Longitudinal predictors of nonadherence to maintenance of mammography

Characterizing "collateral damage" in men and women with metastatic breast cancer (mBC) from diverse racial and ethnic backgrounds in New York City

PURPOSE

Patients from diverse racial, ethnic, and socio-economic backgrounds may be particularly vulnerable to experiencing undue social and financial burdens ("collateral damage") from a metastatic breast cancer (mBC) diagnosis; however, these challenges have not been well explored in diverse populations.

METHODS

From May 2022 to May 2023, English- or Spanish-speaking adults with mBC treated at four New York-Presbyterian (NYP) sites were invited to complete a survey that assessed collateral damage, social determinants of health, physical and psychosocial well-being, and patient-provider communication. Fisher's exact and the Kruskal-Wallis rank-sum tests assessed differences by race and ethnicity.

RESULTS

Of 87 respondents, 14% identified as Hispanic, 28% non-Hispanic Black (NHB), 41% non-Hispanic White (NHW), 7% Asian American Pacific Islander (AAPI), and 10% other/multiracial. While 100% of Hispanic, NHW, and AAPI participants reported stable housing, 29% of NHB participants were worried about losing housing (p = 0.002). Forty-two percent of Hispanic and 46% of NHB participants (vs. 8%, NHW and 0%, AAPI, p = 0.005) were food insecure; 18% of Hispanic and 17% of NHB adults indicated lack of reliable transportation in the last year (vs. 0%, NHW/AAPI, p = 0.033). Participants were generally satisfied with the quality of communication that they had with their healthcare providers and overall physical and mental well-being were modestly poorer relative to healthy population norms.

CONCLUSIONS

In our study, NHB and Hispanic mBC patients reported higher levels of financial concern and were more likely to experience food and transportation insecurity compared to NHW patients. Systematically connecting patients with resources to address unmet needs should be prioritized to identify feasible approaches to support economically vulnerable patients following an mBC diagnosis.

Missed Screening Mammography Appointments: Patient Sociodemographic Characteristics and Mammography Completion After 1 Year

OBJECTIVE

Patients who miss screening mammogram appointments without notifying the health care system (no-show) risk care delays. We investigate sociodemographic characteristics of patients who experience screening mammogram no-shows at a community health center and whether and when the missed examinations are completed.

METHODS

We included patients with screening mammogram appointments at a community health center between January 1, 2021, and December 31, 2021. Language, race, ethnicity, insurance type, residential ZIP code tabulation area (ZCTA) poverty, appointment outcome (no-show, same-day cancelation, completed), and dates of completed screening mammograms after no-show appointments with ≥1-year follow-up were collected. Multivariable analyses were used to assess associations between patient characteristics and appointment outcomes.

RESULTS

Of 6,159 patients, 12.1% (743 of 6,159) experienced no-shows. The no-show group differed from the completed group by language, race and ethnicity, insurance type, and poverty level (all P < .05). Patients with no-shows more often had: primary language other than English (32.0% [238 of 743] versus 26.7% [1,265 of 4,741]), race and ethnicity other than White non-Hispanic (42.3% [314 of 743] versus 33.6% [1,595 of 4,742]), Medicaid or means-tested insurance (62.0% [461 of 743] versus 34.4% [1,629 of 4,742]), and residential ZCTAs with ≥20% poverty (19.5% [145 of 743] versus 14.1% [670 of 4,742]). Independent predictors of no-shows were Black non-Hispanic race and ethnicity (adjusted odds ratio [aOR], 1.52; 95% confidence interval [CI], 1.12-2.07; P = .007), Medicaid or other means-tested insurance (aOR, 2.75; 95% CI, 2.29-3.30; P < .001), and ZCTAs with ≥20% poverty (aOR, 1.76; 95% CI, 1.14-2.72; P = .011). At 1-year follow-up, 40.6% (302 of 743) of patients with no-shows had not completed screening mammogram.

DISCUSSION

Screening mammogram no-shows is a health equity issue in which socio-economically disadvantaged and racially and ethnically minoritized patients are more likely to experience missed appointments and continued delays in screening mammogram completion.

Employment trajectories of young women with breast cancer: an ongoing prospective cohort study in Italy and Switzerland

PURPOSE

Despite extensive research on cancer and work-related outcomes, evidence from longitudinal cohort studies is limited, especially in young women with breast cancer (BC). We aimed to investigate employment trajectories in young BC survivors and to identify potential factors associated with changes in work activity.

METHODS

The HOHO European prospective multicenter cohort study enrolled 300 young women (≤ 40 years) with newly diagnosed BC. Women completed surveys at baseline and every 6 months for 3 years, then yearly for up to 10 years to assess, among other variables, employment status, sociodemographic, medical, and treatment data. Symptoms were assessed by the Breast Cancer Prevention Trial symptom scales and single items from the Cancer Rehabilitation Evaluation System. Univariable and multivariable multinomial logistic regression analyses identified factors associated with changes in employment status.

RESULTS

Among the 245 women included in this analysis, 85% were employed at the last individual post-baseline assessment (1 to 10 years). At 5 years, women had a 29.4% probability (95% CI: 23.6-35.5) of experiencing any reduction and a 14.9% probability (95% CI: 10.6-19.9) of experiencing any increase in work activities. Being enrolled in Switzerland (vs. Italy) and reporting more trouble in performing daily activities were significantly associated with work reduction.

CONCLUSION

Our results suggest that most young BC survivors remain employed in the long-term.

IMPLICATIONS FOR CANCER SURVIVORS

Regular evaluation of symptoms which may interfere with daily life and identification of financial discomfort is critical in providing timely and individually tailored interventions and in limiting unwanted reductions in work activities.

Screening Mammography Utilization in the United States

Breast cancer is the second leading cause of cancer mortality in adult women in the United States. Screening mammography reduces breast cancer mortality between 22% and 48%; however, screening mammography remains underutilized. Screening mammography utilization data are available from insurance claims, electronic medical records, and patient self-report via surveys, and each data source has unique benefits and challenges. Numerous barriers exist that adversely affect the use of screening mammography in the United States. This article will review screening mammography utilization in the United States, explore factors that impact utilization, and briefly discuss strategies to improve utilization.

Extended adjuvant endocrine therapy in a longitudinal cohort of young breast cancer survivors

Extended adjuvant endocrine therapy (eET) improves outcomes in breast cancer survivors. Most studies however have been limited to postmenopausal women, and optimal eET for young survivors is uncertain. We report eET use among participants in the Young Women's Breast Cancer Study (YWS), a multicenter prospective cohort of women age ≤40 newly diagnosed with breast cancer enrolled between 2006-2016. Women with stage I-III hormone receptor-positive breast cancer, ≥6 years from diagnosis without recurrence were considered eET candidates. Use of eET was elicited from annual surveys sent years 6-8 after diagnosis, censoring for recurrence/death. 663 women were identified as eET candidates with 73.9% (490/663) having surveys eligible for analysis. Among eligible participants, mean age was 35.5 (±3.9), 85.9% were non-Hispanic white, and 59.6% reported eET use. Tamoxifen monotherapy was the most reported eET (77.4%), followed by aromatase inhibitor (AI) monotherapy (21.9%), AI-ovarian function suppression (AI-OFS) (6.8%) and tamoxifen-OFS (3.1%). In multivariable analysis, increasing age (per year odds ratio [OR]: 1.10, 95% confidence interval [CI]: 1.04-1.16), stage (II v. I: OR: 2.86, 95% CI: 1.81-4.51; III v. I: OR: 3.73, 95%CI: 1.87-7.44) and receipt of chemotherapy (OR: 3.66, 95% CI: 2.16-6.21) were significantly associated with eET use. Many young breast cancer survivors receive eET despite limited data regarding utility in this population. While some factors associated with eET use reflect appropriate risk-based care, potential sociodemographic disparities in uptake warrants further investigation in more diverse populations.

Fertility Preferences and Practices Among Young Women With Breast Cancer: Germline Genetic Carriers Versus Noncarriers

BACKGROUND

Young women with breast cancer who carry germline genetic pathogenic variants may face distinct fertility concerns, yet limited data exist comparing fertility preferences and practices between carriers and noncarriers.

PATIENTS AND METHODS

Participants in the Young Women's Breast Cancer Study (NCT01468246), a prospective cohort of women diagnosed with breast cancer at ≤40 years, who completed a modified Fertility Issues Survey were included in this analysis.

