Reported drop in mammography : is this cause for concern?

The assessment of the likelihood of mammography usage with relevant factors among women with disabilities

Research that identifies the determinants of low mammography use among disabled people is scant. This study examines the determining factors related to the low usage of mammography among women with disabilities. To identify the barriers that prevent women with disabilities from participating in mammography screening can help authorities conceive feasibly useful strategies for avoiding worse suffering. With women aged between 50 and 69 as subjects, this study was conducted using the database of Ministry of the Interior, Taiwan, in 2008, coupled with information gathered between 2006 and 2008 on preventive health care and medical claim data from the Bureau of Health Promotion and the National Health Research Institutes, respectively. This study examined the factors determining the use of mammography with logistic regression analysis. Only 8.49% of the disabled women used mammographies. When women with disabilities were in higher income level, they were more likely to use mammography for breast cancer screening. Similar findings were found for education levels. Moreover, subjects with a more severe form of disability were less likely to use mammography with ORs of 0.84, 0.63, and 0.52. Disabled women with major organ malfunction, chronic mental illness, or mental retardation had a higher likelihood to use mammography services, whereas women with multiple disabilities had the lowest likelihood of usage. Those with experience using other preventive services showed 1.9 times to 7.54 times (95% CI: 1.82-1.98, 7.15-7.95, respectively) increased likelihood of mammography usage. In summary, mammography usage is relatively different for disabled and nondisabled populations. To mitigate the disparities, we can use community healthcare institutions or public health nurses and social workers to provide related preventive health services through community events to implement integrated cancer screening services.

Mammography capacity and appointment wait times: barriers to breast cancer screening

OBJECTIVE

To assess the impact of mammography capacity on appointment wait times.

METHODS

We surveyed by telephone all mammography facilities federally certified in 2008 in California, Connecticut, Georgia, Iowa, New Mexico, and New York using a simulated patient format. County-level mammography capacity, defined as the number of mammography machines per 10,000 women aged 40 and older, was estimated from FDA facility certification records and US Census data.

RESULTS

1,614 (86%) of 1,882 mammography facilities completed the survey. Time until next available screening mammogram appointment was <1 week at 55% of facilities, 1-4 weeks at 34% of facilities, and >1 month at 11% of facilities. Facilities in counties with lower capacity had longer wait times, and a one-unit increase in county capacity was associated with 21% lower odds of a facility reporting a wait time >1 month (p < 0.01). There was no association between wait time and the availability of evening or weekend appointments or digital mammography.

CONCLUSION

Lower mammography capacity is associated with longer wait times for screening mammograms.

IMPACT

Enhancement of mammography resources in areas with limited capacity may reduce wait times for screening mammogram appointments, thereby increasing access to services and rates of breast cancer screening.

Breast cancer risk assessment in 64,659 women at a single high-volume mammography clinic

RATIONALE AND OBJECTIVES

In 2007, the American Cancer Society (ACS) recommended that women at elevated risk of breast cancer be screened with breast magnetic resonance imaging (MRI) as an adjunct to mammography. This study estimates the proportion of women presenting for screening mammography who are at elevated lifetime risk of breast cancer as determined by the Gail model. This study provides preliminary information for a proposed follow-up study, including the proportion of women who completed the recommended MRI at the same clinic that had conducted the risk assessment.

MATERIALS AND METHODS

This study is an observational prospective cohort of 64,659 women presenting for mammographic screening at a single high-volume clinic. If a woman reported a first-degree maternal relative with breast cancer and had at least 20% lifetime risk on the Gail model, the radiologist's report included a recommendation that the primary care physician refer the woman for breast MRI screening. Records were examined to determine if women completed the recommended MRI at the clinic within one year of the initial risk assessment.

RESULTS

Of 64,659 women, 1,246 (1.9%) had a lifetime risk of breast cancer of 20% or greater, and 436 (0.7 %) had a lifetime risk of breast cancer 25% or greater. Of the women at elevated risk, 173 (13.9%) completed the recommended breast MRI screening at the clinic within a year.

CONCLUSION

The effectiveness of matching screening intensity to risk on cancer detection, biopsy rate, and cost should be evaluated by studying multiple clinics and multiple risk assessment tools.

Was the drop in mammography rates in 2005 associated with the drop in hormone therapy use?

BACKGROUND

In 2005, mammography rates in the United States dropped nationally for the first time among age-eligible women. An increased risk of breast cancer related to hormone therapy (HT) use reported in 2002 led to a dramatic drop in its use by 2005. Because current users of HT also tend to have higher mammography rates, the authors examined whether concurrent drops in HT and mammography use were associated.

METHODS

Multivariate logistic regression was used to test for an interaction between HT use and survey year, controlling for a range of measurable factors in data from the 2000 and 2005 National Health Interview Surveys (NHIS).

RESULTS

Women ages 50 to 64 years were more likely to report a recent mammogram if they also reported more education, a usual source of care, private health insurance, any race except non-Hispanic Asian, talking with an obstetrician/gynecologist or other physician in the past 12 months, or were currently taking HT. Women aged ≥ 65 years were more likely to report a recent mammogram if they also reported younger age (ages 65-74 years), more education, a usual source of care, having Medicare Part B or other supplemental Medicare insurance, excellent health, any race except non-Hispanic Asian, talking with an obstetrician/gynecologist or other physician in the past 12 months, or were currently taking HT.

CONCLUSIONS

The change in HT use was associated with the drop in mammography use for women ages 50 to 64 years but not for women aged ≥ 65 years. NHIS data explained 70% to 80% of the change in mammography use.

Adherence to breast and cervical cancer screening in Spanish women with diabetes: associated factors and trend between 2006 and 2010

AIM

This study aimed to assess the adherence to breast and cervical cancer screening of women with diabetes mellitus (DM), and the associated factors and trend of use over time of these preventative services between 2006 and 2010 in Spain.

METHODS

The study used data from a population of women aged greater or equal to 18 years (n=11,957) who participated in the European Health Interview Survey in Spain (EHISS, 2009). Diabetes status was self-reported and included those with type 2 DM. Adherence to screening for cancer prevention was assessed by asking women aged greater or equel to 40 years whether they had undergone mammography and a Papanicolaou (Pap) cervical smear (in those aged 18-69 years) within the previous 2 and 3 years, respectively. Independent variables included sociodemographic and health-related characteristics. Also, the age-standardized prevalences of mammography and Pap smear uptake were compared in women with diabetes between 2006 and 2010.

RESULTS

Among the diabetic women, 37.9% underwent mammography and 49.1% had a Pap smear vs 53.8% and 64%, respectively, in women without diabetes, with corresponding adjusted odds ratios of 0.81 (95% CI: 0.68-0.97) and 0.74 (95% CI: 0.60-0.91). Among diabetic women, attending more "physician visits" was a positive predictor of having both screening tests. Also, a higher monthly income level was associated with mammography uptake, and a higher educational level with Pap smear uptake. There was also a significant decrease in mammography screening uptake between 2006 and 2010 compared with a stable rate of uptake of cervical cancer screening.

