Screening for breast and cervical cancers: the importance of knowledge and perceived cancer survivability

Community-based free prostate cancer screening program

BACKGROUND

The objective of this study was to demonstrate both the feasibility and importance of a bilingual community-based educational program that offers free prostate cancer screening to Hispanic and black men in a high-risk community.

METHODS

The East Harlem Partnership for Cancer Awareness (EHPCA) brought together an academic medical center, public hospital, and two community health centers to offer monthly free prostate cancer screening programs in neighborhood community health centers. The programs included an educational component in Spanish and English, digital rectal examinations (DRE), and blood testing for prostate-specific antigen (PSA).

RESULTS

Participant evaluations of the program demonstrated that the sessions were informative and helpful as well as successful in increasing knowledge about prostate cancer. Almost 90% of the participants chose to undergo a digital examination and PSA test; 4 of 150 participants were diagnosed as having prostate cancer.

CONCLUSION

Offering free prostate screening is a successful method of reaching men who might otherwise not be tested. We found that men were willing to be tested and follow-up with care, as needed.

Factors associated with intentions to adhere to colorectal cancer screening follow-up exams

Background

To increase adherence rate to recommendations for follow-up after abnormal colorectal cancer (CRC) screening results, factors that inhibit and facilitate follow-up must be identified. The purpose of this study was to identify the factors associated with intention to adhere to CRC screening follow-up exams.

Methods

During a 4-week period in October 2003, this survey was conducted with 426 subjects participating in a community-based CRC screening program in Nagano, Japan. Study measures included intention to adhere to recommendation for clinical follow-up in the event of an abnormal fecal occult blood test (FOBT) result, perceived susceptibility and severity of CRC, perceived benefits and barriers related to undergoing follow-up examination, social support, knowledge of CRC risk factors, health status, previous CRC screening, personality and social demographic characteristics. Univariate and multivariate logistic regression analyses on intention to adhere to recommendations for follow-up were performed.

Results

Among the 288 individuals analyzed, approximately 74.7% indicated that they would definitely adhere to recommendations for follow-up. After controlling for age, gender, marital status, education, economic status, trait anxiety, bowel symptoms, family history of CRC, and previous screening FOBT, analyses revealed that lower levels of perceived barriers, higher levers of perceived benefits and knowledge of CRC risk factors were significantly associated with high intention respectively.

Conclusion

The results of this study suggest that future interventions should focus on reducing modifiable barriers by clarifying misperceptions about follow-up, promoting the acceptance of complete diagnostic evaluations, addressing psychological distress, and making follow-up testing more convenient and accessible. Moreover, educating the public regarding the risk factors of CRC and increasing understanding of the benefits of follow-up is also important.

People's perceptions of cancer survivability: implications for oncologists

Individuals typically overestimate survival for lung cancer and underestimate it for melanoma. However, reporting of results generally masks the extent of disagreement between people on survival rates. Most methods used to question individuals are of little use and are not comparable across studies. The topic of people's perceptions of survival for various cancers is under-researched. A clearer definition is needed of survivability, as is a standard way to measure it and then present the information. We have undertaken a review of studies reporting public perceptions of cancer survival rates and compared the results, where possible, with actual survival rates. We also investigate some potential implications of people's underestimation or overestimation of survival for screening and prevention behaviours and delineate implications for oncologists.

Cancer-specific beliefs and survival: a population-based study of African-American and White breast cancer patients

OBJECTIVE

Beliefs about cancer and its treatment have been shown to influence cancer stage at diagnosis and, thus, prognosis. The association between these beliefs and survival is understudied, especially among racially/ethnically diverse populations. We investigated the relationship between cancer-specific beliefs and survival in a cohort of African-American and White women with newly diagnosed breast cancer followed for up to 15 years.

METHODS

We examined beliefs about cancer detection, treatment, and curability in a population-based cohort of 145 African-American and 177 White women diagnosed with breast cancer in Connecticut, US, between 1987 and 1989. Cox proportional-hazards models were adjusted for stage at diagnosis, other biomedical variables, socio-demographic and lifestyle factors.

