Older Women’s Perspectives Driving Mammography Screening Use and Overuse: a Narrative Review of Mixed-Methods Studies

Examining what older women know and perceive about mammography screening is critical for understanding patterns of under- and overuse, and concordance with screening mammography guidelines in the USA. This narrative review synthesizes qualitative and quantitative evidence around older women’s perspectives toward mammography screening. The majority of 43 identified studies focused on promoting mammography screening in women of different ages, with only four studies focusing on the overuse of mammography in women ≥ 70 years old. Older women hold positive attitudes around screening, perceive breast cancer as serious, believe the benefits outweigh the barriers, and are worried about undergoing treatment if diagnosed. Older women have limited knowledge of screening guidelines and potential harms of screening. Efforts to address inequities in mammography access and underuse need to be supplemented by epidemiologic and interventional studies using mixed-methods approaches to improve awareness of benefits and harms of mammography screening in older racially and ethnically diverse women. As uncertainty around how best to approach mammography screening in older women remains, understanding women’s perspectives along with healthcare provider and system-level factors is critical for ensuring appropriate and equitable mammography screening use in older women.


Introduction
Breast cancer is the most common cancer among women in the USA, representing nearly 30% of all new female cancer diagnoses in 2020 [1]. Mammography screening is critical for the early detection of breast cancer and is associated with a 20% reduction in mortality for women ages 50-74 years [2,3]; however, the margin of benefit is highly dependent on a woman's age, personal risk of breast cancer, and overall health [4][5][6]. Although the incidence of breast cancer generally increases with age, the long-term benefits of mammography may be limited in older women due to increased comorbidities and diminished life expectancy [7][8][9]. Professional guidelines do not support routine mammography screening for older women. The US Preventive Services Task Force (USPSTF) makes no breast cancer screening recommendations for women ≥ 75 years due to insufficient empirical evidence [10,11] while the American Cancer Society recommends biennial screening for women with a life expectancy greater than 10 years [12]. More recently, the American College of Physicians supported the discontinuation of mammography in older women at average risk for breast cancer, such as women without a strong family history or genetic susceptibility [13].
Efforts to ensure equitable access to healthcare have focused on underuse-gaps in care where patients have not received or have limited access to care that will benefit them [14,15]. Less attention has focused on healthcare overusecare where the harms outweigh the benefits or the balance between benefits and harm is unknown [15]. Healthcare overuse more broadly is pervasive within the healthcare system and older adults may be particularly vulnerable to this phenomenon. Mammography screening is a prime example of This article is part of the Topical Collection on Social Epidemiology healthcare overuse for older women with life expectancies less than 10 years. The potential harms of mammography screening are often immediate and include anxiety around false positive results, unnecessary breast biopsies, false assurance from false-negative results, and overdiagnosis and treatment of tumors that would not have resulted in death [5,[16][17][18][19][20][21][22]. Importantly, cancer treatments ranging from surgery to hormonal therapy are associated with greater complication in the presence of comorbidities, which is more prevalent in older adults [16]. Although professional guidelines vary in their recommendations about mammography screening for older women, most agree that the decision to continue or discontinue screening should be individualized, weighing the potential benefits and harms while considering life expectancy, comorbidity burden, and women's preferences [10][11][12][13]. To this end, the benefits of screening mammography in older women need to be considered against the more immediate harms.
Existing research around mammography screening use and overuse in older women has primarily focused on exploring provider-and organizational-level factors driving lack of adherence to guidelines, clinical and sociodemographic factors impacting utilization/adherence to mammography screening, and implications for associated morbidity, mortality, and psychological well-being [6,[23][24][25]. Among the few studies on older women's perspectives toward mammography screening, the majority were conducted outside of the USA [26][27][28][29] or prior to changes in breast cancer screening guidelines over the last decade [30][31][32]. Importantly, there is a lack of a comprehensive and recent synthesis of evidence on what older women know and perceive about mammography screening, which is critical for designing strategies and interventions to address screening mammography inequities related to use and overuse [5,33,34]. To address this critical gap, this review aims to describe the breadth of empirical research on older women's perspectives around screening mammography use and overuse in the USA.

