Predictors of cancer prevention attitudes and participation in cancer screening examinations

Predictors of Nonadherence to Colorectal Cancer Screening among Hospitalized Women

OBJECTIVES

Despite proven mortality benefit, disparities in colorectal cancer (CRC) screening utilization persist, especially among younger women, minorities, and low-income women, even those who are insured. The purpose of the present study is to evaluate and estimate the effects of sociodemographic and clinical variables associated with nonadherence to CRC screening among hospitalized women.

METHODS

A cross-sectional bedside survey was conducted to collect sociodemographic and clinical comorbidity data believed to affect CRC screening adherence of hospitalized women aged 50 to 75 years who were cancer free (except skin cancer) at enrollment. Logistic regression models were used to assess the association between these factors and nonadherence CRC screening.

RESULTS

In total, 510 women were enrolled for participation in the study. After adjustment for sociodemographic and clinical predictors, only two variables were found to be independently associated with nonadherence to CRC screening: age younger than 60 years (odds ratio [OR] 2.62, 95% confidence interval [CI] 1.58-4.33) and nonadherence to breast cancer screening (OR 3.72, 95% CI 2.29-6.04). By contrast, hospitalized women at high risk for CRC were more likely to be compliant with CRC screening (OR 0.14, 95% CI 0.04-0.50).

CONCLUSIONS

Both younger age and behavior toward screening remain barriers to CRC screening. Hospitalization creates an environment where patients are in close proximity to healthcare resources, and strategies could be used to capitalize on this opportunity to counsel, educate, and motivate patients toward this screening that is necessary for health maintenance. Seizing on this opportunity may help improve CRC screening adherence.

Rapid review of factors associated with flexible sigmoidoscopy screening use

Flexible sigmoidoscopy (FS) screening has been shown to reduce colorectal cancer (CRC) incidence and mortality among screened adults. The aim of this review was to identify patient-related factors associated with the screening test's use. We searched PubMed for studies that examined the association between FS screening use and one or more factors. To determine the eligibility of studies, we first reviewed titles, then abstracts, and finally the full paper. We started with a narrow search, which we expanded successively (by adding 'OR' terms) until the number of new publications eligible after abstract review was <1% of the total number of publications. We then abstracted factors from eligible papers and reported the number of times each was found to be positively or negatively associated with FS screening use. We identified 42 papers, most of which reported studies conducted in the United States of America (n = 21, 50%) and the United Kingdom (n = 13, 31%). Across studies, a wide range of factors were examined (n = 123), almost half of which were found to be associated with FS screening use at least once (n = 60). Sociodemographic and health and lifestyle factors that were frequently positively associated with FS screening use included: male gender, higher socioeconomic status and a family history of CRC. Frequently positively associated psychosocial factors included low perceived barriers and high perceived benefits. Findings suggest that future research should focus on developing a theoretical framework of cancer screening behaviour to allow a greater level of consistency and specificity in measuring key constructs.

Non-communicable chronic diseases and timely breast cancer screening among women of the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study

PURPOSE

The Caribbean population faces a growing burden of multiple non-communicable chronic diseases (NCDs). Breast cancer is the leading cause of cancer death for women in the Caribbean. Given the substantial burden of NCDs across the region, cancer prevention and control strategies may need to be specifically tailored for people with multiple co-morbidities. Preventive screening, such as timely mammography, is essential but may be either facilitated or hampered by chronic disease control. The main objective of this study is to examine the relationship between a chronic disease and timely breast cancer screening.

METHODS

We conducted a cross-sectional data analysis using baseline data from the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study-ECS. Our independent variables were presence of chronic diseases (hypertension or diabetes), defined as having been told by a clinical provider. Our dependent variable was timely screening mammography, as defined by receipt of mammography within the past 2 years. We examined bivariate and multivariate associations of covariates and timely screening mammography.

RESULTS

In our sample (n = 841), 52% reported timely screening mammography. Among those with timely screening, 50.8% reported having hypertension, and 22.3% reported having diabetes. In our bivariate analyses, both diabetes and hypertension were associated with timely screening mammography. In partially adjusted models, we found that women with diabetes were significantly more likely to report timely screening mammography than women without diabetes. In our fully adjusted models, the association was no longer significant. Having a usual source of healthcare and a woman's island of residence were significantly associated with timely screening mammography (p < 0.05).

CONCLUSIONS

We found that half of eligible women received timely screening mammography. Diabetes and hypertension, though common, are not associated with timely screening mammography. Usual source of care remains an important factor to timely breast cancer screening.

Determinants of Prostate Cancer Screening Intentions of Young Black Men Aged 18 to 40 Years

INTRODUCTION

Black men are more likely to be diagnosed with prostate cancer, with higher stage and higher grade at presentation. Evidence suggests that for education in health promotion behaviors (such as screenings) in early adult years, young Black men can be better equipped to make informed decisions in later years.

OBJECTIVE

Using the theory of reasoned action (TRA), we assessed the intention of young Black men to screen for prostate cancer when it is recommended and determined its correlates.

METHODS

This was a cross-sectional study of 267 Black men aged 18 to 40 years. A 47-item questionnaire collected information on demographics/personal factors, attitudes toward prostate cancer screening, social influence, comfortability with prostate examinations, cues to action, health screening experiences, knowledge of prostate cancer and screening, and intention. Descriptive statistics were calculated for all variables and hierarchical logistic regression was employed to determine significant predictors of prostate cancer screening intentions.

RESULTS

The regression model accounted for 46% of the variance in intention (p < 0.01), with excellent perception of health, having private or public health insurance, longer regular source of care, positive attitude, positive social influence, positive cues to action, and higher knowledge levels being significant predictors of intentions.

CONCLUSION

This study provides support for the use of TRA in predicting prostate cancer screening intentions among young Black men when it is recommended by a physician. Findings may inform the development of empirical-based interventions to educate and inform at-risk young Black men about the pros and cons of prostate cancer screening so that they can make informed decision on screening when recommended later in life.

Health Behavior: An Interlocking Personal and Social Task

Traditional health behavior models comprise only person-centered motivational components such as personal vulnerability perceptions and specific internal control beliefs. However, such factors as social responsibility, perceived prevalence rates of illnesses, attribution of control to societal agencies, and the motivation to engage oneself for public health concerns are not unrelated to individual health protection. Therefore, an alternative model is proposed, which combines traditional self-centered and social variables. This alternative model was empirically confirmed in a questionnaire study exemplified by cancer preventive activities ( N = 558), which embraced personal cancer prevention as well as efforts to reduce the cancer prevalence within the general population. The readiness to engage in personal cancer preventive measures appeared to be closely related to the readiness to engage oneself for public health programs. The motivational predictors of both categories of activities had significant overlap. Implications for model building and intervention strategies to promote individual as well as public health behavior are discussed.