RESULTS

In multivariate models, perceived cancer incurability was associated with a higher risk of death from any cause (hazards ratio (HR)=1.67, 95 confidence interval (CI)=1.11, 2.51). Further control for tumor characteristics, genetic alterations, access to care, and additional psychosocial factors did not alter these findings. Other cancer-specific beliefs examined here were not related to survival.

CONCLUSIONS

Perceived cancer incurability is independently associated with survival among breast cancer patients in fully adjusted models. The identification of the underlying mechanisms of this association has potential for translation into intervention strategies for cancer patients.

Ethnicity, genetics, and breast cancer: media portrayal of disease identities

OBJECTIVE

To describe, compare, and analyze how the risk of breast cancer is framed in newspapers directed towards an ethnic minority population (Jewish) with higher risk of inherited breast cancer compared with newspaper coverage for the general population (Anglo-Canadian) without this risk.

DESIGN

This investigation utilized a mixed methods (quantitative and qualitative) approach. The design emphasized a content analysis conducted on ethnically specific and non-ethnic newspaper articles.

RESULTS

It is noteworthy that the 'Jewish' newspapers devote a substantially larger proportion of articles on breast cancer to genetic risk as the key risk factor for this disease. Articles in the Jewish newspapers tend to link being a Jewish woman with being at risk for a diagnosis of breast cancer. This ethnic 'identity' is reinforced through the repeated association of Jewish heritage and genetic breast cancer risk at the exclusion of other known risk factors. This isolated genetic link to breast cancer is not a message that is replicated within the provincial newsprint articles.

CONCLUSIONS

These findings assist in the facilitation of prevention and treatment of those with or at risk of breast cancer. The health policy implications of this portrayal as well as suggestions for change are considered.

Social and cultural barriers to Papanicolaou test screening in an urban population

OBJECTIVE

To define screening behaviors, attitudes, and beliefs regarding cancer and its treatment among women with cervical cancer.

METHODS

Between August 2000 and July 2002, 148 consecutive women with invasive cervical cancer were queried about barriers to screening. Women presented to outpatient clinics, emergency departments, or inpatient units of 3 urban hospitals. Two groups of women were identified: those who denied having had a Papanicolaou (Pap) test and those who had recalled having Pap test in the past. Responses were compared using t tests, chi(2) tests, and binary logistic regression.

RESULTS

The 146 (99%) respondents were predominantly African Americans (50%) or Hispanic (27%). Thirty-six (25%) women reported no prior screening. Women never screened were significantly more likely to be Hispanic (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.4-6.7), recent immigrants (OR 5.7, 95% CI 2.0-16), less educated (OR 3.6, 95% CI 1.6-8.0), and uninsured (OR 3.9, 95% CI 1.6-9.7). They were more likely to lack family support (adjusted OR 3.5, 95% CI 1.1-11) and lack knowledge about their risk for cervical cancer (adjusted OR 2.6, 95% CI 1.1-6.4). Unscreened women displayed fatalistic attitudes, believing cancer is bad luck (adjusted OR 2.6, 95% CI 1.0-6.9) and not wanting to know they had cancer (adjusted OR 3.0, 95% CI 1.0-9.4)..

CONCLUSION

We have identified factors and beliefs that are barriers to Pap test screening in urban cervical cancer patients. Further studies should evaluate effects of addressing cultural, cognitive, and financial barriers on Pap test compliance.

Epidemiologic correlates of cervical human papillomavirus prevalence in women with abnormal Pap smear tests: A Taiwan cooperative oncology group (TCOG) study

