Clinical decisions. Mammography screening for breast cancer

The Application of Gail Model to Predict the Risk of Developing Breast Cancer among Jordanian Women

Background and Objectives. Breast cancer has been the most common cancer affecting women in Jordan. In the process of implementing breast cancer prevention and early detection programs, individualized risk assessment can add to the cost-effectiveness of such interventions. Gail model is a widely used tool to stratify patients into different risk categories. However, concerns about its applicability across different ethnic groups do exist. In this study, we report our experience with the application of a modified version of this model among Jordanian women.

Randomized Trial of Personalized Breast Density and Breast Cancer Risk Notification

BACKGROUND

Despite widespread implementation of mammographic breast density (MBD) notification laws, the impact of these laws on knowledge of MBD and knowledge of breast cancer risk is limited by the lack of tools to promote informed decision-making in practice.

OBJECTIVE

To develop and evaluate whether brief, personalized informational videos following a normal mammogram in addition to a legislatively required letter about MBD result can improve knowledge of MBD and breast cancer risk compared to standard care (i.e., legislatively required letter about MBD included with the mammogram result).

DESIGN/PARTICIPANTS

Prospective randomized controlled trial of English-speaking women, age 40-74 years, without prior history of breast cancer, receiving a screening mammogram with a normal or benign finding (intervention group n = 235, control group n = 224).

INTERVENTION

brief (3-5 min) video, personalized to a woman's MBD result and breast cancer risk.

MAIN MEASURES

Primary outcomes were a woman's knowledge of her MBD and risk of breast cancer. Secondary outcomes included whether a woman reported that she discussed the results of her mammogram with her primary care provider (PCP).

KEY RESULTS

Relative to women in the control arm, women in the intervention arm had greater improvement in their knowledge of both their personal MBD (intervention pre/post 39.2%/ 77.5%; control pre/post 36.2%/ 37.5%; odds ratio (OR) 5.34 for change for intervention vs. control, 95% confidence interval (CI) 3.87-7.36; p < 0.001) and risk of breast cancer (intervention pre/post: 66.8%/74.0%; control pre/post 67.9%/ 65.2%; OR 1.42, 95% confidence interval (CI) 1.09-1.84; p = 0.01). Women in the intervention group were more likely than those in the control group to report discussing the results of their mammogram with their PCP (p = 0.05).

CONCLUSIONS

Brief, personalized videos following mammography can improve knowledge of MBD and personal risk of breast cancer compared to a legislatively mandated informational letter. Trial Registration Clinicaltrials.gov (NCT02986360).

Primary Care Providers' Beliefs and Recommendations and Use of Screening Mammography by their Patients

BACKGROUND

Revised breast cancer screening guidelines have fueled debate about the effectiveness and frequency of screening mammography, encouraging discussion between women and their providers.

OBJECTIVE

To examine whether primary care providers' (PCPs') beliefs about the effectiveness and frequency of screening mammography are associated with utilization by their patients.

DESIGN

Cross-sectional survey data from PCPs (2014) from three primary care networks affiliated with the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium, linked with data about their patients' mammography use (2011-2014).

PARTICIPANTS

PCPs (n = 209) and their female patients age 40-89 years without breast cancer (n = 30,233).

MAIN MEASURES

Outcomes included whether (1) women received a screening mammogram during a 2-year period; and (2) screened women had >1 mammogram during that period, reflecting annual screening. Principal independent variables were PCP beliefs about the effectiveness of mammography and their recommendations for screening frequency.

KEY RESULTS

Overall 65.2% of women received >1 screening mammogram. For women 40-48 years, mammography use was modestly lower for those cared for by PCPs who believed that screening was ineffective compared with those who believed it was somewhat or very effective (59.1%, 62.3%, and 64.7%; p = 0.019 after controlling for patient characteristics). Of women with PCPs who reported they did not recommend screening before age 50, 48.1% were nonetheless screened. For women age 49-74 years, the vast majority were cared for by providers who believed that screening was effective. Provider recommendations were not associated with screening frequency. For women ≥75 years, those cared for by providers who were uncertain about effectiveness had higher screening use (50.7%) than those cared for by providers who believed it was somewhat effective (42.8%). Patients of providers who did not recommend screening were less likely to be screened than were those whose providers recommended annual screening, yet 37.1% of patients whose providers recommended against screening still received screening.