Propranolol Reduces Cancer Risk: A Population-Based Cohort Study

β-Blockers have been reported to exhibit potential anticancer effects in cancer cell lines and animal models. However, clinical studies have yielded inconsistent results regarding cancer outcomes and cancer risk when β-blockers were used. This study investigated the association between propranolol and cancer risk.Between January 1, 2000 and December 31, 2011, a patient cohort was extracted from the Longitudinal Health Insurance Database 2000, a subset of the Taiwan National Health Insurance Research Database. A propranolol cohort (propranolol usage >6 months) and nonpropranolol cohort were matched using a propensity score. Cox proportional hazard models were used to estimate the hazard ratio (HR) and 95% confidence intervals (CIs) of cancer associated with propranolol treatment.The study sample comprised 24,238 patients. After a 12-year follow-up period, the cumulative incidence for developing cancer was low in the propranolol cohort (HR: 0.75; 95% CI: 0.67-0.85; P < 0.001). Patients with propranolol treatment exhibited significantly lower risks of cancers in head and neck (HR: 0.58; 95% CI: 0.35-0.95), esophagus (HR: 0.35; 95% CI: 0.13-0.96), stomach (HR: 0.54; 95% CI: 0.30-0.98), colon (HR: 0.68; 95% CI: 0.49-0.93), and prostate cancers (HR: 0.52; 95% CI: 0.33-0.83). The protective effect of propranolol for head and neck, stomach, colon, and prostate cancers was most substantial when exposure duration exceeded 1000 days.This study supports the proposition that propranolol can reduce the risk of head and neck, esophagus, stomach, colon, and prostate cancers. Further prospective study is necessary to confirm these findings.

Effects of Cardiovascular Disease on Compliance with Cervical and Breast Cancer Screening Recommendations Among Adult Women

BACKGROUND

Cardiovascular disease (CVD) is common among women and is a leading cause of death in the United States. This study assessed the impact of CVD on compliance with the US Preventive Services Task Force guidelines for cervical and breast cancer screening among U.S. adult women.

METHODS

A cross-sectional study was conducted on 17,408 women using data from the National Health Interview Survey 2013. A total of 11,788 respondents (21-65 years old) with complete information on Pap smear and 11,409 women (40+ years old) with complete information on mammography compliance were included. Multivariate logistic regression models were used to assess the impact of CVD on cervical and breast cancer screening practices.

RESULTS

Women with CVD were marginally more likely to have had a mammogram in accordance with guidelines (odds ratio 1.17; 95% confidence interval 1.04-1.31) than those without CVD. However, compliance with Pap tests was similar (80.6% vs 82.3%, p>0.05) between the two groups. Myocardial infarction was associated with reduced odds of Pap smear compliance (odds ratio: 0.30; 95% confidence interval 0.18-0.51).

CONCLUSIONS

Women with prior myocardial infarction should be encouraged to continue receiving regular Pap smears. More research is needed to assess whether observed differences in Pap testing between patients with and without a history of myocardial infarction result from lack of provider recommendation or from patient noncompliance with their recommendations.

Psychosocial factors and attendance at a population-based mammography screening program in a cohort of Swedish women

Background

A better understanding of the factors that influence mammography screening attendance is needed to improve the effectiveness of these screening programs. The objective of the study was to examine whether psychosocial factors predicted attendance at a population-based invitational mammography screening program.

Methods

Data on cohabitation, social network/support, sense of control, and stress were obtained from the Malmö Diet and Cancer Cohort Study and linked to the Malmö mammography register in Sweden. We analyzed 11,409 women (age 44 to 72) who were free of breast cancer at study entry (1992 to 1996). Mammography attendance was followed from cohort entry to December 31, 2009. Generalized Estimating Equations were used to account for repeated measures within subjects. Adjusted odds ratios (OR) and 95% confidence intervals (CI) are reported.

Results

Among 69,746 screening opportunities there were 5,552 (8%) cases of non-attendance. Higher odds of non-attendance were found among women who lived alone (OR = 1.47 (1.33-1.63)) or with children only (OR = 1.52 (1.29-1.81)), had one childbirth (OR = 1.12 (1.01-1.24)) or three or more childbirths (OR = 1.34 (1.21-1.48)), had low social participation (OR= 1.21 (1.10-1.31)), low sense of control (OR = 1.12 (1.02-1.23)), and experienced greater stress (OR = 1.24 (1.13-1.36)).

Conclusions

Public health campaigns designed to optimize mammography screening attendance may benefit from giving more consideration of how to engage with women who are less socially involved.

What Factors Impact upon a Woman's Decision to Undertake Genetic Cancer Testing?

INTRODUCTION

The advent of human genome project has lead to genetic tests that identify high-risk states for certain cancers. Many are privately marketed on the Internet. Despite the availability of tests, limited data has evaluated factors that lead to test uptake. The aim of the present study was to explore the attitudes of a cohort of new mothers toward uptake of a genetic cancer test with a 50% predictive value of cancer.

METHODS

A cross-sectional survey was undertaken. The project targeted women who had recently given birth at an Australian tertiary referral hospital. Women were asked about a theoretical blood test that detected an increased risk for the development of cancer. Attitudes and knowledge questionnaires were completed.

RESULTS

Of 232 consecutive women approached, 32 declined, giving a response rate of 86.2%. Only 63 (31.5%) women stated they would have the test. Absence of religious belief, higher level of education, better knowledge of terms used in genetics, an absence of concern over emotional, employment, and insurance discrimination, and previous acceptance of Down syndrome screening in pregnancy were each associated with significantly higher rate of test uptake in univariate analysis (all p < 0.03). In multivariate analysis, a lack of concern over discrimination and a history of having accepted Down syndrome screening in the previous pregnancy remained significantly associated with test uptake (all p < 0.0001).

CONCLUSION

Concern over discrimination and having made a prior decision to have genetic testing were the principal factors associated with decision-making.

CYP2W1, CYP4F11 and CYP8A1 polymorphisms and interaction of CYP2W1 genotypes with risk factors in Mexican women with breast cancer

Breast cancer (BCa) is the leading type of cancer in Mexican women. Genetic factors, such as single nucleotide polymorphisms (SNP) of P450 system, have been reported in BCa. In this report, and for the first time in the literature, we analyzed the rs3735684 (7021 G>A), rs11553651 (15016 G>T) and rs56195291 (60020 C>G) polymorphisms in the CYP2W1, 4F11 and 8A1 genes in patients with BCa and in healthy Mexican women to identify a potential association between these polymorphisms and BCa risk. Patients and controls were used for polymorphism analysis using an allelic discrimination assay with TaqMan probes and confirmed by DNA sequencing. Links with clinic-pathological characteristics were also analyzed. Statistical analysis was performed using the standard χ2 or Fisher exact test statistic. No significant differences were observed in the distributions of CYP2W1 (OR 8.6, 95%CI 0.43-172.5 P>0.05; OR 2.0, 95%CI 0.76-5.4, P>0.05) and CYP4F11 (OR 0.3, 95%CI 0.01-8.4 P>0.05) genotypes between the patients and controls. Only the CYP8A1 CC genotype was detected in patients with BCa and the controls. All polymorphism frequencies were in Hardy-Weinberg Equilibrium (HWE) in the controls (P>0.05). We found a significant association between BCa risk and smoking, use of oral contraceptives or hormonal replacement therapy (HRT), obesity, hyperglycemia, chronic diseases, family history of cancer and menopausal status in the population studied (P<0.05). Tobacco, oral contraceptive or HRT, chronic diseases and obesity or overweight were strongly associated with almost eight, thirty-five, nine and five-fold increased risk for BCa. Tobaco, obesity and hyperglycemia significantly increased the risk of BCa in the patients carrying variant genotypes of CYP2W1 (P<0.05). These results indicate that the CYP2W1 rs3735684, CYP4F11 rs11553651 and CYP8A1 rs56195291 SNPs are not a key risk factor for BCa in Mexican women. This study did not detect an association between the CYP2W1, 4F11 and 8A1 genes polymorphisms and BCa risk in a Mexican population. However, some clinico-pathological risk factors interact with CYP2W1 genotypes and modifies susceptibility to BCa.

