Perceived risk of breast cancer among Latinas attending community clinics: risk comprehension and relationship with mammography adherence

Making Informed Choices On Incorporating Chemoprevention into carE (MiCHOICE, SWOG 1904): Design and methods of a cluster randomized controlled trial

INTRODUCTION

Women with atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS) have a significantly increased risk of breast cancer, which can be substantially reduced with antiestrogen therapy for chemoprevention. However, antiestrogen therapy for breast cancer risk reduction remains underutilized. Improving knowledge about breast cancer risk and chemoprevention among high-risk patients and their healthcare providers may enhance informed decision-making about this critical breast cancer risk reduction strategy.

METHODS/DESIGN

We are conducting a cluster randomized controlled trial to evaluate the effectiveness and implementation of patient and provider decision support tools to improve informed choice about chemoprevention among women with AH or LCIS. We have cluster randomized 26 sites across the U.S. through the SWOG Cancer Research Network. A total of 415 patients and 200 healthcare providers are being recruited. They are assigned to standard educational materials alone or combined with the web-based decision support tools. Patient-reported and clinical outcomes are assessed at baseline, after a follow-up visit at 6 months, and yearly for 5 years. The primary outcome is chemoprevention informed choice after the follow-up visit. Secondary endpoints include other patient-reported outcomes, such as chemoprevention knowledge, decision conflict and regret, and self-reported chemoprevention usage. Barriers and facilitators to implementing decision support into clinic workflow are assessed through patient and provider interviews at baseline and mid-implementation.

RESULTS/DISCUSSION

With this hybrid effectiveness/implementation study, we seek to evaluate if a multi-level intervention effectively promotes informed decision-making about chemoprevention and provide valuable insights on how the intervention is implemented in U.S.

CLINICAL SETTINGS

TRIAL REGISTRATION

NCT04496739.

Breast Cancer Risk Perceptions Among Underserved, Hispanic Women: Implications for Risk-Based Approaches to Screening

BACKGROUND

Understanding factors that shape breast cancer risk perceptions is essential for implementing risk-based approaches to breast cancer detection and prevention. This study aimed to assess multilevel factors, including prior screening behavior, shaping underserved, Hispanic women's perceived risk for breast cancer.

METHODS

Secondary analysis of survey data from Hispanic women (N = 1325, 92% Spanish speaking, 64% < 50) enrolled in a large randomized controlled trial. Analyses were performed in two cohorts to account for the role of age on screening guideline recommendations (< 50 and 50 +). For each cohort, we examined differences in three common measures of perceived risk of breast cancer (percent lifetime, ordinal lifetime, comparative) by participant factors with chi-square or Kruskal-Wallis tests, as appropriate. Multivariate analyses examined the association between mammography history with percent perceived lifetime risk (outcome > 10 vs ≤ 10%).

RESULTS

Overall, 75% reported a lifetime risk between 0 and 10%, 96% rated their ordinal risk as "not high," and 50% rated their comparative risk as "much lower." Women < 50 with a family history of breast cancer reported significantly higher levels of perceived risk across all three measures. Among women 50 + , those reporting lower levels of perceived risk were significantly more likely to be Spanish speaking. No significant association was observed between mammography history and percent lifetime risk of breast cancer.

CONCLUSION

Factors shaping breast cancer risk perceptions differ by age. Prior screening may play less of role in constructing risk perceptions. Research is needed to develop culturally and linguistically appropriate strategies to improve implementation of risk-based screening.

Clinician and patient perspectives on screening mammography among women age 75 and older: A pilot study of a novel decision aid

Objective

Supporting patient-clinician communication is key to implementing tailored, risk-based screening for older adults. Objectives of this multiphase mixed methods study were to identify factors that primary care clinicians consider influential when making screening mammography recommendations for women ≥ 75 years, develop a patient decision aid that incorporates these factors, and gather feasibility and acceptability from the patients' perspective.

Methods

Clinicians from a Mid-Atlantic practice network completed online surveys. Women in the same network completed surveys before and after receiving a tailored booklet that included information about the benefits and harms of screening for women ≥ 75 years, a breast cancer risk-estimate, and a question prompt list to support patient-clinician communication.

Results

Clinicians (N = 21) were primarily women [57.1%] and practiced family medicine [81.0%]. They cited patients' age ≥ 75 years [95.4%], comorbidity [86.4%], functional status [77.3%], cancer family history [63.6%], U.S. Preventive Services Task Force guidelines [81.8%] and new research [77.3%] as factors influencing their recommendations. Fourteen women completed baseline surveys and received personalized decision aids (Mean age = 79.1 years). Eleven completed the post-intervention survey. All were satisfied with the booklet length, 81.8% found the booklet easy to understand and 72.7% helpful in decision-making Perceived lifetime breast cancer risk decreased significantly from pre- to post-intervention (p = 0.02).

Conclusions

Results suggest this decision aid, which incorporates key decisional factors from the clinician's perspective, is feasible and acceptable to patients.

Innovation

A tailored decision aid booklet is innovative as it provides information on personalized risk and potential benefits and harms to older women considering screening.

Patient and Provider Web-Based Decision Support for Breast Cancer Chemoprevention: A Randomized Controlled Trial

Significant underutilization of breast cancer chemoprevention remains, despite guidelines stating that physicians should recommend chemoprevention with antiestrogen therapy to high-risk women. We randomized women, ages 35 to 75 years, who met high-risk criteria for breast cancer, without a personal history of breast cancer or prior chemoprevention use, to standard educational materials alone or combined with a web-based decision aid. All healthcare providers, including primary care providers and breast specialists, were given access to a web-based decision support tool. The primary endpoint was chemoprevention uptake at 6 months. Secondary outcomes included decision antecedents (perceived breast cancer risk/worry, chemoprevention knowledge, self-efficacy) and decision quality (decision conflict, chemoprevention informed choice) based upon patient surveys administered at baseline, 1 and 6 months after randomization. Among 282 evaluable high-risk women enrolled from November 2016 to March 2020, mean age was 57 years (SD, 9.9) and mean 5-year invasive breast cancer risk was 2.98% (SD, 1.42). There was no significant difference in chemoprevention uptake at 6 months between the intervention and control groups (2.1% vs. 3.5%). Comparing the intervention and control arms at 1 month, there were significant differences among high-risk women in accurate breast cancer risk perceptions (56% vs. 39%, P = 0.017), adequate chemoprevention knowledge (49% vs. 27%, P < 0.001), mean decision conflict (34.0 vs. 47.0, P < 0.001), and informed choice (41% vs. 23%, P = 0.003). These differences were no longer significant at 6 months. Although our decision support tools did not result in a significant increase in chemoprevention uptake, we did observe improvements in decision antecedents and decision quality measures.

