Information and involvement preferences of women in their 40s before their first screening mammogram

BACKGROUND: Informed decision making regarding screening mammography is recommended for women in their 40s; however, what information women want and how much involvement in decision making they prefer are not known. METHODS: Surveys were mailed to women aged 40 to 44 scheduled for their first screening mammogram. Women were members of a large New England health maintenance organization and received medical care at a multispecialty practice in the greater Boston area. Outcome measures included information needs and decisional control preferences. RESULTS: Ninety-six women responded. Of 93 identifying their ethnicity, 62 (67%) were white, 18 (19%) were black, 10 (11%) were Asian, 2 (2%) were Hispanic, and 1 (1%) was other. Most (91% [85/93]) wanted their primary care provider to be the source of information regarding screening mammography. Information needs included the next steps to take if the mammogram result was abnormal (89%), how the woman would be contacted (75%), and how quickly (71%). Women also wanted to know about the harms of false-positive (84%) and false-negative (82%) results, benefits of screening in prolonging life (73%), and risk of getting breast cancer (69%). Most women preferred to make the screening decision after considering their medical provider's opinion (38%) or together with their medical provider (46%); fewer than 10% preferred that the decision be made by the woman or her provider alone. CONCLUSIONS: Women cited specific information needs before initiating screening mammography, including screening logistics and potential harms and benefits of screening. They also wanted to participate in the decision-making process. Effective methods should be developed for communicating desired information before screening.     

Breast cancer screening for elderly women with and without comorbid conditions. A decision analysis model.

OBJECTIVE: To determine whether breast cancer screening extends life for women aged 65 years or more with and without comorbid medical conditions. SETTING: A provider-patient encounter. DESIGN: A decision analysis of the utility of screening for breast cancer. MEASUREMENTS: Clinical examination and mammography among four groups of women aged 65 to 85 or more years: average health, mild hypertension, congestive heart failure, and average-health black women. The effects of screening were estimated using the best quality data available. RESULTS: Screening saved life at all ages among patients studied. Savings were highest for black women and decreased with increasing age and comorbidity. Screening all average-health women aged 65 or more saved 67,912 years of life. For women who had cancer, screening extended life by 617 days for average-health women between 65 and 69 years of age and 178 days for those aged 85 years or more. Perioperative mortality and test characteristics had little effect on the results. The risks equaled the benefits of screening only when operative mortality was between 27% and 62%. The marginal costs of screening during a routine office visit were $138 and increased with advancing age and decreasing test specificity. Benefits persisted after adjustment for changes in long-term quality of life; however, for women aged 85 years and older (with and without comorbidities), the short-term morbidity of anxiety or discomfort associated with screening may have outweighed the benefits. CONCLUSION: No inherent reason exists to impose an upper-age limit for breast cancer screening; however, more data are needed on women's preferences for screening strategies.     

Breast cancer screening. Interpreting new data for clinical practice

While multiple trials support routine mammography for women aged 50 to 69 demonstrating a reduction in breast cancer deaths by about 30%, experts disagree on breast cancer screening recommendations for women 40 to 49 years old. A review of the data and its interpretation illustrate the areas of controversy: lack of statistical power, prolonged screening intervals, suboptimal mammographic technical quality, and difficulty applying the data to current mammographic screening practice. Clinical decision making for health care providers and women aged 40 to 49 is guided by understanding the risk of breast cancer and weighing the risk and benefits of screening mammography. Further research to resolve whether breast cancer screening is effective in decreasing breast cancer deaths in women aged 40 to 49 is needed.     

Decision‐Making Regarding Mammography Screening for Older Women

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

Screening mammography in women aged 40-49 years

Screening mammography in women aged 40-49 years reduces breast cancer mortality by 16%-18%, and is recommended by various national organizations. However, one must be aware of the recognized limitations of the approach. The actual benefit appears to be small (absolute risk reduction, 0.07%; the number of women who need to be screened to prevent 1 woman from dying of breast cancer, about 1,500-2,500), and there are associated risks and costs with this approach. The medical and scientific communities, in partnership with advocacy groups, must continue to work to improve our breast diagnostic capabilities, especially in younger women. Since this is an emotional and controversial issue, each woman will need to consider, with the aid of her primary caregiver, whether the risks of screening outweigh its potential benefits, and make an informed decision regarding screening.     