CONCLUSIONS

PCP beliefs about mammography effectiveness and screening recommendations are only modestly associated with use, suggesting other likely influences on patient participation in mammography.

Patient and Provider Perspectives on Mammographic Breast Density Notification Legislation

Background: Patient advocacy has fostered the implementation of mammographic breast density (MBD) notification legislation in many states. Little is known about the perspectives of women, primary care physicians (PCPs), and breast radiologists in response to this legislation. The objective of this research was to elicit qualitative information from these multiple stakeholders to understand varied perspectives on the subject of MBD notification and inform best practices around implementation. Methods: Content analysis of narrative data from focus groups with women (2 groups, total of 16 participants) and in-depth interviews with PCPs (n = 7) and breast radiologists (n = 7). Results: Three major themes emerged from the data: 1) knowledge and general attitudes about legislation, 2) concerns about consequences, and 3) actions patients and clinicians should consider based on MBD information. For each of these themes, the views of women, PCPs, and radiologists often demonstrated different perspectives. Conclusion: This work supports the need for clear and concise tools for patients and providers to understand MBD in the context of a woman's overall breast cancer risk with guidance on next steps.

Screening Mammography Use Among Older Women Before and After the 2009 U.S. Preventive Services Task Force Recommendations

BACKGROUND

It is uncertain how changes in the U.S. Preventive Services Task Force breast cancer screening recommendations (from annual to biennial mammography screening in women aged 50-74 and grading the evidence as insufficient for screening in women aged 75 and older) have affected mammography use among Medicare beneficiaries.

MATERIALS AND METHODS

Cohort study of 12 million Medicare fee-for-service women aged 65-74 and 75 and older to measure changes in 3-year screening use, 2007-2009 (before) and 2010-2012 (after), defined by two measures-proportion screened and frequency of screening by age, race/ethnicity, and hospital referral region.

RESULTS

Fewer women were screened, but with similar frequency after 2009 for both age groups (after vs. before: age 65-74: 60.1% vs. 60.8% screened, 2.1 vs. 2.1 mammograms per screened woman; age 75 and older: 31.7% vs. 33.6% screened, 1.9 vs. 1.9 mammograms per screened woman; all p < 0.05). Black women were the only subgroup with an increase in screening use, and for both age groups (after vs. before: age 65-74: 55.4% vs. 54.0% screened and 2.0 vs. 1.9 mammograms per screened woman; age 75 and older: 28.5% vs. 27.9% screened and 1.8 vs. 1.8 mammograms per screened woman; all p < 0.05). Regional change patterns in screening were more similar between age groups (Pearson correlation r = 0.781 for proportion screened; r = 0.840 for frequency of screening) than between black versus nonblack women (Pearson correlation r = 0.221 for proportion screened; r = 0.212 for frequency of screening).

CONCLUSIONS

Changes in screening mammography use for Medicare women are not fully aligned with the 2009 recommendations.

Provider Attitudes and Screening Practices Following Changes in Breast and Cervical Cancer Screening Guidelines

BACKGROUND

Changes to national guidelines for breast and cervical cancer screening have created confusion and controversy for women and their primary care providers.

OBJECTIVE

To characterize women's primary health care provider attitudes towards screening and changes in practice in response to recent revisions in guidelines for breast and cervical cancer screening.

DESIGN, SETTING, PARTICIPANTS

In 2014, we distributed a confidential web and mail survey to 668 women's health care providers affiliated with the four clinical care networks participating in the three PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium breast cancer research centers (385 respondents; response rate 57.6 %).

MAIN MEASURES

We assessed self-reported attitudes toward breast and cervical cancer screening, as well as practice changes in response to the most recent revisions of the U.S. Preventive Services Task Force (USPSTF) recommendations.

KEY RESULTS

The majority of providers believed that mammography screening was effective for reducing cancer mortality among women ages 40-74 years, and that Papanicolaou (Pap) testing was very effective for women ages 21-64 years. While the USPSTF breast and cervical cancer screening recommendations were widely perceived by the respondents as influential, 75.7 and 41.2 % of providers (for mammography and cervical cancer screening, respectively) reported screening practices in excess of those recommended by USPSTF. Provider-reported barriers to concordance with guideline recommendations included: patient concerns (74 and 36 % for breast and cervical, respectively), provider disagreement with the recommendations (50 and 14 %), health system measurement of a provider's screening practices that use conflicting measurement criteria (40 and 21 %), concern about malpractice risk (33 and 11 %), and lack of time to discuss the benefits and harms with their patients (17 and 8 %).