PREVENTION RELEVANCE

In this randomized controlled trial of decision support for 300 high-risk women and 50 healthcare providers, we did not observe a significant increase in chemoprevention uptake, which remained low at under 5%. However, these decision support tools may increase knowledge and informed choice about breast cancer chemoprevention.

Compliance with COVID-19 Preventive Guidelines Among Minority Communities: the Case of Israeli Arabs

Objectives

The Arab ethnic minority makes up 21% of Israel’s population and accounted for 40.5% of confirmed cases during the second wave of COVID-19. This study aims to assess the characteristics of compliance with the guidelines of the Ministry of Health and related factors that can explain the outbreak of COVID-19 among the Arab population during the second wave.

Methods

A cross-sectional online survey was conducted among 810 respondents from the Arab community during October 2020. The survey was distributed via social media such as Facebook and WhatsApp. The health belief model items, the theory of reasoned action items, trust in formal institutions, and pandemic fatigue were assessed, and a path analysis was performed.

Results

Positive correlations were demonstrated between both personal and social networks compliance (nuclear family, extended family, friends, etc.) and perceived severity of COVID-19, trust in formal institutions, attitudes toward compliance, and subjective norms (r = .12 to r = .64, p < .001, N = 810). Pandemic fatigue was negatively correlated with personal and social networks compliance, perceived severity of COVID-19, trust in institutions, attitudes toward compliance, and subjective norms (r =  − .21 to r =  − .48, p < .001). Positive correlations were evident between compliance with quarantine and perceived severity of COVID-19 and attitudes (r = .31 and r = .28, p < .001, respectively). Personal compliance was significantly lower among men (M = 3.93, SD = 0.94) and younger respondents (M = 4.14, SD = 0.71), while social networks compliance was lower among Muslims (M = 3.78, SD = 0.75).

The negative relationship between pandemic fatigue and personal compliance was mediated by lower perceived severity of COVID-19, attitudes toward compliance, and subjective norms (p < .001). The negative relationship between pandemic fatigue and social network compliance was mediated by lower trust in institutions and subjective norms (p < .001). Lower perceived severity of COVID-19 mediated the relationship between higher pandemic fatigue and lower quarantine compliance (p = .003).

Conclusions

The results highlight the important of perception of the disease severity, social and subjective norms, and the central role of trust in determining adherence to guidelines. Thus, increasing trust on authorities and planning tailored-maid interventions can raise compliance with the preventive guidelines and prevent the spread of the virus. Such interventions will address the characteristics of minority populations and take into account the implications of the guidelines and the possibility that may lead to fatigue, which in turn will lead to non-compliance with those guidelines.

Knowledge, Attitudes, Behavior, and Practices of Self Breast Examination in Nicaragua

Self breast examination (SBE) has been recommended as an important preventative practice for the early identification of breast cancer in women. However, our understanding of women’s knowledge, attitudes, and practices of self breast examination in Nicaragua is limited. In the present study, we conducted a cross-sectional study of women aged 18 years and over (n=500) living in selected urban and rural areas of Nicaragua. Measures included the survey reflected knowledge, attitudes, behaviors, and practices related to self breast examination. We compared these measures between women living in urban and rural areas and women aged 18-39 years and 40+ years. Using a t-test, we tested the significance of these differentials. Results indicate widespread and significant differentials in basic knowledge and behaviors on self-breast examination practices among women living in rural and urban locations in Nicaragua. Further, while younger women reported significant and lower overall knowledge about breast cancer (BC), purpose and reasons for SBE, characteristics of women who tend to be at higher risk for BC, and strategies and steps women take performing SBE compared to women who were in the 40+ age group. Study results call for location and population-specific programs and policies addressing disparities in breast cancer prevention efforts in the country.

Lifestyle Factors and Genetic Variants Associated to Health Disparities in the Hispanic Population

Non-communicable diseases including type 2 diabetes mellitus, coronary heart disease, hepatic steatosis, and cancer are more prevalent in minority groups including Hispanics when compared to Non-Hispanic Whites, leading to the well-recognized terminology of health disparities. Although lifestyle factors including inadequate dietary habits, decreased physical activity, and more prominently, an unhealthy body weight, may be partly responsible for this disproportion in chronic diseases, genetic variations also make a substantial contribution to this problem. In this review, the well-recognized obesity problem in Hispanics that has been associated with chronic disease is examined as well as the influence of diet on promoting an inflammatory environment leading to increased cardiometabolic risk, insulin resistance, fatty liver disease, and cancer. In addition, some of the more studied genetic variations in Hispanics and their association with chronic disease is reviewed.

Reaching Rural Residents to Identify Colorectal Cancer Education and Intervention Targets

Disparities in cancer screening and care in rural communities warrant the need to determine effective ways to reach, engage, and educate the community residents. The purpose of this cross-sectional study was to pilot methods to engage rural residents in colorectal cancer (CRC) research and education activities and assess knowledge of CRC guidelines, symptoms, and screening behaviors in this sample. The community-engaged research approach was employed to develop and distribute a CRC knowledge and screening behavior assessment using various methods such as email and community drop boxes placed throughout the community. Bivariate analysis assessed the relationship between age and CRC knowledge items. Three hundred ninety-one surveys were returned with most received from community drop boxes (60%) followed by educational events (23%). The most ineffective method to distribute surveys was through community events. Most individuals were knowledgeable of CRC symptoms (70%) and screening facts (67%). Bivariate analysis showed that individuals 50 years or older had significantly more knowledge of CRC risks and screening than those under the age of 50. This study highlights the potential of community drop boxes as an effective method for engaging rural communities. Further, findings from the survey highlight the need to focus CRC education on younger individuals in which CRC incidence has increased.

