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Burnside ES, Schrager S, DuBenske L, Keevil J, Little T, Trentham-Dietz A, Rolland B, Shah D, Alagoz O. Team Science Principles Enhance Cancer Care Delivery Quality Improvement: Interdisciplinary Implementation of Breast Cancer Screening Shared Decision Making. JCO Oncol Pract 2023; 19:e1-e7. [PMID: 36126243 PMCID: PMC10476722 DOI: 10.1200/op.22.00355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/05/2022] [Accepted: 07/20/2022] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Implementing shared decision making (SDM), recommended in screening mammography by national guidelines for women age 40-49 years, faces challenges that innovations in quality improvement and team science (TS) are poised to address. We aimed to improve the effectiveness, patient-centeredness, and efficiency of SDM in primary care for breast cancer screening. METHODS Our interdisciplinary team included primary and specialty care, psychology, epidemiology, communication science, engineering, and stakeholders (patients and clinicians). Over a 6-year period, we executed two iterative cycles of plan-do-study-act (PDSA) to develop, revise, and implement a SDM tool using TS principles. Patient and physician surveys and retrospective analysis of tool performance informed our first PDSA cycle. Patient and physician surveys, toolkit use, and clinical outcomes in the second PDSA cycle supported SDM implementation. We gathered team member assessments on the importance of individual TS activities. RESULTS Our first PDSA cycle successfully generated a SDM tool called Breast Cancer Risk Estimator, deemed valuable by 87% of patients surveyed. Our second PDSA cycle increased Breast Cancer Risk Estimator utilization, from 2,000 sessions in 2017 to 4,097 sessions in 2019 while maintaining early-stage breast cancer diagnoses. Although TS activities such as culture, trust, and communication needed to be sustained throughout the project, shared goals, research/data infrastructure support, and leadership were more important earlier in the project and persisted in the later stages of the project. CONCLUSION Combining rigorous quality improvement and TS principles can support the complex, interdependent, and interdisciplinary activities necessary to improve cancer care delivery exemplified by our implementation of a breast cancer screening SDM tool.
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Affiliation(s)
| | - Sarina Schrager
- School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Lori DuBenske
- School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | | | - Terry Little
- School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Amy Trentham-Dietz
- School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Betsy Rolland
- School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Dhavan Shah
- School of Journalism and Mass Communication, University of Wisconsin, Madison, WI
| | - Oguzhan Alagoz
- College of Engineering, University of Wisconsin, Madison, WI
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Patient-provider communication while using a clinical decision support tool: explaining satisfaction with shared decision making for mammography screening. BMC Med Inform Decis Mak 2022; 22:323. [PMID: 36476612 PMCID: PMC9730626 DOI: 10.1186/s12911-022-02058-3] [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: 01/28/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Clinical decision aids may support shared decision-making for screening mammography. To inform shared decision-making between patients and their providers, this study examines how patterns of using an EHR-integrated decision aid and accompanying verbal patient-provider communication predict decision-making satisfaction. METHODS For 51 patient visits during which a mammography decision aid was used, linguistic characteristics of patient-provider verbal communication were extracted from transcribed audio recordings and system logs automatically captured uses of the decision aid. Surveys assessed patients' post-visit decisional satisfaction and its subcomponents. Linear mixed effects models assessed how patients' satisfaction with decision making was related to patterns of verbal communication and navigation of the decision aid. RESULTS The results indicate that providers' use of quantitative language during the encounter was positively associated with patients' overall satisfaction, feeling informed, and values clarity. Patients' question-asking was negatively associated with overall satisfaction, values clarity, and certainty perception. Where system use data indicated the dyad had cycled through the decision-making process more than once ("looping" back through pages of the decision aid), patients reported improved satisfaction with shared decision making and all subcomponents. Overall satisfaction, perceived support, certainty, and perceived effectiveness of decision-making were lowest when a high number of navigating clicks occurred absent "looping." CONCLUSIONS Linguistic features of patient-provider communication and system use data of a decision aid predict patients' satisfaction with shared decision making. Our findings have implications for the design of decision aid tools and clinician training to support more effective shared decision-making for screening mammography.
