Breast Density Awareness, Knowledge, and Attitudes Among US Women: National Survey Results Across 5 Years

A Survey of Patient Experience During Molecular Breast Imaging

Molecular breast imaging (MBI) is one of several options available to patients seeking supplemental screening due to mammographically dense breasts. Patient experience during MBI may influence willingness to undergo the test but has yet to be formally assessed. We aimed to assess patient comfort level during MBI, to compare MBI comfort with mammography comfort, to identify factors associated with MBI discomfort, and to evaluate patients' willingness to return for future MBI. Methods: A 10-question survey was sent by e-mail to patients undergoing MBI between August and December 2022 to obtain quantitative assessments and qualitative opinions about MBI. Results: Of 561 invited patients, 209 (37%) completed the survey and provided study consent. Their average age was 60.1 y (range, 40-81 y). Of the 209 responders, 202 (97%) were presenting for screening MBI, 195 (94%) had dense breasts, and 46 (22%) had a personal history of breast cancer. The average rating of MBI comfort was 2.9 (SD, 1.5; median, 3.0) on a 7-point scale (1 indicating extremely comfortable and 7 indicating extremely uncomfortable). The rating distribution was as follows: 140 (67%) comfortable (rating, 1-3); 24 (12%) neither comfortable nor uncomfortable (rating, 4); and 45 (22%) uncomfortable (rating, 5 or 6). No responders gave a 7 rating. The most frequently mentioned sources of discomfort included breast compression (n = 16), back or neck discomfort (n = 14), and maintaining position during the examination (n = 14). MBI comfort was associated with responder age (74% ≥55 y old were comfortable, versus 53% <55 y old [P = 0.003]) and history of MBI (71% with prior MBI were comfortable, versus 61% having a first MBI [P = 0.006]). Of 208 responders with a prior mammogram, 148 (71%) said MBI is more comfortable than mammography (a significant majority [P < 0.001]). Of 202 responders to the question of whether they were willing to return for a future MBI, 196 (97%) were willing. A notable factor in positive patient experience was interaction with the MBI nuclear medicine technologist. Conclusion: Most responders thought MBI to be a comfortable examination and more comfortable than mammography. Patient experience during MBI may be improved by ensuring back support and soliciting patient feedback at the time of positioning and throughout the examination. Methods under study to reduce imaging time may be most important for improving patient experience.

The impact of breast density notification on psychosocial outcomes in racial and ethnic minorities: A systematic review

BACKGROUND

High breast density is an independent risk factor for breast cancer and decreases the sensitivity of mammography. This systematic review synthesizes the evidence on the impact of breast density (BD) information and/or notification on women's psychosocial outcomes among women from racial and ethnic minority groups.

METHODS

A systematic search was performed in March 2023, and the articles were identified using CINHAL, Embase, Medline, and PsychInfo databases. The search strategy combined the terms "breast", "density", "notification" and synonyms. The authors specifically kept the search terms broad and did not include terms related to race and ethnicity. Full-text articles were reviewed for analysis by race, ethnicity and primary language of participants. Two authors evaluated the eligibility of studies with verification from the study team, extracted and crosschecked data, and assessed the risk of bias.

RESULTS

Of 1784 articles, 32 articles published from 2003 to 2023 were included. Thirty-one studies were conducted in the United States and one in Australia, with 28 quantitative and four qualitative methodologies. The overall results in terms of breast density awareness, knowledge, communication with healthcare professionals, screening intentions and supplemental screening practice were heterogenous across studies. Barriers to understanding BD notifications and intentions/access to supplemental screening among racial and ethnic minorities included socioeconomic factors, language, health literacy and medical mistrust.

CONCLUSIONS

A one-size approach to inform women about their BD may further disadvantage racial and ethnic minority women. BD notification and accompanying information should be tailored and translated to ensure readability and understandability by all women.

Factors Associated with Increased Knowledge about Breast Density in South Australian Women Undergoing Breast Cancer Screening

Background: There is growing awareness of breast density in women attending breast cancer screening; however, it is unclear whether this awareness is associated with increased knowledge. This study aims to evaluate breast density knowledge among Australian women attending breast cancer screening. Method: This cross-sectional study was conducted on women undergoing breast cancer screening at The Queen Elizabeth Hospital Breast/Endocrine outpatient department. Participants were provided with a questionnaire to assess knowledge, awareness, and desire to know their own breast density. Result: Of the 350 women who participated, 61% were familiar with 'breast density' and 57% had 'some knowledge'. Prior breast density notification (OR = 4.99, 95% CI = 2.76, 9.03; p = 0.004), awareness (OR = 4.05, 95% CI = 2.57, 6.39; p = 0.004), younger age (OR = 0.97, 95% CI = 0.96, 0.99; p = 0.02), and English as the language spoken at home (OR = 3.29, 95% CI = 1.23, 8.77; p = 0.02) were independent predictors of 'some knowledge' of breast density. A significant proportion of participants (82%) expressed desire to ascertain their individual breast density. Conclusions: While knowledge of breast density in this Australian cohort is generally quite low, we have identified factors associated with increased knowledge. Further research is required to determine optimal interventions to increase breast density knowledge.

