Cervical cytology screening for sexually-active teenagers

Our aim was to determine the value of cervical cytology for sexually-active teenagers attending genitourinary medicine (GUM) clinics. This is a retrospective review of 57,093 women who had cervical cytology reported at the Royal Bolton Hospital (RBH) during the period 1 April 1994 to 31 March 1996. The results were subdivided into 2 age groups; < or = 19 years and > or = 20 years. Cervical cytology abnormalities within each age group were analysed and compared with the national figures for cervical cytology screening. The results were also subdivided according to their source of referral; general practitioners (GP), GUM and gynaecology. The data from each group were analysed in the same manner as before. The results of the cervical cytology screening from the RBH for major cytological abnormalities (moderate dyskaryosis and above), for the 2 age groups, were comparable and not significantly different (2.1% for each age group, P=0.909) and these figures were within the range of the national figures for cervical cytology screening (1.1%-3.4%). Subdivision of the data by source of referral demonstrated that the percentage of major abnormalities in smears performed at GUM clinics was higher than the national figure for all age groups (41/1000 for the younger age group and 37/1000 for the older age group, 12/1000 for the national figures). In conclusion, cervical cytology screening should be offered to sexually-active teenagers attending GUM clinics.     

Pap smear screening in women 65 and older

Pap smear screening in women 65 years of age and older is controversial. To assess the need to offer screening in this group, we examined Pap results of women 65 and older whose charts were reviewed as part of a cancer screening study in two San Francisco hospitals. Two hundred thirty women (41%) were 65 years of age or older (mean age, 73). Compared with younger women, they were less likely to have had a Pap smear during the past 3 years (61% versus 72%), less likely to have seen a gynecologist (24% versus 34%), and were more likely to have refused Pap screening (11% versus 5%). Of the 140 women who had Paps, five showed atypia (class II). None exhibited dysplasia or carcinoma in situ. Those with atypia were all nonwhite. One had had a hysterectomy; two had a history of previously abnormal Paps. Overall, women with a history of abnormal Paps were far more likely to be screened (91% versus 58%). Those who had had a hysterectomy were significantly less likely to be screened (51% versus 68%). These results showed a low rate of cervical dysplasia/carcinoma in older, low-income women. Although our sample was small, the low rate of abnormals may reflect the relatively high rate of prior screening in this population. Because older women are not likely to see gynecologists, primary care physicians should continue Pap screening in older women (including those with a history of hysterectomy) until a history of repeated, technically adequate, normal Pap smears is documented.     

The prevalence of abnormal cervical cytology in a sexually transmitted diseases clinic

Women seeking sexually transmitted disease (STD) services are at high risk of human papillomavirus infections. Cervical cytological screening with Papanicolau staining (Pap smear) is not consistently offered at public STD clinics. We reviewed Pap smear results on a series of 1000 female STD clinic attendees, abstracted demographics, risk behaviours and STD diagnosis from the clinical record and tested for associations with abnormal Pap smear. In all, 5.7% of the satisfactory specimens (56/993) were abnormal; increasing age category, genital warts, and chlamydia infections were independently associated with an abnormal Pap smear in multivariate analysis. Routine Pap smear screening provided satisfactory results in the STD clinic and, where population-based programmes are not available, should be fully integrated into public STD care, (particularly in settings serving younger women).     

Differences in screening mammography outcomes among White, Chinese, and Filipino women

BACKGROUND: The accuracy of screening mammography among Asian women in the United States has received little attention. We determined whether the accuracy of screening mammography for Chinese and Filipino women differs from that of white women. METHODS: We examined a cohort of white, Chinese, and Filipino women 40 years and older who underwent 200,402, 72,604, and 19,087 screening examinations, respectively, between January 1986 and December 2001 in San Francisco County, California, of whom 2177 were diagnosed with breast cancer within 12 months of a screening examination. By linking screening examinations to the regional Surveillance, Epidemiology and End Results program and the California Cancer Registry, we identified the occurrence of any invasive cancer or ductal carcinoma in situ and then calculated the rate of cancer per 1000 screenings and the sensitivity of mammography. RESULTS: The rate of invasive breast cancer per 1000 screenings was 45% lower for Chinese than for white women aged 50 to 69 years (3.8 vs 6.9; P<.001) and 29% lower for Filipino than for white women (4.9 vs 6.9; P = .03). Rates of ductal carcinoma in situ were similar across all ethnic groups (1.6-1.7 per 1000 screenings; P>or=.60). The sensitivity of mammography was similar for white, Chinese, and Filipino women (81.6%-84.3%; P>.30). CONCLUSIONS: Screening mammography has similar accuracy among white, Chinese, and Filipino women, although the absolute benefit of screening, in terms of breast cancer deaths averted, is likely to be less among Asian women because the rates of invasive cancer are lower compared with white women of similar age. Overdiagnosis of ductal carcinoma in situ with screening mammography among Asian women is likely to be comparable to that of white women because the rate of ductal carcinoma in situ was similar in all the examined ethnic groups.     

