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Benefits and Harms of Mammography Screening in 75 + Women to Inform Shared Decision-making: a Simulation Modeling Study

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Abstract

Background

Guidelines recommend shared decision-making (SDM) around mammography screening for women ≥ 75 years old.

Objective

To use microsimulation modeling to estimate the lifetime benefits and harms of screening women aged 75, 80, and 85 years based on their individual risk factors (family history, breast density, prior biopsy) and comorbidity level to support SDM in clinical practice.

Design, Setting, and Participants

We adapted two established Cancer Intervention and Surveillance Modeling Network (CISNET) models to evaluate the remaining lifetime benefits and harms of screening U.S. women born in 1940, at decision ages 75, 80, and 85 years considering their individual risk factors and comorbidity levels. Results were summarized for average- and higher-risk women (defined as having breast cancer family history, heterogeneously dense breasts, and no prior biopsy, 5% of the population).

Main Outcomes and Measures

Remaining lifetime breast cancers detected, deaths (breast cancer/other causes), false positives, and overdiagnoses for average- and higher-risk women by age and comorbidity level for screening (one or five screens) vs. no screening per 1000 women.

Results

Compared to stopping, one additional screen at 75 years old resulted in six and eight more breast cancers detected (10% overdiagnoses), one and two fewer breast cancer deaths, and 52 and 59 false positives per 1000 average- and higher-risk women without comorbidities, respectively. Five additional screens over 10 years led to 23 and 31 additional breast cancer cases (29–31% overdiagnoses), four and 15 breast cancer deaths avoided, and 238 and 268 false positives per 1000 average- and higher-risk screened women without comorbidities, respectively. Screening women at older ages (80 and 85 years old) and high comorbidity levels led to fewer breast cancer deaths and a higher percentage of overdiagnoses.

Conclusions

Simulation models show that continuing screening in women ≥ 75 years old results in fewer breast cancer deaths but more false positive tests and overdiagnoses. Together, clinicians and 75 + women may use model output to weigh the benefits and harms of continued screening.

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Data Availability

Additional data available upon request.

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Acknowledgements

The authors acknowledge the data provided by the Breast Cancer Surveillance Consortium, and initial data analysis conducted by Joanna Eavey with guidance from Charlotte Gard to develop the input parameters on breast cancer risk, screening performance, and stage distributions.

Funding

Research reported in this publication was supported by the National Institutes of Health (NIH) under the National Institute on Aging grant R01AG065311 and in part under the National Cancer Institute (NCI) grants U01CA152958 and U01CA253911 (CISNET). Dr. Jayasekera was supported by the Division of Intramural Research at the National Institute on Minority Health and Health Disparities of the NIH, and the NIH Distinguished Scholars Program. Dr. Mandelblatt’s effort was supported in part by R35CA197289; a pilot award supported by the Georgetown University Lombardi Cancer Center Support Grant (5P30CA051008).

Breast Cancer Surveillance Consortium (http://www.bcsc-research.org) data collection was supported by the National Cancer Institute (P01CA154292, U54CA163303). Dr. Schonberg’s effort was also supported by a NIA K24AG071906.

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Author notes

  1. Mara A. Schonberg, MD, and Natasha K. Stout, PhD have equal contributions.

Authors and Affiliations

  1. Health Equity and Decision Sciences Research Laboratory, National Institute on Minority Health and Health Disparities (NIMHD) Intramural Research Program (IRP), National Institutes of Health, Bethesda, MD, 20892, USA

    Jinani Jayasekera PhD, Oliver W. A. Wilson PhD, Kaitlyn M. Wojcik MPH, CPH & Dalya Kamil BSc

  2. Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA

    Sarah Stein PhD & Natasha K. Stout PhD

  3. Department of Public Health, Aarhus University, Aarhus, Denmark

    Eeva-Liisa Røssell PhD

  4. Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA

    Linn A. Abraham MS & Ellen S. O’Meara PhD

  5. Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Nancy Li Schoenborn MD

  6. Departments of Family and Social Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA

    Clyde B. Schechter MD

  7. Georgetown Lombardi Institute for Cancer and Aging Research and the Cancer Prevention and Control Program at the Georgetown Lombardi Comprehensive Cancer Center and Department of Oncology, Georgetown University Medical Center, Washington, DC, USA

    Jeanne S. Mandelblatt MD

  8. Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Mara A. Schonberg MD

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  1. Jinani Jayasekera PhD
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Correspondence to Jinani Jayasekera PhD.

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Jayasekera, J., Stein, S., Wilson, O.W.A. et al. Benefits and Harms of Mammography Screening in 75 + Women to Inform Shared Decision-making: a Simulation Modeling Study. J GEN INTERN MED 39, 428–439 (2024). https://doi.org/10.1007/s11606-023-08518-4

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