CONCLUSION

Spanish women with diabetes consistently underuse breast and cervical cancer screening tests compared with non-diabetic women. The decline in mammography uptake rates needs to be carefully monitored and may even call for intervention.

Process outcomes from a randomized controlled trial comparing tailored mammography interventions delivered via telephone vs. DVD

OBJECTIVE

Tailored, interactive mammography-promotion interventions can increase adherence if women are exposed to and find them usable. We compare exposure to and usability of interventions delivered via telephone vs. DVD.

METHODS

Process evaluation measures from 926 women randomly assigned to telephone or DVD intervention and completing post-intervention surveys.

RESULTS

∼83% of each group reported exposure to all content. Partial exposure was higher for DVD (9% vs. 0.4%; p<.01); no exposure was higher for phone (15% vs. 8%; p<.01). There were no differences in exposure by age or race. Full phone exposure was less likely for women who already made mammography appointments. Usability rating was higher for DVD (p<.05), driven by ratings of understandability and length. Usability of both interventions was correlated with lower baseline barriers, and higher fear, benefits, and self efficacy. Higher ratings for phone were associated with lower knowledge and contemplating mammography. Non-whites rated DVD better than whites.

CONCLUSION

Both tailored interactive interventions had wide reach and favorable ratings, but DVD recipients had greatest exposure to at least partial content and more favorable ratings, especially among non-white women.

PRACTICE IMPLICATIONS

This first evaluation of a tailored, interactive DVD provides promise for its use in mammography promotion.

Mammography adherence: a qualitative study

BACKGROUND

Regular mammography accounts for half of the recent declines in breast cancer mortality. Mammography use declined significantly in 2008. Given the success of regular breast cancer screening, understanding why mammography use decreased is important. We undertook a focus group study to explore reasons women who were previously adherent with regular mammography no longer were screened.

METHODS

We conducted 20 focus groups with white non-Hispanic, black non-Hispanic, Hispanic, Japanese American, and American Indian/Alaska Native women, and segmented the groups by age, race/ethnicity, and health insurance status. A conceptual framework, based on existing research, informed the development of the focus group guide. Discussion topics included previous mammography experiences, perceptions of personal breast cancer risk, barriers to mammography, and risks and benefits associated with undergoing mammography. Atlas.ti was used to facilitate data analysis.

RESULTS

All focus groups (n=128 women) were completed in 2009 in five cities across the United States. Half of the groups were held with white non-Hispanic women and the remainder with other racial/ethnic groups. Major barriers to routine mammography included (1) concerns about test efficacy, (2) personal concerns about the procedure, (3) access to screening services, (4) psychosocial issues, and (5) cultural factors. For uninsured women, lack of health insurance was the primary barrier to mammography.

CONCLUSIONS

Multilevel interventions at the health-care provider and system levels are needed to address barriers women experience to undergoing regular mammography screening. Ultimately, breast cancer screening with mammography is an individual behavior; therefore, individual behavioral change strategies will continue to be needed.

The relationship between breast cancer anxiety and mammography: experiential avoidance as a moderator

Although mammography can aid in the early detection and prevention of breast cancer, many women do not receive annual mammograms. It remains unclear whether anxiety about breast cancer inhibits or promotes mammography rates. The way in which women regulate their anxiety (ie, level of experiential avoidance) may play a role in predicting mammography adherence. A community sample of women (N = 84) completed a questionnaire which assessed mammography rates, experiential avoidance, and breast cancer anxiety. The results suggest that, while controlling for breast cancer anxiety, experiential avoidance (β = .31, p < .01) significantly predicted mammography rates. When examining experiential avoidance as a moderator, a multiple regression analysis approached significance (R2 Δ = .04, p = .07), suggesting that a woman's level of experiential avoidance influences the relationship between anxiety and mammography. These findings will help enable health care practitioners to better identify women at risk of non-adherence to mammography recommendations.

Breast cancer knowledge, attitudes and practices among Nepalese women

Although Nepal has an epidemic of early-onset, aggressive, advanced breast cancer, breast cancer knowledge and screening practices of Nepalese women have not been assessed. This paper summarises the results of a physician-administrated survey of gynaecologic inpatients (n= 100) admitted between 1 December 2009 and 31 January 2010 at a Nepalese University. Mean knowledge score of the participants was 65%, significantly higher among highly educated women (P= 0.008), professionals (P= 0.014) and women counselled during medical visits (P= 0.030). Study participants, including highly educated women, had many misconceptions. This included lack of awareness of painless nature and non-lump symptoms of breast cancer as well as the belief that traditional health care can be curative. The majority of participants were unaware of clinical breast examination (68%) and mammography (56%). Only 10% of the participants had undergone breast evaluation in the last 2 years. The practice of breast evaluation was more common among Buddhists (P= 0.043), and women counselled during medical visits (P < 0.001), with high economic status (P= 0.022), higher education (P= 0.013) and a family history of breast cancer (P= 0.049). Counselling during medical visits and higher education level were associated with better knowledge of and screening practices for breast cancer in the studied population.

Factors associated with self-reported mammography use for women with and women without a disability

BACKGROUND

Although their risk of breast cancer is similar to that of women without a disability, women with a disability might be less likely to obtain a mammogram within the recommended time frame. The purpose of this study was to expand our knowledge of the association between mammography use and having a disability by controlling for sociodemographic and health variables.

METHODS

Data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) were used to obtain prevalence of self-reported mammography use in the past 2 years among U.S. women ≥40 years of age (n=204,981) as well as women 50-74 years of age (n=122,374). Logistic regression was used to estimate associations between disability and obtaining a mammogram for each age cohort, controlling for sociodemographic factors.

RESULTS

Prevalence of self-reported mammography use is lower for women with a disability (72.2% for women ≥40 years of age and 78.1% for women 50-74 years of age) than women without a disability (77.8% and 82.6%, respectively). Women with a disability had lower odds of mammography use than women without a disability for both age cohorts (≥40, adjusted odds ratio [aOR] 0.92, p=0.01; 50-74 years, aOR 0.92, p=0.03).

CONCLUSIONS

Disparities in obtaining a mammogram at recommended screening intervals persist for women with disabilities. This demonstrates the need for continued health promotion and prevention activities directed toward women with a disability to improve their accessibility to obtaining a mammogram.

Psychosocial factors influencing breast cancer risk appraisal among older women

Although the incidence of breast cancer increases with age, many older women are uninformed about the increased risk and have lower mammography screening rates than younger women. Understanding older women's perceptions of risk might assist health care providers in offering appropriate resources that result in screening. In this study, we explored psychosocial components influencing older women's breast cancer risk appraisal. To identify key psychosocial components of breast cancer risk appraisal, we conducted focus group interviews. Data saturation occurred with four groups (N = 36) of older Black (58%) and White (42%) women with no prior history of breast cancer. On analysis of the data, we found three themes representing psychosocial factors influencing breast cancer risk appraisal with this cohort. Our findings revealed that worry/fear/anxiety, self-regulating empowerment, and realistic optimism were psychosocial mechanisms older Black and White women in this sample used in appraising breast cancer risk.

