Nationwide cross-sectional adherence to mammography screening guidelines: national behavioral risk factor surveillance system survey results

Biomarkers in Cancer Screening: Promises and Challenges in Cancer Early Detection

Cancer continues to be one the leading causes of death worldwide, primarily due to the late detection of the disease. Cancers detected at early stages may enable more effective intervention of the disease. However, most cancers lack well-established screening procedures except for cancers with an established early asymptomatic phase and clinically validated screening tests. There is a critical need to identify and develop assays/tools in conjunction with imaging approaches for precise screening and detection of the aggressive disease at an early stage. New developments in molecular cancer screening and early detection include germline testing, synthetic biomarkers, and liquid biopsy approaches.

A pragmatic randomized clinical trial of multilevel interventions to improve adherence to lung cancer screening (The Larch Study): Study protocol

BACKGROUND

In real-world settings, low adherence to lung cancer screening (LCS) diminishes population-level benefits of reducing lung cancer mortality. We describe the Larch Study protocol, which tests the effectiveness of two patient-centered interventions (Patient Voices Video and Stepped Reminders) designed to address barriers and improve annual LCS adherence.

METHODS

The Larch Study is a pragmatic randomized clinical trial conducted within Kaiser Permanente Washington. Eligible patients (target n = 1606) are aged 50-78 years with an index low-dose CT (LDCT) of the chest with negative or benign findings. With a 2 × 2 factorial-design, patients are individually randomized to 1 of 4 arms: video only, reminders only, both video and reminders, or usual care. The Patient Voices video addresses patient education needs by normalizing LCS, reminding patients when LCS is due, and encouraging social support. Stepped Reminders prompts primary care physicians to order patient's repeat screening LDCT and patients to schedule their scan. Intervention delivery is embedded within routine healthcare, facilitated by shared electronic health record components. Primary outcome is adherence to national LCS clinical guidelines, defined as repeat LDCT within 9-15 months. Patient-reported outcomes are measured via survey (knowledge of LCS, perception of stigma) approximately 8 weeks after index LDCT. Our mixed-methods formative evaluation includes process data, collected during the trial, and interviews with trial participants and stakeholders.

DISCUSSION

Results will fill an important scientific gap on multilevel interventions to increase annual LCS adherence and provide opportunities for spread and scale to other healthcare settings.

REGISTRATION

Trial is registered at clinicaltrials.gov (#NCT05747443).

From Incidence to Intervention: A Comprehensive Look at Breast Cancer in South Africa

The formidable impact of breast cancer extends globally, with South Africa facing pronounced challenges, including significant disparities in breast cancer screening, treatment and survival along ethnic and socioeconomic lines. Over the last two decades, breast cancer incidence has increased and now accounts for a substantial portion of cancers in women. Ethnic disparities in terms of screening, incidence and survival exacerbate the issue, leading to delayed diagnosis among Black patients and highlighting healthcare inequities. These concerning trends underscore the urgency of enhancing breast cancer screening while mitigating treatment delays, although obstacles within the healthcare system impede progress. The intersection of breast cancer and human immunodeficiency virus (HIV) further complicates matters and particularly affects the Black population. Tackling the aforementioned disparities in breast cancer in South Africa mandates a multifaceted strategy. Robust screening efforts, particularly those targeting marginalised communities, are crucial for early detection. Concurrently, expedited treatment initiation is imperative. Addressing HIV-related complexities requires tailored interventions to ensure effective care. These multifaceted disparities require pan African research and cooperation as well as tailored interventions to enhance breast cancer care within the African region.

Cancer Screening Experiences of Black Breast and Ovarian Cancer Patients and Family Members

Black women experience disproportionate rates of advanced breast cancer diagnoses and mortality. Mammography is a proven and effective tool in early breast cancer detection and impacts patient outcomes. We interviewed Black women with a personal or family history of breast and/or ovarian cancer to understand their screening experiences and views. N = 61 individuals completed an interview. Interview transcripts were qualitatively analyzed for themes regarding clinical experiences, guideline adherence, and family sharing specific to Black women and their families. Most participants were college educated with active health insurance. Women in this cohort were knowledgeable about the benefits of mammography and described few barriers to adhering to annual mammogram guidelines. Some with first-degree family history were frustrated at insurance barriers to mammography before the age of 40. Participants were generally comfortable encouraging family and friends to receive mammograms and expressed a desire for a similar screening tool for ovarian cancer. However, they expressed concern that factors such as screening awareness and education, lack of insurance coverage, and other systematic barriers might prevent other Black women from receiving regular screening. Black women in this cohort reported high adherence to mammography guidelines, but expressed concern about cultural and financial barriers that may impact cancer screening access in the population more generally and contribute to disparities. Participants noted the importance of frank and open discussions of breast cancer screening in their families and community as a means of improving awareness.

Screening Mammography Utilization in the United States

Breast cancer is the second leading cause of cancer mortality in adult women in the United States. Screening mammography reduces breast cancer mortality between 22% and 48%; however, screening mammography remains underutilized. Screening mammography utilization data are available from insurance claims, electronic medical records, and patient self-report via surveys, and each data source has unique benefits and challenges. Numerous barriers exist that adversely affect the use of screening mammography in the United States. This article will review screening mammography utilization in the United States, explore factors that impact utilization, and briefly discuss strategies to improve utilization.

Screening Mammography Utilization Among Women With Visual or Hearing Impairment: Results From the 2019 NHIS

To evaluate for differences in breast cancer screening among women with visual or hearing impairment, the 2019 National Health Interview Survey was analyzed for mammography use in the past 2 years among women age 50-74, adjusting for demographic characteristics, health care access, and comorbidities. Visual impairment was independently associated with decreased likelihood of recent mammography (odds ratio [OR], 0.71; 95% CI, 0.59-0.85; p < .001). Hearing impairment was not independently associated with mammography use (OR, 0.91; 95% CI, 0.75-1.11; p = .37).

Association of time intervals in cancer screenings and older participants' characteristics, in a nationally representative sample

INTRODUCTION

Health agencies and guidelines have proposed various recommendations regarding breast and prostate cancer screening intervals for older adults. However, there is limited data about factors that could impact older individuals' adherence to these guideline-based intervals. This study emphasized the differences in screening rates between men and women undergoing screening for breast (mammogram) and prostate (prostate-specific antigen [PSA] test) cancer. It also investigated the socio-demographic and emotional factors associated with screening time intervals.

