Given Risk-Benefit Data, Women Age 70 Opt for Routine Mammography

SYDNEY, Australia, Oct. 25 -- Seventy-year-old women resoundingly endorsed yearly mammography, rejecting the minuses that were pointed out of them, found investigators here.
The women chose to continue having an annual mammogram after studying a decision booklet citing mammography pros and cons for women their age. Alexandra Barratt, M.B.B.S., Ph.D., of the University of Sydney, and colleagues, reported in the Oct. 22 issue of the Archives of Internal Medicine.
Although better informed than a control group and able to make an informed choice, 95% of the women remained positive about continued screening, they found.
But just as many women in the control group, who received only standard information, also chose to continue screening, the researchers wrote.
Screening is generally recommended for women ages 50 to 69, but for women 70 years or older, in whom harm starts to outweigh benefit, recommendations are less clear.
For example, the U.S. Preventive Services Task Force notes that a mortality benefit from screening is still likely for women older than 70, if life expectancy is not compromised by comorbid disease.
On the other hand, there are concerns about detecting and treating cancers in older women, which, without screening, would not have affected patients' health or life expectancy.
Evaluating the risk and benefits of further screening may be difficult for individual women, and there are no evaluated decision support tools to assist them, the researchers said.
The researchers assessed 734 women in a population-based, randomized controlled trial in New South Wales, Australia. The trial was conduced from August 2005 to June 2006.
Women age 70 who had regularly participated in mammography screening were eligible for the trial. Women in the intervention group (367) received the decision aid, while those in the control group (367) received standard information available from the screening program.
The decision aid, a booklet with information, charts, and worksheets provided a clear, detailed presentation of the risks, benefits, options, and the chances of the possible outcomes for each choice.
For example, according to one of the scenarios, screening 1,000 women 70 or older over the next 10 years would result in:
Two fewer women dying of breast cancer as a result of screening.
15 more women diagnosed with breast cancer, but some of these cancers would never have been found without screening.
135 women having extra tests after an abnormal mammogram, although they do not have breast cancer. However, they may worry.
824 women being correctly reassured that they do not have breast cancer.
Women who received the decision aid were better informed than the control group. The mean increase in knowledge out of a score of 10, was 2.62 for the intervention group versus 0.68 for the control group (P<0.001), the researchers reported.
Furthermore, a significantly greater percentage made what they called an informed choice (73.5% versus 48.8%; P<0.001).
The decision aid did not increase anxiety and slightly reduced decisional conflict, they said.
Women in the intervention group were less likely to be undecided about screening (odds ratio, 0.32, 95% confidence interval, 0.17-0.63, P<0.001).
Among those women who had made a decision about screening, the decision aid did not alter the odds of intending to stop screening (OR, 1.28, CI 0.63-2.61, P=0.02), the researchers reported.
Of the women randomized to the decision aid, 94.7% remained positive about continuing screening, the researchers reported. In the control group, 95.9% were also positive about screening (P=0.50).
One month after the intervention, there was no difference in the percentage of women who had participated in screening between the two groups. Actually, at this time few women had actually had a mammogram, but most indicated that they were in the process of making appointments for screening.
In an accompanying editorial, Louise C. Walter, M.D., of the VA Medical Center and the University of California San Francisco, and Carmen L. Lewis, M.D., of the University of North Carolina, wrote, "Is this high enthusiasm for screening among women in this age group appropriate?"
Currently many patients, even elderly women in poor health, do not make informed decisions about screening because they downplay the potential harm of screening.
Decision aids are a promising tool, they said, although many questions remain unanswered about how to present the information and the integration of decision aids into medical practice.
Further evaluation of strategies to best address the information needs of the diverse elderly population is needed to ensure that older adults are not left behind when it comes to maximizing informed decision making," Drs. Walter and Lewis wrote.
No financial conflicts were reported by the study authors. The study was supported by a grant from the National Health and Medical Research Council of Australia. The sponsor had no role in the design, analysis, or interpretation of the study, or the preparation, review, or approval of the manuscript.
The editorial writers reported no financial conflicts. Their work was supported by a grant from the National Health and Medical Research Council of Australia. The views expressed in this article did not necessarily reflect the position of the Department of Veterans Affairs. Primary source: Archives of Internal MedicineSource reference: Mathieu E, et al "Informed Choice in Mammography Screening: A Randomized Trial of a Decision Aid for 70-Year-Old Women" Arch Intern Med 2007; 167: 2039-2046. Additional source: Archives of Internal MedicineSource reference: Walter LC, Lewis CL, "Maximizing Informed Cancer Screening Decisions" Arch Intern Med 2007; 167: 2027-2028.