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Isautier JMJ, Wang S, Houssami N, McCaffery K, Brennan ME, Li T, Nickel B. The impact of breast density notification on psychosocial outcomes in racial and ethnic minorities: A systematic review. Breast 2024; 74:103693. [PMID: 38430905 PMCID: PMC10918326 DOI: 10.1016/j.breast.2024.103693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 03/05/2024] Open
Abstract
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.
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Affiliation(s)
- J M J Isautier
- The University of Sydney, Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, New South Wales Australia; Wiser Healthcare, School of Public Health, The University of Sydney, New South Wales, Australia
| | - S Wang
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - N Houssami
- Wiser Healthcare, School of Public Health, The University of Sydney, New South Wales, Australia; The Daffodil Centre, The University of Sydney, a Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - K McCaffery
- The University of Sydney, Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, New South Wales Australia; Wiser Healthcare, School of Public Health, The University of Sydney, New South Wales, Australia
| | - M E Brennan
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, Sydney, Australia; National School of Medicine, University of Notre Dame Australia, Sydney, Australia
| | - T Li
- The Daffodil Centre, The University of Sydney, a Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - B Nickel
- The University of Sydney, Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, New South Wales Australia; Wiser Healthcare, School of Public Health, The University of Sydney, New South Wales, Australia.
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Copp T, Pickles K, Smith J, Hersch J, Johansson M, Doust J, McKinn S, Sharma S, Hardiman L, Nickel B. Marketing empowerment: how corporations co-opt feminist narratives to promote non-evidence based health interventions. BMJ 2024; 384:e076710. [PMID: 38355160 DOI: 10.1136/bmj-2023-076710] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Affiliation(s)
- Tessa Copp
- Sydney Health Literacy Lab, Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Kristen Pickles
- Sydney Health Literacy Lab, Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Jenna Smith
- Sydney Health Literacy Lab, Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Jolyn Hersch
- Sydney Health Literacy Lab, Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Minna Johansson
- Global Center for Sustainable Healthcare, School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jenny Doust
- Australian Women and Girls' Health Research Centre, School of Public Health, University of Queensland, Brisbane, Australia
| | - Shannon McKinn
- Sydney Health Literacy Lab, Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Sweekriti Sharma
- Sydney Health Literacy Lab, Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, Sydney, Australia
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, Australia
| | | | - Brooke Nickel
- Sydney Health Literacy Lab, Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, Sydney, Australia
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Best R, Wilkinson LS, Oliver-Williams C, Tolani F, Yates J. Should we share breast density information during breast cancer screening in the United Kingdom? an integrative review. Br J Radiol 2023; 96:20230122. [PMID: 37751169 PMCID: PMC10646652 DOI: 10.1259/bjr.20230122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/25/2023] [Accepted: 08/24/2023] [Indexed: 09/27/2023] Open
Abstract
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.
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Affiliation(s)
- Rebecca Best
- NHS England Screening Quality Assurance Service, Health Education England, England, United Kingdom
| | | | - Clare Oliver-Williams
- NHS England Screening Quality Assurance Service, Health Education England, England, United Kingdom
| | - Foyeke Tolani
- Public Health Department, Bedford Borough Council, Bedford, United Kingdom
| | - Jan Yates
- NHS England Screening Quality Assurance Service, Health Education England, England, United Kingdom
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Nickel B, Ormiston‐Smith N, Hammerton L, Cvejic E, Vardon P, Mcinally Z, Legerton P, Baker K, Isautier J, Larsen E, Giles M, Brennan ME, McCaffery KJ, Houssami N. 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. Med J Aust 2023; 219:423-428. [PMID: 37751916 PMCID: PMC10952548 DOI: 10.5694/mja2.52117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 08/23/2023] [Indexed: 09/28/2023]
Abstract
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).
