Clinician talking points

How to engage women ages 75 and older in shared decision-making around mammography screening

Make clear:

• There’s a decision to make
• There is no right or wrong answer
• Women’s values and preferences matter in that decision
• That you have the patient’s best interest at heart

Talking points to discuss the benefits and harms of mammography screening

• To start: “Let’s talk about the benefits and harms of mammograms so that we can make a decision together…”
• Benefits: “Mammograms may find breast cancers early. Therefore, having a mammogram may lower the chance of having a large and/or more aggressive breast cancer found. For some women, finding breast cancer early might also slightly lower the chance of dying from breast cancer.”
• Harms: “There are harms to having mammograms. Mammograms may find small breast cancers that would never have caused problems. So some women end up getting treated for a cancer that never would have caused any symptoms. This is called overdiagnosis. For some women, it takes a lot of effort to get the testing and treatments done. Mammograms can also cause false alarms that can be stressful.”
• Radiation exposure: “While repeated x-rays may increase the risk of breast cancer, the risk is very small. The amount of radiation from having a mammogram is similar to a 6-hour plane ride. Around 1 woman out of 1,000 who have a mammogram every other year from ages 40-74 will be diagnosed with a breast cancer as a result of radiation from mammograms. Less than 1 (around 0.2 out of 1,000) will die from breast cancer as a result of radiation from mammograms.”
• Elicit the patient’s values and preferences: “How are you feeling about having a mammogram or not?” - “How do you feel about being treated for a breast cancer that never otherwise would have caused problems in your lifetime?” - “What makes you worried about breast cancer?”

Give more time for the decision

The patient should be given as much time as needed to make a decision. The default should not be to order or recommend a mammogram.

Listen to patients to elicit their preferences

• Use silence to allow patients to express their values and/or preferences.

• For patients who prefer a passive role in decision making:

  Some older women may prefer that their primary care clinician make a final recommendation about whether or not they have a mammogram. Based on patients’ comments and thoughts during this discussion, make a recommendation that, to the best of your ability, integrates their values and preferences.
• It may help to elicit if your patient is a minimizer or maximizer regarding medical interventions with this 1-item question: “In general, do you lean toward taking action or do you lean toward waiting and seeing if action is needed?” This may also help you guide your patient in their decision-making around mammography screening.

Discuss other things a woman can do to lower her chance of breast cancer

A woman may lower her chance of breast cancer by maintaining a healthy weight, reducing her alcohol intake, stopping smoking, and/or increasing her physical activity.

What to avoid in the discussion

• Patients tend to find the statement “You may not live long enough to benefit from this test” harsh
• Not giving any explanation as to why to stop screening

How to recommend stopping mammography screening to women ages 75 and older

When it is clear that the harms of mammography screening outweigh the benefits because of an older woman’s low risk of breast cancer and/or poor health, it may be appropriate to discuss stopping screening directly:

Stopping screening

• “At this point, I think it’s more important to focus on your other health goals or conditions (such as xx) than looking for a potential new cancer. I do not think you need to keep getting mammograms. If you have any new symptoms like a breast lump or pain, we can always get a mammogram then. What do you think?”
• “Since having a mammogram is unlikely to help you live longer, and there are harms to them, I recommend we transition away from mammograms. What do you think?

Probe reasons women may be concerned about stopping screening

• Probe for concerns: “It’s your decision, and I will respect that. Tell me what you are worried about if we stop mammograms now?”

• Probe whether patient would want to be worked up for breast cancer:

  “If your mammogram showed something concerning, would you be willing to go for a repeat mammogram or even a breast biopsy?”
• Probe whether patient would want treatment: “Do you think you would want to undergo treatment like surgery, radiation, or chemotherapy if a breast cancer were found? Would you be willing to take another medicationfor treatment of breast cancer?” - “If you wouldn’t want to be tested or treated for breast cancer, then it may not make sense to have a mammogram.”

Reassurances

• That you have the patients’ best interest at heart:

  “It is my job as your doctor/nurse to make sure we do tests that will lead to more good than harm and avoid tests that can lead to more harm than good. This is why I brought up this issue, since the benefit of mammograms in women ages 75 and older are uncertain, and there are potential harms. I’ve seen women ages 75 or older who have been very stressed by false alarms or who have had harmful treatments for cancers that may not have otherwise caused problems. So I want to make sure we make the right decisions for you.”

• That they may have a mammogram if they experience a new symptom:

  “If you have new symptoms like a breast lump or breast pain, we can get a mammogram, but it may not make sense to have a mammogram now when you are not having any issues.”
• That they may change their mind: “Even if you choose to stop having mammograms now, you can always change your mind if something changes.”

Consider weaning

• Continue screening for now, but plant the seed that screening does not need to continue forever. Discuss stopping screening again in 1-2 years.
• Continue screening once more, and agree for this to be the last one.