MATERIALS AND METHODS

This cross-sectional design study used data from the National Social Life Health and Aging Project Wave 3 (NSHAP-W3, 2015). The outcome measures were screening time intervals (PSA test or mammogram). Individuals were asked, "About how long has it been since you last had a screening?" Response categories ranged from 1 = within the past year to 5 = never. Differences in screening time intervals were evaluated and displayed by age group (PSA vs. mammogram). The association between the outcome measures and participants' characteristics was evaluated via ordinal logistic regression.

RESULTS

There were 2320 participants included: 52% women and 48% men. They had a mean age of 66.9 years old, were mostly White (74%) and college graduates (68%). The average time interval between screenings was greater for PSA testing than mammography (mean [M] = 2.28 vs. M = 1.89, p < 0.001). The middle age groups (PSA: 60-79 and mammogram: 65-74), had significantly more frequent screenings compared to the youngest group (50-54). In contrast, older (80+) individuals did not display shorter screening time intervals compared to the youngest group. Furthermore, shorter time intervals between screenings were associated with higher household income (mammogram: odds ratio [OR] = 0.804; PSA: OR = 0.785, p < 0.05), African American descent (mammogram: OR = 0.458, p < 0.001), and higher frequency of physical activity (PSA: OR = 0.921, p = 0.030). Lastly, women who responded "yes" to skipping care due to lack of insurance reported longer periods between mammograms (OR = 1.784, p = 0.002).

DISCUSSION

Findings from this real-world US population representative database highlight the role of age, income, and insurance in the timing between screenings; participants aged between 60 and 79 years old, African American women, and physically active men are more likely to pursue earlier screening. These results emphasize the importance of socioeconomic and lifestyle factors when seeking to impact screening timing.

Impact of early detection on cancer curability: A modified Delphi panel study

Expert consensus on the potential benefits of early cancer detection does not exist for most cancer types. We convened 10 practicing oncologists using a RAND/UCLA modified Delphi panel to evaluate which of 20 solid tumors, representing >40 American Joint Committee on Cancer (AJCC)-identified cancer types and 80% of total cancer incidence, would receive potential clinical benefits from early detection. Pre-meeting, experts estimated how long cancers take to progress and rated the current curability and benefit (improvement in curability) of an annual hypothetical multi-cancer screening blood test. Post-meeting, experts rerated all questions. Cancers had varying estimates of the potential benefit of early cancer detection depending on estimates of their curability and progression by stage. Cancers rated as progressing quickly and being curable in earlier stages (stomach, esophagus, lung, urothelial tract, melanoma, ovary, sarcoma, bladder, cervix, breast, colon/rectum, kidney, uterus, anus, head and neck) were estimated to be most likely to benefit from a hypothetical screening blood test. Cancer types rated as progressing quickly but having comparatively lower cure rates in earlier stages (liver/intrahepatic bile duct, gallbladder, pancreas) were estimated to have medium likelihood of benefit from a hypothetical screening blood test. Cancer types rated as progressing more slowly and having higher curability regardless of stage (prostate, thyroid) were estimated to have limited likelihood of benefit from a hypothetical screening blood test. The panel concluded most solid tumors have a likelihood of benefit from early detection. Even among difficult-to-treat cancers (e.g., pancreas, liver/intrahepatic bile duct, gallbladder), early-stage detection was believed to be beneficial. Based on the panel consensus, broad coverage of cancers by screening blood tests would deliver the greatest potential benefits to patients.

Impact of Health Care-Associated Cost Concerns on Mammography Utilization: Cross-Sectional Survey Results From the National Health Interview Survey

PURPOSE

Health care-related cost concerns and financial toxicity are increasingly recognized barriers along the breast cancer care continuum. The purpose of this study was to evaluate the association between patient-reported cost concerns and screening mammography utilization.

METHODS

Survey participants aged 40 to 74 years from the 2018 National Health Interview Survey without personal history of breast cancer were included (response rate: 64%). Respondents were queried if they had experienced specific access-related health care barriers. Multiple variable logistic regression analyses were performed to evaluate the association between barriers to care and patient-reported screening mammography utilization.

RESULTS

Of survey respondents, 7,511 women were included. Of this group, 68.9% reported receiving a screening mammogram within the last 2 years and 52.2% reported receiving a screening mammogram within the last year. Of all survey respondents, 48.4% reported worry paying medical bills. Patients who reported worry about paying medical bills (odds ratio [OR] 0.86; 95% confidence interval [CI]: 0.76-0.97; P = .01), challenges affording dental care (OR 0.65; 95% CI: 0.54-0.77; P < .01), and challenges affording eyeglasses (OR 0.67; 95% CI: 0.54-0.84; P < .01) were less likely to report screening mammography use than their respective counterparts. Patients who skipped medication doses (OR 0.69; 95% CI: 0.52-0.91; P < .01), took less medication, (OR 0.63; 95% CI: 0.48-0.82; P < .01), and delayed filling prescriptions (OR 0.71; 95% CI: 0.56-0.90; P < .01) to save money were also less likely to report receiving mammography screening.

CONCLUSION

Patient-reported cost-related barriers are associated with decreased utilization of routine mammography.

Cumulative Advanced Breast Cancer Risk Prediction Model Developed in a Screening Mammography Population

BACKGROUND

Estimating advanced breast cancer risk in women undergoing annual or biennial mammography could identify women who may benefit from less or more intensive screening. We developed an actionable model to predict cumulative 6-year advanced cancer (prognostic pathologic stage II or higher) risk according to screening interval.

METHODS

We included 931 186 women aged 40-74 years in the Breast Cancer Surveillance Consortium undergoing 2 542 382 annual (prior mammogram within 11-18 months) or 752 049 biennial (prior within 19-30 months) screening mammograms. The prediction model includes age, race and ethnicity, body mass index, breast density, family history of breast cancer, and prior breast biopsy subdivided by menopausal status and screening interval. We used fivefold cross-validation to internally validate model performance. We defined higher than 95th percentile as high risk (>0.658%), higher than 75th percentile to 95th or less percentile as intermediate risk (0.380%-0.658%), and 75th or less percentile as low to average risk (<0.380%).

