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.     

Is screening mammography effective in elderly women

PURPOSE: Screening mammography is effective in reducing breast cancer mortality in women between the ages of 50 and 69 years. We sought to determine whether older women who undergo screening mammography have a decreased risk of metastatic breast cancer. SUBJECTS AND METHODS: We studied 690,993 women aged 66 to 79 years who were California Medicare beneficiaries from January 1992 to December 1993, and who chose the fee-for-service plan. Health Care Financing Administration part B billing records were used to determine the use of screening mammography. The extent of breast cancer (in situ, local, regional, or metastatic) was ascertained for the 6,767 women who were diagnosed with the disease in 1993, using data from the California State Cancer Registry. For each type (extent) of breast cancer, the relative risk (RR) and 95% confidence (CI) of developing breast cancer was estimated by dividing the risk of its development in screened women by the risk in women who were not screened. RESULTS: A total of 46% of women had mammography during the 2-year study period. In situ, local, and regional breast cancer were more likely to be detected among women who underwent screening mammography. For example, the relative risk of detecting local breast cancer in screened women was 3.3 (95% CI: 3.1 to 3.5). The risk of detecting metastatic breast cancer, on the other hand, was significantly reduced among women aged 66 to 79 years who underwent screening mammography (RR = 0.57, 95% CI: 0.45 to 0.72). CONCLUSION: Screening mammography is associated with a decreased risk of detecting metastatic breast cancer among elderly women. Public health recommendations need to weigh the benefit of screening elderly women against the cost and potential harm from screening and treating early lesions that may have no effect on mortality.     

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.     

Predictors of mammography use in the past year among elderly women

Thirty-two personal characteristics were examined as potential predictors of mammography use in the past year in a geriatric clinic. Interviews assessed demographic, health status, health service utilization, health belief, and psychological and social variables (n = 242, mean age = 76 years). Four variables were independently associated with mammography use in logistic regression analysis: age, historical mammography use, perceived severity, and perceived barriers. The inverse relationship between age and mammography use in the past year was not modified by health status, functional status, and the other independently predictive variables. The authors conclude that geriatrics specialty care does not eliminate the age-associated decline in mammography use that has been previously described. The factors associated with mammography use in this sample were similar to those that have been described in younger populations of women. Variables examined because of specific gerontologic considerations were not independently associated with mammography use in the past year.     

Screening for non-insulin-dependent diabetes mellitus in the elderly

There are three major obstacles to a recommendation for screening the elderly for NIDDM. The first is the conflicting evidence as to whether early detection and treatment reduce complications. The second is that treatment of hyperglycemia with attainment of euglycemia is difficult to achieve in the elderly. Nondrug therapy often fails because of lifelong eating habits, denture problems, fixed income, and physical handicaps. Drug therapy is fraught with the dangers of hypoglycemia and drug interactions. Compliance with therapy often is poor and leads to conflicts between physician and patient that may be detrimental in the treatment of other diseases in which intervention has proven worthwhile. The third obstacle is the lack of data regarding the adverse effects of labeling and noncompliance issues in the face of a positive screening test. Because obesity is a risk factor for NIDDM and hypertension in conjunction with NIDDM leads to atherosclerosis, screening and treatment for these two conditions are warranted whether or not NIDDM is present concurrently. Medicine is in a dynamic state of flux and, undoubtedly, conflicts over the benefits of early treatment and patient compliance will be resolved. Until then, there is no justification for screening for NIDDM in the elderly.     

Screening cognition in the elderly with metabolic syndrome

Abstract Background: Metabolic syndrome reaches its highest prevalence in the elderly, and evidence suggests that metabolic syndrome could be an independent risk factor for cognitive impairment. The aims of this study were to detect whether patients with metabolic syndrome have lower cognition and to investigate whether there is a relationship with cognition and single metabolic syndrome components. Methods: We assessed fasting blood glucose (FBG), high-density lipoprotein cholesterol (HDL-C), triglycerides, high-sensitivity C-reactive protein (hsCRP), and anthropometric measurements. Metabolic syndrome was diagnosed according to National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. The population sample was divided into two groups according to the presence of metabolic syndrome. Cognitive function was investigated through the Mini-Mental State Examination (MMSE). Results: We enrolled 159 elderly subjects (mean age, 69.8±4.8 years). Seventy had metabolic syndrome. Metabolic syndrome subjects had higher hsCRP values (P<0.0001) and lower MMSE scores (P<0.0001) than those without metabolic syndrome. MMSE scores were significantly correlated with body mass index (BMI), hsCRP, metabolic syndrome, the number of metabolic syndrome components, and each of them. However, at multivariate regression analysis, only fasting blood glucose [FBG; B=-0.046; 95% confidence interval (CI) -0.066 to -0.028; P<0.0001] and the number of metabolic syndrome components (B=-0.317; 95% CI -0.572 to -0.010; P=0.042) were found to be independent predictors of lower MMSE scores. Conclusion: We found that subjects with metabolic syndrome have lower MMSE scores than those without, even without symptomatic cognitive impairment, and that the number of metabolic abnormalities is independently associated to lower MMSE scores. We suggest that these patients should always undergo cognitive screening to prevent more severe outcomes.     