Survival from common and rare cancers in Germany in the early 21st century

BACKGROUND

Until recently, population-based data of cancer survival in Germany mostly relied on one registry covering ∼1 million people (1.3% of the German population). Here, we provide up-to-date cancer survival estimates for Germany based on data from 11 population-based cancer registries, covering 33 million people and compare them to survival estimates from the United States.

PATIENTS AND METHODS

Cancer patients diagnosed in 1997-2006 were included. Period analysis was employed to calculate 5-year relative survival for 38 cancers for 2002-2006. German and USA survival rates were compared utilizing the Surveillance, Epidemiology and End Results 13 database.

RESULTS

Five-year relative survival >80% was observed for testicular cancer (93.5%), skin melanoma (89.4%), cancers of the prostate (89.1%) and thyroid (87.8%), Hodgkin's lymphoma (84.5%) and cancers of the breast (83.7%) and endometrium (81.0%), which together account for almost 40% of cases. For the majority of cancers, German survival estimates were close to or below those in the United States. Exceptions with higher survival in Germany were cancers of the stomach, pancreas and kidney and Hodgkin's lymphoma.

CONCLUSIONS

German cancer survival estimates are mostly higher than the 2000-2002 pan-European estimates. Further research is needed to investigate causes responsible for differences between German and USA cancer survival rates.

Effect of health care system distrust on breast and cervical cancer screening in Philadelphia, Pennsylvania

OBJECTIVES

We investigated whether health care system distrust is a barrier to breast and cervical cancer screening and whether different dimensions of distrust-values and competence-have different impacts on cancer screening.

METHODS

We utilized data on 5268 women aged 18 years and older living in Philadelphia, Pennsylvania, and analyzed their use of screening services via logistic and multinomial logistic regression.

RESULTS

High levels of health care system distrust were associated with lower utilization of breast and cervical cancer screening services. The associations differed by dimensions of distrust. Specifically, a high level of competence distrust was associated with a reduced likelihood of having Papanicolaou tests, and women with high levels of values distrust were less likely to have breast examinations within the recommended time period. Independent of other covariates, individual health care resources and health status were associated with utilization of cancer screening.

CONCLUSIONS

Health care system distrust is a barrier to breast and cervical cancer screening even after control for demographic and socioeconomic determinants. Rebuilding confidence in the health care system may improve personal and public health by increasing the utilization of preventive health services.

Radiotransparency of polyvinylpyrrolidone-hydrogel and hydrogel breast implants: a quantitative analysis with mastectomy specimens

Breast cancer is the most common cancer in women. Past evidence suggested that women with silicone implants who had cancer presented with more advanced disease and had the worst prognosis due to difficulty visualizing early lesions on mammography. Hence, new filling materials have been developed. In this study, 10 mastectomy specimens were used. Mammograms of specimens alone and specimens covering polyvinylpyrrolidone-hydrogel and hydrogel implants were performed. The variables studied were number of mammograms necessary to examine each specimen, kilovolts and milliamperes of each mammogram, number of isolated microcalcifications, microcalcification clusters and macroscopic calcifications, and rarefaction areas. No significant differences were found in number of mammograms (p = 0.439), isolated microcalcifications (p = 0.178), macrocalcifications (p = 1.0), and presence of rarefaction areas (p = 0.368). The difference in number of microcalcification clusters was significant (p = 0.0498). Significant differences (p < 0.001) also were observed in the kilovolts and milliamperes of the mammograms performed for specimens alone versus those with implants. Polyvinylpyrrolidone-hydrogel and hydrogel breast implants allow adequate visualization of mammary glands at the expense of greater radiation doses, although it must be considered that the experimental situation does not fully match the real clinical setting.

Dead by 50: lay expertise and breast cancer screening

This paper examines the reactions of women with breast cancer to the 2009 U.S. Preventive Services Task Force recommendations for mammography screening. Specifically, it analyzes electronic postings about the Task Force's recommendations from five breast cancer discussion boards between November 17, 2009 and December 17, 2009. Women's opposition to the recommendations is best understood as a clash between scientific and lay expertise concerning the priorities of medicine and notions of evidentiary significance. We highlight the connective logic - or connectivity - that underlies lay expertise in the electronic era. Connectivity is a unique way of knowing that emerges from an experiential connection to illness and a virtual connection to others with the same illness. Connectivity is based on forms of evidence that enhance the moral authority of lay claims for medical succor. Connectivity is a potent element in contemporary lay challenges to scientific expertise and will become increasingly influential as online illness affiliation becomes ever more commonplace.

Mammogram screening in Chile: using mixed methods to implement health policy planning at the primary care level

Breast cancer has the highest incidence of all cancers among women in Chile. In 2005, a national health program progressively introduced free mammography screening for women aged 50 and older; however, three years later the rates of compliance with mammographic screening was only 12% in Santiago, the capital city of Chile. This implementation article combines the findings of two previous studies that applied qualitative and quantitative methods to improve mammography screening in an area of Santiago. Socio-cultural and accessibility factors were identified as barriers and facilitators during the qualitative phase of the study and then applied to the design of a quantitative randomized clinical trial. After six months of intervention, 6% of women in the standard care group, 51.8% in the low intensity intervention group, and 70.1% in the high intensity intervention group had undergone a screening mammogram. This review discusses how the utilization of mixed methods research can contribute to the improvement of the implementation of health policies in local communities.

Strategies for increasing mammography screening in primary care in Chile: results of a randomized clinical trial

BACKGROUND

Breast cancer is the cancer with the highest incidence among women in Chile and in many Latin American countries. Breast cancer screening has very low compliance among Chilean women.

METHODS

We compared the effects on mammography screening rates of standard care, of a low-intensity intervention based on mail contact, and of a high-intensity intervention based on mail plus telephone or personal contact. A random sample of 500 women with the age of 50 to 70 years registered at a community clinic in Santiago who had not had a mammogram in the past 2 years were randomly assigned to one of the three intervention groups. Six months after randomization, participants were re-evaluated for their compliance with mammography screening. The outcome was measured by self-report and by electronic clinical records. An intention to treat model was used to analyze the results.

RESULTS

Between 92% and 93% of participants completed the study. Based on electronic records, mammography screening rates increased significantly from 6% in the control group to 51.8% in the low-intensity group and 70.1% in the high-intensity group. About 14% of participants in each group received opportunistic advice, 100% of participants in the low- and high-intensity groups received the mail contact, and 50% in the high-intensity group received a telephone or personal contact.

CONCLUSION

A primary care intervention based on mail or brief personal contact could significantly improve mammogram screening rates.

IMPACT

A relatively simple intervention could have a strong impact in breast cancer prevention in underserved communities.