The role of social support in multiple morbidity: self-management among rural residents

Social support generally is considered a valuable asset that may compensate for health service deficiencies among rural populations. Employing a mixed methods approach, we explored how vulnerable rural residents described social support in the context of self-management for multiple chronic conditions. Participants generally felt support was available, though emotional/informational support was perceived as less available than other types of support. Participants did not rely heavily on informal support to help them manage their multiple morbidities, preferring to call on their doctor and their own resources. We discuss implications of these findings for meeting this vulnerable population's self-management needs.

Rural Residents' Perspectives on Multiple Morbidity Management and Disease Prevention

Middle-aged and older adults often experience several simultaneously occurring chronic conditions or "multiple morbidity" (MM). The task of both managing MM and preventing chronic conditions can be overwhelming, particularly in populations with high disease burdens, low socioeconomic status, and health care provider shortages. This article sought to understand Appalachian residents' perspectives on MM management and prevention. Forty-one rural Appalachian residents aged 50 and above with MM were interviewed about disease management and colorectal cancer (CRC) prevention. Transcripts were examined for overall analytic categories and coded using techniques to enhance transferability and rigor. Participants indicate facing various challenges to prevention due, in part, to conditions within their rural environment. Patients and providers spend significant time and energy on MM management, often precluding prevention activities. This article discusses implications of MM management for CRC prevention and strategies to increase disease prevention among this rural, vulnerable population burdened by MM.

Hierarchical dynamic time-to-event models for post-treatment preventive care data on breast cancer survivors

This paper considers modelling data arising in post-treatment preventive care settings, where cancer patients who have undergone disease-directed treatment discontinue seeking preventive care services. Clinicians and public health researchers are interested in explaining such behavioural patterns by modelling the time-to-receiving care while accounting for several patient and treatment attributes. A key feature of such data is that a noticeable number of patients would never return for screening, a concept subtly different from censoring, where an individual does not return for screening in the given time frame of the study. Models distinguishing between these two concepts are known as cure rate models and are often preferred for data where a significant part of the population never experienced the endpoint. Building upon recent work on hierarchical cure model framework we propose modelling a sequence of latent events with a piecewise exponential distribution that remedies oversmoothing encountered in existing models with different latent distributions. We investigate simultaneous regression on the cure fraction and the latent event distribution and derive a flexible class of semiparametric cure rate models.

Predictors for non-compliance of notified hepatitis C virus-positive blood donors with recommendation to seek medical counselling

BACKGROUND

Notification of blood donors represents the commonest method of informing asymptomatic individuals of abnormal test results indicating exposure to hepatitis C virus (HCV) infection. Such notification is therefore important from both health and economic perspectives. This study aimed to identify predictors for non-compliance of HCV-positive blood donors with the National Blood Services recommendation to seek medical counselling.

STUDY DESIGN AND METHODS

The current research is a cross-sectional study. Telephone interviews were conducted with 201 blood donors identified as HCV positive following blood donation during 2001-2002 (40% response rate).

RESULTS

About 25% of all the notified blood donors did not seek any counselling; 29% (44/150) of those who requested medical advice from their primary care physicians (general practitoner's) were not referred to specialists. Age, alcohol consumption and non-practice of health-promoting behaviour were independent predictors of non-compliance with the blood services' recommendation. In particular, smoking (odds ratio, 2.0; 95% confidence interval 1.0-4.2) and not undergoing professional teeth cleaning (odds ratio 2.8; 95% confidence interval 1.3-6.1) were found to be significant predictors of non-compliance.

CONCLUSION

The study provides essential data regarding the extent and risk factors for non-compliance of HCV-positive blood donors with recommendation to seek medical advice. Our results can assist in identifying blood donors who would not seek counselling, based on demographic factors and past exposure to risk factors for HCV. Improvements in the notification process and additional training of general practitoners regarding the management of HCV disease are needed.

Patients with multiple chronic conditions do not receive lower quality of preventive care

BACKGROUND

The implications of measuring and rewarding performance for patients with multiple chronic conditions have not been explored empirically.

OBJECTIVE

To examine whether the number of chronic conditions was associated with patient's receipt of recommended preventive care.

METHODS

We evaluated the association between the likelihood of receiving recommended preventive care and the number of chronic conditions in the diabetic population by analyzing the 2003 Medical Expenditure Panel Survey using logistic regression. Demographic characteristics and the number of chronic conditions were compared using chi(2) tests.

OUTCOME MEASURES

Hemoglobin A1C test and diabetic eye exam.

RESULTS

In 2003, approximately 14.2 million non-institutionalized Americans had diabetes and 23% of them had five or more chronic conditions besides diabetes. Those patients were 67% (p < 0.05) and 50% (p < 0.001) more likely to receive hemoglobin A1C test and eye exams compared with diabetic patients with no additional chronic conditions. After adjusting for the number of office-based physician visits, a larger number of chronic conditions did not significantly affect the likelihood of receiving recommended care. Diabetic patients with more chronic conditions had more frequent office-based physician visits (p < 0.0001), and patients with 11 or more annual office-based physician visits were 43% (p < 0.05) and 40% (p < 0.01) more likely to receive hemoglobin A1C test and eye exam, respectively, compared with diabetic patients who had less than two office-based physician visits.

CONCLUSIONS

Diabetic patients with more chronic conditions may receive better quality of preventive care, partly due to their higher number of office-based physician visits.

The use of preventive health services among elderly uterine cancer survivors

OBJECTIVE

The purpose of the study was to determine whether women who survived uterine cancer received 4 recommended preventive services (mammography, colorectal cancer screening, influenza immunization, and bone density testing) at the same rates as women with no history of cancer.

STUDY DESIGN

We used the Surveillance, Epidemiology, and End Results-Medicare database to compare the rates among survivors aged 67 years or older with a matched group of women with no history of cancer.

