Benefits and Costs of Interventions to Improve Breast Cancer Outcomes in African American Women

Contribution of smoking, disease history, and survival to lung cancer disparities in Black individuals

BACKGROUND

Lung cancer is the leading cause of cancer deaths and disproportionately affects self-identified Black or African American ("Black") people, especially considering their relatively low self-reported smoking intensity rates. This study aimed to determine the relative impact of smoking history and lung cancer incidence risk, histology, stage, and survival on these disparities.

METHODS

We used 2 lung cancer models (MichiganLung-All Races and MichiganLung-Black) to understand why Black people have higher rates of lung cancer deaths. We studied how different factors, such as smoking behaviors, cancer development, histology, stage at diagnosis, and lung cancer survival, contribute to these differences.

RESULTS

Adjusted for smoking history, approximately 90% of the difference in lung cancer deaths between the overall and Black populations (born in 1960) was the result of differences in the risk of getting lung cancer. Differences in the histology and stage of lung cancer and survival had a small impact (4% to 6% for each). Similar results were observed for the 1950 and 1970 birth cohorts, regardless of their differences in smoking patterns from the 1960 cohort.

CONCLUSIONS

After taking smoking into account, the higher rate of lung cancer deaths in Black people can mostly be explained by differences in the risk of developing lung cancer. As lung cancer treatments and detection improve, however, other factors may become more important in determining differences in lung cancer mortality between the Black and overall populations. To prevent current disparities from becoming worse, it is important to make sure that these improvements are available to everyone in an equitable way.

The natural history of ductal carcinoma in situ (DCIS) in simulation models: A systematic review

OBJECTIVE

Assumptions on the natural history of ductal carcinoma in situ (DCIS) are necessary to accurately model it and estimate overdiagnosis. To improve current estimates of overdiagnosis (0-91%), the purpose of this review was to identify and analyse assumptions made in modelling studies on the natural history of DCIS in women.

METHODS

A systematic review of English full-text articles using PubMed, Embase, and Web of Science was conducted up to February 6, 2023. Eligibility and all assessments were done independently by two reviewers. Risk of bias and quality assessments were performed. Discrepancies were resolved by consensus. Reader agreement was quantified with Cohen's kappa. Data extraction was performed with three forms on study characteristics, model assessment, and tumour progression.

RESULTS

Thirty models were distinguished. The most important assumptions regarding the natural history of DCIS were addition of non-progressive DCIS of 20-100%, classification of DCIS into three grades, where high grade DCIS had an increased chance of progression to invasive breast cancer (IBC), and regression possibilities of 1-4%, depending on age and grade. Other identified risk factors of progression of DCIS to IBC were younger age, birth cohort, larger tumour size, and individual risk.

CONCLUSION

To accurately model the natural history of DCIS, aspects to consider are DCIS grades, non-progressive DCIS (9-80%), regression from DCIS to no cancer (below 10%), and use of well-established risk factors for progression probabilities (age). Improved knowledge on key factors to consider when studying DCIS can improve estimates of overdiagnosis and optimization of screening.

Association of Population Screening for Breast Cancer Risk With Use of Mammography Among Women in Medically Underserved Racial and Ethnic Minority Groups

IMPORTANCE

Black women bear a disproportionate burden of breast cancer mortality in the US, in part due to inequities in the use of mammography. Population screening for breast cancer risk in primary care is a promising strategy for mitigating breast cancer disparities, but it is unknown whether this strategy would be associated with increased mammography rates in underserved women of racial and ethnic minority groups.

OBJECTIVE

To examine whether providing individualized breast cancer risk estimates is associated with an increase in the rate of screening mammography.

DESIGN, SETTING, AND PARTICIPANTS

A cohort study was conducted in women receiving individualized risk estimates as part of routine primary health care at federally qualified health centers in medically underserved communities in Chicago, Illinois. The study was conducted from November 5, 2013, to December 19, 2014, with data acquisition completed on March 5, 2017; data analysis was performed from December 30, 2020, to February 2, 2021. A total of 347 women aged 25 to 69 years without a personal history of breast cancer presenting for an annual visit with their primary care clinician were enrolled.

EXPOSURES

Breast cancer risk estimates were obtained with validated risk assessment tools as a standard component of the clinic check-in process. One of 4 women at average risk and all women at high risk were invited to participate in the study.

MAIN OUTCOMES AND MEASURES

The primary outcome was the mammography rate during 18 months of usual care compared with the rate during 18 months after implementation of risk assessment.

RESULTS

Of the 347 women enrolled, 188 were age-eligible for mammography and were included in the analysis (mean [SD] age, 50.8 [7.04] years); 70 women (37.2%) were Hispanic, 114 (60.6%) were non-Hispanic African American, and 4 (2.1%) were from other racial and ethnic groups (4 non-Hispanic White women). Ninety-eight women (52.1%) had an average risk of developing breast cancer and 90 (47.9%) were at high risk. Overall, there was a nonsignificant increase in the mammography rate, from 38.8% during usual care to 48.9% following implementation of risk assessment (odds ratio, 1.37; 95% CI, 0.92-2.03). In preplanned subgroup analysis, the mammography rate among women at high risk was significantly higher after vs before risk assessment (51.1% vs 36.6%; odds ratio, 1.88; 95% CI, 1.10-3.23).

CONCLUSIONS AND RELEVANCE

In this study, providing individualized breast cancer risk estimates as a component of primary health care in federally qualified health centers was associated with increased use of mammography among women of racial and ethnic minority groups who were at high risk. Implementation of this approach in underserved communities could promote equity in the use of mammography and reduce racial disparities in breast cancer mortality. This strategy warrants further investigation.

Engaging Community Health Workers to Increase Cancer Screening: A Community Guide Systematic Economic Review

CONTEXT

The Community Preventive Services Task Force recommends engaging community health workers to increase breast, cervical, and colorectal cancer screenings on the basis of strong evidence of effectiveness. This systematic review examines the economic evidence of these interventions.

EVIDENCE ACQUISITION

A systematic literature search was performed with a search period through April 2019 to identify relevant economic evaluation studies. All monetary values were adjusted to 2018 U.S. dollars, and the analysis was completed in 2019.

