Core Elements of Shared Decision-making for Women Considering Breast Cancer Screening: Results of a Modified Delphi Survey.

BACKGROUND: The United States Preventive Services Task Force recommends individualized breast cancer screening for average-risk women before age 50, advised by risk assessment and shared decision-making (SDM). However, the foundational principles of this recommendation that would inform decision support tools for patients and primary care physicians at the point of care have not been codified. Determining the core elements of SDM for breast cancer screening as valued by patients and primary care providers (PCPs) is necessary for implementing effective SDM tools. The aim of this study is to affirm core elements of SDM in the context of clinical interactions, through a Delphi consensus process. METHODS: A Delphi was conducted with 30 participants (10 women aged 40-49, 10 PCPs, and 10 healthcare decision scientists), to codify core elements of breast cancer screening SDM. The criterion for establishing consensus was a threshold of 80% agreement. The Delphi concluded with an 83% response rate. RESULTS: Of 48 items fielded, 44 met the threshold on the high-importance end of the response scale and were accepted as core elements. Core elements across three thematic categories-information delivery and patient education, interpersonal clinician-patient communication, and framework of the decision-received panelists' support in nearly equal measure. Panelists unanimously agreed that SDM should include provision of clearly understandable information, including that of personal breast cancer risk factors, and benefits and harms of mammography screening, and that PCPs should convey they are listening, knowledgeable, and demonstrate cultural sensitivity. DISCUSSION: This research codifies the core elements of SDM for mammography in women 40-49, augmenting the evidence to inform discussions between patients and physicians. These core elements of SDM have the potential to operationalize SDM for breast cancer screening in an effort to improve public health outcomes.

Age-based versus Risk-based Mammography Screening in Women 40-49 Years Old: A Cross-sectional Study.

Background Risk-based screening in women 40-49 years old has not been evaluated in routine screening mammography practice. Purpose To use a cross-sectional study design to compare the trade-offs of risk-based and age-based screening for women 45 years of age or older to determine short-term outcomes. Materials and Methods A retrospective cross-sectional study was performed by using a database of 20 539 prospectively interpreted consecutive digital screening mammograms in 10 280 average-risk women aged 40-49 years who were screened at an academic medical center between January 1, 2006, and December 31, 2013. Two hypothetical screening scenarios were compared: an age-based (≥45 years) scenario versus a risk-based (a 5-year risk of breast cancer greater than that of an average 50-year-old) scenario. Risk factors for risk-based screening included family history, race, age, prior breast biopsy, and breast density. Outcomes included breast cancers detected at mammography, false-positive mammograms, and benign biopsy findings. Short-term outcomes were compared by using the χ2 test. Results The screening population included 71 148 screening mammograms in 24 928 women with a mean age of 55.5 years ± 8.9 (standard deviation) (age range, 40-74 years). In women 40-49 years old, usual care included 50 screening-detected cancers, 1787 false-positive mammograms, and 384 benign biopsy results. The age-based (≥45 years) screening strategy revealed more cancers than did the risk-based strategy (34 [68%] vs 13 [26%] of 50; P < .001), while prompting more false-positive mammograms (899 [50.3%] vs 216 [12.1%] of 1787; P < .001) and benign biopsy results (175 [45.6%] vs 49 [12.8%] of 384; P < .001). The risk-based strategy demonstrated low levels of eligibility (few screenings) in the 40-44-year age group. Differences in outcomes in the 45-49-year age group explained the overall hypothetical screening strategy differences. Conclusion Risk-based screening for women 40-49 years old includes few women in the 40-44-year age range. Significant trade-offs in the 45-49-year age group explain the overall difference between hypothetical screening scenarios, both of which reduce the benefits as well as the harms of mammography for women 40-49 years old. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Joe and Hayward in this issue.

Key Elements of Mammography Shared Decision-Making: a Scoping Review of the Literature.

BACKGROUND: New guidelines recommend shared decision-making (SDM) for women and their clinician in consideration of breast cancer screening, particularly for women ages 35-50 where guidelines for routine mammography are controversial. A number of models offer general guidelines for SDM across clinical practice, yet they do not offer specific guidance about conducting SDM in mammography. We conducted a scoping review of the literature to identify the key elements of breast cancer screening SDM and synthesize these key elements for utilization by primary care clinicians. METHODS: The Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus); PsycInfo, PubMed (MEDLINE), Scopus, and SocIndex databases were searched. Inclusion criteria were original studies from peer-reviewed publications (from 2009 or later) reporting breast cancer screening (mammography), medical decision-making, and patient-centered care. Study populations needed to include female patients 18+ years of age facing a real-life breast cancer screening decision. Article findings were specific to shared decision-making and/or use of a decision aid. Data extracted includes study design, population, setting, intervention, and critical findings related to breast cancer screening SDM elements. Scoping analysis includes descriptive analysis of study features and content analysis to identify the SDM key elements. RESULTS: Twenty-four articles were retained. Three thematic categories of key elements emerged from the extracted elements: information delivery/patient education (specific content and delivery modes), interpersonal clinician-patient communication (aspects of interpersonal relationship impacting SDM), and framework of the decision (sociocultural factors beyond direct SDM deliberation). A number of specific breast cancer screening SDM elements relevant to primary care clinical practice are delineated. DISCUSSION: The findings underscore the importance of the relationship between the patient and clinician and the necessity of spelling out each step in the SDM process. The clinician needs to be explicit in telling a woman that she has a choice about whether to get a mammogram and the benefits and harms of screening mammography. Finally, clinicians need to be aware of sociocultural factors that can influence their relationships and their patients' decision-making processes and attempt to identify and address these factors.