Cervical smears: comparison of knowledge and practice of a general practice sample with a high-risk group

Successful cervical screening programmes depend on the participation of an informed target population. A national cervical screening programme is shortly to be introduced in the Republic of Ireland. We compare the knowledge, attitudes and practice of 395 Irish urban women with 323 high-risk women, genitourinary medicine (GUM) clinic attenders. There was little difference in knowledge between the 2 groups. Fifty-five per cent of the general practice (GP) sample and 45% of the GUM sample correctly identified the purpose of a smear. Eighty-three per cent of both groups had had at least one smear but only 59% of the high-risk group had had a smear before attending the GUM clinic. Both groups expressed a preference for a female provider. Socio-economic grouping is the strongest predictor of knowledge and uptake of cervical smears and high-risk women were less likely to have opportunistic cervical smears. Information programmes to encourage participation in screening programmes must build on pre-existing knowledge and focus on the relevance and acceptability of the test.     

The frequency of Pap smear screening in the United States

BACKGROUND: U.S. professional medical societies and the national health systems of all other industrialized nations recommend that most women need not undergo Papanicolaou (Pap) smear screening annually. There are no data, however, regarding the frequency at which women actually undergo screening. OBJECTIVE: To describe the frequency of cervical cancer screening in the United States. DESIGN: National Health Interview Survey, a cross-sectional population-based telephone survey conducted by the National Center for Health Statistics. PARTICIPANTS: Representative sample of U.S. women age 21 and older who denied a history of cancer (N = 16,467). MEASUREMENTS: Pap smear screening frequency, categorized as no regular screening or screening at 1 of 3 discrete screening intervals (every year, every 2 years, or every 3 years) based on each woman's reported number of Pap smears in the previous 6 years. RESULTS: The vast majority (93%) of American women report having had at least one Pap smear in their lifetime. Among women with no history of abnormal smears, 55% undergo Pap smear screening annually, 17% report a 2-year screening interval, 16% report being screened every 3 years, and 11% are not being screened regularly. Even the very elderly report frequent screening-38% of women age 75 to 84 and 20% of women age 85 and older reported annual Pap smears. Overall, 20% of women reported having had at least one abnormal Pap smear. Among these women, rates of frequent Pap smear screening are considerably higher-80% undergo annual screening, with only a modest decline in screening frequency with increasing age. CONCLUSIONS: The majority of American women report being screened for cervical cancer more frequently than recommended. Lengthening the screening interval would not only reduce the volume of specimens that cytotechnologists are required to read, but would also reduce the follow-up testing after abnormal smears.     

Increasing breast and cervical cancer screening in low-income women

OBJECTIVE: To determine if women would have higher breast and cervical cancer screening rates if lay health advisers recommended screening and offered a convenient screening opportunity. DESIGN: Controlled trial. SETTING: Urban county teaching hospital. PARTICIPANTS: Women aged 40 years and over attending appointements in several non-primary-care outpatient clinics. INTERVENTIONS: Lay health advisers assessed the participants’ breast and cervical cancer screening status and offered women in the intervention group who were due for screening an appointment with a female nurse practitioner. MEASUREMENTS AND MAIN RESULTS: Screening rates at base-line and at follow-up 1 year after the intervention were determined. At follow-up, the mammography rate was 69% in the intervention group versus 63% in the usual care group (p=.009), and the Pap smear rate was 70% in the intervention group versus 63% in the usual care group (p=.02). In women who were due for screening at baseline, the mammography rate was 60% in the intervention group versus 50% in the usual care group (p=.006), and the Pap smear rate was 63% in the intervention group versus 50% in the usual care group (p=.002). The intervention was effective across age and insurance payer strata, and was particularly effective in Native American women. CONCLUSIONS: Breast and cervical cancer screening rates were improved in women attending non-primary-care outpatient clinics by using lay health advisers and a nurse practitioner to perform screening. The effect was strongest in women in greatest need of screening. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, D.C., May 2, 1996. This research was supported by a grant (R01-CA52994-02) from the National Cancer Institute, Dr. Margolis was supported by an American Cancer Society Clinical Oncology Career Development Award for Primary Care Physicians while this work was carried out.     