RESULTS

Obesity, high breast density, and proliferative disease with atypia were strongly associated with advanced cancer. The model is well calibrated and has an area under the receiver operating characteristics curve of 0.682 (95% confidence interval = 0.670 to 0.694). Based on women's predicted advanced cancer risk under annual and biennial screening, 69.1% had low or average risk regardless of screening interval, 12.4% intermediate risk with biennial screening and average risk with annual screening, and 17.4% intermediate or high risk regardless of screening interval.

CONCLUSION

Most women have low or average advanced cancer risk and can undergo biennial screening. Intermediate-risk women may consider annual screening, and high-risk women may consider supplemental imaging in addition to annual screening.

Report from an NCI Roundtable: Cancer Prevention in Primary Care

The Division of Cancer Prevention in the NCI sponsored a Roundtable with primary care providers (PCP) to determine barriers for integrating cancer prevention within primary care and discuss potential opportunities to overcome these barriers. The goals were to: (i) assess the cancer risk assessment tools available to PCPs; (ii) gather information on use of cancer prevention resources; and (iii) understand the needs of PCPs to facilitate the implementation of cancer prevention interventions beyond routine screening and interventions. The Roundtable discussion focused on challenges and potential research opportunities related to: (i) cancer risk assessment and management of high-risk individuals; (ii) cancer prevention interventions for risk reduction; (iii) electronic health records/electronic medical records; and (iv) patient engagement and information dissemination. Time constraints and inconsistent/evolving clinical guidelines are major barriers to effective implementation of cancer prevention within primary care. Social determinants of health are important factors that influence patients' adoption of recommended preventive interventions. Research is needed to determine the best means for implementation of cancer prevention across various communities and clinical settings. Additional studies are needed to develop tools that can help providers collect clinical data that can enable them to assess patients' cancer risk and implement appropriate preventive interventions.

Cost-Effectiveness of Screening Mammography Beyond Age 75 Years : A Cost-Effectiveness Analysis

BACKGROUND

The cost-effectiveness of screening mammography beyond age 75 years remains unclear.

OBJECTIVE

To estimate benefits, harms, and cost-effectiveness of extending mammography to age 80, 85, or 90 years according to comorbidity burden.

DESIGN

Markov microsimulation model.

DATA SOURCES

SEER (Surveillance, Epidemiology, and End Results) program and Breast Cancer Surveillance Consortium.

TARGET POPULATION

U.S. women aged 65 to 90 years in groups defined by Charlson comorbidity score (CCS).

TIME HORIZON

Lifetime.

PERSPECTIVE

National health payer.

INTERVENTION

Screening mammography to age 75, 80, 85, or 90 years.

OUTCOME MEASURES

Breast cancer death, survival, and costs.

RESULTS OF BASE-CASE ANALYSIS

Extending biennial mammography from age 75 to 80 years averted 1.7, 1.4, and 1.0 breast cancer deaths and increased days of life gained by 5.8, 4.2, and 2.7 days per 1000 women for comorbidity scores of 0, 1, and 2, respectively. Annual mammography beyond age 75 years was not cost-effective, but extending biennial mammography to age 80 years was ($54 000, $65 000, and $85 000 per quality-adjusted life-year [QALY] gained for women with CCSs of 0, 1, and ≥2, respectively). Overdiagnosis cases were double the number of deaths averted from breast cancer.

RESULTS OF SENSITIVITY ANALYSIS

Costs per QALY gained were sensitive to changes in invasive cancer incidence and shift of breast cancer stage with screening mammography.

LIMITATION

No randomized controlled trials of screening mammography beyond age 75 years are available to provide model parameter inputs.

CONCLUSION

Although annual mammography is not cost-effective, biennial screening mammography to age 80 years is; however, the absolute number of deaths averted is small, especially for women with comorbidities. Women considering screening beyond age 75 years should weigh the potential harms of overdiagnosis versus the potential benefit of averting death from breast cancer.

PRIMARY FUNDING SOURCE

National Cancer Institute and National Institutes of Health.

Increasing referral of at-risk women for genetic counseling and BRCA testing using a screening tool in a community breast imaging center

BACKGROUND

Genetic evaluation and testing for hereditary breast and ovarian cancer (HBOC) remain suboptimal. The authors evaluated the feasibility of using a screening tool at a breast imaging center to increase HBOC assessment referrals.

METHODS

A brief questionnaire based on the National Comprehensive Cancer Network HBOC genetic counseling referral guidelines was developed and added to the standard intake forms of patients undergoing mammography at a community breast imaging center from 2012 through 2015. Patients who met the criteria in the guidelines were referred for genetic counseling.

RESULTS

A total of 34,851 patients were screened during the study period, and 1246 (4%) patients were found to be eligible for referral; 245 of these patients made a genetic counseling appointment, and 142 patients received genetic counseling. Forty patients (28%) had a personal history of breast cancer but were not previously tested. Following counseling, 105 patients were tested for BRCA1/2. Eight patients (8%) tested positive for a pathogenic mutation and nine (9%) had a variant of unknown significance. Although they tested negative, many patients met the criteria to add breast magnetic resonance imaging to their screening due to greater than 20% lifetime breast cancer risk based on their family cancer history. This study led to improved clinical risk management in 67% of the patients who underwent genetic counseling.

CONCLUSIONS

This study shows that large-scale screening of patients for HBOC syndromes at time of breast imaging is practical and highly feasible. The screening tool identified women with actionable BRCA1/2 mutations and mutation-negative but high-risk women, leading to significant changes in their risk management; these women would otherwise have been missed.

LAY SUMMARY

Hereditary breast and ovarian cancer (HBOC) caused by pathogenic mutations in breast cancer genes (BRCA1/BRCA2) increase an individual's lifetime risk of getting HBOC. Identifying these high-risk individuals and using proven preventive clinical risk management strategies can significantly reduce their lifetime risk of HBOC. Using an innovative family cancer history questionnaire, 34,000 women were screened at a community breast imaging center, and genetic counseling and testing were provided to eligible women from the screening. Several women at high risk for HBOC were identified and this led to positive clinical risk management changes. These women would have been missed if not for intervention.