To explore factors affecting human papillomavirus (HPV) prevalence in all grades of cervical neoplasia among Chinese women, 1,264 women with abnormal cervical cytology attending the gynaecologic clinics of 11 major medical centres in Taiwan. Patients were interviewed and underwent complete gynaecologic examination including colposcopy. Cervical scrapings were collected for HPV DNA detection by both Hybrid Capture-2 (high-risk probe) and L1 consensus PCR-reverse line blot. The prevalences of HPV in the four different diagnosis groups: (i) suspicious (n = 316), (ii) low-grade intraepithelial lesion (n = 474), (iii) high-grade intraepithelial lesion (n = 450), and (iv) cancer (n = 16), were 36.1%, 74.7%, 83.6%, and 100%, respectively. In the latter two groups, Patients less than 30 or 40 years old, respectively, tended to be infected more frequently with HPV than the older patients were. The main correlates of HPV prevalence were lifetime number of sex partners (odds ratio (OR) for two or more partners: 2.44; 95% CI, 1.44-4.15), vaginal douching after intercourse (OR for douching frequently: 1.44; 95% CI, 1.01-2.04), vitamin supplementation (OR for regular vitamin supplement: 0.71, 95% CI, 0.55-0.92), and performance of Pap smear tests (OR for never having a Pap smear performed: 2.22; 95% CI, 1.19-4.17). The risk for vaginal douching was augmented by the promiscuity of sex partners (OR of 3.19 (1.91-5.34)) and smoking (OR of 1.90 (1.15-3.13)), whereas vitamin supplementation reduced the odds ratio to 1.35 (0.85-2.15). The results of this study provide further evidence of the role of HPV in cervical carcinogenesis. The data also indicate the main areas of risk for the prevalence of HPV in cervical neoplasia in Chinese women living in Taiwan.

Barriers to cancer screening by rural Appalachian primary care providers

CONTEXT

Rural Appalachia has significantly higher overall cancer mortality compared with national rates, and lack of cancer screening is believed to be one of the contributing factors. Reducing the cancer disparity in this region must include strategies to address suboptimal cancer screening practices by rural Appalachian primary care providers (PCPs).

PURPOSE

To identify and investigate barriers to recommending and/or performing cancer screening among rural Appalachian PCPs.

METHODS

A semistructured focus group research design was used to elicit perceived barriers to recommending and/or performing cancer screening from 36 rural Appalachian PCPs (in 5 groups), including physicians, nurse practitioners, and a physician assistant.

FINDINGS

Findings indicate that rural Appalachian PCPs may not be performing recommended cancer screenings for a number of reasons. Time constraints, conflicting guidelines, and perceptions that patients do not value prevention were reported barriers to cancer screening. The PCPs in this study expressed frustration in attempting to encourage cancer screening and cited patient factors such as socioeconomic status, Appalachian culture, and cancer fatalism as barriers to cancer screening.

CONCLUSIONS

Rural Appalachian PCPs encounter various barriers, such as lack of time and multiple cancer screening guidelines, to incorporating cancer screening into their practice routine. The findings underscore the negative impact of some cultural factors on preventive care delivered by PCPs. Increased provider education is needed on how best to encourage cancer screening within a cultural context and should include clarification and understanding of current cancer screening guidelines.

Perspectives on behavioral and social science research on cancer screening

The first section in the current article offered several themes that characterize behavioral and social science cancer screening research to date and are likely to be relevant for studying the adoption and utilization of future screening technologies. The themes discussed included the link between epidemiologic surveillance and the priorities of intervention, the "at-risk" perspective that often guides research on screening and initiatives to redress disparities, the need to monitor the diversification of personal screening histories, the range of intervention groups and study designs that can be tested, the importance of including key questions in population-level surveys and national health objectives, and the desirability of clarifying the characteristics of cancer screening that make it an attractive field of study in its own right. The second section commented on emerging areas in which more research will allow additional lessons to be learned. The other articles in the current supplement presented many more lessons in a variety of areas, and other authors are encouraged to write similar articles that help to identify general themes characterizing cancer screening research.

Characteristics of Participation in Cervical Cancer Screening

Although Papanicolaou test screening rates are reportedly high, a significant proportion of women remain unscreened. With recent revision of Papanicolaou test guidelines, it is critical that interventions and programs for cervical cancer directed toward low participating groups or individuals be developed. The purpose of the study was to examine factors that influence participation in cervical cancer screening by quantifying characteristics of women who engage in Papanicolaou test screening in a 12-month period. Using the 2000 National Health Interview Survey and Cancer Topical Module, the sample (N = 18,388) consisted of women who were older than 18 years. The dependent variable was nominally identified as whether a woman had had a Papanicolaou test in the last 12 months. Independent variables examined were insurance, level of education, place for care, age, race, employment, place of residence, and income level. Using logistic regression, all variables except race and income level were found to be significant for participation in cervical cancer screening (P < .000). Each variable is discussed within the framework of the Institute of Medicine model of access to personal healthcare services. Study findings provide insight and guidance for the development and implementation of methods for accessing women who have lower participation rates.

