Cancer screening in women: body mass index and adherence to physician recommendations

Screening Mammography Adherence Improves After Bariatric Surgery

INTRODUCTION

Poor adherence to mammography screening guidelines has been reported in women with obesity. However, bariatric surgery has been associated with lower incidence of breast cancer postoperatively. The mechanisms for this protective effect are unknown. We examined the relationship between bariatric surgery and screening mammography adherence.

METHODS

Using a commercial health insurance claims database, all female patients between ages 40 and 64 who underwent bariatric surgery were identified and compared to three control groups who did not undergo bariatric surgery stratified across obesity-related billing codes. Screening mammography rates were calculated as the total number of screenings divided by the total person-years of follow-up. THe screening rate was standardized to a frequency of 1 exam every 2 y based on United States Preventative Services Taskforce guidelines. We ran multivariable Poisson regression models of the rate of mammography screening, adjusting for sociodemographic factors and comorbidities.

RESULTS

The rates of screening were 0.91 of the recommended frequency in bariatric surgery patients prior to surgery and 1.22 of the recommended frequency after surgery (P < 0.001). In multivariable models, bariatric surgery patients had a significantly lower rate of mammogram screening in the presurgical period (incidence rate ratio 0.99, 95% CI 0.98-0.99, P = 0.025) and a significantly higher rate in the postsurgical period (incidence rate ratio 1.34, 95% CI 1.32-1.35, P < 0.001) relative to the "no obesity" control group.

CONCLUSIONS

The rate of adherence to recommended mammography screening for breast cancer increased following bariatric surgery. This suggests that women with obesity may experience improved mammography screening adherence following bariatric surgery.

The Relationship Between Death Anxiety and COVID-19 Fear and Anxiety in Women With Breast Cancer

This study determined the relationship between death anxiety and COVID-19 related fear and anxiety in women with breast cancer. This is a descriptive correlation-seeking study. The research included 140 women with breast cancer who visit the day treatment unit of the oncology department of a state university hospital. Personal Information Form, Fear of COVID-19 Scale (FCV-19S), Coronavirus Anxiety Scale (CAS), and Death Anxiety Scale (DAS) were used to collect data. A significant difference was found between the DAS score and body mass index (p = .019) and between FCV-19S score and COVID-19 vaccination status (p = .007). As the fear of COVID-19 and coronavirus anxiety of women with breast cancer increase, death anxiety also increases. In conclusion, death anxiety should be taken into consideration for this patient group while maintaining the continuity of care for these patients now and in future pandemics.

Understanding mechanisms of racial disparities in breast cancer: an assessment of screening and regular care in the Carolina Breast Cancer Study

PURPOSE

Screening history influences stage at detection, but regular preventive care may also influence breast tumor diagnostic characteristics. Few studies have evaluated healthcare utilization (both screening and primary care) in racially diverse screening-eligible populations.

METHODS

This analysis included 2,058 women age 45-74 (49% Black) from the Carolina Breast Cancer Study, a population-based cohort of women diagnosed with invasive breast cancer between 2008 and 2013. Screening history (threshold 0.5 mammograms per year) and pre-diagnostic healthcare utilization (i.e. regular care, based on responses to "During the past ten years, who did you usually see when you were sick or needed advice about your health?") were assessed as binary exposures. The relationship between healthcare utilization and tumor characteristics were evaluated overall and race-stratified.

RESULTS

Among those lacking screening, Black participants had larger tumors (5 + cm) (frequency 19.6% vs 11.5%, relative frequency difference (RFD) = 8.1%, 95% CI 2.8-13.5), but race differences were attenuated among screening-adherent participants (10.2% vs 7.0%, RFD = 3.2%, 0.2-6.2). Similar trends were observed for tumor stage and mode of detection (mammogram vs lump). Among all participants, those lacking both screening and regular care had larger tumors (21% vs 8%, RR = 2.51, 1.76-3.56) and advanced (3B +) stage (19% vs 6%, RR = 3.15, 2.15-4.63) compared to the referent category (screening-adherent and regular care). Under-use of regular care and screening was more prevalent in socioeconomically disadvantaged areas of North Carolina.

CONCLUSIONS

Access to regular care is an important safeguard for earlier detection. Our data suggest that health equity interventions should prioritize both primary care and screening.

The Effects of Obesity on Health Care Delivery

The rates of obesity continue to rise among adults and children in the United States; hence, it is natural that obesity is reshaping health care delivery. This is seen in numerous ways, including physiologic, physical, social, and economic impacts. This article reviews a broad range of topics, from the effects of increased adiposity on drug pharmacokinetics and pharmacodynamics to the changes health care environments are making to accommodate patients with obesity. The significant social impacts of weight bias are reviewed, as are the economic consequences of the obesity epidemic. Finally, a patient case that demonstrates the effects of obesity on health care delivery is examined.

Associated factors and global adherence of cervical cancer screening in 2019: a systematic analysis and modelling study

BACKGROUND

Cervical cancer screening is vital for its prevention. Adherence is a crucial indicator that implies the individual willingness to take cervical cancer screening. We aimed to estimate the global and regional adherence rates of cervical cancer screening in 2019 and identify its associated factors among general women.

METHOD

We searched studies in PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang Database, ProQuest theses database and Google Web, without a lower time limit and until 23 June, 2021. Survey studies were considered eligible if they investigated cervical cancer screening adherence among general women, with data on sample size, the number of adherent subjects, and/or adherence rate. Random-effects were used to pool the odds ratios (ORs) of associated factors of adherence. Using modelling analysis, we estimated 2019 overall and age-specific adherence rates at the global and regional levels in women aged 20-69 years.