Screening mammography for women 40 to 49 years of age: a clinical practice guideline from the American College of Physicians

Breast cancer is one of the most common causes of death for women in their 40s in the United States. Individualized risk assessment plays an important role when making decisions about screening mammography, especially for women 49 years of age or younger. The purpose of this guideline is to present the available evidence for screening mammography in women 40 to 49 years of age and to increase clinicians' understanding of the benefits and risks of screening mammography.     

Race and family history assessment for breast cancer

OBJECTIVE: Studies have demonstrated disparities in breast cancer screening between racial and ethnic groups. Knowledge of a woman's family history of breast cancer is important for initiating early screening interventions. The purpose of this study was to determine whether differences exist in the collection of family history information based on patient race. DESIGN: Cross-sectional patient telephone interview and medical record review. SETTING: Eleven primary care practices in the Greater Boston area, all associated with Harvard Medical School teaching hospitals. PARTICIPANTS: One thousand seven hundred fifty-nine women without a prior history of breast cancer who had been seen at least once by their primary care provider during the prior year. MEASUREMENTS AND MAIN RESULTS: Data were collected on patients regarding self-reported race, family breast cancer history information, and breast cancer screening interventions. Twenty-six percent (462/1,759) of the sample had documentation within their medical record of a family history for breast cancer. On multivariate analysis, after adjusting for patient age, education, number of continuous years in the provider's practice, language, and presentation with a breast complaint, white women were more likely to be asked about a breast cancer family history when compared to nonwhite women (odds ratio, 1.68; 95% confidence interval, 1.21 to 2.35). CONCLUSIONS: The majority of women seen by primary care providers do not have documentation of a family breast cancer history assessment within their medical record. White women were more likely to have family breast cancer information documented than nonwhites.     

The influence of health status, age, and race on screening mammography in elderly women

BACKGROUND: Screening mammography is controversial for elderly women because of an absence of efficacy data. Decisions to screen are based on individualized assessment of risks and benefits. Our objective was to determine how screening mammography varies by age and race when adjusted for propensity to die. METHODS: In a retrospective cohort study, rates of screening mammogram performed in 2000-2001 based on claims, adjusted for propensity to die in 2000, were determined for a nationally representative 5% random sample of female fee-for-service Medicare beneficiaries 65 years and older in (N = 722,310). RESULTS: The overall rate of screening was 39%. When stratified into quintiles by propensity to die, 2-year rates ranged from 61% in the lowest-risk group to 5% in the highest-risk group. In analyses stratified by age and adjusted for propensity to die, 42% of women aged 65 to 69 years were screened, declining to 26% of women 85 years and older (P<.001). Adjusted screening rates for white women, black women, and women of other races were 40%, 30%, and 25%, respectively (P<.001). Thus, among women with similar health status, the youngest women were 1.61 times more likely to be screened compared with the oldest; compared with black women and women of other races, white women were 1.38 and 1.60 times, respectively, more likely to be screened. CONCLUSIONS: Decisions to screen for breast cancer are related not only to health status but also to age and race. Underuse and overuse of screening mammography likely occurs owing to age- and race-associated decision making. Assessment of life expectancy may more accurately identify women who could benefit from screening.     

