Poor patient comprehension of abnormal mammography results

Immediate Access to Radiology Reports: Perspectives on X Before and After the Cures Act Information Blocking Provision

OBJECTIVE

The 21st Century Cures Act's information blocking provision mandates that patients have immediate access to their electronic health information, including radiology reports. We evaluated public opinions surrounding this policy on X, a microblogging platform with over 400 million users.

METHODS

We retrieved 27,522 posts related to radiology reports from October 5, 2020, through October 4, 2021. One reviewer performed initial screening for relevant posts. Two reviewers categorized user type and post theme(s) using a predefined coding system. Posts were grouped as "pre-Cures" (6 months before information blocking) and "post-Cures" (6 months after). Descriptive statistics and χ2 tests were performed.

RESULTS

Among 1,155 final posts, 1,028 unique users were identified (64% patients, 11% non-radiologist physicians, 4% radiologists). X activity increased, with 40% (n = 462) pre-Cures and 60% (n = 693) post-Cures. Early result notification before referring providers was the only theme that significantly increased post-Cures (+3%, P = .001). Common negative themes were frustration (33%), anxiety (27%), and delay (20%). Common positive themes were gratitude for radiologists (52%) and autonomy (21%). Of posts expressing opinions on early access, 84% favored and 16% opposed it, with decreased preference between study periods (P = .006). More patients than physicians preferred early access (92% versus 40%, P < .0001).

DISCUSSION

X activity increased after the information blocking provision, partly due to conversation about early notification. Despite negative experiences with reports, most users preferred early access. Although the Cures Act is a positive step toward open access, work remains to improve patients' engagement with their radiology results.

Generative Pre-trained Transformer 4 makes cardiovascular magnetic resonance reports easy to understand

BACKGROUND

Patients are increasingly using Generative Pre-trained Transformer 4 (GPT-4) to better understand their own radiology findings.

PURPOSE

To evaluate the performance of GPT-4 in transforming cardiovascular magnetic resonance (CMR) reports into text that is comprehensible to medical laypersons.

METHODS

ChatGPT with GPT-4 architecture was used to generate three different explained versions of 20 various CMR reports (n = 60) using the same prompt: "Explain the radiology report in a language understandable to a medical layperson". Two cardiovascular radiologists evaluated understandability, factual correctness, completeness of relevant findings, and lack of potential harm, while 13 medical laypersons evaluated the understandability of the original and the GPT-4 reports on a Likert scale (1 "strongly disagree", 5 "strongly agree"). Readability was measured using the Automated Readability Index (ARI). Linear mixed-effects models (values given as median [interquartile range]) and intraclass correlation coefficient (ICC) were used for statistical analysis.

RESULTS

GPT-4 reports were generated on average in 52 s ± 13. GPT-4 reports achieved a lower ARI score (10 [9-12] vs 5 [4-6]; p < 0.001) and were subjectively easier to understand for laypersons than original reports (1 [1] vs 4 [4,5]; p < 0.001). Eighteen out of 20 (90%) standard CMR reports and 2/60 (3%) GPT-generated reports had an ARI score corresponding to the 8th grade level or higher. Radiologists' ratings of the GPT-4 reports reached high levels for correctness (5 [4, 5]), completeness (5 [5]), and lack of potential harm (5 [5]); with "strong agreement" for factual correctness in 94% (113/120) and completeness of relevant findings in 81% (97/120) of reports. Test-retest agreement for layperson understandability ratings between the three simplified reports generated from the same original report was substantial (ICC: 0.62; p < 0.001). Interrater agreement between radiologists was almost perfect for lack of potential harm (ICC: 0.93, p < 0.001) and moderate to substantial for completeness (ICC: 0.76, p < 0.001) and factual correctness (ICC: 0.55, p < 0.001).

CONCLUSION

GPT-4 can reliably transform complex CMR reports into more understandable, layperson-friendly language while largely maintaining factual correctness and completeness, and can thus help convey patient-relevant radiology information in an easy-to-understand manner.

Artificial Intelligence to Improve Patient Understanding of Radiology Reports

Diagnostic imaging reports are generally written with a target audience of other providers. As a result, the reports are written with medical jargon and technical detail to ensure accurate communication. With implementation of the 21st Century Cures Act, patients have greater and quicker access to their imaging reports, but these reports are still written above the comprehension level of the average patient. Consequently, many patients have requested reports to be conveyed in language accessible to them. Numerous studies have shown that improving patient understanding of their condition results in better outcomes, so driving comprehension of imaging reports is essential. Summary statements, second reports, and the inclusion of the radiologist's phone number have been proposed, but these solutions have implications for radiologist workflow. Artificial intelligence (AI) has the potential to simplify imaging reports without significant disruptions. Many AI technologies have been applied to radiology reports in the past for various clinical and research purposes, but patient focused solutions have largely been ignored. New natural language processing technologies and large language models (LLMs) have the potential to improve patient understanding of their imaging reports. However, LLMs are a nascent technology and significant research is required before LLM-driven report simplification is used in patient care.

Delays in Follow-up Care for Abnormal Mammograms in Mobile Mammography Versus Fixed-Clinic Patients

BACKGROUND

Mobile mammographic services (MM) have been shown to increase breast cancer screening in medically underserved women. However, little is known about MM patients' adherence to follow-up of abnormal mammograms and how this compares with patients from traditional, fixed clinics.

OBJECTIVES

To assess delays in follow-up of abnormal mammograms in women screened using MM versus fixed clinics.

DESIGN

Electronic medical record review of abnormal screening mammograms.

SUBJECTS

Women screened on a MM van or at a fixed clinic with an abnormal radiographic result in 2019 (N = 1,337).

MAIN MEASURES

Our outcome was delay in follow-up of an abnormal mammogram of 60 days or greater. Guided by Andersen's Behavioral Model of Health Services Utilization, we assessed the following: predisposing (age, ethnicity, marital status, preferred language), enabling (insurance, provider referral, clinic site), and need (personal breast cancer history, family history of breast/ovarian cancer) factors.

KEY RESULTS

Only 45% of MM patients had obtained recommended follow-up within 60 days of an abnormal screening compared to 72% of fixed-site patients (p < .001). After adjusting for predisposing, enabling, and need factors, MM patients were 2.1 times more likely to experience follow-up delays than fixed-site patients (CI: 1.5-3.1; p < .001). African American (OR: 1.5; CI: 1.0-2.1; p < .05) and self-referred (OR: 1.8; CI: 1.2-2.8; p < .01) women were significantly more likely to experience delays compared to Non-Hispanic White women or women with a provider referral, respectively. Women who were married (OR: 0.63; CI: 0.5-0.9; p < .01), had breast cancer previously (OR: 0.37; CI: 0.2-0.8; p < .05), or had a family history of breast/ovarian cancer (OR: 0.76; CI: 0.6-0.9; p < .05) were less likely to experience delayed care compared to unmarried women, women with no breast cancer history, or women without a family history of breast/ovarian cancer, respectively.

CONCLUSIONS

A substantial proportion of women screened using MM had follow-up delays. Women who are African American, self-referred, or unmarried are particularly at risk of experiencing delays in care for an abnormal mammogram.