RESULTS

Eight thousand two hundred ninety records were identified, and 153 articles were included. Being married (vs not married: OR, 1.34; 95% confidence interval [CI]: 1.23-1.46), higher educational attainment (higher than high school vs less than high school: OR, 1.44; 95% CI: 1.35-1.53), having healthcare (OR, 1.64; 95% CI: 1.43-1.88), former smoking (OR, 1.20; 95% CI: 1.07-1.34), physical activity (OR, 1.19; 95% CI: 1.05-1.36), parity (OR, 1.07; 95% CI: 1.01-1.12), and chronic disease (OR, 1.17; 95% CI: 1.04-1.32) were associated with better adherence, whereas obesity (vs normal: OR, 0.85; 95% CI: 0.74-0.97) and current smoking (vs former/never: OR, 0.64; 95% CI: 0.54-0.76) were associated with worse adherence. In 2019, the adherence was at 33.66% (95% CI: 23.34-39.30%) worldwide, and was higher in high-income countries (HICs) (75.66, 95% CI: 66.74-82.81%) than in low and middle-income countries (LMICs) (24.91, 95% CI: 14.30-30.24%). It varied across regions, the highest in the European region (65.36, 95% CI: 55.40-74.19%), but the lowest in the African region (5.28, 95% CI: 3.43-8.03%).

CONCLUSIONS

Cervical cancer screening adherence remained low globally, exhibiting geographical discrepancy with HICs higher than LMICs. Further implementations of screening programs should comprehensively consider the local economy, social benefits, and demographic structure to adapt delivery for vulnerable or underserved women to boost screening adherence.

Adherence to Pelvic Floor Physical Therapy Referrals in Women With Fecal Incontinence

OBJECTIVES

This study aimed to determine the incidence of patient adherence with prescribed pelvic floor physical therapy (PFPT) in women presenting with fecal incontinence (FI) and to describe patient characteristics associated with nonadherence.

METHODS

This is a retrospective cohort study of women presenting with FI who were prescribed PFPT between January 2010 and December 2019. Adherence with PFPT was defined as either completion of documented recommended physical therapy sessions or discharge from therapy by the therapist before completion of the prescribed sessions.

RESULTS

Complete data were available for 248 patients. A total of 159 (64.1%) patients attended at least 1 session of PFPT. Patients who did not attend any sessions were more likely to have a concurrent diagnosis of pelvic organ prolapse (69.7% vs 55.3%, P = 0.03). When controlled for confounding variables, concurrent prolapse remained associated with nonattendance (adjusted odds ratio of 1.9 [95% confidence interval, 1.0-3.3]). Of the patients who attended PFPT, the adherence rate was 32.7% (n = 50), whereas the rate was 20% for the total cohort. Nonadherent patients were more likely to have a higher body mass index (28.9 vs 26.9, P = 0.02), but this was no longer statistically significant once other patient characteristics were controlled for. Of the entire cohort, 136 (54.8%) followed up with their physicians after the initial referral to PFPT. Of the 59 patients, 43.7% were offered second-line therapy.

CONCLUSION

Of the women prescribed PFPT for a diagnosis of FI, approximately two thirds attended at least a single session, but only one third of those patients were adherent with the recommended therapy.

The Influence of Selected Psychological Factors on Medication Adherence in Patients with Chronic Diseases

Background: Insufficient adherence to treatment is a relevant problem. This study aims to determine the impact of health locus of control, stress coping style and level of mindfulness on medication adherence in patients with a chronic illness. Methods: The study included 768 people. The diagnostic survey involved the use of: Medication Adherence Questionnaire (MAQ), Multidimensional Health Locus of Control Scale (MHLC), The Coping Inventory for Stressful Situations (CISS), and The Mindful Attention Awareness Scale (MAAS). Results: Participants were divided into two subgroups, i.e., adherent (n = 219) and non-adherent (n = 549). We observed significant differences between the subgroups in age, BMI, sex, place of residence, education, and for all MHLC subscales, two CISS subscales and MAAS. The identified medication adherence variables were: female gender (OR = 1.55), BMI (OR = 0.95), MHLC/Internal (OR = 0.95), CISS/Emotional (OR = 1.03), MAAS (OR = 0.97). Conclusions: A strong internal health locus of control, a higher level of mindfulness and a lower level of emotional-stress coping style increase the likelihood of adherence with medication recommendations in patients with chronic diseases.

Cervical Cancer Screening Among Patients with Physical Disability

Background:

Pap smear has a central role in cervical cancer screening. Previous studies have found that female patients with disabilities are less likely to receive a Pap smear as recommended by guidelines. The aim of our study was to examine the association between physical disability and Pap smear receipt in Israel.

Methods:

This cross-sectional study was conducted using the electronic medical records of the second largest health care maintenance organization in Israel. All female patients during 2012–2017 aged 25–65 were identified. The exposure variable was physical disability, and the outcome variable was Pap smear receipt. We used logistic regression to control for covariates.

Results:

A total of 391,259 patients were eligible for this study, 6,720 (1.7%) with physical disability. 56.7% of patients with disabilities had received Pap smear compared to 63.3% of patients without disabilities, odds ratio (OR) 0.76, 95% confidence interval [CI] 0.72–0.80. When adjusting to sociodemographic and clinical covariates, patients with disabilities were less likely to receive Pap smear, adjusted OR 0.83, 95% CI 0.79–0.88. For all patients, older age, lower socioeconomic status, religious minorities, cardiovascular disease, type-2 diabetes mellitus, hypertension, smoking, and obesity were associated with lower odds of receipt of Pap smear. A history of nongynecologic oncologic disease was associated with increased odds of Pap smear receipt.

Conclusion:

Our study highlights the disparities between patients with and without physical disability with regard to screening for cervical cancer by receipt of Pap smear. Creating an appropriate practice with adequate access to patients with disability should be a focus for health care providers and policy makers.

Choices of (in)action in obesity: Implications for research on treatment and prevention

The obesity epidemic has crossed social-demographic barriers and is a matter of significant concern. Why do individuals fail to restrain from eating high-calorie foods and fail to follow treatment routines that reduce the risk of health complications? These questions have been addressed through behavioral and brain imaging studies on prefrontal cortex inhibitory mechanisms. Failure to inhibit undesirable behaviors has become a hallmark of obesity. In many life situations, obesity risk is increased by inaction (e.g., not taking blood pressure medication, not following a healthy diet). Risk by inaction has been defined as passive risk-taking, and it is correlated with traits such as procrastination, future time perspective, and cognitive avoidance. To the present, passive tendencies, specifically in the context of risk-taking behaviors, have not been addressed in the obesity literature. We introduce a framework in which active and passive risk-taking behaviors are integrated within the scope of bidirectional models of obesity that describe the brain as both the cause and the consequence of obesity vulnerability. The present perspective aims to foster new research on treatment and prevention, and also on the neurobiology of passive behaviors in obesity and other metabolic conditions.