RESULTS

Survivors were significantly more likely to have a mammogram (adjusted odds ratio [OR], 1.40; 95% confidence interval [CI], 1.30-1.50) or a colorectal cancer screening examination (adjusted OR, 1.11; 95% CI, 1.05-1.18). Influenza immunization and bone density testing rates were similar. The 28% of survivors seen by an obstetrician-gynecologist or gynecologic oncologist had the highest rates of use.

CONCLUSION

Efforts need to be made to increase the use of services by all women to achieve the target rates established by Healthy People 2010.

Breast and cervical cancer screening in obese minority women

PURPOSE

Studies using survey data from mostly white women showed that obese women are less likely than nonobese women to undergo breast and cervical cancer screening. It is unclear if these findings are true in nonwhite women. Using chart audit data, we examined the relationship between obesity and mammography and Pap smear screening among minority women.

METHODS

Data from retrospective chart review of women in three urban New Jersey academic family medicine practices were analyzed (n = 1809) using hierarchical logistic regression models. Outcome measures were being up-to-date in mammography and Pap smears among obese and nonobese women.

RESULTS

There was no difference in mammography rates among obese and nonobese women. Independent risk factors for not being up-to-date in mammography included age 40-49, smoking, and comorbidity. Obese women were less likely than nonobese women to be upto- date in Pap smears (69% vs. 77%, p = 0.001). In multivariate analysis, obesity was associated with 25% decreased odds of being up-to-date on Pap smears (OR, 0.75, 95% CI, 0.58-0.99, p = 0.041). Age >or=65 years was also associated with decreased odds of being up-to-date in Pap smears. Hispanic women had increased odds of being up-to-date in mammography (OR 2.43, 95% CI 1.63-3.63) and Pap smears (OR 1.94, 95% CI 1.24-3.03) compared with white women.

CONCLUSIONS

Obesity was associated with decreased Pap smear screening but not with decreased mammography. Further studies are needed to determine barriers and effective interventions to improve screening in obese minority women.

Factors associated with the incompliance with mammogram screening among individuals with a family history of breast cancer or ovarian cancer

OBJECTIVE

The national guidelines recommend more intensive screening for breast cancer for women with a family history of breast or ovarian cancer. Using the data from the 2000 National Health Interview Survey (NHIS), we examined factors related to the underuse of mammogram in this population.

METHOD

The study subjects were 1,215 women aged 30-79 who had a family history of breast or ovarian cancer in their first-degree relatives. According to the American Cancer Society's guidelines for breast cancer screening, having no mammogram in last year was used as an outcome for this study. Socio-demographic characteristics, health-related conditions, lifestyle factors, health behaviors, menstrual/reproductive information and health care access and utilization were analyzed to assess their relations to mammogram underuse using unconditional logistic regression method.

RESULTS

The results showed that younger age, having no place to go when sick (OR = 2.2, 95% CI, 1.2-4.0), having no visits to a general doctor (OR = 1.7, 95% CI, 1.2-2.4) or medical specialist (OR = 2.2, 95% CI, 1.6-3.1) and having no influenza shot in last year (OR = 1.7, 95% CI, 1.2-2.3) increased the risk of underusing mammography screening among women who had a family history of breast or ovarian cancer. Women who had no home care from health professionals in the last year were less likely to underuse mammogram with an OR of 0.3 (95% CI, 0.1-0.6), compared with women who had.

CONCLUSION

Medical care-related factors may affect the use of mammography screening in women with a family history of breast or ovarian cancer.

Mammography use among older women of seven Latin American and Caribbean cities

BACKGROUND

To describe the prevalence of mammography use, and to estimate its association with sociodemographics.

METHODS

A sample of 6207 women aged 60 and older from the first interview of Health, Well-Being and Aging in Latin America and the Caribbean Study (SABE) in seven cities (Buenos Aires, Bridgetown, Havana, Mexico, Montevideo, Santiago, and Sao Paulo). The outcome was reporting a mammogram within the last 2 years.

RESULTS

Prevalence of mammography use ranged from 9.8% in Havana to 34.4% in Sao Paulo. Independent predictors of mammography use across cities were older age (lowest odds ratio [OR] = 0.92, 95% confidence interval [CI] 0.89-0.95), higher education (highest OR = 1.14, 95% CI 1.08-1.20), public health insurance (lowest OR = 0.28, 95% CI 0.11-0.76), or no insurance (lowest OR = 0.08, 95% CI 0.02-0.34) compared with private insurance. In a combined sample of six cities, higher education was associated with higher mammography use, but older age and insurance (public: OR = 0.54, 95% CI 0.45-0.65; no insurance: OR = 0.30, 95% CI 0.23-0.40; compared with private insurance) were associated with lower mammography use.

CONCLUSIONS

Prevalence of mammography use across cities was lower than that reported for Hispanic populations in the US. In the overall sample, mammography use was increased in highly educated people and decreased in people without insurance.

Determinants of non-compliance to recommendations on breast cancer screening among women participating in the French E3N cohort study

Evidence of the benefits of screening for breast cancer using mammography after the age of 50 is considered sufficient. Information on the determinants of compliance to the recommendations on mammography is needed to identify women to which public health messages should be specifically addressed and also to interpret results from epidemiological data in which some breast cancer cases are detected through screening programmes and others are not. The general characteristics and dietary data of French women participating in the E3N cohort study were analysed. Odds ratios of the frequency of non-compliance to recommendations on breast cancer screening were computed in women over and under the age of 50. Non-compliant women over 50 (i.e. never attenders) had a poorer access to physicians and poorer health with regard to specific risk factors even after adjustment for age and educational level. Women who were used to referring to gynaecologists early in life were better attenders later on. Logically, women under 50 who were over-screened, as compared to public health recommendations, had the opposite characteristics. Public health recommendations should be designed specifically according to targeted subgroups of women. Determinants of attendance for screening should be kept in mind in the interpretation of epidemiological studies in which some cases may be over-screened and others not.

Use of intensified early cancer detection in high-risk patients with familial breast and ovarian cancer

A prospective follow-up study was carried out to evaluate the influence of risk and genetic counselling on use of early cancer detection. Five hundred and fifty-six subjects who fulfilled inclusion criteria for a genetic analysis of the BRCA1/2 genes (the high-risk group A) and 205 who did not fulfil the inclusion criteria (the lower risk group B) attended primary consultation in the interdisciplinary cancer genetic clinic. Information about participation in the early cancer detection programme was documented. Information about changes in use after consultation could be evaluated from 349 women (94 group B and 255 group A). Methods such as monthly self-palpation, breast palpation by gynaecologist, ultrasound of the breast, transvaginal ultrasound and pelvic examination had all been commonly used. Consultees at higher risk used mammography less often than women at lower risk. Magnetic resonance imaging of the breast was used rarely. Most methods were used more often at the recommended interval by women at higher risk during the follow-up period. In conclusion, at present intensified early cancer detection programmes for women at risk provide a less invasive option than chemoprevention or prophylactic surgery. Although the methods are used at high frequency it seems feasible to motivate women at risk to participate. This can be done by providing information and counselling in the cancer genetic clinic.