Perception of Breast Density Information Among Women in Miami, FL: a Qualitative Study

The US Food and Drug Administration has proposed requiring that all women undergoing mammography receive written information about their breast density. Past research suggests many women may misperceive the meaning of breast density. Additionally, women with dense breasts may not understand the risks and benefits of pursuing additional imaging studies. The goal of this study was to explore women's beliefs about breast density and their preferences for how this information is conveyed. Women with increased breast density detected on mammography at a university-based breast imaging center in South Florida were recruited for a series of focus groups. Twenty-five women participated, ranging in age from 42 to 65 years. Nine women (36%) self-identified as Hispanic/Latina, eight (32%) as Black, four (16%) as White, three (12%) as Asian, and one as "other." Four focus groups were conducted in English and one in Spanish by professional moderators using a semi-structured format. A constant comparative method was used to identify common themes using a general inductive approach. Areas explored included understanding of the term breast density; personal reaction to being informed of dense breasts; questions about breast density; understanding of supplemental screening; and preferences for how to convey breast density information. Subthemes identified included a misperception that breast density is palpable; a feeling of fear on learning of increased breast density results; a concern about what causes increased breast density and whether it can be reversed; a desire to proceed with supplemental ultrasound imaging; and a preference for simple messages explaining the concept of breast density in multiple formats including video. Participants voiced the incorrect belief that caffeine intake could increase breast density and stated that they wanted to know specific details about their personal results. There is a need for better tools to communicate breast density in a way that allays anxiety while enabling women to make fully informed decisions about their breast health. Clinicians and cancer educators should be aware of misperceptions women may have about breast density. Policymakers should keep in mind potential public confusion about this complex topic when crafting density notification rules.

Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review

Background

Successful breast cancer screening relies on timely follow-up of abnormal mammograms. Delayed or failure to follow-up abnormal mammograms undermines the potential benefits of screening and is associated with poorer outcomes. However, a comprehensive review of inadequate follow-up of abnormal mammograms in primary care has not previously been reported in the literature. This review could identify modifiable factors that influence follow-up, which if addressed, may lead to improved follow-up and patient outcomes.

Methods

A systematic literature review to determine the extent of inadequate follow-up of abnormal screening mammograms in primary care and identify factors impacting on follow-up was conducted. Relevant studies published between 1 January, 1990 and 29 October, 2020 were identified by searching MEDLINE®, Embase, CINAHL® and Cochrane Library, including reference and citation checking. Joanna Briggs Institute Critical Appraisal Checklists were used to assess the risk of bias of included studies according to study design.

Results

Eighteen publications reporting on 17 studies met inclusion criteria; 16 quantitative and two qualitative studies. All studies were conducted in the United States, except one study from the Netherlands. Failure to follow-up abnormal screening mammograms within 3 and at 6 months ranged from 7.2–33% and 27.3–71.6%, respectively. Women of ethnic minority and lower education attainment were more likely to have inadequate follow-up. Factors influencing follow-up included physician-patient miscommunication, information overload created by automated alerts, the absence of adequate retrieval systems to access patient’s results and a lack of coordination of patient records. Logistical barriers to follow-up included inconvenient clinic hours and inconsistent primary care providers. Patient navigation and case management with increased patient education and counselling by physicians was demonstrated to improve follow-up.

Conclusions

Follow-up of abnormal mammograms in primary care is suboptimal. However, interventions addressing amendable factors that negatively impact on follow-up have the potential to improve follow-up, especially for populations of women at risk of inadequate follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08100-3.

Organization Communication Factors and Abnormal Mammogram Follow-up: a Qualitative Study Among Ethnically Diverse Women Across Three Healthcare Systems

BACKGROUND

Regular mammogram screening for eligible average risk women has been associated with early detection and reduction of cancer morbidity and mortality. Delayed follow-up and resolution of abnormal mammograms limit early detection efforts and can cause psychological distress and anxiety.

OBJECTIVE

The goal of this study was to gain insight from women's narratives into how organizational factors related to communication and coordination of care facilitate or hinder timely follow-up for abnormal mammogram results.

DESIGN

We conducted 61 qualitative in-person interviews with women from four race-ethnic groups (African American, Chinese, Latina, and White) in three different healthcare settings (academic, community, and safety-net).

PARTICIPANTS

Eligible participants had an abnormal mammogram result requiring breast biopsy documented in the San Francisco Mammography Registry in the previous year.

APPROACH

Interview narratives included reflections on experience and suggested improvements to communication and follow-up processes. A grounded theory approach was used to identify themes across interviews.

KEY RESULTS

Participants' experiences of follow-up and diagnosis depended largely on communication processes. Twenty-one participants experienced a follow-up delay (> 30 days between index mammogram and biopsy). Organizational factors, which varied across different institutions, played key roles in effective communication which included (a) direct verbal communication with the ability to ask questions, (b) explanation of medical processes and terminology avoiding jargon, and (c) use of interpretation services for women with limited English proficiency.

CONCLUSION

Health organizations varied in their processes for abnormal results communication and availability of support staff and interpretation services. Women who received care from institutions with more robust support staff, such as bilingual navigators, more often than not reported understanding their results and timely abnormal mammogram follow-up. These reports were consistent across women from diverse ethnic groups and suggest the value of organizational support services between an abnormal mammogram and resolution for improving follow-up times and minimizing patient distress.

Patient vs Clinician Perspectives on Communication About Results of Lung Cancer Screening: A Qualitative Study

BACKGROUND

In the incidental pulmonary nodule and breast cancer screening settings, high-quality patient-centered communication can improve adherence to evaluation and mitigate patient distress. Although guidelines emphasize shared decision-making before lung cancer screening, little is known about patient-clinician communication after lung cancer screening.

RESEARCH QUESTION

How do patients and clinicians perceive communication and results notification after lung cancer screening, and are there approaches that may mitigate or exacerbate distress?

STUDY DESIGN AND METHODS

We conducted interviews and focus groups with 49 patients who underwent lung cancer screening in the prior year and 36 clinicians who communicate screening results (primary care providers, pulmonologists, nurses), recruited from lung cancer screening programs at 4 hospitals. We analyzed transcripts using conventional content analysis.

RESULTS

Clinicians and patients diverged in their impressions of the quality of communication after lung cancer screening. Clinicians recognized the potential for patient distress and tailored their approach to disclosure based on how clinically concerning they perceived results to be. Disclosure of normal or low-risk findings usually occurred by letter; clinicians believed this process was efficient and well received by patients. Yet many patients were dissatisfied: several could not recall receiving results at all, and others reported that receiving results by letter left them confused and concerned, with little opportunity to ask questions. By contrast, patients with larger nodules typically received results during an immediate phone call or clinic visit, and both patients and clinicians agreed that these conversations represented high-quality communication that met patient needs. Regardless of their cancer risk, patients who learned their results in a conversation appreciated the opportunity to discuss both the meaning of the nodule and the evaluation plan, and to have their concerns addressed, preempting distress.

INTERPRETATION

Tension exists between clinicians' interest in efficiency of results notification by letter in low-risk cases and patients' need to understand and be reassured about screening results, their implications, and the plan for subsequent screening or nodule evaluation-even when clinicians did not perceive results as concerning. Brief conversations to discuss lung cancer screening results may improve patient understanding and satisfaction while reducing distress.

Time to diagnostic resolution after an uncertain screening mammogram in an underserved population

BACKGROUND

Screening mammography has reduced breast cancer-associated mortality worldwide. Approximately 10% of patients require further diagnostic testing after an uncertain screening mammogram (Breast imaging reporting and data system [BI-RADS] = 0), and time to diagnostic resolution varies after BI-RADS = 0 screening mammogram. There is little data about factors associated with diagnostic resolution in patients of Chinese origin ("Chinese") receiving care in the US.