Changes in beliefs about cancer in Western Australia, 1964–2001

OBJECTIVE

To assess changes in people's knowledge and beliefs about cancer between 1964 and 2001.

DESIGN

Questions in a 1964 survey of beliefs about cancer (randomly selected households) were replicated in a 2001 telephone survey (random-digit dialing).

SETTING

Perth, Western Australia.

PARTICIPANTS

984 and 491 participants aged 20 years or older in the 1964 and 2001 surveys, respectively (response rates, 86.8% and 47.0%).

MAIN OUTCOME MEASURES

Changes in knowledge and beliefs about cancer.

RESULTS

Between 1964 and 2001, there were major improvements in knowledge about the causes of cancer, with several myths dispelled. In 1964, the proportion of Perth residents surveyed who believed that cancer is contagious was 20% (95% CI, 18%-22%), compared with 3% (95% CI, 2%-4%) in 2001. Similarly, the proportion who believed cancer is caused by "a knock" was 25% (95% CI, 22%-28%) in 1964, compared with 1% (95% CI, 0-2%) in 2001. Cancer screening participation rates also greatly improved, from 18% (95% CI, 16%-20%) in 1964 to 77% (95% CI, 73%-81%) in 2001. Changes in participants' sources of knowledge about cancer were also evident, with family members and television increasing markedly as sources of information.

CONCLUSIONS

Improved education of the public in health matters over the past four decades appears to have had a major and positive impact on knowledge about cancer.

Coverage of breast cancer in the Australian print media--does advertising and editorial coverage reflect correct social marketing messages?

Early detection of breast cancer by mammographic screening has the potential to dramatically reduce mortality rates, but many women do not comply with screening recommendations. The media are an important source of health information for many women--through both direct social marketing advertisements and indirect dissemination of information via editorial content. This study investigated the accuracy of breast cancer detection messages in the top-selling Australian women's magazines and three weekend newspapers in the six-month period from December 2000 to May 2001 that included any reference to breast cancer and found that current coverage of breast cancer in the Australian print media conveys messages that are unlikely to encourage appropriate screening.

Beliefs about the risk factors for cervical cancer in a British population sample

BACKGROUND

The introduction of human papillomavirus (HPV) testing into cervical screening has the potential to alter public perceptions of cervical cancer by making explicit the role of a sexually transmitted virus in its etiology. HPV knowledge has been found to be poor, although there is evidence of public awareness of a link between sexual activity and cervical cancer risk. We explored beliefs about the risk factors for cervical cancer in a large population sample.

METHODS

Face-to-face interviews were carried out with a representative sample of the British population. All participants were asked what they thought increased a women's chances of developing cervical cancer.

RESULTS

The response rate was 71% (n = 1940). The most common single response was 'don't know' (38%). Forty-one percent of respondents mentioned factors relating to sex, but only 14% were aware of a link with sexual transmission and fewer than 1% named HPV. Women and more educated people had better knowledge of the established risk factors. The patterning of risk factor awareness by age varied across risk factors.

CONCLUSIONS

Awareness of the role of a sexually transmitted virus in the etiology of cervical cancer is very low in Britain. Provision of information associated with the introduction of HPV testing could change public perceptions of cervical cancer.

The word 'cancer': reframing the context to reduce anxiety arousal

This study investigated reaction to the word 'cancer' versus the phrase 'a cancer' in two ways: (1) assessing associations to the spoken words 'cancer' or 'a cancer'; and (2) presenting participants with a situation where one person says to another in print. 'I have cancer' or 'I have a cancer'. The participants were a convenience sample of 112 adults (i.e. aged 18 years or over), 55 males and 57 females, recruited via a mall intercept survey in the Perth (Western Australia) central business district. Participants were randomly assigned to either the 'cancer' condition or the 'a cancer' condition. Both methods confirmed that cancer arouses primarily negative affective responses in the vast majority of people. It was hypothesised that using 'a cancer' might lead to less negative affect associations than just the word 'cancer'. This was found to be the case for the spoken word association technique, but not for the printed cartoon technique.

