摘要：Objectives. We evaluated mammography rates for cognitively impaired women in the context of their life expectancies, given that guidelines do not recommend screening mammography in women with limited life expectancies because harms outweigh benefits. Methods. We evaluated Medicare claims for women aged 70 years or older from the 2002 wave of the Health and Retirement Study to determine which women had screening mammography. We calculated population-based estimates of 2-year screening mammography prevalence and 4-year survival by cognitive status and age. Results. Women with severe cognitive impairment had lower rates of mammography (18%) compared with women with normal cognition (45%). Nationally, an estimated 120 000 screening mammograms were performed among women with severe cognitive impairment despite this group's median survival of 3.3 years (95% confidence interval = 2.8, 3.7). Cognitively impaired women who had high net worth and were married had screening rates approaching 50%. Conclusions. Although severe cognitive impairment is associated with lower screening mammography rates, certain subgroups with cognitive impairment are often screened despite lack of probable benefit. Given the limited life expectancy of women with severe cognitive impairment, guidelines should explicitly recommend against screening these women. Screening mammography guidelines suggest that women with a life expectancy less than 4 to 5 years at the time of screening are unlikely to benefit from breast cancer screening and, thus, should not be screened. 1 – 3 Although some cancer screening guidelines specify upper-age cutoffs for stopping screening as a surrogate for life expectancy (e.g., prostate-specific antigen screening guidelines suggest stopping at age 75 years), 4 we do not know of any guidelines that specify the types of comorbidity that would preclude screening. This is despite the fact that certain comorbid conditions, such as dementia, are stronger predictors of life expectancy than age. 5 Specifically, patients with dementia generally live less than 5 years 6 – 12 and therefore are unlikely to benefit from screening mammography. In addition, having dementia or severe cognitive impairment increases the likelihood that elderly women will experience harm from screening mammography (e.g., more psychological distress from false-positive results because of the inability to understand screening procedures, and more complications from the treatment of clinically insignificant disease). 13 , 14 Moreover, screening mammography can distract care away from more pressing medical problems arising from either the cognitive impairment itself or from other comorbid conditions. However, it is unknown how often these women with severe cognitive impairment in the United States are undergoing screening mammography. A few prior studies have examined screening mammography rates in women with cognitive impairment; however, they relied on self-report of screening mammography, which is likely to be inaccurate among women with cognitive impairment 15 – 17 or older studies limited to a local geographic area. 17 , 18 To our knowledge, there have not been any recent national studies that have used objective measures, such as Medicare claims, to document the actual mammography rates in older women with severe cognitive impairment. Such data are needed to determine current practice patterns and to identify whether cognitive status appropriately factors into screening mammography decisions. Therefore, we conducted a study to document the actual rates of screening mammography in a US-representative sample of older women stratified according to their cognitive status. We used Medicare claims data linked to the Health and Retirement Study (HRS) to define rates of screening mammography (based on claims data) for women with differing levels of cognitive impairment. We also calculated survival according to level of cognitive impairment to validate that women with severe cognitive impairment defined by a standardized instrument have a median survival less than 5 years and are therefore unlikely to benefit from screening mammography.