HIV testing in antenatal clinics: the impact on women

One hundred and fifty-five women attending antenatal clinics in an inner city area where the rate of AIDS reporting is high were interviewed to examine the acceptability of different modes and purposes of antenatal HIV testing. Eighty-two per cent of women felt the test should be available in antenatal clinics, but only 48% reported that they themselves would take the test. Seventy-four per cent would accept anonymous testing. Potential anxiety levels surrounding the HIV test were significantly higher than for other (currently routine) tests in antenatal clinics. The implications of these findings for policy are discussed.     

Cancer Screening and Early Detection Among Ageing Women: Should Practice or Policy Change?

Australian health authorities recommend cessation of Pap smear screening at the age of 70 years for women who have had two normal Pap smears within the last five years. Pap smear screening should be initiated for women over 70 years of age who never have been screened. Mammographic screening is recommended for women 50–70 years. All adults over 40 years of age are advised to check for rectal blood after every bowel motion. This study was conducted to determine current compliance with these guidelines in an ageing female population, using a self-administered questionnaire. A 94% response rate resulted in 414 completed questionnaires from women aged 60 to 99 years (median 81). Of women over 70 years with intact uteri, 40% never had had a Pap smear. Twelve percent of women over 70 had had a recent screening mammogram. In total, 21% of respondents checked the toilet bowl every time they passed a bowel motion and 27% checked the toilet paper every time. These results demonstrate that cancer screening and early detection practices among ageing women are varied. In contrast to current policies, cervical cancer screening is not always initiated for women over 70 years who never have been screened. Further, mammographic screening continues beyond 70 years of age although there is no evidence of benefit for these older women. Too few studies have been conducted to ascertain the benefits, acceptability and unintended negative sequelae of cancer screening activities in ageing women. Research is required to inform and, if necessary, revise screening policies and clarify the preventive messages promulgated to the elderly and their health care providers.     

The role of smoking in the regulation of energy balance

Sixteen smokers (eight men and eight women) were studied before and six weeks after attending a series of anti-smoking clinics. Mean weight gain for the ten subjects who gave up smoking was 1.36 kg (P less than 0.005) and there was no significant change in body weight of subjects who did not give up smoking. There was a 4 per cent drop in resting metabolic rate of the smokers who successfully gave up (n = 9), but this was only significant when the data were expressed per kg body weight (P less than 0.05). Mean energy intake increased by 6.5 per cent but this change was not significant. Smoking a single cigarette significantly increased the metabolic rate for 30 min by 3 per cent compared with a control condition of sham smoking (n = 15). Thus the discrepancy in body weight between smokers and non-smokers appears to be due to a combination of reduced food intake and the thermogenic effects of smoking.     

Cervical cancer screening in women aged 65 and over

Pap smear screening is an accepted method of detecting cervical dysplasia or malignancy, and use of this test has been shown to reduce the incidence of invasive squamous cervical cancer in young and middle aged women. Conflicting recommendations exist concerning the screening of women over the age of 65, and little information is available concerning the results of screening in this population. Elderly women are routinely omitted from screening, as it is generally believed that they usually refuse testing. This paper reports a study attempting to evaluate the feasibility of screening in women over the age of 64 attending a large urban outpatient geriatric clinic. It demonstrates that pap smear screening is acceptable to this population, particularly if performed by the usual primary care provider. It also confirms previous reports that women in this age group have had very little screening in the past, and that screening uncovers a large number of abnormalities. Of note is the high rate of false positive smears in this population.     

Cost effectiveness of cervical cancer screening for the elderly.