Differences in Breast and Colorectal Cancer Screening Adherence Among Women Residing in Urban and Rural Communities in the United States

Importance

Screening for breast and colorectal cancer has resulted in reductions in mortality; however, questions remain regarding how these interventions are being diffused to all segments of the population. If an intervention is less amenable to diffusion, it could be associated with disparities in mortality rates, especially in rural vs urban areas.

Objectives

To compare the prevalence of breast and colorectal cancer screening adherence and to identify factors associated with screening adherence among women residing in rural vs urban areas in the United States.

Design, Setting, and Participants

This population-based cross-sectional study of women aged 50 to 75 years in 11 states was conducted from 2017 to 2020.

Main Outcomes and Measures

Adherence to cancer screening based on the US Preventative Services Task Force guidelines. For breast cancer screening, women who had mammograms in the past 2 years were considered adherent. For colorectal cancer screening, women who had (1) a stool test in the past year, (2) a colonoscopy in the past 10 years, or (3) a sigmoidoscopy in the past 5 years were considered adherent. Rural status was coded using Rural Urban Continuum Codes, and other variables were assessed to identify factors associated with screening.

Results

The overall sample of 2897 women included 1090 (38.4%) rural residents; 2393 (83.5%) non-Hispanic White women; 263 (9.2%) non-Hispanic Black women; 68 (2.4%) Hispanic women; 1629 women (56.2%) aged 50 to 64 years; and 712 women (24.8%) with a high school education or less. Women residing in urban areas were significantly more likely to be adherent to colorectal cancer screening compared with women residing in rural areas (1429 [82%] vs 848 [78%]; P = .01), whereas the groups were equally likely to be adherent to breast cancer screening (1347 [81%] vs 830 [81%]; P = .78). Multivariable mixed-effects logistic regression analyses confirmed that rural residence was associated with lower odds of being adherent to colorectal cancer screening (odds ratio [OR], 0.81; 95% CI, 0.66-0.99, P = .047). Non-Hispanic Black race was associated with adherence to breast cancer screening guidelines (OR, 2.85; 95% CI, 1.78-4.56; P < .001) but not colorectal cancer screening guidelines.

Conclusions and Relevance

In this cross-sectional study, women residing in rural areas were less likely to be adherent to colorectal cancer screening guidelines but were similarly adherent to breast cancer screening. This suggests that colorectal cancer screening, a more recent intervention, may not be as available in rural areas as breast cancer screening, ie, colorectal screening has lower amenability.

Adherence to Screening Among American Indian Women Accessing a Mobile Mammography Unit

RATIONALE AND OBJECTIVES

Although screening mammography is essential to reducing breast cancer morbidity and mortality, barriers exist especially among underrepresented minority groups. There are few studies of mammogram screening among American Indian women, many of whom reside in rural areas where screening access is challenging. A mobile mammography unit served 24 Indian Health Service clinics during 2013-17. Screening mammography adherence was evaluated.

MATERIALS AND METHODS

Among mobile unit women, 'adherence to screening' was determined by the date of the most recent prior mammogram. Those having a prior mammogram 9-27 months ago were classified as 'adherent to screening'. Comparison screening data were obtained from the American College of Radiology National Mammography Database, consisting of screening cases occurring in year 2015. Additionally, among mobile unit women 'continued adherence to screening' was determined, defined as at least one repeat screening at the mobile unit within the subsequent 9-27 months after a screening there.

RESULTS

Among 1,615 mobile unit women, 624 (38.6%) were adherent to screening. Among 2,509,826 National Mammography Database women, 1,481,021 (59.0%) were adherent to screening. (p<0.0001) The prevalence of a >27-month interval between mammograms was 3.13 (95% CI 2.91-3.36) times greater among mobile unit women than National Mammography Database women. 'Continued adherence to screening' of mobile unit women was 428/1194 (35.9%).

CONCLUSION

Adherence to screening and continued adherence to screening were low among mobile unit women and time interval between screenings was longer than National Mammography Database women. Factors to improve screening adherence among these underserved women should be determined.

Clinical validation of a targeted methylation-based multi-cancer early detection test using an independent validation set

BACKGROUND

A multi-cancer early detection (MCED) test used to complement existing screening could increase the number of cancers detected through population screening, potentially improving clinical outcomes. The Circulating Cell-free Genome Atlas study (CCGA; NCT02889978) was a prospective, case-controlled, observational study and demonstrated that a blood-based MCED test utilizing cell-free DNA (cfDNA) sequencing in combination with machine learning could detect cancer signals across multiple cancer types and predict cancer signal origin (CSO) with high accuracy. The objective of this third and final CCGA substudy was to validate an MCED test version further refined for use as a screening tool.

PATIENTS AND METHODS

This pre-specified substudy included 4077 participants in an independent validation set (cancer: n = 2823; non-cancer: n = 1254, non-cancer status confirmed at year-one follow-up). Specificity, sensitivity, and CSO prediction accuracy were measured.

RESULTS

Specificity for cancer signal detection was 99.5% [95% confidence interval (CI): 99.0% to 99.8%]. Overall sensitivity for cancer signal detection was 51.5% (49.6% to 53.3%); sensitivity increased with stage [stage I: 16.8% (14.5% to 19.5%), stage II: 40.4% (36.8% to 44.1%), stage III: 77.0% (73.4% to 80.3%), stage IV: 90.1% (87.5% to 92.2%)]. Stage I-III sensitivity was 67.6% (64.4% to 70.6%) in 12 pre-specified cancers that account for approximately two-thirds of annual USA cancer deaths and was 40.7% (38.7% to 42.9%) in all cancers. Cancer signals were detected across >50 cancer types. Overall accuracy of CSO prediction in true positives was 88.7% (87.0% to 90.2%).

CONCLUSION

In this pre-specified, large-scale, clinical validation substudy, the MCED test demonstrated high specificity and accuracy of CSO prediction and detected cancer signals across a wide diversity of cancers. These results support the feasibility of this blood-based MCED test as a complement to existing single-cancer screening tests.

CLINICAL TRIAL NUMBER

NCT02889978.