Comorbidity as a predictor of stage of illness for patients with breast cancer

OBJECTIVE

The purpose of this research was to determine whether comorbidity affects the stage at which breast cancer is diagnosed.

METHODS

Data from the Surveillance, Epidemiology and End Results (SEER) program of the National Cancer Institute (NCI) was merged with Medicare claims for 17,468 women diagnosed with breast cancer from 1993 to 1995.

RESULTS

Women with cardiovascular disease, musculoskeletal disorders, mild-to-moderate gastrointestinal disease, and nonmalignant benign breast disease had a 13%, 7%, 14%, and 24% lower odds, respectively, of being diagnosed with advanced breast cancer. Women with diabetes, other endocrine disorders, psychiatric disorders, or hematologic disorders increased the odds of a late-stage diagnosis by 19%, 11%, 20%, and 19% respectively. Mammography screening and contact with the medical care system decreased the odds of late-stage diagnosis.

DISCUSSION

Four hypotheses are suggested to explain this link between comorbid illness and stage at diagnosis: (1) the "surveillance" hypothesis, (2) the "physiological" hypothesis, (3) the "competing demand" hypothesis, and (4) the "death from other causes" hypothesis.

CONCLUSIONS

Comorbidity may complicate the diagnostic decision-making process for breast cancer. The results suggest that contact with the medical care system improves the odds of early-stage diagnosis. Thus, barriers to access for people with chronic conditions may exacerbate those chronic conditions and increase the odds of late-stage breast cancer.

Clinical, demographic, and psychological characteristics of new, asymptomatic participants in a transvaginal ultrasound screening program for ovarian cancer

BACKGROUND

Attitudinal, mood, and personality variables have been identified as predictors of uptake of routine screening for a variety of cancers, including those of the breast, cervix, and colon. Little information exists, however, regarding characteristics of participants in ovarian cancer (OC) screening.

METHOD

Asymptomatic women (n = 312; mean age = 57.45 years; range = 26-80) were assessed immediately before undergoing an initial transvaginal sonography (TVS) screening test for ovarian cancer (OCS group). Their responses were compared to identical information obtained from an age- and education-matched group of women with no history of screening for OC (HC group). All respondents completed measures of OC-related attitudes, knowledge, beliefs and risk perceptions, dispositional characteristics (informational coping style and dispositional optimism), and psychological distress.

RESULTS

Analyses revealed the OCS group was characterized not only by more OC-specific distress and a more extensive family history of OC but also by less optimism and less knowledge of OC risk factors. Group membership was unrelated to beliefs about the efficacy of TVS screening.

CONCLUSION

Results have implications for development of programs to increase appropriate participation in OC screening programs.

Quality of care in stroke prevention: results of an audit study among general practitioners

BACKGROUND

In identifying opportunities to improve the quality of stroke prevention in general practice, insight in areas of suboptimal care is essential. This study investigated the quality of care in stroke prevention in general practice and its relation to the occurrence of stroke.

METHODS

Retrospective case-based audit with guideline-based review criteria and final judgment of suboptimal care by an expert panel.

RESULTS

A total of 292 stroke patients were identified through stroke registers of two main referral hospitals for stroke in Rotterdam. The general practitioners (GPs) (n = 95) of these patients were approached. The overall response rate from GPs was 81%, and a total of 193 patients from 77 GPs were included in the study. Data on the process of care at patient level were collected by chart review and by structured interviews with GPs during site visits. All cases were presented to a six-member panel of GPs and neurologists. In 44% of the cases, suboptimal care was identified (31% judged as possibly or likely failing to prevent stroke). Of the total number of identified shortcomings, 52% was related to inadequate hypertension control, particularly lack of follow-up after established hypertension. Another 17% of identified shortcomings concerned inadequate cardiovascular risk assessment.

CONCLUSIONS

A substantial number of shortcomings in care, particularly in the domain of hypertension control and the assessment of patient's risk profiles for cardiovascular disease (CVD), were identified. This study suggests that improving preventive care delivery in general practice could reduce the occurrence of stroke.

Psychosocial and medical predictors of colorectal cancer screening among low-income medical outpatients

BACKGROUND

Identification of factors related to colorectal cancer screening (CRC) and intent to obtain fecal occult blood tests (FOBTs) among low-income persons are important because CRC incidence and mortality are higher among socioeconomically disadvantaged populations.

METHOD

Participants were 193 individuals 50 years of age and older. CRC screening and intent to obtain FOBTs were dependent measures. Demographic variables, objective risk factors, and health beliefs were independent measures.

RESULTS

Digital rectal examinations and FOBTs were obtained by 41% and 22%, respectively, during the previous year. Flexible sigmoidoscopies were obtained by only 19% of those 55 years of age and older during the previous five years. Multivariate analyses showed that family history of CRC, personal history of polyps, and physician recommendation were the strongest predictors of CRC screening. Family history of CRC and self-efficacy were related to intent to obtain FOBTs.

CONCLUSIONS

Results suggest the importance of physician assessment of personal and family CRC risk factors, as well as recommendation of CRC screening, to all patients as part of routine medical care.

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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.

A simple tool for identifying unaffected women at a moderately increased or potentially high risk of breast cancer based on their family history

Family history of breast cancer is a more important aspect of clinical management following the discovery of the genes BRCA1 and BRCA2. The authors developed a short questionnaire to categorize risk according to breast cancer history in close relatives. It was completed by 559 women attending for screening mammograms in Sydney, Australia. Twenty-three per cent reported a family history sufficient to be classified at a moderately increased or potentially high risk according to national guidelines (category II or III). Only 29 women (5%) made errors such that their risk category could not be determined. Validation of responses from 89 women, 44 from category II or III, found 100% agreement with classification after interview by a genetic counsellor. This questionnaire has the potential to accurately triage risk based on a woman's knowledge of her family history, and could be used in a variety of settings to identify women who may require further assessment, management and referral advice.

Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey

BACKGROUND

Understanding differences in cancer screening among population groups in 2000 and successes or failures in reducing disparities over time among groups is important for planning a public health strategy to reduce or eliminate health disparities, a major goal of Healthy People 2010 national cancer screening objectives. In 2000, the new cancer control module added to the National Health Interview Survey (NHIS) collected more detailed information on cancer screening compared with previous surveys.

METHODS

Data from the 2000 NHIS and earlier surveys were analyzed to discern patterns and trends in cancer screening practices, including Pap tests, mammography, prostate specific antigen (PSA) screening, and colorectal screening. The data are reported for population subgroups that were defined by a number of demographic and socioeconomic characteristics.

RESULTS

Women who were least likely to have had a mammogram within the last 2 years were those with no usual source of health care (61%), women with no health insurance (67%), and women who immigrated to the United States within the last 10 years (61%). Results for Pap tests within the last 3 years were similar. Among both men and women, those least likely to have had a fecal occult blood test or endoscopy within the recommended screening interval had no usual source of care (14% for men and 18% for women), no health insurance (20% for men and 18% for women), or were recent immigrants (20% for men and 18% for women). An analysis of changes in test use since the 1987 survey indicates that the disparities are widening among groups with no usual source of care.

