in poorer outcome. At diagnosis, the health status of older women with breast cancer affects survival and treatment decisions. Age-related comorbidity may limit diagnostic tests, narrow treatment options, and significantly increase mortality not related to breast cancer. Yet, for healthy older women with early-stage breast cancer, stage-adjusted survival is similar to that of younger women. Calendar age is not sufficient to encompass the heterogeneity in health status of the elderly. Instead, management of older women with breast cancer should be based on anticipated survival, functional status, and the goals of the patient for treatment. In this review, we evaluate pertinent data and provide guidance for the management of older women with breast cancer.

Routine screening mammography in women older than 74 years: a review of the available data

OBJECTIVE

The efficacy of population screening mammography for the age group of 50-74 years has been demonstrated. However, only limited data are available regarding women aged 75 and over, and recommendations for breast cancer screening in this age group vary in different countries. The aim of the current study is to review the evidence of the efficacy of breast cancer screening in women over the age of 74 years.

METHODS

Studies published in English were retrieved by systematically searching MEDLINE (for papers published until August 2006), and by manually examining the references of the original articles and reviews retrieved. All studies that dealt with screening mammography over age 74 years were included. The studies were reviewed according to their outcomes and study design, focusing on breast cancer mortality and stage of breast cancer at diagnosis.

RESULTS

Three studies focused on the relationship between breast cancer screening and mortality; in the 75-84 years age group, the risk of disease-specific mortality was approximately two-fold higher among women who did not perform screening mammography compared to women who did. Another four studies showed that women who underwent screening mammography had significantly smaller tumors and earlier disease stage at diagnosis.

CONCLUSIONS

Regular mammography screening in older women may be associated with an earlier-stage disease and lower breast cancer mortality. These data support the use of screening mammography above age 75 years based on individual evaluations, rather than setting an upper age limit for breast cancer screening.

Examining the theory of planned behavior and the construct of self-efficacy to predict mammography intention

This article examines the applicability of the Theory of Planned Behavior (TPB) with the addition of the self efficacy construct in the understanding of the motivation to obtain an initial screening mammogram among Cypriot women. The study sample consisted of 293 women aged 40 to 65 years, asymptomatic of breast cancer, and with no previous mammography experience. The study took place at the General Hospital of Nicosia in Cyprus. The results of the study provided support of the TPB with the addition of self-efficacy in an international setting. Self-efficacy was the strongest predictor of intention. Other predictors of intention included educational level, time of last clinical breast examination, and age. The study also provided some empirical support of the distinction between self-efficacy and perceived behavioral control. Researchers may want to include self-efficacy in addition to the TPB and other demographic characteristics in future applications to more fully explain behavioral outcomes.

Decision making and counseling around mammography screening for women aged 80 or older

BACKGROUND

Despite uncertain benefit, many women over age 80 (oldest-old) receive screening mammography.

OBJECTIVE

To explore decision-making and physician counseling of oldest-old women around mammography screening.

DESIGN

Qualitative research using in-depth semi-structured interviews.

PARTICIPANTS

Twenty-three women aged 80 or older who received care at a large academic primary care practice (13 had undergone mammography screening in the past 2 years) and 16 physicians at the same center.

APPROACH

We asked patients and physicians to describe factors influencing mammography screening decisions of oldest-old women. We asked physicians to describe their counseling about screening to the oldest-old.

RESULTS

Patients and/or physicians identified the importance of physician influence, patient preferences, system factors, and social influences on screening decisions. Although physicians felt that patient's health affected screening decisions, few patients felt that health mattered. Three types of elderly patients were identified: (1) women enthusiastic about screening mammography; (2) women opposed to screening mammography; and (3) women without a preference who followed their physician's recommendation. However, physician counseling about mammography screening to elderly women varies; some individualize discussions; others encourage screening; few discourage screening. Physicians report that discussions about stopping screening can be uncomfortable and time consuming. Physicians suggest that more data could facilitate these discussions.

CONCLUSIONS

Some oldest-old women have strong opinions about screening mammography while others are influenced by physicians. Discussions about stopping screening are challenging for physicians. More data about the benefits and risks of mammography screening for women aged 80 or older could inform patients and improve provider counseling to lead to more rational use of mammography.

