title: Evaluation of a Mammography Screening Decision Aid for Women Aged 75 and Older: Protocol for a Cluster-randomized Controlled Trial.
abstract: OBJECTIVE
  There is insufficient evidence to recommend mammography for women >75 years. Guidelines recommend that older women be informed of the uncertainty of benefit and potential for harm, especially for women with short life expectancy. However, few older women are informed of harms of screening and many with short life expectancy are screened. Therefore, we aim to test whether a mammography screening decision aid (DA) for women >75 years affects their use of mammography, particularly for women with <10 year life expectancy.
  
  
  METHODS
  The DA is a self-administered pamphlet that includes information on screening outcomes, tailored information on breast cancer risk, health, life expectancy, and competing mortality risks, and includes a values clarification exercise. We are conducting a large cluster randomized controlled trial (RCT) of the DA with the primary care provider (PCP) as the unit of randomization to evaluate its efficacy. We plan to recruit 550 women 75-89 years from 100 PCPs to receive either the mammography DA or a pamphlet on home safety for older adults (control arm) before a visit with their PCP, depending on their PCP's randomization assignment. The primary outcome is receipt of mammography screening assessed through chart abstraction. Secondary outcomes include effect of the DA on older women's screening intentions, knowledge, and decisional conflict, and on documented discussions about mammography by their PCPs. We will recruit women from 5 Boston-based primary care practices (3 community-based internal medicine practices and 2 academic practices), and 2 North Carolina-based academic primary care practices.
  
  
  CONCLUSIONS
  It is essential that we test the DA in a large RCT to determine if it is efficacious and to substantiate the need for broad translation into clinical practice. Our DA has the potential to improve health care utilization and care in a manner dictated by patient preferences.
authors.affiliation: Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Mara A
authors.initials: MA
authors.lastname: Schonberg
authors.affiliation: Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Christine E
authors.initials: CE
authors.lastname: Kistler
authors.affiliation: Department of Population Medicine, Harvard Medical School and Department of Medicine, Harvard Vanguard Medical Associates, Boston, MA, USA.
authors.forename: Larissa
authors.initials: L
authors.lastname: Nekhlyudov
authors.affiliation: VA Ann Arbor Center for Clinical Management, Departments of Internal Medicine and Psychology and Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor MI, USA.
authors.forename: Angela
authors.initials: A
authors.lastname: Fagerlin
authors.affiliation: Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Roger B
authors.initials: RB
authors.lastname: Davis
authors.affiliation: Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Christina C
authors.initials: CC
authors.lastname: Wee
authors.affiliation: Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Edward R
authors.initials: ER
authors.lastname: Marcantonio
authors.affiliation: Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
authors.forename: Carmen L
authors.initials: CL
authors.lastname: Lewis
authors.affiliation: Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Whitney A
authors.initials: WA
authors.lastname: Stanley
authors.affiliation: Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Trisha M
authors.initials: TM
authors.lastname: Crutchfield
authors.affiliation: Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors.forename: Mary Beth
authors.initials: MB
authors.lastname: Hamel
keywords: Decision aid; Mammography screening; Older women; Randomized trial