Cancer health disparities in racial/ethnic minorities in the United States

There are well-established disparities in cancer incidence and outcomes by race/ethnicity that result from the interplay between structural, socioeconomic, socio-environmental, behavioural and biological factors. However, large research studies designed to investigate factors contributing to cancer aetiology and progression have mainly focused on populations of European origin. The limitations in clinicopathological and genetic data, as well as the reduced availability of biospecimens from diverse populations, contribute to the knowledge gap and have the potential to widen cancer health disparities. In this review, we summarise reported disparities and associated factors in the United States of America (USA) for the most common cancers (breast, prostate, lung and colon), and for a subset of other cancers that highlight the complexity of disparities (gastric, liver, pancreas and leukaemia). We focus on populations commonly identified and referred to as racial/ethnic minorities in the USA-African Americans/Blacks, American Indians and Alaska Natives, Asians, Native Hawaiians/other Pacific Islanders and Hispanics/Latinos. We conclude that even though substantial progress has been made in understanding the factors underlying cancer health disparities, marked inequities persist. Additional efforts are needed to include participants from diverse populations in the research of cancer aetiology, biology and treatment. Furthermore, to eliminate cancer health disparities, it will be necessary to facilitate access to, and utilisation of, health services to all individuals, and to address structural inequities, including racism, that disproportionally affect racial/ethnic minorities in the USA.

The accuracy of breast cancer risk self-assessment does not correlate with knowledge about breast cancer and knowledge and attitudes towards primary chemoprevention

The increase of breast cancer (BC) incidence has drawn attention to BC risk as means of reducing mortality and morbidity of the disease. The aim of this study was to determine the accuracy of BC risk perception, evaluate factors that affect risk perception and assess the correlation between BC risk perception and attitudes towards BC chemoprevention. A cross-sectional study included total of 258 women with average and high-risk for BC according to the Breast Cancer Risk Assessment Tool (BCRAT). All data were collected by face-to-face interview by three trained 6th year medical school students using a 54-item questionnaire. Each participant's actual BC risk was compared to a perceived risk and the accuracy of the BC risk self-assessment was determined. 72% of high-risk women underestimated their BC risk (p < 0.001). One third of subjects with a family history of BC have also underestimated their own risk (p = 0.002). Women who responded to screening mammography were more informed about BC risk factors (p = 0.001). General knowledge about BC chemoprevention was surprisingly low, regardless of the accuracy of BC risk self-assessment. High-risk women appear to be unrealistically optimistic, since there was a significant difference between the accuracy of self-perceived risk and the objective BC risk.

Demographic and Attitudinal Factors of Adherence to Quarantine Guidelines During COVID-19: The Italian Model

In Italy, a large outbreak of coronavirus disease 2019 (COVID-19) occurred from 2020 January 30, before the World Health Organization has stated that it is a pandemic. The nationwide quarantine had the desired impact of controlling the epidemic, although had presented many challenges, given its large economic and social costs. Complete adherence to recommendations can potentially decelerate and reduce infectious disease outbreaks. To date, it is not clear how compliant the Italian public has been with voluntary home quarantine, neither which factors have influenced an individual's decision to comply with a quarantine order. The purposes of this study were to investigate the degree of the adherence to quarantine restrictions and the factors associated with the self-reported adherence. During the third week of the national lockdown, 3,672 Italian quarantined adult residents (65% females; range, 18-85 years) participated in an online cross-sectional survey focused on the risk perception of contracting COVID-19 and their reported adherence to quarantine protocols. Analysis of variance showed significant differences among demographic groups in tendency to comply with quarantine orders, with women, most educated people, residents of Southern Italy, middle-aged individuals, and health workers more likely to adhere to quarantine guidelines. As well, participants exhibiting the perception, anxiety, and susceptibility of risk of contracting COVID-19 disease were found significantly more likely to adhere to quarantine guidelines. The results of this study can help public health policy makers to recognize target populations for COVID-19 prevention and health education and to understand how inform communication strategies aimed at minimizing the impact and spread of the disease.

BRCA1/2 mutations and risk-reducing bilateral salpingo-oophorectomy among Latinas: The UPTAKE study

Bilateral salpingo-oophorectomy (BSO) is a risk management approach with strong evidence of mortality reduction for women with germline mutations in the tumor suppressor genes BRCA1 and BRCA2 (BRCA1/2). Few studies to date have evaluated uptake of BSO in women from diverse racial and ethnic backgrounds who carry BRCA1/2 mutations. The objective of the UPTAKE study was to explore rates and predictors of risk-reducing BSO among Latinas affected and unaffected with breast cancer who had a deleterious BRCA1/2 mutation. We recruited 100 Latina women with deleterious BRCA1/2 mutations from community hospitals, academic health systems, community, and advocacy organizations. Women completed interviews in Spanish or English. We obtained copies of genetic test reports for participants who provided signed medical release. After performing threefold cross-validation LASSO for variable selection, we used multiple logistic regression to identify demographic and clinical predictors of BSO. Among 100 participants, 68 had undergone BSO at the time of interview. Of these 68, 35 were US-born (61% of all US-born participants) and 33 were not (77% of the non-US-born participants). Among Latinas with BRCA1/2 mutations, older age (p = 0.004), personal history of breast cancer (p = 0.003), higher income (p = 0.002), and not having a full-time job (p = 0.027) were identified as variables significantly associated with uptake of BSO. Results suggest a high rate of uptake of risk-reducing BSO among a sample of Latinas with BRCA1/2 mutations living in the US. We document factors associated with BSO uptake in a diverse sample of women. Relevant to genetic counseling, our findings identify possible targets for supporting Latinas' decision-making about BSO following receipt of a positive BRCA1/2 test.

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.