RESULTS

Of 1052 eligible participants, 118 (11%) tested positive for a pathogenic variant. Similar proportions (P = .23) of carriers (46%, [54/118]) and noncarriers (37%, [346/934]) desired more biologic children prediagnosis, and desire decreased similarly postdiagnosis (carriers, 30% [35/118] vs. noncarriers, 26% [244/934], P = .35). Among those desiring children postdiagnosis (n = 279), concern about cancer risk heritability was more common among carriers (74% [26/35] vs. noncarriers, 36% [88/244], P < .01). Carriers were more likely to report that concern about cancer risk heritability contributed to a lack of certainty or interest in future pregnancies (20% [16/81] vs. noncarriers, 7% [49/674], P = .001). Similar proportions (P = .65) of carriers (36% [43/118]) and noncarriers (38% [351/934]) were somewhat or very concerned about infertility post-treatment; utilization of fertility preservation strategies was also similar (carriers, 14% [17/118] vs. noncarriers, 12% [113/934], P = .78).

CONCLUSION

Carriers were similarly concerned about future fertility and as likely to pursue fertility preservation as noncarriers. Concern about cancer risk heritability was more frequent among carriers and impacted decisions not to pursue future pregnancies for some, underscoring the importance of counseling regarding strategies to prevent transmission to offspring, including preimplantation genetic testing.

Adjuvant endocrine therapy non-initiation and non-persistence in young women with early-stage breast cancer

PURPOSE

Characterizing oral adjuvant endocrine therapy (ET) non-initiation and non-persistence in young women with breast cancer can inform strategies to improve overall adherence in this population.

METHODS

We identified 693 women with hormone receptor-positive, stage I-III breast cancer enrolled in a cohort of women diagnosed with breast cancer at age ≤ 40 years. Women were classified as non-initiators if they did not report taking ET in the 18 months after diagnosis. Women who initiated but did not report taking ET subsequently (through 5-year post-diagnosis) were categorized as non-persistent. We assessed ET decision-making and used logistic regression to identify factors associated with non-initiation/non-persistence and to evaluate the association between non-persistence and recurrence.

RESULTS

By 18 months, 9% had not initiated ET. Black women had higher odds and women with a college degree had lower odds of non-initiation. Among 607 women who initiated, 20% were non-persistent. Younger age, being married/partnered, and reporting more weight problems were associated with higher odds of non-persistence; receipt of chemotherapy and greater hot flash and vaginal symptom burden were associated with lower odds of non-persistence. Adjusting for age and clinical characteristics, non-persistence was associated with lower odds of recurrence. Women who initiated were more likely to report shared decision-making than non-initiators (57% vs. 38%, p = 0.049), while women who were non-persistent were less likely to indicate high confidence with the decision than women who were persistent (40% vs. 63%, p < 0.001).

CONCLUSION

Interventions to improve ET decision-making may facilitate initiation and address barriers to adherence in young breast cancer survivors.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov , NCT01468246.

Coping strategies and anxiety in young breast cancer survivors

PURPOSE

We sought to describe coping strategies reported by young breast cancer survivors and evaluate the relationship between utilization of specific coping strategies and anxiety in survivorship.

METHODS

Participants enrolled in The Young Women's Breast Cancer Study, a multi-center, cohort of women diagnosed with breast cancer at age ≤ 40 years, completed surveys that assessed demographics, coping strategies (reported at 6-month post-enrollment and 18-month post-diagnosis), and anxiety (2 years post-diagnosis). We used univariable and multivariable logistic regression to examine the relationship between coping strategies and anxiety.

RESULTS

A total of 833 women with stage 0-3 breast cancer were included in the analysis; median age at diagnosis was 37 (range: 17-40) years. Social supports were the most commonly reported coping strategies, with the majority reporting moderate or greater use of emotional support from a partner (90%), parents (78%), other family (79%), and reliance on friends (88%) at both 6 and 18 months. In multivariable analyses, those with moderate or greater reliance on emotional support from other family (odds ratio (OR): 0.37, 95% confidence ratio (CI): 0.22-0.63) at 18 months were less likely to have anxiety at 2 years, while those with moderate or greater reliance on alcohol/drug use (OR: 1.83, 95%CI: 1.12-3.00) and taking care of others (OR: 1.90, 95%CI: 1.04-3.45) to cope were more likely to have anxiety.

CONCLUSION

Young breast cancer survivors rely heavily on support from family and friends. Our findings underscore the importance of considering patients' social networks when developing interventions targeting coping in survivorship.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01468246 (first posted November 9, 2011).

Patient perspectives on testing for clonal hematopoiesis of indeterminate potential

Clonal hematopoiesis of indeterminate potential (CHIP), an emerging biomarker for personalized risk-directed interventions, is increased in cancer survivors. However, little is known about patient preferences for CHIP testing. We surveyed participants in a prospective cohort study of young women with breast cancer (BC). The emailed survey included an introduction to CHIP and a vignette eliciting participants' preferences for CHIP testing, considering sequentially: population-based 10-year risk of BC recurrence, hematologic malignancy, and heart disease; increased CHIP-associated risks; current CHIP management; dedicated CHIP clinic; and hypothetical CHIP treatment. Preference changes were evaluated using the McNemar test. The survey response rate was 82.2% (528/642). Median age at time of survey was 46 years and median time from diagnosis was 108 months. Only 5.9% had prior knowledge of CHIP. After vignette presentation, most survivors (87.1%) recommended CHIP testing for the vignette patient. Presented next with CHIP-independent, population-based risks, 11.1% shifted their preference from testing to not testing. After receiving information about CHIP-associated risks, an additional 10.1% shifted their preference to testing. Preference for testing increased if vignette patient was offered a CHIP clinic or hypothetical CHIP treatment, with 7.2% and 14.1% switching preferences toward testing, respectively. Finally, 75.8% of participants desired CHIP testing for themselves. Among participants, 28.2% reported that learning about CHIP caused at least moderate anxiety. Most young survivors favored CHIP testing, with preferences influenced by risk presentation and potential management strategies. Our findings highlight the importance of risk communication and psychosocial support when considering biomarkers for future risk in cancer survivors. This trial has been registered at www.clinicaltrials.gov as #NCT01468246.

Impact of same day screening mammogram results on women’s satisfaction and overall breast cancer screening experience: a quality improvement survey analysis

Background

Most women undergoing screening examinations in the U.S. do not receive immediate results and for many this results in increased stress, inconvenience, delayed diagnosis, and potential loss to follow-up.

Objective

To study the impact of same appointment mammogram results on breast cancer screening experience and patient satisfaction.

Materials and methods

A 6-question survey with questions focused on breast cancer screening experience with our new service of same appointment mammogram results was distributed to 200 patients, with 185 patients returning their responses. Patients evaluated their current experience on receiving their screening results during the same appointment with their prior breast cancer screening experience. Patients who did not respond to their satisfaction score either before or after same appointment results were excluded from the patient cohort analyzing satisfaction score. Remaining questions were analyzed separately as additional satisfaction assessment tools.

Results

About 48% of the patients indicated an improvement in their screening experience with same appointment mammography results service, while 47% of the patients reported no significant difference in their experience.

Conclusion

Although not statistically significant, same appointment mammogram results were able to make a positive impact on breast cancer screening experience among 48% of the patients. Further research elucidating barriers to screening and other ways to improve patient satisfaction will be required to increase breast cancer screening compliance.

"Is it cancer or not?" A qualitative exploration of survivor concerns surrounding the diagnosis and treatment of ductal carcinoma in situ

BACKGROUND

Of the nearly 50,000 women in the United States who undergo treatment for ductal carcinoma in situ (DCIS) annually, many may not benefit from treatment. To better understand the impact of a DCIS diagnosis, patients self-identified as having had DCIS were engaged regarding their experience.

METHODS

In July 2014, a web-based survey was administered through the Susan Love Army of Women breast cancer listserv. The survey included open-ended questions designed to assess patients' perspectives about DCIS diagnosis and treatment. Deductive and inductive codes were applied to the responses; common themes were summarized.

RESULTS

Among the 1832 women included in the analytic sample, the median age at diagnosis was 60 years. Four primary themes were identified: 1) uncertainty surrounding a DCIS diagnosis, 2) uncertainty about DCIS treatment, 3) concern about treatment side effects, and 4) concern about recurrence and/or developing invasive breast cancer. When diagnosed, participants were often uncertain about whether they had cancer or not and whether they should be considered a "survivor." Uncertainty about treatment manifested as questioning the appropriateness of the amount of treatment received. Participants expressed concern about the "cancer spreading" or becoming invasive and that they were not necessarily "doing enough" to prevent recurrence.

CONCLUSIONS

In a large, national sample, participants with a history of DCIS reported confusion and concern about the diagnosis and treatment, which caused worry and significant uncertainty. Developing strategies to improve patient and provider communications regarding the nature of DCIS and acknowledging gaps in the current knowledge of management options should be a priority.

Psychosocial issues and quality of life of parenting partners of young women with breast cancer

PURPOSE

Data are lacking about the association between quality of life (QOL) and psychosocial issues of partners of young women with breast cancer who co-parent dependent children.