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Affiliation(s)
- Brooke Nickel
- School of Public Healththe University of SydneySydneyNSW
| | | | - Lisa Hammerton
- Sunshine Coast Service, BreastScreen QueenslandNambourQLD
| | - Erin Cvejic
- School of Public Healththe University of SydneySydneyNSW
| | - Paul Vardon
- Cancer Screening Unit, Queensland Department of HealthBrisbaneQLD
| | - Zoe Mcinally
- Cancer Screening Unit, Queensland Department of HealthBrisbaneQLD
| | - Paula Legerton
- Cancer Screening Unit, Queensland Department of HealthBrisbaneQLD
| | - Karen Baker
- Cancer Screening Unit, Queensland Department of HealthBrisbaneQLD
| | | | - Emma Larsen
- Sunshine Coast Service, BreastScreen QueenslandNambourQLD
| | | | - Meagan E Brennan
- School of Public Healththe University of SydneySydneyNSW
- The University of Notre Dame AustraliaSydneyNSW
| | | | - Nehmat Houssami
- School of Public Healththe University of SydneySydneyNSW
- The Daffodil Centre, the University of Sydney and Cancer Council NSWSydneyNSW
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Tehranifar P, Bertrand KA. Enhancing Mammography and Empowering Solutions for Breast Cancer Disparities. Cancer Epidemiol Biomarkers Prev 2023; 32:1479-1481. [PMID: 37908191 DOI: 10.1158/1055-9965.epi-23-0926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 08/17/2023] [Accepted: 08/22/2023] [Indexed: 11/02/2023] Open
Abstract
Mammography enables early detection of breast cancer, a critical factor in improving treatment outcomes and breast cancer mortality. Yet, not all women benefit equally, and striking racial disparities in breast cancer mortality persist, with Black women 40% more likely to die from breast cancer compared with non-Hispanic White women. The current issue of Cancer Epidemiology, Biomarkers & Prevention presents three informative reports revealing racial and ethnic variations in mammography's performance in risk stratification, detection, and surveillance. The performance dynamics of mammography across different racial and ethnic groups highlight the urgency for additional research and innovative interventions to ensure equitable breast cancer control. We emphasize a pressing need for a comprehensive evaluation of multilevel influences on the performance and implementation of mammography in racially and ethnically diverse populations, complemented by equally urgent efforts to address factors influencing the risk of aggressive tumor subtypes and timely and effective treatment delivery. See related articles by Kerlikowske et al., p. 1524, Hubbard et al., p. 1531, Nyante et al., p. 1542.
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Affiliation(s)
- Parisa Tehranifar
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Kimberly A Bertrand
- Slone Epidemiology Center at Boston University, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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Smith J, Dodd RH, Gainey KM, Naganathan V, Cvejic E, Jansen J, McCaffery KJ. Factors Influencing Primary Care Practitioners' Cancer Screening Recommendations for Older Adults: a Systematic Review. J Gen Intern Med 2023; 38:2998-3020. [PMID: 37142822 PMCID: PMC10593684 DOI: 10.1007/s11606-023-08213-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/12/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Primary care practitioners (PCPs) play a key role in cancer screening decisions for older adults (≥ 65 years), but recommendations vary by cancer type and jurisdiction. PURPOSE To examine the factors influencing PCPs' recommendations for breast, cervical, prostate, and colorectal cancer screening for older adults. DATA SOURCES MEDLINE, Pre-Medline, EMBASE, PsycINFO, and CINAHL, searched from 1 January 2000 to July 2021, and citation searching in July 2022. STUDY SELECTION Assessed factors influencing PCPs' breast, prostate, colorectal, or cervical cancer screening decisions for older adults' (defined either as ≥ 65 years or < 10-year life expectancy). DATA EXTRACTION Two authors independently conducted data extraction and quality appraisal. Decisions were crosschecked and discussed where necessary. DATA SYNTHESIS From 1926 records, 30 studies met inclusion criteria. Twenty were quantitative, nine were qualitative, and one used a mixed method design. Twenty-nine were conducted in the USA, and one in the UK. Factors were synthesized into six categories: patient demographic characteristics, patient health characteristics, patient and clinician psycho-social factors, clinician characteristics, and health system factors. Patient preference was most reported as influential across both quantitative and qualitative studies. Age, health status, and life expectancy were also commonly influential, but PCPs held nuanced views about life expectancy. Weighing benefits/harms was also commonly reported with variation across cancer screening types. Other factors included patient screening history, clinician attitudes/personal experiences, patient/provider relationship, guidelines, reminders, and time. LIMITATIONS We could not conduct a meta-analysis due to variability in study designs and measurement. The vast majority of included studies were conducted in the USA. CONCLUSIONS Although PCPs play a role in individualizing cancer screening for older adults, multi-level interventions are needed to improve these decisions. Decision support should continue to be developed and implemented to support informed choice for older adults and assist PCPs to consistently provide evidence-based recommendations. REGISTRATION PROSPERO CRD42021268219. FUNDING SOURCE NHMRC APP1113532.
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Affiliation(s)
- Jenna Smith
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006 Australia
| | - Rachael H. Dodd
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- The Daffodil Centre, a joint venture between Cancer Council NSW and The University of Sydney, Faculty of Medicine and Health, Sydney, NSW Australia
| | - Karen M. Gainey
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
| | - Vasi Naganathan
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Centre for Education and Research On Ageing, Department of Geriatric Medicine, Concord Repatriation Hospital, Sydney, NSW Australia
| | - Erin Cvejic
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Kirsten J. McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW Australia
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Acheampong T, Rodríguez CB, O'Neill SC, Agovino M, Argov EJL, Tehranifar P. Scientific uncertainty and perceived mammography benefits in women screened for breast cancer. Cancer Causes Control 2023; 34:611-619. [PMID: 37085746 DOI: 10.1007/s10552-023-01697-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 04/03/2023] [Indexed: 04/23/2023]
Abstract
PURPOSE Personal aversion to scientific uncertainty may influence how women perceive the benefits of mammography, a breast cancer screening practice with conflicting scientific opinions and guidelines. Such associations may even exist among women who participate in screening. METHODS We evaluated the distribution of aversion to ambiguous medical information (AA-Med), using a 6-item scale capturing the level of agreement with statements about obtaining a cancer screening test with conflicting medical recommendations in 665 women (aged 40-60 years; 79.5% Hispanic) recruited during screening mammography appointments in New York City. We assessed the association of AA-Med with perceptions of benefits of mammography (breast cancer mortality reduction, worry reduction, early detection, treatment improvement) using multivariable logistic regression. RESULTS Over a quarter of participants expressed negative reactions to medical ambiguity about a cancer screening test (e.g., fear, lower trust in experts), but a majority endorsed intention to undergo screening. AA-Med was higher in women who were U.S.-born, non-Hispanic black, and had marginal to adequate health literacy, but there were no differences by clinical factors or screening experiences (e.g., family history, prior breast biopsy). Women with higher AA-Med were more likely to perceive treatment benefits from mammography (OR = 1.37, 95% CI = 0.99-1.90), but AA-Med was not associated with other perceived mammography benefits. CONCLUSIONS Aversion to uncertainty regarding cancer screening varies by sociodemographic characteristics but has limited associations with perceived mammography benefits in women who already participate in screening.