OBJECTIVE: To analyze the costs and benefits of alternative cervical cancer screening schedules among elderly women. SETTING: Population-based screening programs. DESIGN: A Markov model predicts the outcomes of periodic screening, diagnosis, and treatment for cervical cancer among women from 65 to 109 years of age. PATIENTS: A hypothetical cohort of one million 65-year-old women; representative of the U.S. population. MEASUREMENTS: The costs and yields of screening. RESULTS: Triennial screening reduced mortality from cervical cancer among the elderly by 74% at a cost of $2254 per year of life saved. Annual screening increased costs to $7345 per year of life saved; less frequent schedules yielded lower costs but decreased savings in life. These results were most sensitive to the quality of the Papanicolaou smear and the characteristics of the women using the benefit. If the sensitivity of the Papanicolaou smear was reduced from a baseline estimate of 75% to 50% and the specificity was decreased to 87% from 95%, the cost effectiveness ratio increased by nearly $7000 per year of life saved. If triennial screening is targeted to women who have not had regular screening, the program will save money as well as years of life; however, screening women who have been screened regularly is considerably less efficient, increasing costs to $33,572 per year of life saved. CONCLUSION: The success of the new Medicare benefit depends substantially on physicians assuring that their elderly patients, particularly women without regular prior screening, obtain high quality Papanicolaou smears. The data also show that after a woman 65 years of age or older has a history of regular negative smears, screening is inefficient and can cease.     

Effect of health beliefs on delays in care for abnormal cervical cytology in a multi-ethnic population

CONTEXT: Women from racial and ethnic minorities in the United States have higher rates of cervical cancer and present with later stage disease compared to whites. Delays in care for abnormal Papanicolaou (Pap) smears can lead to missed cases of cervical cancer or late-stage presentation and may be one explanation for these differences. OBJECTIVE: To determine if race and ethnicity, health beliefs, and cancer knowledge are associated with delays in care for abnormal Pap smears. DESIGN, PARTICIPANTS, AND SETTING: We conducted a mailed survey with telephone follow-up of all women with an abnormal Pap smear who received care at Kaiser Permanente Los Angeles Medical Center between October 1998 and October 1999 (n = 1,049). MEASUREMENTS AND MAIN RESULTS: A delay in care was defined as not attending the first scheduled clinic visit to follow up on an abnormal Pap smear, or requiring multiple contact attempts, including a certified letter, to schedule a follow-up visit. Our response rate was 70% (n = 733) and the sample was 51% Latina. Spanish-speaking Latinas and women of Asian descent were more likely to endorse fatalistic beliefs and misconceptions about cancer. Thirteen percent of the sample delayed follow-up on their abnormal Pap smear. Women who delayed care were more fatalistic and endorsed more misconceptions about cervical cancer. Delays in care were not independently associated with race and ethnicity. CONCLUSIONS: Health beliefs and cancer knowledge differed by race and ethnicity among women in a large managed care organization. Fatalistic health beliefs and misconceptions about cancer, but not race and ethnicity, were independently associated with delays in care.     

Abnormal screening glucose challenge test in pregnancy and future risk of diabetes in young women

Aims Pregnant women commonly undergo screening for gestational diabetes mellitus (GDM) using a 50‐g glucose challenge test (GCT), followed by a diagnostic oral glucose tolerance test (OGTT) in those women in whom the GCT is abnormal. Although it has long been recognized that GDM is associated with subsequent Type 2 diabetes, it has recently emerged that any degree of abnormal antepartum glucose homeostasis predicts an increased risk of postpartum glucose intolerance. Thus, in this context, we sought to determine whether women who have a pregnancy complicated by an abnormal GCT, but who do not have GDM, are at increased risk of subsequent diabetes, compared with their peers with an abnormal GCT. Methods A population‐based, retrospective cohort study was conducted. Women referred for an antepartum OGTT indicative of an abnormal GCT (n = 15 381), but without GDM, were matched (for age, region, socioeconomic status, and year of delivery) with up to four other women without such referral (n = 61 237). The two cohorts were followed over a median 6.4 years for the development of diabetes. Results The rate of incident diabetes was 5.04 cases per 1000 person‐years in the cohort of women who underwent an antepartum OGTT, compared with 1.74 cases per 1000 person‐years in women without an OGTT. The hazard ratio for subsequent diabetes in women with an antepartum OGTT was 2.56 (95% confidence interval 2.28, 2.87) (P < 0.0001). Conclusions Even in the absence of GDM, abnormal screening GCT in pregnancy is associated with an increased future risk of diabetes in young women.     