METHODS

We performed a retrospective analysis to identify patterns of diagnostic resolution in an urban US hospital with a large population of Chinese patients. We evaluated whether location of primary care provider (PCP) impacted time to resolution among Chinese patients, hypothesizing that patients with a PCP outside of the hospital would have longer time to diagnostic resolution than those patients with a PCP within the institution.

RESULTS

Between 2015 and 2016, 368 patients at Tufts Medical Center (Tufts MC) had resulting BI-RADS = 0 after screening mammogram. The majority of patients (341/368, 93%) achieved diagnostic resolution with median time to resolution 27 days (Q1: 14, Q3: 40). Seven percent (27/368) never achieved resolution. Among those with diagnostic resolution, 10% of patients required >60 days to achieve resolution. Chinese origin, no previous breast cancer, subsidized insurance, and outside referring physician were associated with longer time to resolution in univariable analysis. In multivariable regression, after adjusting for age, insurance, marital status, and prior breast cancer, Chinese patients with Tufts MC PCP experienced timelier diagnostic resolution vs Chinese patients without a Tufts MC PCP (hazard ratio [HR] = 1.85, P = .02). Location of PCP did not impact time to resolution among non-Chinese patients.

CONCLUSION

We identified patterns of diagnostic resolution in an urban hospital with a large historically underserved population. We found that Chinese patients without integrated primary care within the institution are at risk for delayed diagnostic resolution. Future interventions need to target at-risk patients to prevent loss of follow-up after uncertain screening mammogram.

Acceptability of an Interactive Computer-Animated Agent to Promote Patient-Provider Communication About Breast Density: a Mixed Method Pilot Study

BACKGROUND

Half of women undergoing mammography have dense breasts. Mandatory dense breast notification and educational materials have been shown to confuse women, rather than empower them.

OBJECTIVE

This study used a mixed method, multi-stakeholder approach to assess acceptability of an interactive, computer-animated agent that provided breast density information to women and changes in knowledge, satisfaction, and informational needs.

DESIGN

A pre-post survey and qualitative focus groups assessed the acceptability of the computer-animated agent among women. An anonymous, online survey measuring acceptability was delivered to a multi-stakeholder group.

PARTICIPANTS

English-speaking, mammography-eligible women ages 40-74 were invited and 44 women participated in one of nine focus groups. In addition, 14 stakeholders representing primary care, radiology, patient advocates, public health practitioners, and researchers completed the online survey.

INTERVENTIONS

A prototype of a computer-animated agent was delivered to women in a group setting; stakeholders viewed the prototype independently.

MAIN MEASURES

Data collected included open-ended qualitative questions that guided discussion about the content and form of the computer-animated agent. Structured surveys included domains related to knowledge, acceptability, and satisfaction. Stakeholder acceptability was measured with a series of statements about aspects of the intervention and delivery approach and are reported as the proportion of respondents who endorsed each statement.

KEY RESULTS

Six of 12 knowledge items demonstrated improvement post-intervention, satisfaction with the agent was high (81%), but the number of unanswered questions did not improve (67% vs. 54%, p = 0.37). Understanding of the distinction between connective and fatty tissue in the breast did not increase (30% vs. 26%, p = 0.48). Results of the multi-stakeholder survey suggest broad acceptability of the approach and agent.

CONCLUSIONS

Findings highlight the benefits of a brief interactive educational exposure as well as misperceptions that persisted. Results demonstrate the need for an evidence-based, accessible intervention that is easy to understand for patients.

A Qualitative Study of Spanish-Speakers' Experience with Dense Breast Notifications in a Massachusetts Safety-Net Hospital

BACKGROUND

Legislation requiring mammography facilities to notify women if they have dense breast tissue found on mammography has been enacted in 34 US states. The impact of dense breast notifications (DBNs) on women with limited English proficiency (LEP) is unknown.

OBJECTIVE

This study sought to understand Spanish-speaking women's experience receiving DBNs in a Massachusetts safety-net hospital.

DESIGN

Eligible women completed one audio-recorded, semi-structured interview via telephone with a native Spanish-speaking research assistant trained in qualitative methods. Interviews were professionally transcribed verbatim and translated. The translation was verified by a third reviewer to ensure fidelity with audio recordings.

PARTICIPANTS

Nineteen Spanish-speaking women ages 40-74 who received mammography with a normal result and recalled receiving a DBN.

APPROACH

Using the verified English transcripts, we conducted a content analysis to identify women's perceptions and actions related to receiving the notification. A structured codebook was developed. Transcripts were independently coded and assessed for agreement with a modification of Cohen's kappa. Content codes were grouped to build themes related to women's perceptions and actions after receiving a DBN.

KEY RESULTS

Nineteen Spanish-speaking women completed interviews. Nine reported not receiving the notification in their native language. Four key themes emerged: (1) The novelty of breast density contributed to notification-induced confusion; (2) women misinterpreted key messages in the notification; (3) varied actions were taken to seek further information; and (4) women held unrealized expectations and preferences for follow-up.

CONCLUSIONS

Not having previous knowledge of breast density and receiving notifications in English contributed to confusion about its meaning and inaccurate interpretations of key messages by Spanish speakers. Tools that promote understanding should be leveraged in seeking equity in risk-based breast cancer screening for women with dense breasts.

A Brochure to Improve Understanding of Incomplete Mammogram Results Among Black Women at a Public Hospital in Miami, Florida

OBJECTIVES

Black women are at increased risk of being called back for additional studies after a screening mammogram. With focus group input, we developed a brochure to improve awareness of the frequency of abnormal results. This study explored the brochure's acceptability and effect on understanding risk and breast cancer fears among black mammography patients at an urban safety-net breast imaging center in Miami, Florida.

METHODS

A randomized controlled trial of the brochure (plus the standard result notification letter) versus usual care (standard notification letter alone). Black English-speaking women with an incomplete mammography result were randomized to the intervention or control group. Consenting participants completed a telephone questionnaire. Outcomes included awareness of result, anxiety level, and brochure acceptability. The χ² or Fisher exact test was used and a univariate logistic regression was performed for intervention and control odds ratios.

RESULTS

A total of 106 women were randomly selected to receive the brochure plus the letter or the letter alone. One chose to opt out; a minimum of three attempts were made to reach each of the remaining 105 women by telephone. Verbal communication was established with 59 of the randomized women, and 51 of those women agreed to participate in a survey to evaluate the brochure. There was no significant difference between the surveyed groups in knowledge of the result and follow-up plan. Surveyed intervention subjects were more likely to agree that "it is very common for women to have to follow up after a mammogram" (odds ratio [OR] 25.91, P = 0.029) and less likely to agree with the statement "getting a follow-up mammogram is scary" (OR 0.24, P = 0.021). Most intervention subjects said the pamphlet helped them understand their result "a lot" (79%, 19) and viewed it as "extremely" or "mostly" clear (96%, 23). Intervention subjects also voiced greater awareness of a telephone number they could call for more information about cancer (OR 11.38, P = 0.029).

CONCLUSIONS

A culturally tailored brochure explaining the frequency of abnormal mammograms was well received by women at a large safety-net health system. Pilot testing suggests that it may improve patient perception of risk and awareness of informational resources. This strategy should be considered to enhance result communication.

Communication of cancer screening results by letter, telephone or in person: A mixed methods systematic review of the effect on attendee anxiety, understanding and preferences

Attending and receiving a result from screening can be an anxious process. Using an appropriate method to deliver screening results could improve communication and reduce negative outcomes for screening attendees. Screening programmes are increasingly communicating results by letter or telephone rather than in-person. We investigated the impact of communication methods on attendees.

