Screening mammography use in older women according to health status: a systematic review and meta-analysis

Breast cancer screening motivation and behaviours of women aged over 75 years: a scoping review

BACKGROUND

This scoping review aimed to identify and present the evidence describing key motivations for breast cancer screening among women aged ≥ 75 years. Few of the internationally available guidelines recommend continued biennial screening for this age group. Some suggest ongoing screening is unnecessary or should be determined on individual health status and life expectancy. Recent research has shown that despite recommendations regarding screening, older women continue to hold positive attitudes to breast screening and participate when the opportunity is available.

METHODS

All original research articles that address motivation, intention and/or participation in screening for breast cancer among women aged ≥ 75 years were considered for inclusion. These included articles reporting on women who use public and private breast cancer screening services and those who do not use screening services (i.e., non-screeners). The Joanna Briggs Institute (JBI) methodology for scoping reviews was used to guide this review. A comprehensive search strategy was developed with the assistance of a specialist librarian to access selected databases including: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Web of Science and PsychInfo. The review was restricted to original research studies published since 2009, available in English and focusing on high-income countries (as defined by the World Bank). Title and abstract screening, followed by an assessment of full-text studies against the inclusion criteria was completed by at least two reviewers. Data relating to key motivations, screening intention and behaviour were extracted, and a thematic analysis of study findings undertaken.

RESULTS

A total of fourteen (14) studies were included in the review. Thematic analysis resulted in identification of three themes from included studies highlighting that decisions about screening were influenced by: knowledge of the benefits and harms of screening and their relationship to age; underlying attitudes to the importance of cancer screening in women's lives; and use of decision aids to improve knowledge and guide decision-making.

CONCLUSION

The results of this review provide a comprehensive overview of current knowledge regarding the motivations and screening behaviour of older women about breast cancer screening which may inform policy development.

The Impact of Morbidity and Disability on Attendance at Organized Breast Cancer-Screening Programs: A Systematic Review and Meta-Analysis

Individuals with morbidity experience worse breast cancer outcomes compared with those without. This meta-analysis assessed the impact of morbidity on breast cancer-screening attendance and subsequent early detection (PROSPERO pre-registration CRD42020204918). MEDLINE, PsychInfo, and CINAHL were searched. Included articles published from 1988 measured organized breast-screening mammography attendance using medical records by women with morbidity compared with those without. Morbidities were assigned to nine diagnostic clusters. Data were pooled using random-effects inverse meta-analyses to produce odds ratios (OR) for attendance. 25 study samples (28 articles) were included. Data were available from 17,755,075 individuals, including at least 1,408,246 participants with one or more conditions;16,250,556 had none. Individuals with any morbidity had lower odds of attending breast screening compared with controls [k = 25; OR, 0.76; 95% confidence interval (CI), 0.70-0.81; P = <0.001; I2 = 99%]. Six morbidity clusters had lower odds of attendance. The lowest were for neurological, psychiatric, and disability conditions; ORs ranged from 0.45 to 0.59 compared with those without. Morbidity presents a clear barrier for breast-screening attendance, exacerbating health inequalities and, includes a larger number of conditions than previously identified. Consensus is required to determine a standardized approach on how best to identify those with morbidity and determine solutions for overcoming barriers to screening participation based on specific morbidity profiles.

Determinants of Non-Participation in Population-Based Breast Cancer Screening: A Systematic Review and Meta-Analysis

Background

Breast cancer (BC) screening can be performed in a screening program (BCSP) or in opportunistic screening. The existing reviews on the determinants of non-participation depend on self-reported data which may be biased. Furthermore, no distinction was made between the probably different determinants of both screening strategies.

Objective

To find the determinants of non-participation in BCSP by means of a meta-analysis.

Methods

PubMed, Embase, and Web of Science were searched for observational studies which quantified factors associated with non-participation in BCSP in a general population. Studies on opportunistic screening and studies using self-reported data were excluded. A random-effect model was used to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). Potential sources of heterogeneity were explored by stratification of the results.

Results

Twenty-nine studies with in a total of 20,361,756 women were included. Low income (OR: 1.20, 95% CI: 1.10–1.30), low education (OR: 1.18, 95% CI: 1.05–1.32), living far from an assigned screening unit (OR: 1.15, 95% CI: 1.07–1.24), being immigrant (OR: 2.64, 95% CI: 2.48–2.82), and having a male family doctor (OR: 1.43, 95% CI: 1.20–1.61) was associated with higher non-participation in screening. Reminders sent to non-attenders and estimations of ORs (adjusted or not) partly explained substantial heterogeneity.

Conclusion

In this meta-analysis excluding studies on the non-participation in opportunistic screening, or with self-reported data on non-participation, the well-known determinants for non-participation are still significant, but less strong. This analysis only supports the relevance of meta-analysis of studies with registered non-participation in a BCSP.

Systematic Review Registration

PROSPERO, CRD42020154016.