How to discuss 10-year life expectancy with women ages 75 and older who are interested in this information

Since breast cancers found on mammograms tend to be slow growing, it can take years before a breast cancer found on a mammogram may affect an older woman’s health. Therefore, guidelines encourage women age 75 and older to consider their overall health when deciding whether to have a mammogram.

Clinicians describe feeling uncomfortable discussing life expectancy with older adults but acknowledge that the information can be useful for clinical decision making.

Older adults state that discussions about life expectancy should be tied to a relevant clinical decision, like deciding when to stop having regular mammograms. Before sharing information about prognosis or life expectancy, clinicians should help older adults understand why the information may be useful.

Ask patients if they are interested in discussing their life expectancy:

Clinicians should also ask older adults their interest in learning about their prognosis or life expectancy before such information is shared. Some example language:

“For some people it helps to have an estimate of how much time they may have left because it may help them make medical decisions. Is that something you would like to talk about?”

“Since it can take years before a breast cancer found on a mammogram may affect your health, would it be helpful to talk about how much longer you are likely to live to help us decide together about mammograms?”

If an older adult is interested in their prognosis/life expectancy:

• Ask patients about their expectations of their life expectancy and consider asking about their goals for their care.
• Emphasize the uncertainty in estimating life expectancy and long-term prognosis. Ask patients how they would like to receive prognostic information.

When sharing prognosis information or life expectancy remind older adults:

• Everyone is different, and it is impossible to know the future, but that the information is obtained from women their age and in similar health.
• You will do everything you can to help her live comfortably for as long as possible.

Talking points for patients interested in learning their 10-year life expectancy/prognosis

Life expectancy: “Based on information from other women your age and in similar health, your life expectancy is estimated to be around 5-10 years. Of course, everyone is different, and it is impossible to know the future.”

Prognosis: “Out of 1,000 women your age and in similar health, around 500 (or 50%) will be alive in 10 years; some will live more and some will live less. Regardless, I will do everything I can to help you live comfortably for as long as possible.”

Note: Some studies find that older adults prefer to learn their prognosis (e.g., you have a 50% chance of living 10 more years) rather than their life expectancy (your life expectancy is approximately 10 years), since prognosis better communicates the uncertainty in these estimates.

Tips for shared decision making with women with low health literacy

Below are tips for engaging older women with low health literacy in shared decision making around mammography screening. These suggestions may be useful for all patients.

• Use plain language
• Limit information to 1-3 key points
• Avoid medical jargon
• Consider using icon arrays (as used on this website) since they have been shown to be an effective format for presenting numerical information. However, some adults with low health literacy have difficulty understanding numerical information in any graphical format.
• Explore and adjust to patients’ preferred role in decision making. If a patient is struggling with the decision and wants you to make the final decision, take into account what would best fit the patient based on the goals or values they have expressed in the past. Summarize your patient’s values to confirm your understanding. “Based on what I have heard from you so far…”
• Acknowledge the complexity of the decision “It is a difficult choice. There is a lot of uncertainty which makes it hard to choose.”
• Repeat and clarify as needed.
• You can check patient understanding of the information by asking patients to think about different hypothetical scenarios of the different outcomes or by offering different perspectives (example perspectives to share are below).
• Involve family or another trusted support person when desired by patient
• Print the patient summary page from this website so that patients may review the information at their own pace after the visit.

Different patient perspectives to offer your patients to help them better understand the issues and to help form their preferences:

1. “Glad it was found early.” Some women value having a breast cancer found early. For these women, they consider the burden of surgery, radiation treatment or hormone pills worth it to avoid having a breast cancer found later when it may be more lethal or when more surgery or treatments may be needed.

2. “Maybe the mammogram would find something I never needed to know about.” Other women do not want to take the risk of having a mammogram that would find a small breast cancer that otherwise would not have caused them problems in their lifetime. The time, costs, and energy of being diagnosed and treated for a small breast cancer that may never affect their health is not worth it. These women are comfortable not having a mammogram to go looking for problems and instead would only have a mammogram if they noticed something wrong like breast pain or a breast lump.

3. “Having a mammogram is not worth the anxiety or hassle.” Mammograms may show something that is of concern to a doctor but may not be breast cancer. In these cases, women are asked to come back for more tests (more mammograms and/or ultrasounds or MRIs) to make sure they do not have breast cancer. Some women have to have a breast biopsy to make sure they do not have breast cancer. In these cases, the doctor is being careful, but the process leads to more scheduling, appointments, worry, and hassle for women for something that often turns out to be nothing.

Adapted from the Agency for Healthcare Research and Quality SHARE approach: https://www.ahrq.gov/sdm/share-approach/index.html

Video examples of a clinician using this conversation aid with a woman aged 75 and older