Interventions for patients, providers, and health care organizations

Clinicians and the organizations within which they practice play a major role in enabling patient participation in cancer screening and ensuring quality services. Guided by an ecologic framework, the authors summarize previous literature reviews and exemplary studies of breast, cervical, and colorectal cancer screening intervention studies conducted in health care settings. Lessons learned regarding interventions to maximize the potential of cancer screening are distilled. Four broad lessons learned emphasize that multiple levels of factors-public policy, organizational systems and practice settings, clinicians, and patients-influence cancer screening; that a diverse set of intervention strategies targeted at each of these levels can improve cancer screening rates; that the synergistic effects of multiple strategies often are most effective; and that targeting all components of the screening continuum is important. Recommendations are made for future research and practice, including priorities for intervention research specific to health care settings, the need to take research phases into consideration, the need for studies of health services delivery trends, and methods and measurement issues.

Has the investment in public cancer education delivered observable changes in knowledge over the past 10 years?

BACKGROUND

During the 1990s, Western countries, such as Australia, directed substantial funds toward public cancer education. An important indicator of whether this investment has been worthwhile is a shift over time in the proportion of the population who have accurate knowledge regarding cancer.

METHODS

In the year 2000, a cross-sectional telephone survey was administered to 685 residents selected from the New South Wales (Australia) Electronic White Pages telephone directory. This study replicated in part a survey conducted in 1989.

RESULTS

In the 2000 survey, smoking (96.0%) and sun exposure (80.4%) were well-known as risk factors for lung cancer and melanoma, respectively. However, community knowledge of risk factors for colorectal, breast, cervical, and prostate cancer was poor. Most respondents were able to nominate mammograms (82.2%) and Pap tests (86.8%) as screening tests for breast and cervical cancer, respectively. Approximately two-thirds of the sample were able to nominate foods that reduce the risk of developing cancer. Compared with the 1989 data, there appeared to have been improvements in community knowledge of mammograms as a screening test for breast cancer. For the other cancers, knowledge gains appeared smaller or marginal. With regard to the lifetime risk of developing these cancers, community understanding remains poor. Predictors of greater knowledge include a higher level of education.

CONCLUSIONS

Where ongoing investments have been made, like in the case of breast cancer education, there have been improvements in community knowledge. However, major challenges remain. Potential targets for future public education campaigns are discussed.

Association between CBE, FOBT, and Pap smear adherence and mammography adherence among older low-income women

BACKGROUND

Adherence to regular and timely mammography screening, especially in older low-income women, continues to fall below objectives. The primary aim of this study was to examine whether engaging in other cancer screenings was associated with mammography adherence for older women.

METHODS

Women, ages 52 and over, without a self-reported history of breast cancer (N = 862) were selected from a larger sample of women residing in Washington, DC, census tracts with >/=30% of households below 200% of the federal poverty threshold. A computer-assisted telephone survey was used to collect data on health care system factors, demographics, cultural beliefs, clinical breast exam (CBE), Pap smear, fecal occult blood testing (FOBT), and mammography. Adherence was defined as receipt of the last two screening tests within recommended intervals for age.

RESULTS

After controlling for other variables, adherence to CBE (OR = 4.15; 95% CI, 2.55-6.73) and Pap smear (OR = 1.82; 95% CI, 1.07-3.12) were highly predictive of mammography adherence. Adherence to FOBT (OR = 1.66; 95% CI, 0.97-2.84) was marginally predictive.

CONCLUSIONS

Results of this study indicate that nonadherence to other cancer screenings can help identify women in need of additional interventions to improve mammography adherence.

Knowledge, attitudes, and behavioral intentions in relation to the early detection of colorectal cancer in the United Kingdom

BACKGROUND

Colorectal cancer (CRC) mortality is high. Understanding the social, psychological, and cognitive predictors of early detection practices such as screening may help improve CRC outcomes. This study examined knowledge of CRC and the relationship between knowledge, attitudes to cancer, and intentions to engage in early detection behaviors for CRC in a national representative population sample.

METHOD

An interview-based survey was carried out in a British population sample of adults ages 16 to 74 years (n = 1637), assessing knowledge, attitudes, and intention with regard to colorectal cancer.

