Research Project 1: Comparative Effectiveness of Screening Mammography for Women with Limited Life Expectancy
Monique Pappadis, PhD
Dr. Pappadis is an Assistant Professor, Division of Rehabilitation Sciences in the School of Health Professions at UTMB. Visit Dr. Pappadis' web bio. Her research areas include ethnic minority health and behavioral health disparities as well as psychosocial adjustment to disability.
Conduct a systematic review of the impact of screening mammography in older women, including evidence from randomized trials, observational studies, and qualitative studies.
Evaluate the comparative effectiveness of screening mammography on breast cancer outcomes in Medicare beneficiaries ages 67 and older based on estimated life expectancy, using Medicare claims and cancer registry data.
Qualitative assessment of patient and physician perceptions on screening harms and their impact on screening mammography decisions in women 70 years and older.
While all medical professional organizations recommend annual or biennial screening mammography for women 50-69 years, recommendations differ for older age groups, reflecting uncertainty about the benefits of screening as women age. Many organizations do not include an upper age limit for screening mammography, while the USPSTF and American College of Physicians do not make recommendations for women ages 75 and older, citing insufficient evidence.
Randomized controlled trials have excluded women older than 74 years, and only one trial included women aged 70-74. This trial found no benefit for older women assigned to screening, but the number enrolled in this age group was low. Therefore, there is little direct evidence of a screening benefit in women 70 years and older, and additional trials in older women are not likely. Indirect evidence from observational and modeling studies suggests that extending screening to women older than 70 years may be beneficial, but results have been inconsistent. A comprehensive review of the literature on breast cancer screening in older women is needed in order to synthesize the available evidence and identify gaps. Previous systematic reviews were limited to randomized controlled trials, or decision-analytic models and did not focus on older women.
The goal and primary benefit of screening mammography is to prevent deaths from breast cancer. The harms of screening mammography include pain and anxiety, abnormal results leading to additional diagnostic procedures, costs, complications, and overdiagnosis. Overdiagnosis is the detection of cancers that would not have become clinically significant during a woman's lifetime. In such cases, women must endure a cancer diagnosis, unnecessary treatment, and reduced quality of life. The balance of benefits and harms of screening mammography depends on life expectancy and individual preference. However, older women are a heterogeneous population, and life expectancy varies considerably based on comorbid conditions, functional status, cognitive status, and sociodemographic factors. For some women, the harms caused by additional diagnoses and treatments may be substantial, while the benefits are theoretically small.
A recent survey of US adults found that most women considered themselves well-informed about breast cancer screening. However, women consistently overestimated the risks of being diagnosed with and dying from breast cancer. In addition, many older women are unaware of any risks of screening. These findings may explain why as many as 40-50% of older women in very poor health continue to undergo screening mammography despite the substantial risks and remote benefits. At the same time, many older women in very good health do not undergo screening. In addition, racial and socioeconomic disparities exist in mammography use among healthy older women. Differences in knowledge about cancer and cancer prevention contribute to disparities in mammography use. Decision support may improve the quality of decision making and reduce disparities in screening mammography.