Table 2 Details of included studies

Beckmeyer 2020 USA [45]

13 women aged 75 + 

Quantitative Pilot test decision aid and pre/post survey design

Receipt of mammography screening at 18 months

Knowledge of the benefits and harms of mammography, decisional conflict around screening (including 5 subscales), preferred decision-making role, whether participants discussed mammography or HS with their PCP, and changes in screening intention, acceptability of the DA

3

Prior to intervention, all participants planned to have a screening mammogram in the next year. Post-intervention, 5 of the 8 women (62.5%) indicated they intended to continue to receive mammography; however, 3 participants planned to get them less often. When asked whether they thought their physician would want them to get a mammogram, 80% said “yes” on pre-test; this figure decreased to 62.5%. This pilot study suggests that the use of a decision-aid may result in fewer women ≥ 75 years old continuing to screen for breast cancer as of the 7 women who at pre-test thought they would get an-other mammogram, only 4 individuals at post-test said that they intended to get one in the next year. This is consistent with a previous-study of the DA showing a decrease in intent-to- screen from 82% pre-test to 56% post-test on post-test

Brotzman 2022 USA [46]

19 women aged 71–93

Qualitative description

Experiences, beliefs, and opinions about screening mammography in relation to aging and health

1,2,

Three main themes emerged: (1) older women typically perceive mammograms as a positive, beneficial, and routine component of care; (2) participation in routine mammography is reinforced by factors at interpersonal, provider, and healthcare system levels; and (3) older women do not endorse discontinuation of screening mammography due to advancing age or poor health, but some may be receptive to reducing screening frequency. Only a few older women reported having discussed mammography cessation or the potential harms of screening with their providers. A few women reported they would insist on receiving mammography even without a provider recommendation

Cadet 2021 USA [48]

43 aged 75–89

Quantitative Pre/post-test trial

Knowledge of benefits and harms, decisional conflict, decision making role and acceptability

1,3

Receipt of the DA significantly affected knowledge of mammography’s benefits and harms (pre-test(M = 3.75,SD = 1.05) to post-test (M = 4.42,SD = 1.19), p = .03).Receipt of the DA did not significantly affect decisional conflict (pre-test M = 3.10,SD = .97) to post-test M = 3.23,SD = 1.02,p = .71)- higher scores = lower decisional conflict. The majority of the women (97%) indicated that the DA was helpful

Cadet 2021 USA [49]

18 women aged 75–89

Qualitative

Knowledge, acceptability of the DA

1,3

Findings indicate that women in this study lacked knowledge and understanding that one can decide on mammography screening based on their personal values. Women were enthusiastic about screening based on an interest in taking care of themselves but rely on their providers for health care decisions. Overall, most women found the DA helpful and would recommend the use of the DA

Cadet 2021 USA [47]

283 aged 75–89

Quantitative Secondary analysis

Association between women’s educational attainment and their knowledge of the benefits and harms of mammography

Decisional conflict, change in screening intention, discussions with PCP and receipt of screening

3

Regardless of educational attainment, 87.2% of the 283 women found the DA helpful. Women with lower educational attainment were less likely to understand all the DA’s content (46.3% vs 67.5%; P < .001), had less knowledge of the benefits and harms of mammography (adjusted mean ± standard error knowledge score, 7.1 ± 0.3 vs 8.1 ± 0.3; P < .001), and were less likely to lower screening intentions (adjusted percentage, 11.4% vs 19.4%; P = .01). Receipt of screening did not differ by educational attainment

Collins 2010 UK [23]

26 interviews and 479 questionnaires

Mixed methods

Breast screening knowledge and uptake

Breast screening awareness and behaviour, views about screening and preferences for screening

1,2

Over half (52.9%) of the respondents were unaware that they could request a mammography by voluntary self-referral and were unaware how to arrange this. Most (81.5%) had not attended breast screening since turning 70 years. Most (75.6%) felt screening was beneficial and would attend if invited. Most (90.1%) felt screening should be offered to all women regardless of age or health. The overwhelming view across both the interview and questionnaire data was that breast screening should be offered to all women indefinitely and regardless of age, health status or fitness (90.1%, CI: 87.0–92.6%). There was a strong preference for unrestricted screening with 42.9%, indicating their preference for automatic recall extended indefinitely regard-less of age or health status. Almost three in four women surveyed (74.1%) indicated a preference for a postal reminder letter every 3 years

Eisinger 2011 France [56]