RESULTS

Knowledge levels were very low; 58% (n = 995) of respondents could not list any colorectal cancer risk factors and 24% (n = 393) were unable to identify any warning signs for cancer. Knowledge was lower among men (chi(2)[2] = 52.8, P < 0.0001), younger respondents (chi(2)[10] = 79.9, P <.0001), and those with less education (chi(2)[4] = 73.9, P < 0.0001). Attitudes to cancer were more negative among women (chi(2) [2] = 7.4, P = 0.025), younger participants (chi(2)[10] = 22.4, P = 0.013), and those with less education (chi(2) [4] = 75.0, P < 0.0001). Low knowledge was associated with negative attitudes (P < 0.0001) and both factors were associated with lower intentions to participate in colorectal cancer screening (P < 0.0001). Multivariate analysis indicated that attitudes partially mediated the effect of knowledge on screening intentions.

CONCLUSIONS

Increasing knowledge may reduce negative public perceptions of cancer which may impact positively on intentions to participate in screening.

Reliability and validity of the mammography screening beliefs questionnaire among Chinese American women

Cancer is the leading cause of death for Asian American women, and the breast is a primary site of cancer in Chinese women. Although a number of studies have used constructs from the Health Belief Model (HBM) to examine their relation to mammogram screening, the validity and reliability of the instruments on HBM constructs among Chinese women have not been consistently examined. The purpose of this study was to describe the psychometric properties of a culturally sensitive questionnaire for measuring Chinese women's beliefs (susceptibility, seriousness, benefits, and barriers) related to breast cancer and mammogram screening. The items developed for the questionnaire were drawn from a comprehensive literature review and focus groups. The instrument was translated using back translation technique and evaluated by a panel of professional experts and lay experts. A total of 220 Chinese American women ages 40 to 85 years residing in a suburban Midwestern community were included in the sample. Psychometric testing demonstrated satisfactory internal consistency and validity of the instrument for this group of women. The Cronbach alpha for the subscales ranged from.77 to.90. Construct validity was supported by exploring the factor structure of the instrument using confirmatory factor analysis and testing correlations with mammography compliance.

Comparison of mammography use by older black and white women

OBJECTIVES

To identify differences in the prevalence of ever having had a mammogram and having had a recent mammogram between older black and white women and to compare factors associated with mammography use in older black and white women.

DESIGN

Data analysis and comparative study using nationally representative multistage sampling survey.

SETTING

Data were obtained from the 1998 National Health Interview Survey.

PARTICIPANTS

Four hundred forty-nine black and 3,328 white older women were examined.

MEASUREMENTS

The outcome variables included never having had a mammogram (yes/no) and not having had a mammogram in the past 3 years (yes/no).

RESULTS

The results of chi-square tests showed that older blacks were less likely to have ever had a mammogram than older whites, but there was no difference in having had a recent mammogram between older blacks and whites. After adjusting for other related factors, race was not related to mammography use in older blacks and whites. Health insurance was related to mammography use in older whites but not in older blacks. Family income was associated with never having had a mammogram in older whites but not in older blacks. Older blacks with less than 12 years of education were less likely to have had a mammogram (recently or ever) than older whites with less than 12 years of education.

CONCLUSIONS

Even though race, per se, was not associated with mammography use in older black and white women, many barriers to mammography use between older black and white women were different or did not have similar effects. To promote mammography use in older black and white women, barriers need to be specifically targeted for each group to enhance the effectiveness of breast cancer screening programs.

Knowledge of cervical cancer risk factors among Chinese immigrants in Seattle

Chinese American immigrants are a growing part of the United States population. Cervical cancer is a significant cause of morbidity and mortality among Chinese Americans. Pap smear testing is less common in Chinese American immigrants than in the general population. During 1999, we conducted a community-based survey of Chinese American women living in Seattle. We assessed knowledge of cervical cancer risk factors and history of Pap smear testing along with socioeconomic and acculturation characteristics. The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample included 472 women. Most cervical cancer risk factors were recognized by less than half of our participants. Factors independently associated with knowledge of cervical cancer risk factors included marital status, employment, and education. Respondents with the highest knowledge had greater odds of ever receiving a Pap smear, compared to those respondents with the lowest knowledge (OR 2.5; 95% CI: 1.1,5.8). Our findings suggest a need for increased recognition of cervical cancer risk factors among Chinese American immigrants. Culturally and linguistically appropriate educational interventions for cervical cancer risk factors should be developed, implemented and evaluated.

