Pilot Study Shows Decision Aid Helps in Decision-Making Regarding Mammography Screening in Women Aged ≥ 75 Years
Although it is recommended that women aged ≥ 75 years be informed of the benefits and risks of mammography before being screened, it appears that this is not common practice. As reported in JAMA Internal Medicine by Schonberg et al, a decision aid developed by the investigators helped improved women’s decision-making about screening.
Study Details
The study involved women aged 75 to 89 years in a Boston academic primary care practice. Eligible women were English speaking, had not had a mammogram in 9 months but had been screened within the past 3 years, and did not have a history of dementia or invasive or noninvasive breast cancer. Of 84 women approached, 27 declined to participate, 12 were unable to complete the study for logistical reasons, and 45 participated.
The decision aid designed by the investigators provides information on the entire screening process, including follow-up tests and treatment. It includes information on breast cancer risk factors for women aged ≥ 75 years, health and life expectancy, likely outcomes if screened and not screened with mammography, competing mortality risks, breast cancer treatments, and a values clarification exercise. It also asks users about their intentions of being screened on a 15-point validated scale and invites users to share the information with their doctor.
Participants completed a pretest survey and read the decision aid before an appointment with their primary care physician and completed a post-test survey after the appointment. Medical records were reviewed for follow-up information.
Knowledge about mammography was assessed using a 10-question instrument, decisional conflict was assessed using a validated 16-item scale, and screening intentions were assessed using a 15-point validated scale. Preferred role in decision-making was assessed as shared, passive, or active. The post-test survey asked participants’ opinions regarding the decision aid.
Improved Knowledge and Reduced Intent to Be Screened
Participants had a median age of 79 years, 69% were white, and 60% had at least some college. Comparison of pretest and post-test results showed that knowledge of the benefits and risks of screening had significantly improved (P < .001) and that the proportion of participants who intended to be screened had significantly declined, from 82% to 56% (P = .03), including a reduction from 85% to 50% among women with life expectancy ≤ 9 years (n = 26, P = .004). There was also a trend toward reduced decisional conflict (P = .10).
Increased Discussion With Physicians
Within 6 months after use of the decision aid, 53% of participants had a primary care physician note documenting discussion of the risks and benefits of screening compared with 11% in the previous 5 years (P < .001). Whereas 84% of participants had undergone screening in the 2 years prior to study participation, 60% underwent screening within 15 months after participating at ≥ 2 years since their last mammogram (P = .01). Overall, 93% of participants reported that the decision aid was helpful.
The investigators concluded, “Findings from this pilot study suggest that we have developed a promising [decision aid] that may improve older women’s mammography screening decisions. In a small sample of older women, our [decision aid] improved their knowledge of the risks and benefits of mammography, led to fewer older women intending to be screened (particularly those with a short life expectancy), and possibly resulted in fewer women with a short life expectancy being screened. Providing the [decision aid] before a visit with a [primary care physician] may also have led to improved patient-physician communication about screening.”
Mara A. Schonberg, MD, MPH, of Beth Israel Deaconess Medical Center, is the corresponding author for the JAMA Internal Medicine article.
The study was supported by the Paul B. Beeson Career Development Award in Aging funded by the National Institute on Aging and by the John A. Hartford Foundation, the Atlantic Philanthropies, the Starr Foundation, and the American Federation for Aging Research. For full disclosures of the study authors, visit archinte.jamanetwork.com.
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