Breast cancer screening

Patient Barriers to Mammography Identified During a Reminder Program

Background: Patient mammogram reminders are effective at increasing screening, but patient barriers remain. We evaluated patient characteristics and reported barriers for their association with mammogram completion after a reminder program. Methods: This retrospective cohort study used data from electronic records and a subgroup survey. Participants were female Kaiser Permanente Northwest health maintenance organization (HMO) members aged 50-69 who were 20 months past their last mammogram (index date) and had received a reminder intervention (n = 4708). A mailed survey was completed by 340 of 667 (50.2%) women who received it. The intervention was a "mammogram due soon" postcard 20 months after the last mammogram, followed by up to two automated phone calls and one live call for nonresponders. The outcome was mammogram completion at 10 months after index date. Results: Characteristics associated with lower mammogram completion rates were aged <60 (odds ratio [OR] 0.69, p < 0.0001), health plan membership <5 years (OR 0.81, p = 0.019), family income <$40,000/year (OR 0.77, p = 0.018), and obesity (OR 0.67, p < 0.0001). Obese women were more likely than nonobese women to report "too much pain" from mammograms (31.3% vs.18.8%, p < 0.01). Younger women were more likely to endorse that they were "too busy" (19.1% vs. 6.4%, p < 0.001) and had more worries about mammogram accuracy (2.5 vs. 2.3 on a 5-point scale, p < 0.05). Pain mediated the relationship between obesity and mammogram completion rates (indirect effect = -0.111, p = 0.008). Conclusions: Important barriers to mammogram completion remain even after an effective mammogram reminder system among insured patients. Tailored interventions are necessary to overcome these barriers.

Effect of a multimodal reminder program on repeat mammogram screening

BACKGROUND

Patient mammogram reminders are effective but have not been fully implemented in practice to improve routine screening. The effectiveness of implementation and maintenance phases of a multimodal reminder program that incorporated automated calls capable of efficiently reaching large numbers of women was evaluated to improve repeat mammography screening.

DESIGN

A quasi-experimental study was conducted in 2008 using electronic medical record data during three time periods: pre-reminder phase (2004), post-reminder implementation phase (2006), and post-reminder maintenance phase (January 1-July 1, 2007).

SETTING/PARTICIPANTS

Participants were female Kaiser Permanente Northwest HMO members aged 42 years or more who were 20 months past their last mammogram (index date) (N=35,104). The intervention program targeted women aged 50-69 years. Women aged 42-49 years (for whom clinical guidelines also recommend mammography) not targeted by the program constituted the primary comparison group (CG1).

INTERVENTION

A "mammogram due soon" postcard was mailed to participants 20 months after their last mammogram, followed by up to two automated phone calls and one live call for nonresponders.

MAIN OUTCOME MEASURES

The outcome measure was the time until participants received a mammogram in the 10 months following the index date.

RESULTS

Pre-reminder, 63.4% of targeted women completed a mammogram; this number increased to 75.4% in the post-reminder implementation phase; 80.6% completed a mammogram in the maintenance phases. After controlling for demographics and clinic visits, intervention women were 1.51 times more likely to complete a mammogram (CI=1.40, 1.62) post-reminder implementation, compared to CG1. The effect was maintained in 2007 (hazard ratio 1.81, CI=1.65, 1.99).

CONCLUSIONS

The study found that this multimodal reminder system could be effectively implemented and maintained in a large health system. If widely implemented, this intervention could substantially improve community mammography screening.

Mammography screening rates decline: a person-time approach to evaluation

OBJECTIVES

Early detection through mammography can reduce breast cancer mortality. This cohort study evaluated trends in mammography screening, demonstrating a person-time approach.

METHODS

Included were women HMO members aged 50-69 from 1999 to 2002 who had not had breast cancer, dysplasia, fibrocystic disease, or implant. The amount of person-time covered by mammography as a percent of the time eligible for mammography screening (the prevention index (PI)) was calculated using electronic data. The denominator was the time during which the guidelines recommended that each participant should have been covered by a mammogram (every 24 months), excluding times when breast mass, abnormal mammogram, galactorrhea, or other breast disorders were under evaluation. The numerator was the time during which she was covered by a mammogram.

RESULTS

The number of women who contributed person-time increased from 43,283 to 49,512 and the number of screening mammograms declined from 23,586 to 22,719. The overall PI for screening mammography declined from 67.0 (67% of eligible person-time was appropriately covered by a mammogram) to 62.5, and the proportion of women with no coverage during a given year increased 16%.

CONCLUSIONS

This study shows a declining pattern of mammography screening using a person-time approach, a decline greater than that shown by methods that include diagnostic mammograms. The study highlights opportunities for use of the PI and quality improvement initiatives to improve breast cancer outcomes.