We systematically reviewed the literature on the communication methods used to deliver results in cancer screening programmes for women, focusing on screening attendee anxiety, understanding of results and preferences for results communication. We included qualitative and quantitative research. We searched MEDLINE, PsycINFO, CINAHL, Cochrane Library and Embase. Results were analysed using framework synthesis. 10,558 papers were identified with seven studies meeting the inclusion criteria.

Several key ideas emerged from the synthesis including speed, accuracy of results, visual support, ability to ask questions, privacy of results location and managing expectations.

Verbal communication methods (telephone and in-person) were preferred and facilitated greater understanding than written methods, although there was considerable variability in attendee preferences. Findings for anxiety were mixed, with no clear consensus on which method of communication might minimise attendee anxiety.

The low number of identified studies and generally low quality evidence suggest we do not know the most appropriate communication methods in the delivery of cancer screening results. More research is needed to directly compare methods of results communication, focusing on what impact each method may have on screening attendees.

Mammography facilities serving vulnerable women have longer follow-up times

Objective

To investigate mammography facilities’ follow‐up times, population vulnerability, system‐based processes, and association with cancer stage at diagnosis.

Data Sources

Prospectively collected from San Francisco Mammography Registry (SFMR) 2005‐2011, California Cancer Registry 2005‐2012, SFMR facility survey 2012.

Study Design

We examined time to biopsy for 17 750 abnormal mammogram results (BI‐RADS 4/5), categorizing eight facilities as short or long follow‐up based on proportion of mammograms with biopsy at 30 days. We examined facility population vulnerability (race/ethnicity, language, education), and system processes. Among women with a cancer diagnosis, we modeled odds of advanced‐stage (≥IIb) cancer diagnosis by facility follow‐up group.

Data Extraction Methods

Merged SFMR, Cancer Registry and facility survey data.

Principal Findings

Facilities (N = 4) with short follow‐up completed biopsies by 30 days for 82% of mammograms compared with 62% for facilities with long follow‐up (N = 4) (P < 0.0001). All facilities serving high proportions of vulnerable women were long follow‐up facilities. The long follow‐up facilities had fewer radiologists, longer biopsy appointment wait times, and less communication directly with women. Having the index abnormal mammogram at a long follow‐up facility was associated with higher adjusted odds of advanced‐stage cancer (OR 1.45; 95% CI 1.10‐1.91).

Conclusions

Providing mammography facilities serving vulnerable women with appropriate resources may decrease disparities in abnormal mammogram follow‐up and cancer diagnosis stage.

Patient-Centered Radiology Reporting: Using Online Crowdsourcing to Assess the Effectiveness of a Web-Based Interactive Radiology Report

PURPOSE

The aim of this study was to evaluate the effectiveness of a patient-centered web-based interactive mammography report.

METHODS

A survey was distributed on Amazon Mechanical Turk, an online crowdsourcing platform. One hundred ninety-three US women ≥18 years of age were surveyed and then randomized to one of three simulated BI-RADS^® 0 report formats: standard report, Mammography Quality Standards Act-modeled patient letter, or web-based interactive report. Survey questions assessed participants' report comprehension, satisfaction with and perception of the interpreting radiologist, and experience with the presented report. Two-tailed t tests and χ² tests were used to evaluate differences among groups.

RESULTS

Participants in the interactive web-based group spent more than double the time viewing the report than the standard report group (160.0 versus 64.2 seconds, P < .001). Report comprehension scores were significantly higher for the interactive web-based and patient letter groups than the standard report group (P < .05). Scores of satisfaction with the interpreting radiologist were significantly higher for the web-based interactive report and patient letter groups than the standard report group (P < .01). There were no significant differences between the patient letter and web-based interactive report groups.

CONCLUSIONS

Radiology report format likely influences communication effectiveness. For result communication to a non-medical patient audience, patient-centric report formats, such as a Mammography Quality Standards Act-modeled patient letter or web-based interactive report, may offer advantages over the standard radiology report. Future work is needed to determine if these findings are reproducible in patient care settings and to determine how best to optimize radiology result communication to patients.

Disparities in abnormal mammogram follow-up time for Asian women compared with non-Hispanic white women and between Asian ethnic groups

BACKGROUND

Delays in abnormal mammogram follow-up contribute to poor outcomes. In the current study, the authors examined differences in abnormal screening mammogram follow-up between non-Hispanic white (NHW) and Asian women.

METHODS

The authors used a prospective cohort of NHW and Asian women with a Breast Imaging, Reporting and Data System (BI-RADS) abnormal result of category 0 or 3-plus in the San Francisco Mammography Registry between 2000 and 2010. Kaplan-Meier estimation for the median number of days to follow-up with a diagnostic radiologic test was performed, and the authors compared the percentage of women with follow-up at 30 days, 60 days, and 90 days and no follow-up at 1 year for Asian women overall (and Asian ethnic groups) and NHW women. In addition, the authors assessed the relationship between race/ethnicity and time to follow-up with adjusted Cox proportional hazards models.

RESULTS

Among Asian women, Vietnamese and Filipina women had the longest, and Japanese women the shortest, median follow-up (32 days, 28 days, and 19 days, respectively) compared with NHW women (15 days). The percentage of women receiving follow-up at 30 days was lower for Asians versus NHWs (57% vs 77%; P<.0001), and these disparities persisted at 60 days and 90 days for all Asian ethnic groups except Japanese. Asian women had a reduced hazard of follow-up compared with NHW women (adjusted hazard ratio, 0.70; 95% confidence interval, 0.69-0.72). Asian women also had a higher rate of receiving no follow-up compared with NHW women (15% vs 10%; P<.001); among Asian ethnic groups, Filipinas were found to have the highest percentage of women with no follow-up (18.1%).

CONCLUSIONS

Asian women, particularly Filipina and Vietnamese women, were less likely than NHW women to receive timely follow-up after an abnormal screening mammogram. Research should disaggregate Asian ethnicity to better understand and address barriers to effective cancer prevention. Cancer 2017;123:3468-75. © 2017 American Cancer Society.

Conversations about Abnormal Mammograms on Distress and Timely Follow-up Across Ethnicity

Communication with healthcare providers, family, and friends is associated with increased mammography use. Less is known about the abnormal mammogram experience, especially in terms of the interval between screening and follow-up appointments (time to follow-up) and psychological distress. The impact of communication may vary across ethnicity, depending on cultural emphases placed on interpersonal relationships. The current study's objectives were to (a) explore the role of family/friend and provider communication with regard to time to follow-up and distress and (b) examine if family/friend and provider communication moderates associations between ethnicity and these outcomes. A convenience-based sample of 41 Latina and 41 non-Latina White (NLW) women who had received an abnormal mammogram result was recruited from Washington State. Women who discussed results with providers had a shorter time to follow-up, although this was not significant when including health insurance. A significant interaction between conversations with family/friends and ethnicity was found: Latinas who did not have conversations with family/friends had particularly elevated psychological distress relative to NLW women and slightly more than other Latinas. This exploratory study suggests health communication with providers and family/friends is important for timely receipt of follow-up care and reduced distress among women who receive an abnormal mammogram result, which has implications for cancer education intervention development and adaptation. Larger, population-based research is necessary to confirm these findings.

