Screening Mammography Use in Medicare Beneficiaries Reflects 4-Year Mortality Risk
ABSTRACT Breast cancer screening guidelines recommend that women and physicians consider life expectancy when making screening decisions in older women. However, prior studies suggest that screening mammography patterns are dependent on age rather than health status or mortality risk of women. Our objective is to determine the association between 4-year mortality risk and use of screening mammography in women aged ≥ 65 years using Medicare Current Beneficiary Survey data.
The primary predictor variable is 4-year mortality risk derived from a published and validated prognostic index with 4 strata of increasing probability of death in 4 years (risk groups 1, 2, 3, and 4 with 4%, 15%, 42%, and 64% risk of 4-year mortality, respectively). The main outcome was self-reported receipt of mammography in the last year.
There was a significant decreasing trend in the use of mammography with mortality risk groups 1, 2, 3, and 4 (62.7%, 51.5%, 36.6%, and 24%, respectively; trend test P<.001). The adjusted odds of mammography use were greatest in the low mortality risk group and show a gradual decline with increasing mortality risk for risk groups 1, 2, 3, and 4 (odds ratio [confidence interval]): 1.00; 0.69 [0.53-0.90]; 0.37 [0.27-0.49], and 0.22 [0.13-0.36], respectively.
Screening mammography use in older Medicare beneficiaries seems to reflect their 4-year risk of mortality rather than age alone, suggesting that patients and providers consider prognosis in screening decisions. Prospective studies are needed to explore the use of the prognostic index as a mammography screening decision tool.
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ABSTRACT: Annual surveillance mammograms in older long-term breast cancer survivors are recommended, but this recommendation is based on little evidence and with no guidelines on when to stop. Surveillance mammograms should decrease breast cancer mortality by detecting second breast cancer events at an earlier stage. We examined the association between surveillance mammography beyond 5 years after diagnosis on breast cancer-specific mortality in a cohort of women aged ≥65 years diagnosed 1990-1994 with early stage breast cancer. Our cohort included women who survived disease free for ≥5 years (N = 1,235) and were followed from year 6 through death, disenrollment, or 15 years after diagnosis. Asymptomatic surveillance mammograms were ascertained through medical record review. We used Cox proportional hazards regression stratified by follow-up year to calculate the association between time-varying surveillance mammography and breast cancer-specific and other-than-breast mortality adjusting for site, stage, primary surgery type, age and time-varying Charlson Comorbidity Index. The majority (85 %) of the 1,235 5-year breast cancer survivors received ≥1 surveillance mammogram in years 5-9 (yearly proportions ranged from 48 to 58 %); 82 % of women received ≥1 surveillance mammogram in years 10-14. A total of 120 women died of breast cancer and 393 women died from other causes (average follow-up 7.3 years). Multivariable models and lasagna plots suggested a modest reduction in breast cancer-specific mortality with surveillance mammogram receipt in the preceding year (IRR 0.82, 95 % CI 0.56-1.19, p = 0.29); the association with other-cause mortality was 0.95 (95 % CI 0.78-1.17, p = 0.64). Among older breast cancer survivors, surveillance mammography may reduce breast cancer-specific mortality even after 5 years of disease-free survival. Continuing surveillance mammography in older breast cancer survivors likely requires physician-patient discussions similar to those recommended for screening, taking into account comorbid conditions and life-expectancy.Breast Cancer Research and Treatment 10/2013; 142(1). DOI:10.1007/s10549-013-2720-x · 4.20 Impact Factor
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ABSTRACT: Cancer screening in individuals with limited life expectancy increases the risk of diagnosis and treatment of cancer that otherwise would not have become clinically apparent. To estimate screening mammography use in women with limited life expectancy, its geographic variation, and association with access to primary care and mammographic resources. We assessed screening mammography use in 2008-2009 in 106,737 women aged 66 years or older with an estimated life expectancy of <7 years using a 5% national sample of Medicare beneficiaries. Descriptive statistics were used to estimate the screening mammography utilization, by access to primary care. Among women with a life expectancy of <7 years, 28.5% received screening mammography during 2008-2009. The screening rates were 34.6% versus 20.5% for women with and without an identifiable primary care physician, respectively. The screening rates were higher among women who saw >1 generalist physician and who had more visits to generalist physicians. There was substantial geographic variation across the United States, with an average rate of 39.5% in the hospital referral regions (HRRs) in the top decile of screening versus 19.5% in the HRRs in the bottom decile. The screening rates were higher among HRRs with more primary care physicians (r=0.14, P=0.02), mammography facilities (r=0.12, P=0.04), and radiologists (r=0.22, P<0.001). Substantial proportions of women with limited life expectancy receive screening mammography. Results presented sound a cautionary note that greater access to primary care and mammographic resources is also associated with higher overuse.Medical care 06/2014; 52(6):490-5. DOI:10.1097/MLR.0000000000000115 · 2.94 Impact Factor
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ABSTRACT: Disparities in US breast cancer mortality between older Black and White women have increased in the last 20 years. Regular mammography use is important for early detection and treatment: its utilization among older Blacks especially in counties with high Black mortality is of interest, but its extent and determinants are unknown. We used Medicare claims for Black and White women 65-74 years old in 203 counties with the highest Black breast cancer mortality. Outcomes over 6 years were as follows: ever mammogram, i.e., ≥ 1 screening mammogram, and regular mammogram, i.e., ≥ 3 mammograms. With logistic regressions, we examined the independent effect of race on screening controlling for individual- and county-level factors. Of 406,602 beneficiaries, 17 % were Black. Ever and regular mammogram was significantly lower among Blacks (51.6 vs. 56.9 %; 32.9 vs. 43.1 %, respectively). Controlling for covariates, including use of cervical cancer screening, flu shots, or lipids tests, Black women were more likely to have ever mammogram (OR 1.23, CI 1.20-1.25), but not regular mammogram (OR 0.95, CI 0.93-0.97) than White women. County-level managed care penetration was negatively associated with ever and regular mammograms. In Medicare enrollees from these counties, breast cancer screening was low. Black women had same or better odds of screening than White women. Some health care factors, e.g., managed care, were negatively associated with screening. Further studies on the determinants of mammography utilization in older women from these counties are warranted.Cancer Causes and Control 09/2013; 24(12). DOI:10.1007/s10552-013-0295-9 · 2.96 Impact Factor