METHODS

We conducted a cross-sectional analysis of partners of women with breast cancer diagnosed at age ≤ 40. Among those partners reporting at least one dependent child under 18 years old at the time of diagnosis, we used multiple linear regression to examine associations between partner QOL and sociodemographic and psychosocial factors, and the patient's cancer stage and time since diagnosis.

RESULTS

Of the 219 parenting partners, all identified as male with a median age of 44 years; 96% (204/213) reported working full-time at the time of the survey. Fifty-four percent endorsed behaviors indicating maladaptive coping. In adjusted analyses, less than full-time employment (β =  - 8.76; 95% CI =  - 17.37, - 0.14), younger age (β =  - 0.35; 95% CI =  - 0.069, - 0.02), greater parenting concerns (β = 0.56; 95% CI = 0.36, 0.75), clinically relevant anxiety symptoms (β = 13.79; 95% CI = 10.24, 17.35), lower post-traumatic growth score (β =  - 0.33; 95% CI =  - 0.51, - 0.16), lower social support (β =  - 0.21; 95% CI =  - 0.29, - 0.12), lower sexual satisfaction (β =  - 0.40; 95% CI =  - 0.62, - 0.19), and breast cancer stages 3 (β = 7.61; 95% CI = 0.19, 15.02) and 4 (β = 12.63; 95% CI = 1.91, 23.34), when compared to stage 0, were associated with lower partner QOL.

CONCLUSION

Parenting partners of young women with breast cancer have substantial unmet psychosocial needs. Interventions are needed to enhance QOL and promote adaptive coping for this population.

Long-term Mammography Adherence among Uninsured Women Enrolled in the Breast Screening and Patient Navigation (BSPAN) Program

BACKGROUND

The Breast Screening and Patient Navigation (BSPAN) Program provides access to no-cost breast cancer screening services to uninsured women in North Texas. Using data from the longitudinal BSPAN program (2012-2019), we assessed prevalence and correlates of (i) baseline adherence and (ii) longitudinal adherence to screening mammograms.

METHODS

Outcomes were baseline adherence (adherent if women received second mammogram 9-30 months after the index mammogram) and longitudinal adherence (assessed among baseline adherent women and defined as being adherent 39 months from the index mammogram). We used multivariable logistic regression and multivariable Cox proportional hazards model to assess associations of sociodemographic and clinical characteristics with baseline and longitudinal adherence, respectively.

RESULTS

Of 19,292 women, only 5,382 (27.9%) were baseline adherent. Baseline adherence was more likely among women who were partnered, preferred speaking Spanish, had poor reading ability, had prior Papanicolaou (PAP) testing, and prior screening mammograms, compared with women who were non-partnered, preferred speaking English, had good reading ability, had no prior PAP testing, and no prior screening mammograms, respectively. Of those who were baseline adherent, 4,364 (81.1%) women demonstrated longitudinal adherence. Correlates of longitudinal adherence were similar to those from baseline adherence.

CONCLUSIONS

A large proportion of baseline adherent women (>80%) achieved longitudinal adherence, which highlights the importance of concentrating resources during the second mammogram in the progression toward continued adherence.

IMPACT

Results from our unique dataset provide realistic mammography adherence rates and may be generalizable to other areas introducing no-cost screening to low-income women, independent of any regular patient-centered medical home.

Association of Rurality With Annual Repeat Lung Cancer Screening in the Veterans Health Administration

PURPOSE

Lung cancer causes the largest number of cancer-related deaths in the United States. Lung cancer incidence rates, mortality rates, and rates of advanced stage disease are higher among those who live in rural areas. Known disparities in lung cancer outcomes between rural and nonrural populations may be in part because of barriers faced by rural populations. The authors tested the hypothesis that among Veterans who receive initial lung cancer screening, rural Veterans would be less likely to complete annual repeat screening than nonrural Veterans.

METHODS

A retrospective cohort study was conducted of 10 Veterans Affairs medical centers from 2015 to 2019. Rural and nonrural Veterans undergoing lung cancer screening were identified. Rural status was defined using the rural-urban commuting area codes. The primary outcome was annual repeat lung cancer screening in the 9- to 15-month window (primary analysis) and 31-day to 18-month window (sensitivity analysis) after the first documented lung cancer screening. To examine rurality as a predictor of annual repeat lung cancer screening, multivariable logistic regression models were used.

RESULTS

In the final analytic sample of 11,402 Veterans, annual repeat lung cancer screening occurred in 27.7% of rural Veterans (641 of 2,316) and 31.8% of nonrural Veterans (2,891 of 9,086) (adjusted odds ratio: 0.86; 95% confidence interval: 0.73-1.03). Similar results were seen in the sensitivity analysis, with 41.6% of rural Veterans (963 of 2,316) versus 45.2% of nonrural Veterans (4,110 of 9,086) (adjusted odds ratio: 0.88; 95% confidence interval: 0.73-1.04) having annual repeat screening in the expanded 31-day to 18-month window.

CONCLUSIONS

Among a national cohort of Veterans, rural residence was associated with numerically lower odds of annual repeat lung cancer screening than nonrural residence. Continued, intentional outreach efforts to increase annual repeat lung cancer screening among rural Veterans may offer an opportunity to decrease deaths from lung cancer.

Association of Local Therapy With Quality-of-Life Outcomes in Young Women With Breast Cancer

Importance

Increasing rates of bilateral mastectomy have been most pronounced in young women with breast cancer, but the association of surgery with long-term quality of life (QOL) remains largely unknown.

Objective

To examine the association of surgery with longer-term satisfaction and QOL in young breast cancer survivors.

Design, Setting, and Participants

This multicenter cross-sectional study of a prospective cohort was conducted from October 2016 to November 2017, at academic and community hospitals in North America. Women 40 years or younger enrolled in the Young Women's Breast Cancer Study were assessed. Data analysis was performed from during a 1- to 2-year period after conclusion of the study.

Exposures

Primary breast surgery, reconstruction, and radiotherapy.

Main Outcomes and Measures

Mean BREAST-Q breast satisfaction and physical, psychosocial, and sexual well-being scores were compared by type of surgery; higher BREAST-Q scores (range, 0-100) indicate better QOL. Linear regression was used to identify demographic and clinical factors associated with BREAST-Q scores for each domain.

Results

A total of 560 women with stage 0 to III breast cancer (median age at diagnosis, 36 years; range, 17-40 years; 484 [86%] with stage 0-II disease) completed the BREAST-Q a median of 5.8 years (range, 1.9-10.4 years) from diagnosis. A total of 290 patients (52%) of patients underwent bilateral mastectomy, 110 patients (20%) underwent unilateral mastectomy, and 160 patients (28%) received breast-conserving therapy. Among mastectomy patients, 357 (89%) had reconstruction and 181 (45%) received radiotherapy. In multivariate analyses, implant-based reconstruction (vs autologous) was associated with decreased breast satisfaction (β = -7.4; 95% CI, -12.8 to -2.1; P = .007) and complex reconstruction (vs autologous) with worse physical well-being (β = -14.0; 95% CI, -22.2 to -5.7; P < .001).

Conclusions and Relevance

These results suggest that local therapy in young breast cancer survivors is persistently associated with poorer scores in multiple QOL domains, particularly among those treated with mastectomy and radiotherapy, irrespective of breast reconstruction. Socioeconomic stressors also appear to play a role.

Uptake of cancer risk management strategies among women who undergo cascade genetic testing for breast cancer susceptibility genes

BACKGROUND

Uptake of cancer risk management based on inherited predispositions, which encompasses bilateral mastectomy (BLM), bilateral salpingo-oophorectomy (BSO), and intensified screening, is the primary motivation for cascade testing for hereditary breast and ovarian cancer (HBOC). However, long-term outcome data for cascade testers are lacking.

METHODS

Medical records were abstracted for all unaffected women with pathogenic variants in HBOC genes from 2 cancer hospitals (2013-2019) with at least 1 year of follow-up to compare the uptake of surgery and screening between cascade and noncascade testers.

RESULTS

Cascade testers (79.8%) were younger than noncascade testers (mean age, 37.6 vs 43.5 years; P = .002). Among women aged ≥40 years, 43% underwent BLM, and 71.6% underwent BSO, with no significant difference in uptake between cascade and noncascade testers. The mean time to BSO among cascade testers was shorter among women aged ≥40 years versus those aged <40 years (11.8 vs 31.9 months; P = .04); no such difference was observed among noncascade testers. Mammography and breast magnetic resonance imaging rates were low in the recorded 6 years for both groups after genetic counseling.

CONCLUSIONS

Management uptake among cascade testers is high with rates comparable to those for unaffected BRCA-positive women. A large proportion of women act on cascade test results, and this represents a novel report of utilization of cancer management strategies.