Should we share breast density information during breast cancer screening in the United Kingdom? an integrative review

OBJECTIVE

Dense breasts are an established risk factor for breast cancer and also reduce the sensitivity of mammograms. There is increasing public concern around breast density in the UK, with calls for this information to be shared at breast cancer screening.

METHODS

We searched the PubMed database, Cochrane Library and grey literature, using broad search terms in October 2022. Two reviewers extracted data and assessed the risk of bias of each included study. The results were narratively synthesised by five research questions: desire for information, communication formats, psychological impact, knowledge impact and behaviour change.

RESULTS

We identified 19 studies: three Randomised Controlled Trials (RCTs), three cohort studies, nine cross-sectional studies, one qualitative interview study, one mixed methods study and two 2021 systematic reviews. Nine studies were based in the United States of America (USA), five in Australia, two in the UK and one in Croatia. One systematic review included 14 USA studies, and the other 27 USA studies, 1 Australian and 1 Canadian. The overall GRADE evidence quality rating for each research question was very low to low.Generally, participants wanted to receive breast density information. Conversations with healthcare professionals were more valued and effective than letters. Breast density awareness after notification varied greatly between studies.Breast density information either did not impact frequency of mammography screening or increased the intentions of participants to return for routine screening as well as intention to access, and uptake of, supplementary screening. People from ethnic minority groups or of lower socioeconomic status (SES) had greater confusion following notification, and, along with those without healthcare insurance, were less likely to access supplementary screening.

CONCLUSION

Breast density specific research in the UK, including different communities, is needed before the UK considers sharing breast density information at screening. There are also practical considerations around implementation and recording, which need to be addressed.

ADVANCES IN KNOWLEDGE

Currently, sharing breast density information at breast cancer screening in the UK may not be beneficial to participants and could widen inequalities. UK specific research is needed, and measurement, communication and future testing implications need to be carefully considered.

Protocol for a pragmatic stepped wedge cluster randomized clinical trial testing behavioral economic implementation strategies to increase supplemental breast MRI screening among patients with extremely dense breasts

BACKGROUND

Increased breast density augments breast cancer risk and reduces mammography sensitivity. Supplemental breast MRI screening can significantly increase cancer detection among women with dense breasts. However, few women undergo this exam, and screening is consistently lower among racially minoritized populations. Implementation strategies informed by behavioral economics ("nudges") can promote evidence-based practices by improving clinician decision-making under conditions of uncertainty. Nudges directed toward clinicians and patients may facilitate the implementation of supplemental breast MRI.

METHODS

Approximately 1600 patients identified as having extremely dense breasts after non-actionable mammograms, along with about 1100 clinicians involved with their care at 32 primary care or OB/GYN clinics across a racially diverse academically based health system, will be enrolled. A 2 × 2 randomized pragmatic trial will test nudges to patients, clinicians, both, or neither to promote supplemental breast MRI screening. Before implementation, rapid cycle approaches informed by clinician and patient experiences and behavioral economics and health equity frameworks guided nudge design. Clinicians will be clustered into clinic groups based on existing administrative departments and care patterns, and these clinic groups will be randomized to have the nudge activated at different times per a stepped wedge design. Clinicians will receive nudges integrated into the routine mammographic report or sent through electronic health record (EHR) in-basket messaging once their clinic group (i.e., wedge) is randomized to receive the intervention. Independently, patients will be randomized to receive text message nudges or not. The primary outcome will be defined as ordering or scheduling supplemental breast MRI. Secondary outcomes include MRI completion, cancer detection rates, and false-positive rates. Patient sociodemographic information and clinic-level variables will be examined as moderators of nudge effectiveness. Qualitative interviews conducted at the trial's conclusion will examine barriers and facilitators to implementation.

DISCUSSION

This study will add to the growing literature on the effectiveness of behavioral economics-informed implementation strategies to promote evidence-based interventions. The design will facilitate testing the relative effects of nudges to patients and clinicians and the effects of moderators of nudge effectiveness, including key indicators of health disparities. The results may inform the introduction of low-cost, scalable implementation strategies to promote early breast cancer detection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05787249. Registered on March 28, 2023.

Psychosocial outcomes and health service use after notifying women participating in population breast screening when they have dense breasts: a BreastScreen Queensland randomised controlled trial

BACKGROUND

Robust evidence regarding the benefits and harms of notifying Australian women when routine breast screening identifies that they have dense breasts is needed for informing future mammography population screening practice and policy.