The ties that bind: Cancer history, communication, and screening intention associations among diverse families

OBJECTIVE

Breast and cervical cancers are screen-detectable; yet, challenges exist with ensuring uptake of mammography and Pap smear. Family, a central factor in developing knowledge to carry out health promotion behaviors, may be an asset to improving intention to screen among non-adherent women from underrepresented minority groups. We explored familial cancer; communication; and breast and cervical screening intention among non-adherent Black, Latina, and Arab women in the United States who participated in a randomized controlled trial of the Kin KeeperSM Cancer Prevention Intervention study. The intervention was a culturally-targeted breast and cervical cancer literacy tool for Black, Latina, and Arab women, consisting of two family-focused education sessions on the cancers, their screening guidelines, and risk-reducing health-related behaviors.

METHODS

For this secondary analysis, we assessed family cancer history, family communication, and screening intention for breast and cervical cancer in age-eligible, non-adherent participants. Descriptive statistics examined sample characteristics of the intervention and control groups. Odds ratios were estimated from logistic regression modeling to assess the intervention and sample characteristic effects on screening intention.

RESULTS

Of the 516 participants, 123 and 98 were non-adherent to breast and cervical cancer screening, respectively. The intervention (OR = 1.95 for mammography; OR = 1.62 for Pap smear) and highly communicative (OR = 2.57 for mammography; OR = 3.68 for Pap smear) families reported greater screening intention. Family history of cancer only increased screening intention for mammography (OR = 2.25).

CONCLUSION

Family-focused approaches supporting communication may increase breast and cervical cancer screening intention among non-adherent, underrepresented minority groups.

The Prevalence and Associated Factors of Cancer Screening Uptake Among a National Population-Based Sample of Adults in Marshall Islands

Background:

The study aimed to estimate the prevalence and associated factors of cancer screening among men and women in the general population in Marshall Islands.

Methods:

The national cross-sectional sub-study population consisted of 2,813 persons aged 21-75 years (Median = 37.4 years) from the “2017/2018 Marshall Islands STEPS survey”. Information about cancer screening uptake included Pap smear or Vaginal Inspection with Acetic Acid (=VIA), clinical breast examination, mammography, faecal occult blood test (FOBT), and colonoscopy.

Results:

The prevalence of past 2 years mammography screening was 21.7% among women aged 50-74 years, past year CBE 15.9% among women aged 40 years and older, past 3 years Pap smear or VIA 32.6% among women 21-65 years, past year FOBT 21.8% among women and 22.3% among men aged 50-75 years, and past 10 years colonoscopy 9.1% among women and 7.3% among men aged 50-75 years. In adjusted logistic regression, cholesterol screening (AOR: 1.91, 95% CI: 1.07-3.41) was associated with past 2 years mammography screening among women aged 50-74 years. Blood pressure screening (AOR: 2.39, 95% CI: 1.71-3.35), glucose screening (AOR: 1.59, 95% CI: 1.13-2.23), dental visit in the past year (AOR: 1.51, 95% CI: 1.17, 1.96), binge drinking (AOR: 1.88, 95% CI: 1.07-3.30), and 2-3 servings of fruit and vegetable consumption a day (AOR: 1.42, 95% CI: 1.03-1.95) were positively and high physical activity (30 days a month) (AOR: 0.56, 95% CI: 0.41-0.76) was negatively associated with Pap smear or VIA screening among women aged 21-65 years. Higher education (AOR: 2.58, 95% CI: 1.02-6.58), and cholesterol screening (AOR: 2.87, 95% CI: 1.48-5.59), were positively and current smoking (AOR: 0.09, 95% CI: 0.01-0.65) was negatively associated with past 10 years colonoscopy uptake among 50-75 year-olds.

Conclusion:

The study showed a low cancer screening uptake, and several factors were identified that can assist in promoting cancer screening in Marshall Islands.

Bone health assessment via digital wrist tomosynthesis in the mammography setting

Bone fractures attributable to osteoporosis are a significant problem. Though preventative treatment options are available for individuals who are at risk of a fracture, a substantial number of these individuals are not identified due to lack of adherence to bone screening recommendations. The issue is further complicated as standard diagnosis of osteoporosis is based on bone mineral density (BMD) derived from dual energy x-ray absorptiometry (DXA), which, while helpful in identifying many at risk, is limited in fully predicting risk of fracture. It is reasonable to expect that bone screening would become more prevalent and efficacious if offered in coordination with digital breast tomosynthesis (DBT) exams, provided that osteoporosis can be assessed using a DBT modality. Therefore, the objective of the current study was to explore the feasibility of using digital tomosynthesis imaging in a mammography setting. To this end, we measured density, cortical thickness and microstructural properties of the wrist bone, correlated these to reference measurements from microcomputed tomography and DXA, demonstrated the application in vivo in a small group of participants, and determined the repeatability of the measurements. We found that measurements from digital wrist tomosynthesis (DWT) imaging with a DBT scanner were highly repeatable ex vivo (error = 0.05%-9.62%) and in vivo (error = 0.06%-10.2%). In ex vivo trials, DWT derived BMDs were strongly correlated with reference measurements (R = 0.841-0.980), as were cortical thickness measured at lateral and medial cortices (R = 0.991 and R = 0.959, respectively) and the majority of microstructural measures (R = 0.736-0.991). The measurements were quick and tolerated by human patients with no discomfort, and appeared to be different between young and old participants in a preliminary comparison. In conclusion, DWT is feasible in a mammography setting, and informative on bone mass, cortical thickness, and microstructural qualities that are known to deteriorate in osteoporosis. To our knowledge, this study represents the first application of DBT for imaging bone. Future clinical studies are needed to further establish the efficacy for diagnosing osteoporosis and predicting risk of fragility fracture using DWT.

Lung cancer screening eligibility and use with low-dose computed tomography: Results from the 2018 Behavioral Risk Factor Surveillance System cross-sectional survey

BACKGROUND

In randomized controlled trials, lung cancer screening with low-dose chest computed tomography (LCS) has been reported to reduce lung cancer mortality. Although initial studies suggested that only approximately 5% of eligible patients have undergone LCS, recent studies have indicated that use of LCS may be increasing nationwide. The objective of the current study was to estimate recent LCS use using cross-sectional survey data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey.