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Affiliation(s)
- Teofilia Acheampong
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Carmen B Rodríguez
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Suzanne C O'Neill
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Mariangela Agovino
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Erica J Lee Argov
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Parisa Tehranifar
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA.
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Pandya T, Liu Z, Dolan H, Hersch J, Brennan M, Houssami N, Nickel B. Australian Women's Responses to Breast Density Information: A Content Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1596. [PMID: 36674351 PMCID: PMC9861812 DOI: 10.3390/ijerph20021596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 06/17/2023]
Abstract
Breast density (BD) is an independent risk factor for breast cancer and reduces mammographic sensitivity. This study explored women's responses and intentions if notified that they had dense breasts. METHODS Content analysis was used to assess responses from a written questionnaire undertaken in conjunction with focus groups on BD involving 78 Australian women aged 40-74. RESULTS Half the women reported that they would feel a little anxious if notified they had dense breasts, while 29.5% would not feel anxious. The most common theme (29.5%) related to anxiety was the psychosocial impact of the possibility of developing cancer, and women believed that being better informed could help with anxiety (26.9%). When asked what they would do if notified of having dense breasts, the most common response was to consult their doctor for information/advice (38.5%), followed by considering supplemental screening (23%). Consequently, when asked directly, 65.4% were interested in undergoing supplemental screening, while others (10.3%) said they "wouldn't worry about it too much". DISCUSSION These findings have important implications for health systems with population-based breast screening programs that are currently considering widespread BD notification in terms of the impact on women, health services and primary care.
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Affiliation(s)
- Tanvi Pandya
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Zixuan Liu
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Hankiz Dolan
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Jolyn Hersch
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
| | - Meagan Brennan
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2145, Australia
- The National School of Medicine, The University of Notre Dame Australia, Sydney, NSW 2007, Australia
| | - Nehmat Houssami
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
- The Daffodil Centre, The University of Sydney, a Joint Venture with Cancer Council NSW, Sydney, NSW 2006, Australia
| | - Brooke Nickel
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia
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Beidler LB, Kressin NR, Wormwood JB, Battaglia TA, Slanetz PJ, Gunn CM. Perceptions of Breast Cancer Risks Among Women Receiving Mammograph Screening. JAMA Netw Open 2023; 6:e2252209. [PMID: 36689223 PMCID: PMC9871800 DOI: 10.1001/jamanetworkopen.2022.52209] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/02/2022] [Indexed: 01/24/2023] Open
Abstract
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.
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Affiliation(s)
- Laura B. Beidler
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Nancy R. Kressin
- Section of General Internal Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts
| | | | - Tracy A. Battaglia
- Section of General Internal Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts
| | - Priscilla J. Slanetz
- Department of Radiology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Christine M. Gunn
- Dartmouth Cancer Center, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Tosteson AN, Schifferdecker KE, Smith RE, Wernli KJ, Zhao W, Kaplan CP, Buist DS, Henderson LM, Sprague BL, Onega T, Budesky J, Jackson-Nefertiti G, Johnson D, Miglioretti DL, Kerlikowske K. Women's Breast Cancer Screening Confidence by Screening Modality and Breast Density: A Breast Cancer Surveillance Consortium Survey Study. J Womens Health (Larchmt) 2022; 31:1547-1556. [PMID: 36356184 PMCID: PMC9700351 DOI: 10.1089/jwh.2021.0649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: Little is known about women's confidence in their breast cancer screening. We sought to characterize breast cancer screening confidence by imaging modality and clinically assessed breast density. Materials and Methods: We undertook a cross-sectional survey of women ages 40-74 years who received digital mammography (DM), digital breast tomosynthesis (DBT), and/or breast magnetic resonance imaging (MRI) with a normal screening exam in the prior year. The main outcome was women's confidence (Very, Somewhat, A little, Not at all) in their breast cancer screening detecting any cancer. Multivariable logistic regression identified correlates of being very confident in breast cancer screening by screening modality group: Group 1) DM vs. DBT and Group 2) DM or DBT alone vs. with supplemental MRI. Results: Overall, 2329 of 7439 (31.3%) invitees participated, with 30%-61% being very confident in their screening across modality and density subgroups. Having dense versus nondense breasts was associated with lower odds of being very confident (Group 1: odds ratio [OR]: 0.58; 95% confidence interval [CI]: 0.46-0.79; Group 2: OR: 0.56; 95% CI: 0.40-0.79). There were no differences by modality within Group 1, but for Group 2, women undergoing MRI had higher odds of being very confident (OR: 1.69; 95% CI: 1.21-2.37). Other correlates of greater screening confidence were as follows: Group 1-being offered a screening test choice and cost not influencing modality received, and Group 2-decision satisfaction and worry. Conclusions: Women with dense breasts had lower screening confidence regardless of screening modality and those undergoing MRI had higher confidence regardless of density. The importance of informing women about screening options is underscored by observed associations between screening choice, decision satisfaction, and screening confidence. ClinicalTrials.gov: NCT02980848.
