Mammography decision making: Trends and predictors of provider communication in the Health Information National Trends Survey, 2011 to 2014

Community Pharmacists' Readiness for Breast Cancer Mammogram Promotion: A National Survey from Jordan

Purpose

Mammography is the gold standard screening technique for early detection of breast cancer. This study aimed to assess the knowledge of community pharmacists of different aspects emphasized by the JBCP programs. This study also identifies the attitudes and barriers towards promoting early detection services.

Patients and Methods

This study was a cross-sectional survey of community pharmacists in Jordan. Pharmacists were randomly selected and asked to complete an electronic questionnaire. Inclusion criteria: a pharmacist with a bachelor's degree or higher and registered at the JPA working in a community pharmacy. The questionnaire included demographic and socioeconomic information, knowledge, attitudes towards breast cancer screening mammography services, and barriers towards participation in the promotion of these services.

Results

A total of 1,088 community pharmacists were approached, 1,000 (91.8%) completed the questionnaire. Participants had an average age of 34 years ± 10.8 and average experience of 9.1 ± 9.5 years. Only 48 (37.8%) of the female pharmacists aged 40 years or older underwent a mammogram. Knowledge of symptoms of breast cancer was the highest with a score of 755, followed by knowledge of risk factors (670) and finally early detection of breast cancer (540). Many barriers were reported by the community pharmacists including lack of educational materials and time constraints. Pharmacists with higher educational levels (p<0.001), of female gender (p<0.001), attended continuous cancer-related education (p<0.001), encountered a higher percentage of female customers (p<0.001), in a certain geographic location (p=0.003), underwent mammography (p=0.014), and encountered high frequency of inquiries on mammogram by the customers (p<0.001) were all associated with higher knowledge scores.

Conclusion

Despite the reported barriers and insufficient knowledge in certain aspects of early detection of breast cancer, community pharmacists have positive attitudes and can be a valuable asset for awareness-raising efforts.

The Impact of IT-Based Healthcare Communication on Mammography Screening Utilization among Women in the United States: National Health Interview Survey (2011-2018)

Effective patient-provider communication improves mammography utilization. Using information technology (IT) promotes health outcomes. However, there are disparities in access to IT that could contribute to disparities in mammography utilization. This study aims to assess the association between IT-based health care communication and mammography utilization and to evaluate if this effect is modified by race/ethnicity and age. To this end, this study was conducted using the National Health Interview Survey from 2011 to 2018. A total of 94,290 women aged 40 years and older were included. Multiple logistic regression models were used, and odds ratios were reported. The study found that all IT-based healthcare communication strategies were significantly associated with mammography utilization in all years from 2011 to 2018. In 2018, women who looked up health information on the internet, scheduled a medical appointment on the internet, and communicated with providers by email had a significantly higher chance to use mammography (p ≤ 0.005 for all strategies across all years). White women and women aged 50 years and older benefited the most from IT-based healthcare communication. In conclusion, facilitating access to IT may help increase mammography utilization, which may contribute to eliminating disparities in breast cancer mortality.

"It's something I'll do until I die": A qualitative examination into why older women in the U.S. continue screening mammography

BACKGROUND

Professional guidelines in the U.S. do not recommend routine screening mammography for women ≥75 years with limited life expectancy and/or poor health. Yet, routine mammography remains widely used in older women. We examined older women's experiences, beliefs, and opinions about screening mammography in relation to aging and health.

METHODS

We performed thematic analysis of transcribed semi-structured interviews with 19 women who had a recent screening visit at a mammography clinic in New York City (average age: 75 years, 63% Hispanic, 53% ≤high school education).

RESULTS

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

CONCLUSIONS

Older women's positive experiences and views, as well as multilevel and frequently automated cues toward mammography are important drivers of routine screening in older women. These findings suggest a need for synergistic patient, provider, and system level strategies to reduce mammography overuse in older women.