Methods
We conducted a narrative review of the literature to synthesize quantitative and qualitative studies of older women's perspectives toward mammography screening including knowledge, attitudes, experiences, and health beliefs. Databases PubMed, Medline, and PsychINFO were electronically searched to identify quantitative, qualitative, and mixed-method studies performed in the USA reporting original data, applying the following search strategy: (women* OR woman*) AND (knowledge OR awareness OR perspective OR understanding OR perceptions OR attitude OR belief) AND (mammogra* OR breast screening OR breast cancer screening).
We limited our search to original peer-reviewed studies published in English between January 2009 and March 2020 with full-text availability. The decision to limit our search to studies published after 2009 was to both capture recent literature and coincide with the USPSTF guideline change for mammography screening in women aged ≥ 75 years [10,11]. While guidelines are specific to women aged ≥ 75 years, we expanded the definition of older women to women ages ≥ 65 years to be more inclusive of a larger number of relevant studies focusing on aging populations. Where the specific age distribution was unavailable, we used the overall sample age distribution and included studies where at least 25% of the sample were women ≥ 60 or the mean age was ≥ 55 to ensure sufficient representation of older women and their perspectives in the findings. We excluded studies exclusively recruiting high-risk populations defined as follows: (1) women with a history of breast cancer; (2) women with a family history of breast cancer; (3) women with a genetic predisposition for cancer. We also excluded studies that evaluated older women's perceptions toward diagnostic or future mammography after receiving an abnormal mammogram.

Results
The database search yielded 4421 articles. After deleting 1356 duplicate articles, the titles and abstracts from 3065 articles were independently screened by two reviewers, followed by a full-text screen and reference list scan for 37 systematic reviews. One researcher extracted data from studies satisfying all inclusion/exclusion criteria (Fig. 1).
We identified 43 studies: 31 quantitative (24 observational, 7 intervention), 11 qualitative, and 1 mixedmethod. The details of the extracted studies are presented in Table 1

Knowledge of Mammography Screening
Over one third of the studies assessed or described older women's knowledge of breast cancer and/or mammography screening, mainly to understand perspectives contributing to mammography underuse. Several studies found a significant positive association between knowledge and mammography behavior [42,49,52,55,66,68]. Knowledge of guideline recommendations regarding the initiation and frequency of screening varied across studies; between 61% and 88% of women perceived they should receive a mammogram every 1 to 2 years [42, 52, 57•, 60•]. One study found that 67% of women felt confused about the frequency of screening following changes in USPSTF guidelines recommendations [41] and another study found that less than half of women were aware of updates to the USPSTF guidelines around the frequency of screening [60•].
Only two studies measured knowledge of mammography screening in the context of mammography overuse. In a study assessing women aged ≥ 75 years, knowledge around the harms and benefits of mammography screening found that women correctly identified an average of 6.3 out of 10 questions [78]. In a mixed-methods study with women ≥ 70 years, few women had heard about the concept of mammography overuse and less than half understood the meaning of overuse after being presented with hypothetical scenarios illustrating the potential harms and benefits of overuse [36••].

Perceived Susceptibility and Perceived Seriousness of Breast Cancer
Over half of the studies assessed or described women's perceived susceptibility and perceived seriousness toward breast cancer related to mammography use or overuse. Perceived susceptibility was primarily operationalized as one's perceived risk or chance of getting breast cancer while perceived seriousness was often defined as severity, worry, fear of a cancer diagnosis, or belief that cancer is a death sentence (fatalism). Terminology varied across studies with some studies operationalizing perceived susceptibility or seriousness as a barrier or facilitator to mammography screening.
Quantitative and qualitative studies suggest that older women perceive low susceptibility to breast cancer; between 43% and 72% of women perceived they had little to no chance of getting breast cancer [ Insights from qualitative studies suggest that women's perceived level of susceptibility was shaped by age, the presence/absence of breast symptoms, family history, and understanding around the causes of breast cancer [39,71,[75][76][77]. For instance, a woman between 65 and 75 years of age shared in an interview that she did not perceive herself to be at risk of breast cancer and would only get a mammogram if she felt like "there's something that's going on" [77]. In another qualitative study with women between 65 and 94 years, several described that one's perceived susceptibility to breast cancer increased if there was a family history of breast cancer or by "hitting" or "squeezing" one's breast [39•].
Despite relatively low levels of perceived susceptibility among older women, several studies support the notion that older women perceive breast cancer to be serious, are worried or fearful about getting breast cancer and undergoing treatment, and/or believe there is not much one can do to keep from getting cancer [39•, 42, 45, 48•, 56, 70, 71, 74, 76, 77]. The association between perceived seriousness and mammography screening behavior differed across studies likely due to variation in operationalization, measurement, and study populations. For instance, one cross-sectional study found that Korean-American women ≥ 65 years perceive breast cancer to be more serious compared to Korean-American women ≤ 65 years [48•] and a cross-sectional study of women ≥ 65 years from racially and ethnically diverse backgrounds found that women who are more worried about breast cancer were more likely to undergo screening [45]. In contrast, older Hopi women who  feared a breast cancer diagnosis were less likely to undergo mammography screening [42] while a study among Dominican Latinas found no association between mammography behavior and the belief that there is not much one can do to keep from getting cancer or that cancer was a death sentence [40].