Patients' resistance to risk information in genetic counseling for BRCA1/2

BACKGROUND: Risk information from health care providers is relevant to and used in nearly all medical decisions. Patients often misunderstand their risks, yet little is known about the risk perception that patients derive from risk communications with health care providers. This study examines patients' risk perceptions following communication with health care providers during genetic counseling about the risks of breast cancer and BRCA1/2 mutations. METHODS: A prospective, longitudinal study was conducted from October 2002 to February 2004 of women who received genetic counseling. The women completed a survey before their counseling and a telephone interview in the week after the counseling. Main outcome measures included change from precounseling in risk perception and accuracy of postcounseling risk perception (relative to actual risk information communicated). RESULTS: A total of 108 women agreed to participate in the study. The women's postcounseling risk perceptions were significantly lower than their precounseling risk perceptions (breast cancer: 17%, P<.001; mutation: 13%, P<.001) but were significantly higher than the actual risk information communicated (breast cancer: 19%, P<.001; mutation: 24%, P<.001). Accuracy of breast cancer risk perception but not mutation risk perception was associated with precounseling worry (P = .04), even after adjusting for trait anxiety (P = .01). CONCLUSIONS: This research demonstrates patients' resistance to risk information. Inappropriately high risk perception derived from a risk communication with a health care provider can lead patients to make different, and potentially worse, medical decisions than they would with an accurate risk perception and to be unnecessarily distressed about their risk.     

The relation between projected breast cancer risk, perceived cancer risk, and mammography use

BACKGROUND: Although the use of mammography on at regular intervals can save lives, not all women obtain the repeat mammography recommended in guidelines. OBJECTIVE: To assess the associations between routine mammography use, perceived cancer risk, and actual projected cancer risk. METHODS: We include women who were 45 to 75 years of age and who had responded to the 2000 National Health Interview Survey. Women who reported that they believed their risk of getting cancer in the future was "medium" or "high" were considered jointly as "medium/high-risk perception."Routine mammography use" was defined as having > or =3 mammograms in the previous 6 years. We used logistic regression to determine the independent relation between cancer risk perception, projected breast cancer risk, and routine mammography use. RESULTS: Of the 6,002 women who met our inclusion criteria, 63.1% reported routine mammography use. About 76% of women in the highest quartile of projected breast cancer risk reported routine mammography use, compared with only 68%, 64%, and 51% in the third, second, and first quartiles, respectively (P<.001 chi-square test for trend). After adjusting for indicators of access to care, sociodemographic and behavioral factors, and perceived cancer risk, women in the highest quartiles of projected cancer risk were significantly more likely to report routine mammogram use than women in the lowest quartile (odds ratio [OR] of women in third and fourth quartiles were 1.57 [1.24 to 1.99], and 2.23 [1.73 to 2.87] vs the lowest quartile, respectively). Women with a higher perceived cancer risk were significantly more likely to undergo routine mammography (adjusted OR: 1.29 [1.12 to 1.48] P=.001). Cancer risk perceptions tended to be higher among women who were younger age, obese, smokers, depressed, or reported one of the following breast cancer risk factors: family breast cancer history, prior abnormal mammogram, and early age at menarche. CONCLUSION: Actual and perceived risk were independent predictors of routine mammography use, suggesting that efforts to incorporate risk profiles into clinical decision making may need to involve more than just relaying information about projected risks to patients, but also to explore how risk perceptions can be affected by this information.     

Breast cancer in older women: trends in diagnosis

Breast cancer is a disease of elderly as well as middle-aged women. Even in patients of advanced age, breast cancer shortens life expectancy. Early diagnosis, through preventative screening with mammography and physical examination, offers the best hope of cure. Deterrents to use of mammography have included radiation risk, unnecessary biopsies, and cost. However, current low radiation doses minimize radiation risks; test specificity is much better in older women, leading to fewer unnecessary biopsies; and new Medicare guidelines lower out-of-pocket patient cost. With increased education of older women and health care providers, methods to decrease mortality from breast cancer in the elderly can become widespread.     

Feasibility of universal screening mammography. Lessons from a community intervention

It is estimated that 44,500 American women will die of breast cancer in 1991. The breast cancer screening guidelines of the American Cancer Society and the National Cancer Institute calling for annual mammography for all women older than 50 years have been endorsed by numerous professional groups. Third-party reimbursement for screening mammography is becoming more prevalent, and payment for screening mammography is now a Medicare benefit. Our studies, conducted as part of a National Cancer Institute grant to increase the routine use of screening mammography and clinical breast examination in women 50 to 75 years of age, have uncovered a number of significant barriers to the implementation of screening guidelines among women, primary care physicians, and providers of mammography services. These barriers, as well as methods to assure the quality of mammography, need to be addressed before universal screening is feasible.     