EVIDENCE SYNTHESIS

A total of 19 studies were included in the final analysis with 3 on breast cancer, 5 on cervical cancer, 9 on colorectal cancer, and 2 that combined costs for breast and cervical cancers and for breast, cervical, and colorectal cancers. For cervical cancer screening, 2 U.S. studies reported incremental cost per quality-adjusted life year saved of $762 and $34,405. For colorectal cancer screening, 2 U.S. studies reported both a negative incremental cost and an increase in quality-adjusted life years saved with colonoscopy screening.

CONCLUSIONS

Engaging community health workers to increase cervical and colorectal cancer screenings is cost effective on the basis of estimated incremental cost-effectiveness ratios that were less than the conservative $50,000 per quality-adjusted life year threshold. In addition, quality-adjusted life years saved from colorectal screening with colonoscopy were associated with net healthcare cost savings.

Leveraging system sciences methods in clinical trial evaluation: An example concerning African American women diagnosed with breast cancer via the Patient Navigation in Medically Underserved Areas study

BACKGROUND

Systems science methodologies offer a promising assessment approach for clinical trials by: 1) providing an in-silico laboratory to conduct investigations where purely empirical research may be infeasible or unethical; and, 2) offering a more precise measurement of intervention benefits across individual, network, and population levels. We propose to assess the potential of systems sciences methodologies by quantifying the spillover effects of randomized controlled trial via empirical social network analysis and agent-based models (ABM).

DESIGN/METHODS

We will evaluate the effects of the Patient Navigation in Medically Underserved Areas (PNMUA) study on adult African American participants diagnosed with breast cancer and their networks through social network analysis and agent-based modeling. First, we will survey 100 original trial participants (50 navigated, 50 non-navigated) and 150 of members of their social networks (75 from navigated, 75 non-navigated) to assess if navigation results in: 1) greater dissemination of breast health information and breast healthcare utilization throughout the trial participants' networks; and, 2) lower incremental costs, when incorporating navigation effects on trial participants and network members. Second, we will compare cost-effectiveness models, using a provider perspective, incorporating effects on trial participants versus trial participants and network members. Third, we will develop an ABM platform, parameterized using published data sources and PNMUA data, to examine if navigation increases the proportion of early stage breast cancer diagnoses.

DISCUSSION

Our study results will provide promising venues for leveraging systems science methodologies in clinical trial evaluation.

Valuing the health states associated with breast cancer screening programmes: A systematic review of economic measures

Policy decisions regarding breast cancer screening and treatment programmes may be misplaced unless the decision process includes the appropriate utilities and disutilities of mammography screening and its sequelae. The objectives of this study were to critically review how economic evaluations have valued the health states associated with breast cancer screening, and appraise the primary evidence informing health state utility values (cardinal measures of quality of life). A systematic review was conducted up to September 2018 of studies that elicited or used utilities relevant to mammography screening. The methods used to elicit utilities and the quality of the reported values were tabulated and analysed narratively. 40 economic evaluations of breast cancer screening programmes and 10 primary studies measuring utilities for health states associated with mammography were reviewed in full. The economic evaluations made different assumptions about the measures used, duration applied and the sequalae included in each health state. 22 evaluations referenced utilities based on assumptions or used measures that were not methodologically appropriate. There was significant heterogeneity in the utilities generated by the 10 primary studies, including the methods and population used to derive them. No study asked women to explicitly consider the risk of overdiagnosis when valuing the health states described. Utilities informing breast screening policy are restricted in their ability to reflect the full benefits and harms. Evaluating the true cost-effectiveness of breast cancer screening will remain problematic, unless the methodological challenges associated with valuing the disutilities of screening are adequately addressed.

Structure, Function, and Applications of the Georgetown-Einstein (GE) Breast Cancer Simulation Model

BACKGROUND

The Georgetown University-Albert Einstein College of Medicine breast cancer simulation model (Model GE) has evolved over time in structure and function to reflect advances in knowledge about breast cancer, improvements in early detection and treatment technology, and progress in computing resources. This article describes the model and provides examples of model applications.

METHODS

The model is a discrete events microsimulation of single-life histories of women from multiple birth cohorts. Events are simulated in the absence of screening and treatment, and interventions are then applied to assess their impact on population breast cancer trends. The model accommodates differences in natural history associated with estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) biomarkers, as well as conventional breast cancer risk factors. The approach for simulating breast cancer natural history is phenomenological, relying on dates, stage, and age of clinical and screen detection for a tumor molecular subtype without explicitly modeling tumor growth. The inputs to the model are regularly updated to reflect current practice. Numerous technical modifications, including the use of object-oriented programming (C++), and more efficient algorithms, along with hardware advances, have increased program efficiency permitting simulations of large samples.

RESULTS

The model results consistently match key temporal trends in US breast cancer incidence and mortality.

CONCLUSION

The model has been used in collaboration with other CISNET models to assess cancer control policies and will be applied to evaluate clinical trial design, recurrence risk, and polygenic risk-based screening.

Cost-Effectiveness Models in Breast Cancer Screening in the General Population: A Systematic Review

BACKGROUND

Many Western countries have long-established population-based mammography screening programs. Prior to implementing these programs, decision-analytic modeling was widely used to inform decisions.

OBJECTIVE

The aim of this study was to perform a systematic review of cost-effectiveness models in breast cancer screening in the general population to analyze their structural and methodological approaches.

METHODS

A systematic literature search for health economic models was performed in the electronic databases MEDLINE (Ovid), EMBASE, CRD Databases, Cochrane Library, and EconLit in August 2011 with updates in June 2013, April 2015, and November 2016. To assess studies systematically, a standardized form was applied to extract relevant information that was then summarized in evidence tables.

RESULTS

Thirty-five studies were included; 27 state-transition models were analyzed using cohort (n = 12) and individual-level simulation (n = 15). Twenty-one studies modeled the natural history of breast cancer and predicted mortality as a function of the early detection modality. The models employed different assumptions regarding ductal carcinoma in situ. Thirteen studies performed cost-utility analyses with different sources for utility values, but assumptions were often made about utility weights. Twenty-two models did not report any validation.

CONCLUSION

State-transition modeling was the most frequently applied analytic approach. Different methods in modeling the progression of ductal carcinoma in situ to invasive cancer were identified because there is currently no agreement on the biological behavior of noninvasive breast cancer. Main weaknesses were the lack of precise utility estimates and insufficient reporting of validation. Sensitivity analyses of assumptions regarding ductal carcinoma in situ and in particular adequate validation are critical to minimize the risk of biased model outcomes.