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Affiliation(s)
- Anna N.A. Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire, USA
- Dartmouth Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Karen E. Schifferdecker
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire, USA
| | - Rebecca E. Smith
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire, USA
| | - Karen J. Wernli
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Wenyan Zhao
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire, USA
| | - Celia P. Kaplan
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Diana S.M. Buist
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Louise M. Henderson
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brian L. Sprague
- Department of Surgery, University of Vermont Cancer Center, University of Vermont, Burlington, Vermont, USA
| | - Tracy Onega
- Department of Population Health Science, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Jill Budesky
- Department of Public Health Sciences, University of California, Davis, California, USA
| | | | - Dianne Johnson
- Department of Public Health Sciences, University of California, Davis, California, USA
| | - Diana L. Miglioretti
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
- Department of Public Health Sciences, University of California, Davis, California, USA
| | - Karla Kerlikowske
- Department of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, California, USA
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11
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Portable NMR for quantification of breast density in vivo: Proof-of-concept measurements and comparison with quantitative MRI. Magn Reson Imaging 2022; 92:212-223. [PMID: 35843446 DOI: 10.1016/j.mri.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/17/2022] [Accepted: 07/11/2022] [Indexed: 11/23/2022]
Abstract
Mammographic Density (MD) is the degree of radio-opacity of the breast in an X-ray mammogram. It is determined by the Fibroglandular: Adipose tissue ratio. MD has major implications in breast cancer risk and breast cancer chemoprevention. This study aimed to investigate the feasibility of accurate, low-cost quantification of MD in vivo without ionising radiation. We used single-sided portable nuclear magnetic resonance ("Portable NMR") due to its low cost and the absence of radiation-related safety concerns. Fifteen (N = 15) healthy female volunteers were selected for the study and underwent an imaging routine consisting of 2D X-ray mammography, quantitative breast 3T MRI (Dixon and T1-based 3D compositional breast imaging), and 1D compositional depth profiling of the right breast using Portable NMR. For each participant, all the measurements were made within 3-4 h of each other. MRI-determined tissue water content was used as the MD-equivalent quantity. Portable NMR depth profiles of tissue water were compared with the equivalent depth profiles reconstructed from Dixon and T1-based MR images, which were used as the MD-equivalent reference standard. The agreement between the depth profiles acquired using Portable NMR and the reconstructed reference-standard profiles was variable but overall encouraging. The agreement was somewhat inferior to that seen in breast tissue explant measurements conducted in vitro, where quantitative micro-CT was used as the reference standard. The lower agreement in vivo can be attributed to an uncertainty in the positioning of the Portable NMR sensor on the breast surface and breast compression in Portable NMR measurements. The degree of agreement between Portable NMR and quantitative MRI is encouraging. While the results call for further development of quantitative Portable NMR, they demonstrate the in-principle feasibility of Portable NMR-based quantitative compositional imaging in vivo and show promise for the development of safe and low-cost protocols for quantification of MD suitable for clinical applications.
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12
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Nickel B, Copp T, Li T, Dolan H, Brennan M, Verde A, Vaccaro L, McCaffery K, Houssami N. A systematic assessment of online international breast density information. Breast 2022; 65:23-31. [PMID: 35763979 PMCID: PMC9240362 DOI: 10.1016/j.breast.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background Breast density has become a topic of international discussion due to its associated risk of breast cancer. As online is often a primary source of women's health information it is therefore essential that breast density information it is understandable, accurate and reflects the best available evidence. This study aimed to systematically assess online international breast density information including recommendations to women. Methods Searches were conducted from five different English-speaking country-specific Google locations. Relevant breast density information was extracted from the identified websites. Readability was assessed using the SHeLL Editor, and understandability and actionability using the Patient Education Materials Assessment Tool (PEMAT). A content analysis of specific recommendations to women was also conducted. Results Forty-two eligible websites were identified and systematically assessed. The included informational content varied across websites. The average grade reading level across all websites was 12.4 (range 8.9–15.4). The mean understandability was 69.9% and the mean actionability was 40.1%, with 18/42 and 39/42 websites respectively scoring lower than adequate (70%). Thirty-six (85.7%) of the websites had breast density-related recommendation to women, with ‘talk to your doctor’ (n = 33, 78.6%) the most common. Conclusions Online information about breast density varies widely and is not generally presented in a way that women can easily understand and act on, therefore greatly reducing the ability for informed decision-making. International organisations and groups disseminating breast density information need to ensure that women are presented with health literacy-sensitive and balanced information, and be aware of the impact that recommendations may have on practice. First study to systematically assess online international breast density information. Information across the websites varies widely. Readability, understandability and actionability are low and poor. The most common recommendation to women is to ‘talk to your doctor’. More health literacy-sensitive online information about breast density is needed internationally.
