Background
Although limited guidance exists regarding breast cancer screening in women above the recommended screening age, clinicians may recommend mammography on an individual basis, based on patient characteristics, preferences and life expectancy. However, evidence on the extent of mammography use among these women in Europe remains scarce. The European Health Interview Survey (EHIS) collects data on mammography use and provides an opportunity to estimate the prevalence of mammography use in this population. 

Objectives

1. To estimate the age-standardised prevalence of mammography use in the three previous years among women above the recommended age for cancer screening by European country and to contextualise these estimates with national breast cancer incidence and mortality rates in the same age-group
2. To examine variations in mammography use across sociodemographic and health-related characteristics in Europe and by European country.

Methods
We calculated age-standardised prevalence of mammography use based on self-reported data from the third wave of the EHIS (2019). For each included country, the study population was defined according to either the upper age limit of the national breast cancer screening programme or the Council of Europe’s recommendations (69 years). Age-standardised breast cancer incidence and mortality rates were extracted from the European Cancer Information System. We estimated the prevalence of mammography use in all European countries combined, by area of residence, educational attainment, partner status, equivalised income level, and self-perceived general health.  

Results
Substantial variation in mammography use was observed across Europe, ranging from 5.3% (95% CI: 4.4-6.6) in Romania to 62.8% (95% CI: 59.9-65.5) in Czechia (Figure 1.A). Countries with higher mammography use prevalence generally had a national breast cancer screening programme and higher breast cancer incidence (Figure 1.B) but lower breast cancer mortality (Figure 1.C). Higher breast cancer mortality coincided with lower mammography use prevalence.
Women living in cities (38.2%, 95% CI: 36.1-40.7), with high education (41.1%, 95% CI: 38.0-44.8), higher equivalised level of income (42.0, 95% CI: 37.6-48.8), living with a partner (39.1%, 95% CI: 37.2-41.4), and reporting good health (37.3%, 95% CI: 35.3-39.5) had higher mammography use prevalence, compared to those living in rural areas (32.0%, 95% CI: 30.0-34.1), with low education (32.6%, 95% CI: 30.3-34.8), not living with a partner (34.2%, 95% CI: 32.7-35.7), with low income (32.2%, 95% CI: 30.0-34.6) or reporting poor health (32.7%, 95% CI: 30.1-35.2).

Conclusions
This study reveals substantial variation in the prevalence of mammography use among women above the recommended screening age across Europe. Although the data do not allow to distinguish screening from diagnostic examinations, the overall use of mammography in this age group suggests that opportunistic screening is likely to be common. Further research is needed to quantify the proportion of women receiving mammography for screening purposes and to inform evidence-based guidance on breast cancer screening in older women in Europe.

Age-standardised prevalence of mammography use in 2019 (A), breast cancer incidence in 2022 (B), and breast cancer mortality (C) in 2022 among women aged above the recommended screening age in Europe, classified into quintiles.