Nationwide cross-sectional adherence to mammography screening guidelines: national behavioral risk factor surveillance system survey results

PURPOSE

Varying recommendations about breast cancer screening have generated much confusion about when and how often to undergo mammography screening, yet there is limited population-based data about the extent to which patients adhere to various mammographic screening guidelines in practice. Our purpose was to evaluate population-based adherence to mammographic screening using criteria from major guideline-producing organizations.

METHODS

Women aged 40-74 in the 2014 Behavioral Risk Factor Surveillance System survey were included. Self-reported mammographic screening within 1 or 2 years, according to major guideline-producing organizations (American Cancer Society [ACS], US Preventative Services Task Force [USPSTF], American College of Radiology [ACR], American College of Obstetricians and Gynecologists [ACOG]) was calculated with logistic regression, adjusting for demographics and indices of access to health care.

RESULTS

159,123 women were included. By age category, cross-sectional adherence to USPSTF guidelines ranged from 76 to 81%, ACS (55-81%) and ACR/ACOG (45-64%) with increasing age being associated improved adherence. The highest proportions of women undergoing mammographic screening were seen in women ages 65-69 (66% within last year, 81% within last 2 years). Statistically significant predictors of adherence to mammography screening included increased income category (OR 1.08, 1.07-1.09), higher education category (OR 1.13, 1.11-1.16), and increased access to health care (OR 2.25, 1.94-2.60), adjusted for age categories.

CONCLUSIONS

Adherence to mammography screening was closest to USPSTF guidelines with 76-81% cross-sectional adherence. Frequency of screening increases with age with highest screening proportions in women ages 65-69 (66% within last year, 81% within last 2 years). For all screening guidelines, adherence to mammography screening remains poor in women with limited access to health insurance with less than half of women obtaining recommended screening.

Breast Cancer Risk Assessment Among Low-Income Women of Color in Primary Care: A Pilot Study

PURPOSE

The US Preventive Services Task Force recommends identifying candidates for breast cancer (BC) chemoprevention and referring them for genetic counseling as part of routine care. Little is known about the feasibility of implementing these recommendations or how low-income women of color might respond to individualized risk assessment (IRA) performed by primary care providers (PCPs).

METHODS

Women recruited from a federally qualified health center were given the option to discuss BC risk status with their PCP. Comprehensive IRA was performed using a software tool designed for the primary care environment combining three assessment instruments and providing risk-adapted recommendations for screening, prevention, and genetic referral. Logistic regression models assessed factors associated with wanting to learn and discuss BC risk with PCP.

RESULTS

Of 237 participants, only 12.7% (n = 30) did not want to discuss IRA results with their PCP. Factors associated with lower odds of wanting to learn results included having private insurance and reporting ever having had a mammogram. Factors associated with higher odds of wanting to learn results included older age (50 to 69 years) and increased BC worry. For all women wishing to learn results, IRA was successfully completed and delivered to the PCP immediately before the encounter for incorporation into the well-visit evaluation.

CONCLUSION

Incorporation of US Preventive Services Task Force recommendations as part of routine primary care is feasible. Interest in IRA seems high among underserved women. This approach warrants further investigation as a strategy for addressing disparities in BC mortality.

Factors influencing breast cancer screening in low-income African Americans in Tennessee

This study examined demographic and lifestyle factors that influenced decisions and obstacles to being screened for breast cancer in low-income African Americans in three urban Tennessee cities. As part of the Meharry Community Networks Program (CNP) needs assessment, a 123-item community survey was administered to assess demographic characteristics, health care access and utilization, and screening practices for various cancers in low-income African Americans. For this study, only African American women 40 years and older (n = 334) were selected from the Meharry CNP community survey database. There were several predictors of breast cancer screening such as marital status and having health insurance (P < .05). Additionally, there were associations between obstacles to screening and geographic region such as transportation and not having enough information about screenings (P < .05). Educational interventions aimed at improving breast cancer knowledge and screening rates should incorporate information about obstacles and predictors to screening.

Benefits and harms of mammography screening after age 74 years: model estimates of overdiagnosis

BACKGROUND

The aim of this study was to quantify the benefits and harms of mammography screening after age 74 years, focusing on the amount of overdiagnosis of invasive breast cancer and ductal carcinoma in situ (DCIS).

METHODS

Three well-established microsimulation models were used to simulate a cohort of American women born in 1960. All women received biennial screening starting at age 50 years with cessation ages varying from 74 up to 96 years. We estimated the number of life-years gained (LYG), quality-adjusted life-years, breast cancer deaths averted, false-positives, and overdiagnosed women per 1000 screens.

RESULTS

The models predicted that there were 7.8 to 11.4 LYG per 1000 screens at age 74 years (range across models), decreasing to 4.8 to 7.8 LYG per 1000 screens at age 80 years, and 1.4 to 2.4 LYG per 1000 screens at age 90 years. When adjusted for quality-of-life decrements, the LYG decreased by 5% to 13% at age 74 years and 11% to 22% at age 80 years. At age 90 to 92 years, all LYG were counterbalanced by a loss in quality-of-life, mainly because of the increasing number of overdiagnosed breast cancers per 1000 screens: 1.2 to 5.0 at age 74 years, 1.8 to 6.0 at age 80 years, and 3.7 to 7.5 at age 90 years. The age at which harms began to outweigh benefits shifted to a younger age when larger or longer utility losses because of a breast cancer diagnosis were assumed.

CONCLUSION

The balance between screening benefits and harms becomes less favorable after age 74 years. At age 90 years, harms outweigh benefits, largely as a consequence of overdiagnosis. This age was the same across the three models, despite important model differences in assumptions on DCIS.