CONCLUSIONS

No striking improvements have been observed for the groups with greatest need. Although screening use for most groups has increased since 1987, major disparities remain. Some groups, notably individuals with no usual source of care and the uninsured are falling further behind; and, according to the 2000 data, recent immigrants also experience a significant gap in screening utilization. More attention is needed to overcome screening barriers for these groups if the population benefits of cancer screening are to be achieved.

Increasing attendance at colorectal cancer screening: testing the efficacy of a mailed, psychoeducational intervention in a community sample of older adults

This article describes a trial of a psychoeducational intervention designed to modify negative attitudes toward flexible sigmoidoscopy screening and thereby increase screening attendance. The intervention materials addressed the multiple barriers shown to be associated with participation in earlier studies. Adults ages 55-64 (N = 2,966), in a "harder-to-reach" group were randomized either to receive an intervention brochure or to a standard invitation group. Attitudes and expectations were assessed by questionnaire, and attendance at the clinic was recorded. Compared with controls, the intervention group had less negative attitudes, anticipated a more positive experience, and had a 3.6% higher level of attendance. These results indicate that psychoeducational interventions can provide an effective means of modifying attitudes and increasing rates of screening attendance.

Promoting fecal occult blood testing in rural African American women

PURPOSE

The purpose of this experimental study was to test the effectiveness of a multiphasic culturally relevant intervention, delivered over a 1-year period to increase the rates of participation in fecal occult blood testing (FOBT) at the initial screening opportunity and at the 1-year follow-up screening opportunity among rural African American women.

DESCRIPTION OF STUDY

The study used a pretest/post-test design among African American women who attended senior citizen centers in a rural southern state. The centers were randomly assigned to the cultural and self-empowerment group, who received the five-phased intervention, the modified cultural group, who received phase I of the intervention only, or the traditional group, who served as the control group. Data were collected at the initial and 1-year follow-up screenings. Hemoccult kits were distributed, collected, and analyzed at no cost to the participants. Data were analyzed using descriptive statistics, repeated measures, and longitudinal models for binary outcomes.

RESULTS

Women in the cultural and self-empowerment group had a significantly higher rate of participation in FOBT than did those in the modified cultural group and the traditional group. The modified cultural group had a significantly higher rate of participation in FOBT than the did the traditional group. Predictors of participation in FOBT were the women's family history of colorectal cancer and the average number of visits to their healthcare provider.

CLINICAL IMPLICATIONS

Colorectal cancer screening and diagnostic testing opportunities should be offered consistently to women who visit their provider for routine, nonemergent office visits. As successful interventions to increase colorectal cancer screening are introduced into community settings, these interventions also should be tested within physicians' offices and other community agencies.

Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys

BACKGROUND

Screening to detect cancer early, an increasingly important cancer control activity, cannot be effective unless it is widely used.

METHODS

Use of Pap smears, mammography, fecal occult blood tests (FOBTs), sigmoidoscopy, and digital rectal examination (DRE) was evaluated in the 1987, 1992, and 1998 National Health Interview Surveys. Levels and trends in screening use were examined by sex, age, and racial/ethnic group. The effects of income, educational level, and health care coverage were examined within age groups. Logistic regression analyses of 1998 data were used to develop a parsimonious, policy-relevant model.

RESULTS

Use of all screening modalities increased over the period examined; for mammography and DRE, the increase was more rapid in the first half of the decade; for the Pap test and sigmoidoscopy, the increase was more rapid in the second half of the decade. Levels of colorectal cancer screening (both sigmoidoscopy and FOBTs) in 1998 were less than the level that prevailed a decade earlier for mammography. Patterns of change for all screening modalities differed between age, sex, and racial/ethnic groups, but prevalence of use during the study, within recommended time intervals, was consistently lower among groups with lower income and less education. Logistic regression analyses indicated that insurance coverage and, to a greater extent, usual source of care had strong independent associations with screening usage when age, sex, racial/ethnic group, and educational level were taken into account.

CONCLUSIONS

While cancer screening is generally increasing in the United States, usage is relatively low for colorectal cancer screening and among groups that lack health insurance or a usual source of care.

Screening mammography: Is it suitably targeted to older women who are most likely to benefit?

OBJECTIVES

To determine whether screening mammography is suitably targeted to older women who are most likely to benefit.

DESIGN

Prospective cohort study.

SETTING

New Haven County, Connecticut.

PARTICIPANTS

Eight hundred forty-four community-dwelling older women were interviewed as part of the 1990 New Haven Established Populations for the Epidemiologic Study of the Elderly (EPESE) program.

MEASUREMENTS

Mammography use was ascertained from Medicare Part B claims data. A four-level prognostic mortality index was developed using items previously shown to be predictive of mortality. Mammography use and all-cause mortality were evaluated by prognostic stage over a 5-year period, January 1, 1991, to December 31, 1995.

RESULTS

Five-year mortality increased steadily with each prognostic stage (12% to 68%, P = .001), whereas the 5-year mammography use rate declined (48% to 7%, P = .001). Over half the women (53%) in the most favorable prognostic group did not receive a mammogram, whereas 13% in the two worst prognostic groups received at least one mammogram.

CONCLUSION

Screening mammography may be underutilized among older women who are the most likely to benefit and overutilized among those who are unlikely to benefit.

Predictors of proximal vs. distal colorectal cancers

BACKGROUND

Because proximal colorectal cancers have a tendency to present at a more advanced stage and thus have a poorer prognosis, it is important to understand the factors associated with the development of proximal colorectal cancer. We hypothesized that older age, female gender, and the presence of comorbid illness would be associated with proximal cancers.

METHODS

Incident cases of colorectal cancer (n = 9,550) occurring in 1994 were identified from Florida's population-based statewide cancer registry. We categorized colorectal cancers as either proximal (cecum, ascending colon, and transverse colon) or distal (descending colon, sigmoid colon, rectosigmoid, and rectum). Multiple logistic regression analysis was used to determine the multivariable relationship between clinical characteristics and the odds of a proximal-occurring lesion.

RESULTS

Four characteristics emerged as independent predictors of a proximal lesion. Each year of increasing age was associated with a 2.2 percent increase in the odds of a proximal lesion, whereas female gender was associated with a 38 percent increase in the odds of a proximal lesion. The presence of a comorbid condition was associated with a 28 percent greater odds of a proximal lesion, and, finally, black, non-Hispanic race was associated with a 24 percent greater odds of a proximal lesion.

CONCLUSIONS

We found that increasing age, female gender, black, non-Hispanic race, and the presence of comorbid illnesses were factors associated with a greater likelihood of developing colorectal cancer in a proximal location. Further studies will be required to confirm these findings and to establish the mechanism by which comorbidity influences the site of colorectal cancer development.