Cancer screening practices from National Health Interview Surveys: past, present, and future

The National Health Interview Survey (NHIS) has provided data about health behaviors at the national level since 1957. The 1987 and 1992 Cancer Control Supplements to the NHIS, along with other supplemental surveys administered intermittently on self-reported cancer-related behaviors, have contributed to important research and public health purposes. In this article, we reviewed 73 papers published between 1980 and 2001 that used NHIS data, including the first report from the 1998 NHIS, to examine what has been learned from past surveys. Our goal was to facilitate future analyses of recently released data on cancer screening practices from the Cancer Control Supplement to the 2000 NHIS, which is now known as the Cancer Control Module. We categorized the papers according to which of the following three study approaches they used: trends in screening rates, correlates of these rates with factors that may influence screening, and linkages or comparisons of NHIS data with other surveys or sources of information. We summarize knowledge gained in cancer screening for each of these three categories and identify areas that could benefit from more research. We highlight some of the new information available for the first time on the Cancer Control Module of the 2000 NHIS as fresh opportunities for cancer control research. Finally, we describe how the Cancer Control Supplements to the NHIS are integrated with the objectives of and developments in national cancer surveillance research that have emerged from federal planning efforts and collaborations with national partners in cancer surveillance in recent years.

The determinants of breast cancer screening behavior: a focus group study of women in the United Arab Emirates

PURPOSE/OBJECTIVES

To explore perceptions, knowledge, attitudes, and beliefs about breast cancer and its screening among Emirati national women in Al Ain, United Arab Emirates.

DESIGN

A qualitative study using focus group methods.

SETTING

Primary healthcare centers and a community-based women's association in the United Arab Emirates.

SAMPLE

41 women, aged 25-45 years.

METHODS

Four 90-minute focus group discussions exploring perceptions, knowledge, attitudes, beliefs, and practices regarding breast cancer were audiotaped, transcribed, translated, and analyzed.

MAIN RESEARCH VARIABLES

Social and cultural themes related to breast cancer and its screening.

FINDINGS

Focus group methodology worked well in this setting. The women's perceptions, knowledge, attitudes, and beliefs regarding cancer and screening, together with aspects of the healthcare system and social milieu, appeared to strongly influence the women's preventive practices. Some of these factors had an encouraging effect on the women's practices, and others had a deterring effect. The encouraging factors included feelings of susceptibility, high levels of knowledge in some women, attitudes and beliefs about personal responsibility for health, and a supportive social milieu. Deterring factors included anxiety and fear leading to denial; lack of knowledge about cancer and the screening program; fear, embarrassment, and mistrust of health care; and belief in predestination.

CONCLUSIONS

Health planners and healthcare providers must capitalize on encouraging factors and minimize deterring factors to optimize breast cancer screening practices among these women.

IMPLICATIONS FOR NURSING

Identifying and accounting for the factors that encourage or deter women in their breast cancer screening practices will help to optimize screening programs.

Abnormal cervical screen follow-up among low-income Latinas: Project SAFe

BACKGROUND

Cervical cancer incidence and mortality rates are dramatically higher among low-income women than in the general population, in part due to poor adherence to recommended diagnostic follow-up after an index Pap test. This report describes a pilot study of the Screening Adherence Follow-Up Program (SAFe), an individualized, structured case management program designed to assess for and intervene in response to a variety of potential personal and systems barriers to follow-up adherence. Interventions included health education, counseling, and systems navigation.

METHODS

A clinical decision-making algorithm was used to determine service intensity and level of intervention. Services were provided to 196 low-income women, predominantly Latinas, who had either a low-grade or high-grade squamous intraepithelial lesion (LGSIL or HGSIL) abnormal Pap result. Adherence rates to at least one follow-up appointment after enrollment and baseline intervention were 83% following LGSIL and 93% for HGSIL.

RESULTS

Over 1 year post-enrollment, 41% of women with LGSIL were fully adherent, with 42% partially adherent; 61% of women with HGSIL were fully adherent, with 32% partially adherent. In a comparison group of 369 nonenrollees (women who refused participation or could not be located for consent), adherence rates were 58% for LGSIL and 67% for HGSIL. A survey among a random sample of women served indicated that 93% were "mostly" or "very" satisfied, overall, with SAFe services.