Simulation models in population breast cancer screening: A systematic review

The aim of this review was to critically evaluate published simulation models for breast cancer screening of the general population and provide a direction for future modeling. A systematic literature search was performed to identify simulation models with more than one application. A framework for qualitative assessment which incorporated model type; input parameters; modeling approach, transparency of input data sources/assumptions, sensitivity analyses and risk of bias; validation, and outcomes was developed. Predicted mortality reduction (MR) and cost-effectiveness (CE) were compared to estimates from meta-analyses of randomized control trials (RCTs) and acceptability thresholds. Seven original simulation models were distinguished, all sharing common input parameters. The modeling approach was based on tumor progression (except one model) with internal and cross validation of the resulting models, but without any external validation. Differences in lead times for invasive or non-invasive tumors, and the option for cancers not to progress were not explicitly modeled. The models tended to overestimate the MR (11-24%) due to screening as compared to optimal RCTs 10% (95% CI - 2-21%) MR. Only recently, potential harms due to regular breast cancer screening were reported. Most scenarios resulted in acceptable cost-effectiveness estimates given current thresholds. The selected models have been repeatedly applied in various settings to inform decision making and the critical analysis revealed high risk of bias in their outcomes. Given the importance of the models, there is a need for externally validated models which use systematical evidence for input data to allow for more critical evaluation of breast cancer screening.

Individual breast cancer risk assessment in underserved populations: integrating empirical bioethics and health disparities research

Research suggests that individual breast cancer risk assessment may improve adherence to recommended screening and prevention guidelines, thereby decreasing morbidity and mortality. Further research on the use of risk assessment models in underserved minority populations is critical to informing national public health efforts to eliminate breast cancer disparities. However, implementing individual breast cancer risk assessment in underserved patient populations raises particular ethical issues that require further examination. After reviewing these issues, we will discuss how empirical bioethics research can be integrated with health disparities research to inform the translation of research findings. Our in-progress National Cancer Institute (NCI) funded study, How Do Underserved Minority Women Think About Breast Cancer?, conducted in the context of a larger study on individual breast cancer risk assessment, is presented as a model.

Using the interactive systems framework to support a quality improvement approach to dissemination of evidence-based strategies to promote early detection of breast cancer: planning a comprehensive dynamic trial

Dissemination efforts must optimize interventions for new settings and populations. As such, dissemination research should incorporate principles of quality improvement. Comprehensive Dynamic Trial (CDT) designs examine how information gained during dissemination may be used to modify interventions and improve performance. Although CDT may offer distinct advantages over static designs, organizing the many necessary roles and activities is a significant challenge. In this article, we discuss use of the Interactive Systems Framework for Dissemination and Implementation to systematically implement a CDT. Specifically, we describe "Bronx ACCESS", a program designed to disseminate evidence-based strategies to promote adherence to mammography guidelines. In Bronx ACCESS, the Intervention Delivery System will elicit information needed to adapt strategies to specific settings and circumstances. The Intervention Synthesis and Translation System will use this information to test changes to strategies through "embedded experiments". The Intervention Support System will build local capacities found to be necessary for intervention institutionalization. Simulation modeling will be used to integrate findings across systems. Results will inform on-going policy debate about interventions needed to promote population-level screening. More generally, this project is intended to advance understanding of research paradigms necessary to study dissemination.

Computational modeling and multilevel cancer control interventions

This chapter presents an overview of computational modeling as a tool for multilevel cancer care and intervention research. Model-based analyses have been conducted at various "beneath the skin" or biological scales as well as at various "above the skin" or socioecological levels of cancer care delivery. We review the basic elements of computational modeling and illustrate its applications in four cancer control intervention areas: tobacco use, colorectal cancer screening, cervical cancer screening, and racial disparities in access to breast cancer care. Most of these models have examined cancer processes and outcomes at only one or two levels. We suggest ways these models can be expanded to consider interactions involving three or more levels. Looking forward, a number of methodological, structural, and communication barriers must be overcome to create useful computational models of multilevel cancer interventions and population health.

The Italian health surveillance (SiVeAS) prioritization approach to reduce chronic disease risk factors

OBJECTIVE

Because public health funds are limited, programs need to be prioritized.

METHODS

We used data on 15 risk factors from Italy's public health surveillance to inform prioritization of programs. We ranked risk factors using a score based on the product of six criteria: deaths attributable to risk factors; prevalence of risk factors; risk factor prevalence trend; disparity based on the ratio of risk factor prevalence between low and high education attainment; level of intervention effectiveness; and cost of the intervention.

RESULTS

We identified seven priorities: physical inactivity; cigarette smoking (current smoking); ever told had hypertension; not having blood pressure screening; ever told had high cholesterol; alcohol (heavy drinking); not eating five fruits and vegetables a day; and not having a fecal occult blood test.

CONCLUSIONS

This prioritization method should be used as a tool for planning and decision making.

A simulation model approach to analysis of the business case for eliminating health care disparities

BACKGROUND

Purchasers can play an important role in eliminating racial and ethnic disparities in health care. A need exists to develop a compelling "business case" from the employer perspective to put, and keep, the issue of racial/ethnic disparities in health care on the quality improvement agenda for health plans and providers.

METHODS

To illustrate a method for calculating an employer business case for disparity reduction and to compare the business case in two clinical areas, we conducted analyses of the direct (medical care costs paid by employers) and indirect (absenteeism, productivity) effects of eliminating known racial/ethnic disparities in mammography screening and appropriate medication use for patients with asthma. We used Markov simulation models to estimate the consequences, for defined populations of African-American employees or health plan members, of a 10% increase in HEDIS mammography rates or a 10% increase in appropriate medication use among either adults or children/adolescents with asthma.

RESULTS

The savings per employed African-American woman aged 50-65 associated with a 10% increase in HEDIS mammography rate, from direct medical expenses and indirect costs (absenteeism, productivity) combined, was $50. The findings for asthma were more favorable from an employer point of view at approximately $1,660 per person if raising medication adherence rates in African-American employees or dependents by 10%.

CONCLUSIONS

For the employer business case, both clinical scenarios modeled showed positive results. There is a greater potential financial gain related to eliminating a disparity in asthma medications than there is for eliminating a disparity in mammography rates.

Do recently diagnosed black breast cancer patients find questions about cancer fatalism acceptable? A preliminary report

Socio-cultural factors such as cancer fatalism have been understudied in cancer patients. Women from two cancer centers completed a structured phone survey and an open-ended cognitive interview. Socio-cultural variables of fatalism, hope, and spiritual coping were measured using standardized scales. Older women had significantly higher fatalism scores compared to younger women (p < 0.01). Fatalism rates were low. Ratings of hope and collaborative religious coping were high (m = 20, m = 35, respectively). Qualitative comments confirmed the overall low acceptability of the fatalism measures. Further research is needed to identify measures that are acceptable to newly diagnosed patients.