OBJECTIVES

To assess the psychosocial and health services use effects of notifying women participating in population-based breast cancer screening that they have dense breasts; to examine whether the mode of communicating this information about its implications (print, online formats) influences these effects.

METHODS AND ANALYSIS

The study population comprises women aged 40 years or older who attend BreastScreen Queensland Sunshine Coast services for mammographic screening and are found to have dense breasts (BI-RADS density C or D). The randomised controlled trial includes three arms (952 women each): standard BreastScreen care (no notification of breast density; control arm); notification of dense breasts in screening results letter and print health literacy-sensitive information (intervention arm 1) or a link or QR code to online video-based health literacy-sensitive information (intervention arm 2). Baseline demographic data will be obtained from BreastScreen Queensland. Outcomes data will be collected in questionnaires at baseline and eight weeks, twelve months, and 27 months after breast screening. Primary outcomes will be psychological outcomes and health service use; secondary outcomes will be supplemental screening outcomes, cancer worry, perceived breast cancer risk, knowledge about breast density, future mammographic screening intentions, and acceptability of notification about dense breasts.

ETHICS APPROVAL

Gold Coast Hospital and Health Service Ethics Committee (HREC/2023/QGC/89770); Sunshine Coast Hospital and Health Service Research Governance and Development (SSA/2023/QSC/89770).

DISSEMINATION OF FINDINGS

Findings will be reported in peer-reviewed journals and at national and international conferences. They will also be reported to BreastScreen Queensland, BreastScreen Australia, Cancer Australia, and other bodies involved in cancer care and screening, including patient and support organisations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12623000001695p (prospective: 9 January 2023).

Analytic Hierarchy Process Analysis of Patient Preferences for Contrast-Enhanced Mammography Versus MRI as Supplemental Screening Options for Breast Cancer

OBJECTIVE

To guide implementation of supplemental breast screening by assessing patient preferences for contrast-enhanced mammography (CEM) versus MRI using analytic hierarchy process (AHP) methodology.

METHODS

In an institutional review board-approved, HIPAA-compliant protocol, from March 23 to June 3, 2022, we contacted 579 women who had both CEM screening and MRI. Women were e-mailed an invitation to complete an online survey developed using an AHP-based model to elicit preferences for CEM or MRI. Methods for categorical data analysis were used to evaluate factors affecting preferences, under the Bonferroni correction for multiplicity.

RESULTS

Complete responses were received from 222 (38.3%) women; the 189 women with a personal history of breast cancer had a mean age 61.8 years, and the 34 women without a personal history of breast cancer had a mean age of 53.6 years. Of 222 respondents, 157 (70.7%, confidence interval [CI]: 64.7-76.7) were determined to prefer CEM to MRI. Breast positioning was the most important criterion for 74 of 222 (33.3%) respondents, with claustrophobia, intravenous line placement, and overall stress most important for 38, 37, and 39 women (17.1%, 16.7%, and 17.6%), respectively, and noise level, contrast injection, and indifference being emphasized least frequently (by 10 [4.5%], 11 [5.0%], and 13 [5.9%] women, respectively). CEM preference was most prevalent (MRI least prevalent) for respondents emphasizing claustrophobia (37 of 38 [97%], CI: 86.2-99.9); CEM preference was least prevalent (MRI most prevalent) for respondents emphasizing breast positioning (40 of 74 [54%], CI: 42.1-65.7).

CONCLUSIONS

AHP-based modeling reveals strong patient preferences for CEM over MRI, with claustrophobia favoring preference for CEM and breast positioning relatively favoring preference for MRI. Our results should help guide implementation of screening CEM and MRI.

Perceptions of Breast Cancer Risks Among Women Receiving Mammograph Screening

Importance

Breast density is an independent risk factor for breast cancer. Despite the proliferation of mandated written notifications about breast density following mammography, there is little understanding of how women perceive the relative breast cancer risk associated with breast density.

Objective

To assess women's perception of breast density compared with other breast cancer risks and explore their understanding of risk reduction.

Design, Setting, and Participants

This mixed-methods qualitative study used telephone surveys and semistructured interviews to investigate perceptions about breast cancer risk among a nationally representative, population-based sample of women. Eligible study participants were aged 40 to 76 years, reported having recently undergone mammography, had no history of prior breast cancer, and had heard of breast density. Survey participants who had been informed of their personal breast density were invited for a qualitative interview. Survey administration spanned July 1, 2019, to April 30, 2020, with 2306 women completing the survey. Qualitative interviews were conducted from February 1 to May 30, 2020.

Main Outcomes and Measures

Respondents compared the breast cancer risk associated with breast density with 5 other risk factors. Participants qualitatively described what they thought contributed to breast cancer risk and ways to reduce risk.