What predicts a Cypriot woman's decision to obtain or not obtain a screening mammogram? Implications for the promotion of screening mammography in Cyprus

BACKGROUND

Breast cancer is an important public health issue in Cyprus. The purpose of the study was to assess: (a) the differences in motivational beliefs between women who decided to obtain a mammogram and women who did not; and (b) which beliefs predict the decision to get a mammogram.

METHODS

Data were collected through face-to-face interviews from 293 women (mean age = 52) at the outpatient clinics of the General Hospital of Nicosia. Variables of interests include demographics, other preventive behaviours, and cognitions. T-tests for independent samples and multiple logistic regression were the primary analytic techniques.

RESULTS

One hundred and eight women decided to obtain their first mammogram within the next 6 months. Deciders were more motivated to obtain a mammogram than non-deciders. Significant statistical differences were found regarding women's attitude, perceived social pressure, perceived control over environmental factors, and self-efficacy towards obtaining a mammogram. The self-efficacy beliefs as well as the physician recommendation were the most predictive factors in the decision to obtain a mammogram.

CONCLUSIONS

In the planning of successful educational campaigns promoting breast cancer screening in Cyprus, practitioners could focus on the following: (a) enhancing self-efficacy, (b) promoting a clinical environment conducive to mammography screening, and (c) encouraging physician recommendation.

Screening for colorectal, breast, and cervical cancer in the elderly: a review of the evidence

There is general consensus that screening can reduce mortality from colorectal, breast, and cervical cancer among persons in their 50s and 60s. However, few screening trials have included persons over age 70 years. Therefore, indirect evidence must be used to determine when results in younger persons should be extrapolated to older persons. In this review, we focus on cancer screening tests that are well accepted in younger persons (mammography, Papanicolaou smears, and colorectal cancer screening) and discuss the strength of inference concerning benefits and harms of screening older persons. Some aspects of aging favor screening (eg, increased absolute risk of dying of cancer) whereas other aspects do not (eg, decreased life expectancy). Age also affects the behavior of some cancers (eg, increases the proportion of slow-growing breast cancers) and affects the accuracy of some screening tests (eg, increases the accuracy of mammography; decreases the accuracy of sigmoidoscopy). These effects make the application of evidence in younger populations to older populations complex. However, given the heterogeneity of the elderly population, there is no evidence of one age at which potential benefits of screening suddenly cease or potential harms suddenly become substantial for everyone. Therefore, characteristics of individual patients that go beyond age should be the driving factors in screening decisions. For example, persons who have a life expectancy less than 5 years or persons who would decline treatment should generally not be screened. Decisions to either continue or discontinue screening in the elderly should be based on health status, the benefits and harms of the test, and preferences of the patient, rather than solely on the age of the patient.

Breast cancer treatment in older women

This article presents the author's current approaches to the management of breast cancer in older women, with emphasis on clinical and surgical treatment of the disease in this population. There are controversies surrounding the management of breast cancer in this population regarding adjuvant therapy, radiation therapy and surgical options. We endeavor to address these issues in the article.

Breast cancer screening in women aged 80 and older: results from a national survey

OBJECTIVES

To estimate the national rates of mammography screening in women aged 80 and older and examine the relationship between health status and screening within the previous 2 years.

DESIGN

Population-based survey.

SETTING

United States.

PARTICIPANTS

Eight hundred eighty-two women aged 80 and older who responded to the 2000 National Health Interview Survey, representing an estimated 3.83 million noninstitutionalized women nationally.

MEASUREMENTS

Screening mammography, disease burden, and functional status were assessed using a questionnaire.

RESULTS

Of the 882 women, 41.5% were aged 85 and older; 19.6% had two or more significant diseases; and 12.1% were dependent in at least one activity of daily living (ADL). More than half (50.8%) had received a screening mammogram within the previous 2 years. Women with two or more significant diseases were less likely to have received screening than those without significant disease, but the difference was not statistically significant (43.9% vs 54.0%, P=.152). Women dependent in at least one ADL were less likely to receive screening mammography than women without functional impairment (37.2% vs 55.9%, P<.001). After adjustment, the likelihood of screening remained lower in women with two or more significant diseases (adjusted odds ratio (AOR)=0.63, 95% confidence interval (CI)=0.40-1.05) and in women with at least one ADL dependency (AOR=0.44, 95% CI=0.22-0.88). Of 294 women likely to have life expectancies of less than 5 years because of poor health, 39.4% received screening mammography.