Does racism affect health? Evidence from the United States and the United Kingdom

Blacks have worse overall health than whites in both the United States and the United Kingdom. However, the relative difference in health between the two groups within each cultural context differs between each context. In this article, we attempt to glean insights into these health disparities. We do so by first examining what is currently known about differences in morbidity and mortality for blacks and whites in the United States and the United Kingdom. We then turn to medical examination data by race and country of birth in an attempt to further untangle the complex interplay of socioeconomic status (SES), race, and racism as determinants of health in the United States and the United Kingdom. We find that (1) longer exposure of blacks to the recipient country is a risk for mortality in the United States but not in the United Kingdom; (2) adjustment for SES matters a good deal for mortality in the United States, but less so in the United Kingdom; (3) morbidity indicators do not paint a clear picture of black disadvantage relative to whites in either context; and (4) were one to consider medical examination data alone, differences between the two groups exist only in the United States. Taken together, we conclude that it is possible that the "less racist" United Kingdom provides a healthier environment for blacks than the United States. However, there remain many mysteries that escape simple explanation. Our findings raise more questions than they answer, and the health risks and health status of blacks in the United States are much more complex than previously thought.

Risk-specific optimal cancer screening schedules: an application to breast cancer early detection

The optimal schedules for breast cancer screening in terms of examination frequency and ages at examination are of practical interest. A decision-theoretic approach is explored to search for optimal cancer screening programs which should achieve maximum survival benefit while balancing the associated cost to the health care system. We propose a class of utility functions that account for costs associated with screening examinations and value of survival benefit under a non-stable disease model. We consider two different optimization criteria: optimize the number of screening examinations with equal screening intervals between exams but without a pre-fixed total cost; and optimize the ages at which screening should be given for a fixed total cost. We show that an optimal solution exists under each of the two frameworks. The proposed methods may consider women at different levels of risk for breast cancer so that the optimal screening strategies will be tailored according to a woman's risk of developing the disease. Results of a numerical study are presented and the proposed models are illustrated with various data inputs. We also use the data inputs from the Health Insurance Plan of New York (HIP) and Canadian National Breast Screening Study (CNBSS) to illustrate the proposed models and to compare the utility values between the optimal schedules and the actual schedules in the HIP and CNBSS trials. Here, the utility is defined as the difference in cure rates between cases found at screening examinations and cases found between screening examinations while accounting for the cost of examinations, under a given screening schedule.

Race-specific impact of natural history, mammography screening, and adjuvant treatment on breast cancer mortality rates in the United States

BACKGROUND

U.S. Black women have higher breast cancer mortality rates than White women despite lower incidence. The aim of this study is to investigate how much of the mortality disparity can be attributed to racial differences in natural history, uptake of mammography screening, and use of adjuvant therapy.

METHODS

Two simulation models use common national race, and age-specific data for incidence, screening and treatment dissemination, stage distributions, survival, and competing mortality from 1975 to 2010. Treatment effectiveness and mammography sensitivity are assumed to be the same for both races. We sequentially substituted Black parameters into the White model to identify parameters that drive the higher mortality for Black women in the current time period.

RESULTS

Both models accurately reproduced observed breast cancer incidence, stage and tumor size distributions, and breast cancer mortality for White women. The higher mortality for Black women could be attributed to differences in natural history parameters (26-44%), use of adjuvant therapy (11-19%), and uptake of mammography screening (7-8%), leaving 38% to 46% unexplained.

CONCLUSION

Black women appear to have benefited less from cancer control advances than White women, with a greater race-related gap in the use of adjuvant therapy than screening. However, a greater portion of the disparity in mortality appears to be due to differences in natural history and undetermined factors.

IMPACT

Breast cancer mortality may be reduced substantially by ensuring that Black women receive equal adjuvant treatment and screening as White women. More research on racial variation in breast cancer biology and treatment utilization is needed.

Are breast cancer navigation programs cost-effective? Evidence from the Chicago Cancer Navigation Project

OBJECTIVES

One of the aims of the Chicago Cancer Navigation Project (CCNP) is to reduce the interval of time between abnormal breast cancer screening and definitive diagnosis in patients who are navigated as compared to usual care. In this article, we investigate the extent to which total costs of breast cancer navigation can be offset by survival benefits and savings in lifetime breast cancer-attributable costs.

METHODS

Data sources for the cost-effectiveness analysis include data from published literature, secondary data from the NCI's Surveillance Epidemiology and End Results (SEER) program, and primary data from the CCNP.

RESULTS

If women enrolled in CCNP receive breast cancer diagnosis earlier by 6 months as compared to usual care, then navigation is borderline cost-effective for $95,625 per life-year saved. Results from sensitivity analyses suggest that the cost-effectiveness of navigation is sensitive to: the interval of time between screening and diagnosis, percent increase in number of women who receive cancer diagnosis and treatment, women's age, and the positive predictive value of a mammogram.

CONCLUSIONS

In planning cost-effective navigation programs, special considerations should be made regarding the characteristics of the disease, program participants, and the initial screening test that determines program eligibility.

Development of decision-support intervention for Black women with breast cancer

BACKGROUND

Adjuvant therapy improves breast cancer survival but is underutilized by Black women. Few interventions have addressed this problem. This preliminary report describes the process we used to develop a decision-support intervention for Black women eligible for adjuvant therapy. Aims were to use qualitative methods to describe factors that influence Black women's adjuvant therapy decisions, use these formative data to develop messages for a treatment decision-support intervention, and pilot test the acceptability and utility of the intervention with community members and newly diagnosed women.

METHODS

Thirty-four in-depth interviews were conducted with breast cancer patients in active treatment, survivors and cancer providers to gather qualitative data. Participant ages ranged from 38 to 69 years. A cultural framework was used to analyze the data and to inform intervention messages. Most women relied on their providers for treatment recommendations. Several women reported problems communicating with providers and felt unprepared to ask questions and discuss adjuvant treatment options. Other factors related to treatment experiences were: spiritual coping, collectivism and sharing breast cancer experiences with other Black survivors.

RESULTS

Using these formative data, we developed an intervention that is survivor-based and includes an in-person session which incorporates sharing personal stories, communication skills training and decision support. Intervention materials were reviewed by community members, researchers/clinicians and patients newly diagnosed with breast cancer.