Results

Of the 2306 women who completed the survey, 1858 (166 [9%] Asian, 503 [27%] Black, 268 [14%] Hispanic, 792 [43%] White, and 128 [7%] other race or ethnicity; 358 [19%] aged 40-49 years, 906 [49%] aged 50-64 years, and 594 [32%] aged ≥65 years) completed the revised risk perception questions and were included in the analysis. Half of respondents thought breast density to be a greater risk than not having children (957 [52%]), having more than 1 alcoholic drink per day (975 [53%]), or having a prior breast biopsy (867 [48%]). Most respondents felt breast density was a lesser risk than having a first-degree relative with breast cancer (1706 [93%]) or being overweight or obese (1188 [65%]). Of the 61 women who were interviewed, 6 (10%) described breast density as contributing to breast cancer risk, and 43 (70%) emphasized family history as a breast cancer risk factor. Of the interviewed women, 17 (28%) stated they did not know whether it was possible to reduce their breast cancer risk.

Conclusions and Relevance

In this qualitative study of women of breast cancer screening age, family history was perceived as the primary breast cancer risk factor. Most interviewees did not identify breast density as a risk factor and did not feel confident about actions to mitigate breast cancer risk. Comprehensive education about breast cancer risks and prevention strategies is needed.

Australian General Practitioners' Current Knowledge, Understanding, and Feelings Regarding Breast Density Information and Notification: A Cross-Sectional Study

BACKGROUND

There is a lack of evidence around Australian general practitioners' (GPs) views of issues surrounding breast density. The current study aimed to quantitatively assess GPs' current knowledge, understanding, and feelings around breast density information and notification.

METHODS

This study involved a cross-sectional survey using an online platform to collect quantitative data from Australian GPs. Survey data were analysed with descriptive statistics.

RESULTS

A total 60 responses from GPs were analysed. Most (n = 58; 97%) had heard or read about breast density and nearly 90% (n = 52; 87%) have had discussions about breast density with patients. Three-quarters (n = 45; 75%) were supportive of making breast density notification mandatory for patients with dense tissue and a similar proportion (n = 45/58; 78%) felt they need or want more education on breast density.

CONCLUSIONS

There is strong support for notifying patients of breast density, and interest in further education and training among the surveyed GPs. As GPs play a central role in cancer prevention and control, their involvement in discussions related to breast density notification, evaluation and appraisal of evidence, development of communication strategies, and participation in ongoing research on the topic will be indispensable.

A letter is not enough: Women's preferences for and experiences of receiving breast density information

OBJECTIVE

Despite evidence of disparate uptake of breast density (BD) information, little is known about diverse women's preferences for and experiences learning about BD.

METHODS

Telephone survey among 2306 racially/ethnically and literacy diverse women; qualitative interviews with 61 survey respondents. Responses by participant race/ethnicity and literacy were examined using bivariate, then multivariable analyses. Interviews were content-analyzed for themes.

RESULTS

Most women (80%) preferred learning of personal BD from providers, with higher rates among Non-Hispanic Black (85%) than Non-Hispanic White women (80%); and among Non-Hispanic White than Asian women (72%, all ps<0.05). Women with low literacy less often preferred receiving BD information from providers (76% v. 81%), more often preferring written notification (21% vs. 10%); women with high literacy more often preferred learning through an online portal (9% vs 3%). Most women (93%) received BD information from providers (no between group differences). Qualitative findings detailed women's desires for obtaining BD information from providers, written information, and visual depictions of BD.

CONCLUSIONS

When educating women about BD, one size does not fit all.

PRACTICE IMPLICATIONS

Additional educational methods are needed beyond written BD notifications to sufficiently address the varying informational needs and preferences of all USA women.

Women's Understandings and Misunderstandings of Breast Density and Related Concepts: A Mixed Methods Study

Background: Most U.S. states require written notification of breast density after mammograms, yet effects of notifications on knowledge are mixed. Little is known about potential misunderstandings. Methods: We used a sequential mixed-methods study design to assess women's knowledge about breast density, after receiving a notification. We conducted a telephone survey among a racially/ethnically and health-literacy level diverse sample (N = 754) and qualitative interviews with 61 survey respondents. Results: In survey results, 58% of women correctly indicated that breast density is not related to touch, with higher accuracy among non-Hispanic White women and those with greater health literacy. Next, 87% of women recognized that breast density is identified visually via mammogram, with no significant differences in responses by race/ethnicity or health literacy. Most (81%) women recognized that a relationship exists between breast tissue types and density; Non-Hispanic White women were less likely to respond correctly. Only 47% of women correctly indicated that having dense breasts increases one's risk of breast cancer; women with low health literacy were more often correct. Qualitative results revealed additional dimensions of understanding: Some women incorrectly reported that density could be felt, or dense breasts were lumpier, thicker, or more compacted; others identified "dense" tissue as fatty. Interpretations of risk included that breast density was an early form of breast cancer. Conclusion: We found areas of consistent knowledge and identified misperceptions surrounding breast density across race/ethnicity and health literacy levels. Further education to address disparities and correct misunderstandings is essential to promote better knowledge, to foster informed decisions.