Effect of accessibility improvement in a national population-based breast cancer screening policy on mammography utilization among women with comorbid conditions in Taiwan

In Taiwan, a Cancer Screening Quality Improvement Program (CAQIP), implemented in 2010, provides financial support to qualified hospitals to improve accessibility. This study aimed to examine the effect of CAQIP on mammography participation among women aged 50-69 years at various health statuses. A natural experimental study design before and after CAQIP implementation in 2010 was conducted. Phase 1 included 437,875 screened and 1,490,453 non-screened women, and 830,348 and 1,03,454 in Phase 2. Compared with women with no comorbidity, women with severe chronic conditions were less likely to participate in mammography screening. CAQIP was positively associated with the likelihood of mammography participation (OR 3.899, 95% CI 3.878-3.920); the magnitude of the effect was smaller for women with comorbid conditions. The findings provide evidences and economic theorical perspectives of potential benefits of health policy interventions to improve accessibility and mammography participation among women aged 50-69 years with comorbid conditions.

Factors associated with mammography use: A side-by-side comparison of results from two national surveys

BACKGROUND

Mammography use is affected by multiple factors that may change as public health interventions are implemented. We examined two nationally representative, population-based surveys to seek consensus and identify inconsistencies in factors associated with mammography use in the entirety of the US population, and by black and white subgroups.

METHODS

Self-reported mammography use in the past year was extracted for 12 639 and 169 116 women aged 40-74 years from the 2016 National Health Interview Survey (NHIS) and the 2016 Behavioral Risk Factor Surveillance System (BRFSS), respectively. We applied a random forest algorithm to identify the risk factors of mammography use and used a subset of them in multivariable survey logistic regressions to examine their associations with mammography use, reporting predictive margins and effect sizes.

RESULTS

The weighted prevalence of past year mammography use was comparable across surveys: 54.31% overall, 54.50% in white, and 61.57% in black in NHIS and 53.24% overall, 56.97% in white, and 62.11% in black in BRFSS. Overall, mammography use was positively associated with black race, older age, higher income, and having health insurance, while negatively associated with having three or more children at home and residing in the Western region of the US. Overweight and moderate obesity were significantly associated with increased mammography use among black women (NHIS), while severe obesity was significantly associated with decreased mammography use among white women (BRFSS).

CONCLUSION

We found higher mammography use among black women than white women, a change in the historical trend. We also identified high parity as a risk factor for mammography use, which suggests a potential subpopulation to target with interventions aimed at increasing mammography use.

Weight-lowering Effects of Glucagon-like Peptide-1 Receptor Agonists and Detection of Breast Cancer Among Obese Women with Diabetes

BACKGROUND

It has been proposed that the weight loss associated with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may improve detection of breast cancer in patients undergoing this treatment. We aimed to determine whether the weight-lowering effects of GLP-1 RAs are associated with an increased detection of breast cancer among obese women with type 2 diabetes.

METHODS

Using the UK Clinical Practice Research Datalink, we conducted a propensity score-matched cohort study among female obese patients with type 2 diabetes newly treated with antidiabetic drugs between 1 January 2007 and 31 January 2018. New users of GLP-1 RAs (n = 5,510) were matched to new users of second- to third-line noninsulin antidiabetic drugs (n = 5,510). We used time-dependent Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of breast cancer associated with different GLP-1 RA maximal weight loss categories (<5%, 5%-10%, >10%).

RESULTS

Breast cancer incidence gradually increased with GLP-1 RA maximal weight loss categories, with the highest HR observed for patients achieving at least 10% weight loss (HR = 1.8, 95% CI = 1.1, 2.8). In secondary analyses, the HR for >10% weight loss was highest in the 2-3 years since treatment initiation (HR = 2.9, 95% CI = 1.2, 6.9).

CONCLUSIONS

In this population-based study, the detection of breast cancer gradually increased with GLP-1 RA weight loss categories, particularly among those achieving >10% weight loss. These results are consistent with the hypothesis that substantial weight loss with GLP-1 RAs may improve detection of breast cancer among obese patients with type 2 diabetes.

The determinants of cervical cancer screening uptake in women with obesity: application of the Andersen's behavioral model to the CONSTANCES survey

PURPOSE

Despite their higher risk for and mortality from cervical cancer, evidence indicates low rates of cervical cancer screening (CCS) among women with obesity. The literature on the specific factors related to CCS nonadherence in this population is limited.

METHODS

We examined the data on 2,934 women with obesity included in the CONSTANCES survey from 2012 to 2015. Using the Andersen's behavioral model, we studied the relationships between the socioeconomic, sociodemographic, health, health personal behaviors, and healthcare use-related factors with CCS nonadherence. The analysis was performed using structural equation models.

RESULTS

Regular follow-up by a gynecologist, good quality of primary care follow-up, and comorbidities were negatively associated with CCS nonadherence. Limited literacy, older age, being single, living without children, and financial strain were positively associated with CCS nonadherence. Our results do not point to competitive care, since women with comorbidities had better CCS behaviors, which were explained by a good quality of primary care follow-up.

CONCLUSION

Our study identified the factors that explain CCS nonadherence among women with obesity and clarified the effects of health status and healthcare use on screening. Further efforts should be undertaken to reduce the obstacles to CCS by improving care among women with obesity.

Obesity and breast cancer screening: Cross-sectional survey results from the behavioral risk factor surveillance system

BACKGROUND

Postmenopausal obese women demonstrate an elevated breast cancer risk and experience increased breast cancer morbidity and mortality compared with women with a normal body mass index (BMI). However, to the authors' knowledge, prior studies have yielded inconclusive results regarding the effects of obesity on mammography screening adherence. Using national cross-sectional survey data, the objective of the current study was to assess the current association between increasing BMI and use of mammography screening.

METHODS

Cross-sectional survey data from the 2016 Behavioral Risk Factor Surveillance System, a state-based national telephone survey of noninstitutionalized adults in the United States, was used to identify the association between mammography screening use and increasing incremental BMI categories, including normal (18.5-24.9 kg/m2 ), overweight (25-29.9 kg/m2 ), obese class I (30-34.9 kg/m2 ), obese class II (35-39.9 kg/m2 ), and obese class III (>40 kg/m2 ), with adjustments for potential confounders. A multivariable logistic regression model was used to evaluate the effect of each BMI category on self-reported mammography use, using unadjusted and adjusted odds ratios. Effect modification by race/ethnicity was determined by testing interaction terms using Wald tests.