Impact of fertility concerns on endocrine therapy decisions in young breast cancer survivors

BACKGROUND

The diagnosis and treatment of breast cancer can have profound effects on a young woman's family planning and fertility, particularly among women with hormone receptor-positive breast cancer.

METHODS

The Young Women's Breast Cancer Study was a multicenter cohort of women aged 40 years or younger and newly diagnosed with breast cancer from 2006 to 2016. Surveys included assessments of fertility concerns, endocrine therapy (ET) preferences, and use. Characteristics were compared between women who reported that fertility concerns affected ET decisions and those who did not. Logistic regression was used to identify factors associated with having an ET decision affected by fertility concerns.

RESULTS

Of 643 eligible women with hormone receptor-positive, stage I to III breast cancer, one-third (213 of 643) indicated that fertility concerns affected ET decisions. In a multivariable analysis, only parity at diagnosis was significantly associated with fertility concerns affecting ET decisions (odds ratio for nulliparous vs ≥2 children, 6.96; 95% confidence interval, 4.09-11.83; odds ratio for 1 vs ≥2 children, 5.30; 95% confidence interval, 3.03-9.87). Noninitiation/nonpersistence was higher among women with fertility concerns versus those without fertility concerns (40% vs 20%; P < .0001). Among women with fertility-related ET concerns, 7% (15 of 213) did not initiate ET, and 33% (70 of 213) were nonpersistent over 5 years of follow-up. Of these women, 66% (56 of 85) reported 1 or more pregnancies or pregnancy attempts; 27% (15 of 56) had resumed ET at the last available follow-up through 5 years.

CONCLUSIONS

Concern about fertility is a contributor to adjuvant ET decisions among a substantial proportion of young breast cancer survivors. Ensuring family planning is addressed in the setting of ET recommendations should be a priority throughout the cancer care continuum.

Arm Morbidity After Local Therapy for Young Breast Cancer Patients

BACKGROUND

The impact of patient demographics and local therapy choice on arm morbidity in young breast cancer patients is understudied despite its importance given the long survivorship period. This study assessed patient-reported arm morbidity in the Young Women's Breast Cancer Study (YWS), a prospective cohort study.

METHODS

From 2006 to 2016, 1302 women with breast cancer diagnosed at the age of 40 years or younger enrolled in the YWS. The participants regularly complete surveys. The response rates are higher than 86%. Using the Breast Cancer Prevention Trial Checklist, this study examined the prevalence of patient-reported postoperative arm swelling and decreased range of motion (ROM) 1 year after diagnosis, stratified by local therapy strategy, in patients who had surgery for stages 1 to 3 disease. Logistic regression analysis was used to identify risk factors for arm morbidity.

RESULTS

Among 888 eligible participants (median age, 37 years), 14% reported arm swelling and 34% reported decreased ROM at 1 year. Arm swelling was reported by 23.6% of the patients who had axillary lymph node dissection (ALND) and 24.6% of the patients who received ALND and post-mastectomy radiation therapy (PMRT). In the multivariable analysis, the patients who reported being financially uncomfortable or who had ALND were at higher risk of arm swelling at 1 year. Being overweight, receiving ALND after sentinel lymph node biopsy, and receiving PMRT were associated with decreased ROM at 1 year.

CONCLUSION

High rates of self-reported arm morbidity in young breast cancer survivors were reported, particularly in patients receiving ALND and PMRT. Attention to the risks and benefits of differing local therapy strategies for ALND and PMRT patients is warranted.

Screening Mammography Utilization Among Female Medicare Beneficiaries and Breast Cancer Survivors in 2002-2016

Background: The use of screening mammography varies by patient characteristics. This study examined the annual mammography utilization trends among female Medicare beneficiaries and breast cancer survivors, overall and by beneficiary characteristics. Materials and Methods: This retrospective, serial cross-sectional study used the 2002-2016 Medicare Current Beneficiary Survey (MCBS), including fee-for-service female Medicare beneficiaries who resided in community settings and who completed the survey (n = 53,788, weighted n = 206,259,890). Self-reported mammography utilization and breast cancer history were identified through the survey. Annual trends in the proportion of using mammography were examined using simple linear regression models, overall and by beneficiary's age, race, geographic region, and count of comorbidities. Multivariable models with generalized estimating equations were used to examine factors associated with mammography utilization. Results: Overall, the mammography utilization trends significantly decreased during the 2002-2016 period for both cohorts (p = 0.004 for female beneficiaries from 50.85% in 2002 to 40.55% in 2016 and p = 0.041 for breast cancer survivors from 68.36% in 2002 to 55.21% in 2016). Among female beneficiaries, trends also significantly decreased in different age groups, Whites, residential regions (Midwest, South, West, Metro, and Nonmetro), and count of comorbid conditions (all p < 0.05). Trends also declined among the breast cancer survivors who were ≥70 years old, ≥40 years old, and in South region (all p < 0.05). Beneficiary's demographic and socioeconomic factors, comorbidity, smoking, and health status were associated with the likelihood of screening mammography utilization among female beneficiaries; however, such associations were limited among breast cancer survivors. Conclusions: In 2002-2016, the overall trends in mammography use among female Medicare beneficiaries and breast cancer survivors declined significantly. Variations in mammography use among different subgroups were observed.

Partners of young breast cancer survivors: a cross-sectional evaluation of psychosocial concerns, coping, and mental health

PURPOSE

Evaluation of psychosocial concerns, coping style, and mental health in partners of young (diagnosed at ≤40 years) survivors of early-stage breast cancer (BC).

DESIGN

Cross-sectional; partners participated in a one-time survey.

SAMPLE

289 participants; most were male, white, working full-time, college educated, with median age of 43 years, parenting children <18 years old.

METHODS

Logistic regression was used to explore associations with anxiety and depression (≥8 on Hospital Anxiety and Depression sub-scales).

FINDINGS

Overall, 41% reported symptoms of anxiety, 18% reported symptoms of depression, and 44% identified maladaptive coping. Multivariable regression analyses revealed: lower social support and poorer quality of life significantly associated with depression (p < .05); maladaptive coping, fulltime employment, poorer caregiver QOL, and less education significantly associated with anxiety.

CONCLUSIONS

Partners of young BC survivors who use more maladaptive coping strategies, report less social support, work fulltime, and/or who have lower education levels experience negative mental health outcomes.

IMPLICATIONS FOR PSYCHOSOCIAL ONCOLOGY

Enhancing constructive coping and ensuring all partners have access to supportive resources may improve partners' emotional adjustment.

Implementation and Utilization of a "Pink Card" Walk-In Screening Mammography Program Integrated With Physician Visits

PURPOSE

The aim of this study was to evaluate the implementation and utilization of the Pink Card program, which links a physician-delivered reminder that a woman is due for screening mammography (SM) during an office visit with the opportunity to undergo walk-in screening.

METHODS

In 2016, the authors' community-based breast imaging center provided physicians from three primary care and obstetrics and gynecology practices located in the same outpatient facility business card-sized Pink Cards to offer women due for SM during office visits. The card includes a reminder that screening is due and can be used to obtain SM on a walk-in basis. The primary outcome measure was the proportion of women who used Pink Cards among all screened women over 2 years. Independent predictors of Pink Card utilization were evaluated using multivariate logistic regression analyses.

RESULTS

Among 3,688 women who underwent SM, Pink Cards were used by 19.9% (733 of 3,688). Compared with women with prescheduled screening visits, Pink Card users were more likely to be Asian (odds ratio [OR], 1.37; P =.032), Black (OR, 2.05; P = .002), and Medicaid insured (OR, 1.71; P = .013) and less likely to use English as their primary language (OR, 2.75; P = .003). Additionally, Pink Card users were less likely to be up to date for biennial SM compared with women with prescheduled visits (31.9% [234 of 733] versus 66.6% [1,968 of 2,955], P < .001).

CONCLUSIONS

The Pink Card walk-in SM program can improve screening access, particularly for racial/ethnic minorities and Medicaid-insured patients. Expansion of this program may help reduce disparities and increase engagement in breast cancer screening.

Posttraumatic stress in breast cancer survivors diagnosed at a young age

OBJECTIVE

Young breast cancer patients experience greater psychosocial distress compared with older patients, which raises concern for their risk of posttraumatic stress disorder (PTSD). We sought to characterize the prevalence of clinically significant symptoms of PTSD and associated factors among breast cancer survivors diagnosed at a young age.

METHODS

The Young Women's Breast Cancer Study, an ongoing prospective cohort study, enrolled 1302 women diagnosed with breast cancer at age ≤ 40 between 2006 and 2016. Participants complete serial surveys, and we obtained additional information from medical record review. Socio-demographics, anxiety and depression, social support, and psychiatric co-morbidities and medications were assessed at study baseline (median, 5 months post-diagnosis). We defined a participant as having clinically significant posttraumatic stress symptoms (PTSS) by scoring ≥50 on the PTSD Checklist-Specific Version, administered on the 30-month survey.