Mammography adherence in relation to function-related indicators in older women

Prior studies of screening mammography patterns by functional status in older women show inconsistent results. We used Breast Cancer Surveillance Consortium-Medicare linked data (1999-2014) to investigate the association of functional limitations with adherence to screening mammography in 145,478 women aged 66-74 years. Functional limitation was represented by a claims-based function-related indicator (FRI) score which incorporated 16 items reflecting functional status. Baseline adherence was defined as mammography utilization 9-30 months after the index screening mammography. Longitudinal adherence was examined among women adherent at baseline and defined as time from the index mammography to end of the first 30-month gap in mammography. Multivariable logistic regression and Cox proportional hazards models were used to investigate baseline and longitudinal adherence, respectively. Subgroup analyses were conducted by age (66-70 vs. 71-74 years). Overall, 69.6% of participants had no substantial functional limitation (FRI score 0), 23.5% had some substantial limitations (FRI score 1), and 6.8% had serious limitations (FRI score ≥ 2). Mean age at baseline was 68.5 years (SD = 2.6), 85.3% of participants were white, and 77.1% were adherent to screening mammography at baseline. Women with a higher FRI score were more likely to be non-adherent at baseline (FRI ≥ 2 vs. 0: aOR = 1.13, 95% CI = 1.06, 1.20, p-trend < 0.01). Similarly, a higher FRI score was associated with longitudinal non-adherence (FRI ≥ 2 vs. 0: aHR = 1.16, 95% CI = 1.11, 1.22, p-trend < 0.01). Effect measures of FRI did not differ substantially by age categories. Older women with a higher burden of functional limitations are less likely to be adherent to screening mammography recommendations.

Impact of Risk-Stratified Therapy on Health Status in Survivors of Childhood Acute Lymphoblastic Leukemia: A Report from the Childhood Cancer Survivor Study

BACKGROUND

Prior studies have identified that survivors of childhood acute lymphoblastic leukemia (ALL) report poor health status. It is unknown how risk-stratified therapy impacts the health status of ALL survivors.

METHODS

We estimated and compared the prevalence of self-reported poor health status among adult (≥18 years) survivors of childhood ALL diagnosed at age <21 years from 1970 to 1999 and sibling controls, excluding proxy reports. Therapy combinations defined treatment groups representative of 1970s therapy (70s), standard- and high-risk 1980s and 1990s therapy (80sSR, 80sHR, 90sSR, 90sHR), and relapse/bone marrow transplant (R/BMT). Log-binomial models, adjusted for clinical and demographic factors, compared outcomes between groups using prevalence ratios (PR) with 95% confidence intervals (CI).

RESULTS

Among 5,119 survivors and 4,693 siblings, survivors were more likely to report poor health status in each domain including poor general health (13.5% vs. 7.4%; PR = 1.92; 95% CI, 1.69-2.19). Compared with 70s, 90sSR and 90sHR were less likely to report poor general health (90sSR: PR = 0.75; 95% CI, 0.57-0.98; 90sHR: PR = 0.58; 95% CI, 0.39-0.87), functional impairment (90sSR: PR = 0.56; 95% CI, 0.42-0.76; 90sHR: PR = 0.63; 95% CI, 0.42-0.95), and activity limitations (90sSR: 0.61; 95% CI, 0.45-0.83; 90sHR: PR = 0.59; 95% CI, 0.38-0.91). An added adjustment for chronic conditions in multivariable models partially attenuated 90sSR risk estimates.

CONCLUSIONS

Risk-stratified ALL therapy has succeeded in reducing risk for poor general health, functional impairment, and activity limitations among more recent survivors of standard- and high-risk therapy.

IMPACT

Future research into the relationship between risk-stratified therapy, health status, and late health outcomes may provide new opportunities to further improve late morbidity among survivors.

Comorbidity Profiles and Lung Cancer Screening among Older Adults: U.S. Behavioral Risk Factor Surveillance System 2017 to 2019

RATIONALE

Although lung cancer screening (LCS) with low-dose computed tomography (LDCT) is now recommended for those meeting standard risk factor-based eligibility criteria, the role of comorbidity in the uptake of LCS with LDCT in an older real-world U.S. population is not well established.

OBJECTIVE

To examine the relationships between comorbidity, functional status and LCS utilization in the United States.

METHODS

Using population-based data from the 2017-2019 Behavioral Risk Factor Surveillance System (BRFSS), we examined the association of comorbid conditions and functional limitations regarding activities of daily living with LCS utilization among participants that met the LCS criteria based on the US Preventive Service Taskforce guidelines. We employed multivariable weighted logistic regression models to evaluate these associations, both overall and within subgroups defined by age (<65 vs. ≥65 years), gender, and smoking history.