RESULTS

Of 116,343 survey respondents, 33.5% (38,984 respondents) had a normal BMI, 32.6% (37,969 respondents) were overweight, 19.3% (22,416 respondents) were classified as obese class I, 8.4% (9791 respondents) were classified as obese class II, and 6.2% (7183 respondents) were classified as obese class III. There was no statistically significant difference (P < .05) observed with regard to mammography use between women with a normal BMI and obese women from each obese class (classes I-III) when compared individually. There also was no evidence of effect modification by race (P = .53).

CONCLUSIONS

In contrast to prior reports, the results of the current study demonstrated no association between obesity and adherence to screening mammography. These findings may relate to the increasing social acceptance of obesity among women from all racial/ethnic groups and the removal of weight-related facility-level barriers over time.

Weight bias and health care utilization: a scoping review

Aim:

The purpose of this scoping review was to explore the evidence on how perceptions and/or experiences of weight bias in primary health care influence engagement with and utilization of health care services by individuals with obesity.

Background:

Prior studies have found discrepancies in the use of health care services by individuals living with obesity; a greater body mass index has been associated with decreased health care utilization, and weight bias has been identified as a major barrier to engagement with health services.

Methods:

PubMed was searched from January 2000 to July 2017. Four reviewers independently selected 21 studies examining perceptions of weight bias and its impact on engagement with primary health care services.

Findings:

A thematic analysis was conducted on the 21 studies that were included in this scoping review. The following 10 themes were identified: contemptuous, patronizing, and disrespectful treatment, lack of training, ambivalence, attribution of all health issues to excess weight, assumptions about weight gain, barriers to health care utilization, expectation of differential health care treatment, low trust and poor communication, avoidance or delay of health services, and ‘doctor shopping’. Overall, our scoping review reveals how perceptions and/or experiences of weight bias from primary care health professionals negatively influence patient engagement with primary health care services.

Association of body mass and systemic immune-inflammation indices with endocrine therapy resistance in luminal breast cancers

OBJECTIVE

To explore correlations between body mass index (BMI), preoperative systemic immune-inflammation index (SII) and endocrine therapy resistance, and evaluate BMI and SII as predictors of resistance, in patients with luminal breast cancer.

METHODS

This retrospective study included patients with luminal breast cancer who underwent endocrine therapy at Hebei General Hospital. Relationships between BMI and SII subgroups, and clinicopathological parameters were analysed using χ2-tests. Disease-free survival was assessed using Log-rank statistics. Multivariate analysis of factors related to disease progression were analysed using Cox proportional hazards model.

RESULTS

Out of 161 patients, those with normal BMI and low SII had significantly lower endocrine resistance rates versus those with high BMI and SII, and BMI was significantly positively correlated with SII. High BMI or SII was associated with significantly lower disease-free survival rates. Hazard ratios for disease progression risk were 6.036, 3.508 and 1.733, for SII, BMI and TNM stage, respectively.

CONCLUSION

In patients with luminal breast cancer, high BMI (>23 kg/m2) and SII (>518 × 109/L) levels may predict high endocrine resistance rates. BMI, SII and TNM stage were independent prognostic factors for endocrine therapy resistance.

Double Discourse: Qualitative Perspectives on Breast Screening Participation among Obese Women and Their Health Care Providers

Obesity in Australia is rising rapidly, and is a major public health concern. Obesity increases the risk of breast cancer and worsens associated outcomes, yet breast screening participation rates in Australia are suboptimal and can be lower in higher risk, obese women. This study qualitatively explored barriers to breast screening participation in obese women in Australia. In-depth interviews (n = 29), were conducted with obese women (body mass index ≥ 30) and key health providers. A disconnect between providers’ and women’s perceptions was found. For women, low knowledge around a heightened need to screen existed, they also reported limited desire to prioritize personal health needs, reluctance to screen due to poor body image and prior negative mammographic experiences due to issues with weight. Providers perceived few issues in screening obese women beyond equipment limitations, and health and safety issues. Overall, weight was a taboo topic among our interviewees, indicating that a lack of discourse around this issue may be putting obese women at increased risk of breast cancer morbidity and mortality. Consideration of breast screening policy in obese women is warranted. Targeted health promotion on increased breast cancer risk in obese women is required as is a need to address body image issues and encourage screening participation.

Patient and physician characteristics affect adherence to screening mammography: A population-based cohort study

BACKGROUND

Screening mammograms are widely recommended biennially for women between the ages of 50 and 74. Despite the benefits of screening mammograms, full adherence to recommendations falls below 75% in most developed countries. Many studies have identified individual (obesity, smoking, socio-economic status, and co-morbid conditions) and primary-care physician parameters (physician age, gender, clinic size and cost) that influence adherence, but little data exists from large population studies regarding the interaction of these individual factors.

METHODS

We performed a historical cohort study of 44,318 Israeli women age 56-74 using data captured from electronic medical records of a large Israeli health maintenance organization. Univariate analysis was used to examine the association between each factor and adherence (none, partial or full) with screening recommendations between 2008-2014. Multivariate analysis was used to examine the significance of these factors in combination, using binary and multinomial logistic regression.

RESULTS

Among 44,318 women, 42%, 43% and 15% were fully, partially and non-adherent to screening recommendations, respectively. Factors associated with inferior adherence identified in our population included: smoking, obesity, low body weight, low socio-economic status, depression, diabetes mellitus and infrequent physician visits, while, women with ischemic heart disease, female physicians, physicians between the ages of 40 and 60, and medium-sized clinics were associated with higher screening rates. Most factors remained significant in the multivariate analysis.

CONCLUSIONS

Both individual and primary-care physician factors contribute to adherence to mammography screening guidelines. Strategies to improve adherence and address disparities in mammography utilization will need to address these factors.

Layered stigma? Co-occurring depression and obesity in the public eye

OBJECTIVES

Obesity and depression are common conditions in the general public and show a high level of co-morbidity. Both conditions are stigmatized, i.e., associated with negative attitudes and discrimination. Previous research shows that devalued conditions can overlap or combine to produce a layered stigma which is associated with more negative health outcomes than either single devalued condition alone. This study therefore set out to investigate the double stigma of obesity and depression.