METHODS

The BRFSS is a nationally representative, cross-sectional telephone survey of adults in the United States (response rate of approximately 50%). The 2018 BRFSS survey included questions regarding LCS eligibility and use in 8 states. The primary outcome was the percentage of participants (aged 55-79 years with a smoking history of >30 pack-years) who reported undergoing LCS. Logistic regression analyses evaluated the association between LCS use and sociodemographic characteristics, adjusted for potential confounders and accounting for complex survey design elements.

RESULTS

A total of 26,910 participants were included, 9.9% of whom were eligible for LCS (95% CI, 8.8%-10.6%). Of the eligible patients, 19.2% reported undergoing LCS (95% CI, 14.0%-24.4%). Approximately 16.4% of current smokers were eligible for LCS (95% CI, 14.2%-18.6%). In our multiple variable analyses of eligible patients, age, sex, marital status, current smoking status, and race were not found to be associated with statistically significant differences in reported LCS (P > .05). Retired patients, patients with personal physicians, and patients who did not complete a high school education were more likely to report receiving LCS (P < .05).

CONCLUSIONS

Compared with previously published studies, the results of the current study suggested that LCS use is increasing. However, LCS use remains low (19%) among eligible participants.

Potential of using mammography screening appointments to identify high-risk women: cross sectional survey results from the national health interview survey

PURPOSE

Mammography screening encounters may represent ideal opportunities to identify high-risk women for risk-based screening. During mammography appointments, radiology practices evaluate breast density and ascertain known breast cancer risk factors. Our purpose was to evaluate the potential for mammographic screening encounters to identify high-risk women by estimating the (1) proportion of high-risk women who report that they have undergone mammographic screening and the (2) proportion of high-risk women who receive recommendations for breast MRI screening.

METHODS

Women ages 30-85 without breast cancer histories were included from the 2015 National Health Interview Survey, a nationally representative cross-sectional household survey (response rate 80%). Breast Cancer Risk Assessment Tool was used to determine high-risk (lifetime risk>20%). Among high-risk women, primary outcome was proportion reporting mammography screening, secondary outcome was receipt of a breast MRI recommendation after recent mammogram, accounting for complex survey design.

RESULTS

14,958 women were included. 1.0% were high-risk of whom: 91.9% ever had a mammogram, 68.0% had a mammogram within the last year, 81.5% had a mammogram within the last 2 years. 6.4% were recommended to undergo breast MRI. Among high-risk women, women with dense breast tissue were more likely (OR 496.0, 95%CI 52.6,4674.0) and older women were less likely (OR 0.91, 95%CI 0.84,0.99) to receive recommendations for breast MRI.

CONCLUSIONS

Among high-risk women, 92% reported undergoing at least one mammogram in their lives. 94% did not receive recommendations for breast MRI screening and 32% did not have a mammogram within the last year. To identify high-risk women, breast imaging centers should consider determining lifetime breast cancer risk during mammography screening visits.

A Global Perspective on Screening

Breast cancer is emerging as a major global public health problem. Incidence and mortality continues to rise in low- and middle-income countries (LMICs). A significant and growing disparity exists between high-income countries and LMICs in the availability of screening services and associated preventable mortality. However, population imaging-based screening programs are not appropriate for all settings. Planners should perform a thorough assessment of the target setting prior to implementing any breast cancer detection program, as appropriate guidelines vary according to the resources available. Financial, social, and cultural barriers to breast cancer care need to be addressed to sustainably improve the morbidity and mortality of the populations and make efficient use of available services. Creative approaches, such as mobile and portable imaging and bundling of services, can facilitate the installation of early breast cancer detection programs in LMICs. While image-based screening programs are not initially resource-appropriate in many LMICs, planners can work towards this goal as part of their comprehensive breast cancer detection strategy.

Implementation and Utilization of a "Pink Card" Walk-In Screening Mammography Program Integrated With Physician Visits

PURPOSE

The aim of this study was to evaluate the implementation and utilization of the Pink Card program, which links a physician-delivered reminder that a woman is due for screening mammography (SM) during an office visit with the opportunity to undergo walk-in screening.

METHODS

In 2016, the authors' community-based breast imaging center provided physicians from three primary care and obstetrics and gynecology practices located in the same outpatient facility business card-sized Pink Cards to offer women due for SM during office visits. The card includes a reminder that screening is due and can be used to obtain SM on a walk-in basis. The primary outcome measure was the proportion of women who used Pink Cards among all screened women over 2 years. Independent predictors of Pink Card utilization were evaluated using multivariate logistic regression analyses.

RESULTS

Among 3,688 women who underwent SM, Pink Cards were used by 19.9% (733 of 3,688). Compared with women with prescheduled screening visits, Pink Card users were more likely to be Asian (odds ratio [OR], 1.37; P =.032), Black (OR, 2.05; P = .002), and Medicaid insured (OR, 1.71; P = .013) and less likely to use English as their primary language (OR, 2.75; P = .003). Additionally, Pink Card users were less likely to be up to date for biennial SM compared with women with prescheduled visits (31.9% [234 of 733] versus 66.6% [1,968 of 2,955], P < .001).

CONCLUSIONS

The Pink Card walk-in SM program can improve screening access, particularly for racial/ethnic minorities and Medicaid-insured patients. Expansion of this program may help reduce disparities and increase engagement in breast cancer screening.

Black patients referred to a lung cancer screening program experience lower rates of screening and longer time to follow-up

BACKGROUND

Racial disparities are well-documented in preventive cancer care, but they have not been fully explored in the context of lung cancer screening. We sought to explore racial differences in lung cancer screening outcomes within a lung cancer screening program (LCSP) at our urban academic medical center including differences in baseline low-dose computed tomography (LDCT) results, time to follow-up, adherence, as well as return to annual screening after additional imaging, loss to follow-up, and cancer diagnoses in patients with positive baseline scans.

METHODS

A historical cohort study of patients referred to our LCSP was conducted to extract demographic and clinical characteristics, smoking history, and lung cancer screening outcomes.

RESULTS

After referral to the LCSP, blacks had significantly lower odds of receiving LDCT compared to whites, even while controlling for individual lung cancer risk factors and neighborhood-level factors. Blacks also demonstrated a trend toward delayed follow-up, decreased adherence, and loss to follow-up across all Lung-RADS categories.