CONCLUSION

More than half of women aged 80 and older in the United States receive screening mammograms. Nearly 40% of women very unlikely to benefit because of poor health received screening mammography.

Social context and outcomes for the ageing breast cancer patient: considerations for clinical practitioners

Current incidence, prevalence and survival rates determine that breast cancer is primarily a disease of older women. This integrative essay provides an extensive review of the literature on (i). the social and psychological factors that influence adjustment to breast cancer and survival from it, (ii). the social and health status of older women, and (iii). the medical treatment of older breast cancer patients. It is concluded that while psychological orientation to the disease, coping strategies and functional continuities of breast cancer patients are important for disease outcome, adjustment to and survival from breast cancer by older women may be compromised by the social context - with respect to marriage and intimate ties, social participation, socio-economic status, and mental and physical health. The paper concludes with the suggestion that clinical practitioners need to be aware of the both the resources of, and limitations facing the older breast cancer patient, and with the provision of specific recommendations about the clinical management of this population for nurses and other health professionals.

Screening and Cognitive Impairment: Ethics of Forgoing Mammography in Older Women

Mammographic screening for breast cancer in cognitively impaired women poses significant ethical questions. Many woman with dementia should not be screened because of the greater harm than benefits and the difficulty in obtaining informed consent. This article reviews the current controversy about mammography and then suggests a risk/benefit analysis for this vulnerable population. Autonomy, decision-making capacity, and the roles of surrogates and physicians are considered, as are ageism and the risk of undertreatment. The harm of overdiagnosis and subsequent overtreatment for women who are cognitively impaired, have comorbidity and a limited life span are outlined. In these cases, the burdens of mammography outweigh the benefits. For women with early cognitive impairment and longer life expectancies, the potential benefits may outweigh the harms. A decision-making process by the patient, proxy, and practitioner that takes account of foreseeable risks and benefits, patient capacity and preferences, and the effect of this screening intervention on quality of life is outlined.

5-Year mammography rates and associated factors for older women

BACKGROUND

Major national interventions occurred in the early and mid-1990s to increase mammography screening rates among older women. The current study examined mammography utilization by older women during this period. Relation between mammography utilization and demographic measures and health care-related factors also were examined.

METHODS

A cross-sectional design examined variations in mammography during the 5 years between 1993 to 1997 in a representative sample of 10,000 female Medicare beneficiaries in Michigan age >or= 65 years in 1993. Medicare and census data were used. Separate analyses were performed for having undergone any mammogram and, for the 5680 women who had undergone a mammogram, the number of mammograms. Relations were examined between mammography utilization and 15 demographic variables (e.g., age and African-American race) and health care-related variables (e.g., inpatient admissions and number of physicians involved in care).

RESULTS

In the 5 years 43% of older women had no evidence of having undergone a mammogram. Those with any mammogram averaged 2.8 mammograms. Meaningful independent predictors of both having undergone a mammogram and having more than one mammogram were more physicians involved in care, fewer inpatient admissions, and younger age. Having undergone a mammogram also was found to be associated with seeing an obstetrician/gynecologist.

CONCLUSIONS

Even with screening mammography as a covered benefit and after several national informational campaigns, the current study found that in 5 years, 60% of older women either had not undergone a mammogram or had undergone only 1. Intervention efforts should emphasize screening based on functional status, not age. This message should be targeted to physicians as well as to older women without claims for recent mammograms and who are likely to be in good health.

Personalized targeted mailing increases mammography among long-term noncompliant medicare beneficiaries: a randomized trial

OBJECTIVES

The study purpose was to increase mammography screening among older women by identifying female Medicare beneficiaries without a recent mammogram and assesses the cost-effectiveness of a personalized targeted mailing encouraging them to have a mammogram.