Psychological Outcomes After a False Positive Mammogram: Preliminary Evidence for Ethnic Differences Across Time

Adverse psychological consequences of screening mammography are well-documented for women who receive a false positive result. However, little is known about ethnic differences. To address this gap, we examine distress associated with an abnormal mammogram (results-related distress) and perceived lifetime risk of breast cancer (perceived risk) among Latinas and non-Latina White (NLW) women 3 months after receipt of a false positive result. A sample of 28 Latina and 27 NLW women who received an initial abnormal mammogram result and later, a definitive non-cancer diagnosis were recruited for this descriptive, longitudinal study. Women were interviewed twice: within 30 days and 3 months after a false positive result. Questionnaires included standard sociodemographic questions, the Impact of Events Scale-Revised, and two perceived breast cancer risk items. All participants experienced decreased distress 3 months after the initial results. Latinas experienced higher levels of distress, F(1,45) = 4.58, p = 0.04, and had a significant increase in perceived breast cancer risk over time, F(1,45) = 3.99, p = 0.05. Larger population-based studies are necessary to confirm ethnic differences in mental health consequences of false positive results. Given cultural emphases concerning respect for authority figures, healthcare professionals may be particularly helpful in working with Latinas to mitigate distress and clarify accurate perceptions of breast cancer risk through evidence-based practice.

Text Messaging May Improve Abnormal Mammogram Follow-Up in Latinas

PURPOSE/OBJECTIVES

To develop and pilot test a text message notification process to reduce follow-up time for women with abnormal mammograms.
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DESIGN

Formative analysis; randomized trial with delayed intervention control group.
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SETTING

Tiburcio Vasquez Health Clinic (TVHC), a federally qualified health center in Hayward, California.
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SAMPLE

29 Spanish-speaking Latinas with abnormal mammograms.
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METHODS

A Spanish text message was developed based on findings from two focus groups and five interviews with TVHC healthcare providers. Thirteen women were assigned to receive text messages within 24 hours of receipt of abnormal mammogram by TVHC (intervention group) and 16 to receive text messages four weeks later (delayed intervention group).
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MAIN RESEARCH VARIABLES

Number of days between the abnormal mammogram and the return for follow-up appointment.
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FINDINGS

The median number of days from the abnormal mammogram report to the return for follow-up was 23 days for the intervention group and 59 days for the delayed intervention group (p = 0.0569).
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CONCLUSIONS

This study successfully developed a text message that, in Latinas, may decrease the time from receipt of an abnormal mammogram report to attendance at a follow-up visit.
.

IMPLICATIONS FOR NURSING

This simple, low-cost approach could result in earlier detection of breast cancers, lowering morbidity and mortality among Latinas.

How do breast imaging centers communicate results to women with limited English proficiency and other barriers to care?

Research suggests that women with Limited English Proficiency (LEP) and ethnic minority women are at increased risk of being inadequately informed of their mammogram result. The purpose of this study is to explore breast imaging centers' communication practices and assess how these centers accommodate women with low literacy and LEP. A 35-question survey was distributed to a national association of more than 700 breast health centers. Descriptive analysis of the overall sample and Fisher's exact or Chi squared testing to distinguish differences between subgroups were performed. Respondents from 206 centers completed questionnaires. 29% of respondents stated that more than a quarter of their patients were black, 27% of respondents stated that more than a quarter of their patients were Hispanic/Latina, and 13% of respondents stated that more than a quarter of their patients had LEP. Overall, 18% of respondents reported they do not routinely telephone patients with results, 15% do not have multilingual staff or translators available to answer questions, and 69% send result letters in English only. Of note, 69% use patient navigators. Centers reported systemic strengths and barriers to clear communication of mammography results. Our findings are consistent with past investigations identifying a general need to improve the communication of breast imaging results and suggesting that result notification letters alone are inadequate in ensuring that every woman understands her personal results and follow-up plan.

Overcoming Barriers to Mammography Screening: A Quasi-randomised Pragmatic Trial in a Community-based Primary Care Setting

Introduction: Breast cancer is the leading cancer among women in Singapore. Five years after a population-wide breast cancer screening programme was introduced, screening rates remained relatively low at 41%. Studies have shown decreased screening propensity among medically underserved women typically of minority or socioeconomically disadvantaged status. We conducted a quasi-randomised pragmatic trial aimed at encouraging mammography screening among underscreened or unscreened women in a publicly funded primary care facility in Singapore. Materials and Methods: The study was conducted from May to August 2010. Components of intervention included (1) tailored education, (2) doctor’s reminder, and (3) cost reduction. Researchers administered a structured questionnaire to eligible female polyclinic attendees and patient companions aged 40 to 69 years. Individual knowledge, attitudes, beliefs, and barriers towards mammography screening were identified and educational messages tailored. Doctor’s reminder and cost reduction were implemented additively. Results: Overall, out of 448 participants, 87 (19.4%, 95% confidence interval (CI), 15.8% to 23.1%) completed mammography screening across 3 arms of study. Participants who received a cost reduction were more likely to attend screening compared to participants in other intervention arms (adjusted odds ratio (OR) 2.4, 95% CI, 1.2 to 4.5, P = 0.009). Cost of screening, ethnicity, prior screening history, and attitudes towards mammography screening were identified as significant factors predicting mammogram attendance. Conclusion: Including a cost reduction component was the most effective intervention that increased mammography screening rates. Women's underlying beliefs, attitudes, and other predisposing factors should also be considered for integration into existing breast cancer screening programmes. Key words: Asia, Breast cancer, Community health services, Patient navigation, Singapore

Understanding the patient-provider communication needs and experiences of Latina and non-Latina White women following an abnormal mammogram

Latinas are more likely to delay recommended follow-up care than non-Latina White (NLW) women after an abnormal mammogram result. Ethnic differences in communication needs and experiences with health-care staff and providers may contribute to these delays as well as satisfaction with care. Nonetheless, little research has explored the aspects of communication that may contribute to patient comprehension, adherence to follow-up care, and satisfaction across ethnicity. The purpose of this exploratory, qualitative study was to identify patients' communication needs and experiences with follow-up care among Latina and NLW women who received an abnormal mammogram. We conducted 41 semi-structured interviews with 19 Latina and 22 NLW women between the ages of 40 and 74 who had received an abnormal mammogram. Communication themes indicated that women's needs and experiences concerning abnormal mammograms and follow-up care varied across ethnicity. Latinas and NLW women appeared to differ in their comprehension of abnormal results and follow-up care as a result of language barriers and health literacy. Both groups of women identified clear, empathic communication as being important in patient-provider communication; however, Latinas underscored the need for warm communicative styles, and NLW women emphasized the importance of providing more information. Women with high levels of satisfaction with patient-provider interactions appeared to have positive perspectives of subsequent screening and cancer treatment. To improve patient satisfaction and adherence to follow-up care among Latinas, educational programs are necessary to counsel health-care professionals with regard to language, health literacy, and empathic communication needs in health-care service delivery.

What do you mean, a spot?: A qualitative analysis of patients' reactions to discussions with their physicians about pulmonary nodules

BACKGROUND

More than 150,000 Americans each year are found to have a pulmonary nodule. Even more will be affected following the publication of the National Lung Screening Trial. Patient-doctor communication about pulmonary nodules can be challenging. Although most nodules are benign, it may take 2 to 3 years to rule out cancer. We sought to characterize patients’ perceptions of communication with their providers about pulmonary nodules.

METHODS

We conducted four focus groups at two sites with 22 adults with an indeterminate pulmonary nodule. Transcripts were analyzed using principles of grounded theory.