The importance of health insurance as a determinant of cancer screening: evidence from the Women's Health Initiative

BACKGROUND

Amid current changes in health care access across the United States, the importance of health insurance status and insurance type relative to demographic, actual, and perceived health variables as determinants of screening for breast, colorectal, and cervical cancer is uncertain. This analysis evaluates the hypothesis that health insurance independently predicts cancer screening in the Women's Health Initia tive Observational Study cohort.

METHODS

Questionnaire data from 55,278 women en rolled in the Women's Health Initiative Observational Study between September 1994 and February 1997 were analyzed by multiple logistic regression to identify predictors of self-reported mammography within 2 years, Pap smear within 3 years, and stool guaiac or flexible sigmoidoscopy within 5 years.

RESULTS

Positive determinants of reporting cancer screening were age, ethnic origin, household income, educational level, family history of cancer, having a usual care provider, time since last provider visit, and insurance status and type. Smoking, diabetes, and, among older women, prior cardiovascular events were negative determinants of cancer screening. Among women younger than 65, lacking health insurance or having fee-for-service insurance was strongly associated with failure to report cancer screening, independently of having or using a usual care provider and of demographics, self-perceived health, and health characteristics. Among women 65 and older, those with Medicare alone were less likely, whereas those with Medicare + prepaid insurance were more likely, to report cancer screening.

CONCLUSIONS

In the Women's Health Initiative Obser vational Study, a large, diverse group of older women, health insurance type and status were among the most important determinants of cancer screening indepen dent of demographics, chronic health conditions, and self-perceived health characteristics.

Predictors of participation in primary care group-format back pain self-care interventions

OBJECTIVE

The goal of this study was to explain how primary care back pain patients who volunteer for a group-format self-care intervention differ from nonvolunteers. This is relevant to the generalizability of studies that rely on volunteers as well as the characteristics of patients who do not seek out self-care interventions.

SETTING

This study was conducted at a large health maintenance organization in western Washington state.

PATIENTS

"Volunteers" (n = 481) were primary care back pain patients participating in randomized trials of a self-management intervention who were recruited through passive nonintensive means (a mailed invitation). "Nonvolunteers" (n = 967) consisted of a representative sample of consecutive back pain patients. We compared the baseline characteristics of these two groups.

RESULTS

The relatively small percentage (8%) of primary care back pain patients who volunteered for, and ultimately participated in, group self-management classes tended to be white, older, better educated, and more likely to be retired than nonvolunteers. The two groups did not differ significantly on most clinical measures, including pain intensity and persistence. Patients experiencing the highest (and lowest) levels of pain-related activity interference were less likely to volunteer than those with moderate activity limitations, however.

CONCLUSIONS

Those individuals volunteering to participate in a group-format self-care intervention in a primary care setting differed from nonvolunteers primarily on demographic measures as opposed to clinical measures. Back pain patients experiencing the highest levels of activity limitations were somewhat less likely to participate than those with moderate activity limitations. Recruitment for effective self-care interventions is an important issue in determining their impact on a population basis.

Psychological and behavioral factors associated with colorectal cancer screening among Ashkenazim

BACKGROUND

Psychological and behavioral factors related to annual colorectal cancer (CRC) screening were examined in a sample of Ashkenazi Jewish individuals. Identification of factors related to regular CRC screening in this population is important because of the possibility of a heightened incidence of CRC.

METHODS

Eligible participants were 171 Ashkenazi Jewish adults 40 years or older attending an educational program about breast cancer genetics. Compliance with recommended guidelines for digital rectal examination and fecal occult blood test in the past year were dependent measures. Demographic variables, family history of CRC, perceived risk, physician recommendation, and worry about cancer were independent measures.

RESULTS

Digital rectal examinations and fecal occult blood tests had been obtained in the past year by 46 and 31% of the participants, respectively. A logistic regression showed that physician recommendation was related significantly to obtaining digital rectal examinations. Physician recommendation and education were related significantly to obtaining fecal occult blood tests. Although participants with family histories of CRC perceived themselves as being at increased risk of developing CRC, and were more worried about developing colon cancer, they were no more likely to adhere to CRC screening guidelines than those without such histories.

CONCLUSIONS

Overall, compliance with recommended CRC screening was low even among high-risk individuals. Physicians play a key role in motivating people to comply with CRC screening. Physicians need to en courage all asymptomatic patients 50 years and older to be screened for CRC.

Breast cancer screening and family history among rural women in Wisconsin

This study examines the relationship between family history of breast cancer and current compliance with mammography screening guidelines. A random telephone survey of women age 40 or older living in rural Wisconsin (N = 2398) was conducted to determine mammography screening knowledge, family history of breast cancer, attitudes, intentions, physician recommendation, and compliance with screening guidelines. Compared with women without a family history of breast cancer, women with a family history were significantly more likely to demonstrate correct knowledge (p = 0. 01); express intentions in compliance with recommended screening guidelines (p < 0.001); report having been advised by a physician to obtain a mammogram (p < 0.001); and be in current compliance with mammography screening guidelines (p < 0.001). Results of simultaneous and individual logistic regression suggest that the effects of family history on compliance with screening guidelines are directly mediated through the combination of women's knowledge, women's intentions, and physician recommendation. Thus, programs to increase compliance with mammography screening guidelines should address both women and providers.

Breast and cervix cancer screening among multiethnic women: role of age, health, and source of care

OBJECTIVE

The aim of this study was to evaluate the relationships between age, health status, access to care, and breast and cervical cancer screening among multiethnic elderly and nonelderly women.

METHODS

A structured telephone survey of a quota sample of 1,420 New York City women from four Hispanic groups (Columbian, Dominican, Puerto Rican, Ecuadorian) and three black groups (U.S., Caribbean, and Haitian) was performed. Outcome measures included "ever" and "recent" self-reported use of mammography, clinical breast examination (CBE), and Pap smears. Logistic regression models assessed the predictors of screening use.

RESULTS

Having a regular source of care significantly predicted all screening use for both elderly and nonelderly, controlling for ethnicity, sociodemographics, health status, access to care, proportion of life in the United States, and cancer attitudes. Elderly women (>/=65 years) were significantly less likely to have ever had (OR = 0.79, 95% CI 0.65-0. 96) and to have recently had (OR = 0.67, 95% CI 0.57-0.79) Pap smears than younger women, controlling for the other variables; being elderly also tended to be an independent predictor of ever and recent mammography and CBE use. Interestingly, there was a trend for health status to act differently in predicting Pap smear use for the two age groups. For younger women, being in poor health increased the odds of Pap smear screening, while for elderly women, being in good health increased the odds of screening.

CONCLUSIONS

Elderly women reported being screened less than younger women; interactions between health status and age need further exploration.