Study protocol: Randomized controlled trial of web-based decision support tools for high-risk women and healthcare providers to increase breast cancer chemoprevention

BACKGROUND

Chemoprevention using selective estrogen receptor modulators and aromatase inhibitors has been shown to reduce invasive breast cancer incidence in high-risk women. Despite this evidence, few high-risk women who are eligible for chemoprevention utilize it as a risk-reducing strategy. Reasons for low uptake include inadequate knowledge about chemoprevention among patients and healthcare providers, concerns about side effects, time constraints during the clinical encounter, and competing comorbidities.

METHODS/DESIGN

We describe the study design of a randomized controlled trial examining the effect of two web-based decision support tools on chemoprevention decision antecedents and quality, referral for specialized counseling, and chemoprevention uptake among women at an increased risk for breast cancer. The trial is being conducted at a large, urban medical center. A total of 300 patients and 50 healthcare providers will be recruited and randomized to standard educational materials alone or in combination with the decision support tools. Patient reported outcomes will be assessed at baseline, one and six months after randomization, and after their clinic visit with their healthcare provider.

DISCUSSION

We are conducting this trial to provide evidence on how best to support personalized breast cancer risk assessment and informed and shared decision-making for chemoprevention. We propose to integrate the decision support tools into clinical workflow, which can potentially expand quality decision-making and chemoprevention uptake.

TRIAL REGISTRATION

NCT03069742.

Pilot study of decision support tools on breast cancer chemoprevention for high-risk women and healthcare providers in the primary care setting

Background

Breast cancer chemoprevention can reduce breast cancer incidence in high-risk women; however, chemoprevention is underutilized in the primary care setting. We conducted a pilot study of decision support tools among high-risk women and their primary care providers (PCPs).

Methods

The intervention included a decision aid (DA) for high-risk women, RealRisks, and a provider-centered tool, Breast Cancer Risk Navigation (BNAV). Patients completed validated surveys at baseline, after RealRisks and after their PCP clinical encounter or at 6-months. Referral for high-risk consultation and chemoprevention uptake were assessed via the electronic health record. The primary endpoint was accuracy of breast cancer risk perception at 6-months.

Results

Among 40 evaluable high-risk women, median age was 64.5 years and median 5-year breast cancer risk was 2.19%. After exposure to RealRisks, patients demonstrated an improvement in accurate breast cancer risk perceptions (p = 0.02), an increase in chemoprevention knowledge (p < 0.01), and 24% expressed interest in taking chemoprevention. Three women had a high-risk referral, and no one initiated chemoprevention. Decisional conflict significantly increased from after exposure to RealRisks to after their clinical encounter or at 6-months (p < 0.01). Accurate breast cancer risk perceptions improved and was sustained at 6-months or after clinical encounters. We discuss the side effect profile of chemoprevention and the care pathway when RealRisks was introduced to understand why patients experienced increased decision conflict.

Conclusion

Future interventions should carefully link the use of a DA more proximally to the clinical encounter, investigate timed measurements of decision conflict and improve risk communication, shared decision making, and chemoprevention education for PCPs. Additional work remains to better understand the impact of decision aids targeting both patients and providers.

Trial registration

ClinicalTrials.gov Identifier: NCT02954900 November 4, 2016 Retrospectively registered.

Correlates of Dominicans' Identification of Cancer as a Worrisome Health Problem

There is a paucity of studies centering on the correlates of cancer worry among Hispanics from the Dominican Republic and the potential informatics strategies to address such worries. Data were analyzed using descriptive and correlational statistics, and logistic regression with the dependent variable of cancer worry. Independent variables for the regression were: age, gender, marital status, education, socioeconomic status, previous diagnosis of cancer, anxiety, depression, sleep disturbance, and chronic burden. Four variables significantly increased cancer worry: married marital status (OR = 1.19 [95% CI 1.01, 1.41]), younger age (OR = .992 [95% CI 0.987, 0.997]), less depression (OR = .96 [95% CI 0.94, 0.98]), and cancer diagnosis (OR = 2.12 [95% CI 1.24, 3.65]). New knowledge was generated on the contextual factors that influence these health concerns in a major Hispanic sub-group. Implications for practice, research and education are discussed.

An Example from the Rural Areas of Turkey: Women Breast Cancer Risk Levels and Application and Knowledge Regarding Early Diagnosis-Scan of Breast Cancer

OBJECTIVE

This research has been conducted for the purpose of determining the cancer risk levels of women living in a small village of in Saraycık village of Ankara and their knowledge and application of breast cancer early diagnose-scan methods.

MATERIALS AND METHODS

317 women were taken as examples for the study. Data were collected by giving survey forms to women and conducting face-to-face interviews. In determining breast cancer risk, "the form to determine the breast cancer risk" has been used. For breast cancer informational questions, one point has been given for each correct answer. In evaluating the data, number, percentage calculations, average and standard deviation, Mann-Whitney U (MU), Kruskal-Wallis (KW), One-way analysis of variance (F) independent sample T (t) tests have been used.

RESULTS

It has been found that breast cancer risk is low, the knowledge level about cancer early recognition methods are medium among the women. It has been determined that 74.4% women didn't perform breast self-examination. 89.6% of women don't have mammography taken and 88.6% don't have their breast examined by health personnel.

CONCLUSION

In our study, it has been found that the risk levels of women are low, their knowledge about early diagnosis and cure are at a medium level and their use of these methods are inadequate. For this reason, we suggest that responsibility of healthcare professionals have to be increased in determining breast cancer risk among women and education and advisory services for this subject to be offered.

A Risk Assessment Comparison of Breast Cancer and Factors Affected to Risk Perception of Women in Turkey: A Cross-sectional Study

BACKGROUND

The increase in breast cancer incidence has enhanced attention towards breast cancer risk. The aim of this study was to determine the risk of breast cancer and risk perception of women, factors that affect risk perception, and to determine differences between absolute risk and the perception of risk.

METHODS

This cross-sectional study was carried out among 346 women whose score in the Gail Risk Model (GRM) was ≥ 1.67% and/or had a 1^st degree relative with breast cancer in Bahçeşehir town in Istanbul, Turkey between Jul 2012 and Dec 2012. Data were collected through face-to-face interviews. The level of risk for breast cancer has been calculated using GRM and the Breast Cancer Risk Assessment Form (BCRAF). Breast cancer risk perception (BCRP), has been evaluated by visual analogue 100-cm-long scale.