Australian Women's Intentions and Psychological Outcomes Related to Breast Density Notification and Information: A Randomized Clinical Trial

IMPORTANCE

Whether the benefits of notifying women about breast density outweigh the potential harms to inform current and future mammogram screening practice remains unknown.

OBJECTIVE

To assess the effect of mammographic breast density notification and information provision on women's intention to seek supplemental screening and psychological outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A 3-arm online randomized clinical trial was conducted from August 10 to 31, 2021. Data analysis was conducted from September 1 to October 20, 2021. Participants included Australian residents identifying as female, aged between 40 and 74 years, with no history of breast cancer who were residing in jurisdictions without existing breast density notification with screening mammograms.

INTERVENTIONS

Women were randomized to receive 1 of the following hypothetical breast screening test result letters: screening mammogram result letter without breast density messaging (control), screening mammogram result letter with breast density messaging and an existing density information letter taken from a screening service in Australia (intervention 1), and screening mammogram result letter with breast density messaging and a health literacy-sensitive version of the letter adapted for people with lower health literacy (intervention 2).

MAIN OUTCOMES AND MEASURES

Primary outcomes were intention to seek supplemental screening; feeling anxious (uneasy, worried, or nervous), informed, or confused; and having breast cancer worry.

RESULTS

A total of 1420 Australian women were randomized and included in the final analysis. The largest group consisted of 603 women aged 60 to 74 years (42.5%). Compared with the control cohort (n = 480), women who received density notification via intervention 1 (n = 470) and intervention 2 (n = 470) reported a significantly higher intention to seek supplemental screening (0.8% vs 15.6% and 14.2%; P < .001) and feeling anxious (14.2% vs 49.4% and 48.5%; P < .001), confusion (7.8% vs 24.0% and 23.6%; P < .001), and worry about breast cancer (quite/very worried: 6.9% vs 17.2% and 15.5%; P < .001). There were no statistically significant differences in these outcomes between the 2 intervention groups.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, breast density notification and information integrated with screening mammogram results increased women's intention to seek supplemental screening and made women feel anxious, confused, or worried about breast cancer. These findings have relevance and implications for mammogram screening services and policy makers considering whether and, if so, how best to implement widespread notification of breast density as part of mammography screening.

TRIAL REGISTRATION

ACTRN12621000253808.

Variation in Breast Cancer Risk Model Estimates Among Women in Their 40s Seen in Primary Care

Background: The Gail, Breast Cancer Surveillance Consortium (BCSC), and Tyrer-Cuzick breast cancer risk prediction models are recommended for use in primary care. Calculating breast cancer risk is particularly important for women in their 40s when deciding on mammography, with some guidelines recommending screening for those with 5-year risk similar to women age 50 (≥1.1%). Yet, little is known about risk estimate agreement among models for these women. Materials and Methods: Four hundred nine Boston-area women 40-49 years of age completed a risk questionnaire before a primary care visit to compute their breast cancer risk. The kappa statistic was used to examine when (1) Gail and BCSC agreed on 5-year risk ≥1.1%; (2) Gail estimated 5-year risk ≥1.7% and Tyrer-Cuzick estimated 10-year risk ≥5% (guideline thresholds for recommending prevention medications); and when (3) Gail and Tyrer-Cuzick agreed on lifetime risk ≥20% (threshold for breast MRI using Tyrer-Cuzick). Results: Participant mean age was 44.1 years, 56.7% were non-Hispanic white, and 7.8% had a first-degree relative with breast cancer. Of 266 with breast density information to estimate both Gail and BCSC, the models agreed on 5-year risk being ≥1.1% for 36 women, kappa = 0.34 (95% confidence interval: 0.23-0.45). Gail and Tyrer-Cuzick estimates led to agreement about prevention medications for 8 women, kappa 0.41 (0.20-0.61), and models agreed on lifetime risk ≥20% for 3 women, kappa 0.08 (-0.01 to 0.16). Conclusions: There is weak agreement on breast cancer risk estimates generated by risk models recommended for primary care. Using different models may lead to different clinical recommendations for women in their 40s.

Evaluating educational interventions to increase breast density awareness among Latinas: A randomized trial in a Federally Qualified Health Center

BACKGROUND

The objective of this randomized trial was to evaluate the short-term effect of bilingual written and interpersonal education regarding mammographic breast density (MBD).

METHODS

Latinas aged 40 to 74 years who were presenting for screening mammography were recruited and randomized 1:1:1 to receive a letter with their mammogram and MBD results (usual care [UC]), a letter plus a brochure (enhanced care [ENH]), or a letter plus a brochure and telephonic promotora education (interpersonal care [INT]). Surveys were administered at enrollment (T₀ ) and 2 weeks to 6 months after intervention delivery (T₁ ). Differences were assessed with χ² , Kruskal-Wallis, and McNemar tests and pairwise comparisons as appropriate. INT metrics and audio recordings were analyzed with descriptive statistics and qualitative content analysis.