Cultural and Religious Beliefs
A number of studies emphasized the role of cultural and religious beliefs in shaping attitudes and health beliefs toward mammography screening. Only one qualitative study explored the role of cultural and religious beliefs among women ≥ 65 years [39•] and no study explored the role of cultural or religious beliefs around mammography overuse. Language-related barriers to care, modesty concerns around exposing oneself to strangers, beliefs that talking about breast cancer will result in breast cancer, and not wanting to burden families were commonly reported as culturally specific barriers to mammography screening [49,54,72,73,75,77]. Cultural and religious beliefs also shaped knowledge around the causes of breast cancer and perceptions around one's risk of getting breast cancer [39•, 54, 63, 66]. For instance, a qualitative study of African-American women ≥ 65 years found that many perceived their health to be "in God's hands" and although they feared breast cancer, they believed they needed to put their family's needs before their own; these beliefs in turn impacted their mammography screening behavior [39•].

Attitudes and Benefits toward Mammography Screening
Nearly two thirds of studies describe attitudes and perceived benefits of screening. Older women generally held positive attitudes toward mammography screening and reported high levels of perceived benefits [43, 46, 48•, 50, 51, 56, 58, 59, 60•, 62, 65, 68, 70, 72, 74-76]. The desire for early detection and a personal responsibility to stay healthy emerged as the primary benefit of mammography screening [35••, 36, 39, 42, 50, 52, 56, 60, 70, 74, 76]. However, the extent to which perceived benefits and/or positive attitudes shape mammography use or overuse differed across studies. Specifically, a study with a nationally representative sample found no statistically significant direct or indirect pathway linking perceived benefits to mammography behavior [62] while a cross-sectional study considering women ≥ 65 years separately from younger women found higher levels of perceived benefits was associated with an increased likelihood of having a mammogram in the older age group [48•].
Among the five studies reporting data only on women ≥ 65 years, between 50 and 85% of older women intended intended) to continue mammography screening [35••, 36••, 37••, 38•, 39•, 43, 48•]. Data from a qualitative study with women ≥ 70 years who received a mammogram in the past 3 years found that positive attitudes and the habitual nature of mammography screening resulted in many resisting the idea of reducing or discontinuing screening, even when presented with a number of scenarios such as poor physical health, provider/expert recommendation to stop screening, lack of beneficial effects for life expectancy, and/or not receiving treatment [35••]. In a study testing the effects of a paper-based mammography screening decision aid for women ≥ 75 years on their screening decisions, over two thirds of women believed that their providers wanted them to have a mammogram at baseline [38•]. This finding is supported by other studies inclusive of women ≥ 65 years suggesting that a recommendation or reminder from their provider [36••, 50, 65, 72, 74-76] and/or a family or friend recommendation or encouragement [35••, 50, 62, 65, 72, 76] may facilitate mammography use.