RESULTS

Even though 39.6% of the women considered themselves as high-risk carriers, according to the GRM and the BCRAF, only 11.6% and 9.8% of women were in the "high risk" category, respectively. There was a positive significant correlation between the GRM and the BCRAF scores (P<0.001), and the BCRAF and BCRP scores (P<0.001). Factors related to high-risk perception were age (40-59 yr), post-menopausal phase, high-very high economic income level, existence of breast cancer in the family, having regular breast self-examination and clinical breast examination (P<0.05).

CONCLUSION

In women with high risk of breast, cancer there is a significant difference between the women's risk perception and their absolute risk level.

Predictors of Breast Cancer Worry in a Hispanic and Predominantly Immigrant Mammography Screening Population

OBJECTIVE

Worry about developing breast cancer (BC) has been associated with participation in screening and genetic testing and with follow-up of abnormal screening results. Little is known about the scope and predictors of BC worry in Hispanic and immigrant populations.

METHODS

We collected in-person interview data from 250 self-identified Hispanic women recruited from an urban mammography facility (average age 50.4 years; 82% foreign-born). Women reported whether they worried about developing breast cancer rarely/never (low worry), sometimes (moderate worry), or often/all the time (high worry). We examined whether sociocultural and psychological factors (e.g., acculturation, education, perceived risk), and risk factors and objective risk for BC (e.g., family history, Gail model 5-year risk estimates, parity) predicted BC worry using multinomial and logistic regression.

RESULTS

In multivariable models, women who perceived higher absolute BC risk (odds ratio, 1.66 [95% confidence interval, 1.28-2.14] for a one-unit increase in perceived lifetime risk) and comparative BC risk (e.g., odds ratio, 2.73, 95% confidence interval, 1.23-6.06) were more likely to report high BC worry than moderate or low BC worry. There were no associations between BC worry and indicators of objective risk or acculturation.

CONCLUSIONS

In Hispanic women undergoing screening mammography, higher perceptions of BC risk, in both absolute and comparative terms, were associated independently with high BC worry, and were stronger predictors of BC worry than indicators of objective BC risk, including family history, mammographic density, and personal BC risk estimates.

Latinas' Mammography Intention Following a Home-Based Promotores-Led Intervention

Despite increases in mammography rates among Latinas, screening rates remain lower than in non-Latina Whites and Latinas typically present with breast cancer at a later stage. Trained lay community workers (promotores) have been successfully used to increase screening mammography intention in Latinas. Little is known, however, about the potential mechanisms of these interventions, such as increased breast cancer knowledge (knowledge) and social interactions concerning mammography practices (social engagement). This prospective pre-post study examined this gap in the literature by (1) documenting changes in knowledge and social engagement after receipt of a promotores-based intervention; and (2) establishing if post-intervention knowledge and social engagement predicted mammography intention, after adjusting for socio-demographic and lifetime mammography history. There were significant increases in knowledge and social engagement about mammography. Finally, post-intervention social engagement was a significant predictor of mammography intention. Future promotores-based interventions should focus on enhancing social engagement to improve mammography intention and use.

A systematic review of barriers and facilitators to mammography in Hispanic women

PURPOSE

A systematic review of the research on barriers and facilitators to mammography in Latinas was conducted to determine if the challenges faced by these women are unique to this population.

METHOD

Medline and CINAHL database searches for the years 2005-2013 were included. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to guide this review.

RESULTS

Of the 174 articles identified, 18 articles met inclusion criteria. The most consistent findings were that income and education were associated with screening.

CONCLUSIONS

Financial barriers and social characteristics were significant predictors of mammography in these studies, which were composed almost exclusively of low-income Latinas. These findings are similar to those found in other populations of low-income women and therefore are not likely unique to Latinas.

IMPLICATIONS FOR PRACTICE

It is likely that there is little difference between poor Latinas and other populations of poor, non-English-speaking women in barriers and facilitators to mammography.

Changes in risk perception following a smoking cessation intervention: the role of acculturation in a sample of Latino caregivers

The present exploratory study examined the role of acculturation in the perception of the risks of smoking following a smoking cessation induction intervention among Latino caregivers of children with asthma. The sample consisted of 131 Latino smokers (72.9% female; 18.3% born in the U.S.) who were caregivers of a child with asthma. Caregivers were randomized to one of two smoking cessation interventions that were part of a home-based asthma program. Self-report measures of risk-perception were assessed at baseline, end of treatment (2 months after baseline), and 2- and 3-months post-treatment. At baseline, caregivers, regardless of level of acculturation, reported moderate to high levels of concern about the effects of secondhand smoke on their child's health as well as perceived risk regarding the effect of smoking on their own health. However, caregivers who were low in acculturation had a greater increase in concern about the effects of smoking on their child from pre-to post treatment compared to those who were high in acculturation (p = .001). Lastly, level of acculturation moderated the association between caregivers' concern about smoking on their child's health and their motivation to quit smoking (p < .05), but not cessation rates or reduced secondhand smoke exposure (p > .05). Specifically, motivation to quit at 3 months was greater for those with low acculturation. Though exploratory, these findings suggest that risk perception may be more easily influenced in low versus high acculturated populations and this should be considered in the design of clinical interventions and potentially mass media campaigns seeking to influence risk of caregiver behavior on child health with ethnic and racial minorities.

Compliance with screening recommendations according to breast cancer risk levels in Izmir, Turkey

Early diagnosis has a major role in improving prognosis of breast cancer. The purpose of this study was to assess the risk status of women 35-69 years of age using risk assessment models and the prevalence of mammography in a community setting. The sample of this cross sectional study consisted of 227 women, 35-69 years of age residing in Izmir, a city located in western region of Turkey. A questionnaire was used to collect data and the Gail and Cuzick-Tyrer models were applied to assess the risk of breast cancer. In this study, 52.7% of women had mammography at least once, and 41.3% of the women over the age of 40 had mammography screening in the last two years. The five years risk for breast cancer was high in 15.8% of women according to the Gail model and ten years risk was high in 21.7% with the Cuzick-Tyrer model. In the present study, the breast cancer risk levels were assessed in a population setting for the first time in Turkey using breast cancer risk level assessment models. Being in 60-69 age group, having low education and not being in menopause were significant risk factors for not having mammography according to logistic regression analysis. Mammography utilization rate was low. Women must be educated about breast cancer screening methods and early diagnosis. The women in the high risk group should be informed on their risk status which may increase their attendance at breast cancer screening.