Patient Barriers to Mammography Identified During a Reminder Program

Background: Patient mammogram reminders are effective at increasing screening, but patient barriers remain. We evaluated patient characteristics and reported barriers for their association with mammogram completion after a reminder program. Methods: This retrospective cohort study used data from electronic records and a subgroup survey. Participants were female Kaiser Permanente Northwest health maintenance organization (HMO) members aged 50-69 who were 20 months past their last mammogram (index date) and had received a reminder intervention (n = 4708). A mailed survey was completed by 340 of 667 (50.2%) women who received it. The intervention was a "mammogram due soon" postcard 20 months after the last mammogram, followed by up to two automated phone calls and one live call for nonresponders. The outcome was mammogram completion at 10 months after index date. Results: Characteristics associated with lower mammogram completion rates were aged <60 (odds ratio [OR] 0.69, p < 0.0001), health plan membership <5 years (OR 0.81, p = 0.019), family income <$40,000/year (OR 0.77, p = 0.018), and obesity (OR 0.67, p < 0.0001). Obese women were more likely than nonobese women to report "too much pain" from mammograms (31.3% vs.18.8%, p < 0.01). Younger women were more likely to endorse that they were "too busy" (19.1% vs. 6.4%, p < 0.001) and had more worries about mammogram accuracy (2.5 vs. 2.3 on a 5-point scale, p < 0.05). Pain mediated the relationship between obesity and mammogram completion rates (indirect effect = -0.111, p = 0.008). Conclusions: Important barriers to mammogram completion remain even after an effective mammogram reminder system among insured patients. Tailored interventions are necessary to overcome these barriers.

Actionable reminders did not improve performance over passive reminders for overdue tests in the primary care setting

Actionable reminders (electronic reminders linked to computerized order entry) might improve care by facilitating direct ordering of recommended tests. The authors implemented four enhanced actionable reminders targeting performance of annual mammography, one-time bone-density screening, and diabetic testing. There was no difference in rates of appropriate testing between the four intervention and four matched, control primary care clinics for screening mammography (OR 0.81, 95% CI 0.64 to 1.02), bone-density exams (OR 1.29, 95% CI 0.82 to 2.02), HbA1c monitoring (OR 0.91, 95% CI 0.58 to 1.42) and LDL cholesterol monitoring (OR 1.40, 95% CI 0.76 to 2.59). Of the survey respondents, 79% almost never used the system or were unaware of the functionality. In the 9/228 (3.9%) cases with indirect evidence of mammography reminder use, there was a significantly lower proportion with test performance. Our actionable reminders did not improve receipt of overdue testing, potentially due to limitations of workflow integration.

Health awareness campaigns and diagnosis rates: evidence from National Breast Cancer Awareness Month

Awareness campaigns are often used to encourage medical screening that allows for early detection of health problems, but much remains unknown about the effectiveness of these programs. This paper evaluates whether National Breast Cancer Awareness Month (NBCAM) has led to increased diagnosis of breast cancer. The analysis examines the number of diagnoses made in November (1 month after NBCAM) during years before and after NBCAM was initiated. We find that from 1993 to 1995, the period when breast cancer advocacy was expanding rapidly into a nationwide movement, NBCAM led to an increase in the number of November diagnoses. During earlier periods (from the mid-1980s to the early-1990s), when breast cancer advocacy was still a nascent grassroots movement, and in later periods, when breast cancer advocacy had become a well-established nationwide cause, there is little evidence that October NBCAM events had an effect on November diagnoses.

Update on mammography trends: comparisons of rates in 2000, 2005, and 2008

BACKGROUND

Mammography screening allows for the early detection of breast cancer, which helps reduce mortality from breast cancer, especially in women aged 50 to 69 years. For this report, the authors updated a previous analysis of trends in mammography using newly available data from the National Health Interview Survey (NHIS).

METHODS

NHIS data from 2008 were used to update trends in rates of US women who had a mammogram within the 2 years before their interview, and 2 methods of calculating rates were compared. The authors focused particularly on the 2000, 2005, and 2008 mammography rates for women aged ≥ 40 years, 40 to 49 years, 50 to 64 years, and ≥ 65 years according to selected sociodemographic and healthcare access characteristics.

RESULTS

For women aged 50 to 64 years and ≥ 65 years, the patterns were similar: Rates rose rapidly from 1987 to 2000, declined, or were stable and then declined, from 2000 to 2005, and increased from 2005 to 2008. Rates for women aged 40 to 49 years rose rapidly from 1987 to 1992 and were relatively stable through 2008. There were large increases in mammography rates among immigrants who had been in the United States for <10 years, non-Hispanic Asian women, and women aged ≥ 65 years who were without ambulatory care insurance.

CONCLUSIONS

Overall, mammography rates did not continue to decline between 2005 and 2008. Even so, in 2008, the percentage of women aged ≥ 40 years who had a recent mammogram fell below the Healthy People 2010 objective of 70%, which was met in 2000. However, women aged 50 to 64 years exceeded the Healthy People objective in 2000, 2005, and 2008; and some groups with very low mammography rates currently are catching up. These are important public health achievements.

Geographic disparities in late-stage breast cancer diagnosis in California

Using cancer registry data for the population of California women aged 67+ with breast cancers, we estimated random intercept logistic models to examine how two socio-ecological predictors (residential isolation and poverty) were associated with probability of late-stage diagnosis for breast cancer. Using the multilevel modeling results, we calculated fully adjusted predicted probabilities associated with women in each Medical Service Study Area (MSSA) in California and classified the areas into two distinct groups: MSSAs with predicted rates below the 25th percentile (presumably the better outcome areas) and MSSAs with predicted rates above the 75th percentile (presumably the worse outcome areas) for two minority groups. Some areas had better outcomes for one group but worse outcomes for the other, suggesting that interventions to improve outcomes need different strategies for different groups in the same areas. Using information from geographic risk factors and multilevel modeling, this study informs interventions designed to reduce disparities in breast cancer outcomes.

Data and trends in cancer screening in the United States: results from the 2005 National Health Interview Survey

BACKGROUND

This paper examines the prevalence of cancer screening use as reported in 2005 among US adults, focusing on differences among historically underserved subgroups. We also examine trends from 1992 through 2005 to determine whether differences in screening use are increasing, staying the same, or decreasing.

METHODS

Data from the National Health Interview Surveys between 1992 and 2005 were analyzed to describe patterns and trends in cancer screening practices, including Papanicolaou test, mammography, prostate-specific antigen, and colorectal screening. Logistic regression was used to report 2005 data for population subgroups defined by several demographic and socioeconomic characteristics.

RESULTS

Rates of use for cancer tests are rising only for colorectal cancer, due largely to the increase in colorectal endoscopy screening. Use of all the modalities was strongly influenced by contact with a physician and by having health insurance coverage.

CONCLUSIONS

There remain large gaps in use for all screening modalities by education, income, usual source of care, health insurance, and recent physician contact. These specific populations would benefit from interventions to overcome these barriers to screening.

