December 1, 2004
Challenges in Mammography Screening for Older Women
Although the risk of breast cancer increases with age, older women are less likely to be routinely screened than younger women. Forty-eight percent of newly diagnosed invasive breast cancer and 58% of breast cancer deaths occur in women over the age of 65.' Breast cancer is the most common cause of cancer deaths in older women, but older women are less likely to have mammograms than younger women.
Recent Medicare statistics report that only 51% of women over the age of 65 receive biennial mammograms, meaning that even though Medicare pays for yearly mammograms, only about one-half of eligible women receive one every 2 years.2 This problem persists even though the postmenopausal status of older women makes them ideal candidates for screening. Loss of density in breast tissue facilitates the detection of changes, leading to an earlier and more reliable diagnosis of Stage I disease, less radical surgery, less disfigurement and disability, better quality of life, and better survival rates.
Older disabled women are even less likely to seek mammography screening than nondisabled elders.3-6 Factors such as activity limitations, major mobility problems, and limited ability to carry out daily living activities occur more often as age increases, thereby decreasing the frequency of mammography screening. Blustein and Weiss6 researched the extent to which health, physical functioning, and age influenced mammography use in a large sample of older women and found that only 27% received a mammogram within the previous 2 years, with the lowest rates occurring as age increased.
Coexisting medical conditions further complicate the probability of screening for elders. As the number and severity of medical conditions increase (diabetes, cardiac, respiratory, bone and joint diseases, and vision and hearing loss), acute and supportive care needs often preempt cancer surveillance. However, women with one or two comorbid conditions are known to benefit by regular breast cancer screening.
In a study of mammography use, comorbidity, and survival of older women with breast cancer, McPherson et al7 found a decreased risk of death among older women with mild- (one condition) to moderate-(two conditions) comorbidity who had been screened, including those over 85 years of age.
* Evidence-Based Practice
The authors completed a descriptive study of 98 older women to identify predictor variables for mammography use and to clarify constraints related to under-use of mammography. Participants were classified into three groups: "users" (mammogram in past 24 months), "under-users" (previous mammogram, but not within the past 24 months), and "nevers" (never had a mammogram). Mean number of months since last mammogram was only 9 months for users and 53 months (> 4 years) for underusers (see Table: "Demographic and Descriptive Variables"). Under-users were older and had more limitations in mobility (difficulty in walking 3 blocks, standing 20 minutes, climbing 10 stairs, bending/stooping/ kneeling, reaching over head, lifting 10 pounds, moving a heavy object), and more comorbid (coexisting medical) conditions. Fifty-nine percent of under-users reported routine use of a walker and 21% used a cane. Also, more under-users (67%) and nevers (62%) resided in assisted living facilities. Even though the vast majority of these women received annual primary care, the most common reason under-users gave for not having routine mammograms was lack of provider recommendation (26%). Of women who had never received a mammogram, 39% believed that it was unnecessary.
These findings suggest that vulnerable elderly and mobility- limited populations, particularly those in assisted living facilities, would benefit by caregiver interventions directed at: 1) making specific recommendations for routine mammogram screening, and 2) making the screening process easier and more disability- friendly. Nurse practitioners (NPs) should encourage mammography at recommended frequencies and streamline or facilitate the process of getting the mammogram.
Under-users are women who at some point in their lives were philosophically convinced of the benefits of mammography. Now that they are older, perhaps not enjoying optimum health and often using mobility assistance devices, nursing interventions should be aimed at helping these women schedule the mammogram and planning transportation to the site, assuring short distances required for walking to the machine once the site is reached, and minimizing wait times.
For those women who have never had a mammogram, one-onone education programs with compelling data related to risk and benefits of screening should be implemented. These elders may be ideal candidates for peer coaching or mentoring by other elders who are routinely screened.
* Screening Recommendations
The authors' study reinforces other issues facing NPs as they plan screening strategies for aging populations, and points to some difficult clinical questions. How do clinicians balance ideal standards of screening for vulnerable elders with ongoing priorities related to disability, chronic illness, and functional limitations? Are some women too old or too disabled to benefit from mammography?
Health Maintenance Clinical Glidepaths8 are new outpatient tools intended to assist geriatric clinicians in decision-making. They recommend mammography every 1 to 2 years up to age 85 for the robust elderly, every 1 to 2 years up to age 75 for the frail elderly, every 1 to 2 years up to age 70 for the moderately demented, and not at all for end-of-life elderly. These are reasonable clinical guidelines that can be used to assist NPs and patients in the question of whether or not an individual may benefit from routine mammography screening.
This study was supported by Research Incentive Grant #9-98449 (2002-03) from Boston College.
Demographic and Descriptive Variables (N=98)
Statistics show that even though Medicare pays for yearly mammograms, only about one-half of eligible women receive one every 2 years.
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1. McCarthy E, Burns R, Freund K et al.: Mammography use, breast cancer stage at diagnosis, and survival among older women. I Am Geriatr Soc 2000;48:1226-33.
2. Centers for Medicare and Medicaid Services (CMS). Non-HMO women age 65+ with biennial mammography services paid by Medicare, 1999-2001. Retrieved April 22, 2003, from http://cms.hhs.gov/ preventiveservices/lb.asp.
3. DHHS. U.S. Department of Health and Human Services. Healthy People 2010, 2nd ed. With Understanding and Improving Health and Objectives for Improving Health. Washington, DC: U.S. Government Printing Office. Last update: 2000 Available at http:// www.health.gov/healthypeople. Accessed May 5, 2003.
4. Iezzoni L, McCarthy E, Davis R. et al.: Mobility impairments and use of screening and preventive services. Am J Public Health 2000; 90: 955-61.
5. Chan L, Doctor J, MacLehose R et al: Do medicare patients with disabilities receive preventive services? A population-based study. Arch Phys Med Rehabil 1999;80:642-6.
6. Blustein J, Weiss L: Use of mammography by women aged 75 and older: Factors related to health, functioning, and age. J Am Geriatr Soc 1998;46: 941-46.
7. McPherson CP, Swenson KK, Lee MW: The effects of mammographic detection and comorbidity on the survival of older women with breast cancer. J Am Geriatr Soc 2002;50:1061-8.
8. Flaherty JH, Morley JE, Murphy, DJ et al: The development of outpatient clinical glidepaths. J Am Geriatr Soc 2002:50:1886-901.
Robin Y. Wood, EdD, RN
Karen K. Giuliano, PhD(c), RN, FAAN
Linda M. Liu, ANP, GNP
ABOUT THE AUTHORS
At the William F. Connell School of Nursing, Boston College Chestnut Hill, Mass. Robin Y. Wood is an Associate Professor and Coordinator of Learning Resource Centers and Karen K. Giuliano is a University Fellow. Linda M. Liu is an ANP at United Health Group, Everton Division, Newton, Mass.
Copyright Springhouse Corporation Nov 2004