Publications

IMPORTANCE: Guidelines recommend individualizing screening mammography decisions for women aged 75 years and older. However, little pragmatic guidance is available to help counsel patients.

OBJECTIVE: To provide an evidence-based approach for individualizing decision-making about screening mammography in older women.

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 aged 65 years and older and to quantify the benefits and harms of screening mammography for women aged 75 years and older.

FINDINGS: Age 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 RELEVANCE: For 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.

IMPORTANCE: Guidelines recommend that women 75 years and older should be informed of the benefits and risks of mammography before being screened. However, few are adequately informed.

OBJECTIVES: To develop and evaluate a mammography screening decision aid (DA) for women 75 years and older.

DESIGN: We designed the DA using international standards. Between July 14, 2010, and April 10, 2012, participants completed a pretest survey and read the DA before an appointment with their primary care physician. They completed a posttest survey after their appointment. Medical records were reviewed for follow-up information.

SETTING AND PARTICIPANTS: Boston, Massachusetts, academic primary care practice. Eligible women were aged 75 to 89 years, 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.

INTERVENTIONS: The DA includes information on breast cancer risk, life expectancy, competing mortality risks, possible outcomes of screening, and a values clarification exercise.

MAIN OUTCOMES AND MEASURES: Knowledge of the benefits and risks of screening, decisional conflict, and screening intentions; documentation in the medical record of a discussion of the risks and benefits of mammography with a primary care physician within 6 months; and the receipt of screening within 15 months. We used the Wilcoxon signed rank test and McNemar test to compare pretest-posttest information.

RESULTS: The median age of participants was 79 years, 69% (31 of 45) were of non-Hispanic white race/ethnicity, and 60% (27 of 45) had attended at least some college. Comparison of posttest results with pretest results demonstrated 2 findings. First, knowledge of the benefits and risks of screening improved (P < .001). Second, fewer participants intended to be screened (56% [25 of 45] afterward compared with 82% [37 of 45] before, P = .03). Decisional conflict declined but not significantly (P = .10). In the following 6 months, 53% (24 of 45) of participants had a primary care physician note that documented the discussion of the risks and benefits of screening compared with 11% (5 of 45) in the previous 5 years (P < .001). While 84% (36 of 43) had been screened within 2 years of participating, 60% (26 of 43) were screened within 15 months after participating (≥ 2 years since their last mammogram) (P = .01). Overall, 93% (42 of 45) found the DA helpful.

CONCLUSIONS AND RELEVANCE: A DA may improve older women's decision making about mammography screening.

BACKGROUND: Prostate-specific antigen (PSA) screening for prostate cancer remains controversial. Most groups recommend informed decision making for men with 10 years of remaining life expectancy. The primary objective of this observational cohort study was to investigate the association between predicted 9-year mortality and prostate cancer screening among American men aged ≥65 years in 2005 and 2010. The second objective was to analyze the proportions of men who discussed screening with their physicians.

METHODS: Data were extracted from the 2005 and 2010 National Health Interview Surveys. Men aged ≥65 years without prostate cancer were divided into predicted 9-year mortality quartiles. The proportions of men confirming a screening PSA within the prior year were determined. Logistic regression was used to compare screening rates.

RESULTS: Screening rates for men aged ≥65 years were 48% in 2005 and 48% in 2010 (P = .9). Men ages 65 to 74 years who had <27% predicted 9-year mortality were most commonly screened, with 56% screened in 2010, compared with 34% of men aged ≥75 years with >75% predicted 9-year mortality. Approximately 55% of screened men aged ≥75 years who had ≥53% predicted 9-year mortality recalled discussing the advantages of screening, whereas 25% recalled discussing the disadvantages.

CONCLUSIONS: Prostate cancer screening with PSA did not differ significantly between 2005 and 2010 for men aged ≥65 years based on predicted 9-year mortality. Approximately 33% of older men with a high likelihood of 9-year mortality were screened despite minimal clinical benefit. Twice as many men recalled discussing the potential advantages of screening compared with the disadvantages. Cancer 2014;120:1491-1498. © 2014 American Cancer Society.