METHODS

A telephone-based representative study of the German population was conducted. Vignettes describing women with obesity, depression or both conditions were presented, followed by a set of items on semantic differentials based on previous stigma research of depression (depression stigma DS) and obesity (Fat Phobia Scale FPS). Personal experience with depression and obesity was assessed.

RESULTS

All comparisons were significant in univariate ANOVA, showing negative attitudes measured by the FPS and the DS to be most pronounced in the double stigma condition. Multivariate analysis, controlling for age, gender, education and personal experience with the stigma condition (e.g. having obesity or depression), show that the double stigma obesity and depression is associated to more negative attitudes on the FPS (b=0.163, p<0.001) and the DS (b=0.154, p=0.002) compared to the single-stigma condition.

CONCLUSIONS

The magnitude of the layered stigma of obesity and depression may need to be considered in mental health settings when treating the depressed patient with obesity, but likewise in obesity care when treating the obese patient with depression.

Psychological distress associated with cancer screening: A systematic review

BACKGROUND

Current national cancer screening recommendations include the potential risk of psychological harm related to screening. However, data on the relation of psychological distress to cancer screening is limited. The authors conducted a systematic review to assess psychological distress associated with cancer screening procedures.

METHODS

Studies that administered measures of psychological distress between 2 weeks before and 1 month after the screening procedure were included.

RESULTS

In total, 22 eligible studies met criteria for review, including 13 observational trials and 9 randomized controlled trials. Eligible studies used a broad range of validated and unvalidated measures. Anxiety was the most commonly assessed construct and was measured using the State Trait Anxiety Inventory. Studies included breast, colorectal, prostate, lung, and cervical screening procedures. Distress was low across procedures, with the exception of colorectal screening. Distress did not vary according to the time at which distress was measured. None of the studies were conducted exclusively with the intention of assessing distress at the time of screening.

CONCLUSIONS

Evidence of low distress during the time of cancer screening suggests that distress might not be a widespread barrier to screening among adults who undergo screening. However, more studies are needed using validated measures of distress to further understand the extent to which screening may elicit psychological distress and impede adherence to national screening recommendations. Cancer 2017;123:3882-94. © 2017 American Cancer Society.

Using Social Media to Characterize Public Sentiment Toward Medical Interventions Commonly Used for Cancer Screening: An Observational Study

Background

Although cancer screening reduces morbidity and mortality, millions of people worldwide remain unscreened. Social media provide a unique platform to understand public sentiment toward tools that are commonly used for cancer screening.

Objective

The objective of our study was to examine public sentiment toward colonoscopy, mammography, and Pap smear and how this sentiment spreads by analyzing discourse on Twitter.

Methods

In this observational study, we classified 32,847 tweets (online postings on Twitter) related to colonoscopy, mammography, or Pap smears using a naive Bayes algorithm as containing positive, negative, or neutral sentiment. Additionally, we characterized the spread of sentiment on Twitter using an established model to study contagion.

Results

Colonoscopy-related tweets were more likely to express negative than positive sentiment (negative to positive ratio 1.65, 95% CI 1.51-1.80, P<.001), in contrast to the more positive sentiment expressed regarding mammography (negative to positive ratio 0.43, 95% CI 0.39-0.47, P<.001). The proportions of negative versus positive tweets about Pap smear were not significantly different (negative to positive ratio 0.95, 95% CI 0.87-1.04, P=.18). Positive and negative tweets tended to share lexical features across screening modalities. Positive tweets expressed resonance with the benefits of early detection. Fear and pain were the principal lexical features seen in negative tweets. Negative sentiment for colonoscopy and mammography spread more than positive sentiment; no correlation with sentiment and spread was seen for Pap smear.

Conclusions

Analysis of social media data provides a unique, quantitative framework to better understand the public’s perception of medical interventions that are commonly used for cancer screening. Given the growing use of social media, public health interventions to improve cancer screening should use the health perceptions of the population as expressed in social network postings about tests that are frequently used for cancer screening, as well as other people they may influence with such postings.

Why Do Chilean Women Choose to Have or Not Have Pap Tests?

OBJECTIVE

To describe the perceptions of Chilean women about why women choose to have or not have Pap test screening.

DESIGN

Qualitative research using content analysis according to Krippendorf.

SETTING

Four urban health clinics in Santiago, Chile.

PARTICIPANTS

Fifty-seven Chilean women.

METHODS

Audiotaped focus groups.

RESULTS

Six themes emerged: Reasons that make it difficult for women to schedule appointments, Characteristics of health professionals that make it difficult to have a Pap test, Characteristics of the test that are barriers to having a Pap test, The relationship of the test with cancer, Family context, and Each woman's personal characteristics.

CONCLUSION

Primary health care providers play an important role in promoting adherence to cervical cancer screening. Nurses should proactively address women's perceptions and knowledge about screening and openly and uniformly discuss the importance and benefits of Pap test screening.

The relationship of obesity, mammographic breast density, and magnetic resonance imaging in patients with breast cancer

PURPOSE

The purpose was to evaluate the relationship between body mass index (BMI), mammographic breast density, magnetic resonance (MR) background parenchymal enhancement (BPE), and MR fibroglandular tissue (FGT) in women with breast cancer.

METHODS

Our institutional database was queried for patients with preoperative mammography and breast MR imaging.

RESULTS

There were 573 women eligible for analysis. Elevated BMI was associated with advanced stage of disease (P=.01), lower mammographic density (P<.0001), lower FGT (P<.0001), higher BPE (P=.005), and nonpalpable lesions (P=.04).

CONCLUSIONS

Higher BMI was associated with decreased breast density and FGT. Higher BMI was also associated with advanced stage disease and nonpalpable tumors on clinical exam.

Predictors of Non-Adherence to Breast Cancer Screening among Hospitalized Women

Objective

Disparities in screening mammography use persists among low income women, even those who are insured, despite the proven mortality benefit. A recent study reported that more than a third of hospitalized women were non-adherent with breast cancer screening. The current study explores prevalence of socio-demographic and clinical variables associated with non-adherence to screening mammography recommendations among hospitalized women.

