Supporting breast cancer screening decisions for caregivers of older women with dementia: study protocol for a randomized controlled trial

BACKGROUND: Alzheimer's disease and related dementias (ADRD) impact a woman's life expectancy and her ability to participate in medical decision-making about breast cancer screening, necessitating the involvement of family caregivers. Making decisions about mammography screening for women with ADRD is stressful. There are no data that suggest that breast cancer screening helps women with ADRD live longer or better. Decision aids may improve the quality of decision-making about mammography for ADRD patients and may inform family caregivers about the risks, benefits, and need for decision-making around mammography screening. METHODS/DESIGN: The Decisions about Cancer Screening in Alzheimer's Disease (DECAD) trial, a randomized controlled clinical trial, will enroll 426 dyads of older women with ADRD (≥75 years) and a family caregiver from clinics and primary-care practices in Indiana to test a novel, evidence-based decision aid. This decision aid includes information about the impact of ADRD on life expectancy, the benefit of mammograms, and the impact on the quality of life for older women with ADRD. Dyads will be randomized to receive the decision aid or active control information about home safety. This trial will examine the effect on the caregiver's decisional conflict (primary outcome) and the caregiver's decision-making self-efficacy (secondary outcome). A second follow-up at 15 months will include a brief, semi-structured interview with the caregiver regarding the patient's experience with mammograms and decision-making about mammograms. At the same time, a review of the patient's electronic medical record (EMR) will look at discussions about mammography with their primary-care physician and mammogram orders, receipt, results, and burden (e.g., additional diagnostic procedures due to false-positive results, identification of an abnormality on the screening exam but further work-up declined, and identification of a clinically unimportant cancer). A third follow-up at 24 months will extract EMR data on mammogram orders, occurrences, results, and the burden of mammograms. DISCUSSION: We hypothesize that caregivers who receive the decision aid will have lower levels of decisional conflict and higher levels of decision-making self-efficacy compared to the control group. We also hypothesize that the DECAD decision aid will reduce mammography use among older women with ADRD

Factors influencing elderly women's mammography screening decisions: implications for counseling

<p>Abstract</p> <p>Background</p> <p>Although guidelines recommend that clinicians consider life expectancy before screening older women for breast cancer, many older women with limited life expectancies are screened. We aimed to identify factors important to mammography screening decisions among women aged 80 and older compared to women aged 65–79.</p> <p>Methods</p> <p>Telephone surveys of 107 women aged 80+ and 93 women aged 65–79 randomly selected from one academic primary care practice who were able to communicate in English (60% response rate). The survey addressed the following factors in regards to older women's mammography screening decisions: perceived importance of a history of breast disease, family history of breast cancer, doctor's recommendations, habit, reassurance, previous experience, mailed reminder cards, family/friend's recommendations or experience with breast cancer, age, health, and media. The survey also assessed older women's preferred role in decision making around mammography screening.</p> <p>Results</p> <p>Of the 200 women, 65.5% were non-Hispanic white and 82.8% were in good to excellent health. Most (81.3%) had undergone mammography in the past 2 years. Regardless of age, older women ranked doctor's recommendations as the most important factor influencing their decision to get screened. Habit and reassurance were the next two highly ranked factors influencing older women to get screened. Among women who did not get screened, women aged 80 and older ranked age and doctor's counseling as the most influential factors and women aged 65–79 ranked a previous negative experience with mammography as the most important factor. There were no significant differences in preferred role in decision-making around mammography screening by age, however, most women in both age groups preferred to make the final decision on their own (46.6% of women aged 80+ and 50.5% of women aged 65–79).</p> <p>Conclusion</p> <p>While a doctor's recommendation is the most important factor influencing elderly women's mammography screening decisions, habit and reassurance also strongly influence decision-making. Interventions aimed at improving clinician counseling about mammography, which include discussions around habit and reassurance, may result in better decision-making.</p