RESULTS

Of 11,214 participants that met the eligibility criteria for LCS, 1731 (16%) underwent LCS with LDCT. The majority were white (90%), male (55%), former smokers (52%) and living with at least one chronic comorbid condition (77%). Over 28% had 3 or more comorbid conditions and approximately 40% of participants reported having some form of functional limitations. In the multivariable models, the likelihood of undergoing LCS with LDCT within the past year was positively associated with higher levels of comorbidity (≥5 vs. 0: aOR=2.34, 95% CI=1.22,4.48) but not with functional limitations (≥3 vs. 0: aOR=1.00, 95% CI=0.66, 1.50).

CONCLUSION

The presence of comorbid conditions is associated with a higher likelihood of undergoing LCS with LDCT. Because poor health status may diminish the benefits of screening, future research is needed to precisely characterize the health status of LCS-eligible individuals.

Factors associated with receipt of mammogram among caregivers: a comparison with non-caregivers

BACKGROUND

caregiving responsibilities significantly impact females' decisions on adhering to preventive mammography. The purpose of this study is to examine (1) the levels of mammogram receipt, (2) the role of caregiving factors on the receipt of mammogram in caregiving group, and (3) the role of cancer beliefs on mammogram screening in caregivers and non-caregivers.

METHODS

the 2017 Health Information National Trends Survey (HINTS) provides samples of 1228 women aged 40 to 75 years old for this secondary analysis. By using Andersen's Behavioral Model of Health Services Use, a binomial logistic regression model was used to analyze associations between mammography and socioeconomic factors, caregiving factors, and cancer belief factors.

RESULTS

caregivers who provided more caregiving hours per week (OR = 0.749, 95% CI = 0.564-0.94) and caregivers who had the belief of rather not knowing the likelihood of getting cancer (OR = 0.673, 95% CI = 0.496-0.914) were less likely to use mammogram. However, caregivers who believed cancer is more common than heart disease (OR = 1.490, 95% CI = 1.302-2.151) were more likely to use a mammogram. Non-caregivers who worried about getting cancer (OR = 1.158, 95% CI = 0.793-1.691) were more likely to use mammogram, but non-caregivers who had the belief of rather not know the likelihood of getting cancer (OR = 0.825, 95% CI = 0.713-0.955) were less likely to use mammogram.

CONCLUSIONS

to support caregivers' breast cancer prevention, caregiving-related policies based on caregiving hours should be developed. Particularly, effort to promote breast cancer screening education and care support among older primary caregivers will likely increase their adherence to preventive mammography uptake. The development of targeted cancer prevention interventions on specific cancer beliefs held by both groups are also urgently needed to promote mammography.

Older Women’s Perspectives Driving Mammography Screening Use and Overuse: a Narrative Review of Mixed-Methods Studies

Purpose of Review

Examining what older women know and perceive about mammography screening is critical for understanding patterns of under- and overuse, and concordance with screening mammography guidelines in the USA. This narrative review synthesizes qualitative and quantitative evidence around older women’s perspectives toward mammography screening.

Recent Findings

The majority of 43 identified studies focused on promoting mammography screening in women of different ages, with only four studies focusing on the overuse of mammography in women ≥ 70 years old. Older women hold positive attitudes around screening, perceive breast cancer as serious, believe the benefits outweigh the barriers, and are worried about undergoing treatment if diagnosed. Older women have limited knowledge of screening guidelines and potential harms of screening.

Summary

Efforts to address inequities in mammography access and underuse need to be supplemented by epidemiologic and interventional studies using mixed-methods approaches to improve awareness of benefits and harms of mammography screening in older racially and ethnically diverse women. As uncertainty around how best to approach mammography screening in older women remains, understanding women’s perspectives along with healthcare provider and system-level factors is critical for ensuring appropriate and equitable mammography screening use in older women.

Preventive Care: How Mammography Utilization Changes as Women Age

OBJECTIVE

To evaluate the impact of comorbid conditions and age on mammography use.

METHODS

We used data from the 2011 to 2015 Medical Expenditure Panel Survey, which contained records for 40,752 women over the age of 40. Use was defined as a mammogram within the previous 1 or 2 years, analyzed separately. A logit model was employed to evaluate associations between use and comorbidities and age. Statistical significance was defined by a P < .05 by two-sided test.

RESULTS

Of the 36,575 women in our study sample, 45.9%, 43.6%, 3.9%, and 5.7% reported a history of hypertension (HTN), hyperlipidemia (HLD), prior heart attack (MI), and prior stroke, respectively. Among women without a comorbid condition, there was 47.3% annual mammography use. HTN and HLD were associated with increased use (2.5 and 6.8 percentage points [pp], P< .01). In comparison, prior MI was associated with decreased annual use (-8.2 pp, P < .01). Prior stroke was not significantly associated with annual mammography (-1.5 pp, P = .42). Results were similar for biennial use. The age trend in use showed that the age with maximum screening use was approximately 60 years.

DISCUSSION

Mammography use was higher in patients with HTN and HLD and lower in patients with prior MI and stroke, which may reflect differences in comorbidity-related general health care use. Use increased until it peaked around age 60. An understanding of how mammography use naturally evolves as people age may help better target specific populations and improve overall use of preventive care.