Patients and Methods

A cross sectional bedside survey was conducted to collect socio-demographic and clinical comorbidity data thought to effect breast cancer screening adherence of hospitalized women aged 50–75 years. Logistic regression models were used to assess the association between these factors and non-adherence to screening mammography.

Results

Of 250 enrolled women, 61% were of low income, and 42% reported non-adherence to screening guidelines. After adjustment for socio-demographic and clinical predictors, three variables were found to be independently associated with non-adherence to breast cancer screening: low income (OR = 3.81, 95%CI; 1.84–7.89), current or ex-smoker (OR = 2.29, 95%CI; 1.12–4.67), and history of stroke (OR = 2.83, 95%CI; 1.21–6.60). By contrast, hospitalized women with diabetes were more likely to be compliant with breast cancer screening (OR = 2.70, 95%CI 1.35–5.34).

Conclusion

Because hospitalization creates the scenario wherein patients are in close proximity to healthcare resources, at a time when they may be reflecting upon their health status, strategies could be employed to counsel, educate, and motivate these patients towards health maintenance. Capitalizing on this opportunity would involve offering screening during hospitalization for those who are overdue, particularly for those who are at higher risk of disease.

The impact of level of education on adherence to breast and cervical cancer screening: Evidence from a systematic review and meta-analysis

OBJECTIVE

To assess the inequalities in adherence to breast and cervical cancer screening according to educational level.

METHODS

A systematic review was carried out between 2000 and 2013 by querying an electronic database using specific keywords. Studies published in English reporting an estimation of the association between level of education and adherence to breast and/or cervical cancer screening were included in the study. Two different meta-analyses were carried out for adherence to breast and cervical cancer screening, respectively: women with the highest level of education and women with the lowest level of education were compared. The level of heterogeneity was investigated and subgroup analyses were carried out.

RESULTS

Of 1231 identified articles, 10 cross-sectional studies were included in the analysis. The meta-analyses showed that women with the highest level of education were more likely to have both screenings with an overall OR=1.61 (95% CI 1.36-1.91; I(2)=71%) for mammography and OR=1.96 (95% CI 1.79-2.16; I(2)=0%) for Pap test, respectively. Stratified meta-analysis for breast cancer screening included only studies that reported guidelines with target age of population ≥50 years and showed a reduction in the level of heterogeneity and an increase of 36% in the adherence (95% CI 1.19-1.55; I(2)=0%).

CONCLUSIONS

This study confirms and reinforces evidence of inequalities in breast and cervical cancer screening adherence according to educational level.

Association between Pap smear screening and job stress in Taiwanese nurses

PURPOSE

Nursing is a professional job characterized by high stress. Stress could be associated with less practice of health promoting behaviors; however, no study has investigated the relationship between job stress and health screening behaviors among nurses. This study aimed to describe the rate of Pap smears in hospital nurses and examine the effects of job stress on receiving a Pap smear.

METHODS

This study was a cross-sectional survey. The study participants were 30,681 full-time female nurses who were at least 30 years of age working in 100 hospitals across Taiwan. The study participants filled out an anonymous structured questionnaire from May to July, 2011. The outcome variable was having a Pap test during the previous 3 years. The level of stress was measured by a 19-item scale, with higher scores indicating higher stress levels.

RESULTS

About 62.4% of the nurses had a Pap smear during the previous three years. Each point increase in the stress score decreased the likelihood of Pap smears (OR = .997, 95% CI: .995-.999), after adjustment for participant characteristics, health status, health behaviors, and hospital characteristics.

CONCLUSION

Despite more knowledge and higher accessibility, nurses were less likely to have Pap smear screening than the general population. A higher level of job stress was associated with a lower likelihood of having a Pap smear. Hospital administrators could help decrease work-related stress and improve stress adaption among nurses in order to improve their health screening behaviors.

Body mass index and participation in organized mammographic screening: a prospective cohort study

Background

Breast cancer is the leading cancer among women, and early diagnosis is essential for future prognosis. Evidence from mainly cross-sectional US studies with self-reported exposure and outcome found positive association of body mass index (BMI) with non-participation in mammographic screening, but hardly addressed the influence of potential effect-modifiers. We studied the association between objective measures of BMI and participation in mammographic screening in a Danish prospective cohort, and explored the influence of menopausal status, hormone therapy (HT), previous screening participation, and morbidities on this relationship.

Methods

A total of 5,134 women from the Diet, Cancer, and Health cohort who were invited to population based mammographic screening in Copenhagen were included in analysis. Women were 50–64 years old at inclusion (1993–97) when their height and weight were measured and covariates collected via questionnaire. Odds ratios (OR) and 95% confidence intervals (CI) for the association between BMI and mammographic screening participation were estimated by logistic regression, adjusted for other breast cancer risk factors and morbidities. Effect modification was evaluated by an interaction term and tested by Wald test.

Results

Underweight (BMI < 18.5 kg/m², OR: 95% CI; 2.24: 1.27-3.96) and obese women of class II (BMI 35–40 kg/m², 1.54: 0.99-2.39) and III (BMI ≥ 40 kg/m², 1.81: 0.95-3.44) had significantly higher odds of non-participation than women with normal weight. This association was limited to postmenopausal women (Wald test p = 0.08), with enhanced non-participation in underweight (2.83: 1.52-5.27) and obese women of class II and III (1.84: 1.15-2.95; 2.47: 1.20-5.06) as compared to normal weight postmenopausal women. There was no effect modification by HT, previous screening participation, or morbidities, besides suggestive evidence of enhanced non-participation in diabetic overweight and obese women.

Conclusions

Underweight and very obese postmenopausal women were significantly less likely to participate in mammographic screening than women with normal weight, while BMI was not related to screening in premenopausal women. Effect of BMI on mammographic screening participation was not significantly modified by HT, previous screening participation, or morbidities.

Obesity and Healthcare Avoidance: A Systematic Review

This review addresses the issue of health care avoidance and obesity. English language journal articles published between 1990 and 2012 that addressed the review question; “is being overweight or obese an unrecognized factor in healthcare avoidance?” were located using major databases. A modified JADAD scoring system was then used to assess papers. Ten papers were identified which directly addressed the review question. A positive relationship exists between obesity and healthcare avoidance. The major contributory factors were being female, have a diagnosed mental health problem and perceived or actual bias and discrimination by health professionals. The review also highlights the importance of the relationship between healthcare professionals and their patients, and the physical environment in which interactions occur as these may contribute to avoidance behaviors. Concern about obesity is rising and while there has been much discussion about strategies to reduce obesity this review highlights the need for thinking more broadly about the way in which overweight and obese individuals interact with preventative health strategies.