CONCLUSIONS

Overall, lung cancer screening annual adherence rates were low, regardless of race, highlighting the need for increased patient education and outreach. Furthermore, the disparities in race we identified encourage further research with the purpose of creating culturally competent and inclusive LCSPs.

Breast Cancer Risk Perception and Mammography Screening Behavior of Women in Northeast Brazil

Background: Previous studies suggest that education and income affect Brazilian women's breast cancer prevention behavior. The present study focused on the impact of perceived and estimated risk on mammography screening (MS) behavior. Materials and Methods: Information regarding socioeconomic variables and risk perception was obtained from 396 healthy women aged 40-79 years. Perceived comparative risk was measured on a seven-point Likert scale. A Breast Cancer Risk Assessment Tool of 5-year risk to develop breast cancer was used to determine objective risk. Estimated comparative risk was determined as categories of perceived risk relative to the objective risk. Regression analysis was applied to determine odds ratios (ORs) and confidence intervals (95% CIs) of variables. Results: Asked about the potential of MS to lower risk of death because of breast cancer, 215 (54.29%) responded that it does not lower risk. Women with low perceived comparative risk had a twofold (OR = 0.493; 95% CI: 0.24-1.00) decreased chance to participate in MS annually, compared with women with high-perceived comparative risk (p = 0.020). Women without family history had a 7.6-fold (OR = 0.132; 95% CI: 0.07-0.25) decreased chance of having a high-perceived comparative risk (p = 0.000). If compared with underestimation, the overestimation and accurate estimation of comparative risk tended to be associated with a decreased chance of MS attendance (p = 0.017). Regression modeling indicated that low educational level, no occupation, and no family history decreased the chance of women having MS (p = 0.040; p = 0.010; p = 0.022). Conclusions: Risk perception depended on family history. Present data did not indicate that overestimation, or accurate estimation of comparative risk, increased chance of MS attendance. Educational level, occupation status, and family history, instead, determined MS performance.

Sensitive and specific multi-cancer detection and localization using methylation signatures in cell-free DNA

BACKGROUND

Early cancer detection could identify tumors at a time when outcomes are superior and treatment is less morbid. This prospective case-control sub-study (from NCT02889978 and NCT03085888) assessed the performance of targeted methylation analysis of circulating cell-free DNA (cfDNA) to detect and localize multiple cancer types across all stages at high specificity.

PARTICIPANTS AND METHODS

The 6689 participants [2482 cancer (>50 cancer types), 4207 non-cancer] were divided into training and validation sets. Plasma cfDNA underwent bisulfite sequencing targeting a panel of >100 000 informative methylation regions. A classifier was developed and validated for cancer detection and tissue of origin (TOO) localization.

RESULTS

Performance was consistent in training and validation sets. In validation, specificity was 99.3% [95% confidence interval (CI): 98.3% to 99.8%; 0.7% false-positive rate (FPR)]. Stage I-III sensitivity was 67.3% (CI: 60.7% to 73.3%) in a pre-specified set of 12 cancer types (anus, bladder, colon/rectum, esophagus, head and neck, liver/bile-duct, lung, lymphoma, ovary, pancreas, plasma cell neoplasm, stomach), which account for ∼63% of US cancer deaths annually, and was 43.9% (CI: 39.4% to 48.5%) in all cancer types. Detection increased with increasing stage: in the pre-specified cancer types sensitivity was 39% (CI: 27% to 52%) in stage I, 69% (CI: 56% to 80%) in stage II, 83% (CI: 75% to 90%) in stage III, and 92% (CI: 86% to 96%) in stage IV. In all cancer types sensitivity was 18% (CI: 13% to 25%) in stage I, 43% (CI: 35% to 51%) in stage II, 81% (CI: 73% to 87%) in stage III, and 93% (CI: 87% to 96%) in stage IV. TOO was predicted in 96% of samples with cancer-like signal; of those, the TOO localization was accurate in 93%.

CONCLUSIONS

cfDNA sequencing leveraging informative methylation patterns detected more than 50 cancer types across stages. Considering the potential value of early detection in deadly malignancies, further evaluation of this test is justified in prospective population-level studies.

A mixed methods study: Midlife African American women's knowledge, beliefs, and barriers to well-woman visit, flu vaccine, and mammogram use

African American women (AAW) are particularly at risk for deleterious health outcomes that might be mitigated through increased preventive care use. A mixed methods study that examined relationships between knowledge of, beliefs about, and barriers to well-woman visits, flu vaccines, and mammograms was conducted with midlife AAW who participated in an online survey (n = 124) and in-depth interviews (n = 19). Findings showed that greater knowledge of preventive service recommendations and positive patient-provider relationships were associated with greater preventive service use. Flu vaccines were significantly underused. Study implications inform strategies to increase preventive care utilization among AAW and increase capacities to improve health disparities.

Mobile Mammography Participation Among Medically Underserved Women: A Systematic Review

Introduction

Although breast cancer deaths have declined, the mortality rate among women from medically underserved communities is disproportionally high. Screening mammography is the most effective tool for detecting breast cancer in its early stages, yet many women from medically underserved communities do not have adequate access to screening mammograms. Mobile mammography may be able to bridge this gap by providing screening mammograms at no cost or low cost and delivering services to women in their own neighborhoods, thus eliminating cost and transportation barriers. The objective of this systematic review was to describe the scope and impact of mobile mammography programs in promoting mammographic screening participation among medically underserved women.

Methods

We searched electronic databases for English-language articles published in the United States from January 2010 through March 2018 by using the terms “mobile health unit,” “mammogram,” “mammography,” and “breast cancer screening.” Of the 93 articles initially identified, we screened 55; 16 were eligible to be assessed and 10 qualified for full text review and data extraction. Each study was coded for study purpose, research design, data collection, population targeted, location, sample size, outcomes, predictors, analytical methods, and findings.

Results

Of the 10 studies that qualified for review, 4 compared mobile mammography users with users of fixed units, and the other 6 characterized mobile mammography users only. All the mobile mammography units included reached underserved women. Most of the women screened in mobile units were African American or Latina, low income, and/or uninsured. Mobile mammography users reported low adherence to 1-year (12%–34%) and 2-year (40%–48%) screening guidelines. Some difficulties faced by mobile clinics were patient retention, patient follow-up of abnormal or inconclusive findings, and women inaccurately perceiving their breast cancer risk.