Breast and cervical cancer screening: knowledge, attitudes and behavior among schoolteachers in Italy

The study explores knowledge, attitudes and behavior regarding screening for breast and cervical cancers. All female teachers in primary and secondary schools in Crotone and in Cassino (Italy) received a questionnaire on demographic and socioeconomic characteristics, clinical history, knowledge, behavior and attitudes about breast and cervical cancer and related screening procedures. A response rate of 65% was achieved. Knowledge on effectiveness of mammography and pap test in finding related cancers was widely spread in the sample. Only about 30% and 50% had respectively undergone their last mammogram and pap test according to the recommended time interval. Having been examined by a physician in the previous year and having had a screening CBE or a screening pap smear in the past three years were significantly more likely in women who underwent mammography for screening purposes in the past two years. Pap smear in the previous three years was significantly more likely in women in their forties, with a higher family income and in those who had been examined by a physician in the previous year. The results strongly recommend continued emphasis of physicians on education of women regarding mammography and pap smear.

Cigarette smoking, alcohol consumption, and screening mammography among women ages 50 and older

BACKGROUND

The associations among cigarette smoking and alcohol consumption with recent screening mammograms were evaluated among women ages 50 years and older.

METHODS

The sample included 946 white and African-American women ages 50 years and older from the 1995 Maryland Behavioral Risk Factor Survey. Bivariate and logistic regression analyses were performed to evaluate the associations between current cigarette smoking and alcohol consumption in the past month (none, 1-7 drinks, >7 drinks) with obtaining a screening mammogram in the past 2 years (recent mammogram), controlling for sociodemographic and health variables.

RESULTS

Seventy-eight percent of respondents had recent mammograms, 15% smoked cigarettes, 18% reported 1-7 drinks, and 12% reported >7 drinks in the past month. Smokers had lower mammography rates than nonsmokers (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.30-0.75). Women who drank alcoholic beverages had higher mammography rates than nondrinkers (OR = 1.37, 95% CI = 1.03-1.83). Smokers had the lowest mammography rates, regardless of their consumption of alcohol. An interaction was observed among white but not African-American women: nonsmokers who consumed moderate amounts of alcohol (1-7 drinks) had the highest mammography rates in this subgroup.

CONCLUSIONS

To reduce breast cancer mortality, it is important to increase screening mammography among all women over age 50 and especially among smokers and the oldest women.

Chronic disease as a barrier to breast and cervical cancer screening

OBJECTIVE

To assess whether chronic disease is a barrier to screening for breast and cervical cancer.

DESIGN

Structured medical record review of a retrospectively defined cohort.

SETTING

Two primary care clinics of one academic medical center.

PATIENTS

All eligible women at least 43 years of age seen during a 6-month period in each of the two study clinics (n = 1,764).

MEASUREMENTS AND MAIN RESULTS

Study outcomes were whether women had been screened: for mammogram, every 2 years for ages 50-74; for clinical breast examinations (CBEs), every year for all ages; and for Pap smears, every 3 years for ages under 65. An index of comorbidity, adapted from Charlson (0 for no disease, maximum index of 8 among our patients), and specific chronic diseases were the main independent variables. Demographics, clinic use, insurance, and clinical data were covariates. In the appropriate age groups for each test, 58% of women had a mammogram, 43% had a CBE, and 66% had a Pap smear. As comorbidity increased, screening rates decreased (p < .05 for linear trend). After adjustment, each unit increase in the comorbidity index corresponded to a 17% decrease in the likelihood of mammography (p = .005), 13% decrease in CBE (p = .006), and 20% decrease in Pap smears (p = .002). The rate of mammography in women with stable angina was only two fifths of that in women without.

CONCLUSIONS

Among women who sought outpatient care, screening rates decreased as comorbidity increased. Whether clinicians and patients are making appropriate decisions about screening is not known.

Psychological predictors of attendance at annual breast screening examinations

This retrospective analysis of psychological predictors of attendance studied the women from the annual screening arm of the United Kingdom Coordinating Committee on Cancer Research (UKCCCR) trial of annual screening mammography for the early detection of breast cancer. Some women attended screening at the first invitation in year 1 (attenders), others did not attend for screening at any time (non-attenders), whereas a third group delayed attending until year 2 (ambivalent attenders). A total of 147 women were recruited to the study: 80 attenders, 28 non-attenders and 39 ambivalent attenders. It proved extremely difficult to contact non-attenders to take part in the study. Non-attenders were significantly more depressed on the Hospital Anxiety and Depression Scale; had experienced more miscarriages, stillbirths or terminations of pregnancy; were less knowledgeable about mammography; and were displeased to have received an invitation to screening. Whereas non-attenders are unlikely ever to attend breast screening because of their long-standing attitudes and preferred coping styles, ambivalent attenders may become more amenable to screening with the passage of time. In this study such women were persuaded to attend in year 2 with a simple, cost-effective intervention: an additional invitation letter after a year.

Neuroblastoma screening in the United States: results of the Texas Outreach Program for neuroblastoma screening

BACKGROUND

Mass screening of infants for neuroblastoma began in Japan after studies suggested that survival rates could be improved by early detection. This study was initiated in 1991 to test the methodology and feasibility of screening for neuroblastoma within the U. S. health care system.

METHODS

Infants ages 5-10 months (mean age, 9 months, 25 days) who were born in Texas were screened for neuroblastoma. An enzyme-linked immunoadsorbent assay (ELISA) for homovanillic acid (HVA) and vanillylmandelic acid (VMA) used to quantify the HVA and VMA was performed on urine extracted from specimens dried on filter paper. Infants were recruited to participate in the study by several methods, and the effectiveness of each method was determined by calculating compliance rates.

RESULTS

Between February 1991 and June 1994 a total of 14,046 infants were recruited to participate in neuroblastoma screening. Neuroblastoma was detected in 2 children for an incidence rate of 1 in 7023. A total of 291,158 screening kits were distributed to the parents of these infants, resulting in an overall compliance rate of only 4.8%. Compliance rates varied by method of distribution of the test kits: Houston Women, Infants, and Children (WIC) clinic (53%), volunteers (31%), Rio Grande Valley WIC clinics (14.5%), the patient's private physician (9.9%), and by mail (4.7%).

CONCLUSIONS

Early detection of neuroblastoma in infants ages 5-10 months was achieved using ELISA. Compliance rates were poor, but clinics with a preventive health focus, such as the WIC clinics, achieved higher compliance rates than did private physicians.

Prostate cancer screening in the midst of controversy: Canadian men's knowledge, beliefs, utilization, and future intentions

Despite controversy about prostate cancer screening, administrative data show that the use of prostate specific antigen (PSA) testing in Canada has increased. This study sought to determine awareness and knowledge of prostate cancer and screening, use to date, and future intentions to have a digital rectal examination (DRE) and PSA test among Canadian men aged 40 and over. Data were collected through a Canada-wide cross-sectional random digit dial telephone survey of 629 men. Awareness of DRE and PSA, use to date, and future intended use varied with age and education. Although only 9% of respondents had had PSA testing for screening, future intentions to undergo this test were higher than use to date. Knowledge of prostate cancer and screening controversies was low, and men received more information about PSA from the media than from doctors. Men would, therefore, benefit from age- and education-specific information regarding the factors to consider in making an informed choice about prostate cancer screening.