RESULTS

Patients described conversations with 53 different providers about the pulmonary nodule. Almost all patients immediately assumed that they had cancer when first told about the nodule. Some whose providers did not discuss the actual cancer risk or explain the evaluation plan experienced confusion and distress that sometimes lasted for months. Patients were frustrated when their providers did not address their concerns about cancer or potential adverse effects of surveillance (eg, prolonged uncertainty, radiation exposure), which in some cases led to poor adherence to evaluation plans. Patients found it helpful when physicians used lay terms, showed the CT image, and quantified cancer risk. By contrast, patients resented medical jargon and dismissive language.

CONCLUSIONS

Patients commonly assume that a pulmonary nodule means cancer. What providers tell (or do not tell) patients about their cancer risk and the evaluation plan can strongly influence patients’ perceptions of the nodule and related distress. We describe simple communication strategies that may help patients to come to terms with an indeterminate pulmonary nodule.

Factors influencing time to diagnosis after abnormal mammography in diverse women

BACKGROUND

Abnormal mammograms are common, and the risk of false positives is high. We surveyed women in order to understand the factors influencing the efficiency of the evaluation of an abnormal mammogram.

METHODS

Women aged 40-80 years, identified from lists with Breast Imaging Reporting and Data System (BIRADS) classifications of 0, 3, 4, or 5, were surveyed. Telephone surveys asked about the process of evaluation, and medical records were reviewed for tests and timing of evaluation.

RESULTS

In this study, 970 women were surveyed, and 951 had chart reviews. Overall, 36% were college graduates, 68% were members of a group model health plan, 18% were Latinas, 25% were African Americans, 15% were Asian, and 43% were white. Of the 352 women who underwent biopsies, 151 were diagnosed with cancer (93 invasive). Median time to diagnosis was 183 days for BIRADS 3 compared to 29 days for BIRADS 4/5 and 27 days for BIRADS 0. At 60 days, 84% of BIRADS 4/5 women had a diagnosis. Being African American (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.49-0.97, p=0.03), income < $10,000 (HR 0.55, 95% CI 0.31-0.98, p<0.04), perceived discrimination (HR 0.22, 95% CI 0.09-0.52, p<0.001), not fully understanding the results of the index mammogram (HR 0.49, 95% CI 0.32-0.75, p=0.001), and being notified by letter (HR 0.66, 95% CI 0.48-0.90, p=0.01) or telephone (HR 0.62, 95% CI 0.42-0.92, p=0.02) rather than in person were all associated with significant delays in diagnosis.

CONCLUSIONS

Evaluation of BIRADS 0, 4, or 5 abnormal mammograms was completed in most women within the recommended 60 days. Even within effective systems, correctible communication factors may adversely affect time to diagnosis.

Ethnic disparities in breast cancer

Breast cancer is the leading cause of cancer death for women worldwide. While breast cancer incidence is lower for many ethnic minority women than for white women, stage at diagnosis and survival are often worse. These disparities are most marked for African-American women, but are also present for Asians, Latinas, Native Americans and Hawaiians. The etiology of ethnic disparities in breast cancer is multifactorial, including differences in tumor characteristics, genetics, access to care and insurance, prevalence of risk factors, screening participation and processes of care, such as timeliness of diagnosis and quality of communication and treatment. This review will examine what is known regarding ethnic differences in all of these areas, what questions remain, and where researchers and policy makers should focus their future efforts.

"But what does it mean for me?" Primary care patients' communication preferences for test results notification

BACKGROUND

The best ways to communicate test results in primary care to achieve patient satisfaction and assist patients to incorporate results into their personal health decision making are unknown. A study was conducted to determine the factors that patients believe are important in achieving those goals.

METHODS

Semistructured interviews were conducted with a convenience sample of 12 adults, at least half with a chronic disease requiring regular testing, who shared experiences about receiving test results from physicians' offices and how they used them in their health decision making. In addition, "think aloud" interviewing techniques were used to assess participants' satisfaction and stated understanding with six different formats for receiving a hypothetical test result (a mildly elevated lipid profile). The interviews were analyzed using the editing technique to determine important factors in test results notification.

FINDINGS

Three themes were found to be important in satisfaction with and stated understanding and use of test results: (1) the information shared (test result, clinician interpretation and guidance), (2) significance of the results (testing purpose, abnormal or normal result) and (3) personal preferences for communication (timeliness, interpersonal connection, and hard copy). Participants' stated understanding was highest, among several potential formats, for actual values with desired/normal values, a low-literacy description of the test's purpose, and a simple graph.

CONCLUSIONS

A results notification algorithm includes (1) communication elements (the purpose of the test, the actual results with desired values, clinician guidance, and a graphical representation) and (2) appropriate choice of notification technique (phone/visit for diagnostic tests and all significantly abnormal results and mail/e-mail/Web for all others).

The interaction of perceived risk and benefits and the relationship to predicting mammography adherence in African American women

PURPOSE/OBJECTIVES

To test the interaction of perceived risk and benefits and how they impact stage of mammography readiness and adherence.

DESIGN

Cross-sectional study.

SETTING

Community gathering centers and healthcare clinics across Indiana.

SAMPLE

299 African American women who had not had a mammogram in more than 18 months.

METHODS

In-person interviews were used to collect data on sociodemographics, health belief variables, and stage of readiness to undertake mammography screening. Four categories were created to measure the combined magnitude of high or low levels of perceived risk and benefit, with health belief variables linked to modified mammography screening behavior.

MAIN RESEARCH VARIABLES

Perceived risks and benefits, stage of readiness, and mammography adherence.

FINDINGS

The lowest rate of mammography adherence was in women with a high perceived risk and low perceived benefit toward mammography adherence (26%). The highest rate of adherence was in women with a high perceived benefit and low perceived risk (46%). Differences in mammography adherence were statistically significant between the groups (p = 0.009).

CONCLUSIONS

The interaction of high perceived risk and low perceived benefits impacted readiness to undergo screening mammography.

IMPLICATIONS FOR NURSING

Reducing disparities in breast cancer diagnosis and survival requires timely and efficient mammography adherence. African American medically underserved women with high perceived risk and low perceived benefits exhibited a reluctance to move forward with mammography adherence. Interventions are needed to increase the perception of mammography benefit and to subsequently reduce breast cancer mortality rates in that population.

Language barriers, location of care, and delays in follow-up of abnormal mammograms

BACKGROUND

Breast cancer is frequently diagnosed after an abnormal mammography result. Language barriers can complicate communication of those results.

OBJECTIVES

We evaluated the association of non-English language with delay in follow-up.

METHODS

Retrospective cohort study of women at 3 mammography facilities participating in the San Francisco Mammography Registry with an abnormal mammogram result from 1997 to 2008. We measured median time from report of abnormal result to first follow-up test.

RESULTS

Of 13,014 women with 16,109 abnormal mammograms, 4027 (31%) had a non-English patient language. Clinical facilities differed in proportion of non-English speakers and in time to first follow-up test: facility A (38%; 25 d), facility B (18%; 14 d), and facility C (51%; 41 d). Most mammography examinations (67%) had breast imaging and reporting data system 0 (incomplete) assessment, requiring radiographic follow-up. At 30 days of follow-up, 67% of all English speakers with incomplete assessments had a follow-up examination compared with 50% of all non-English speakers (P<0.0001). The facility with the least delay and the lowest proportion of non-English speakers, had the biggest difference by language; compared with English speakers and adjusting for education, non-English speakers had twice the odds ratio of >30-day delay in follow-up (odds ratio=2.3; 95% confidence interval, 1.4-3.9).

CONCLUSIONS

There are considerable differences among facilities in delays in diagnostic follow-up of abnormal mammography results. More attention must be paid to understanding mammography facility factors, such as wait time to schedule diagnostic mammography and radiology workload, to improve rates of timely follow-up, particularly for those facilities disproportionately serving vulnerable non-English speaking patients.