CONCLUSIONS

The intervention team--a peer counselor and a master's degreed social worker--addressed multiple psychosocial and systems navigation problems to reduce potential barriers to adherence, including knowledge, attitudinal, psychosocial, psychological distress, systems communication, and resource access problems. SAFe appears highly acceptable to women and may significantly enhance medical care management following an abnormal cervical screen for a carefully targeted group of women at risk for suboptimal follow-up adherence.

Abnormal mammogram follow-up: a pilot study women with low income

PURPOSE

The purpose of this study was to test an intervention (the Screening Adherence Follow-up Program [SAFe]) that was designed to reduce the number of known barriers to diagnostic follow-up adherence and initiation of treatment among women with low incomes who had abnormal mammogram findings.

DESCRIPTION OF PROGRAM

The investigators developed and implemented a highly structured, theory- and evidence-based intervention that combined health education, counseling, and systems navigation, which was delivered by a team consisting of a peer counselor and a social worker who held a masters degree. A scripted baseline telephone interview identified potential barriers to follow-up adherence and provided counseling interventions for each patient. Patients were assigned to different service intensities based on the level of risk for nonadherence. Patients with significant mental health symptoms, psychosocial stressors, or who had received a diagnosis of cancer were referred to the team social worker for further assessment and intervention. Patients also received reinforcing telephone follow-up calls at 6 and 12 months.

RESULTS

An observational pilot study of SAFe (N = 605) in two large urban diagnostic centers showed that 71% of women receiving SAFe were Hispanic, 18% were Black, and 11% were from other ethnic backgrounds. Adherence rates through diagnostic resolution and the initiation of treatment for women who had received a diagnosis of cancer were 93% and 90%, respectively, at the two study sites. Rates of adherence among women who could not be located or who refused study consent were significantly lower (72% and 69%, respectively). The rate of timely adherence was also higher among the women served. Patient satisfaction with SAFe was generally high.

CLINICAL IMPLICATIONS

Study results support the combining of interventions and the practical utility of a clinical decision-making algorithm to determine individualized nonadherence risk and to assign service intensity based on individual need. Problems in locating women for enrollment were experienced.

Risk factors and health promotion in families of patients with breast cancer

Women with a family history of breast cancer have an increased risk of developing the disease. Women identified as "high risk" for developing breast cancer have been shown to exhibit increased levels of psychological distress and anxiety related to breast cancer. Oncology nurses can address this barrier and others, such as altered risk perception and lack of physician recommendation for screening. Oncology nurses also can identify high-risk families that may be candidates for genetic testing for breast cancer susceptibility, provide comprehensive teaching about breast self-examination (BSE), and clarify misconceptions about early detection. Primary prevention measures for hereditary breast cancer include prophylactic mastectomy and oophorectomy and chemopreventative agents. Secondary prevention measures include screening and early detection with mammography, clinical breast examinations, and BSE. Nurses have a responsibility to educate families of patients with breast cancer about risk factors, primary and secondary preventive measures, genetic testing, and screening recommendations.

[Knowledge, attitudes, and practices related to the Pap smear among women with cervical cancer]

Despite screening programs, Brazil has a high cervical cancer mortality rate. The objective of this cross-sectional study was to analyze knowledge, attitudes, and practices related to the Pap smear and to understand why women fail to submit to this screening test. A structured questionnaire was used to interview 138 women: 90 with high grade intraepithelial neoplasia and 48 with invasive cervical cancer. Inadequate practices were more frequent among women with invasive cancer. In terms of difficulties in obtaining medical care, more than 80% of women reported lack of motivation, 60% reported that physicians failed to conduct a complete physical examination, and some 50% reported that physicians' schedules were busy. Having a Pap smear usually depended on a physician's request and the woman being symptomatic. Women over than 56 years old showed more frequent inadequate knowledge, attitudes and practices. However, those with more schooling were more knowledgeable of the Pap smear procedure. Age and less schooling could be barriers against women participating in screening programs, but socioeconomic problems must also be considered for improving practices related to the Pap smear.