Effect of false-positive mammograms on interval breast cancer screening in a health maintenance organization.

BACKGROUND: Despite the mortality benefits of breast cancer screening, not all women receive regular mammography. Such factors as age, socioeconomic status, and physician recommendation have been associated with greater use of screening. However, we do not know whether having an abnormal mammogram affects future screening. OBJECTIVE: To examine the effect of a false-positive mammogram on adherence to the next recommended screening mammogram. DESIGN: Prospective cohort study. SETTING: The breast cancer screening program at Group Health Cooperative, a health maintenance organization in Washington state. PATIENTS: 5059 women 40 years of age or older with no history of breast cancer or breast surgery who had false-positive (n = 813) or true-negative (n = 4246) index screening mammograms between 1 August 1990 and 31 July 1992. MEASUREMENTS: Screening rates and odds ratios for recommended interval screening up to 42 months after the index mammogram. RESULTS: After adjustment for differences in age; previous use of mammography; family history of breast cancer; exogenous hormone use; and age at menarche, first childbirth, and menopause, women with false-positive index mammograms were more likely than those with true-negative index mammograms to obtain their next recommended screening mammogram (odds ratio, 1.21 [95% CI, 1.01 to 1.45]). The relation between a false-positive mammogram and the likelihood of adherence to screening in the next recommended interval was strongest among women who had not previously undergone mammography (odds ratio, 1.66 [CI, 1.26 to 2.17]). CONCLUSIONS: Having a false-positive mammogram did not adversely affect screening behavior in the next recommended interval. Women with false-positive mammograms, especially those without previous mammography, were more likely to return for the next scheduled screening.     

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.     

Breast cancer screening in older women: practices and barriers reported by primary care physicians

Annual mammography, in combination with clinical breast examinations, can reduce mortality from breast cancer. However, surveys of both patients and physicians suggest that mammography is underutilized. This study examined whether physicians' reported breast cancer screening practices and barriers to mammography varied with patients' age. Data from 576 primary care physicians (internal medicine, family/general practice, and obstetrics/gynecology) who participated in a mailed statewide survey were analyzed. Physicians reported screening elderly women significantly less often than younger women, regardless of family history of breast cancer. With the exception of medical specialty, physicians' demographic and practice characteristics were not associated with reported screening practices. However, physicians' knowledge and beliefs about breast cancer in older women were associated with reported screening practices. When analyzing barriers to ordering mammography, cost to the patient was viewed as a barrier for women of all ages, and pain was viewed as a greater barrier for younger women; otherwise, physicians consistently believed that their elderly patients faced considerably more barriers compared with younger women. Further investigation is required to examine why primary care physicians report age-related differences in both breast screening and barriers to mammography.     

Screening for breast cancer

There is very good evidence that screening for breast cancer reduces mortality in women older than 50 years and suggestive but inconsistent evidence that screening is effective in reducing long-term mortality in women younger than 50 years. The probability that an average-risk woman will be diagnosed with breast cancer in the coming 10 years is about 130 in 10,000 for a 40-year-old woman, 230 in 10,000 for a 55-year-old woman, and 280 in 10,000 for a 65-year-old woman. The chance of dying from breast cancer diagnosed in the coming 10 years is about 90 in 10,000, 123 in 10,000, and 120 in 10,000 for women age 40, 55, and 65, respectively. Mathematical models based on data from controlled trials of screening programs indicate that screening annually for 10 years with breast physical examination will decrease the probability of death from breast cancer by about 25 in 10,000 for women in the three age groups and increase life expectancy by about 20 days. Adding annual mammography will decrease the probability of death from breast cancer an additional 25 in 10,000 and increase life expectancy an additional 20 days. The actual reductions in mortality observed in controlled trials are slightly lower. If women are screened annually for 10 years with breast physical examination and mammography, the chance for a false-positive result over the 10-year period is approximately 2500 in 10,000. On the population level, if 25% of women age 40 to 75 are screened annually with both examinations, deaths from breast cancer would be decreased by about 4000 in the year 2000. Net annual costs would be approximately $1.3 billion. Recommending a screening strategy requires weighing the benefits against the risks and costs.     