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Esserman LJ, Parker BA, LaCroix AZ. Why It Is Time to Challenge Entrenched Beliefs About Breast Cancer Screening. J Womens Health (Larchmt) 2022; 31:903-904. [PMID: 35849752 DOI: 10.1089/jwh.2022.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Laura J Esserman
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Barbara A Parker
- Department of Medicine, Moores Cancer Center, University of California, San Diego, San Diego, California, USA
| | - Andrea Z LaCroix
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California, USA
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Clift AK, Dodwell D, Lord S, Petrou S, Brady SM, Collins GS, Hippisley-Cox J. The current status of risk-stratified breast screening. Br J Cancer 2022; 126:533-550. [PMID: 34703006 PMCID: PMC8854575 DOI: 10.1038/s41416-021-01550-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 08/25/2021] [Accepted: 09/14/2021] [Indexed: 12/23/2022] Open
Abstract
Apart from high-risk scenarios such as the presence of highly penetrant genetic mutations, breast screening typically comprises mammography or tomosynthesis strategies defined by age. However, age-based screening ignores the range of breast cancer risks that individual women may possess and is antithetical to the ambitions of personalised early detection. Whilst screening mammography reduces breast cancer mortality, this is at the risk of potentially significant harms including overdiagnosis with overtreatment, and psychological morbidity associated with false positives. In risk-stratified screening, individualised risk assessment may inform screening intensity/interval, starting age, imaging modality used, or even decisions not to screen. However, clear evidence for its benefits and harms needs to be established. In this scoping review, the authors summarise the established and emerging evidence regarding several critical dependencies for successful risk-stratified breast screening: risk prediction model performance, epidemiological studies, retrospective clinical evaluations, health economic evaluations and qualitative research on feasibility and acceptability. Family history, breast density or reproductive factors are not on their own suitable for precisely estimating risk and risk prediction models increasingly incorporate combinations of demographic, clinical, genetic and imaging-related parameters. Clinical evaluations of risk-stratified screening are currently limited. Epidemiological evidence is sparse, and randomised trials only began in recent years.
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Affiliation(s)
- Ash Kieran Clift
- Cancer Research UK Oxford Centre, Department of Oncology, University of Oxford, Oxford, UK.
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Simon Lord
- Department of Oncology, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Li M, Reintals M, D'Onise K, Farshid G, Holmes A, Joshi R, Karapetis CS, Miller CL, Olver IN, Buckley ES, Townsend A, Walters D, Roder DM. Investigating the breast cancer screening-treatment-mortality pathway of women diagnosed with invasive breast cancer: Results from linked health data. Eur J Cancer Care (Engl) 2021; 31:e13539. [PMID: 34850484 DOI: 10.1111/ecc.13539] [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: 02/25/2021] [Revised: 08/23/2021] [Accepted: 11/12/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine the screening-treatment-mortality pathway among women with invasive breast cancer in 2006-2014 using linked data. METHODS BreastScreen histories of South Australian women diagnosed with breast cancer (n = 8453) were investigated. Treatments recorded within 12 months from diagnosis were obtained from linked registry and administrative data. Associations of screening history with treatment were investigated using logistic regression and with cancer mortality outcomes using competing risk analyses, adjusting for socio-demographic, cancer and comorbidity characteristics. RESULTS AND CONCLUSION For screening ages of 50-69 years, 70% had participated in BreastScreen SA ≤ 5 years and 53% ≤ 2 years of diagnosis. Five-year disease-specific survival post-diagnosis was 90%. Compared with those not screened ≤5 years, women screened ≤2 years had higher odds, adjusted for socio-demographic, cancer and comorbidity characteristics, and diagnostic period, of breast-conserving surgery (aOR 2.5, 95% CI 1.9-3.2) and radiotherapy (aOR 1.2, 95% CI 1.1-1.3). These women had a lower unadjusted risk of post-diagnostic cancer mortality (SHR 0.33, 95% CI 0.27-0.41), partly mediated by stage (aSHR 0.65, 95% CI 0.51-0.81), and less breast surgery (aSHR 0.78, 95% CI 0.62-0.99). Screening ≤2 years and conserving surgery appeared to have a greater than additive association with lower post-diagnostic mortality (interaction term SHR 0.42, 95% CI 0.23-0.78). The screening-treatment-mortality pathway was investigated using linked data.
