Mammography Screening Practices in Average-Risk Women Aged 40-49 Years in Primary Care: A Comparison of Physician and Nonphysician Providers in Minnesota

Employing a Risk Assessment Tool for Shared Decision-Making in Breast Cancer Screening

Background: The existing guidelines for breast cancer screening incorporate assessing individual risk but contain no universally recommended risk assessment tool in the primary care setting. Local Problem: A family planning program utilizing nurses and nurse practitioners for assessment, education, and referral lacked a risk assessment tool for assessing breast cancer risk. Methods: A breast cancer risk assessment tool was implemented in practice. Interventions: The interventions involved assessing the patient's risks, providing education on risk reduction strategies, and determining the need for clinical breast exams and referrals for mammography. Results: The study demonstrated a clear correlation between the number of breast cancer risks identified and the extent of education provided to patients based on their specific risk profiles (0 vs. 1.5 risks; 2 vs. 4.6 educational components). Among patients under age 35, 80% opted for a clinical breast exam, while 100% of patients age 40 and above agreed to both clinical breast exams and referrals for mammography after discussing individual risks. Conclusions: The use of a breast cancer risk assessment tool provided an evidence-based foundation for the shared decision-making conversation between patient and nurse/provider on risk reduction. The discussion included current evidence on the risk versus benefit of age-based screening options for breast cancer, allowing for an informed decision made jointly between the patient and provider.

Factors Associated with Mammography Screening Choices by Women Aged 40-49 at Average Risk

Background: The U.S. Preventive Services Task Force (USPSTF) does not recommend routine mammogram screening for women aged 40-49 years at average risk for breast cancer. We aimed to assess the extent to which women were following guideline recommendations and to examine whether guideline awareness and other individual-level factors were associated with adherence. Materials and Methods: We surveyed a nationally representative panel of 383 U.S. women aged 40-49 years at low risk for hereditary breast cancer in October 2019. Results: Only 29% of women reported not having initiated screening mammography. Most women (80%) were unaware of the USPSTF screening guideline related to age of initiation and frequency of mammography. Being aware of the recommendation to initiate screening at age 50 increased the odds of not initiating screening (odds ratio [OR] = 6.70, p < 0.001), whereas being older than 45 years (OR = 0.22, p < 0.001) and having a primary care doctor decreased the odds of not initiating screening (OR = 0.25, p < 0.001). Conclusions: Mammogram screening in excess of USPSTF recommendations is prevalent among U.S. women aged 40-49 years. Efforts are needed to increase women's awareness of the rationale for guidelines and the opportunities to discuss with providers whether delaying mammograms is appropriate.

Patient and Clinician Characteristics That Predict Breast Cancer Screening Behavior in 40-49-Year-Old Women

Guidelines recommend that clinicians practice shared decision-making (SDM) with women in their 40s to discuss breast cancer screening. Traditionally, SDM includes discussion of values and preferences to help determine a decision that is congruent with what the patient desires. We analyzed 54 women's breast cancer screening decisions after a SDM conversation with their clinician. We looked at both patient and clinician characteristics that predicted whether or not a woman would get a screening mammogram. Women with a family history of breast cancer or who had a previous abnormal mammogram had higher rates of screening. Screening rates also varied widely between clinicians, raising the question of whether clinician attitudes impacted the SDM conversation.

Physician associate/assistant contributions to cancer diagnosis in primary care: a rapid systematic review

BACKGROUND

Symptom recognition and timely referral in primary care are crucial for the early diagnosis of cancer. Physician assistants or associates (PAs) have been introduced in 18 healthcare systems across the world, with numbers increasing in some cases to address primary care physician shortages. Little is known about their impact on suspected cancer recognition and referral. This review sought to summarise findings from observational studies conducted in high income countries on PAs' competence and performance on processes concerned with the quality of recognition and referral of suspected cancer in primary care.

METHOD

A rapid systematic review of international peer-reviewed literature was performed. Searches were undertaken on OVID, EMBASE, Web of Science, and CINAHL databases (2009-2019). Studies were eligible if they reported on PA skills, processes and outcomes relevant to suspected cancer recognition and referral. Title and abstract screening was followed by full paper review and data extraction. Synthesis of qualitative and quantitative findings was undertaken on three themes: deployment, competence, and performance. Preliminary findings were discussed with an expert advisory group to inform interpretation.