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Affiliation(s)
- Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Tessa Copp
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Tong Li
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
| | - Hankiz Dolan
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Meagan Brennan
- The University of Notre Dame Australia, School of Medicine Sydney, Sydney, Australia; Westmead Breast Cancer Institute, Westmead Hospital, Sydney, Australia
| | - Angela Verde
- Breast Cancer Network Australia, Melbourne, Australia
| | - Lisa Vaccaro
- Health Consumers New South Wales, Sydney, Australia; Discipline of Behavioural and Social Sciences in Health, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Nehmat Houssami
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, Australia
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13
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Nickel B, Dolan H, Houssami N, Cvejic E, Brennan M, Hersch J, Dorrington M, Verde A, Vaccaro L, McCaffery K. Factors associated with women's supplemental screening intentions following dense breast notification in an online randomised experimental study. J Med Screen 2022; 30:92-95. [PMID: 36071630 DOI: 10.1177/09691413221125320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Controversy surrounding recommendations for supplemental screening (ultrasound and magnetic resonance screening) in women with dense breasts exists, as the long-term benefits from these additional modalities may not outweigh the harms. This study aimed to examine factors associated with supplemental screening intentions following a hypothetical breast density notification in a population of women who have not been routinely notified. Australian women of breast screening age participated in an online randomised experimental study where they were presented with one of two breast density notifications (with or without health literacy-sensitive information) and asked their screening intentions. After adjusting for covariates in multivariable analyses, women in both groups (n = 940) who indicated higher levels of breast cancer worry, had private health insurance, had a family history of breast cancer, and had a greater number of times previously attending mammography screening had higher intentions for supplemental screening. Understanding women's supplemental screening intentions following notification of dense breasts has important implications for health systems with breast screening considering the impacts of widespread notification. Personal, clinical and psychological factors should be considered when discussing both the benefits and harms of supplemental screening with women with dense breasts.
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Affiliation(s)
- Brooke Nickel
- Wiser Healthcare, School of Public Health, 4334University of Sydney, Sydney, Australia.,Sydney Health Literacy Lab, School of Public Health, University of Sydney, Sydney, Australia
| | - Hankiz Dolan
- Wiser Healthcare, School of Public Health, 4334University of Sydney, Sydney, Australia.,Sydney Health Literacy Lab, School of Public Health, University of Sydney, Sydney, Australia
| | - Nehmat Houssami
- Wiser Healthcare, School of Public Health, 4334University of Sydney, Sydney, Australia.,The Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia
| | - Erin Cvejic
- Wiser Healthcare, School of Public Health, 4334University of Sydney, Sydney, Australia.,Sydney Health Literacy Lab, School of Public Health, University of Sydney, Sydney, Australia
| | - Meagan Brennan
- School of Medicine Sydney, 3431University of Notre Dame Australia, Sydney, Australia.,Westmead Breast Cancer Institute, Westmead Hospital, Sydney, Australia
| | - Jolyn Hersch
- Wiser Healthcare, School of Public Health, 4334University of Sydney, Sydney, Australia.,Sydney Health Literacy Lab, School of Public Health, University of Sydney, Sydney, Australia
| | | | - Angela Verde
- 104351Breast Cancer Network Australia, Melbourne, Australia
| | - Lisa Vaccaro
- 430854Health Consumers New South Wales, Sydney, Australia.,Discipline of Behavioural and Social Sciences in Health, School of Health Sciences, University of Sydney, Sydney, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, School of Public Health, 4334University of Sydney, Sydney, Australia.,Sydney Health Literacy Lab, School of Public Health, University of Sydney, Sydney, Australia
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14
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Kressin NR, Wormwood JB, Battaglia TA, Slanetz PJ, Gunn CM. A letter is not enough: Women's preferences for and experiences of receiving breast density information. PATIENT EDUCATION AND COUNSELING 2022; 105:2450-2456. [PMID: 35534300 PMCID: PMC9250336 DOI: 10.1016/j.pec.2022.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Nancy R Kressin
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
| | - Jolie B Wormwood
- Department of Psychology, University of New Hampshire, Durham, NH, USA
| | - Tracy A Battaglia