Urban women's preferences for learning of their mammogram result: a qualitative study

Research suggests that communication of mammogram results is flawed for many low-income ethnic minority women. This study conducted four focus groups with low-income inner-city minority women (n = 34). The goals of our project were: (1) to elucidate women's experiences learning of their result; (2) to elicit their preferences as to how this communication could be improved; and (3) to gather information to help inform the development of a new tool for communicating mammogram results. Salient themes included dissatisfaction with result communication; difficulty elucidating the meaning of a typical results notification letter; a preference for direct verbal communication of results and for print materials that included pictures, testimonials, and an action plan including a hotline to call with questions; and a strong interest in advance education about the likelihood of having to return for additional follow up. Video and other programs to inform patients before the test about what happens after may improve patient satisfaction and enhance women's understanding of their personal result and follow up plan.

Influence of false-positive mammography results on subsequent screening: do physician recommendations buffer negative effects?

OBJECTIVE

Cancer screening guidelines often include discussion about the unintended negative consequences of routine screening. This prospective study examined effects of false-positive mammography results on women's adherence to subsequent breast cancer screening and psychological well-being. We also assessed whether barriers to screening exacerbated the effects of false-positive results.

METHODS

We conducted secondary analyses of data from telephone interviews and medical claims records for 2406 insured women. The primary outcome was adherence to screening guidelines, defined as adherent (10-14 months), delayed (15-34 months), or no subsequent mammogram on record.

RESULTS

About 8% of women reported that their most recent screening mammograms produced false-positive results. In the absence of self-reported advice from their physicians to be screened, women were more likely to have no subsequent mammograms on record if they received false-positive results than if they received normal results (18% vs. 7%, OR = 3.17, 95% CI = 1.30, 7.70). Receipt of false-positive results was not associated with this outcome for women who said their physicians had advised regular screening in the past year (7% vs. 10%, OR = 0.74, 95% CI = 0.38, 1.45). False-positive results were associated with greater breast cancer worry (P < .01), thinking more about the benefits of screening (P < .001), and belief that abnormal test results do not mean women have cancer (P < .01), regardless of physicians' screening recommendations.

CONCLUSION

False-positive mammography results, coupled with reports that women's physicians did not advise regular screening, could lead to non-adherence to future screening. Abnormal mammograms that do not result in cancer diagnoses are opportunities for physicians to stress the importance of regular screening.

Mammography result notification letters: are they easy to read and understand?

BACKGROUND

Federal law mandates that mammography centers notify women of their result in writing. The purpose of this study is to assess the readability and ease of use of the sample letters provided as a template for the notification letters centers send to patients.

METHODS

This is a cross-sectional analysis of the 43 mammography result notification template letters available from the American College of Radiology and two leading transcription software services. To assess readability, we used the Flesch-Kincaid grade level scale and the Lexile framework. To assess document suitability, we used the Suitability Assessment of Materials (SAM). Acceptable scores were based on established standards: ≤6th grade for the Flesch-Kincaid level, ≤900 for the Lexile analysis, and ≥40% on the SAM scale. Means, standard deviations (SDs), and ranges were calculated by diagnostic category, as indicated by BI-RADS level. The Kruskal-Wallis test was used to assess differences in readability and suitability by diagnostic category.

RESULTS

The Flesch Kincaid score ranged from 7.7 to 13.5, with a mean of 10.2. The Lexile score ranged from 880 to 1270, with a mean of 1113. The mean SAM score ranged from 16% to 36%, with a mean of 29%. Mean grade level, Lexile score, and SAM score did not vary significantly by diagnostic category. No single document had an acceptable suitability score, and only two had acceptable Lexile scores. Common deficiencies included use of the passive voice, vague wording, and technical jargon.

CONCLUSIONS

The letters we analyzed were written at levels too difficult for many patients to understand. Future investigations should explore clearer ways of communicating mammography results.

Timing of follow-up after abnormal screening and diagnostic mammograms

OBJECTIVE

To evaluate woman-level characteristics associated with timing of follow-up after abnormal mammograms in an integrated healthcare system with an active breast health program.

STUDY DESIGN

Retrospective cohort study.

METHODS

The study included women aged 40-84 years who had an abnormal mammogram (20,060 screening and 3184 diagnostic) recommended for follow-up. We compared characteristics of women who received any follow-up evaluation within <7, 8 to 14, 15 to 21, and 22 to 180 days. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariate ordinal logistic regression.

RESULTS

The proportion of women seeking care within 7 days was 23% for screening and 69% for diagnostic mammograms. Characteristics associated with later follow-up (>8 days vs <7 days) after an abnormal screening mammogram included being older (OR=1.15; 95% CI, 1.04-1.26 [age 70-79 years]; OR=1.31; 95% CI, 1.14-1.51 [age 80+ years]), Asian (OR=1.18; 95% CI, 1.04-1.33), or having a college degree (OR=1.10; 95% CI, 1.01-1.19). Characteristics associated with earlier follow-up included family history of breast cancer (OR=0.93; 95% CI, 0.88-0.98), symptoms at time of mammogram (OR=0.79; 95% CI, 0.70-0.88), or extremely dense breasts (OR=0.82; 95% CI, 0.69-0.96). For diagnostic mammograms, symptoms at time of mammogram (OR=0.47; 95% CI, 0.39-0.56) and being obese (OR=0.79; 95% CI, 0.65-0.98) were associated with earlier follow-up.

CONCLUSIONS

Several woman-level characteristics were associated with timely follow-up after an abnormal screening exam, but only presence of symptoms and being obese was associated with timely follow-up after an abnormal diagnostic exam.

Timely care after an abnormal mammogram among low-income women in a public breast cancer screening program

BACKGROUND

Since 1990, the National Breast and Cervical Cancer Early Detection Program (BCCEDP) has funded breast cancer screening and diagnostic services for low-income, underinsured women. Case management was implemented in 2001 to address barriers to follow-up after an abnormal mammogram, and free treatment was introduced in 2004. However, the effect of these policies on timeliness of care has not been empirically evaluated.

METHODS

Among 2252 BCCEDP participants in Massachusetts during 1998 through 2007, we conducted a time-to-event analysis with prepolicy-postpolicy comparisons to examine associations of case management and free treatment with diagnostic and treatment delays (>60 days and >90 days, respectively) after an abnormal mammogram.

RESULTS

The proportion of women experiencing a diagnostic delay decreased from 33% to 23% after the introduction of case management (P < .001), with a significant reduction in the adjusted risk of diagnostic delay (relative risk [RR], 0.65; 95% confidence interval [CI], 0.53-0.79) that did not differ by race and ethnicity. However, case management was not associated with changes in treatment delay (RR, 0.93; 95% CI, 0.80-1.10). Free treatment was not associated with changes in the adjusted risk of diagnostic delay (RR, 0.61; 95% CI, 0.33-1.14) or treatment delay (RR, 0.77; 95% CI, 0.43-1.38) beyond improvements associated with case management.

CONCLUSIONS

Case management to assist women in overcoming logistic and psychosocial barriers to care may improve time to diagnosis among low-income women who receive free breast cancer screening and diagnostic services. Programs that provide services to coordinate care, in addition to free screening and diagnostic tests, may improve population health.

Women's and residents' experiences of communication in the diagnostic mammography suite

OBJECTIVE

To gain understanding of radiology residents' and women's experiences, concerns, information needs, coping strategies and perspectives about optimal communication during diagnostic mammography.

