Older Patient Experiences in the Mammography Decision-Making Process

The benefit of mammography for breast cancer screening among women older than 75 years is unclear owing to competing comorbidity and lack of evidence.¹ In this area of uncertainty, an individualized approach to cancer screening that considers a patient's age, health status, and preferences is desirable.² Such an approach would optimize screening practices and avoid screening women unlikely to benefit; a phenomenon that may apply to 2 of every 5 mammograms in this age group.³

When considering cancer screening, shared decision making is particularly important for older persons. In the absence of evidence-based recommendations, patients should have the opportunity to discuss the pros and cons of screening with their health care providers. Individualizing cancer screening in this age group requires a balanced patient-provider conversation that considers patients' overall health, communicates the potential benefits and adverse outcomes of screening, and elicits patients' preferences. We conducted this study to (1) describe the patient-provider conversation surrounding screening mammography among women older than 75 years and (2) evaluate if the patients' perceptions of their health care providers' screening recommendations varied according to age and health status.

We analyzed responses from the breast cancer screening module within the DECISIONS study, a national random-digit dial telephone survey with a 51% weighted response rate, conducted between 2006 and 2007.⁴ Respondents were limited to those 40 years and older without a history of breast cancer. A complete description of the survey design, including questions, response scales, and survey weights, is available from the Inter-University Consortium for Political and Social Research.⁴

To account for the sampling design, weighted frequency comparisons were performed using PROC SURVEYFREQ (SAS version 9.2; SAS Institute Inc). These analyses compared the frequency with which women discussed reasons to have or not have a mammogram, whether their preferences were elicited, and if a physician recommendation was given across age (40-74 vs ≥75 years) and self-reported health (excellent to good vs fair to poor) groups.

Responses from 873 women were included; 10% were 75 years or older. Most women were white, had at least a high school education, and were insured. Annual income, self-reported health status, and perceived risk of breast cancer decreased with age.

Women 75 years and older were less likely to discuss reasons to have a mammogram than younger women (40-74 years, 92%, vs ≥75 years, 83%; P = .02). A discussion that included reasons not to have a mammogram (19% vs 21%; P = .81) or one that elicited a patient's screening preference (38% vs 39%; P = .93) was relatively uncommon across both age groups. The receipt of any health care provider recommendation did not vary by age (79% vs 78%; P = .92) and was nearly always in favor of screening (99% vs 98%; P = .35; Table).

Compared with women in excellent-good health, women in fair-poor health were as likely to discuss reasons to have a mammogram (fair to poor, 94%, vs excellent to good, 91%; P = .32) or not have a mammogram (12% vs 21%; P = .09). A discussion that elicited a patient's screening preference (41% vs 38%; P = .64) or the receipt of a recommendation to undergo screening (99% vs 98%; P = .35) did not vary according to health status. When restricting this analysis to patients 75 years and older and evaluating these same end points across health status groups, similar results were observed.

Older patients are concerned about how screening and treatment will or will not affect their overall survival and independence.⁵ Unfortunately, we found that health care providers were less likely to discuss the reasons to undergo screening mammography with women 75 years or older and infrequently discussed reasons to not undergo mammography. Furthermore, only 39% believed that their health care providers sought their preferences about screening mammography. This imbalance in counseling was mirrored in health care providers' universally recommending screening mammography across health or age groups.

This failure to discuss “the good with the bad” of mammographic screening or consider a patient's likelihood to benefit when making recommendations could lead to screening women unlikely to benefit. Studies based on the National Health Interview Survey and regional populations suggest that women older than 74 years receive screening mammograms despite poor health status and may account for up to 40% of women who receive screening in this age group.⁶ Lack of clinical time, sensitivity of the discussion, and the position of mammography in popular culture may all contribute to a suboptimal patient-provider discussion surrounding mammography use or screening cessation.⁷

To address this issue, we must create patient-centered decision aids that facilitate an informed cancer screening discussion between patients and health care providers. System-level incentives should allow time for dedicated wellness visits, include electronic reminders to discuss rather than order screening tests, and involve a more thoughtful tailoring of performance measures toward appropriate, patient-centered testing.⁸

Correspondence: Dr Fox, Robert Wood Johnson Foundation Clinical Scholars Program, Yale University School of Medicine, 333 Cedar St, Room SHM 1E-61, PO Box 208088, New Haven, CT 06520-8088 (justin.p.fox@yale.edu).

Author Contributions:Study concept and design: Fox and Gross. Acquisition of data: Zikmund-Fisher. Analysis and interpretation of data: Fox and Zikmund-Fisher. Drafting of the manuscript: Fox. Critical revision of the manuscript for important intellectual content: Zikmund-Fisher and Gross. Statistical analysis: Fox. Study supervision: Gross.

Funding/Support: Drs Fox and Gross are involved with the Clinical Scholar's Program, which is supported by the Robert Wood Johnson Foundation. Dr Zikmund-Fisher is supported by a career development award from the American Cancer Society (MRSG-06-130-01-CPPB). The DECISIONS study was funded by the Foundation for Informed Medical Decision Making.