Individualizing Approaches to Surveillance Mammography in Older Breast Cancer Survivors - PROJECT SUMMARY/ABSTRACT Evidence-based approaches to surveillance mammography for older breast cancer survivors do not exist. Data suggest a life expectancy of ~10 years is necessary for early detection to translate into a small survival benefit. Conversely, the harms of mammography persist and are immediate, including false positives, overdiagnosis, and related over-treatment. Currently, mammography use in survivors is high, even when life expectancy is limited. As part of a National Cancer Institute (NCI) R21, the “Are Mammograms Still Right for Me?” shared decision making (SDM) toolkit was developed to support SDM between clinicians and older women around when to discontinue surveillance mammography. The SDM toolkit is designed for any survivorship setting and contains clinician-facing expert-consensus guidelines, talking points, and a companion patient guide on the benefits and harms of surveillance mammography. What remains lacking and critically needed is evidence as to the effectiveness of the SDM toolkit in decreasing mammography use in those who are more likely to experi- ence harm than benefit. The long-term goal is to accelerate the development and implementation of breast cancer survivorship guidelines tailored to individuals. The overall objective for this application is to determine the effects of the SDM toolkit on mammography use, decision quality, and mammography knowledge in breast cancer survivors aged ≥80, an age where median life expectancy is <10 years. The central hypothesis is that the toolkit will lead to more appropriate utilization of testing while improving knowledge and the decisional pro- cess. The following three specific aims are proposed: 1) Determine the effect of the SDM toolkit on mammogra- phy use and clinical outcomes; 2) Determine the toolkit’s effects on mammography knowledge and on SDM between patients and clinicians; and 3) Evaluate the facilitators and barriers to implementation of the SDM toolkit and discontinuation of mammography in this setting using the Consolidated Framework for Implementa- tion Research (CFIR). To evaluate the efficacy of the SDM toolkit, a randomized controlled trial will be con- ducted that randomizes 52 clinicians and 312 older breast cancer survivors from 6 U.S. cancer centers to the (a) SDM toolkit intervention or (b) Usual Care over three years. The proposed research is innovative because it represents a substantive departure from the status quo by focusing on determining the effectiveness and po- tential broad implementation of a novel, promising state-of-the-art SDM toolkit. The proposed research is sig- nificant because the results of this pragmatic trial are expected to provide strong justification for broad clinical deployment of an effective evidence-based SDM toolkit for proper use of surveillance mammography for older breast cancer survivors. Ultimately, the results of this research continuum are expected to have a positive im- pact on the quality of follow-up care for the >50,000 women age ≥80 diagnosed with breast cancer annually in the U.S. and the growing population of older breast cancer survivors.