RESULTS

Among 700 women with stage 1-3 disease, the prevalence of PTSS was 6.3% (95%CI = 4.5-8.1). In multivariable analyses, PTSS was significantly associated with anxiety (OR 12.43, 95%CI = 5.81-26.59, P < .0001) and stage 2 vs 1 disease (OR 2.26, 95%CI = 1.04-4.93, P = .04). PTSS was inversely associated with having a college degree (OR 0.29, 95%CI = 0.13-0.62, P = .002) and greater social support (OR 0.44, 95%CI = 0.21-0.94, P = .03).

CONCLUSIONS

We found similar rates of cancer-related PTSS in breast cancer survivors diagnosed at a young age compared with the general breast cancer population despite their well-documented increased risk of overall distress. Nevertheless, factors associated with posttraumatic stress should be considered at diagnosis and in survivorship to identify young patients who may benefit from psychosocial resources.

Association of a Lung Screening Program Coordinator With Adherence to Annual CT Lung Screening at a Large Academic Institution

BACKGROUND

Detection of early-stage lung cancer improves during subsequent rounds of screening with low-dose CT and potentially leads to saving lives with curative treatment. Therefore, adherence to annual lung screening is important. We hypothesized that adherence to annual screening would increase after hiring of a dedicated program coordinator.

METHODS

We performed a mixed-methods study in a retrospective cohort of patients who underwent lung screening at our academic institution between January 1, 2014, and March 31, 2018. Patients with baseline lung screening examinations performed between January 1, 2014, and September 30, 2016, with Lung CT Screening Reporting & Data System 1 or 2 scores and a 12-month follow-up recommendation were included. We tracked patient adherence to annual follow-up lung screening over time (before and after hiring of a program coordinator) and conducted a cross-sectional survey of patients nonadherent to annual follow-up to elicit quantitative and qualitative feedback.

RESULTS

Of the 319 patients who completed baseline lung screening with normal results, 189 (59%) were adherent to annual follow-up recommendations and 130 (41%) were nonadherent. Patient adherence varied over time: 21.7% adherence (10 of 46) before hiring a program coordinator and 65.6% adherence (179 of 273) after the program coordinator's hire date. Patients reported the following reasons for nonadherence to annual lung screening: lack of transportation, financial cost, lack of communication by physicians, and lack of current symptoms.

CONCLUSIONS

Adherence to annual lung screening after normal baseline studies increased significantly over time. Hiring a full-time program coordinator was likely associated with this increased in adherence.

Mode of detection and breast cancer mortality by follow-up time and tumor characteristics among screened women in Cancer Prevention Study-II

PURPOSE

In a screened population, breast cancer-specific mortality is lower for screen-detected versus symptom-detected breast cancers; however, it is unclear whether this association varies by follow-up time and/or tumor characteristics. To further understand the prognostic utility of mode of detection, we examined its association with breast cancer-specific mortality, overall and by follow-up time, estrogen receptor status, tumor size, and grade.

METHODS

In the Cancer Prevention Study-II Nutrition Cohort, 3975 routinely screened women were diagnosed with invasive breast cancer (1992-2015). Among 2686 screen-detected and 1289 symptom-detected breast cancers, 206 and 209 breast cancer deaths, respectively, occurred up to 24 years post diagnosis. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated from Cox proportional hazard regression models.

RESULTS

Controlling for prognostic factors, symptom detection was associated with higher risk of breast cancer-specific death up to 5 years after diagnosis (HR_≤5years = 1.88, 95% CI 1.21-2.91) this association was attenuated in subsequent follow-up (HR_>5years = 1.26, 95% CI 0.98-1.63). Within tumor characteristic strata, there was a 1.3-2.7-fold higher risk of breast cancer death associated with symptom-detected cancers ≤ 5 years of follow-up, although associations were only significant for women with tumors < 2 cm (HR_≤5years = 2.42, 95% CI 1.19-4.93) and for women with grade 1 or 2 tumors (HR_≤5years = 2.72, 95% CI 1.33-5.57). In subsequent follow-up, associations were closer to the null.

CONCLUSIONS

Screen detection is a powerful prognostic factor for short-term survival. Among women who survived at least 5 years after breast cancer diagnosis, other clinical factors may be more predictive of breast cancer survival.

Employment trends in young women following a breast cancer diagnosis

PURPOSE

Little is known about how a breast cancer diagnosis and treatment affects job-related outcomes in young women with breast cancer, who are an integral part of the workforce. We sought to describe employment trends among young breast cancer survivors.

METHODS

911 women with non-metastatic breast cancer were surveyed about employment-related outcomes 1 year post-diagnosis. Participants were enrolled in the Young Women's Breast Cancer Study an ongoing, multi-center cohort of women diagnosed with breast cancer at age ≤ 40.

RESULTS

Among 911 women, median age at diagnosis was 36 years (range 17-40). Most women (80%, n = 729) were employed 1 year post-diagnosis. Among the 7% (n = 62) employed before diagnosis but who reported unemployment at 1 year, approximately half reported they were unemployed for health reasons. Among employed women, 7% said treatment affected their ability to perform their job. Women with stage-three disease (vs. stage 1 disease, odds ratio (OR): 3.73, 95% CI 1.39-9.97) and those who reported having money to pay bills after cutting back or difficulty paying bills at baseline (vs. having enough money for special things, OR 2.70, 95% CI 1.32-5.52) at baseline were more likely to have transitioned out of the workforce.

CONCLUSIONS

Our results suggest an impact of disease burden and socioeconomic status on employment in young breast cancer survivors. There is a need to ensure young survivors who leave the workforce following diagnosis are sufficiently supported given the potential adverse psychosocial and financial impacts of unemployment on survivors, their families, communities, and society.

What risk of death would people take to be cured of HIV and why? A survey of people living with HIV

People living with HIV (PLWHIV) can reasonably expect near-normal longevity, yet many express a willingness to assume significant risks to be cured. We surveyed 200 PLWHIV who were stable on antiretroviral therapy (ART) to quantify associations between the benefits they anticipate from a cure and their risk tolerance for curative treatments. Sixty-five per cent expected their health to improve if cured of HIV, 41% predicted the virus would stop responding to medications over the next 20 years and 54% predicted experiencing serious medication side effects in the next 20 years. Respondents' willingness to risk death for a cure varied widely (median 10%, 75th percentile 50%). In multivariate analyses, willingness to risk death was associated with expected long-term side effects of ART, greater financial resources and being employed (all P < 0.05) but was not associated with perceptions of how their health would improve if cured.

Predicting reattendance to the second round of the Maltese national breast screening programme: an analytical descriptive study

BACKGROUND

A range of barriers influence women's uptake to a first breast screening invitation. Few studies however, have examined factors associated with second screening uptake. This study follows Maltese women to explore predictors and behaviours to re-attendance, and to determine if uptake of first invitation to the Maltese Breast Screening Programme (MBSP) is a significant predictor of second screening uptake.

METHODS

A prospective study was conducted to determine factors associated with re-attendance for 100 women invited to the second MBSP round. Records of women's second attendance to the MBSP were extracted in January 2016 from the MBSP database. Data were analyzed using chi-square tests, Independent Samples t-test, Mann Whitney test, Shapiro Wilk test and logistic regression.

RESULTS

There were no significant associations for sociodemographic or health status variables with second screening uptake (p > 0.05), except breast condition (Fisher's exact test, p = 0.046). Non-attendees at second screening were most unsure of screening frequency recommendations (χ2 = 9.580, p = 0.048). Attendees were more likely to perceive their susceptibility to breast cancer (p = 0.041), believed breast cancer to be life changing (p = 0.011) and considered cues to action to aid attendance (p = 0.028). Non-attendees were in stronger agreement on mammography pain (p = 0.008) and were less likely to consider cues to action (15.4% non-attendees vs 1.4% attendees) (p = 0.017 respectively). 'Perceived barriers', 'breast cancer identity', 'causes' and 'consequences' were found to be significant predictors of second screening uptake, with 'perceived barriers' being the strongest. The inclusion of illness perception items improved the regression model's accuracy in predicting non-attendance to the second screening round (84.6% vs 30.8%). First screening uptake was found to be a significant predictor of subsequent uptake (OR = 0.102; 95% CI = 0.037, 0.283; p = 0.000).

CONCLUSIONS

Interventions to increase uptake should target first invitees since attending for the first time is a strong predictor of uptake to the second cycle. Further research is required given the small sample. Particular attention should be paid to women who did not respond to their first invite or are unsure or reluctant participants initially.