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Affiliation(s)
- Ming Li
- Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Michelle Reintals
- BreastScreen South Australia, Government of South Australia, Adelaide, South Australia, Australia
| | - Katina D'Onise
- Prevention and Population Health, SA Health Department for Health and Wellbeing, Adelaide, South Australia, Australia
| | - Gelareh Farshid
- SA Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Andrew Holmes
- BreastScreen South Australia, Government of South Australia, Adelaide, South Australia, Australia
| | - Rohit Joshi
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Cancer Research and Clinical Trials, Adelaide Oncology and Haematology, North Adelaide, South Australia, Australia
| | - Christos S Karapetis
- Department of Medical Oncology, Flinders University, Bedford Park, South Australia, Australia
| | - Caroline L Miller
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Health Policy Centre, South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Ian N Olver
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Elizabeth S Buckley
- Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Amanda Townsend
- Clinical Cancer Research, Queen Elizabeth Hospital, Woodville South, South Australia, Australia.,Basil Hetzel Institute for Translational Health Research, Woodville South, South Australia, Australia
| | - David Walters
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Department of Surgery, Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - David M Roder
- Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia
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Ho PJ, Wong FY, Chay WY, Lim EH, Lim ZL, Chia KS, Hartman M, Li J. Breast cancer risk stratification for mammographic screening: A nation-wide screening cohort of 24,431 women in Singapore. Cancer Med 2021; 10:8182-8191. [PMID: 34708579 PMCID: PMC8607242 DOI: 10.1002/cam4.4297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/10/2021] [Accepted: 08/26/2021] [Indexed: 12/19/2022] Open
Abstract
Background Breast cancer incidence is increasing in Asia. However, few women in Singapore attend routine mammography screening. We aim to identify women at high risk of breast cancer who will benefit most from regular screening using the Gail model and information from their first screen (recall status and mammographic density). Methods In 24,431 Asian women (50–69 years) who attended screening between 1994 and 1997, 117 developed breast cancer within 5 years of screening. Cox proportional hazard models were used to study the associations between risk classifiers (Gail model 5‐year absolute risk, recall status, mammographic density), and breast cancer occurrence. The efficacy of risk stratification was evaluated by considering sensitivity, specificity, and the proportion of cancers identified. Results Adjusting for information from first screen attenuated the hazard ratios (HR) associated with 5‐year absolute risk (continuous, unadjusted HR [95% confidence interval]: 2.3 [1.8–3.1], adjusted HR: 1.9 [1.4–2.6]), but improved the discriminatory ability of the model (unadjusted AUC: 0.615 [0.559–0.670], adjusted AUC: 0.703 [0.653–0.753]). The sensitivity and specificity of the adjusted model were 0.709 and 0.622, respectively. Thirty‐eight percent of all breast cancers were detected in 12% of the study population considered high risk (top five percentile of the Gail model 5‐year absolute risk [absolute risk ≥1.43%], were recalled, and/or mammographic density ≥50%). Conclusion The Gail model is able to stratify women based on their individual breast cancer risk in this population. Including information from the first screen can improve prediction in the 5 years after screening. Risk stratification has the potential to pick up more cancers.
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Affiliation(s)
- Peh Joo Ho
- Genome Institute of Singapore, Singapore, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Fuh Yong Wong
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Wen Yee Chay
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Elaine Hsuen Lim
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Zi Lin Lim
- Genome Institute of Singapore, Singapore, Singapore
| | - Kee Seng Chia
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Mikael Hartman
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine National University of Singapore, Singapore, Singapore
| | - Jingmei Li
- Genome Institute of Singapore, Singapore, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine National University of Singapore, Singapore, Singapore
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Burnside ES, Warren LM, Myles J, Wilkinson LS, Wallis MG, Patel M, Smith RA, Young KC, Massat NJ, Duffy SW. Quantitative breast density analysis to predict interval and node-positive cancers in pursuit of improved screening protocols: a case-control study. Br J Cancer 2021; 125:884-892. [PMID: 34168297 PMCID: PMC8438060 DOI: 10.1038/s41416-021-01466-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 05/18/2021] [Accepted: 06/10/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND This study investigates whether quantitative breast density (BD) serves as an imaging biomarker for more intensive breast cancer screening by predicting interval, and node-positive cancers. METHODS This case-control study of 1204 women aged 47-73 includes 599 cancer cases (302 screen-detected, 297 interval; 239 node-positive, 360 node-negative) and 605 controls. Automated BD software calculated fibroglandular volume (FGV), volumetric breast density (VBD) and density grade (DG). A radiologist assessed BD using a visual analogue scale (VAS) from 0 to 100. Logistic regression and area under the receiver operating characteristic curves (AUC) determined whether BD could predict mode of detection (screen-detected or interval); node-negative cancers; node-positive cancers, and all cancers vs. controls. RESULTS FGV, VBD, VAS, and DG all discriminated interval cancers (all p < 0.01) from controls. Only FGV-quartile discriminated screen-detected cancers (p < 0.01). Based on AUC, FGV discriminated all cancer types better than VBD or VAS. FGV showed a significantly greater discrimination of interval cancers, AUC = 0.65, than of screen-detected cancers, AUC = 0.61 (p < 0.01) as did VBD (0.63 and 0.53, respectively, p < 0.001). CONCLUSION FGV, VBD, VAS and DG discriminate interval cancers from controls, reflecting some masking risk. Only FGV discriminates screen-detected cancers perhaps adding a unique component of breast cancer risk.