RESULTS

Between October 2016 and October 2019, 943 of 1108 Latina participants (85%) completed both surveys. At T₁ , INT participants were more likely (P < .001) to report seeing their MBD results in the letter (70.2%) than UC (53.1%) or ENH participants (55.1%). The percentage of INT women who reported speaking with a provider about MBD (29.0%) was significantly greater (P < .001) than the percentage of UC (14.7%) or ENH participants (15.6%). All groups saw significant (P < .001) but nondifferential improvements in their knowledge of MBD as a masking and risk factor. In the INT group, the promotora delivered education to 77.1% of the 446 participants randomized to INT and answered questions at 28.3% of the encounters for an average of $4.70 per participant.

CONCLUSIONS

Among Latinas in a low-resource setting, MBD knowledge may increase with written or interpersonal education, but with modest investment, interpersonal education may better improve MBD awareness and prompt patient-provider discussions.

Breast cancer worry, uncertainty, and perceived risk following breast density notification in a longitudinal mammography screening cohort

BACKGROUND

Dense breast notification (DBN) legislation aims to increase a woman's awareness of her personal breast density and the implications of having dense breasts for breast cancer detection and risk. This information may adversely affect women's breast cancer worry, perceptions of risk, and uncertainty about screening, which may persist over time or vary by sociodemographic factors. We examined short- and long-term psychological responses to DBN and awareness of breast density (BD).

METHODS

In a predominantly Hispanic New York City screening cohort (63% Spanish-speaking), ages 40-60 years, we assessed breast cancer worry, perceived breast cancer risk, and uncertainties about breast cancer risk and screening choices, in short (1-3 months)- and long-term (9-18 months) surveys following the enrollment screening mammogram (between 2016 and 2018). We compared psychological responses by women's dense breast status (as a proxy for DBN receipt) and BD awareness and examined multiplicative interaction by education, health literacy, nativity, and preferred interview language.

RESULTS

In multivariable models using short-term surveys, BD awareness was associated with increased perceived risk (odds ratio (OR) 2.27, 95% confidence interval (CI) 0.99, 5.20 for high, OR 2.19, 95% CI 1.34, 3.58 for moderate, vs. low risk) in the overall sample, and with increased uncertainty about risk (OR 1.97 per 1-unit increase, 95% CI 1.15, 3.39) and uncertainty about screening choices (OR 1.73 per 1-unit increase, 95% CI 1.01, 2.9) in Spanish-speaking women. DBN was associated with decreased perceived risk among women with at least some college education (OR 0.32, 95% CI 0.11, 0.89, for high, OR 0.50, 95% CI 0.29, 0.89, for moderate vs. low risk), while those with a high school education or less experienced an increase (OR 3.01, 95% CI 1.05, 8.67 high vs. low risk). There were no associations observed between DBN or BD awareness and short-term breast cancer worry, nor with any psychological outcomes at long-term surveys.

CONCLUSIONS

Associations of BD awareness and notification with breast cancer-related psychological outcomes were limited to short-term increases in perceived breast cancer risk dependent on educational attainment, and increases in uncertainty around breast cancer risk and screening choices among Spanish-speaking women.

Breast Density Knowledge and Awareness Among Latinas in a Low-Resource Setting

PURPOSE

Latinas in low-resource settings face additional barriers to understanding mammographic breast density (MBD) implications. The authors compared MBD awareness and knowledge in Latinas from a safety-net clinic in Arizona with a national sample.

METHODS

Latinas 40 to 74 years of age were recruited within a safety-net clinic during screening mammography appointments from 2016 to 2019 (AZ cohort) and from a nationally representative online panel in 2017 (NS cohort). Surveys completed in either English or Spanish assessed awareness and knowledge of MBD. Chi-square tests and logistic regression were used for comparisons.

RESULTS

The NS cohort (n = 152) was older, more educated, more likely to have undergone prior mammography, and more likely to prefer English compared with the AZ cohort (n = 1,327) (P ≤ .03 for all) The NS cohort was more likely to be aware of MBD (32.6% versus 20.7%). Of those aware, the NS cohort was more likely to understand MBD's effect on masking (67.8% versus 37.0%) and breast cancer risk (72.2% versus 32.6%) compared with the AZ cohort (P ≤ .001 for all). Adjusting for age, education, screening history, and language, MBD awareness was similar between the two cohorts (adjusted odds ratio [ORadj], 0.95; P = .83), but knowledge of MBD as a masking factor (ORadj, 2.8; P = .03) and risk factor (ORadj, 7.2; P < .001) remained higher in the NS cohort compared with the AZ cohort.