Factors associated with the utilization of mammographic screening in Greece

Breast cancer is the most commonly diagnosed type of cancer in women and the primary cause of death by cancer in women globally. Early diagnosis and treatment can be achieved through screening, mainly mammographic; however, international experience has shown that women do not attend mammographic screening adequately. The aim of the present study was to investigate and assess the factors that affect demand for mammography by women to improve and enhance the use of mammography by women in Greece, especially those in the 50-70 age group. The data used in the analysis were extracted from the National Health Survey of 2009, conducted by the Hellenic Statistical Authority. The sample for the analysis included 2294 women aged 30-70 years. To investigate the factors that affect mammography use, binary logistic regression models were constructed for women in the 30-39, 40-49 and 50-70 age groups. 61.70% of the sample had ever undergone a mammogram, 46.80% of which were during the last 12 months. Factors associated with mammography use in at least one of the binary logistic regression models were pap-test, blood cholesterol test, level of education, income level and country of birth. In the 50-70 age group, income level [odds ratio (OR)=1.164; 95% confidence interval (CI)=1.038, 1.305], blood cholesterol test ever (OR=6.096; 95% CI=2.498, 14.872) and pap-test (OR=20.148; 95% CI=11.264, 36.040) were found to be statistically significant predictors of mammography uptake. As mammography utilization in Greece is mostly opportunistic, it is necessary to organize screening provision to cover the majority of the population through nationally organized screening programmes, with a focus on women 50-70 years of age.

Multilevel Predictors of Continued Adherence to Breast Cancer Screening Among Women Ages 50-74 Years in a Screening Population

Background: U.S. women of ages 50-74 years are recommended to receive screening mammography at least biennially. Our objective was to evaluate multilevel predictors of nonadherence among screened women, as these are not well known. Materials and Methods: A cohort study was conducted among women of ages 50-74 years with a screening mammogram in 2011 with a negative finding (Breast Imaging-Reporting and Data System 1 or 2) within Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium research centers. We evaluated the association between woman-level factors, radiology facility, and PROSPR research center, and nonadherence to breast cancer screening guidelines, defined as not receiving breast imaging within 27 months of an index screening mammogram. Multilevel mixed-effects logistic regression was used to calculate odds ratios and 95% confidence intervals. Results: Nonadherence to guideline-recommended screening interval was 15.5% among 51,241 women with a screening mammogram. Non-Hispanic Asian/Pacific Islander women, women of other races, heavier women, and women of ages 50-59 years had a greater odds of nonadherence. There was no association with ZIP code median income. Nonadherence varied by research center and radiology facility (variance = 0.10, standard error = 0.03). Adjusted radiology facility nonadherence rates ranged from 10.0% to 26.5%. One research center evaluated radiology facility communication practices for screening reminders and scheduling, but these were not associated with nonadherence. Conclusions: Breast cancer screening interval nonadherence rates in screened women varied across radiology facilities even after adjustment for woman-level characteristics and research center. Future studies should investigate other characteristics of facilities, practices, and health systems to determine factors integral to increasing continued adherence to breast cancer screening.

Assessing the mediating role of breast conflict on cognitive factors associated with adopting mammography

Breast conflict may represent a woman's unpleasant feelings toward her breasts, which may adversely affect her decision to undertake the procedures for an early detection of breast cancer. The purpose of the present study was to examine the mediating role of breast conflict in cognitive factors, as suggested by the Health Belief Model (HBM), for adopting mammography. In this explanatory cross-sectional study, multistage cluster sampling was employed to recruit 738 women in the age range of 40 to 69 years in Iran. Champion's revised HBM Scale for mammography adoption and the Women's Breast Conflict Scale were used to measure the variables of interest. Generalized structural equation modeling and hierarchical logistic regression were used for data analysis. Breast conflict was negatively associated with perceived barriers of mammography. Perceived barriers were inversely related to self-efficacy, which was positively related to mammography, suggesting the mediating role of perceived barriers and self-efficacy, connecting breast conflict to mammography indirectly. The mediating role of breast conflict in perceived barriers and self-efficacy suggests an indirect link between breast conflict and mammography. Clinicians and public health-care providers must pay attention to women's feelings in formulating and delivering appropriate interventions and consultations.

Associations of County-level Radiologist and Mammography Facility Supply with Screening Mammography Rates in the United States

RATIONALE AND OBJECTIVES

The present study aims to assess associations of Medicare beneficiary screening mammography rates with local mammography facility and radiologist availability.

MATERIALS AND METHODS

Mammography screening rates for Medicare fee-for-service beneficiaries were obtained for US counties using the County Health Rankings data set. County-level certified mammography facility counts were obtained from the United States Food and Drug Administration. County-level mammogram-interpreting radiologist and breast imaging subspecialist counts were determined using Centers for Medicare & Medicaid Services fee-for-service claims files. Spearman correlations and multivariable linear regressions were performed using counties' facility and radiologist counts, as well as counts normalized to counties' Medicare fee-for-service beneficiary volume and land area.

RESULTS

Across 3035 included counties, average screening mammography rates were 60.5% ± 8.2% (range 26%-88%). Correlations between county-level screening rates and total mammography facilities, facilities per 100,000 square mile county area, total mammography-interpreting radiologists, and mammography-interpreting radiologists per 100,000 county-level Medicare beneficiaries were all weak (r = 0.22-0.26). Correlations between county-level screening rates and mammography rates per 100,000 Medicare beneficiaries, total breast imaging subspecialist radiologists, and breast imaging subspecialist radiologists per 100,000 Medicare beneficiaries were all minimal (r = 0.06-0.16). Multivariable analyses overall demonstrated radiologist supply to have a stronger independent effect than facility supply, although effect sizes remained weak for both.

CONCLUSION

Mammography facility and radiologist supply-side factors are only weakly associated with county-level Medicare beneficiary screening mammography rates, and as such, screening mammography may differ from many other health-care services. Although efforts to enhance facility and radiologist supply may be helpful, initiatives to improve screening mammography rates should focus more on demand-side factors, such as patient education and primary care physician education and access.

Anxiety and Depression in Young Women With Metastatic Breast Cancer: A Cross-Sectional Study

BACKGROUND

Young adults with cancer experience disruptions in their normal developmental trajectories and commonly experience psychologic distress related to their diagnoses. Young women with metastatic breast cancer (MBC) are at particular risk of adverse mental health outcomes.

OBJECTIVE

We sought to determine the prevalence of and factors associated with anxiety and depression symptoms in young women with newly diagnosed de novo MBC.

METHODS

A total of 54 women with newly diagnosed de novo MBC were identified from an ongoing, prospective, multicenter cohort of women diagnosed with breast cancer at age <40. Depression and anxiety symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS). Items assessing socio-demographics, physical symptom burden, social support, and disease and treatment history, with complementary medical record review, were used to assess variables potentially associated with anxiety and depression symptoms.

RESULTS

Mean HADS Depression score was 4.4 (standard deviation = 3.7) and mean HADS Anxiety score was 7.9 (standard deviation = 5.0). Eleven (20%) women scored ≥8 on the HADS Depression subscale, the suggested threshold for depression/anxiety screening, and 24 (44%) women scored ≥8 on the HADS Anxiety subscale. In a multivariable model of anxiety, higher physical symptom scores (odds ratio = 4.41, p = 0.005) was significantly associated with higher anxiety scores. None of the other variables improved the model fit.

CONCLUSION

In this study, a considerable proportion of young women with newly diagnosed MBC experienced anxiety symptoms, although depression was less common. Future strategies focused on distress reduction in young MBC patients should focus on physical symptom management as well as anxiety identification and management.

Healthcare Factors for Obtaining a Mammogram in Latinas With a Variable Mammography History

PURPOSE/OBJECTIVES

To understand the relationship between mammography history and current thoughts about obtaining a mammogram among Latinas and examine the mediation effects of several healthcare factors.
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DESIGN

Cross-sectional survey.
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SETTING

Federally qualified health centers (Sea Mar Community Health Centers) in western Washington.
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SAMPLE

641 Latinas nonadherent and adherent with screening mammography.
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METHODS

Baseline survey data from Latinas with a mammography history of never, not recent (more than two years), or recent (less than two years) were analyzed. Preacher and Hayes methods were used to estimate the mediation effect of healthcare factors.
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MAIN RESEARCH VARIABLES

The survey assessed mammography history, sociodemographic and healthcare factors, and current thoughts about obtaining a mammogram.
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FINDINGS

Latinas' thoughts about obtaining a mammogram were associated with mammography history. Having had a clinical breast examination mediated 70% of differences between Latinas with a never and recent mammography history. Receipt of a provider recommendation mediated 54% of differences between Latinas with and without a recent mammography history.
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CONCLUSIONS

These findings emphasize the importance of the patient-provider relationship during a clinic visit and help inform how nurses may be incorporated into subsequent screening mammography interventions tailored to Latinas.
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IMPLICATIONS FOR NURSING

As providers, health educators, and researchers, nurses have critical roles in encouraging adherence to screening mammography guidelines among Latinas.