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Priscilla J Slanetz
- Department of Radiology, Boston University School of Medicine, Boston, MA, USA
| | - Christine M Gunn
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
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15
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Kressin NR, Wormwood JB, Battaglia TA, Maschke AD, Slanetz PJ, Pankowska M, Gunn CM. Women's Understandings and Misunderstandings of Breast Density and Related Concepts: A Mixed Methods Study. J Womens Health (Larchmt) 2022; 31:983-990. [PMID: 35230164 PMCID: PMC9299527 DOI: 10.1089/jwh.2021.0343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Nancy R. Kressin
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jolie B. Wormwood
- Department of Psychology, University of New Hampshire, Durham, New Hampshire, USA
| | - Tracy A. Battaglia
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ariel D. Maschke
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Priscilla J. Slanetz
- Department of Radiology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Magdalena Pankowska
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Christine M. Gunn
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
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16
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Dolan H, McCaffery K, Houssami N, Cvejic E, Brennan M, Hersch J, Dorrington M, Verde A, Vaccaro L, Nickel B. Australian Women's Intentions and Psychological Outcomes Related to Breast Density Notification and Information: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2216784. [PMID: 35708691 PMCID: PMC9204548 DOI: 10.1001/jamanetworkopen.2022.16784] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Hankiz Dolan
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Nehmat Houssami
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia
| | - Erin Cvejic
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Meagan Brennan
- University of Notre Dame Australia, School of Medicine Sydney, Sydney, Australia
- Westmead Breast Cancer Institute, Westmead Hospital, Sydney, Sydney, Australia
| | - Jolyn Hersch
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | | | - Angela Verde
- Breast Cancer Network Australia, Melbourne, Australia
| | - Lisa Vaccaro
- Health Consumers New South Wales, Sydney, Australia
- Discipline of Behavioural and Social Sciences in Health, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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17
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Smith RE, Sprague B, Henderson LM, Kerlikowske K, Miglioretti DL, Buist DSM, Wernli KJ, Onega T, Schifferdecker K, Jackson-Nefertiti G, Johnson D, Budesky J, Tosteson ANA. Breast Density Knowledge in a Screening Mammography Population Exposed to Density Notification. J Am Coll Radiol 2022; 19:615-624. [PMID: 35341697 PMCID: PMC9119699 DOI: 10.1016/j.jacr.2022.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/06/2022] [Accepted: 02/11/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Women are increasingly informed about their breast density due to state density reporting laws. However, accuracy of personal breast density knowledge remains unclear. We compared self-reported with clinically assessed breast density and assessed knowledge of density implications and feelings about future screening. METHODS From December 2017 to January 2020, we surveyed women aged 40 to 74 years without prior breast cancer, with a normal screening mammogram in the prior year, and ≥1 recorded breast density measures in four Breast Cancer Surveillance Consortium registries with density reporting laws. We measured agreement between self-reported and BI-RADS breast density categorized as "ever-dense" if heterogeneously or extremely dense within the past 5 years or "never-dense" otherwise, knowledge of dense breast implications, and feelings about future screening. RESULTS Survey participation was 28% (1,528 of 5,408), and 59% (896 of 1,528) of participants had ever-dense breasts. Concordance between self-report versus clinical density was 76% (677 of 896) among women with ever-dense breasts and 14% (89 of 632) among women with never-dense breasts, and 34% (217 of 632) with never-dense breasts reported being told they had dense breasts. Desire for supplemental screening was more frequent among those who reported having dense breasts 29% (256 of 893) or asked to imagine having dense breasts 30% (152 of 513) versus those reporting nondense breasts 15% (15 of 102) (P = .003, P = .002, respectively). Women with never-dense breasts had 6.3-fold higher odds (95% confidence interval:3.39-11.80) of accurate knowledge in states reporting density to all compared to states reporting only to women with dense breasts. DISCUSSION Standardized communications of breast density results to all women may increase density knowledge and are needed to support informed screening decisions.
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Affiliation(s)
- Rebecca E Smith
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire.