Perceived versus objective breast cancer risk in diverse women

BACKGROUND

Prior research suggests that women do not accurately estimate their risk for breast cancer. Estimating and informing women of their risk is essential for tailoring appropriate screening and risk reduction strategies.

METHODS

Data were collected for BreastCARE, a randomized controlled trial designed to evaluate a PC-tablet based intervention providing multiethnic women and their primary care physicians with tailored information about breast cancer risk. We included women ages 40-74 visiting general internal medicine primary care clinics at one academic practice and one safety net practice who spoke English, Spanish, or Cantonese, and had no personal history of breast cancer. We collected baseline information regarding risk perception and concern. Women were categorized as high risk (vs. average risk) if their family history met criteria for referral to genetic counseling or if they were in the top 5% of risk for their age based on the Gail or Breast Cancer Surveillance Consortium Model (BCSC) breast cancer risk model.

RESULTS

Of 1,261 participants, 25% (N=314) were classified as high risk. More average risk than high risk women had correct risk perception (72% vs. 18%); 25% of both average and high risk women reported being very concerned about breast cancer. Average risk women with correct risk perception were less likely to be concerned about breast cancer (odds ratio [OR]=0.3; 95% confidence interval [CI]=0.2-0.4) while high risk women with correct risk perception were more likely to be concerned about breast cancer (OR=5.1; 95%CI=2.7-9.6).

CONCLUSIONS

Many women did not accurately perceive their risk for breast cancer. Women with accurate risk perception had an appropriate level of concern about breast cancer. Improved methods of assessing and informing women of their breast cancer risk could motivate high risk women to apply appropriate prevention strategies and allay unnecessary concern among average risk women.

Relationship between colorectal cancer screening adherence and knowledge among vulnerable rural residents of Appalachian Kentucky

BACKGROUND

Colorectal cancer (CRC) is 1 of the leading causes of cancer-related deaths among residents of rural Appalachia. Rates of guideline-consistent CRC screening in Appalachian Kentucky are suboptimal.

OBJECTIVE

This study sought to determine the relationship between CRC screening knowledge, specifically regarding recommended screening intervals, and receipt of screening among residents of rural Appalachian Kentucky.

METHODS

Residents of Appalachian Kentucky (n = 1096) between the ages of 50 and 76 years completed a telephone survey including questions on demographics, health history, and knowledge about CRC screening between November 20, 2009, and April 22, 2010.

RESULTS

Although 67% of respondents indicated receiving screenings according to guidelines, respondents also demonstrated significant knowledge deficiencies about screening recommendations. Nearly half of respondents were unable to identify the recommended screening frequency for any of the CRC screening modalities. Accuracy about the recommended frequency of screening was positively associated with screening adherence.

CONCLUSIONS

Enhanced educational approaches have the potential to increase CRC screening adherence in this population and reduce cancer mortality in this underserved region.

IMPLICATIONS FOR PRACTICE

Nurses play a critical role in patient education, which ultimately may increase screening rates. To fulfill this role, nurses should incorporate current recommendation about CRC screening into educational sessions. Advanced practices nurses in rural settings should also be aware of the increased vulnerability of their patient population and develop strategies to enhance awareness about CRC and the accompanying screening tests.

Perceived and objective breast cancer risk assessment in Chilean women living in an underserved area

BACKGROUND

Breast cancer is the most frequently diagnosed malignancy among Chilean women and an increasingly significant public health threat. This study assessed the accuracy of breast cancer risk perception among underserved, Chilean women.

METHODS

Women aged 50 to 70 years, with no mammogram during the last 2 years, were randomly selected from a community clinic registry in Santiago, Chile (n = 500). Perceived risk was measured using three methods: absolute risk, comparative risk, and numerical risk. Risk comprehension was measured by comparing women's perceived and objective risk estimates. Multivariate logistic regression was used to assess overestimation of perceived risk.

RESULTS

Women at high risk of breast cancer were more likely than average risk women to perceive themselves at high or higher risk, using absolute and comparative risk approaches (P < 0.001). The majority of participants (67%) overestimated their breast cancer risk, on the basis of risk comprehension; although, participants achieved higher accuracy with comparative risk (40%) and absolute risk (31.6%) methods. [Age, breast cancer knowledge and Breast Cancer Risk Assessment Tool (BCRAT) 5-year risk were significantly associated (P < 0.01) with accuracy of perceived risk].

CONCLUSION

Chilean women residing in an underserved community may not accurately assess their breast cancer risk, although risk perception and level of accuracy differed between perceived risk measures. Comparative and absolute risk methods may better reflect women's interpretation and accuracy of risk perception.

IMPACT

Improving our understanding of Chilean women's perceptions of developing breast cancer may lead to the development of culturally relevant efforts to reduce the breast cancer burden in this population.

A review of cancer in U.S. Hispanic populations

There are compelling reasons to conduct studies of cancer in Hispanics, the fastest growing major demographic group in the United States (from 15% to 30% of the U.S. population by 2050). The genetically admixed Hispanic population coupled with secular trends in environmental exposures and lifestyle/behavioral practices that are associated with immigration and acculturation offer opportunities for elucidating the effects of genetics, environment, and lifestyle on cancer risk and identifying novel risk factors. For example, traditional breast cancer risk factors explain less of the breast cancer risk in Hispanics than in non-Hispanic whites (NHW), and there is a substantially greater proportion of never-smokers with lung cancer in Hispanics than in NHW. Hispanics have higher incidence rates for cancers of the cervix, stomach, liver, and gall bladder than NHW. With respect to these cancers, there are intriguing patterns that warrant study (e.g., depending on country of origin, the five-fold difference in gastric cancer rates for Hispanic men but not Hispanic women). Also, despite a substantially higher incidence rate and increasing secular trend for liver cancer in Hispanics, there have been no studies of Hispanics reported to date. We review the literature and discuss study design options and features that should be considered in future studies.