Preliminary Evaluation of a Breast Cancer Screening Shared Decision-Making Aid Utilized Within the Primary Care Clinical Encounter

Introduction:

The US Preventative Services Task Force recommends shared decision-making (SDM) between women aged 40 and 49 years and their physician regarding timing of mammography screening. This preliminary study evaluates women’s and physician’s satisfaction using Breast Cancer Risk Estimator & Decision Aid (BCARE-DA), a shared decision aid utilized during the clinical encounter, and examines SDM quality for these encounters.

Methods:

Fifty-three women and their physician utilized BCARE-DA and completed surveys measuring satisfaction with Likert-type and open-ended items and women completed the Decision Conflict Scale. Clinic visit transcripts were evaluated for SDM quality using Observer OPTION-5 and Breast Cancer Screening Decision Core Components Checklist.

Results:

Women and physicians positively evaluated BCARE-DA. Women had low decision conflict. Physicians demonstrated moderate effort toward SDM, greatest in offering options, and lowest for team talk. Physicians demonstrated 2/3 of core SDM elements in 80% to 100% of encounters.

Conclusion:

Preliminary findings suggest specific promise for such Decision Aids to facilitate SDM through understanding of personal risks for breast cancer formulated within each screening option, while some SDM elements likely require additional facilitating.

Engaging Women with Limited Health Literacy in Mammography Decision-Making: Perspectives of Patients and Primary Care Providers

BACKGROUND

Limited health literacy is a driver of cancer disparities and associated with less participation in medical decisions. Mammography screening decisions are an exemplar of where health literacy may impact decision-making and outcomes.

OBJECTIVE

To describe informational needs and shared decision-making (SDM) experiences among women ages 40-54 who have limited health literacy and primary care providers (PCPs).

DESIGN

Qualitative, in-depth interviews explored experiences with mammography counseling and SDM.

PARTICIPANTS

Women ages 40-54 with limited health literacy and no history of breast cancer or mammogram in the prior 9 months were approached before a primary care visit at a Boston academic, safety-net hospital. PCPs practicing at this site were eligible for PCP interviews.

APPROACH

Interviews were audio-recorded and transcribed verbatim. A set of deductive codes for each stakeholder group was developed based on literature and the interview guide. Inductive codes were generated during codebook development. Codes were compared within and across patient and PCP interviews to create themes relevant to mammography decision-making.

KEY RESULTS

The average age of 25 interviewed patients was 46.5; 18 identified as black, 3 as Hispanic, 2 as non-Hispanic white, and 2 had no recorded race or ethnicity. Of 20 PCPs, 15 were female; 12 had practiced for >5 years. Patients described a lack of technical (appropriate tests and what they do) and process (what happens during a mammogram visit) knowledge, viewing these as necessary for decision-making. PCPs were reluctant to engage patients with limited health literacy in SDM due to time constraints and feared that increased information might confuse patients or deter them from having mammograms. Both groups felt pre-visit education would facilitate mammography-related SDM during clinical visits.

CONCLUSION

Both patients and PCPs perceived a need for tools to relay technical and process knowledge about mammography prior to clinical encounters to address the scope of information that patients with limited health literacy desired.

Predictors of Women's Awareness of the Benefits and Harms of Mammography Screening and Associations with Confusion, Ambivalence, and Information Seeking

In recent years, there has been a shift toward promoting informed decision making for mammography screening for average-risk women in their 40s. Professional organizations such as the American Cancer Society and U.S. Preventive Services Task Force recommend that women weigh the potential benefits and harms of mammography prior to initiating screening. This decision-making process assumes that women are aware of both the benefits and harms of screening, yet little is known about the prevalence and antecedents of such awareness. Moreover, it is conceivable that women who are aware of both the benefits and harms may interpret this information as conflicting - which could be concerning, as researchers have documented adverse effects of exposure to conflicting health information in prior research. Using data from a population-based survey of U.S. women aged 30-59 (N = 557), the current study found that awareness of mammography's harms is relatively low compared to awareness of benefits. Health news exposure and interpersonal communication about health were associated with greater awareness of harms. In addition, women's awareness of both the benefits and harms was positively associated with confusion about breast cancer screening recommendations, ambivalence about getting a mammogram, and mammogram-related information seeking from online sources. Implications for cancer screening communication are discussed.