CONCLUSIONS

Differences in MBD awareness, but not knowledge, between Latinas in a low-resource setting compared with a national sample could be explained by age, education, screening history, and language preference, underscoring the need for tailored approaches to MBD education among Latinas.

The Impact of Breast Density Information or Notification on Women's Cognitive, Psychological, and Behavioral Outcomes: A Systematic Review

BACKGROUND

Breast density (BD) is an independent risk factor for breast cancer and reduces the sensitivity of mammography. This systematic review aims to synthesize evidence from existing studies to understand the impact of BD information and/or notification on women's cognitive, psychological, and behavioral outcomes.

METHODS

Studies were identified via relevant database searches up to March 2020. Two authors evaluated the eligibility of studies with verification from the study team, extracted and crosschecked data, and assessed the risk of bias.

RESULTS

Of the 1134 titles identified, 29 studies were included. Twenty-three studies were quantitative, including only 1 randomized controlled trial of women receiving BD information, and 6 were qualitative. Twenty-seven studies were conducted in the United States, with 19 conducted post-BD legislation. The overall results in terms of BD awareness, knowledge, attitudes, perceptions, and intentions were heterogeneous across included studies, with the strongest consistency demonstrated regarding the importance of communication with and involvement of health-care professionals. Together, the studies did, however, highlight that there is still limited awareness of BD in the community, especially in more socioeconomic disadvantaged communities, and limited knowledge about what BD means and the implications for women. Importantly, BD information in the context of overall breast cancer risk has not yet been studied.

CONCLUSIONS

There are important gaps in the understanding of the impact of BD information or notification on women and how best to communicate BD information to women. More high-quality evidence to inform both current and future practice related to BD is still needed.

Breast Density Awareness and Knowledge in a Mammography Screening Cohort of Predominantly Hispanic Women: Does Breast Density Notification Matter?

BACKGROUND

New York State law mandates that women with dense breasts receive a written notification of their breast density (BD) and its implications, but data on the impact of dense breast notification (DBN) on BD awareness and knowledge in diverse populations remain limited.

METHODS

Between 2016 and 2018, we collected survey and mammographic data from 666 women undergoing screening mammography in New York City (ages 40-60, 80% Hispanic, 69% Spanish-speaking) to examine the impact of prior DBN on BD awareness by sociodemographic and breast cancer risk factors, and describe BD knowledge by sources of information.

RESULTS

Only 24.8% of the overall sample and 34.9% of women receiving DBN had BD awareness. In multivariable models adjusting for DBN, awareness was significantly lower in women who were Spanish-speaking [OR, 0.16; 95% confidence interval (CI), 0.09-0.30 vs. English speakers], were foreign-born (OR, 0.31; 95% CI, 0.16-0.58 vs. U.S.-born), and had lower educational attainment (e.g., high school degree or less; OR, 0.14; 95% CI, 0.08-0.26 vs. college or higher degree). Women receiving DBN were more likely to be aware of BD (OR, 2.61; 95% CI, 1.59-4.27) but not more knowledgeable about the impact of BD on breast cancer risk and detection. However, women reporting additional communication about their BD showed greater knowledge in these areas.

CONCLUSIONS

DBN increases BD awareness disproportionately across sociodemographic groups.

IMPACT

Efforts to improve communication of DBN must focus on addressing barriers in lower socioeconomic and racially and ethnically diverse women, including educational and language barriers.

Effect of an educational intervention on women's healthcare provider knowledge gaps about breast density, breast cancer risk, and screening

OBJECTIVES

We sought to assess the effect of an educational intervention, based on DenseBreast-info.org website content, on women's healthcare provider knowledge of breast density, its risk and screening implications, and comfort level discussing these topics with patients.

METHODS

US-based women's healthcare providers participated in a web-based pretest/posttest study from May 14, 2019 to September 30, 2019. Pretest included demographics; comfort/knowledge discussing breast density impact on risk and screening; and educational material. Posttest contained the same knowledge and comfort questions. We assessed mean pretest/posttest score and comfort level differences (paired t tests) and pretest/posttest knowledge gap differences (McNemar test). We evaluated associations of baseline characteristics with pretest score and score improvement using multiple linear regression, and associations with knowledge gaps using logistic regression.

RESULTS

Of 177 providers analyzed, 74.0% (131/177) were physicians and 71.8% (127/177) practiced obstetrics/gynecology. Average test score increased from 40.9% (5.7/14) responses correct pretest to 72.1% (10.1/14) posttest (P < 0.001). Pretest, 56.5% (100/177) knew women with extremely dense breasts have four-to-six-fold greater breast cancer risk than those with fatty breasts; 29.4% (52/177) knew risk increases with increasing glandular tissue; only 5.6% (10/177) knew 3D/tomosynthesis does not improve cancer detection in extremely dense breasts over 2D mammography; and 70.6% (125/177) would consider supplemental ultrasound after mammography in an average-risk 50-year old with dense breasts. Postintervention, these knowledge gaps resolved or reduced (all P < 0.005) and comfort in discussing breast density implications increased (all P < 0.001).

