Mulling over mammography: Decision aid helps older women make screening choice

A decision aid may improve the decision making process of women 75 years and older regarding mammography screening, according to a study published on Dec. 20 in JAMA Internal Medicine.

Currently, decision support does not exist for women 75 years and older to help them decide if they should undergo mammography screening. Recommendations from organizations such as the American Cancer Society and the U.S. Preventive Services Task Force are inconclusive about screening for older women, which could benefit some who are at risk of major morbidity from the disease but cause more harm than good for others.

Decision aids help patients learn more about medical interventions and provide in-depth explanations of options and outcomes of particular medical decisions. The study’s lead author, Mara A. Schonberg, MD, MPH, of Harvard Medical School in Boston, and colleague wrote of the informational tools: “The use of [decision aids] has been shown to improve medical decision making, and they are especially recommended when the ratio of benefits to risks of an intervention is uncertain, as is the case for mammography screening among women 75 years and older.”

Using international standards, Schonberg and colleagues thus created a thorough and easily readable decision aid for women of older age who were considering mammography in order to educate them about the risks and benefits of the screening modality. The aid was then evaluated in a pilot pretest-posttest trial to assess its effects on older women’s mammography knowledge, decisional conflict, and ultimate screening decisions. The study’s authors also examined the distribution of the aid to patients before a clinic visit to determine if it led to a more balanced discussion with their primary care physician (PCP) about mammography.

The study’s population was composed of 45 women between the ages of 75 and 89 who had undergone mammography in the past three years but had not had the screening in nine months. The participants completed a pretest survey and read the decision aid before an appointment with their PCP. A posttest survey was filled out after their appointment and the researchers reviewed their medical records for follow-up information.

Comparison between posttest and pretest results indicated that knowledge of the benefits and risks of mammography screening improved amongst the participants. During the pretest, 82 percent of the women wanted to undergo screening while only 56 percent indicated that they intended to get a mammogram during the posttest.

While decisional conflict did decrease, the decline was not significant. Six months after the study, 53 percent of the participants had a PCP document a discussion about the risks and benefits associated with screening. Before the study was performed, only 11 percent of the patients had PCP documentation of a dialogue concerning the risks and benefits of mammography within the previous five years. Though 84 percent of the women had been screened within two years of the study, only 60 percent were screened within 15 months after the study was completed.

Overall, 93 percent of the participants considered the decision aid helpful.

“The [decision aid] may lead to improved decision making regarding mammography, especially among older women with a short life expectancy who are least likely to benefit and are at greater risk of being harmed from screening,” wrote the Schonberg and colleagues.

The study’s authors plan to test the efficacy of the aid in a large randomized clinical trial in the future.