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Effect of a Mammography Screening Decision Aid for Women 75 Years and OlderA Cluster Randomized Clinical Trial

Educational Objective
To describe the effects of receipt of a paper-based mammography screening decision aid (DA) for women 75 years and older.
1 Credit CME
Key Points

Question  How does use of a workbook mammography screening decision aid (DA) for women 75 years and older affect their screening decisions?

Findings  In this cluster randomized clinical trial of 546 women aged 75 to 89 years, receipt of the decision aid before a visit with their clinician led to women 75 years and older being more knowledgeable about mammography screening, having more discussions with their primary care physician about screening, and fewer women being screened.

Meaning  Use of a mammography screening decision aid may help women 75 years and older make more informed decisions about mammography screening and, as a result, may reduce overscreening.


Importance  Guidelines recommend that women 75 years and older be informed of the benefits and harms of mammography before screening.

Objective  To test the effects of receipt of a paper-based mammography screening decision aid (DA) for women 75 years and older on their screening decisions.

Design, Setting, and Participants  A cluster randomized clinical trial with clinician as the unit of randomization. All analyses were completed on an intent-to-treat basis. The setting was 11 primary care practices in Massachusetts or North Carolina. Of 1247 eligible women reached, 546 aged 75 to 89 years without breast cancer or dementia who had a mammogram within 24 months but not within 6 months and saw 1 of 137 clinicians (herein referred to as PCPs) from November 3, 2014, to January 26, 2017, participated. A research assistant (RA) administered a previsit questionnaire on each participant’s health, breast cancer risk factors, sociodemographic characteristics, and screening intentions. After the visit, the RA administered a postvisit questionnaire on screening intentions and knowledge.

Interventions  Receipt of the DA (DA arm) or a home safety (HS) pamphlet (control arm) before a PCP visit.

Main Outcomes and Measures  Participants were followed up for 18 months for receipt of mammography screening (primary outcome). To examine the effects of the DA, marginal logistic regression models were fit using generalized estimating equations to allow for clustering by PCP. Adjusted probabilities and risk differences were estimated to account for clustering by PCP.

Results  Of 546 women in the study, 283 (51.8%) received the DA. Patients in each arm were well matched; their mean (SD) age was 79.8 (3.7) years, 428 (78.4%) were non-Hispanic white, 321 (of 543 [59.1%]) had completed college, and 192 (35.2%) had less than a 10-year life expectancy. After 18 months, 9.1% (95% CI, 1.2%-16.9%) fewer women in the DA arm than in the control arm had undergone mammography screening (51.3% vs 60.4%; adjusted risk ratio, 0.84; 95% CI, 0.75-0.95; P = .006). Women in the DA arm were more likely than those in the control arm to rate their screening intentions lower from previsit to postvisit (69 of 283 [adjusted %, 24.5%] vs 47 of 263 [adjusted %, 15.3%]), to be more knowledgeable about the benefits and harms of screening (86 [adjusted %, 25.5%] vs 32 [adjusted %, 11.7%]), and to have a documented discussion about mammography with their PCP (146 [adjusted %, 47.4%] vs 111 [adjusted %, 38.9%]). Almost all women in the DA arm (94.9%) would recommend the DA.

Conclusions and Relevance  Providing women 75 years and older with a mammography screening DA before a PCP visit helps them make more informed screening decisions and leads to fewer women choosing to be screened, suggesting that the DA may help reduce overscreening.

Trial Registration  ClinicalTrials.gov Identifier: NCT02198690

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: February 3, 2020.

Corresponding Author: Mara A. Schonberg, MD, MPH, Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, 1309 Beacon, Office 219, Brookline, MA 02446 (mschonbe@bidmc.harvard.edu).

Published Online: April 20, 2020. doi:10.1001/jamainternmed.2020.0440

Author Contributions: Dr Schonberg had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Hamel and Davis are co–senior authors.

Concept and design: Schonberg, Lewis, Wee, Fagerlin, Nekhlyudov, Marcantonio, Hamel, Davis.

Acquisition, analysis, or interpretation of data: Schonberg, Kistler, Pinheiro, Jacobson, Aliberti, Karamourtopoulos, Hayes, Neville, Lewis, Nekhlyudov, Hamel, Davis.

Drafting of the manuscript: Schonberg, Nekhlyudov.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Schonberg, Pinheiro, Karamourtopoulos, Neville, Davis.

Obtained funding: Schonberg.

Administrative, technical, or material support: Schonberg, Kistler, Jacobson, Aliberti, Karamourtopoulos, Hayes, Lewis, Wee.

Supervision: Schonberg, Marcantonio.

Conflict of Interest Disclosures: Dr Schonberg reported receiving grants from the National Cancer Institute (NCI) and receiving royalties for reviewing an UpToDate page on geriatric health maintenance. Drs Wee, Marcantonio, and Davis reported receiving grants from the National Institutes of Health (NIH). No other disclosures were reported.

Funding/Support: This research was supported by the NIH/NCI (R01CA181357) (Dr Schonberg). Dr Marcantonio was supported by a Midcareer Investigator Award in Patient-Oriented Research from the National Institute on Aging (K24 AG035075).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: This paper was presented in part at the 2019 Annual Meeting of the Society of General Internal Medicine; May 9, 2019; Washington, DC.

Data Sharing Statement: See Supplement 3.

Additional Contributions: Whitney Stanley Mitchelides, MSPH, CCRP, helped in writing the standard operating procedures for this study and in reaching out to participating sites when she was a research coordinator at Beth Israel Deaconess Medical Center. She is now with Atrium Health, Charlotte, North Carolina. She was not compensated for her contributions.

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