Long-term psychosocial outcomes of BRCA1/BRCA2 testing: differences across affected status and risk-reducing surgery choice

BACKGROUND

Numerous studies have documented the short-term impact of BRCA1/BRCA2 (BRCA1/2) testing; however, little research has examined the long-term impact of testing. We conducted the first long-term prospective study of psychosocial outcomes in a U.S. sample of women who had BRCA1/2 testing.

METHODS

Participants were 464 women who underwent genetic testing for BRCA1/2 mutations. Prior to testing, we measured sociodemographics, clinical variables, and cancer specific and general distress. At long-term follow-up (Median = 5.0 years; Range = 3.4-9.1 years), we assessed cancer-specific and genetic testing distress, perceived stress, and perceived cancer risk. We evaluated the impact of BRCA1/2 test result and risk-reducing surgery on long-term psychosocial outcomes.

RESULTS

Among participants who had been affected with breast or ovarian cancer, BRCA1/2 carriers reported higher genetic testing distress (β = 0.41, P < 0.0001), uncertainty (β = 0.18, P < 0.0001), and perceived stress (β = 0.17, P = 0.005) compared with women who received negative (i.e., uninformative) results. Among women unaffected with breast/ovarian cancer, BRCA1/2 carriers reported higher genetic testing distress (β = 0.39, P < 0.0001) and lower positive testing experiences (β = 0.25, P = 0.008) than women with negative results. Receipt of risk-reducing surgery was associated with lower perceived cancer risk (P < 0.0001).

CONCLUSIONS

In this first prospective long-term study in a U.S. sample, we found modestly increased distress in BRCA1/2 carriers compared with women who received uninformative or negative test results. Despite this modest increase in distress, we found no evidence of clinically significant dysfunction.

IMPACT

Although a positive BRCA1/2 result remains salient among carriers years after testing, testing does not seem to impact long-term psychologic dysfunction.

Closing the gap in mammogram screening: an experimental intervention among low-income Hispanic women in community health clinics

A low rate of mammogram screening exists among low-income Hispanic women. To address this disparity, an experimental intervention containing audiovisual and written media was conducted using the health belief model as a framework. The purpose of this study was to determine if low-income Hispanic women, more than 40 years of age, who received targeted cancer prevention education (n = 105) had a significantly greater perceived threat of breast cancer, greater benefits and lower barriers to screening, and stronger intentions to obtain mammograms compared to a control group (n = 105). Intervention participants reported significantly greater perceived benefits, self-efficacy, and mammogram screening intentions than the control group. Predictors of mammogram screening intentions, when controlling for covariates, included receiving the intervention, and having greater perceived benefits, self-efficacy, and lower barriers. Results demonstrate the effectiveness of a low-cost, theory-based intervention aimed at increasing mammogram screening to assist in the monitoring of Healthy People 2020 objectives.

Interest in genetic testing for modest changes in breast cancer risk: implications for SNP testing

BACKGROUND

Advances in genomics may eventually lead to 'personalized genetic medicine,' yet the clinical utility of predictive testing for modest changes in risk is unclear. We explored interest in genetic testing for genes related to modest changes in breast cancer risk in women at moderate to high risk for breast cancer.

METHODS

Women (n = 105) with a negative breast biopsy and ≥1 relative with breast or ovarian cancer completed telephone surveys. We measured demographic and psychosocial variables and, following presentation of hypothetical scenarios of genetic tests for lower-penetrance breast cancer gene mutations, assessed interest in willingness to pay for and comprehension of test results. We used logistic regression models with generalized estimating equations to evaluate combinations of risk level, cost and behavioral modifiers.

RESULTS

Many women (77%) reported 'definite' interest in genetic testing, with greater interest in tests that conveyed more risk and cost less. Behavioral modifiers of risk (taking a vitamin; diet/exercise), having a regular physician, greater perceived benefits of genetic testing, and greater cancer worry also influenced interest. Most participants (63%) did not understand relative vs. absolute risk. Women with less understanding reported more cancer worry and greater willingness to pay for testing.

CONCLUSION

Interest in genetic testing for mutations related to modest changes in risk was high, modified by both test and psychosocial factors. Findings highlight the need for education about benefits and risks of testing for mutations that convey modest changes in risk, particularly given the current lack of clinical validity/utility and availability of direct-to-consumer genetic testing.

The influence of nativity and neighborhoods on breast cancer stage at diagnosis and survival among California Hispanic women

BACKGROUND

In the US, foreign-born Hispanics tend to live in socioeconomic conditions typically associated with later stage of breast cancer diagnosis, yet they have lower breast cancer mortality rates than their US-born counterparts. We evaluated the impact of nativity (US- versus foreign-born), neighborhood socioeconomic status (SES) and Hispanic enclave (neighborhoods with high proportions of Hispanics or Hispanic immigrants) on breast cancer stage at diagnosis and survival among Hispanics.

METHODS

We studied 37,695 Hispanic women diagnosed from 1988 to 2005 with invasive breast cancer from the California Cancer Registry. Nativity was based on registry data or, if missing, imputed from case Social Security number. Neighborhood variables were developed from Census data. Stage at diagnosis was analyzed with logistic regression, and survival, based on vital status determined through 2007, was analyzed with Cox proportional hazards regression.

RESULTS

Compared to US-born Hispanics, foreign-born Hispanics were more likely to be diagnosed at an advanced stage of breast cancer (adjusted odds ratio (OR) = 1.14, 95% confidence interval (CI): 1.09-1.20), but they had a somewhat lower risk of breast cancer specific death (adjusted hazard ratio (HR) = 0.94, 95% CI: 0.90-0.99). Living in low SES and high enclave neighborhoods was associated with advanced stage of diagnosis, while living in a lower SES neighborhood, but not Hispanic enclave, was associated with worse survival.

CONCLUSION

Identifying the modifiable factors that facilitate this survival advantage in Hispanic immigrants could help to inform specific interventions to improve survival in this growing population.