RESULTS

From 883 references, 15 eligible papers were identified, of which 13 were from the USA. Seven studies reported on general clinical processes in primary care that would support cancer diagnosis, most commonly ordering of diagnostic tests (n = 6) and referrals to specialists (n = 4). Fewer papers reported on consultation processes, such as examinations or history taking (n = 3) Six papers considered PAs' competence and performance on cancer screening. PAs performed similarly to primary care physicians on rates of diagnostic tests ordered, referrals and patient outcomes (satisfaction, malpractice, emergency visits). No studies reported on the timeliness of cancer diagnosis.

CONCLUSION

This review of peer-reviewed literature combined with advisory group interpretation suggests the introduction of PAs into primary care may maintain the quality of referrals and diagnostic tests needed to support cancer diagnosis. It also highlights the lack of research on several aspects of PAs' roles, including outcomes of the diagnostic process.

Variation in Breast Cancer Screening Recommendations by Primary Care Providers Surveyed in Wisconsin

BACKGROUND

Cancer screening is chiefly performed by primary care providers (PCPs) who rely on organizational screening guidelines. These guidelines provide evidence-based recommendations; however, they are often without unanimity leading to divergent screening recommendations.

OBJECTIVE

Due to the high incidence of breast cancer, the availability of screening methods, and the presence of multiple incongruent guideline recommendations, we sought to understand breast cancer screening practices in Wisconsin to identify patterns that would allow us to improve evidence-based screening adherence.

METHODS

A 46-question survey on breast cancer screening beliefs and practices for average-risk women was sent to healthcare providers in Wisconsin in 2018, who provided cancer screening services to women. Providers included physicians, nurse practitioners (NPs), physician assistants (PAs), and midwives.

RESULTS

A total of 295 people responded to the survey, for a response rate of 28.6%. Most respondents were physicians (64.1%), followed by NPs (25.7%), PAs (5.3%), and midwives (1.5%). Of physicians, most practiced family medicine (65.3%), followed by internal medicine (25.3%) and gynecology (9.4%). The United States Preventive Services Task Force (USPSTF) was reported as being "very influential" for 60.5% of providers, followed by the American Cancer Society at 46.8%. For patients 40-49 years old, 75.6% of providers performed clinical breast exams and 58.5% recommended self-breast exams; these numbers increased for women 50+ years old to 78.7% and 61.2%, respectively. Mammography was more likely to be recommended annually for women aged 40-49 rather than biennially by non-physician clinicians compared to physicians (p < .001).

CONCLUSIONS

PCPs in Wisconsin continue to overestimate the efficacy of clinical and self-breast exams as well as overuse these in clinical practice. Providers find multiple screening guidelines influential but favor the USPSTF; however, these guidelines are frequently not being followed. Further research needs to be done to investigate the lack of national guideline adherence by providers to improve compliance with evidence-based screening recommendations.

Image quality and clinical usefulness of automatic tube current modulation technology in female chest computed tomography screening

The study was aimed to evaluate the image quality and radiation dose during female chest computed tomography (CT) screening using organ-based tube current modulation technology X-ray combined applications to reduce exposure (XCARE).Five hundred sixty female individuals undergoing chest CT scan were prospectively enrolled and divided into 4 groups based on body mass index (BMI). Then they were randomly and equally divided into control and experimental subgroup and respectively accepted conventional low-dose and XCARE technology spiral CT scan with same parameters. Signal-to-noise ratio and contrast-to-noise ratio were calculated. The quality of the images was evaluated by 2 radiologists using a 5-point scale.Among experimental subgroups of the 4 BMI groups, Signal-to-noise ratios, CT dose index of volume, dose-length product, effective dose, and contrast-to-noise ratio all displayed significant differences, as well as in control subgroups (P < .001). Both the experimental and control subgroups showed an increasing trend in radiation dose with the increasing of BMI. Parameters of image quality and radiation dose displayed no significant differences between control and experimental subgroups in the 4 groups. In multiple linear regression analysis, age and scanning protocol were not associated with radiation dose (P > .05), while BMI was significantly associated with increased CT dose index of volume (P < .05). The display of the lesions for the patients in the control and experimental subgroups of the 4 groups with different BMIs exhibited no statistically significant difference.The same image quality and radiation dose can be obtained using XCARE technology compared to conventional chest CT scans, which can be used regularly in female patients.Advances in knowledge: Using automatic tube current modulation technology to reduce exposure in breast. In this study, we sought a radiation protection method for sensitive tissue in chest CT screening.