CONCLUSIONS

Primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential.

Screening mammography: update and review of publications since our report in the New England Journal of Medicine on the magnitude of the problem in the United States

RATIONALE AND OBJECTIVES

After a half century of clinical trials, expansive observations, vigorous advocacy and debate, screening mammography could not be in a more controversial condition, especially the potential harm of overdiagnosis. Despite a simple rationale (catch the cancer early and either prevent death or at least decrease the amount of therapy needed for cure), the estimates to date of overdiagnosis rates are conflicting and the interpretations complex.

MATERIALS AND METHODS

Since the author's 2012 publication in the New England Journal of Medicine (NEJM), the peer-reviewed publications on overdiagnosis caused by screening mammography are reviewed and the NEJM analyses updated with three additional calendar years of results.

RESULTS

The recent peer-reviewed medical literature on screening mammography induced overdiagnosis of breast cancer has increased exponentially, nearly 10-fold in 10 years. The average estimate of overdiagnosis is about 30%, but the range extends from 0% to 70+%. An update of the NEJM report estimates that in the US, 78,000 women and 30%-31% of those diagnosed with breast cancer at the age of 40 years or older during 2011 were overdiagnosed.

CONCLUSIONS

Until we have better screening procedures that identify who really has cancer and needs to be treated, the risk of overdiagnosis relative to the benefit of screening merits more effective public and professional education. Radiologists, pathologists, and other professionals involved with screening mammography should recognize that the potential harm of overdiagnosis is downplayed or not discussed with the patient and family, despite agreement that the objective is informed choice.

Benefits and harms of mammography screening

Mammography screening for breast cancer is widely available in many countries. Initially praised as a universal achievement to improve women's health and to reduce the burden of breast cancer, the benefits and harms of mammography screening have been debated heatedly in the past years. This review discusses the benefits and harms of mammography screening in light of findings from randomized trials and from more recent observational studies performed in the era of modern diagnostics and treatment. The main benefit of mammography screening is reduction of breast-cancer related death. Relative reductions vary from about 15 to 25% in randomized trials to more recent estimates of 13 to 17% in meta-analyses of observational studies. Using UK population data of 2007, for 1,000 women invited to biennial mammography screening for 20 years from age 50, 2 to 3 women are prevented from dying of breast cancer. All-cause mortality is unchanged. Overdiagnosis of breast cancer is the main harm of mammography screening. Based on recent estimates from the United States, the relative amount of overdiagnosis (including ductal carcinoma in situ and invasive cancer) is 31%. This results in 15 women overdiagnosed for every 1,000 women invited to biennial mammography screening for 20 years from age 50. Women should be unpassionately informed about the benefits and harms of mammography screening using absolute effect sizes in a comprehensible fashion. In an era of limited health care resources, screening services need to be scrutinized and compared with each other with regard to effectiveness, cost-effectiveness and harms.

Comparing electronic health record portals to obtain patient-entered family health history in primary care

BACKGROUND

There is growing interest in developing systems to overcome barriers for acquiring and interpreting family health histories in primary care.

OBJECTIVE

To examine the capacity of three different electronic portals to collect family history from patients and deposit valid data in an electronic health record (EHR).

DESIGN

Pilot trial.

PARTICIPANTS, INTERVENTION

Patients were enrolled from four primary care practices and were asked to collect family health history before a physical exam using either telephone-based interactive voice response (IVR) technology, a secure Internet portal, or a waiting room laptop computer, with portal assigned by practice. Intervention practices were compared to a "usual care" practice, where there was no standard workflow to document family history (663 participants in the three intervention arms were compared to 296 participants from the control practice).

MAIN MEASURES

New documentation of any family history in a coded EHR field within 30 days of the visit. Secondary outcomes included participation rates and validity.

KEY RESULTS

Demographics varied by clinic. Documentation of new family history data was significantly higher, but modest, in each of the three intervention clinics (7.5 % for IVR clinic, 20.3 % for laptop clinic, and 23.1 % for patient portal clinic) versus the control clinic (1.7 %). Patient-entered data on common conditions in first degree relatives was confirmed as valid by a genetic counselor for the majority of cases (ranging from 64 to 82 % in the different arms).