The relationship between body mass index and cancer screening utilization among older women in Latin American and Caribbean cities

To examine the relationship between body mass index and cancer screening utilization, we analyzed data from six cities of the Health, Well-Being and Aging in Latin America and the Caribbean Study on 5,230 women aged 60 and older, from 1999 to 2000. We found that underweight women were less likely to have had a mammogram, a breast self-exam, and a Pap smear, relative to normal-weight women. However, overweight or obese women were more likely to have a breast self-exam and a Pap smear. Thus, being underweight had a role for decreased cancer screening utilization among older women in Latin American cities, but not being overweight or obese, which was associated with decreased cancer screening in most previous studies.

The impact of overweight and obesity on breast cancer: data from Switzerland, so far a country little affected by the current global obesity epidemic

This review presents results from the project "The Impact of Overweight/Obesity on Breast Cancer: data from Switzerland". Swiss data is interesting because the general female population is distinctive in two areas when compared to that of most other industrialized countries: Switzerland has comparatively low rates of overweight (22-23%) and obesity (7-8%) and has rather stable rates of overweight and obesity. The entire project comprised three major issues: (I) etiology of breast cancer (BC). There is a consistently shown association between obesity and postmenopausal BC risk in countries with high obesity prevalence rates in the literature. In our Swiss study group, however, we did not find higher rates of overweight and obesity in postmenopausal BC cases than in the general population. A possible explanation for this observation may be a curvilinear dose-response relationship between BMI and postmenopausal BC risk, so that an increased risk may only be observed in populations with a high prevalence of obese/very obese women; (II) tumor characteristics. BMI was significantly associated with tumor size; this applied not only to the cases where the tumor was found by self-detection, but also to lesions detected by radiological breast examinations. In addition, a higher BMI was positively correlated with advanced TNM stage, unfavorable grading and a higher St. Gallen risk score. No associations were observed between BMI and histological subtype, estrogen receptor status, HER2 status and triple negative BC; (III) patient compliance and persistence towards adjuvant BC therapy. Many studies found that the prognosis of overweight/obese BC patients was significantly lower than that of normal weight patients. However, failure of compliance and persistence towards therapy on the part of the patient is not a contributing factor for this observed unfavorable prognosis. In most therapy modes, patients with increasing BMI demonstrated greater motivation and perseverance towards the recommended treatment.

In a safety net population HPV4 vaccine adherence worsens as BMI increases

Objectives

Obesity adversely inhibits antibody response to vaccination. Three doses of HPV4 may or may not provide adequate long term protection against HPV 16/18 in obese females. The aim of this study was to determine whether adherence to HPV4 vaccination in a safety net population was reduced with increasing body mass index (BMI).

Methods

We designed a historical prospective study evaluating the number and dates of HPV4 dosing that occurred from July 1, 2006 through October 1, 2009 by the demographic characteristics of the 10–26 year old recipient females. The defined dosing intervals were adapted from the literature and obesity categories were defined by the WHO.

Results

1240 females with BMI measurements received at least one dose of HPV4; 38% were obese (class I, II and III) and 25% were overweight. Females with normal BMI received on-time triplet dosing significantly more often than did the obese class II and III females (30% vs. 18%, p<0.001). Obese class II/III females have a significant 45% less chance of completing the on-time triplet HPV4 series than normal women (OR = 0.55, 95% CI: 0.37, 0.83). Pregnancy history has a significant influence on BMI and HPV4 dosing compliance in this safety net population where 71% had been gravid. Hispanic females were less likely to complete HPV4 dosing regardless of BMI (aOR = 0.39, 95% CI: 0.16, 0.95).

Conclusions

Obesity, as well as gravidity and Hispanic race, are risk factors for lack of HPV4 vaccine adherence among young females in a safety net population.

Impact of body mass index on prognostically relevant breast cancer tumor characteristics

BACKGROUND

This study analyzes the association of body mass index (BMI) and prognostically relevant breast cancer (BC) characteristics in a country that has been rather spared of the global obesity epidemic.

PATIENTS AND METHODS

Based on 20-year data (1999-2009, n = 1,414) of the prospective relational BC database of the University Hospital Basel, Switzerland, the associations between BMI, tumor size and stage, histological subtype, grading, hormonal receptor status, HER2 status and 'triple-negative' status were evaluated. Multivariate analysis considered BMI and patient's age.

RESULTS

The association between increasing BMI and the above-mentioned variables were as follows (results described in each case: Beta-coefficient or odds ratio, 95% confidence interval, p value): tumor size, (1) entire cohort: 0.03 (0.01-0.05), p < 0.001, (2) tumor found by self-palpation: 0.05 (0.03-0.07), p < 0.001, (3) tumor found by radiological examination: 0.03 (0-0.07), p = 0.044; advanced TNM stage: 1.16 (1.02-1.31), p = 0.022; histological subtype: 1.04 (0.89-1.22), p = 0.602; unfavorable grading: 1.11 (1.00-1.25), p = 0.057; positive estrogen receptor status: 0.95 (0.83-1.09), p = 0.459; positive HER2 status: 0.92 (0.74-1.15), p = 0.467; presence of a 'triple-negative' carcinoma: 1.19 (0.93-1.52), p = 0.165. Consideration of only postmenopausal BC patients (n = 1,063) did attenuate the results, but did not change the direction of the associations with BMI.

CONCLUSION

BMI was positively associated with TNM stage, grading and tumor size for tumors that were found by self-detection, as well as for those lesions detected by radiological breast examinations.

Breast cancer screening in an insured population: whom are we missing?

INTRODUCTION

Kaiser Permanente Colorado is an integrated health care system that uses automatic reminder programs and reduces barriers to access preventive services, including financial barriers. Breast cancer screening rates have not improved during the last five years, and rates differ between subgroups: for example, black and Latina women have lower rates of mammography screening than other racial groups.

