Our study explored the complex nature of decision making about mammography screening for women aged 80 or older. We identified several content areas and consistent emerging themes that influenced women aged 80 or older's screening decisions including physician's influence, patient preferences, system factors, and social influences. We found that some women aged 80 or older have strong opinions about whether or not to get screening mammography, while others appear to follow their doctor's or daughter's recommendations. Some physicians individualize their discussions about screening to oldest-old women, others generally encourage screening unless a patient has a very short life expectancy; and few discourage screening. Physicians feel that discussing stopping screening with women aged 80 or older is difficult because the discussions can be uncomfortable and time consuming. Many requested more data about the benefits and risks of mammography screening for women aged 80 or older to facilitate these discussions.
To date no studies have explored factors influencing mammography screening decisions among women aged 80 and older. Several studies have examined factors that influence screening decisions among younger women.23–25
Nekhlyudov et al.24
explored decision-making around screening among 16 women aged 38 to 45 without prior screening mammograms and found that decisions for screening were motivated by the media, medical providers, other women with breast cancer, and psychosocial factors. Salazar and Moor25
explored decision making around mammography screening among 87 working women aged 39 to 75 and found that challenges arranging mammography screening, fear of breast cancer or breast cancer treatment, the cost of screening, and the influence of a health care provider, among other factors, influenced screening decisions. We found that some of the factors that influenced younger women's screening decisions also influenced women aged 80 or older's screening decisions (e.g., doctor's recommendation, perceived risk of breast cancer); however, we also found that other factors were important to women aged 80 or older (e.g., habit, functional status, personal history of breast disease, or daughter's recommendation). We also found that some factors that appeared to influence younger women's decisions may be less important to older women (e.g., media, cost of mammography).
Since prior studies have generally found that elderly women more than younger women defer medical decisions to their physicians,26–28
we were interested to learn that many women aged 80 or older had their own opinions about whether or not they should be screened with mammography. In the future, we will determine which factors are most important to women aged 80 or older when considering mammography screening and how the importance of these factors differs for women aged 80 or older compared with younger women. Our goal is to help patients make decisions about mammography screening in accordance with their values and preferences and to insure that screening is targeted to those most likely to benefit.
We were somewhat surprised to find how enthusiastic some women aged 80 or older were about mammography screening, especially when there is no clinical trial data demonstrating a mortality benefit for these women. Our results may have been biased toward enthusiasm for screening, since women who agreed to participate in our study were more likely to have been screened with mammography in the past 2 years than those who refused to participate. The enthusiasm expressed by many oldest-old women in our study may be a result of years of messages from public health officials, physicians, and advocacy groups, persuading women about the importance of mammography screening. Schwartz et al.29
recently sampled a random sample of U.S. adults and found that 87% believed routine cancer screening is almost always a good idea and 41% of women felt it was irresponsible of an 80-year-old woman to choose not to be screened with mammography. Public health messages about mammography screening in the future may need to present a more balanced picture of the benefits and risks to insure informed decision-making, particularly for the oldest-old.
Interestingly, daughters of the oldest-old appear to play an important role in their mother's decisions around mammography screening. Experts have described that medical decision making in geriatrics often occurs in collaboration between older patients, their physicians, and their family members.30–32
Daughters may encourage their oldest-old mothers to undergo mammography screening since they know that mammography screening is important for their own health and assume that it must be equally important to their mother's health. Daughters may see themselves as advocates of their older mother's health and may view physicians who do not offer their mothers mammography screening as ageist, especially since there is some evidence to suggest that there are some age-related disparities in cancer screening.33
It is important to explore the role of daughters in elderly women's decision-making to ensure that screening and other medical decisions reflect the preferences of patients and not only of their daughters.
Since experts encourage physicians to discuss both the benefits and harms of screening to elderly patients,19
we were interested in learning more about physician counseling about mammography screening to women aged 80 or older. Prior studies have found that physicians generally highlight the benefits of screening because it is difficult to explain population statistics to an individual patient during short clinic visits.34,35
In addition to these difficulties, we found that physicians are particularly uncomfortable discussing stopping screening with oldest-old women as it requires discussing patient's life expectancy. This discomfort may be similar to the discomfort physicians feel when discussing end-of-life care with patients.36,37
To improve end-of-life discussions, experts recommend that physicians initiate and re-initiate these discussions, clarify prognosis, identify goals, and develop a treatment plan.38,39
These same principles may help physicians when discussing stopping mammography screening. Physicians may need to initiate and re-initiate screening discussions, discuss patient's life expectancy, determine patients' preferences for work-up and treatment of abnormal mammograms, and focus on health promotion measures that can benefit oldest-old women in a shorter time frame. As it is important to learn how to encourage patients to undergo screening it is also important to learn how to discuss stopping screening with patients who have little chance to benefit. More data on the risks and benefits of screening may help physicians with these discussions.
In addition, physicians understanding which factors are influencing oldest-old women's screening preferences may help physicians individualize their discussions about mammography screening. For instance, a woman with limited life expectancy who prefers to undergo mammography screening because it gives her a sense that she is doing all she can for her health may benefit from her physician discussing other ways besides mammography that she can maintain her health, perhaps through physical activity. Similarly, a woman in her early 80s without significant illness but who prefers not to get screened because “she is too old” may benefit from a more thoughtful discussion about the risks and benefits of screening. Physicians should work to become more comfortable discussing stopping screening with those patients who defer their screening decisions to their physicians. Finally, physicians may want to question whether annual reminder cards about mammography screening are appropriate for oldest-old women who may not benefit. Ideally, mammography screening should be targeted to oldest-old women most likely to benefit.
Our study has several limitations that must be acknowledged. All of the in-depth interviews took place at one academic medical center in Boston, limiting generalizability. Participants were more likely to have received a recent mammogram than nonresponders which may bias our results to more favorable views of mammography screening, however, nearly half of the women in our sample had not been screened with mammography in the past 2 years. Since we used qualitative methods we cannot use our data to estimate the prevalence of ideas. Additionally, although we had 3 independent coders, coding of interviews is subjective. Finally, due to small sample size we were unable to look at differences within patient groups (e.g., recent use of mammography) or physician groups (e.g., specialty).
In this qualitative study, we identified factors that influenced oldest-old women's mammography screening decisions and explored physician counseling around mammography screening to oldest-old women. We were interested to learn how enthusiastic some women aged 80 or older were about mammography screening and that physicians find discussing stopping screening with patients difficult and uncomfortable. Understanding which factors influence a patient's decision-making may aid with discussions about screening as would more data about the benefits and risks of mammography screening for women aged 80 and older. Ideally, women aged 80 and older should understand the benefits and risks associated with each possible course of action that they might choose when deciding on mammography screening.