Changes in invasive breast cancer and ductal carcinoma in situ rates in relation to the decline in hormone therapy use

PURPOSE

To assess trends in invasive breast cancer and ductal carcinoma in situ (DCIS) incidence in association with changes in hormone therapy (HT) use in regular mammography screeners.

METHODS

We included 2,071,814 screening mammography examinations performed between January 1997 and December 2006 on 696,385 women age 40 to 79 years; 9,586 breast cancers were diagnosed within 12 months of a screening examination. We calculated adjusted annual rates (mammogram level) for prevalent HT use, incident invasive breast cancer (overall and by tumor histology and estrogen receptor [ER] status), and incident DCIS.

RESULTS

After a precipitous decrease in HT use in 2002, the incidence of invasive breast cancer decreased significantly in 2002 to 2006 among women age 50 to 69 years (P(trend(2002-2006)) = .005) and 70 to 79 years (P(trend(2002-2006)) = .003) but not in women age 40 to 49 years (P(trend(2002-2006)) = .45). DCIS rates significantly decreased in women age 50 to 69 years after 2002 (P(trend(2002-2006)) = .02). Invasive ductal tumors significantly declined in women age 50 to 69 years and 70 to 79 years in 2002 to 2006. In women age 50 to 69 years, invasive lobular and ER-positive cancer rates declined steadily in 2002 to 2005 (P(trend(2002-2005)) = .02 and .03, respectively), but an elevated rate in 2006 rendered the overall trend nonsignificant (P(trend(2002-2006)) = .89 and .91, respectively).

CONCLUSION

In parallel to the sharp decline in HT use in women undergoing regular mammography screening, invasive breast cancer rates decreased in women age 50 to 69 and 70 to 79 years after 2002, and DCIS rates decreased in women age 50 to 69 years, consistent with evidence that HT cessation reduces breast cancer risk. However, the decrease in incidence may have started to level off in 2006; this finding has not been uniformly reported in other populations, warranting further investigation.

Trends in cancer screening among Hispanic and white non-Hispanic women, 2000-2005

BACKGROUND

Hispanics are the largest and fastest growing ethnic group in the United States. Compared with white non-Hispanic women, however, Hispanic women have significantly lower cancer screening rates. Programs designed to increase cancer screening rates, including the national Screen for Life campaign, which specifically promoted colorectal cancer (CRC) screening, regional educational/research programs, and state cancer control programs, have been launched. Screen for Life and some of these other intervention programs have targeted Hispanic populations by providing educational materials in Spanish in addition to English.

METHODS

The objective of this study was to compare changes in colorectal, breast, and cervical cancer screening rates from 2000 to 2005 among Hispanic and white non-Hispanic women, using data from the National Health Interview Survey (NHIS). The age ranges of study subjects and the definitions of cancer screening were site specific and based on the American Cancer Society (ACS) screening recommendations.

RESULTS

Although overall screening rates were found to be lower among Hispanic women, CRC screening increased about 1.5-fold among both Hispanic and white non-Hispanic women, mainly driven by endoscopic screening, which increased 2.1-fold and 2.9-fold, respectively, from 2000 to 2005 (p < 0.01). Fecal occult blood testing (FOBT) for CRC declined among white non-Hispanic women and remained stable among Hispanic women during the same period. Mammogram and Pap smear screening tended to decline during the study period for both ethnic groups, especially white non-Hispanic women.

CONCLUSION

Although cancer screening rates may be affected by multiple factors, culturally sensitive and linguistically appropriate national educational programs may have contributed to the increase in endoscopic CRC screening compliance.

Finding the minimal intervention needed for sustained mammography adherence

BACKGROUND

Regular adherence to mammography screening saves lives, yet few women receive regular mammograms.

DESIGN

RCT.

SETTING/PARTICIPANTS

Participants were recruited through a state employee health plan. All were women aged 40-75 years and had recent mammograms prior to enrollment (n=3547). Data were collected from 2004 to 2009.

INTERVENTION

Trial tested efficacy of a two-step adaptively-designed intervention to increase mammography adherence over 4 years. The first intervention step consisted of three reminder types: enhanced usual care reminders (EUCR); enhanced letter reminders (ELR); both delivered by mail, and automated telephone reminders (ATR). After delivery of reminders, women who became off-schedule in any of the 4 years received a second step of supplemental interventions. Three supplemental intervention arms contained priming letters and telephone counseling: barriers only (BarriCall); barriers plus positive consequences of getting mammograms (BarriConCall+); and barriers plus negative consequences of not getting mammograms (BarriConCall-).

MAIN OUTCOME MEASURES

Average cumulative number of days non-adherent to mammography over 4 years based on annual screening guidelines (analyses conducted in 2009).

RESULTS

All reminders performed equally well in reducing number of days of non-adherence. Women randomized to receive supplemental interventions had significantly fewer days of non-adherence compared to women who received EUCR (p=0.0003). BarrConCall+ and BarrConCall- conditions did not significantly differ in days non-adherent compared to women in the barriers-only condition (BarriCon).

CONCLUSIONS

The minimal intervention needed for sustained mammography use is a combination of a reminder followed by a priming letter and barrier-specific telephone counseling for women who become off-schedule. Additional costs associated with supplemental interventions should be considered by organizations deciding which interventions to use.

TRIAL REGISTRATION NUMBER

NCT01148875.

A meta-analysis of computer-tailored interventions for health behavior change

OBJECTIVE

Computer-tailored interventions have become increasingly common for facilitating improvement in behaviors related to chronic disease and health promotion. A sufficient number of outcome studies from these interventions are now available to facilitate the quantitative analysis of effect sizes, permitting moderator analyses that were not possible with previous systematic reviews.

METHOD

The present study employs meta-analytic techniques to assess the mean effect for 88 computer-tailored interventions published between 1988 and 2009 focusing on four health behaviors: smoking cessation, physical activity, eating a healthy diet, and receiving regular mammography screening. Effect sizes were calculated using Hedges g. Study, tailoring, and demographic moderators were examined by analyzing between-group variance and meta-regression.

RESULTS

Clinically and statistically significant overall effect sizes were found across each of the four behaviors. While effect sizes decreased after intervention completion, dynamically tailored interventions were found to have increased efficacy over time as compared with tailored interventions based on one assessment only. Study effects did not differ across communication channels nor decline when up to three behaviors were identified for intervention simultaneously.

CONCLUSION

This study demonstrates that computer-tailored interventions have the potential to improve health behaviors and suggests strategies that may lead to greater effectiveness of these techniques.

State-based estimates of mammography screening rates based on information from two health surveys

OBJECTIVES

We compared national and state-based estimates for the prevalence of mammography screening from the National Health Interview Survey (NHIS), the Behavioral Risk Factor Surveillance System (BRFSS), and a model-based approach that combines information from the two surveys.

METHODS

At the state and national levels, we compared the three estimates of prevalence for two time periods (1997-1999 and 2000-2003) and the estimated difference between the periods. We included state-level covariates in the model-based approach through principal components.