The Influence of Patient-Provider Communication on Cancer Screening

Few studies have examined how different qualities and modes (face-to-face vs electronic) of patient-provider communication (PPC) influence cancer screening uptake. Our objective was to determine whether receiving a breast, cervical, and colorectal cancer screening is influenced by (1) qualities of face-to-face and (2) the use of e-mail PPC. We analyzed Health Information National Trends Survey 4, cycles 1 to 4 data. To assess qualities of face-to-face PPC, adults reported how often physicians spent enough time with them, explained so they understood, gave them a chance to ask questions, addressed feelings and emotions, involved them in decisions, confirmed understanding, and helped them with uncertainty. Adults reported whether they used e-mail PPC. We used multivariable logistic regression to evaluate the odds of receiving cancer screenings based on face-to-face and e-mail PPC. Adults whose health-care providers involved them in decision-making had highest odds of receiving breast (odds ratio [OR] = 1.38; 95% confidence interval [CI] = 1.11-1.71), cervical (OR = 1.30; 95% CI = 1.06-1.60), and colorectal (OR = 1.25; 95% CI = 1.03-1.51) cancer screenings. No significant associations were observed between e-mail PPC and cancer screenings. More research is needed to explore this association.

Complex Multimorbidity and Breast Cancer Screening Among Midlife and Older Women: The Role of Perceived Need

BACKGROUND AND OBJECTIVES

There is minimal survival benefit to cancer screening for those with poor clinical presentation (complex multimorbidity) or at advanced ages. The current screening mammography guidelines consider these objective indicators. There has been less attention, however, to women's subjective assessment of screening need. This study examines the interplay between complex multimorbidity, age, and subjective assessments of health and longevity for screening mammography receipt.

RESEARCH DESIGN AND METHOD

This cross-sectional study uses self-reported data from 8,938 women over the age of 52 in the 2012 Health and Retirement Study. Logistic regression models estimated the association between women's complex multimorbidity (co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes), subjective health and longevity assessments, age, and screening mammography in the 2 years before the interview. These associations were evaluated adjusting for sociodemographic and behavioral factors.

RESULTS

Both age and complex multimorbidity were negatively associated with screening mammography. However, women's perceived need for screening moderated these effects. Most significantly, women optimistic about their chances of living another 10-15 years were more likely to have had screening mammography regardless of their health conditions or advanced age.

DISCUSSION AND IMPLICATIONS

Women with more favorable self-assessed health and perceived life expectancy were more likely to receive screening mammography even if they have poor clinical presentation or advanced age. This is contrary to current cancer screening guidelines and suggests an opportunity to engage women's subjective health and longevity assessments for cancer screening decision making in both for screening policy and in individual clinician recommendations.

The Evolution of Mammography Controversy in the News Media: A Content Analysis of Four Publicized Screening Recommendations, 2009 to 2016

BACKGROUND

There is longstanding expert disagreement about the age at and frequency with which women should be screened for breast cancer. These debates are reflected in the conflicting recommendations about mammography issued by major professional organizations, such as the U.S. Preventive Services Task Force and the American Cancer Society. Previous research has shown that these recommendations garner substantial media attention-and therefore might affect women's screening perceptions and behaviors-but to date analyses of such media coverage have focused on single publicized announcements.

METHODS

To assess whether media coverage of mammography screening recommendations has evolved, we conducted a content analysis of televised news from four discrete media events from 2009 to 2016, all of which focused on publicized screening recommendations from the U.S. Preventive Services Task Force and American Cancer Society (N = 364 stories).

RESULTS

Media coverage of mammography screening recommendations has featured persistent messages of conflict and/or controversy over time. The evolution of controversy was also reflected in shifts in the relative attention given to mammography screening's risks and benefits, with consistent and, in some cases, heightened attention to screening's risks during more recent media events. Overall, the accuracy of media coverage improved over time.