Screening Mammography in Older Women

IMPORTANCE: Guidelines recommend individualizing screening mammography decisions for women 75 and older. However, little pragmatic guidance is available to inform this approach. OBJECTIVE: To provide an evidence-based approach to individualizing decision-making about screening mammography that considers older women's risk of breast cancer and the potential benefits and harms of screening in the context of varying life expectancies and preferences. EVIDENCE ACQUISITION: We searched PubMed for English-language studies in peer-reviewed journals published from January 1, 1990 to February 1, 2014 to identify risk factors for late-life breast cancer in women 65 and older and to quantify the benefits and harms of screening mammography for women 75 and older. FINDINGS: Age is the major risk factor for late-life breast cancer. In general, traditional breast cancer risk factors (e.g., age at first birth, age at menarche) that represent hormonal exposures in the distant past are less predictive of late-life breast cancer than factors indicating recent exposure to endogenous hormones (e.g., bone mass, obesity). None of the randomized trials of screening mammography included women over age 74, such that it is uncertain whether screening mammography is beneficial in these women. Observational data favor extending screening mammography to older women who have a life expectancy > 5-10 years. Modeling studies suggest approximately 2 fewer women per 1,000 die from breast cancer if women in their 70's continue biennial screening for 10 years, versus stopping screening at age 69. Potential benefits must be weighed with potential harms of continued screening over ten years, which include false-positive mammograms (~200 per 1,000 women screened) and overdiagnosis (~13 per 1,000 women screened). Providing these frequencies both verbally and graphically may help inform older women's decision-making. CONCLUSIONS AND RELEVANCE: For women with less than a 5-10 year life expectancy, recommendations to stop screening mammography should be framed around increased harms and the need to refocus health promotion on interventions likely to be beneficial over a shorter timeframe. For women with a life expectancy > 5-10 years, the decision about whether potential benefits of screening outweigh harms is a value judgment that requires a realistic understanding of screening outcomes

Screening Mammography in Older Women: A Review

ImportanceGuidelines recommend individualizing screening mammography decisions for women aged 75 years and older. However, little pragmatic guidance is available to help counsel patients.ObjectiveTo provide an evidence-based approach for individualizing decision-making about screening mammography in older women.Evidence acquisitionWe searched PubMed for English-language studies in peer-reviewed journals published from January 1, 1990, to February 1, 2014, to identify risk factors for late-life breast cancer in women aged 65 years and older and to quantify the benefits and harms of screening mammography for women aged 75 years and older.FindingsAge is the major risk factor for developing and dying from breast cancer. Breast cancer risk factors that reflect hormonal exposures in the distant past, such as age at first birth or age at menarche, are less predictive of late-life breast cancer than factors indicating recent hormonal exposures such as high bone mass or obesity. Randomized trials of the benefits of screening mammography did not include women older than 74 years. Thus it is not known if screening mammography benefits older women. Observational studies favor extending screening mammography to older women who have a life expectancy of more than 10 years. Modeling studies estimate 2 fewer breast cancer deaths/1000 women who in their 70s continue biennial screening for 10 years instead of stopping screening at age 69. Potential harms of continued screening over 10 years include false-positive mammograms in approximately 200/1000 women screened and overdiagnosis (ie, finding breast cancer that would not have clinically surfaced otherwise) in approximately 13/1000 women screened. Providing information about life expectancy along with potential benefits and harms of screening may help older women's decision-making about screening mammography.Conclusions and relevanceFor women with less than a 10-year life expectancy, recommendations to stop screening mammography should emphasize increased potential harms from screening and highlight health promotion measures likely to be beneficial over the short term. For women with a life expectancy of more than 10 years, deciding whether potential benefits of screening outweigh harms becomes a value judgment for patients, requiring a realistic understanding of screening outcomes

Preventive health care among older women: missed opportunities and poor targeting

BACKGROUND: Experts recommend that clinicians target mammography and colon cancer screening to individuals with at least 5 years life expectancy. Generally, immunizations and exercise counseling are recommended for all women aged ≥65 years, while Pap smears are generally not encouraged for these women. METHODS: We used the 2005 National Health Interview Survey to examine receipt of several preventive health measures simultaneously among community dwelling US women aged ≥65 years by age and health status. We used functional status, significant diseases, and perceived health to categorize women into those most likely to be in above-average, average, or below-average health status. We used age and health status to estimate life expectancy. RESULTS: Of 4683 participants, 25.8% were ≥80 years; 81.8% were non-Hispanic white; 21% were in above-average and 20% were in below-average health status. Receipt of mammography and colon cancer screening decreased with age and was not associated with health status for women aged ≥80 years. Nearly half (49%) of women aged ≥80 years in below-average health received mammography screening, while 19% of women aged 65-79 years in above-average health did not report receiving mammography. Nearly half of women aged 65-79 years (49%) in above-average health did not report receiving colon cancer screening. Pap smear screening was common among older women. Few (34%) reported receiving exercise counseling. Many did not report receiving pneumococcal (43%) or flu vaccinations (40%). CONCLUSIONS: In our comprehensive review of preventive health measures for older women, we found evidence to suggest a need to improve delivery and targeting of preventive health services