Impact of Mammography Screening Interval on Breast Cancer Diagnosis by Menopausal Status and BMI

BACKGROUND

Controversy remains regarding the frequency of screening mammography. Women with different risks for developing breast cancer because of body mass index (BMI) may benefit from tailored recommendations.

OBJECTIVE

To determine the impact of mammography screening interval for women who are normal weight (BMI < 25), overweight (BMI 25–29.9), or obese (BMI ≥ 30), stratified by menopausal status.

DESIGN

Two cohorts selected from the Breast Cancer Surveillance Consortium. Patient and mammography data were linked to pathology databases and tumor registries.

PARTICIPANTS

The cohort included 4,432 women aged 40–74 with breast cancer; the false-positive analysis included a cohort of 553,343 women aged 40–74 without breast cancer.

MAIN MEASURES

Stage, tumor size and lymph node status by BMI and screening interval (biennial vs. annual). Cumulative probability of false-positive recall or biopsy by BMI and screening interval. Analyses were stratified by menopausal status.

KEY RESULTS

Premenopausal obese women undergoing biennial screening had a non-significantly increased odds of a tumor size > 20 mm relative to annual screeners (odds ratio [OR]?=?2.07; 95 % confidence interval [CI] 0.997 to 4.30). Across all BMI categories from normal to obese, postmenopausal women with breast cancer did not present with higher stage, larger tumor size or node positive tumors if they received biennial rather than annual screening. False-positive recall and biopsy recommendations were more common among annually screened women.

CONCLUSION

The only negative outcome identified for biennial vs. annual screening was a larger tumor size (> 20 mm) among obese premenopausal women. Since annual mammography does not improve stage at diagnosis compared to biennial screening and false-positive recall/biopsy rates are higher with annual screening, women and their primary care providers should weigh the harms and benefits when deciding on annual versus biennial screening.     

Breast cancer screening

The recommendations of the U.S. Preventive Services Task Force are reviewed in regard to screening for breast cancer. In contradistinction to those issued by some other national organizations, screening for breast cancer using mammography at ages 40–49 is not recommended. It is concluded that the scientific evidence is insufficient at present to recommend mammography screening for women aged 40–49. The recommendations of the task force are: all women over age 40 should receive an annual breast examination; all women should bave mammography every one or two years beginning at age 50 and concluding at approximately age 75 unless disease bas been detected; and it may be prudent to begin mammography at an earlier age for women at high risk of breast cancer. These recommendations are appropriate in light of the available evidence; though at present there is no evidence that clinical examination of the breasts at any age reduces breast cancer mortality; the upper age beyond which breast cancer screening no longer bas a significant effect in reducing breast cancer mortality is unknown; and there is no evidence that women at high risk for breast cancer benefit to a different degree from screening than women not at high risk.     

Patient-centered discussions about prostate cancer screening: a real-world approach

National guidelines recommend that primary care providers discuss the risks and benefits of prostate cancer screening with their patients but give little guidance on how to fit such a complex discussion into a busy clinic encounter. The authors propose a process-oriented approach (Ask-Tell-Ask) that promotes tailored conversations and value-based recommendations. The Ask-Tell-Ask approach includes diagnosing a patient's informational needs, providing targeted education based on those needs, and making a shared decision about testing. This time-efficient model emphasizes the provider's role as an interactive guide rather than a one-way supplier of information. Although there is no way to make these discussions simple, this streamlined strategy can help patients and providers efficiently negotiate the complex and important decision of screening for prostate cancer.