Conclusions
This narrative review makes an important and timely contribution to the literature by examining older women's perspectives around mammography screening in the USA. Overall, knowledge around guideline recommendations or the potential harms of screening is limited and older women continue to hold positive attitudes around mammography screening and believe that the benefits outweigh the barriers. Although perceived susceptibility to breast cancer varied, older women generally believe that breast cancer is serious and are worried about being diagnosed with breast cancer and undergoing treatment. These findings coupled with the belief that mammography screening is critical for the early detection of cancer may explain strong intentions to continue mammography screening in older women. These findings are generally consistent with prior research demonstrating widespread support for cancer screening among older adults in the USA and with studies performed outside of the USA [26][27][28][29].
Indicated by this review, research efforts to address mammography screening inequities continue to prioritize underuse among racial/ethnic minority groups. Consistent with published research, older racial/ethnic minority women experience a variety of attitudinal, personal, and structural barriers to screening mammography [14,79,80]. Mammography underuse among population groups experiencing inequities in late stage breast cancer and mortality risk remains an important priority area. However, efforts to address inequities in mammography access and use may inadvertently expose older women to the immediate harms of mammography screening that are disproportionate to the potential for long-term benefits [81]. More epidemiologic and interventional research using mixed-method approaches is needed to understand the scope of mammography overuse in racially and ethnically diverse populations that differ in their values, beliefs, experiences, and norms and to ensure that older racial and ethnic minority women are not inadvertently being targeted for more screening when the harms outweigh the benefits. This, in turn, can aid in developing strategies and interventions that are culturally and linguistically tailored to populations of interest [82][83][84].
This review highlights that perspectives driving screening mammography overuse among older women remains a critical yet understudied area [14,85,86]. Reducing or discontinuing the use of harmful, low-value care, referred to as de-implementation, is emerging as a key area of implementation science research [14,85]. There is also growing recognition that approaches to deimplementation are likely distinct from implementation, meaning that we need research focused specifically on methods that promote de-implementation. Understanding perspectives driving mammography overuse at the patient level is a critical first step to successful de-implementation; however, screening mammography is often routine, automatic, obligatory, and not perceived as a decision. These attributes make de-implementation of mammography screening particularly challenging. As seen in this review, informing older women about the option to reduce the frequency of or discontinuing routine mammography screening may run counterintuitive to long-standing attitudes and beliefs, and may provoke confusion or skepticism [31,32,87,88]. As a result, traditional patient-level approaches to educate and target cognitive processes to decision-making may prove insufficient. Although this review focuses and highlights the importance of considering patient-level perspectives in future efforts, changing women's perspectives will need to involve strategies and approaches at the policy, health system, and provider levels. To this end, de-implementation efforts will need to consider multiple levels synergistically with a comprehensive patient-level component focused on addressing commonly held attitudes and beliefs that may be more resistant to change and more unconscious processes that occur in response to emotive cues derived from a previously learned behavior [89,90].
This review set out to summarize older women's perspectives toward mammography use and overuse following the updates to guidelines recommendations in the USA; yet, there are several limitations. Our search strategy identified peer-reviewed articles of studies that included older women ages ≥ 65; however, the vast majority of studies also included women in younger age groups, and thus our findings also represent perspectives of younger women. The focus of this review was also to provide a narrative synthesis and no formal evaluation of the quality of all empirical evidence was performed. The majority of studies included in this review used observational quantitative or qualitative study designs, and showed substantial variations in age distribution, operationalization and measurement of perspectives, and demographic characteristics, thereby limiting the generalizability of our findings and our ability to make meaningful comparisons across studies and populations. Future research efforts should give greater consideration to sample characteristics, notably age, given changes in guideline recommendations that increasingly consider age-relevant burden of potential harms, evidence on benefits, life expectancy, and comorbidities. This review includes seven intervention studies reporting baseline perspectives of knowledge, attitudes, and beliefs toward mammography screening; however, interpreting baseline levels of perspectives was challenging due to insufficient reporting on the reliability, validity, and scoring of survey items. Thus, there is a need for more rigorous study designs, such as mixed-methods, and improved reporting and measurement of outcomes to identify the most salient factors and underlying processes explaining mammography use and overuse in older women.
Despite these limitations, this narrative review highlighted key gaps in our understanding of older women's perspectives contributing to mammography overuse more broadly and among racially and ethnically diverse populations. Findings from the present study also help to distinguish differences in perspectives related to underuse and overuse, as well as differences in perspectives by race, ethnicity, and advancing age. Collectively, findings from this review emphasize the need for approaches, strategies, and messaging tailored to the values, attitudes, and beliefs of patients and aligns with calls to prioritize de-implementation of overuse of mammography screening in older adults.

Compliance with Ethical Standards
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References
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