CONCLUSIONS

Within primary care practices, valid patient entered family health history data can be obtained electronically at higher rates than a standard of care that depends on provider-entered data. Further research is needed to determine how best to match different portals to individual patient preference, how the tools can best be integrated with provider workflow, and to assess how they impact the use of screening and prevention.

A nation-wide multicenter retrospective study of the epidemiological, pathological and clinical characteristics of breast cancer in situ in Chinese women in 1999 - 2008

BACKGROUND

Compared with invasive breast cancer, breast cancer in situ (BCIS) is seldom life threatening. However, an increasing incidence has been observed in recent years over the world. The purpose of our study is to investigate the epidemiological, clinical and pathological profiles of BCIS in Chinese women from 1999-2008.

METHODS

Four thousand and two hundred-eleven female breast cancer (BC) patients were enrolled in this hospital-based nation-wide and multi-center retrospective study. Patients were randomly selected from seven hospitals in seven representative geographical regions of China between 1999 and 2008. The epidemiological, clinical and pathological data were collected based on the designed case report form (CRF).

RESULTS

There were one hundred and forty-three BCIS cases in four thousand and two hundred-eleven BC patients (3.4%). The mean age at diagnosis was 48.3 years and BCIS peaked in age group 40-49 yrs (39.9%). The most common subtype was ductal carcinoma in situ (DCIS) (88.0%). 53.8% were positive for estrogen receptor (ER). Human epidermal growth factor receptor 2 (HER2) positive status was observed in 23.8% of patients. All patients underwent surgeries and 14.7% of them had breast conservation therapies (BCT) (21/143), but 41.9% accepted chemotherapy (64/143). Much less patients underwent radiotherapy (16.0%, 23/143) and among patients who had BCT, 67% accepted radiotherapy (14/21). Endocrine therapy was taken in 44.1% patients (63/143).

CONCLUSIONS

The younger age of BCIS among Chinese women than Western countries and increasing number of cases pose a great challenge. BCT and endocrine therapy are under great needs.

Real and artificial controversies in breast cancer screening

SUMMARY We review the apparent disparities between different reviews of the effects of mammographic screening on mortality from breast cancer and overdiagnosis. When results of each review are expressed with respect to a common population and a common baseline, all find a substantial mortality benefit and variation among estimates is minor. There are genuine disagreements about overdiagnosis, but methods that take account of lead time and underlying incidence trends yield estimates of overdiagnosis that are modest and are outweighed by the mortality benefit. There is potential for individualized screening regimens, particularly with respect to breast density.

Trends in mammography screening rates after publication of the 2009 US Preventive Services Task Force recommendations

BACKGROUND

In November 2009, the US Preventive Services Task Force (USPSTF) issued new recommendations regarding mammography screening. The Task Force recommended against routine screening for women ages 40 to 49 years and recommended biennial screening for women ages 50 to 74 years. The recommendations met great controversy in mass media and medical literature; whether they have had an impact on screening patterns is not known. The objective of this study was to determine whether the 2009 USPSTF recommendations led to changes in screening rates among women ages 40 to 49 years and ages 50 to 74 years.

METHODS

The authors performed cross-sectional assessments of mammography screening in 2005, 2008, and 2011 using data from the National Health Interview Survey, a nationally representative, in-person, household survey of the civilian, noninstitutionalized US population. In total, 27,829 women ages ≥ 40 years responded to the 2005, 2008, or 2011 surveys and reported about their mammography use. The primary outcome assessed was self-reported mammography screening in the past year.

RESULTS

When adjusted for race, income, education level, insurance, and immigration status, mammography rates increased slightly from 2008 to 2011 (from 51.9% to 53.6%; P = .07) and did not decline within any age group. Among women ages 40 to 49 years, screening rates were 46.1% in 2008 and 47.5% in 2011 (P = 0.38). For women ages 50 to 74, screening rates were 57.2 in 2008 and 59.1 in 2011 (P = 0.09).

CONCLUSIONS

Mammography rates did not decrease among women aged >40 years after publication of the USPSTF recommendations in 2009, suggesting that the vigorous policy debates and coverage in the media and medical literature have had an impact on the adoption of these recommendations.