HIV infection among pregnant women in Bobo-Dioulasso, Burkina Faso: comparison of voluntary and blinded seroprevalence estimates

The objective of our study was to estimate the prevalence of HIV infection among pregnant women in Bobo-Dioulasso (Burkina Faso) according to 2 survey methods. Unlinked anonymous HIV screening was performed among women attending 2 antenatal clinics. Voluntary and confidential HIV counselling and testing were offered to women attending 2 other antenatal clinics in the same time period, September-October 1996. Voluntary HIV testing was performed in the context of a clinical trial on mother-to-child transmission of HIV (ANRS 049 clinical trial) with an acceptance rate of HIV testing of 93%. The first survey recruited 200 women and the second, 424. The mean age (24.6 years vs 24.8 years) and the mean number of pregnancies (3.1 vs 3.3) of women were comparable, in the 2 studies (P=0.69 and P=0.26, respectively). Prevalence of HIV infection in the blinded survey was estimated at 10.0% (95% confidence interval (CI): 6.4-15.2), while it was 9.4% (95% CI: 6.9-12.7) in the voluntary HIV screening programme. These 2 estimates were not statistically different (P=0.82). In the voluntary screening study, the prevalence of HIV infection was significantly different between age groups 15-24 years and 25-49 years (13.9% vs 4.5%, P < 0.001). In the age group 25-49 years, the prevalence of HIV infection estimated in the blinded study and in the voluntary screening study were significantly different (10.5% vs 4.5%, P=0.04) suggesting a potential participation bias among pregnant women of older age in the voluntary, confidential HIV screening group. In conclusion, for the purpose of HIV surveillance, the most reliable method for HIV prevalence remains the unlinked, anonymous testing.     

Advancing age and cervical cancer screening and prognosis

OBJECTIVES: To determine associations between advancing age and screening behavior and prognosis in long-term members of a prepaid health plan diagnosed with invasive cervical cancer (ICC). DESIGN: Case series. SETTING: Prepaid health plan. PARTICIPANTS: All women diagnosed with ICC at Kaiser Permanente Medical Care Program-Northern California health plan from 1988 to 1994. MEASUREMENTS: From medical records, we recorded participants' age, stage at diagnosis, tumor histology, and results of and reasons for all previous cervical smears. We limited our analysis to women who had been members of the health plan for at least 30 of the 36 months preceding diagnosis (n = 455). RESULTS: Women in older age groups were less likely than younger women to have been screened within the 3 years before diagnosis (P = .005 for trend). Nonadherence to follow-up of abnormal cervical smears was uncommon (17/455, 3.7%) and not age related (P = .932 for trend). The proportions of ICC that were interval cancers, defined as ICC diagnosed within 3 years of a negative screening smear, were highest in women under age 30 (P = .004 for trend). In multivariate analyses controlling for stage at diagnosis, women age 60 and older were not more likely to die of ICC within 3 years of diagnosis than were women younger than age 60 (odds ratio 1.30, 95% confidence interval 0.75-2.28). CONCLUSION: The disproportionate burden of cervical cancer observed in older women appears to be largely attributable to lack of screening within the 3 years before diagnosis.     

Risk factors and other epidemiologic considerations for cervical cancer screening: a narrative review for the U.S. Preventive Services Task Force

Despite the success of cervical cancer screening programs, questions remain about the appropriate time to begin and end screening. This review explores epidemiologic and contextual data on cervical cancer screening to inform decisions about when screening should begin and end. Cervical cancer is rare among women younger than 20 years. Screening for cervical cancer in this age group is complicated by lower rates of detection and higher rates of false-positive results than in older women. Methods used to diagnose and treat cervical intraepithelial neoplasia have important potential adverse effects. High-risk human papillomavirus infections and abnormalities on cytologic and histologic examination have relatively high rates of regression. Accordingly, cervical cancer screening in women younger than 20 years may be harmful. The incidence of, and mortality rates from, cervical cancer and the proportion of U.S. women aged 65 years or older who have had a Papanicolaou smear within 3 years have decreased since 2000. Available evidence supports discontinuation of cervical cancer screening among women aged 65 years or older who have had adequate screening and are not otherwise at high risk. Further reductions in the burden of cervical cancer in older women are probably best achieved by focusing on screening those who have not been adequately screened.     