CONCLUSION

Patients reported satisfaction with the intervention and felt better prepared to talk with providers. The intervention will be tested in a randomized trial to enhance decision support and increase use of indicated adjuvant treatment.

Challenges of illness in metastatic breast cancer: A low-income African American perspective

Objective:

Disparities in breast cancer survival and treatment for African American and low income women are well documented, yet poorly understood. As care for women with metastatic breast cancer (MBC) evolves to a chronic care model, any inequities in optimal treatment and management of symptoms must also be identified and eliminated. The purpose of this study was to explore how race and income status influence women's experiences with MBC, particularly the management of symptoms, by describing the perceived challenges and barriers to achieving optimal symptom management among women with MBC and exploring whether the perceived challenges and barriers differed according to race or income.

Method:

Quantitative techniques were used to assess demographics, clinical characteristics, symptom distress, and quality of life and to classify women into groups according to race and income. Qualitative techniques were used to explore the perceived challenges, barriers, and potential influences of race and income on management of symptoms in a prospective sample of 48 women with MBC.

Results:

Commonalities of themes across all groups were faith, hope, and progressive loss. Low-income African American women uniquely experienced greater physical and social distress and more uncertainty about treatment and treatment goals than the other delineated racial and economic groups.

Significance of results:

There are many commonalities to the challenges of illness presented to women with MBC. There are also interesting, emerging thematic racial and economic differences, most compelling among the low income African American women with resultant practice and research implications.

Cost-effectiveness analysis of mammography and clinical breast examination strategies: a comparison with current guidelines

PURPOSE

Breast cancer screening by mammography and clinical breast exam are commonly used for early tumor detection. Previous cost-effectiveness studies considered mammography alone or did not account for all relevant costs. In this study, we assessed the cost-effectiveness of screening schedules recommended by three major cancer organizations and compared them with alternative strategies. We considered costs of screening examinations, subsequent work-up, biopsy, and treatment interventions after diagnosis.

METHODS

We used a microsimulation model to generate women's life histories, and assessed screening and treatment effects on survival. Using statistical models, we accounted for age-specific incidence, preclinical disease duration, and age-specific sensitivity and specificity for each screening modality. The outcomes of interest were quality-adjusted life years (QALY) saved and total costs with a 3% annual discount rate. Incremental cost-effectiveness ratios were used to compare strategies. Sensitivity analyses were done by varying some of the assumptions.

RESULTS

Compared with guidelines from the National Cancer Institute and the U.S. Preventive Services Task Force, alternative strategies were more efficient. Mammography and clinical breast exam in alternating years from ages 40 to 79 years was a cost-effective alternative compared with the guidelines, costing $35,500 per QALY saved compared with no screening. The American Cancer Society guideline was the most effective and the most expensive, costing over $680,000 for an added QALY compared with the above alternative.

CONCLUSION

Screening strategies with lower costs and benefits comparable with those currently recommended should be considered for implementation in practice and for future guidelines.

Calibration methods used in cancer simulation models and suggested reporting guidelines

Increasingly, computer simulation models are used for economic and policy evaluation in cancer prevention and control. A model's predictions of key outcomes, such as screening effectiveness, depend on the values of unobservable natural history parameters. Calibration is the process of determining the values of unobservable parameters by constraining model output to replicate observed data. Because there are many approaches for model calibration and little consensus on best practices, we surveyed the literature to catalogue the use and reporting of these methods in cancer simulation models. We conducted a MEDLINE search (1980 through 2006) for articles on cancer-screening models and supplemented search results with articles from our personal reference databases. For each article, two authors independently abstracted pre-determined items using a standard form. Data items included cancer site, model type, methods used for determination of unobservable parameter values and description of any calibration protocol. All authors reached consensus on items of disagreement. Reviews and non-cancer models were excluded. Articles describing analytical models, which estimate parameters with statistical approaches (e.g. maximum likelihood) were catalogued separately. Models that included unobservable parameters were analysed and classified by whether calibration methods were reported and if so, the methods used. The review process yielded 154 articles that met our inclusion criteria and, of these, we concluded that 131 may have used calibration methods to determine model parameters. Although the term 'calibration' was not always used, descriptions of calibration or 'model fitting' were found in 50% (n = 66) of the articles, with an additional 16% (n = 21) providing a reference to methods. Calibration target data were identified in nearly all of these articles. Other methodological details, such as the goodness-of-fit metric, were discussed in 54% (n = 47 of 87) of the articles reporting calibration methods, while few details were provided on the algorithms used to search the parameter space. Our review shows that the use of cancer simulation modelling is increasing, although thorough descriptions of calibration procedures are rare in the published literature for these models. Calibration is a key component of model development and is central to the validity and credibility of subsequent analyses and inferences drawn from model predictions. To aid peer-review and facilitate discussion of modelling methods, we propose a standardized Calibration Reporting Checklist for model documentation.

Understanding the role of reactions to race-based treatment in breast and cervical cancer screening

Racial and ethnic disparities in breast and cervical cancer mortality persist despite effective screening methods. We examined associations between race/ethnicity and Pap testing within three years or mammography within two years, controlling for a composite reactions-to-race-based-treatment variable created using data from the 2002 and 2004 Behavioral Risk Factor Surveillance System Reactions to Race module, which assessed respondents experiences based on one's race. We calculated prevalence of Pap testing (for women aged > or = 18) and mammography (for women aged > or = 40) by race, and fit logistic regression models to estimate the strength of association of reactions to race-based treatment with screening and race--before and after controlling for demographics, socioeconomic status, health status, smoking and healthcare access. In the reduced model, black women were more likely (2.03: 95% CI: 1.55-2.65) to be screened for cervical cancer than whites. Reactions to race-based treatment did not impact the odds of black women receiving Pap tests or mammograms. Given current racial and ethnic disparities in breast and cervical cancer mortality, we suggest that more attention needs to be focused on follow-up of abnormal results and state-of-the art treatment for black and Hispanic women.

Cultural Values and Secondary Prevention of Breast Cancer in African American Women

Background

Improving mammography initiation and maintenance among African American women has been suggested as a strategy for reducing breast cancer mortality in this population.