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Affiliation(s)
- Elizabeth S Burnside
- Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, E3/311 Clinical Science Center, Madison, WI, USA.
| | - Lucy M Warren
- National Co-ordinating Centre for the Physics of Mammography (NCCPM), Medical Physics Department, Royal Surrey County Hospital, Guildford, UK
| | - Jonathan Myles
- Centre for Cancer Prevention, Queen Mary University of London, Wolfson Institute of Preventive Medicine, London, UK
| | | | - Matthew G Wallis
- Cambridge Breast Unit and NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Mishal Patel
- Scientific Computing, Medical Physics Department, Royal Surrey County Hospital, Guildford, UK
| | | | - Kenneth C Young
- National Co-ordinating Centre for the Physics of Mammography (NCCPM), Medical Physics Department, Royal Surrey County Hospital, Guildford, UK
| | - Nathalie J Massat
- Centre for Cancer Prevention, Queen Mary University of London, Wolfson Institute of Preventive Medicine, London, UK
| | - Stephen W Duffy
- Centre for Cancer Prevention, Queen Mary University of London, Wolfson Institute of Preventive Medicine, London, UK
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DuBenske L, Ovsepyan V, Little T, Schrager S, Burnside E. Preliminary Evaluation of a Breast Cancer Screening Shared Decision-Making Aid Utilized Within the Primary Care Clinical Encounter. J Patient Exp 2021; 8:23743735211034039. [PMID: 34377770 PMCID: PMC8326620 DOI: 10.1177/23743735211034039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: The US Preventative Services Task Force recommends shared decision-making (SDM) between women aged 40 and 49 years and their physician regarding timing of mammography screening. This preliminary study evaluates women’s and physician’s satisfaction using Breast Cancer Risk Estimator & Decision Aid (BCARE-DA), a shared decision aid utilized during the clinical encounter, and examines SDM quality for these encounters. Methods: Fifty-three women and their physician utilized BCARE-DA and completed surveys measuring satisfaction with Likert-type and open-ended items and women completed the Decision Conflict Scale. Clinic visit transcripts were evaluated for SDM quality using Observer OPTION-5 and Breast Cancer Screening Decision Core Components Checklist. Results: Women and physicians positively evaluated BCARE-DA. Women had low decision conflict. Physicians demonstrated moderate effort toward SDM, greatest in offering options, and lowest for team talk. Physicians demonstrated 2/3 of core SDM elements in 80% to 100% of encounters. Conclusion: Preliminary findings suggest specific promise for such Decision Aids to facilitate SDM through understanding of personal risks for breast cancer formulated within each screening option, while some SDM elements likely require additional facilitating.
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Affiliation(s)
- Lori DuBenske
- Department of Psychiatry, University of Wisconsin, Madison, WI, USA
| | - Viktoriya Ovsepyan
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, WI, USA
| | - Terry Little
- Department of Radiology, University of Wisconsin, Madison, WI, USA
| | - Sarina Schrager
- Department of Family Medicine and Community Health, University of Wisconsin, Madison, WI, USA
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Yang EF, Shah DV, Burnside ES, Little TA, Garino N, Campbell CE. Framing the Clinical Encounter: Shared Decision-Making, Mammography Screening, and Decision Satisfaction. JOURNAL OF HEALTH COMMUNICATION 2020; 25:681-691. [PMID: 33111640 PMCID: PMC7772277 DOI: 10.1080/10810730.2020.1838003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The study examines whether physicians' framing of clinical interactions is related to patient shared decision-making (SDM) satisfaction when using a clinical decision support tool (CDST) concerning mammographic screening. To answer this question, we combined (a) system log data from a CDST, (b) content coding of the physicians' message framing while using the CDST, and (c) a post-visit patient survey to assess SDM satisfaction concerning screening mammography. Results suggest that two types of message frames - consequence frames and numerical frames - moderated the relationship of the CDST on SDM satisfaction. When the CDST displayed low risk of breast cancer for a patient, physicians were able to improve the cognitive aspects of SDM satisfaction by framing the consequences of mammography screening in positive terms. However, when the physician delivered the numerical information in relative, rather than absolute terms, the patient's SDM satisfaction was reduced. Our study advances previous message framing effect research in health communication from experimental settings to clinical encounters. It also discusses the importance of delivering risk-congruent frames in clinical settings.
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Affiliation(s)
- Ellie F Yang
- School of Journalism and Mass Communication, UW-Madison , Madison, WI, USA
| | - Dhavan V Shah
- School of Journalism and Mass Communication, UW-Madison , Madison, WI, USA
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Joe BN, Hayward JH. More Lives Risked with Risk-based versus Age-based Breast Cancer Screening. Radiology 2019; 292:329-330. [PMID: 31184982 DOI: 10.1148/radiol.2019191040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Bonnie N Joe
- Form the Department of Radiology and Biomedical Imaging, University of California San Francisco, 1600 Divisadero St, Room C250, Box 1667, San Francisco, CA 94115
| | - Jessica H Hayward
- Form the Department of Radiology and Biomedical Imaging, University of California San Francisco, 1600 Divisadero St, Room C250, Box 1667, San Francisco, CA 94115
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