Routine colonoscopy, diabetic eye care, mammogram and pap smear screening in vascular surgery patients

Objective An increasing emphasis on preventive medicine has been supported by the recent reforms in United States health care system. Majority of the patients seen in vascular surgery clinics are elderly with more extensive medical comorbidities compared to the general population. Thus, these patients would be expected at higher risk for common malignant pathologies such as colon, breast and cervical cancer, and nonmalignant diseases such as diabetic retinopathy. This study looked at the screening compliance of vascular patients compared to data provided by Centers for Disease Control on the national and state levels. Methods The office records of 851 consecutive patients seen in Brooklyn and Staten Island vascular clinics were examined. We queried patients regarding their last colonoscopy, diabetic eye exams, recent mammograms, and Pap smears. Our patient screening compliance was compared between the two clinics as well as to the national and New York state data provided by Centers for Disease Control. Compliance with regard to patient's age was also examined. Results Patients referred to the Staten Island office have a better colonoscopy compliance compared to the Brooklyn office ( P = .0001) and the national Centers for Disease Control average ( P = .026). Compliance for mammography and cervical cancer screening was higher in Staten Island office compared to the Brooklyn office ( P = .0001, P < .0001), respectively. Compliance was lower for Pap smear ( P = .0273) in Brooklyn when compared to the national average. Compliance for colonoscopy increased with age for both clinics ( P = .001, P < .001), while Pap smear decreased ( P < .001, P = .004). Conclusion Patients in vascular clinics in an urban setting had better adherence to screening protocol than the national and state average, with the exception of female patients for colonoscopy in our Brooklyn vascular office. There exists variability in both patient populations based on sub-specific locality and demographics including socioeconomic status. Overall, however patients in Staten Island had better compliance and adherence to the screening protocol than Brooklyn vascular clinic.

Effects of a Randomized Controlled Trial to Increase Repeat Mammography Screening in Iranian Women

BACKGROUND

Although mammography use has increased in developed countries, regular screening in developing countries including Iran remains low. Multiple frameworks, including the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB), have been used to understand screening practices among Iranians. The HBM includes intrapersonal constructs such as perceptions of breast cancer and mammography. The TPB includes interpersonal and environmental constructs, such as perceived control and subjective norms.

OBJECTIVES

The current study had 2 objectives: (1) to examine changes in the HBM and TPB constructs and repeat mammography screening in women receiving either intervention and women in the control group and (2) to compare changes in the HBM and TPB constructs and repeat mammography screening across the 2 interventions.

METHODS

One hundred eight-four women from 3 randomly selected health centers in Sanandaj, Iran, participated. Eligibility criteria were being 50 years or older, having received a mammogram in the past 2 to 3 years, and no intention to obtain a mammogram within the next year.

RESULTS

The TPB and HBM participants exhibited greater changes in the HBM and TPB constructs and were more likely to have a mammogram relative to control participants. The TPB and HBM participants exhibited comparable changes in constructs and repeat mammography.

CONCLUSION

Findings suggest both interventions equally improved mammography screening. Additional studies are furthermore warranted to address nonadherent Iranian women's needs in line with these conceptual models.

IMPLICATIONS FOR PRACTICE

Use of the HBM and TPB constructs in clinical practice may be helpful to promote continued screening among this population.

Patterns and determinants of mammography screening in Lebanese women

The associations of ever using and/or repeating a mammography test with psychosocial and socio-demographic factors were surveyed in 2014 among Lebanese women ≥ 40. A sample of 2400 women was selected across Lebanon. Variables with significant bivariate associations with various types of behaviors were entered in multivariate analysis. Of the total, 105 women (4·4%) had never heard of mammography as a tool for early breast cancer detection. Among the remaining 2295, 45% had ever used it, of whom 10% had obtained it for the first time within the 12 months preceding the survey. Repeaters were 67% of 926 women who had the time opportunity to do so (median lifetime frequency: 2). Older age, higher socio-economic status (SES) and living within the Greater Beirut (GB) area were significantly associated with ever-use. Within GB, psychosocial factors such as perceived susceptibility and benefits were most strongly associated with ever-use. Outside GB, socio-economic advantage seemed to mostly affect ever-use. Only 4% reported opposition from husbands to their mammography, and husband's support was significant for adherence to mammography guidelines mostly outside GB. Higher education emerged also as a significant socio-demographic determinant for ever-repeating in all regions. Perceived comfort of the previous test strongly affected the likelihood of repeating it. Providing mammography free-of-charge may alleviate some obstacles among women with socio-economic disadvantage. Stressing that good results one year do not make the cancer less likely or repeating the test less important, as well as improving the comfort of mammography testing could ensure test repeating.

Automated telephone communication systems for preventive healthcare and management of long-term conditions

BACKGROUND

Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone's touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention.

OBJECTIVES

To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes.

SEARCH METHODS

We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015.

SELECTION CRITERIA

Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods to select and extract data and to appraise eligible studies.

MAIN RESULTS

We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear.For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening.Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data.The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use.Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers.Only four trials (3%) reported adverse events, and it was unclear whether these were related to the interventions.

AUTHORS' CONCLUSIONS

ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost-effective.

Prevalence and Determinants of Repeat Mammography Among Women from a Developing Country

Failures in repeat mammography decrease the potential benefits of screening; however, it is notable that the recent use of mammography is more frequently studied than repeat use. We estimated the prevalence and analyzed determinants for repeat mammography among women from Mexico, a developing country of Latin America. It was a two-stage study with an initial cross-sectional design (n = 1045) and a final case-control design that involved women of at least 45 years of age with no history of breast, ovarian, or uterine cancer. Case subjects were those with three or more mammograms in the last 5 years, with the last one carried out within the last two years (n = 444); control subjects included those who underwent ≥3 mammograms throughout their life with the most recent carried out >2 years ago (n = 444). Through interviews, we evaluated context-dependency, fulfillment of expected outcomes, self-efficacy, and risk perception, among other factors. We estimated the prevalence with 95 % confidence intervals (CI), and odds ratios (OR) using multivariate binary logistic regression. The prevalence of repeat mammography was 40.4 % (95 % CI 37.4-43.4). Self-efficacy demonstrated the highest effect on repeat use (OR 7.7, 95 % CI 4.7-12.6), followed by awareness context-dependency (OR 4.9, 95 % CI 3.3-7.2), the use of Papanicolaou testing (OR 3.5, 95 % CI 2.3-5.2), the fulfillment of expected waiting time outcome (OR 2.4, 95 % CI 1.2-4.7), and context-dependency related to self-referral/health provider referral (OR 2.4, 95 % CI 1.7-3.4), independent of risk perception, age, education, and positive emotional state of mind. The study showed a need for increasing the prevalence of promoting awareness of the determining factors of repeat mammography, which is a necessary component in the early detection of breast cancer.

Predictors of Participation in Mammography Screening among Non-Hispanic Black, Non-Hispanic White, and Hispanic Women

INTRODUCTION

Many factors influence women's decisions to participate in guideline-recommended screening mammography. We evaluated the influence of women's socioeconomic characteristics, health-care access, and cultural and psychological health-care preferences on timely mammography screening participation.

MATERIALS AND METHODS

A random digit dial survey of United States non-Hispanic Black, non-Hispanic White, and Hispanic women aged 40-75, from January to August 2009, determined self-reported time of most recent mammogram. Screening rates were assessed based on receipt of a screening mammogram within the prior 12 months, the interval recommended at the time by the American Cancer Society.

RESULTS

Thirty-nine percent of women reported not having a mammogram within the last 12 months. The odds of not having had a screening mammography were higher for non-Hispanic White women than for non-Hispanic Black (OR = 2.16, 95% CI = 0.26, 0.82, p = 0.009) or Hispanic (OR = 4.17, 95% CI = 0.12, 0.48, p = 0.01) women. Lack of health insurance (OR = 3.22, 95% CI = 1.54, 6.73, p = 0.002) and lack of usual source of medical care (OR = 3.37, 95% CI = 1.43, 7.94, p = 0.01) were associated with not being screened as were lower self-efficacy to obtain screening (OR = 2.43, 95% CI = 1.26, 4.73, p = 0.01) and greater levels of religiosity and spirituality (OR = 1.42, 95% CI = 1.00, 2.00, p = 0.05). Neither perceived risk nor present temporal orientation was significant.

DISCUSSION

Odds of not having a mammogram increased if women were uninsured, without medical care, non-Hispanic White, older in age, not confident in their ability to obtain screening, or held passive or external religious/spiritual values. Results are encouraging given racial disparities in health-care participation and suggest that efforts to increase screening among minority women may be working.