RESULTS

The national mammography screening prevalence estimate based on the BRFSS was substantially larger than the NHIS estimate for both time periods. This difference may have been due to nonresponse and noncoverage biases, response mode (telephone vs. in-person) differences, or other factors. However, the estimated change between the two periods was similar for the two surveys. Consistent with the model assumptions, the model-based estimates were more similar to the NHIS estimates than to the BRFSS prevalence estimates. The state-level covariates (through the principal components) were shown to be related to the mammography prevalence with the expected positive relationship for socioeconomic status and urbanicity. In addition, several principal components were significantly related to the difference between NHIS and BRFSS telephone prevalence estimates.

CONCLUSIONS

Model-based estimates, based on information from the two surveys, are useful tools in representing combined information about mammography prevalence estimates from the two surveys. The model-based approach adjusts for the possible nonresponse and noncoverage biases of the telephone survey while using the large BRFSS state sample size to increase precision.

Socioeconomic disparities in the decline in invasive breast cancer incidence

Breast cancer incidence in the United States has declined dramatically since the year 2002. To improve our understanding of the underlying factors driving breast cancer trends, we explored potential socioeconomic disparities in the recent decline in incidence. We examined the decline in breast cancer incidence according to county-level socioeconomic indicators using data from the Surveillance, Epidemiology and End Results (SEER) program. Since socioeconomic status is associated with mammography screening, we also examined the relation between incidence of ductal carcinoma in situ (DCIS; a strong marker of mammography utilization) and the decline in invasive breast cancer. The reduction in invasive breast cancer incidence between 1998-2001 and 2003-2006 in the SEER 9 registries was greatest among women living in counties with higher median household income (-16% change for > or = $85,000 vs. -4% for <$35,000; P(trend) < 0.01) and a higher percentage of adults aged 25 years or older with a bachelor's degree (-13% change for > or = 40% vs. -8% for <15%; P(trend) < 0.01). Counties with higher DCIS incidence during 1985-2001 had a larger decrease in invasive breast cancer incidence (absolute decrease 1.7 percentage points greater per 5 per 100,000 increase in DCIS incidence; P = 0.01). This association was present for both ER-positive and ER-negative invasive cancers (P < 0.05). In summary, the decline in breast cancer incidence has been largest in areas with high socioeconomic status and high screening utilization rates. These results are consistent with the hypothesis that a saturation of screening mammography utilization contributed to the overall decline in breast cancer incidence.

Global patterns of cancer incidence and mortality rates and trends

While incidence and mortality rates for most cancers (including lung, colorectum, female breast, and prostate) are decreasing in the United States and many other western countries, they are increasing in several less developed and economically transitioning countries because of adoption of unhealthy western lifestyles such as smoking and physical inactivity and consumption of calorie-dense food. Indeed, the rates for lung and colon cancers in a few of these countries have already surpassed those in the United States and other western countries. Most developing countries also continue to be disproportionately affected by cancers related to infectious agents, such as cervix, liver, and stomach cancers. The proportion of new cancer cases diagnosed in less developed countries is projected to increase from about 56% of the world total in 2008 to more than 60% in 2030 because of the increasing trends in cancer rates and expected increases in life expectancy and growth of the population. In this review, we describe these changing global incidence and mortality patterns for select common cancers and the opportunities for cancer prevention in developing countries.

Black residential segregation, disparities in spatial access to health care facilities, and late-stage breast cancer diagnosis in metropolitan Detroit

This study evaluates the role of black residential segregation and spatial access to health care in explaining the variation in late-stage diagnosis of breast cancer in metropolitan Detroit. Data pertaining to female breast cancer from 1998 to 2002 are obtained from the Michigan Cancer Surveillance Program. An isolation index is used to assess black segregation. The 2-step floating catchment area approach integrated with a Gaussian function is used to estimate the health care access. While socioeconomic factors at ZIP code level are controlled, ordinary least squares and spatial lag models are used to explore the association between the rates of late-stage diagnosis and segregation and health care access. Results suggest that living in areas with greater black segregation and poorer mammography access significantly increases the risk of late diagnosis of breast cancer. Disadvantaged populations including those with low socioeconomic status or sociocultural barriers tend to experience high rates of late diagnosis. Findings emphasize the need for heightened screening, surveillance, and intervention programs in these areas.

Interventions to promote repeat breast cancer screening with mammography: a systematic review and meta-analysis

BACKGROUND

Various interventions to promote repeat use of mammography have been evaluated, but the efficacy of such interventions is not well understood.

METHODS

We searched electronic databases through August 15, 2009, and extracted data to calculate unadjusted effect estimates (odds ratios [ORs] and 95% confidence intervals [CIs]). Eligible studies were those that reported estimates of repeat screening for intervention and control groups. We tested homogeneity and computed summary odds ratios. To explore possible causes of heterogeneity, we performed stratified analyses, examined meta-regression models for 15 a priori explanatory variables, and conducted influence analyses. We used funnel plots and asymmetry tests to assess publication bias. Statistical tests were two-sided.

RESULTS

The 25 eligible studies (27 effect estimates) were statistically significantly heterogeneous (Q = 69.5, I(2) = 63%, P < .001). Although there were homogeneous subgroups in some categories of the 15 explanatory variables, heterogeneity persisted after stratification. For all but one explanatory variable, subgroup summary odds ratios were similar with overlapping confidence intervals. The summary odds ratio for the eight heterogeneous reminder-only studies was the largest observed (OR = 1.79, 95% CI = 1.41 to 2.29) and was statistically significantly greater than the summary odds ratio (P(diff) = .008) for the homogeneous group of 17 studies that used the more intensive strategies of education/motivation or counseling (OR = 1.27, 95% CI = 1.17 to 1.37). However, reminder-only studies remained statistically significantly heterogeneous, whereas the studies classified as education/motivation or counseling were homogeneous. Similarly, in meta-regression modeling, the only statistically significant predictor of the intervention effect size was intervention strategy (reminder-only vs the other two combined as the referent). Publication bias was not apparent.

CONCLUSIONS

The observed heterogeneity precludes a summary effect estimate. We also cannot conclude that reminder-only intervention strategies are more effective than alternate strategies. Additional studies are needed to identify methods or strategies that could increase repeat mammography.

The future of mammography: radiology residents' experiences, attitudes, and opinions

OBJECTIVE

The objective of our study was to assess the experiences and preferences of radiology residents with respect to breast imaging.

MATERIALS AND METHODS

We surveyed radiology residents at 26 programs in New York and New Jersey. Survey topics included plans for subspecialty training, beliefs, and attitudes toward breast imaging and breast cancer screening and the likelihood of interpreting mammography in the future.