| | - Brian Sprague
- Associate Professor of Surgery, Director of the Vermont Breast Cancer Surveillance System, and Senior Epidemiologist at the Vermont Center on Behavior and Health, Department of Surgery and University of Vermont Cancer Center, University of Vermont, Burlington, Vermont
| | - Louise M Henderson
- Professor of Radiology, Director of the Carolina Mammography Registry, and Director of the North Carolina Lung Screening Registry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Karla Kerlikowske
- Professor of Medicine and Epidemiology and Biostatistics, Co-Director of the Women's Clinic, and Director of the Women's Health Fellowship at the San Francisco Veterans Affairs Medical Center, Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Diana L Miglioretti
- Dean's Professor and Division Chief of Biostatistics, Department of Public Health Sciences, University of California, Davis, CA, USA; Principal Investigator of the Breast Cancer Surveillance Consortium (BCSC) Administrative Core, and Affiliate Scientific Investigator, Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington
| | - Diana S M Buist
- Affiliate Professor of Epidemiology, Affiliate Professor of Health Systems and Population Health, and Director of Research and Strategic Partnerships, Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington
| | - Karen J Wernli
- Affiliate Associate Professor of Epidemiology and Affiliate Associate Professor of Health Systems and Population Health, Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington
| | - Tracy Onega
- Jon M. and Karen Huntsman Presidential Professor in Cancer Research, Senior Director of Population Sciences, and Professor of Population Health Sciences, Department of Population Health Science, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Karen Schifferdecker
- Associate Professor, and Director of the Center for Program Design and Evaluation, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, New Hampshire
| | | | - Dianne Johnson
- Department of Public Health Sciences, University of California, Davis, California
| | - Jill Budesky
- Department of Public Health Sciences, University of California, Davis, California
| | - Anna N A Tosteson
- James J Carroll Professor, The Dartmouth Institute for Health Policy and Clinical Practice, and Departments of Medicine and of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA; and Associate Director for Population Sciences, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH USA
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18
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A Case Study in Breast Density Evaluation Using Bioimpedance Measurements. SENSORS 2022; 22:s22072747. [PMID: 35408360 PMCID: PMC9002785 DOI: 10.3390/s22072747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/16/2022]
Abstract
(1) Background: As breast cancer studies suggest, a high percentage of breast density (PBD) may be related to breast cancer incidence. Although PBD screening is one of the strongest predictors of breast cancer risk, X-ray-based mammography evaluation is subjective. Therefore, new objective PBD measuring techniques are of interest. A case study analyzing the PBD of thirteen female participants using a bioimpedance-based method, the anomalies tracking circle (ATC), is described in this paper. (2) Methods: In the first stage, the breast bioimpedance of each participant was measured. Then, the participant breast density was determined by applying a mammogram just after the breast bioimpedance measurement stage. In the third stage, the ATC algorithm was applied to the measured bioimpedance data for each participant, and a results analysis was done. (3) Results: An ATC variation according to the breast density was observed from the obtained data, this allowed the use of classification techniques to determine the PBD. (4) Conclusions: The described breast density method is a promising approach that might be applied as an auxiliary tool to the mammography in order to obtain precise and objective results for evaluation of breast density and with that determine potential breast cancer risk.
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Lee Argov EJ, Rodriguez CB, Agovino M, Wei Y, Shelton RC, Kukafka R, Schmitt KM, Desperito E, Terry MB, Tehranifar P. Breast cancer worry, uncertainty, and perceived risk following breast density notification in a longitudinal mammography screening cohort. Breast Cancer Res 2022; 24:95. [PMID: 36544225 PMCID: PMC9773500 DOI: 10.1186/s13058-022-01584-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 11/27/2022] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Erica J. Lee Argov
- grid.21729.3f0000000419368729Department of Epidemiology, Columbia University Mailman School of Public Health, 722 W 168th St., New York, NY USA
| | - Carmen B. Rodriguez
- grid.21729.3f0000000419368729Department of Epidemiology, Columbia University Mailman School of Public Health, 722 W 168th St., New York, NY USA
| | - Mariangela Agovino
- grid.21729.3f0000000419368729Department of Epidemiology, Columbia University Mailman School of Public Health, 722 W 168th St., New York, NY USA
| | - Ying Wei
- grid.21729.3f0000000419368729Department of Biostatistics, Columbia University Mailman School of Public Health, 722 W 168th St., New York, NY USA
| | - Rachel C. Shelton
- grid.21729.3f0000000419368729Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 W 168th St., New York, NY USA ,grid.239585.00000 0001 2285 2675Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 161 Fort Washington Ave., New York, NY USA
| | - Rita Kukafka
- grid.21729.3f0000000419368729Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, 722 W 168th St., New York, NY USA ,grid.239585.00000 0001 2285 2675Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 161 Fort Washington Ave., New York, NY USA ,grid.21729.3f0000000419368729Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, 622 West 168th St., New York, NY USA
| | - Karen M. Schmitt
- grid.239585.00000 0001 2285 2675Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 161 Fort Washington Ave., New York, NY USA ,grid.21729.3f0000000419368729Division of Academics, Columbia University School of Nursing, New York, NY USA
| | - Elise Desperito
- grid.239585.00000 0001 2285 2675Department of Radiology, Columbia University Irving Medical Center, New York, NY USA
| | - Mary Beth Terry
- grid.21729.3f0000000419368729Department of Epidemiology, Columbia University Mailman School of Public Health, 722 W 168th St., New York, NY USA ,grid.239585.00000 0001 2285 2675Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 161 Fort Washington Ave., New York, NY USA
| | - Parisa Tehranifar
- grid.21729.3f0000000419368729Department of Epidemiology, Columbia University Mailman School of Public Health, 722 W 168th St., New York, NY USA ,grid.239585.00000 0001 2285 2675Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, 161 Fort Washington Ave., New York, NY USA