Methods

We examined cultural values in relation to self-reported breast cancer screening among 572 low-income, urban, African American women. Cultural values examined included time orientation, family authority, employment aspirations, value of past vs modern life, and reliance on medical professionals. Also, implications for continued development of culturally tailored health interventions and opportunities for the consideration of cultural values in health communication are discussed.

Results

Bivariate analyses showed that more traditional values were associated with worse screening histories and lower intentions for future screening. In multivariate analyses, two interactions were observed between cultural values and age: for younger women, more traditional values were associated with lower odds of having ever received a mammogram, and for older women, more traditional values were associated with lower odds of intentions to receive a mammogram in the next 2 years.

Conclusions

This study adds to the evidence that cultural constructs, such as values, are associated with secondary prevention of breast cancer and supports the consideration of cultural constructs as important in increasing mammography and reducing breast cancer disparities for African American women.

P.O.W. (protect our women): results of a breast cancer prevention project targeted to older African-American women

OBJECTIVE

Encourage older African-American women to participate in breast cancer detection. Breast cancer deaths for older African-American women are higher than for Caucasian counterparts. Effective outreach education about mammography and breast exam is one method to reduce the disparity by encouraging women to enter treatment earlier through earlier diagnosis. Traditional outreach strategies have proven ineffective with this cohort.

METHOD

In this study we utilized the trust placed in known community leaders to recruit older African-American women to participate in breast health education leading to completion of a mammogram. One hundred sixty-two women were identified as participants.

RESULTS

Seventy-nine percent of the women who completed the project obtained mammograms and 9% had mammograms scheduled at 1-month follow-up, whereas 22% of the individuals who received only mailed educational materials completed mammograms and none had scheduled mammograms pending.

DISCUSSION

Health education for difficult-to-reach populations can be effective but requires greater inclusion of community partners to offset issues related to trust, health beliefs, and access.

Psychosocial influences on suboptimal adjuvant breast cancer treatment adherence among African American women: implications for education and intervention

Despite lower incidence, African American women are at increased risk of dying from breast cancer relative to their European American counterparts. Although there are key differences in both screening behavior and tumor characteristics, an additional part of this mortality difference may lie in the fact that African American women receive suboptimal adjuvant chemotherapy and may receive suboptimal hormonal therapy, therapies that are known to increase survival. The authors consider ethnic differences in the psychosocial factors that have been shown to relate to poor screening adherence and consider how they may influence adherence to breast cancer adjuvant treatment, thus the receipt of suboptimal adjuvant chemo or hormonal therapy. To this end, they review ethnic differences in cognitive, emotional, and social network variables. Psychosocial variables should be included in research designed to understand cancer disparities as well interventions that can be tailored to culturally diverse populations to improve treatment adherence.

Cost effectiveness of mammography screening for Chinese women

BACKGROUND

Although the cost effectiveness of screening mammography in most western developed populations has been accepted, it may not apply to Chinese women, who have a much lower breast cancer incidence. The authors estimated the cost effectiveness of biennial mammography in Hong Kong Chinese women to inform evidence-based screening policies.

METHODS

For the current study, a state-transition Markov model was developed to simulate mammography screening, breast cancer diagnosis, and treatment in a hypothetical cohort of Chinese women. The benefit of mammography was modeled by assuming a stage shift, in which cancers in screened women were more likely to be diagnosed at an earlier disease stage. The authors compared costs, quality-adjusted life years (QALYs) saved, and life years saved (LYS) for 5 screening strategies.

RESULTS

Biennial screening resulted in a gain in life expectancy ranging from 4.3 days to 9.4 days compared with no screening at an incremental cost of from US $1,166 to US $2,425 per woman. The least costly, nondominated screening option was screening from ages 40 years to 69 years, with an incremental cost-effectiveness ratio (ICER) of US $61,600 per QALY saved or US $64,400 per LYS compared with no screening. In probabilistic sensitivity analyses, the probability of the ICER being below a threshold of US $50,000 per QALY (LYS) was 15.3% (14.6%).

CONCLUSIONS

The current results suggested that mammography for Hong Kong Chinese women currently may not be cost effective based on the arbitrary threshold of US $50,000 per QALY. However, clinicians must remain vigilant and periodically should revisit the question of population screening: Disease rates in China have been increasing because of westernization and socioeconomic development.

Health limitations and quality of life associated with cancer and other chronic diseases by phase of care

OBJECTIVE

To estimate health limitations and health-related quality of life (HRQL) associated with cancer and other chronic conditions in a nationally representative sample within a phase-of-care framework.

STUDY DESIGN AND SETTING

We used a nested case-control design to assess health limitations and HRQL in individuals reporting a breast, colorectal, prostate, or lung cancer diagnosis, or a diagnosis of arthritis, diabetes, heart disease, or hypertension compared with similar controls without these conditions. All subjects were selected from the 1986-1994 National Health Interview Surveys linked to mortality files in 1995, and classified into the initial, continuing, or last year of life phase of care. Health limitations and HRQL were compared for cases and controls for each condition with 2-sided statistical tests.

RESULTS

Across all conditions, individuals in the last year of life phase of care reported greater health limitations and lower HRQL, as measured by the Health Activities and Limitations Index (HALex), than did individuals in the initial and continuing phases of care. Compared with their matched controls, individuals with cancer or other chronic conditions were more likely to report health limitations and lower mean HALex values in the initial, continuing, and last year of life phases of care (P < 0.05).

CONCLUSIONS

We observed greater health limitations and lower HRQL associated with cancer and other chronic diseases compared with similar individuals without these conditions. The phase-of-care framework used in this study seems to be applicable to the assessment of HRQL for cancer and other chronic diseases.

Supportive-expressive group therapy for women with metastatic breast cancer: survival and psychosocial outcome from a randomized controlled trial

BACKGROUND

Mixed reports exist about the impact of supportive-expressive group therapy (SEGT) on survival.

METHODS

From 485 women with advanced breast cancer recruited between 1996-2002, 227 (47%) consented and were randomized within an average 10 months of cancer recurrence in a 2:1 ratio to intervention with 1 year or more of weekly SEGT plus three classes of relaxation therapy (147 women) or to control receiving three classes of relaxation therapy (80 women). The primary outcome was survival; psychosocial well-being was appraised secondarily. Analysis was by intention-to-treat.