BACKGROUND: Little is known about older women's experience with a benign breast biopsy.

OBJECTIVES: To examine the psychological impact and experience of women ≥ 65 years of age with a benign breast biopsy.

DESIGN: Prospective cohort study using quantitative and qualitative methods.

SETTING: Three Boston-based breast imaging centers.

PARTICIPANTS: Ninety-four English-speaking women ≥ 65 years without dementia referred for breast biopsy as a result of an abnormal mammogram, not aware of their biopsy results at baseline, and with a subsequent negative biopsy.

MEASUREMENTS: We interviewed women at the time of breast biopsy (before women knew their results) and 6 months post-biopsy. At both interviews, participants completed the validated negative psychological consequences of screening mammography questionnaire (PCQ, scores range from 0 to 36 [high distress], PCQ ≥ 1 suggests a psychological consequence, PCQs <1 are reported at time of screening) and women responded to open-ended questions about their experience. At follow-up, participants described the quality of information received after their benign breast biopsy. We used a linear mixed effects model to examine if PCQs declined over time. We also reviewed participants' open-ended comments for themes.

RESULTS: Overall, 88% (83/94) of participants were non-Hispanic white and 33% (31/94) had a high-school degree or less. At biopsy, 76% (71/94) reported negative psychological consequences from their biopsy compared to 39% (37/94) at follow-up (p < 0.01). In open-ended comments, participants noted the anxiety (29%, 27/94) and discomfort (28%, 26/94) experienced at biopsy (especially from positioning on the biopsy table). Participants requested more information to prepare for a biopsy and to interpret their negative results. Forty-four percent (39/89) reported at least a little anxiety about future mammograms.

CONCLUSIONS: The high psychological burden of a benign breast biopsy among older women significantly diminishes with time but does not completely resolve. To reduce this burden, older women need more information about undergoing a breast biopsy.

OBJECTIVES: To examine receipt of mammography screening according to life expectancy in women aged 75 and older.

DESIGN: Population-based survey.

SETTING: United States.

PARTICIPANTS: Community dwelling U.S. women aged 75 and older who participated in the 2008 or 2010 National Health Interview Survey.

MEASUREMENTS: Using a previously developed and validated index, women were categorized according to life expectancy (>9, 5-9, <5 years). Receipt of mammography screening in the past 2 years was examined according to life expectancy, adjusting for sociodemographic characteristics, access to care, preventive orientation (e.g., receipt of influenza vaccination), and receipt of a clinician recommendation for screening.

RESULTS: Of 2,266 respondents, 27.1% had a life expectancy of greater than 9 years, 53.4% had a life expectancy of 5 to 9 years, and 19.5% had a life expectancy of less than 5 years. Overall, 55.7% reported receiving mammography screening in the past 2 years. Life expectancy was strongly associated with receipt of screening (P < .001), yet 36.1% of women with less than 5 years life expectancy were screened, and 29.2% of women with more than 9 years life expectancy were not screened. A clinician recommendation for screening was the strongest predictor of screening independent of life expectancy. Higher educational attainment, age, receipt of influenza vaccination, and history of benign breast biopsy were also independently associated with being screened.

CONCLUSION: Despite uncertainty of benefit, many women aged 75 and older are screened with mammography. Life expectancy is strongly associated with receipt of screening, which may reflect clinicians and patients appropriately considering life expectancy in screening decisions, but 36% of women with short life expectancies are still screened, suggesting that new interventions are needed to further improve targeting of screening according to life expectancy. Decision aids and guidelines encouraging clinicians to consider patient life expectancy in screening decisions may improve care.

RATIONALE: Inpatient consultation by specialists is one of the most common medical interventions in the modern intensive care unit (ICU), but few data exist on components of high-quality consultation.

OBJECTIVES: Our objective was to use qualitative methods to develop a conceptual framework of consultative quality in critically ill patients.