CONCLUSIONS

Important knowledge gaps about implications of breast density exist among women's healthcare providers, which can be effectively addressed with web-based education.

The impact of mandatory mammographic breast density notification on supplemental screening practice in the United States: a systematic review

PURPOSE

Dense breast tissue is an independent risk factor for breast cancer and lowers the sensitivity of screening mammography. Supplemental screening with ultrasound or MRI improves breast cancer detection rate but has potential harms. Breast density notification (BDN) legislation has been introduced in the United States (US) and its impact on supplemental screening practice is unclear. This study systematically reviewed current evidence to explore the impact of BDN on supplemental screening practice in the US.

METHODS

Medline, PubMed, Embase, Cochrane and the Cinhal Library databases were searched (2009-August 2020). Studies were assessed for eligibility, data were extracted and summarised, and study quality was evaluated.

RESULTS

Evidence from the included studies (n = 14) predominantly showed that BDN legislation increased the overall utilisation of supplemental screening by 0.5-143%. This effect was amplified if the notification included a follow-up telephone call informing women about additional screening benefits, and if the state's law mandated insurance cover for supplemental screening. Likelihood of supplemental screening was also influenced by history of breast biopsy and family history of breast cancer, race, age, socioeconomic status, density category, and physician's specialty and region. Some studies reported increases in biopsy rate (up to 4%) and cancer detection rate (up to 11%) after implementation of BDN legislation.

CONCLUSION

BDN leads to increased use of supplemental screening. This has implications for women and the health system. These findings can help inform current and future screening programs, where breast density notification is currently implemented or being considered.

Characteristics Associated with Participation in ENGAGED 2 - A Web-based Breast Cancer Risk Communication and Decision Support Trial

PURPOSE

We evaluated demographic and clinical characteristics associated with participation in a clinical trial testing the efficacy of an online tool to support breast cancer risk communication and decision support for risk mitigation to determine the generalizability of trial results.

METHODS

Eligible women were members of Kaiser Permanente Washington aged 40-69 years with a recent normal screening mammogram, heterogeneously or extremely dense breasts and a calculated risk of > 1.67% based on the Breast Cancer Surveillance Consortium 5-year breast cancer risk model. Trial outcomes were chemoprevention and breast magnetic resonance imaging by 12-months post-baseline. Women were recruited via mail with phone follow-up using plain language materials notifying them of their density status and higher than average breast cancer risk. Multivariable logistic regression calculated independent odds ratios (ORs) for associations between demographic and clinical characteristics with trial participation.

RESULTS

Of 2,569 eligible women contacted, 995 (38.7%) participated. Women with some college (OR = 1.99, 95% confidence interval [CI] 1.34-2.96) or college degree (OR = 3.35, 95% CI 2.29-4.90) were more likely to participate than high school-educated women. Race/ethnicity also was associated with participation (African-American OR = 0.50, 95% CI 0.29-0.87; Asian OR = 0.22, 95% CI 0.12-0.41). Multivariate adjusted ORs for family history of breast/ovarian cancer were not associated with trial participation.

DISCUSSION

Use of plain language and potential access to a website providing personal breast cancer risk information and education were insufficient in achieving representative participation in a breast cancer prevention trial. Additional methods of targeting and tailoring, potentially facilitated by clinical and community outreach, are needed to facilitate equitable engagement for all women.

Confusion and Anxiety Following Breast Density Notification: Fact or Fiction?

In the absence of evidence-based screening recommendations for women with dense breasts, it is important to know if breast density notification increases women's anxiety. This study describes psychological reactions and future screening intentions of women attending a public mammographic screening program in Western Australia. Two-thirds of notified women indicated that knowing their breast density made them feel informed, 21% described feeling anxious, and 23% confused. Of the notified women who reported anxiety, 96% intended to re-screen when due (compared to 91% of all notified women and 93% of controls; p = 0.007 and p < 0.001, respectively). In summary, reported anxiety (following breast density notification) appears to increase women's intentions for future screening, not the reverse.

Evaluation of existing patient educational materials and development of a brochure for women with dense breasts

OBJECTIVES

In this pilot study, we developed and assessed acceptability of a brochure for women with dense breasts.

MATERIAL AND METHODS

We measured Flesch-Kincaid Readability of 22 existing breast density educational materials. We then developed a brochure and tested it in two populations of women: 44 safety net hospital patients and 13 Breast Cancer Surveillance Consortium stakeholders.

RESULTS

Average grade score of existing materials was 10.0 (range: 5.5-12.7). Our brochure had a grade score of 5.9, and patients reported it was easy to understand.

CONCLUSION

Our plain language brochure could improve patient understanding following mandatory dense breast notification.