RESULTS

SEGT did not prolong survival (median survival 24.0 months in SEGT and 18.3 in controls; univariate hazard ratio for death 0.92 [95% CI, 0.69-1.26]; multivariate hazard ratio, 1.06 [95% CI, 0.74-1.51]). Significant predictors of survival were treatment with chemotherapy and hormone therapy (p<0.001), visceral metastases (p<0.001) and advanced disease at first diagnosis (p<0.05). SEGT ameliorated and prevented new DSM-IV depressive disorders (p = 0.002), reduced hopeless-helplessness (p = 0.004), trauma symptoms (p = 0.04) and improved social functioning (p = 0.03).

CONCLUSIONS

SEGT did not prolong survival. It improved quality of life, including treatment of and protection against depression.

Common psychosocial factors underlying breast cancer screening and breast cancer treatment adherence: a conceptual review and synthesis

In this paper, we review the literature on psychosocial influences on breast cancer screening and treatment adherence with an eye to identifying common cognitive, emotional, and social network factors that may lead to poor screening adherence and suboptimal treatment in the case of diagnosed breast cancer. Nonadherence to breast cancer screening and treatment guidelines can significantly and negatively impact the prospects for prevention and control of breast cancer. Psychosocial factors are an especially important focus for research, inasmuch as belief structures and psychosocial characteristics (such as patterns of emotion regulation and the quality of social relations) are modifiable and are, thus, eminently suitable to intervention.

Differences in breast carcinoma characteristics in newly diagnosed African–American and Caucasian patients

BACKGROUND

Breast carcinomas in African-American patients appear to be more aggressive than in Caucasian patients due to multifactorial differences.

METHODS

The authors compiled pathology data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database regarding stage, histologic grade, and estrogen receptor (ER) expression in breast carcinomas diagnosed in 197,274 African-American and Caucasian patients between 1990 and 2000, and the same information, along with nuclear grade, Ki-67, c-erb-B2, and p53 expression, in 2230 African-American and Caucasian patients diagnosed at Thomas Jefferson University Hospital between 1995 and 2002. Immunohistochemical markers were assayed in paraffin-embedded, formalin-fixed tissue stained with hematoxylin and eosin using antibodies to these proteins, with differences in expression analyzed by the chisquare test.

RESULTS

In both databases, more African-American patients presented with advanced stage tumors and higher histologic (P < .001) and nuclear grade (P < .001) than Caucasian patients. African-American patients had less ER positivity (51.9% vs 63.1%; P < .001) but significantly higher Ki-67 (42.4% vs 28.7%; P < .001) and p53 expression (19.4% vs 13.1%; P < .05) than Caucasian patients with all stages of disease. In addition, the basal or "triple-negative" breast cancer phenotype was more common in African-American patients than in Caucasian patients (20.8% vs 10.4%; P < .0001), and was associated with higher histologic and nuclear grade (P < .0001).

CONCLUSIONS

African-American patients with breast carcinomas are more likely than Caucasian patients to present with tumors that are of a later stage and higher grade, with higher Ki-67 expression and more ER negativity, thereby highlighting a greater need for early screening among African-American women. Molecular studies that may explain these differences, and correlations with survival, have been proposed to identify therapeutic targets.

New drugs in prostate cancer

PURPOSE OF REVIEW

The survival of hormone-refractory metastatic prostate cancer patients has improved with the use of docetaxel-based chemotherapy. The survival benefits, however, are modest suggesting that rationally designed therapeutic approaches are needed. We discuss recent developments in the therapeutic approach to advanced metastatic hormone-refractory prostate cancer, including molecularly targeted therapy, signal transduction inhibitors, stem-cell targeted therapy, anti-angiogenic compounds, vaccines and immunomodulating agents, differentiation agents, cytotoxics, and pro-apoptotic agents.

RECENT FINDINGS

Over 200 compounds have entered clinical development for use in advanced prostate cancer, alone or in combination with cytotoxic agents such as docetaxel, or in other combinations. This article will review the results of emerging targets since the approval of docetaxel in 2004, concentrating on some of those compounds that, in our opinion, have the greatest potential and rationale for use.

SUMMARY

The growing field of targeted molecular therapy of prostate cancer has opened up numerous opportunities for therapeutic impact. Knowledge of the molecular determinants of progression, relapse after local therapy, chemotherapeutic resistance, and hormone refractoriness remains essential in the rational design of clinical trials of these agents. Given the complexity, heterogeneity, and crosstalk of molecular pathways and the molecular lesions in prostate cancer, combination or sequential therapy may be a necessary step towards significant therapeutic progress. Novel translational clinical trial methodologies may assist in a more rapid identification of active compounds at biologically active doses for phase-III testing.

Retrospective cost-effectiveness analysis of screening mammography

BACKGROUND

Many guidelines recommend screening mammography every 1-2 years for women older than 40 years; more than 70% of women now participate in routine screening. No studies have examined the societal impact of screening practices over the past decade in the United States on costs and quality-adjusted life-years (QALYs). We performed a retrospective cost-effectiveness analysis comparing actual and alternative screening mammography scenarios.

METHODS

We used a discrete-event simulation model of breast cancer epidemiology to estimate the costs and the number of QALYs that were associated with observed screening mammography patterns in the United States from 1990 to 2000 for women aged 40 years or older. We also estimated costs and QALYS for no screening and for 64 alternative screening scenarios. Incremental cost-effectiveness ratios were computed. Sensitivity analyses were performed on key parameters.

RESULTS

Actual U.S. screening patterns from 1990 to 2000 accrued 947.5 million QALYs and cost $166 billion over the lifetimes of the screened women, resulting in a gain of 1.7 million QALYs for an additional cost of $62.5 billion compared with no screening. Among those polices that were not dominated--i.e., for which no alternative existed that produced more QALYs for lower costs--screening all women aged 40-80 years annually per some U.S. guidelines was the most expensive option, costing $58,000 per additional QALY gained compared with the next most costly alternative, screening all women aged 45-80 years annually. Many alternative screening scenarios generated more QALYs for less cost (with savings up to $6 billion) than actual screening patterns over the study period. Sensitivity analysis showed that conclusions about the cost-effectiveness of screening mammography policies were highly sensitive to small, short-term detrimental effects on quality of life from the screening test itself.

CONCLUSIONS

Choosing among the efficient policies to guide current screening recommendations requires consideration of costs to promote participation in screening and measurement of acute quality-of-life effects of mammography.