RESULTS

Three hundred forty-four residents completed the survey (response rate, 62%). The length of time spent training in breast imaging varied from no dedicated time (37%) to 1-8 weeks (40%) to more than 9 weeks (23%). Most respondents (97%) agreed that mammography is important to women's health. More than 85% of residents believed that mammography should be interpreted by breast imaging specialists. Respondents shared negative views about mammography, agreeing with statements that the field was associated with a high risk of malpractice (99%), stress (94%), and low reimbursement (68%). Respondents endorsed several positive attributes of mammography, including job availability (97%), flexible work schedules (94%), and few calls or emergencies (93%). Most radiology residents (93%) said that they were likely to pursue subspecialty training, and 7% expressed interest in breast imaging fellowships.

CONCLUSION

Radiology residents' negative and positive views about mammography seem to be independent of time spent training in mammography and of future plans to pursue fellowship training in breast imaging. Systematic assessment of the plans and preferences of radiology residents can facilitate the development of strategies to attract trainees to careers in breast imaging.

Geographic access and the use of screening mammography

BACKGROUND

Screening mammography rates vary geographically and have recently declined. Inadequate mammography resources in some areas may impair access to this technology. We assessed the relationship between availability of mammography machines and the use of screening.

METHODS

The location and number of all mammography machines in the United States were identified from US Food and Drug Administration records of certified facilities. Inadequate capacity was defined as <1.2 mammography machines per 10,000 women age 40 or older, the threshold required to meet the Healthy People 2010 target screening rate. The impact of capacity on utilization was evaluated in 2 cohorts: female respondents age 40 or older to the 2006 Behavioral Risk Factor Surveillance System survey (BRFSS) and a 5% nationwide sample of female Medicare beneficiaries age 65 or older in 2004-2005.

RESULTS

About 9% of women in the BRFSS cohort and 13% of women in the Medicare cohort lived in counties with <1.2 mammography machines per 10,000 women age 40 or older. In both cohorts, residence in a county with inadequate mammography capacity was associated with lower odds of a recent mammogram (adjusted odds ratio in BRFSS: 0.89, 95% CI: 0.80-0.98, P < 0.05; adjusted odds ratio in Medicare: 0.86, 95% CI: 0.85-0.87, P < 0.05), controlling for demographic and health care characteristics.

CONCLUSION

In counties with few or no mammography machines, limited availability of imaging resources may be a barrier to screening. Efforts to increase the number of machines in low-capacity areas may improve mammography rates and reduce geographic disparities in breast cancer screening.

Temporal trends in geographic disparities in small-area breast cancer incidence and mortality, 1988 to 2005

BACKGROUND

A goal of Healthy People 2010 was to reduce health disparities. We determined the extent of reductions in geographic disparities in five breast cancer screening indicators.

METHODS

We examined the extent of reductions in geographic disparities in five breast cancer screening indicators using data about women ages 40 years and older from 200 counties in the 1988 to 2005 Surveillance, Epidemiology, and End Results Program database. County-level trends in five breast cancer indicators (in situ, stage I, lymph node-positive, locally advanced, and mortality) were summarized using the estimated annual percentage change. Observed county rates were smoothed using hierarchical Bayesian spatiotemporal methods to calculate measures of absolute and relative geographic disparity and their changes over time.

RESULTS

For in situ breast cancer, absolute disparity increased 93.7% during 1988 to 2005. Relative disparity declined 61.5% during the entire study period. Absolute and relative disparity for stage I breast cancer declined 18.5% and 41.4%, respectively. Absolute disparity for lymph node-positive breast cancer declined 37.9% during the study period, whereas relative disparity declined 17.6%. Absolute disparity for locally advanced breast cancer declined 66.5%, whereas relative disparity declined 17.8% during the study period. Absolute disparity in breast cancer mortality declined 60.5%, whereas relative disparity declined 19.8%.

CONCLUSIONS

Absolute and relative geographic disparities narrowed over time for all breast cancer indicators except for in situ breast cancer.

IMPACT

Progress has been made toward reducing geographic disparities in breast cancer outcomes, particularly in advanced-stage breast cancer incidence and mortality rates, although disparities remain.

Construct validity of a mammography processes of change scale and invariance by stage of change

The development and use of validated processes of change (POC) measures have received little attention in the literature despite their importance in the Transtheoretical Model. Using survey data (N = 2909), we examined the construct validity of a 22-item mammography POC scale by testing for factorial validity and factorial invariance across stage of change. We also used MANOVA with Tukey post-hoc tests to confirm stage differences in POC use (concurrent validity). Our results confirm the a priori correlated four-factor structure of this scale and provide some support for the measurement equivalence of this scale across stage, supporting comparisons of POC use across stage.

Next generation sequencing of serum circulating nucleic acids from patients with invasive ductal breast cancer reveals differences to healthy and nonmalignant controls

Circulating nucleic acids (CNA) isolated from serum or plasma are increasingly recognized as biomarkers for cancers. Recently developed next generation sequencing provides high numbers of DNA sequences to detect the trace amounts of unique serum biomarkers associated with breast carcinoma. Serum CNA of 38 women with ductal carcinoma was extracted and sequenced on a 454/Roche high-throughput GS-FLX platform and compared with healthy controls and patients with other medical conditions. Repetitive elements present in CNA were detected and classified, and each repetitive element was normalized based on total sequence count or repeat count. Multivariate regression models were calculated using an information-theoretical approach and multimodel inference. A total of 423,150 and 953,545 sequences for the cancer patients and controls, respectively, were obtained. Data from 26 patients with stages II to IV tumors and from 67 apparently healthy female controls were used as the training data set. Using a bootstrap method to avoid sampling bias, a five-parameter model was developed. When this model was applied to a validation data set consisting of patients with tumor stage I (n = 10) compared with healthy and nonmalignant disease controls (n = 87; 1,261,561 sequences) a sensitivity of 70% at a specificity of 100% was obtained. At a diagnostic specificity level of 95%, a sensitivity of 90% was calculated. Identification of specific breast cancer-related CNA sequences provides the basis for the development of a serum-based routine laboratory test for breast cancer screening and monitoring.

Declining death rates reflect progress against cancer

BACKGROUND

The success of the "war on cancer" initiated in 1971 continues to be debated, with trends in cancer mortality variably presented as evidence of progress or failure. We examined temporal trends in death rates from all-cancer and the 19 most common cancers in the United States from 1970-2006.

METHODOLOGY/PRINCIPAL FINDINGS

We analyzed trends in age-standardized death rates (per 100,000) for all cancers combined, the four most common cancers, and 15 other sites from 1970-2006 in the United States using joinpoint regression model. The age-standardized death rate for all-cancers combined in men increased from 249.3 in 1970 to 279.8 in 1990, and then decreased to 221.1 in 2006, yielding a net decline of 21% and 11% from the 1990 and 1970 rates, respectively. Similarly, the all-cancer death rate in women increased from 163.0 in 1970 to 175.3 in 1991 and then decreased to 153.7 in 2006, a net decline of 12% and 6% from the 1991 and 1970 rates, respectively. These decreases since 1990/91 translate to preventing of 561,400 cancer deaths in men and 205,700 deaths in women. The decrease in death rates from all-cancers involved all ages and racial/ethnic groups. Death rates decreased for 15 of the 19 cancer sites, including the four major cancers, with lung, colorectum and prostate cancers in men and breast and colorectum cancers in women.