CONCLUSIONS

Results underscore the continued prevalence of conflicting and/or controversial information about mammography screening in the public information environment. Cumulative exposure to such messages could influence women's decision making around screening and trust in cancer prevention recommendations. Strategies are needed to better equip all women (and particularly underserved women) to negotiate mammography controversy and weigh the benefits and risks of screening.

How Do Women View Risk-Based Mammography Screening? A Qualitative Study

BACKGROUND

Decades of persuasive messages have reinforced the importance of traditional screening mammography at regular intervals. A potential new paradigm, risk-based screening, adjusts mammography frequency based on a woman's estimated breast cancer risk in order to maximize mortality reduction while minimizing false positives and overdiagnosis. Women's views of risk-based screening are unknown.

OBJECTIVE

To explore women's views and personal acceptability of a potential risk-based mammography screening paradigm.

DESIGN

Four semi-structured focus group discussions about screening mammography and surveys before provision of information about risk-based screening. We analyzed coded focus group transcripts using a mixed deductive (content analysis) and inductive (grounded theory) approach.

PARTICIPANTS

Convenience sample of 29 women (40-74 years old) with no personal history of breast cancer recruited by print and online media in New Hampshire and Vermont.

RESULTS

Twenty-seven out of 29 women reported having undergone mammography screening. All participants were white and most were highly educated. Some women accepted the idea that early cancer detection with traditional screening was beneficial-although many also reported hearing inconsistent recommendations from clinicians and mixed messages from media reports about mammography. Some women were familiar with a risk-based screening paradigm (primarily related to cervical cancer, n = 8) and thought matching screening mammography frequency to personal risk made sense (n = 8). Personal acceptability of risk-based screening was mixed. Some believed risk-based screening could reduce the harms of false positives and overdiagnosis (n = 7). Others thought screening less often might result in missing a dangerous diagnosis (n = 14). Many (n = 18) expressed concerns about the feasibility of risk-based screening and questioned whether breast cancer risk estimates could be accurate. Some suspected that risk-based mammography was motivated by a desire to save money (n = 6).

CONCLUSION

Some women thought risk-based screening made sense. Willingness to abandon traditional screening for the new paradigm was mixed. Broad acceptability of risk-based screening will require clearer communication about its rationale and feasibility and consistent messages from the health care team.

Key Elements of Mammography Shared Decision-Making: a Scoping Review of the Literature

BACKGROUND

New guidelines recommend shared decision-making (SDM) for women and their clinician in consideration of breast cancer screening, particularly for women ages 35-50 where guidelines for routine mammography are controversial. A number of models offer general guidelines for SDM across clinical practice, yet they do not offer specific guidance about conducting SDM in mammography. We conducted a scoping review of the literature to identify the key elements of breast cancer screening SDM and synthesize these key elements for utilization by primary care clinicians.

METHODS

The Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus); PsycInfo, PubMed (MEDLINE), Scopus, and SocIndex databases were searched. Inclusion criteria were original studies from peer-reviewed publications (from 2009 or later) reporting breast cancer screening (mammography), medical decision-making, and patient-centered care. Study populations needed to include female patients 18+ years of age facing a real-life breast cancer screening decision. Article findings were specific to shared decision-making and/or use of a decision aid. Data extracted includes study design, population, setting, intervention, and critical findings related to breast cancer screening SDM elements. Scoping analysis includes descriptive analysis of study features and content analysis to identify the SDM key elements.

RESULTS

Twenty-four articles were retained. Three thematic categories of key elements emerged from the extracted elements: information delivery/patient education (specific content and delivery modes), interpersonal clinician-patient communication (aspects of interpersonal relationship impacting SDM), and framework of the decision (sociocultural factors beyond direct SDM deliberation). A number of specific breast cancer screening SDM elements relevant to primary care clinical practice are delineated.

DISCUSSION

The findings underscore the importance of the relationship between the patient and clinician and the necessity of spelling out each step in the SDM process. The clinician needs to be explicit in telling a woman that she has a choice about whether to get a mammogram and the benefits and harms of screening mammography. Finally, clinicians need to be aware of sociocultural factors that can influence their relationships and their patients' decision-making processes and attempt to identify and address these factors.