Conclusion

Mobile mammography clinics may be effective at reaching medically underserved women. Adding patient navigation to mobile mammography programs may promote attendance at mobile sites and increase follow-up adherence. Efforts to promote mammographic screening should target women from racial/ethnic minority groups, women from low-income households, and uninsured women. Future research is needed to understand how to best improve visits to mobile mammography clinics.

Quantifying performance thresholds for recommending screening mammography: a revealed preference analysis of USPSTF guidelines

PURPOSE

During ongoing controversies about mammography screening, many investigators have stated that performance improvements in screening mammography may mitigate concerns about harms. However, there have been few attempts to quantify performance improvements required to recommend mammography screening. Based on USPSTF benchmarks, we utilized revealed preference methods to ascertain quantitative thresholds at which screening mammography would be recommended beyond biennial screening in women 50 and older.

METHODS

Benefits of routine screening mammography (breast cancer deaths averted) were from published USPSTF meta-analyses. Potential harms (10-year cumulative probability of at least one false-positive) were from published Breast Cancer Surveillance Consortium estimates. We identified the implicit threshold (benefit/harm ratio) to recommend biennial screening starting at age 50. Using this threshold, we ascertained reductions of false-positives required to recommend more frequent screening and screening initiation under age 50 using revealed preference analyses.

RESULTS

Using USPSTF implied benefit/harm ratio, routine biennial screening would be recommended starting at 40 if false-positives declined by at least 62%. Reductions of false-positive proportions of 74% would be required to recommend annual screening starting at 40 and reductions of false-positive proportions of 31% would be required to support annual screening starting at 50.

CONCLUSIONS

Using USPSTF revealed preferences, 31-74% reductions in false-positives would be required to recommend mammography screening beyond biennial screening starting at age 50. Widespread implementation of tomosynthesis and reducing recall rates to the lower end of recommended recall rates (5-12%) would provide support for expanding screening beyond biennial screening in women age 50.

Associations of County-level Radiologist and Mammography Facility Supply with Screening Mammography Rates in the United States

RATIONALE AND OBJECTIVES

The present study aims to assess associations of Medicare beneficiary screening mammography rates with local mammography facility and radiologist availability.

MATERIALS AND METHODS

Mammography screening rates for Medicare fee-for-service beneficiaries were obtained for US counties using the County Health Rankings data set. County-level certified mammography facility counts were obtained from the United States Food and Drug Administration. County-level mammogram-interpreting radiologist and breast imaging subspecialist counts were determined using Centers for Medicare & Medicaid Services fee-for-service claims files. Spearman correlations and multivariable linear regressions were performed using counties' facility and radiologist counts, as well as counts normalized to counties' Medicare fee-for-service beneficiary volume and land area.

RESULTS

Across 3035 included counties, average screening mammography rates were 60.5% ± 8.2% (range 26%-88%). Correlations between county-level screening rates and total mammography facilities, facilities per 100,000 square mile county area, total mammography-interpreting radiologists, and mammography-interpreting radiologists per 100,000 county-level Medicare beneficiaries were all weak (r = 0.22-0.26). Correlations between county-level screening rates and mammography rates per 100,000 Medicare beneficiaries, total breast imaging subspecialist radiologists, and breast imaging subspecialist radiologists per 100,000 Medicare beneficiaries were all minimal (r = 0.06-0.16). Multivariable analyses overall demonstrated radiologist supply to have a stronger independent effect than facility supply, although effect sizes remained weak for both.

CONCLUSION

Mammography facility and radiologist supply-side factors are only weakly associated with county-level Medicare beneficiary screening mammography rates, and as such, screening mammography may differ from many other health-care services. Although efforts to enhance facility and radiologist supply may be helpful, initiatives to improve screening mammography rates should focus more on demand-side factors, such as patient education and primary care physician education and access.

Breast and Cervical Cancer Screening Prevalence and Associated Factors among Women in the South African General Population

Purpose: The aims of the study were to estimate the prevalence of breast and cervical cancer screening among women in the South African general population and assess associated factors. Methods: Data from a national populationbased cross-sectional household survey in South Africa in 2012 for 10,831 women aged 30+ years were analysed using bivariate and multivariable logistic regression. The outcome variables were cervical cancer screening (Papanicolaou smear test) and breast cancer screening (mammography). Exposure variables were sociodemographic factors, lifestyle variables, and chronic conditions. Results: The prevalences of Papanicolaou (PAP) smear test and mammography participation were 52.0% and 13.4%, respectively. On multivariable logistic regression analysis, women with higher education, those who were non-black African, having medical aid and having chronic conditions were more likely to undergo a Pap smear test and mammography. Living in rural areas was related to a lower likelihood of receiving both types of screening. In addition, undertaking moderate or vigorous physical activity was associated with breast cancer screening. Conclusion: Screening for cervical cancer was relatively high but for breast cancer it was low, despite the latter being a major public health problem in South Africa. This may be attributed to the limited availability, affordability, and accessibility of breast cancer screening services among socio-economically disadvantaged individuals There are some socio-economic disparities in adopting both breast and cervical cancer screening guidelines that could be targeted by interventions.

Racial and ethnic disparities among state Medicaid programs for breast cancer screening

Breast cancer screening by mammography has been shown to reduce breast cancer morbidity and mortality. The use of mammography screening though varies by race, ethnicity, and, sociodemographic characteristics. Medicaid is an important source of insurance in the US for low-income beneficiaries, who are disproportionately members of racial or ethnic minorities, and who are less likely to be screened than women with higher socioeconomic statuses. We used 2006-2008 data from Medicaid claims and enrollment files to assess racial or ethnic and geographic disparities in the use of breast cancer screening among Medicaid-insured women at the state level. There were disparities in the use of mammography among racial or ethnic groups relative to white women, and the use of mammography varied across the 44 states studied. African American and American Indian women were significantly less likely than white women to use mammography in 30% and 39% of the 44 states analyzed, respectively, whereas Hispanic and Asian American women were the minority groups most likely to receive screening compared with white women. There are racial or ethnic disparities in breast cancer screening at the state level, which indicates that analyses conducted by only using national data not stratified by insurance coverage are insufficient to identify vulnerable populations for interventions to increase the use of mammography, as recommended.