METHODS: We conducted a qualitative study of medical ICU physicians at a single institution using a novel, semistructured interview guide. We elicited physicians' attitudes toward processes of obtaining specialty consultation, identified perceived elements of high-quality consults, and identified barriers to obtaining high-quality consults. We used grounded theory to identify themes.

MEASUREMENTS AND MAIN RESULTS: ICU physicians described four common reasons for involving a consulting physician: the need for clinical or procedural expertise, an explicit or implicit protocol of the institution mandating the consult, an opportunity to provide education to the primary or consulting team, and/or at the family's request. Participants identified seven components of a high-quality consult, including the consulting teams' (1) decisiveness, (2) thoroughness, (3) level of interest, (4) professionalism, (5) expertise, (6) timeliness, and (7) involvement with the family of the patient. The intensive care team, the consult team, the health system, and the temporal context in which the consultation takes place may influence the quality of the consultation.

CONCLUSIONS: Several key factors are necessary for a consult to be judged high quality. An opportunity exists to develop an instrument to assess and to improve specialty consultations in the ICU based on these findings.

CONTEXT: To better target services to those who may benefit, many guidelines recommend incorporating life expectancy into clinical decisions.

OBJECTIVE: To assess the quality and limitations of prognostic indices for mortality in older adults through systematic review.

DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane, and Google Scholar from their inception through November 2011.

STUDY SELECTION: We included indices if they were validated and predicted absolute risk of mortality in patients whose average age was 60 years or older. We excluded indices that estimated intensive care unit, disease-specific, or in-hospital mortality.

DATA EXTRACTION: For each prognostic index, we extracted data on clinical setting, potential for bias, generalizability, and accuracy.

RESULTS: We reviewed 21,593 titles to identify 16 indices that predict risk of mortality from 6 months to 5 years for older adults in a variety of clinical settings: the community (6 indices), nursing home (2 indices), and hospital (8 indices). At least 1 measure of transportability (the index is accurate in more than 1 population) was tested for all but 3 indices. By our measures, no study was free from potential bias. Although 13 indices had C statistics of 0.70 or greater, none of the indices had C statistics of 0.90 or greater. Only 2 indices were independently validated by investigators who were not involved in the index's development.

CONCLUSION: We identified several indices for predicting overall mortality in different patient groups; future studies need to independently test their accuracy in heterogeneous populations and their ability to improve clinical outcomes before their widespread use can be recommended.

BACKGROUND: Data are needed on how life expectancy affects treatment decisions among women ≥80 years with early stage breast cancer. METHODS: We used the linked Surveillance Epidemiology and End Results-Medicare claims dataset from 1992-2005 to identify women aged ≥80 newly diagnosed with lymph node negative, estrogen receptor positive tumors, ≤5 centimeters. To estimate life expectancy, we matched these women to women of similar age, region, and insurance, not diagnosed with breast cancer. We examined 5-year mortality of matched controls by illness burden (measured with the Charlson Comorbidity Index [CCI]) using Kaplan-Meier statistics. We examined treatments received by estimated life expectancy within CCI levels. We further examined factors associated with receipt of radiotherapy after breast conserving surgery (BCS). RESULTS: Of 9,932 women, 39.6% underwent mastectomy, 30.4% received BCS plus radiotherapy, and 30.0% received BCS alone. Estimated 5-year mortality was 72% for women with CCIs of 3+, yet 38.0% of these women underwent mastectomy and 22.9% received radiotherapy after BCS. Conversely, estimated 5-year mortality was 36% for women with CCIs of 0 and 26.6% received BCS alone. Age 80-84, urban residence, higher grade, recent diagnosis, mammography use, and low comorbidity, were factors associated with receiving radiotherapy after BCS. Among women with CCIs of 3+ treated with BCS, 36.9% underwent radiotherapy. CONCLUSIONS: Many women aged ≥80 with limited life expectancies receive radiotherapy after BCS for treatment of early stage breast cancers while many in excellent health do not. More consideration needs to be given to patient life expectancy when considering breast cancer treatments. KEY WORDS: Breast cancer, older women, treatment, life expectancy, radiation.