Screening mammography use in Medicare beneficiaries reflects 4-year mortality risk

Objective

Breast cancer screening guidelines recommend that women and physicians consider life expectancy when making screening decisions in older women. However, prior studies suggest that screening mammography patterns are dependent on age rather than health status or mortality risk of women. Our objective is to determine the association between 4-year mortality risk and use of screening mammography in women aged ≥ 65 years using Medicare Current Beneficiary Survey data.

Methods

The primary predictor variable is 4-year mortality risk derived from a published and validated prognostic index with 4 strata of increasing probability of death in 4 years (risk groups 1, 2, 3, and 4 with 4%, 15%, 42%, and 64% risk of 4-year mortality, respectively). The main outcome was self-reported receipt of mammography in the last year.

Results

There was a significant decreasing trend in the use of mammography with mortality risk groups 1, 2, 3, and 4 (62.7%, 51.5%, 36.6%, and 24%, respectively; trend test P <.001). The adjusted odds of mammography use were greatest in the low mortality risk group and show a gradual decline with increasing mortality risk for risk groups 1, 2, 3, and 4 (odds ratio [confidence interval]): 1.00; 0.69 [0.53-0.90]; 0.37 [0.27-0.49], and 0.22 [0.13-0.36], respectively.

Conclusion

Screening mammography use in older Medicare beneficiaries seems to reflect their 4-year risk of mortality rather than age alone, suggesting that patients and providers consider prognosis in screening decisions. Prospective studies are needed to explore the use of the prognostic index as a mammography screening decision tool.     

Screening mammography in older women. Effect of wealth and prognosis

BACKGROUND: Wealthy women have higher rates of screening mammography than poor women do. Screening mammography is beneficial for women with substantial life expectancies, but women with limited life expectancies are unlikely to benefit. It is unknown whether higher screening rates in wealthy women are due to increased screening in women with substantial life expectancies, limited life expectancies, or both. This study examines the relationship between wealth and screening mammography use in older women according to life expectancy. METHODS: A cohort study was performed of 4222 women 65 years or older with Medicare participating in the 2002 and 2004 Health and Retirement Survey. Women were categorized according to wealth and life expectancy (based on 5-year prognosis from a validated prognostic index). The outcome was self-reported receipt of screening mammography within 2 years. RESULTS: Overall, within 2 years, 68% of women (2871 of 4222) received a screening mammogram. Screening was associated with wealth (net worth, > $100 000) and good prognosis (< or = 10% probability of dying in 5 years). Screening mammography was more common among wealthy women than among poor women (net worth, < $10 000) both for women with good prognosis (82% vs 68%; P < .001) and for women with limited prognoses (> or = 50% probability of dying in 5 years) (48% vs 32%; P = .02). These associations remained after multivariate analysis accounting for age, race, education, proxy report, and rural residence. CONCLUSIONS: Poorer older women with favorable prognoses are at risk of not receiving screening mammography when they are likely to benefit. Wealthier older women with limited prognoses are often screened when they are unlikely to benefit.     

Screening mammography participation and invitational strategy: the Quebec Breast Cancer Screening Program, 1998-2000

In the Quebec Breast Cancer Screening Program, a personalized letter signed by a regional program physician is sent to every woman in the province 50 to 69 years of age, inviting her to have a screening mammogram. A reminder letter is also frequently sent. The aim of this study was to evaluate the influence of this screening invitational strategy on rates of participation. The population studied was comprised of 684,028 women in Quebec aged 50-69. The baseline (expected) monthly mammography screening rate was estimated from the rate of screening mammograms recorded between the date a woman became eligible for screening and the mailing date of her personalized invitational letter; the observed monthly mammography screening rate was calculated after the mailing of the letter. Compared to baseline (expected) screening rates, observed rates were substantially increased (p<.05). The ratios of observed to expected rates were respectively 3.05 and 2.23 in the second and fourth months, respectively, after the letter mailing, coinciding with the mailing of the initial and reminder letters. In the twelve months after the mailing, the ratio of observed to expected rates was 1.68 (95% CI: 1.67-1.69). Twelve months following the mailing, 30 percent of the women who were letter recipients had undergone a screening mammography, compared to an expected cumulative probability of 20 percent for women not receiving a letter. The strength of this effect was similar to one seen in randomised controlled trials.