METHODS

We retrospectively evaluated data from 47,946 women age 52 to 69 years who had continuous membership for 24 months but had not undergone mammography. Poisson regression models estimated relative risk for the impact of self-identified race/ethnicity, socioeconomic characteristics, health status, and use of health care services on screening completion.

RESULTS

The distribution of race/ethnicity among unscreened women was 55.5% white, 7.0% Latina, and 3.7% black, but race/ethnicity data were missing for 29%. Of these, no record of race/ethnicity was available for 86.7%, and for 5.1%, the data request was recorded but the women declined to identify their race/ethnicity. Nonwhite ethnicity increased risk of screening failure if black, Latina, "other" (eg, American Indian), or missing race/ethnicity. Population-attributable risks were low for minorities compared with the group for whom race/ethnicity data was missing. A greater number of office visits in any setting was associated with greater likelihood of undergoing mammography. Women with missing race/ethnicity data had fewer visits and were less likely to have an identified primary care physician.

CONCLUSIONS

Greater improvement in mammography screening rates could be achieved in our population by increasing screening among women with missing race/ethnicity data, rather than by targeting those who are known to be of racial/ethnic minorities. Efforts to address screening disparities have been refocused on inreach and outreach to our "missing women."

The link between women's body image disturbances and body-focused cancer screening behaviors: a critical review of the literature and a new integrated model for women

A large body of literature demonstrates the association between body image disturbances and health compromising behaviors among women (e.g., pathological eating, substance use, inappropriate exercise). However, given that disturbed body image is a pervasive problem, it is likely inversely related to health maintenance behaviors. Cancer screenings for breast, skin, and cervical cancer represent an important type of health maintenance behavior, yet adherence rates are low. Given the body-focused nature of these screenings, body image may be a salient predictor. This paper reviews the literature on the relationship between body image disturbances and cancer screening behaviors among women culminating in the proposal of a theoretical model. This model posits that body shame and body avoidance predict performance of cancer screenings and that variables drawn from the cancer literature, including risk perception, health anxiety, subjective norms, and self-efficacy, may moderate this relationship. Clinical implications and suggestions for research are discussed.

Breast cancer screening: evidence of benefit depends on the method used

In this article, we discuss the most common epidemiological methods used for evaluating the ability of mammography screening to decrease the risk of breast cancer death in general populations (effectiveness). Case-control studies usually find substantial effectiveness. However when breast cancer mortality decreases for reasons unrelated to screening, the case-control design may attribute to screening mortality reductions due to other causes. Studies based on incidence-based mortality have obtained contrasted results compatible with modest to considerable effectiveness, probably because of differences in study design and statistical analysis. In areas where screening has been widespread for a long time, the incidence of advanced breast cancer should be decreasing, which in turn would translate into reduced mortality. However, no or modest declines in the incidence of advanced breast cancer has been observed in these areas. Breast cancer mortality should decrease more rapidly in areas with early introduction of screening than in areas with late introduction of screening. Nonetheless, no difference in breast mortality trends has been observed between areas with early or late screening start. When effectiveness is assessed using incidence-based mortality studies, or the monitoring of advanced cancer incidence, or trends in mortality, the ecological bias is an inherent limitation that is not easy to control. Minimization of this bias requires data over long periods of time, careful selection of populations being compared and availability of data on major confounding factors. If case-control studies seem apparently more adequate for evaluating screening effectiveness, this design has its own limitations and results must be viewed with caution.See related Opinion article: http://www.biomedcentral.com/1741-7015/10/106 and Commentary http://www.biomedcentral.com/1741-7015/10/164.

Physician recommendation and patient adherence for colorectal cancer screening

BACKGROUND

Physician recommendation is one of the strongest, most consistent predictors of colorectal cancer (CRC) screening. Little is known regarding characteristics associated with patient adherence to physician recommendations in community and academic based primary care settings.

METHODS

Data were analyzed from 975 patients, aged ≥50 years, recruited from 25 primary care practices in New Jersey. Chi-square and generalized estimate equation analyses determined independent correlates of receipt of and adherence to physician recommendation for CRC.

RESULTS

Patients reported high screening rates for CRC (59%). More than three fourths of patients reported either screening or having received a screening recommendation (82%). Men (P = .0425), nonsmokers (P = .0029), and patients who were highly educated (P = .0311) were more likely to receive a CRC screening recommendation. Patients more adhere to CRC screening recommendations were older adults (P < .0001), nonsmokers (P = .0005), those who were more highly educated (P = .0365), Hispanics (P = .0325), and those who were married (P < .0001).

CONCLUSIONS

Community and academic primary care clinicians appropriately recommended screening to high-risk patients with familial risk factors. However, they less frequently recommended screening to others (ie, women and smokers) also likely to benefit. To further increase CRC screening, clinicians must systematically recommend screening to all patients who may benefit.

Linguistic and ethnic disparities in breast and cervical cancer screening and health risk behaviors among Latina and Asian American women

PURPOSE

This study intends to (1) describe breast and cervical cancer screening patterns and health risk behaviors for Latina and Asian American women, with consideration for their language, and (2) investigate the impact of health risk behaviors on breast and cervical cancer screenings after controlling for demographic characteristics and language.

METHODS

Data derived from the California Health Interview Survey 2007, which was a random-digit-dial population-based survey, were used. Latina (n = 3513) and Asian American (n = 2538) women were included in this study. Breast and cervical cancer screenings were measured by recent mammography and Pap smear examinations, respectively. Physical activity, smoking habits, alcohol consumption, and body mass index (BMI) were measured to assess health risk behaviors.

RESULTS

This study demonstrated that Asian Americans have better outcomes in health risk behaviors in general. However, Latinas were more likely than Asian Americans to receive mammograms and Pap smears. English-speaking Latinas and Asian Americans showed better outcomes in cancer screening and health risk behaviors, but BMI patterns differed based on language. Unhealthy risk behaviors were related to low screening rates, except for BMI and drinking, among Latina women.

CONCLUSIONS

The findings reveal unique ethnic and linguistic patterns that are relevant to health risk behaviors and cancer screening and that influence overall health outcomes. These findings suggest that health risk behaviors and cancer screening for ethnic minority populations may be framed by cultural contexts. Intervention strategies designed to promote healthy lifestyles and cancer screening may have greater sustainable benefits.