Barriers to and facilitative processes of endocrine therapy adherence among women with breast cancer

The treatment of chronic illness, and the prevention of disease progression and recurrence, often involve long-term adherence to prescription medications in breast cancer. Despite the survival benefit of endocrine therapies, nonadherence remains high. In this study, we examined barriers to and facilitators of endocrine therapy adherence among women with breast cancer (n = 1371). Participants currently taking tamoxifen or aromatase inhibitors were recruited from Dr. Susan Love Research Foundation's Army of Women(®) Registry. Participants responded online to open-ended and close-ended questions about thoughts, feelings, and behaviors relevant to endocrine therapy. Two weeks later, women were invited to complete a second online questionnaire regarding current endocrine therapy adherence. Approximately one-third (36 %) of participants reported the presence of factors that make endocrine therapy difficult; reporting any barrier to medication adherence was significantly associated with nonadherence (P < 0.001). In addition, 31 % of women used one or more strategies to maintain their motivation to adhere and the use of cognitive self-talk (e.g., thoughts regarding endocrine therapy efficacy) was related to higher adherence. Hierarchical linear regressions revealed a significant behavioral barrier × behavioral facilitator interaction (P < 0.05); participants who endorsed a behavioral barrier in the absence of a behavioral facilitator reported the lowest adherence. Findings suggest that a sizeable minority of women face barriers to taking endocrine therapy, which are associated with nonadherence.

Prevalence of major risk factors and use of screening tests for cancer in the United States

Much of the suffering and death from cancer could be prevented by more systematic efforts to reduce tobacco use, improve diet, increase physical activity, reduce obesity, and expand the use of established screening tests. Monitoring the prevalence of cancer risk factors and screening is important to measure progress and strengthen cancer prevention and early detection efforts. In this review article, we provide recent prevalence estimates for several cancer risk factors, including tobacco, obesity, physical activity, nutrition, ultraviolet radiation exposure as well as human papillomavirus and hepatitis B vaccination coverage and cancer screening prevalence in the United States. In 2013, cigarette smoking prevalence was 17.8% among adults nationally, but ranged from 10.3% in Utah to 27.3% in West Virginia. In addition, 15.7% of U.S. high school students were current smokers. In 2011-2012, obesity prevalence was high among both adults (34.9%) and adolescents (20.5%), but has leveled off since 2002. About 20.2% of high school girls were users of indoor tanning devices, compared with 5.3% of boys. In 2013, cancer screening prevalence ranged from 58.6% for colorectal cancer to 80.8% for cervical cancer and remains low among the uninsured, particularly for colorectal cancer screening where only 21.9% of eligible adults received recommended colorectal cancer screening.

Mediators of repeat mammography in two tailored interventions for Iranian women

Background

Many theory-based interventions exist that incorporate theoretical constructs (e.g., self-efficacy, behavioral control) believed to increase the likelihood of mammography. Nonetheless, little work to date has examined if increased screening among women receiving such interventions occurs due to changes in these targeted constructs. The aim of this study is to address this gap in the literature in the context of two interventions for improving regular screening among Iranian women.

Methods

A sample of 176 women over 50 years old in Tehran, Iran were randomly allocated into one of these three conditions: 1) an intervention based on Health Belief Model (HBM); 2) an intervention based on an integration of the HBM and selected constructs from the TPB (TPB); and 3) a control group (CON). Questionnaires were administered before the intervention and after a 6-month follow-up. The Preacher and Hayes method of mediation was used in analytic models.

Results

Changes in susceptibility, self-efficacy, and perceived control appeared to mediate HBM-CON differences in screening. Barriers attenuated the mediating effect of self-efficacy. Changes in barriers and self-efficacy appeared to mediate TPB-CON differences in screening.

Conclusion

This study was successful in identifying which theory-based constructs appear to underlie the effectiveness of HBM- and TPB-based interventions. Specific constructs have been identified that should be targeted in clinical practice to increase mammography practices among Iranian women.

Perceptions, Attributions, and Emotions Toward Endocrine Therapy in Young Women with Breast Cancer

PURPOSE

The aims of this study were to describe symptoms attributed to endocrine therapy (ET) and perceptions of ET in a sample of young women with breast cancer and to explore whether these factors are associated with adherence to ET.

METHODS

An online questionnaire was completed by 106 young women taking ET for hormone receptor-positive breast cancer. In addition to demographic and medical characteristics, the survey assessed symptom attribution, emotions, and perceptions related to ET. A supplemental survey measuring adherence to ET was completed by 82/106 women. Means, medians, and frequency distributions were calculated for continuous and categorical covariates, respectively. An exploratory analysis evaluated whether adherence was associated with patient characteristics and views.

RESULTS

The mean age of respondents was 39 years (range 22-45 years). Two-thirds of women had stage 1 or 2 breast cancer. Women attributed an average of nine symptoms to ET; hot flashes, night sweats, and decreased libido were the most frequently attributed symptoms. Positive emotions toward ET were more common than negative emotions were, although only 48% of respondents believed that ET was essential. Women of higher financial status and those who reported more positive emotions toward ET reported greater adherence with ET. A significant difference in symptom attribution was not detected between less and more adherent respondents.

CONCLUSIONS

Young women's views regarding ET may play an important role in determining adherence behavior. Given that young women have a higher risk of recurrence, some of which may be attributable to ET non-adherence, further work is needed to confirm these findings and determine whether interventions designed to modify young women's perceptions of ET could promote adherence.

Changing organizational culture: using the CEO cancer gold standard policy initiatives to promote health and wellness at a school of public health

Background

Worksite wellness initiatives for health promotion and health education have demonstrated effectiveness in improving employee health and wellness. We examined the effects of a multifaceted health promotion campaign on organizational capacity to meet requirements to become CEO Cancer Gold Standard Accredited.

Methods

We conducted an online survey to assess perceived organizational values and support for the five CEO Cancer Gold Standard Pillars for cancer prevention: tobacco cessation; physical activity; nutrition; cancer screening and early detection; and accessing information on cancer clinical trials. Baseline and follow-up surveys were sent 6-months apart to faculty, staff, and students at a school of public health to test the impact of a multifaceted health promotion campaign on perceived organizational change. Descriptive analyses were used to characterize percent improvement. Multivariate logistic regression analyses were used to control for participants’ university status.

Results

The current organizational culture highly supported tobacco cessation at both time points. Significant improvements (p < .05) from baseline to follow-up were observed for questions measuring organizational values for ‘prevention, screening, and early detection of cancer’ and ‘accessing cancer treatment and clinical trials’.

Conclusions

Health promotion and education efforts using multiple approaches were effective to improve perceived organizational values and support for cancer prevention and early detection, and increase access to information about cancer clinical trials. Future studies are needed to examine broader impacts of implementing worksite health promotion initiatives.

Impact of Age and Comorbidity on Cervical and Breast Cancer Literacy of African Americans, Latina, and Arab Women

This study examines the relationship between age, comorbidity, and breast and cervical cancer literacy in a sample of African American, Latina, and Arab women (N = 371) from Detroit, Michigan. The Age-adjusted Charlson Comorbidity Index (ACC) was used characterize the impact of age and comorbidity on breast and cervical cancer literacy. The relationship between ACC and breast and cervical cancer screening, and group differences, were assessed. There was a statistically significant difference between breast cancer literacy scores. ACC had a greater impact on breast cancer literacy for African Americans.

Differences in health beliefs across stage of adoption of mammography in Iranian women

BACKGROUND

Despite evidence that screening for breast cancer is effective, adherence with screening recommendations in Iranian women is low.

OBJECTIVES

The aims of this study were to (a) examine the relationships between related beliefs and (b) to determine to what extent women in stages of mammography adoption differ in their agreement of individual perceived health beliefs.

METHODS

A sample of 686 Iranian women completed a questionnaire including selected constructs of the Health Belief Model and stages of mammography adoption.

RESULTS

Proportions of participants who were in the preadoption and adoption stages were 75% and 17.8%, respectively. Precontemplators showed significantly lower positive attitude and greater agreement for most of the barrier items than did those in other adoption stages. In terms of specific items, women in the relapse and maintenance stages endorsed greatest agreement for the barrier items "not knowing how to get a mammogram" and "forget to schedule," respectively. Common barriers for women in preadoption stages were being painful, taking much time, and embarrassing.

CONCLUSION

Iranian women are less likely than other Asian women to be in the maintenance and action stages. Identifying the associations between perceived related beliefs items and stages of mammography adoption may provide detailed information to allow for future research and guide the development of interventions not only for Iranian women but also for similar cultural and immigrant groups that have been neglected to date in the breast cancer literature.

IMPLICATIONS FOR PRACTICE

Examining the interactions between perceived related beliefs items and other beliefs such as perceived control and self-efficacy to having a mammography is warranted.