METHODS

Qualitative analysis of focus groups of radiology residents and women who had undergone diagnostic mammograms.

RESULTS

Five categories of themes emerged from our analysis: information needs, perspectives and ideals, emotional experiences and observations, working together, individual experiences, and others' roles. Women preferred continuous orientation, clear explanations and emotional support by physicians and radiology technologists throughout diagnostic processes. Communication about diagnostic mammogram results evoked the threat of breast cancer and was experienced as "bad news" by women, but not necessarily by all radiology residents. Lack of collaboration among radiologists, technologists and other healthcare professionals engendered confusion and anxiety in patients. Radiology residents felt inadequately prepared to meet the communication challenges of providing information and emotional support tailored to women's needs in this context.

CONCLUSION

Women's experiences are influenced by the extent to which they receive clear information and support, and perceive collaboration among professionals involved in the diagnostic mammography process.

PRACTICE IMPLICATIONS

Radiology education must address communication with patients and among healthcare professionals involved in the care of patients undergoing diagnostic procedures and interventions.

Racial/ethnic disparities in time to follow-up after an abnormal mammogram

BACKGROUND

Although non-Hispanic white women have an increased risk of developing breast cancer, the disease-specific survival is lower for African American and Hispanic women. Little is known about disparities in follow-up after an abnormal mammogram. The goal of this study was to investigate potential disparities in follow-up after an abnormal mammogram.

METHODS

A retrospective cohort study of 6722 women with an abnormal mammogram and documented follow-up from January 2000 through December 2002 was performed at an academic medical center in New York City. The outcome was the number of days between the abnormal mammogram and follow-up imaging or biopsy. Cox proportional hazards models were used to assess the effect of race/ethnicity and other potential covariates.

RESULTS

The median number of days to diagnostic follow-up after an abnormal mammogram was greater for African American (20 days) and Hispanic (21 days) women compared with non-Hispanic white (14 days) women (p < 0.001). Racial/ethnic disparities remained significant in a multivariable model controlling for age, Breast Imaging Reporting and Data System (BIRADS) category, insurance status, provider practice location, and median household income.

CONCLUSIONS

After an abnormal mammogram, African American and Hispanic women had longer times to diagnostic follow-up compared with non-Hispanic white women. Future efforts will focus on identifying the barriers to follow-up so that effective interventions may be implemented.

Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study

OBJECTIVE

To understand factors that women feel facilitate or hinder their receipt of diagnostic services following an abnormal screening mammogram.

METHODS

This qualitative study used a purposive sampling strategy to identify low-income, ethnically diverse women aged 40 or over who had a recent abnormal mammogram. Working with a community health center, breast evaluation center, and mobile mammography van, 64 women were interviewed to identify salient themes that differentiated women who received timely follow-up from those who did not.

RESULTS

Prominent themes among women who delayed follow-up included dissatisfaction with communication of results; perceived disrespect on the part of providers and clinic staff; logistical barriers to access of diagnostic services; anxiety and fear about a possible cancer diagnosis; and a lack of information about breast cancer screening and symptoms. Women who received timely care more often reported an appreciation of efforts by providers and clinic staff to support their prompt follow-up; availability of social support that facilitated appointment-keeping; confidence in their ability to advocate for their health; and a high priority placed on self-care.

CONCLUSION

A comprehensive approach to improving timely diagnostic follow-up among underserved groups must address patient beliefs and attitudes, provider practices and communication, and practices at the health care systems level.

PRACTICE IMPLICATIONS

Implications and strategies for improving patient education, patient-provider communication, and organizational practices are discussed.

Patients as partners in radiology education: an innovative approach to teaching and assessing patient-centered communication

RATIONALE AND OBJECTIVES

Effective communication is essential for high quality care, yet little is known about radiologists' communication with patients, what constitutes "best communication practices," and how best to teach and evaluate it. We piloted educational strategies and an assessment instrument to teach and evaluate radiologists' communication skills. We focused on communication in the diagnostic mammography suite, where patient-radiologist interactions are often intense and stressful.

MATERIALS AND METHODS

We adapted existing instruments to create a Radiology Communication Skills Assessment Tool (RCSAT). We piloted an educational program that included patients as teachers and raters of interpersonal and communication skills, and implemented a radiology objective structured clinical examination (OSCE). We measured radiology residents' self-assessed skills, confidence and stress, as well as patient-rated communication skills using the RCSAT.

RESULTS

Residents' baseline self-assessed communication skills regarding abnormal mammograms were fair, confidence in their communication was minimal, and they found this communication stressful. Overall baseline communication skills, rated by patient-teachers using the RCSAT, were 3.62 on a 5-point scale (1 = poor to 5 = excellent). Analysis of post-OSCE debriefing comments yielded nine themes regarding effective radiology communication, as well as residents' reflections on the communication challenges they experience. The themes were integrated into subsequent RCSAT revisions. Residents' reflections were used to inform teaching workshops.

CONCLUSION

Educational curricula on communication about difficult information can be implemented in radiology training programs. Radiology residents' performance can be assessed using a communication skills assessment tool during standardized patient-teacher encounters. Further research is necessary in this important domain.

Racial and ethnic differences in mammography use among U.S. women younger than age 40

OBJECTIVE

Evidence-based recommendations for routine breast cancer screening suggest that women begin mammography at age 40, although some women receive a mammogram before that age. Little is known about mammography use among younger women, especially with respect to race and ethnicity.

METHODS

We used data from the 2005 National Health Interview Survey to examine racial/ethnic differences in mammography use among U.S. women ages 30-39. We examined descriptive characteristics of women who reported ever having a mammogram, and used logistic regression to estimate associations between race/ethnicity and mammography use among women at average risk for breast cancer.

RESULTS

Our sample comprised 3,098 women (18% Hispanic, 13% non-Hispanic [NH] black, 69% NH white), of whom 29% reported having ever had a mammogram. NH black women were more likely than NH white women to report ever having a mammogram and receiving multiple mammograms before age 40 among women of average risk. Patterns of mammography use for Hispanic women compared to NH white women varied.

CONCLUSION

Findings suggest differential utilization of mammograms by race/ethnicity among women outside current recommendations and of average risk. Future studies should examine the role of practice patterns and patient-provider communication.

Patient navigation and case management following an abnormal mammogram: a randomized clinical trial

BACKGROUND

A high rate of low-income, ethnic minority women delay or fail to keep appointments following abnormal mammograms. This study was designed to test the effectiveness of a structured counseling and patient navigation intervention for improving follow-up rates at a large public sector medical center.

METHODS

This randomized clinical trial, conducted in Los Angeles 2001-2002, included 204 women with abnormal mammograms referred for follow-up who were then assigned to intervention or usual care. The primary outcome was the rate of follow-up through diagnostic resolution within eight months.

RESULTS

The intervention resulted in a significant increase in the rate of adherence to follow-up through diagnostic resolution. The intervention group was much more likely to be adherent through diagnostic resolution than the control group (90% vs. 66%, OR=4.48, p<0.001) and were more likely to experience timely adherence than UC patients (77% vs. 57%, OR=2.5, p=0.01). Intervention effectiveness was not significantly different for women assigned to different levels of service intensity.

CONCLUSIONS

Patient navigation and counseling driven by a structured clinical algorithm are highly effective strategies to improve diagnostic resolution follow-up among low-income, ethnic minority women with abnormal mammograms. The intervention algorithm and available training materials can be adapted for diverse care systems serving high-risk women to decrease loss to follow-up.