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20
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Smith J, Dodd RH, Gainey KM, Naganathan V, Cvejic E, Jansen J, McCaffery KJ. Patient-Reported Factors Associated With Older Adults' Cancer Screening Decision-making: A Systematic Review. JAMA Netw Open 2021; 4:e2133406. [PMID: 34748004 PMCID: PMC8576581 DOI: 10.1001/jamanetworkopen.2021.33406] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Decisions for older adults (aged ≥65 years) and their clinicians about whether to continue to screen for cancer are not easy. Many older adults who are frail or have limited life expectancy or comorbidities continue to be screened for cancer despite guidelines suggesting they should not; furthermore, many older adults have limited knowledge of the potential harms of continuing to be screened. OBJECTIVE To summarize the patient-reported factors associated with older adults' decisions regarding screening for breast, prostate, colorectal, and cervical cancer. EVIDENCE REVIEW Studies were identified by searching databases from January 2000 to June 2020 and were independently assessed for inclusion by 2 authors. Data extraction and risk of bias assessment were independently conducted by 2 authors, and then all decisions were cross-checked and discussed where necessary. Data analysis was performed from September to December 2020. FINDINGS The search yielded 2475 records, of which 21 unique studies were included. Nine studies were quantitative, 8 were qualitative, and 4 used mixed method designs. Of the 21 studies, 17 were conducted in the US, and 10 of 21 assessed breast cancer screening decisions only. Factors associated with decision-making were synthesized into 5 categories: demographic, health and clinical, psychological, physician, and social and system. Commonly identified factors associated with the decision to undergo screening included personal or family history of cancer, positive screening attitudes, routine or habit, to gain knowledge, friends, and a physician's recommendation. Factors associated with the decision to forgo screening included being older, negative screening attitudes, and desire not to know about cancer. Some factors had varying associations, including insurance coverage, living in a nursing home, prior screening experience, health problems, limited life expectancy, perceived cancer risk, risks of screening, family, and a physician's recommendation to stop. CONCLUSIONS AND RELEVANCE Although guidelines suggest incorporating life expectancy and health status to inform older adults' cancer screening decisions, older adults' ingrained beliefs about screening may run counter to these concepts. Communication strategies are needed that support older adults to make informed cancer screening decisions by addressing underlying screening beliefs in context with their perceived and actual risk of developing cancer.
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Affiliation(s)
- Jenna Smith
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Rachael H. Dodd
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Karen M. Gainey
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Erin Cvejic
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Kirsten J. McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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21
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Nickel B, Houssami N. Improving Breast Density Communication: Does the Provision of Complex Health Information Online Work? J Womens Health (Larchmt) 2021; 30:1527-1528. [PMID: 34520271 DOI: 10.1089/jwh.2021.0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Brooke Nickel
- Wiser Healthcare and Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,Sydney Health Literacy Lab, Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nehmat Houssami
- Wiser Healthcare and Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Sydney, New South Wales, Australia
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22
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Nickel B, Copp T, Brennan M, Farber R, McCaffery K, Houssami N. Breast Density Notification: A Systematic Review of the Impact on Primary Care Practitioners. J Womens Health (Larchmt) 2021; 30:1457-1468. [PMID: 33656924 DOI: 10.1089/jwh.2020.8898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: In the last decade, there has been an unprecedented amount of advocacy and attention surrounding the issue of breast density (BD) in relation to mammography screening. It is largely unknown what impact notifying women of their BD has had on clinical practice for PCPs. This systematic review aimed to synthesize evidence from existing studies to understand the impact of BD notification on primary care practitioners' (PCPs) knowledge, attitudes, and practice implications. Methods: Empirical studies were identified through relevant database searches (database inception to May 2020). Two authors evaluated the eligibility of studies, extracted and crosschecked data, and assessed the risk of bias. Results were synthesized in a narrative form. Results: Six studies of the 232 titles identified and screened were included. All studies were undertaken in the United States, with five conducted postlegislation in their respective states, and one study conducted in states that were both prelegislation and postlegislation. Five studies were quantitative, including four cross-sectional surveys, and one study was qualitative. Findings consistently demonstrated PCPs' overall lack of knowledge about BD, low level of comfort in discussing and managing patients in relation to dense breasts, and limited consensus on the most appropriate approach for managing women with dense breasts, particularly in relation to supplemental screening. Conclusions: This review highlights important gaps in PCPs' understanding of BD and confidence in having discussions with women about the implications of dense breasts. It identifies the need for high-quality research and the development of evidence-based guidelines to better support PCPs.
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Affiliation(s)
- Brooke Nickel
- Wiser Healthcare, Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Sydney Health Literacy Lab, Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Tessa Copp
- Wiser Healthcare, Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Sydney Health Literacy Lab, Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Meagan Brennan
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, Australia.,School of Medicine Sydney, The University of Notre Dame, Sydney, Australia
| | - Rachel Farber
- Wiser Healthcare, Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Sydney Health Literacy Lab, Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Nehmat Houssami
- Wiser Healthcare, Faculty of Medicine and Health, Sydney School of Public Health, The University of Sydney, Sydney, Australia
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