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Comment & Response
September 14, 2020

Decision Aids and the Absence of Expected Longevity Benefits of Mammography Screening in Women 75 Years and Older—Reply

Author Affiliations
  • 1Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 2Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill
JAMA Intern Med. Published online September 14, 2020. doi:10.1001/jamainternmed.2020.3617

In Reply In their letter about our cluster randomized clinical trial of a mammography screening decision aid (DA) for women 75 years and older,1 Donzelli and Giudicatti recommended that the DA be more explicit about the lack of data that mammography screening extends life. To inform the DA, we reviewed outcomes from mammography screening trials and from simulation models. A 2016 meta-analysis of mammography screening trials found a 33% reduction in breast cancer mortality with screening for women 60 to 69 years (risk ratio [RR], 0.67 [95% CI, 0.54-0.83]) and a 20% reduction in breast cancer mortality for women 70 to 74 years (RR, 0.80 [95% CI, 0.51-1.28]).2 This same meta-analysis found no reduction in all-cause mortality for breast cancer screening, but there was a trend for a reduction in all-cause mortality in older women (for women 60 to 69 years [RR, 0.97; 95% CI, 0.90-1.04; I2 = 0%; P = .65] and for women 70 to 74 years [RR, 0.98; 95% CI, 0.86-1.14; I2 = 72.4%; P = .06]). An Australian simulation model found that, out of 1000 women aged 69 years who continued to undergo biennial mammography screening over 10 years compared with 1000 women who stopped screening at age 69, 2 fewer women screened died of breast cancer (6 vs 8) and that 2 fewer women screened died overall over 10 years (206 vs 208).3 Based on these data, our DA states that “physicians are unsure that having a mammogram will lower the chances of dying from breast cancer.”1 The DA does not differentiate breast cancer death from overall death because in pilot testing we learned that this is a very sophisticated concept for older women and made the DA harder to understand. Fortunately, the current DA was found to be acceptable and clear to older women and to primary care–based staff who may be asked to deliver the DA.1,4

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