136 women 75 years and over as a subset of a larger sample

Quantitative survey

Screening intention

2

For 136 women aged 75 years and over, who were breast cancer-free and who had undergone a mammography at least once in their lifetime, 62 (51%) had done so during the previous two years. Of these 62 women, 37 (60%) intended to pursue screening in the future; of the 60 women who had never undergone a mammography, 27 (36%) intended to do so in the future. Future intentions regarding screening varied significantly [odds ratio (OR) = 2.6, 95% confidence interval (CI) = 1.2–5.4]. However, no sociodemographic differences were observed between screened and unscreened women regarding level of education, income, health risk behaviour (smoking, alcohol consumption), knowledge about the importance and the process of screening, or psychological features (fear of the test, fear of the results, fear of the disease, trust in screening impact)

Gray 2018 USA [50]

Not reported at individual level

Quantitative using data from national cross-sectional survey

Impact of social interaction on screening

Education, income and employment

1

For all women, evidence was found of social interactions associated with individual’s education, employment, and poor health. In addition, number of age-group-specific social multipliers was found. The strongest evidence of spill over in mammography was found for women ages 75 and older. Policy makers should be aware that, in the presence of a social multiplier, the value of any type of screening intervention is higher than the one that would be measured at the individual-level

Hoover 2019 USA [51]

31 women aged 75 + 

Qualitative descriptive

Knowledge of benefits and harms of screening

Information provision about over-diagnosis

1,2

Participants wanted to hear about the benefits and harms of screening mammography, including over diagnosis. Participants requested information be communicated via physicians or other healthcare providers, included in brochures/pamphlets, and presented outside of clinical settings (e.g., in senior groups). Results were consistent regardless of participants’ age, race/ethnicity, or education. Findings revealed that older women desire information about the benefits and harms of screening mammography and would prefer to learn this information through discussions with healthcare providers and multiple other formats

Housten 2018 USA [33]

11 women aged 75 + 

Qualitative

Reasons for discontinuation of screening

1

All women expressed a strong intention to continue screening. Based on the hypothetical physician recommendations, intentions to continue screening appeared to remain strong. They did not envision a change in their health status that would lead them to discontinue screening and were sceptical of expert/government recommendations. There were no differences observed according to age, race/ethnicity, or education

Salzman 2020 USA [52]

24 women aged 75 + 

Qualitative

Knowledge about screening, discussions with providers,

1,3

Most participants (75%) reported familiarity with current breast cancer screening guidelines. Twenty-nine percent reported prior discussions with providers about continuing breast cancer screenings. Sixty percent did not need assistance completing DAs while 40% did. 66.7% found the decision aids “very helpful” in reflecting their breast cancer screening thoughts; 58.3% had no preference regarding either decision aid version. 75% of participants were willing to complete the decision aid before a provider visit. Participants equally preferred a health educator or provider facilitating discussion of breast cancer screening harms and benefits and potential cessation

Schoenborn

2021 USA [53]

283 women aged 75 + 

Quantitative as part of a larger RCT (pre/post visit with PCP)

Intention to be screened and receipt of mammography screening

1, 3

From pre to post visit with their PCP, 21.7% of women lowered their intentions to be screened, 7.9% increased their intentions to be screened, and 70.4% did not change. Lower screening intention is associated with lower breast cancer screening rates among older women, suggesting that screening intention is a reasonable proximal outcome for interventions aimed at reducing over screening in older women

Schonberg 2014 USA [55]

45 women aged 75 + 

Quantitative Pre/post-test trial design

Knowledge about mammography

Decisional conflict, screening intention, decision-making role, acceptability and discussions with providers and receipt of screening

3

The median age of participants was 79 years. Comparison of post-test results with pre-test results demonstrated 2 findings. First, knowledge of the benefits and risks of screening improved (P < .001). Second, fewer participants intended to be screened (56% [25 of 45] afterward compared with 82% [37 of 45] before, P = .03). Decisional conflict declined but not significantly (p = .10). In the following 6 months, 53% (24 of 45) of participants had a primary care physician note that documented the discussion of the risks and benefits of screening compared with 11% (5 of 45) in the previous 5 years (P < .001). While 84% (36 of 43) had been screened within 2 years of participating, 60% (26 of 43) were screened within 15 months after participating (2 years since their last mammogram) (P = .01). Overall, 93% (42 of 45) found the DA helpful

Schonberg 2020 USA (54)

283 women aged 75 + that received the DA

Quantitative RCT

Receipt of mammography screening at 18 months

Knowledge of the benefits and harms of mammography, decisional conflict around screening (including 5 subscales), discussed mammography or HS with their PCP, and changes in screening intention. Preferred decision-making role, whether participants

3

Receipt of the decision aid before a visit with their clinician led to women 75 years and older being more knowledgeable about mammography screening, having more discussions with their primary care physician about screening, and fewer women being screened