METHODS

A randomized paired controlled trial included 1229 pairs of women matched on zip code, race, and urban or rural county. Postintervention mammography claims were measured from November 1997 through December 1998. The subjects were female Medicare beneficiaries age > or = 70, living in Michigan for > or = 5 years, having no significant comorbidity likely to affect screening, and no mammogram for > or = 5 years. Intervention subjects received a personally addressed letter from the Medical Director of Michigan Medicare with materials emphasizing the individual's lack of use of the Medicare mammography screening benefit, reasons for screening, and how to be screened.

RESULTS

Women who received the mailing were 60% more likely to have a subsequent mammogram (OR 1.6, P <0.005), with diagnostic mammograms increasing more than screening mammograms (2.8% vs. 0.8%). The absolute increase was greatest for women age 70 to 79, 10.6% in the intervention group versus 6.5% for controls, odds ratio 1.7 (P <0.02). A statewide Medicare intervention in Michigan would cost of 108,000 US dollars to 238,000 US dollars, producing 3500 to 4300 additional mammograms at 31 US dollars to 55 US dollars per additional mammogram.

CONCLUSION

The intervention increased mammography among long-term noncompliant older women, particularly increasing diagnostic mammograms. This approach can be directly implemented in other states and nationally. It may also be useful for other preventive services.

Comparison of mammography use by older black and white women

OBJECTIVES

To identify differences in the prevalence of ever having had a mammogram and having had a recent mammogram between older black and white women and to compare factors associated with mammography use in older black and white women.

DESIGN

Data analysis and comparative study using nationally representative multistage sampling survey.

SETTING

Data were obtained from the 1998 National Health Interview Survey.

PARTICIPANTS

Four hundred forty-nine black and 3,328 white older women were examined.

MEASUREMENTS

The outcome variables included never having had a mammogram (yes/no) and not having had a mammogram in the past 3 years (yes/no).

RESULTS

The results of chi-square tests showed that older blacks were less likely to have ever had a mammogram than older whites, but there was no difference in having had a recent mammogram between older blacks and whites. After adjusting for other related factors, race was not related to mammography use in older blacks and whites. Health insurance was related to mammography use in older whites but not in older blacks. Family income was associated with never having had a mammogram in older whites but not in older blacks. Older blacks with less than 12 years of education were less likely to have had a mammogram (recently or ever) than older whites with less than 12 years of education.

CONCLUSIONS

Even though race, per se, was not associated with mammography use in older black and white women, many barriers to mammography use between older black and white women were different or did not have similar effects. To promote mammography use in older black and white women, barriers need to be specifically targeted for each group to enhance the effectiveness of breast cancer screening programs.

Health promotion practices of older adults: model testing

The purpose of this study was to describe the primary and secondary health promotion activities of a group of older adults living independently in a continuing care retirement community. Primary and secondary health promotion activities were described and compared among the young old (ages 65-80), the old (ages 81-85), and the old-old (ages 86-101). Model testing of the factors that influence participation in health-promoting activities was also completed. This descriptive study included 206 of 210 residents who participated in a single face-to-face interview. The majority of the participants were female (79%), white (99%), and cognitively intact. Those in the old-old age group were less likely than the old and young-old groups to have: (1) their stools checked for occult blood; (2) their skin checked for lesions; or (3) a recent mammogram, Pap test, or prostate exam. Model testing found that age, chronic illnesses, degree of physical and mental health, and cognitive status directly or indirectly influenced older adults' participation in primary and secondary health behaviors.

Screening mammography in older women: a pilot study of residents' decisions

BACKGROUND

Screening mammography is a commonly employed preventive modality. The employment of mammography in older women is not supported by evidence from clinical trials, largely because elderly women were excluded from such trials. Most guidelines do not recommend routine screening in older women. How residents reason in this gray zone has been subject to little empirical study.

PURPOSES

This study sought to answer two questions: How variable are residents' decision responses to mammography screening scenarios in older women where there is no clear evidence? What reasons do residents give to justify these decisions?

METHODS

Residents were asked to respond to four scenarios and give their screening recommendations and the reasons justifying their decisions.

RESULTS

There was considerable variability in resident responses to the four scenarios. Only in one scenario was there near unanimity on the preferred screening decision. Resident perceptions of quality of life, longevity and understanding of the guidelines were cited as justification for their decisions.

CONCLUSION

Clinical preceptors should be aware of how the variability of resident perceptions of such factors as quality of life and prognosis may influence decision-making.