CONCLUSIONS/SIGNIFICANCE

Progress in reducing cancer death rates is evident whether measured against baseline rates in 1970 or in 1990. The downturn in cancer death rates since 1990 result mostly from reductions in tobacco use, increased screening allowing early detection of several cancers, and modest to large improvements in treatment for specific cancers. Continued and increased investment in cancer prevention and control, access to high quality health care, and research could accelerate this progress.

Generational risks for cancers not related to tobacco, screening, or treatment in the United States

BACKGROUND

To assess trends in cancer, the authors evaluated the risk of 1 generation compared with that 25 years earlier (generational risk) for 3 groupings of cancers: those related to tobacco; those that reflect advances in screening or treatment; and a residual category of all other cancers.

METHODS

In individuals ages 20 years to 84 years, age-period-cohort models were used to summarize time trends in terms of generational risk and average annual percentage change for US cancer incidence (1975-2004) and mortality (1970-2004) rates associated with these 3 cancer groupings.

RESULTS

Adult white men today developed 16% fewer tobacco-related cancers and had 21% fewer deaths because of those cancers than their fathers' generation, whereas adult white women experienced increases of 28% and 19%, respectively, relative to their mothers. The incidence of commonly screened cancers rose 74% in men and 10% in women, whereas mortality fell 25% in men and 31% in women. For cancers that have not been linked chiefly to tobacco or screening, the incidence was 34% and 23% higher in white men and white women, respectively, than in their parents' generation 25 years earlier. Mortality in this residual category decreased 14% in men and 18% in women. Results among blacks were qualitatively similar to those among whites.

CONCLUSIONS

Despite declining overall cancer death rates, adults are experiencing increased incidence of cancers that are not associated with tobacco or screening relative to their parents. Future research should examine whether similar patterns are exhibited in other modern nations and should identify population-wide avoidable risks that could account for unexplained increases in these residual cancers.

Timeliness of breast cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program, 1996-2005

OBJECTIVES

To determine the effects of program policy changes, we examined service delivery benchmarks for breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

METHODS

We analyzed NBCCEDP data for women with abnormal mammogram or clinical breast examination (n=382 416) from which 23 701 cancers were diagnosed. We examined time to diagnosis and treatment for 2 time periods: 1996 to 2000 and 2001 to 2005. We compared median time for diagnostic, treatment initiation, and total intervals with the Kruskal-Wallis test. We calculated adjusted proportions (predicted marginals) with logistic regression to examine diagnosis and treatment within program benchmarks (<or=60 days) and time from screening to treatment (<or=120 days).

RESULTS

Median diagnostic intervals decreased by 2 days (25 vs 23; P<.001). Median treatment initiation intervals increased by 2 days (12 vs 14; P<.001). Total intervals decreased by 3 days (43 vs 40; P<.001). Women meeting the 60-day benchmark for diagnosis improved the most for women with normal mammograms and abnormal clinical breast examinations from 77% to 82%.

CONCLUSIONS

Women screened by the NBCCEDP received diagnostic follow-up and initiated treatment within preestablished program guidelines.

Screening mammography: a cross-sectional study to compare characteristics of women aged 40 and older from the deep South who are current, overdue, and never screeners

PURPOSE

We sought to identify unique barriers and facilitators to breast cancer screening participation among women aged 40 and older from Mississippi who were categorized as current, overdue, and never screeners.

METHODS

Cross-sectional data from a 2003 population-based survey with 987 women aged 40 and older were analyzed. Chi-square analysis and multinomial logistic regression examined how factors organized under the guidance of the Model of Health Services Utilization were associated with mammography screening status.

RESULTS

Nearly one in four women was overdue or had never had a mammogram. Enabling factors, including poor access to care (no annual checkups, no health insurance) and to health information, lack of social support for screening, and competing needs, were significantly associated with being both overdue and never screeners. Pertaining to factors unique to each screening group, women were more likely to be overdue when they had no usual source of health care and believed that treatment was worse than the disease. In turn, women were more likely to be never screeners when they were African American, lacked a provider recommendation for screening, and held the fatalistic view that not much could be done to prevent breast cancer.

CONCLUSION

Similar and unique factors impact utilization of mammography screening services among women. Those factors could inform efforts to increase screening rates.

Sensitivity of self-report mammography use in older women

BACKGROUND

Recent survey evidence indicates a decline in mammography use among older women.

PURPOSE

The objective of this study was to detect sensitivity of self-reported mammography use and pose evidence-based suggestions to increase survey accuracy.

METHODS

Using the 1991-2006 Medicare Current Beneficiary Survey, 15,357 women, aged > or =65 years, were selected based on use of mammography services. The women were interviewed in the community setting at random periods after screening and asked, Have you had a mammogram or breast X-ray since [today's date or previous supplement round interview date] a year ago? Statistical analyses were conducted between March 11 and April 28 of 2008. This study tested whether sensitivity (i.e., probability of an affirmative response) was dependent on length of the recall period and on respondent demographic and socioeconomic characteristics.

RESULTS

Overall, 90.4% of the older women self-reported use; however, sensitivity decreased as the recall period lengthened (90% at 6 months, 80% at 12 months). This time effect was significantly higher among older, economically disadvantaged women. Sensitivity also decreased an additional 13.8% if the event occurred in the previous calendar year, and 3.5% if conducted in a non-English language or by proxy.

CONCLUSIONS

Greatest sensitivity occurred during the 6-month period after service without straddling calendar years. These findings may aid the tailoring of future surveys for older adults, improving the recall of preventive services.

Screening mammography intervals among postmenopausal hormone therapy users and nonusers

BACKGROUND

The recent decline in US breast cancer incidence rates has been attributed to the marked reduction in use of postmenopausal hormone therapy (HT). An alternative explanation is that women who are not routinely seeking medical care to renew HT prescriptions may be less adherent to recommendations for mammographic screening. To investigate the latter possibility, we compared mammographic intervals according to HT use.

METHODS

Using data (1995-2007) from the New Hampshire Mammography Network (NHMN), a state-based mammography registry, we assessed mammographic intervals corresponding to HT use or nonuse among postmenopausal women. We used linear mixed effects models to assess whether the length of screening mammogram intervals differed according to HT use.

RESULTS

A total of 310,185 mammograms, representing 76,192 postmenopausal women and 319,353 person-years of screening, were included in the analysis. The median screening interval corresponding to HT use overall was 13.0 months (interquartile range: 12.4-15.1) and for nonuse was 13.1 (interquartile range: 12.4-15.8). Virtually, all screening mammograms occurred within a 2-year interval regardless of HT use or nonuse (98.5 and 98.1%, respectively).

CONCLUSIONS

Our findings indicate that screening mammography intervals are similar whether or not women are using HT. Thus, reduced utilization of screening mammography is unlikely to account for the decrease in breast cancer incidence seen soon after the WHI report.