To the Editors,

We read with great interest Dr. Mara Schonberg’s editorial, “Overutilization of Breast Cancer Screening in the US: Awareness of a Growing Problem.”1 As primary care and geriatrics clinicians and researchers, we fully agree that there is wide variation in primary care provider recommendations regarding breast cancer screening in older women. Furthermore, the discussions between PCPs and patients regarding the harms and benefits of breast cancer screening are complex and involve potentially sensitive topics such as life expectancy. Therefore, useful shared decision-making tools for breast cancer screening in older women are vital.1

As part of our work in cancer screening in older adults, we recently conducted a focus group with eight primary care providers (five family medicine physicians, two geriatricians, and one nurse practitioner) affiliated with an academic medical center in Philadelphia. Topics included participants’ current approaches to cancer screening discussions with older adults and the potential use of decision aids, including Dr. Schonberg’s paper mammography decision aid for older women2 and e-prognosis app.3 Providers cited incorporating clinical information, patient values and preferences, and benefits and harms in these discussions. They acknowledged that these discussions are complex, and that they often worry about patients’ reactions to cessation of cancer screening. Most did not use decision aids for conversations, but were receptive to this approach. They found the paper decision aid and app could be helpful for facilitating an evidence-based discussion with patients regarding the harms and benefits of cancer screening. However, they expressed concerns regarding the patient literacy and numeracy levels needed to understand the decision aids, and were concerned that they lacked time for using these aids in standard visits.

Additionally, our focus group explored a strategy not mentioned in Dr. Schonberg’s editorial: the use of trained health educators/peer navigators, which have been used successfully in cancer screening shared decision-making.4,5 Providers were open to the use of a health educator, provided that the educator communicated the results of their discussions with the PCP for follow-up. We are currently evaluating the feasibility and acceptability of these decision aids with older African-American women, who comprise a significant portion of our patient population. We are also exploring patients’ receptivity to having a breast cancer screening discussion with a health educator. These findings will inform a future office-based shared decision-making program for breast cancer screening in older African-American women that will inform high-value care.