Electrical Impedance Scanning for the Early Detection of Breast Cancer in Young Women: Preliminary Results of a Multicenter Prospective Clinical Trial

Purpose

To evaluate the feasibility and patient satisfaction with electrical impedance scanning (EIS) for early detection of breast cancer in young women.

Methods

Women undergoing screening clinical breast examination, imaging, or biopsy were eligible for EIS examination with T-Scan 2000ED (Mirabel Medical Systems, Austin, TX). Multiple logistic regression analysis evaluated the association between clinical variables and EIS performance. Patients completed a screening EIS satisfaction questionnaire (1 = least satisfied to 5 = most satisfied).

Results

Twenty-nine cancers were identified among 1,103 women. Sixty-six percent (19 of 29) of cancers were nonpalpable and 55% (16 of 29) were in women age ≤ 50 years. EIS sensitivity and specificity in women younger than 40 years was 50% and 90%, respectively. Exogenous estrogen use (P < .001) and menopausal status (P = .007) correlated significantly with EIS performance. False-positive rates were increased in postmenopausal women and those taking exogenous hormones. No correlation was evident between EIS performance and family history, prior breast cancer, breast density, or palpability. EIS-positive women younger than age 40 were 4.5 times more likely to have breast carcinoma than were women randomly selected from the general population. Patients were highly satisfied with the comfort, speed, and reporting of EIS screening (mean score, 4.8).

Conclusion

EIS seems promising for early detection of breast cancer, and identification of young women at increased risk for having the disease at time of screening. Positive EIS-associated breast cancer risk compares favorably with relative risks of conditions commonly used to justify early breast cancer screening. Patients are satisfied with a screening paradigm involving breast EIS.

Personalized targeted mailing increases mammography among long-term noncompliant medicare beneficiaries: a randomized trial

OBJECTIVES

The study purpose was to increase mammography screening among older women by identifying female Medicare beneficiaries without a recent mammogram and assesses the cost-effectiveness of a personalized targeted mailing encouraging them to have a mammogram.

METHODS

A randomized paired controlled trial included 1229 pairs of women matched on zip code, race, and urban or rural county. Postintervention mammography claims were measured from November 1997 through December 1998. The subjects were female Medicare beneficiaries age > or = 70, living in Michigan for > or = 5 years, having no significant comorbidity likely to affect screening, and no mammogram for > or = 5 years. Intervention subjects received a personally addressed letter from the Medical Director of Michigan Medicare with materials emphasizing the individual's lack of use of the Medicare mammography screening benefit, reasons for screening, and how to be screened.

RESULTS

Women who received the mailing were 60% more likely to have a subsequent mammogram (OR 1.6, P <0.005), with diagnostic mammograms increasing more than screening mammograms (2.8% vs. 0.8%). The absolute increase was greatest for women age 70 to 79, 10.6% in the intervention group versus 6.5% for controls, odds ratio 1.7 (P <0.02). A statewide Medicare intervention in Michigan would cost of 108,000 US dollars to 238,000 US dollars, producing 3500 to 4300 additional mammograms at 31 US dollars to 55 US dollars per additional mammogram.

CONCLUSION

The intervention increased mammography among long-term noncompliant older women, particularly increasing diagnostic mammograms. This approach can be directly implemented in other states and nationally. It may also be useful for other preventive services.

Angular disparity in ETACT scintimammography

Emission tuned aperture computed tomography (ETACT) has been previously shown to have the potential for the detection of small tumors (<1 cm) in scintimammography. However, the optimal approach to the application of ETACT in the clinic has yet to be determined. Therefore, we sought to determine the effect of the angular disparity between the ETACT projections on image quality through the use of a computer simulation. A small, spherical tumor of variable size (5, 7.5 or 10 mm) was placed at the center of a hemispherical breast (15 cm diameter). The tumor to nontumor ratio was either 5:1 or 10:1. The detector was modeled to be a gamma camera fitted with a 4-mm-diam pinhole collimator. The pinhole-to-detector and the pinhole-to-tumor distances were 25 and 15 cm, respectively. A ray tracing technique was used to generate three sets of projections (10 degrees, 15 degrees, and 20 degrees, angular disparity). These data were blurred to a resolution consistent with the 4 mm pinhole. The TACT reconstruction method was used to reconstruct these three image sets. The tumor contrast and the axial spatial resolution was measured. Smaller angular disparity led to an improvement in image contrast but at a cost of degraded axial spatial resolution. The improvement in contrast is due to a slight improvement in the in-plane spatial resolution. Since improved contrast should lead to better tumor detectability, smaller angular disparity should be used. However, the difference in contrast between 10 degrees and 15 degrees was very slight and therefore a reasonable clinical choice for angular disparity is 15 degrees.