Prevalence of thyroid disease in an older Australian population

Aim: To determine the prevalence of thyroid disease in an older Australian population in a population‐based cross‐sectional study. Background: Community‐living subjects, aged 49 years or older, in two Blue Mountains postcodes were invited to participate in an eye, nutrition and health study between 1997 and 2000. Methods: Three thousand five hundred and nine of the 4489 identified persons participated. Fifty‐seven per cent of 3504 who completed questionnaires were women; their mean age was 66.8 years. Thyroid‐stimulating hormone (TSH) was measured in 2665 subjects (76% of those completing the questionnaire). The main outcome measures were serum TSH and free thyroxine levels, serum lipids, urate and sugar levels and questionnaire responses. Results: The prevalence of recognized thyroid disease (either self‐reported history of thyroid disease or current thyroxine treatment) was 10% (95% confidence interval (CI) 8.9–11.1%). An additional 3.6% (95%CI 2.9–4.3%) of participants had unrecognized thyroid disease (abnormal TSH). The TSH was abnormal in 7.1% (95%CI 5.8–8.4%) of women and 3.7% (95%CI 2.6–4.8%) of men. Sixty‐five per cent of those with an abnormal TSH did not report a history of thyroid disease, whereas 25% of those taking thyroxine replacement therapy had an abnormal TSH level. The prevalence of hypothyroidism increased with increasing age in women. The mean fasting cholesterol was 0.36 mmol/L (95%CI 0.15–0.57) higher in hypothyroid subjects than in euthyroid subjects. Conclusion: Thyroid disease in older Australian women is relatively common and may be undiagnosed. Ongoing monitoring of patients on thyroxine replacement therapy is important, given that 25% of treated patients had an abnormal TSH.     

Mitral valve disorders and bile duct diseases]

In a number of cases of post-mortem examinations of patients with mitral valve defects a morbidity rate of cholelithiasis of 41.3 per cent was found, above all by the larger morbidity rate in younger women. Up to the 50th year it was 37.1 per cent at an average death age of 40.7 years. Is was conspicuous that more women who had not been delivered suffered from cholelithiasis than those ones who had been delivered (68.9 per cent of the nulliparae). Before the 50th year 55.6 per cent of the women who had not been delivered suffered from such a disease at an average death age of 39.3 years. Probably in these women the heart disease was so severe that there did not develop a gravidity.     

Screening mammography for frail older women

OBJECTIVE: The potential benefits and harms of screening mammography in frail older women are unknown. Therefore, we studied the outcomes of a screening mammography policy that was instituted in a population of community-living nursing home-eligible women as a result of requirements of state auditors. We focused on the potential burdens that may be experienced. METHODS: Between January 1995 and December 1997, we identified 216 consecutive women who underwent screening mammography after enrolling in a program designed to provide comprehensive care to nursing home-eligible patients who wished to stay at home. Mammograms were performed at 4 radiology centers. From computerized medical records, we tracked each woman through September 1999 for performance and results of mammography, additional breast imaging and biopsies, documentation of psychological reactions to screening, as well as vital status. Mean follow-up was 2.6 years. RESULTS: The mean age of the 216 women was 81 years. Sixty-three percent were Asian, 91% were dependent in at least 1 activity of daily living, 49% had cognitive impairment, and 11% died within 2 years. Thirty-eight women (18%) had abnormal mammograms requiring further work-up. Of these women, 6 refused work-up, 28 were found to have false-positive mammograms after further evaluation, 1 was diagnosed with ductal carcinoma in situ (DCIS), and 3 were diagnosed with local breast cancer. The woman diagnosed with DCIS and 1 woman diagnosed with breast cancer were classified as not having benefited, because screening identified clinically insignificant disease that would not have caused symptoms in the women's lifetimes, since these women died of unrelated causes within 2 years of diagnosis. Therefore, 36 women (17%; 95% confidence interval [CI], 12 to 22) experienced burden from screening mammography (28 underwent work-up for false-positive mammograms, 6 refused further work-up of an abnormal mammogram, and 2 had clinically insignificant cancers identified and treated). Forty-two percent of these women had chart-documented pain or psychological distress as a result of screening. Two women (0.9%; 95% CI, 0 to 2) may have received benefit from screening mammography. CONCLUSION: We conclude that screening mammography in frail older women frequently necessitates work-up that does not result in benefit, raising questions about policies that use the rate of screening mammograms as an indicator of the quality of care in this population. Encouraging individualized decisions may be more appropriate and may allow screening to be targeted to older women for whom the potential benefit outweighs the potential burdens.