Adherence to a breast cancer screening program and its predictors in underserved women in southern Brazil

BACKGROUND

Adherence to breast cancer screening is a key element to ensure effectiveness of programs aiming at downstaging of breast cancer. In this study, we evaluated adherence to a screening program and its predictors in underserved women in southern Brazil.

METHODS

Attendance to the program, which is based on yearly mammogram and clinical examination, was evaluated prospectively. Mean time frames between visits were calculated. Possible predictors of adherence (defined as mean intervals ≤18 mo), such as socioeconomic indicators and health/lifestyle behaviors, were investigated.

RESULTS

A total of 3,749 women (age 51 ± 8 y, illiteracy rate of 6.8%, 57.4% with parity ≥3) were analyzed. Median time between screening rounds was 16.5 months (interquartile range, 13.1-25.7), and median number of rounds attended was 3 (interquartile range, 2-4); 57.6% had mean intervals ≤18, and 71% ≤24 months. The most important independent predictors of adherence were high genetic risk [relative risk (RR), 1.25; 95% confidence interval (95% CI), 1.11-1.40], illiteracy (RR, 0.77; 95% CI, 0.67-0.90), parity ≥5 (RR, 0.89; 95% CI, 0.83-0.96), and smoking (RR, 0.82; 95% CI, 0.77-0.88).

CONCLUSIONS

Although the proposed screening interval was 1 year, compliance to biannual screening (accepted in several international programs) was high, especially when considering the low socioeconomic level of the sample.

IMPACT

This project aims to test a breast cancer screening model for underserved populations in limited-resource countries where adherence is an issue. The identification of worst adherence predictors can point to interventions to improve outcomes of similar public health screening strategies.

Health disparities in the Latino population

In this review, the authors provide an approach to the study of health disparities in the US Latino population and evaluate the evidence, using mortality rates for discrete medical conditions and the total US population as a standard for comparison. They examine the demographic structure of the Latino population and how nativity, age, income, and education are related to observed patterns of health and mortality. A key issue discussed is how to interpret the superior mortality indices of Latino immigrants and the subsequent declining health status of later generations. Explanations for differences in mortality include selection, reverse selection, death record inconsistencies, inequalities in health status, transnational migration, social marginality, and adaptation to environmental conditions in the United States. The utility of the public health social inequality framework and the status syndrome for explaining Latino disparities is discussed. The authors examine excess mortality from 8 causes: diabetes, stomach cancer, liver cancer, cervical cancer, human immunodeficiency virus/acquired immunodeficiency syndrome, liver disease, homicide, and work-related injuries. The impact of intergenerational changes in health behavior within the Latino population and the contributory role of suboptimal health care are interpreted in the context of implications for future research, public health programs, and policies.

Access to mammography screening in a large urban population: a multi-level analysis

Objective

To understand area-based sociodemographics, physician and medical practice characteristics, and community indicators associated with mammography use in Los Angeles County. An earlier multi-level analysis by Gumpertz et al. found that distance to the nearest mammography facility helped explain the higher proportion of Latinas diagnosed with late stage breast cancer compared with non-Latina Whites in Los Angeles County. Our study examined whether Latinas also have lower rates of mammography use.

Methods

We used a multi-level spatial modeling approach to examine individual and community level associations with mammography use among a diverse group of women aged 40–84 years in Los Angeles County. To build our multi-level spatial data set, we integrated five data sources: (1) 2001 California Health Interview Survey (CHIS) data, (2) 2001 Food and Drug Administration (FDA) certified mammography facility data, (3) 2003 LA Transit Authority data, (4) 2000 US Decennial Census data, and (5) 2001 Community Tracking Study (CTS) Physician’s Survey data.

Results

Our study confirmed for Los Angeles County many associations for mammography use found in other locations. An unexpected finding was that women with limited English proficiency (predominantly Latina) were significantly more likely to have had a recent mammogram than English-proficient women. We also found that, after controlling for other factors, mammography use was higher in neighborhoods with a greater density of mammography facilities.

Conclusion

Women with limited English proficiency were especially likely to report recent mammography in Los Angeles. This unexpected finding suggests that the intensive Spanish-language outreach program conducted by the Every Woman Counts (EWC) Program in low-income Latina communities in Los Angeles has been effective. Our study highlights the success of this targeted community-based outreach conducted between 1999 and 2001. These are the same populations that Gumpertz et al. identified as needing intervention. It would be useful to conduct another study of late-stage diagnosis in Los Angeles County to ascertain whether increased rates of mammography have also led to less late-stage diagnosis among Latinas in the neighborhoods where they are concentrated in Los Angeles.

Are health-care relationships important for mammography adherence in Latinas?

BACKGROUND

Latinas are the fastest growing racial ethnic group in the United States and have an incidence of breast cancer that is rising three times faster than that of non-Latino white women, yet their mammography use is lower than that of non-Latino women.

OBJECTIVES

We explored factors that predict satisfaction with health-care relationships and examined the effect of satisfaction with health-care relationships on mammography adherence in Latinas.

DESIGN AND SETTING

We conducted a cross-sectional survey of 166 Latinas who were >or=40 years old. Women were recruited from Latino-serving clinics and a Latino health radio program.

MEASUREMENTS

Mammography adherence was based on self-reported receipt of a mammogram within the past 2 years. The main independent variable was overall satisfaction with one's health-care relationship. Other variables included: self report of patient-provider communication, level of trust in providers, primary language, country of origin, discrimination experiences, and perceptions of racism.

RESULTS

Forty-three percent of women reported very high satisfaction in their health-care relationships. Women with high trust in providers and those who did not experience discrimination were more satisfied with their health-care relationships compared to women with lower trust and who experienced discrimination (p < .01). Satisfaction with the health-care relationship was, in turn, significantly associated with mammography adherence (OR: 3.34, 95% CI: 1.47-7.58), controlling for other factors.

CONCLUSIONS

Understanding the factors that impact Latinas' mammography adherence may inform intervention strategies. Efforts to improve Latina's satisfaction with physicians by building trust may lead to increased use of necessary mammography.