Explaining Breast Density Recommendations: An Introductory Workshop for Breast Health Providers

A Scoping Review of Obstetrics and Gynecology Curricula in Primary Care Residency Programs

BACKGROUND

While Women's Health (WH) is a priority for primary care, (Family Medicine (FM), Internal Medicine (IM), Pediatrics (Peds), and combined Medicine/Pediatrics (Med/Peds)), residency curricula remain heterogeneous with deficits in graduates' WH expertise and skills. The overall objective of this study was to assess the quality of WH curricula at primary care residency programs in the United States (US), with a focus on topics in obstetrics and gynecology (OBGYN).

METHODS

PubMed®, ERIC, The Cochrane Library, MedEdPORTAL, and professional organization websites were systematically searched in 2019 and updated in 2021. Included studies described OBGYN educational curricula in US primary care residency programs. Following abstract screening and full-text review, data from eligible studies was abstracted and quality assessed using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

A total of 109 studies met the inclusion criteria. Over a quarter of studies were interdepartmental or interdisciplinary. The most common single-department studies were IM (38%) and FM (26%). Twenty (25%) studies addressed comprehensive OBGYN curricula; the most common individual topics were cervical and breast cancer screening (31%) and contraception (16%). Most studies utilized multiple instructional modalities, most commonly didactics (54%), clinical experiences (41%), and/or simulation (21%). Most studies included self-reported outcomes by residents (70%), with few (11%) reporting higher-level assessments (i.e., patient, or clinical outcomes). Most studies were single-group pre- and post-test (42%) with few randomized controlled trials (4%). The mean MERSQI score for studies with sufficient data (90%) was 9.8 (range 3 to 15.5).

DISCUSSION

OBGYN educational curricula for primary care trainees in the US was varied with gaps in represented residents, content, assessments, and study quality.

Synthesis of Existent Oncology Curricula for Primary Care Providers: A Scoping Review With a Global Equity Lens

PURPOSE

Global increases in cancer, coupled with a shortage of cancer specialists, has led to an increasing role for primary care providers (PCP) in cancer care. This review aimed to examine all extant cancer curricula for PCPs and to analyze the motivations for curriculum development.

METHODS

A comprehensive literature search was conducted from inception to October 13, 2021, with no language restrictions. The initial search yielded 11,162 articles and 10,902 articles underwent title and abstract review. After full-text review, 139 articles were included. Numeric and thematic analyses were conducted and education programs were evaluated using Bloom's taxonomy.

RESULTS

Most curricula were developed in high-income countries (HICs), with 58% in the United States. Cancer-specific curricula focused on HIC priority cancers, such as skin/melanoma, and did not represent the global cancer burden. Most (80%) curricula were developed for staff physicians and 73% focused on cancer screening. More than half (57%) of programs were delivered in person, with a shift toward online delivery over time. Less than half (46%) of programs were codeveloped with PCPs and 34% did not involve PCPs in the program design and development. Curricula were primarily developed to improve cancer knowledge, and 72 studies assessed multiple outcome measures. No studies included the top two levels of Bloom's taxonomy of learning (evaluating; creating).

CONCLUSION

To our knowledge, this is the first review to assess the current state of cancer curricula for PCPs with a global focus. This review shows that extant curricula are primarily developed in HICs, do not represent the global cancer burden, and focus on cancer screening. This review lays a foundation to advance the cocreation of curricula that are aligned to the global cancer burden.

Breast cancer worry, uncertainty, and perceived risk following breast density notification in a longitudinal mammography screening cohort

BACKGROUND

Dense breast notification (DBN) legislation aims to increase a woman's awareness of her personal breast density and the implications of having dense breasts for breast cancer detection and risk. This information may adversely affect women's breast cancer worry, perceptions of risk, and uncertainty about screening, which may persist over time or vary by sociodemographic factors. We examined short- and long-term psychological responses to DBN and awareness of breast density (BD).

METHODS

In a predominantly Hispanic New York City screening cohort (63% Spanish-speaking), ages 40-60 years, we assessed breast cancer worry, perceived breast cancer risk, and uncertainties about breast cancer risk and screening choices, in short (1-3 months)- and long-term (9-18 months) surveys following the enrollment screening mammogram (between 2016 and 2018). We compared psychological responses by women's dense breast status (as a proxy for DBN receipt) and BD awareness and examined multiplicative interaction by education, health literacy, nativity, and preferred interview language.

RESULTS

In multivariable models using short-term surveys, BD awareness was associated with increased perceived risk (odds ratio (OR) 2.27, 95% confidence interval (CI) 0.99, 5.20 for high, OR 2.19, 95% CI 1.34, 3.58 for moderate, vs. low risk) in the overall sample, and with increased uncertainty about risk (OR 1.97 per 1-unit increase, 95% CI 1.15, 3.39) and uncertainty about screening choices (OR 1.73 per 1-unit increase, 95% CI 1.01, 2.9) in Spanish-speaking women. DBN was associated with decreased perceived risk among women with at least some college education (OR 0.32, 95% CI 0.11, 0.89, for high, OR 0.50, 95% CI 0.29, 0.89, for moderate vs. low risk), while those with a high school education or less experienced an increase (OR 3.01, 95% CI 1.05, 8.67 high vs. low risk). There were no associations observed between DBN or BD awareness and short-term breast cancer worry, nor with any psychological outcomes at long-term surveys.

CONCLUSIONS

Associations of BD awareness and notification with breast cancer-related psychological outcomes were limited to short-term increases in perceived breast cancer risk dependent on educational attainment, and increases in uncertainty around breast cancer risk and screening choices among Spanish-speaking women.

General practitioners' (GPs) understanding and views on breast density in Australia: a qualitative interview study

OBJECTIVES

To understand general practitioners' (GPs') awareness and knowledge of mammographic breast density (BD) and their perspectives around information and potential notification of BD for women.

DESIGN

Qualitative study using semistructured telephone interviews. Interviews were audiorecorded, transcribed and analysed using framework analysis.

SETTING

Australia.

PARTICIPANTS

Australian GPs (n=30).

RESULTS

GPs had limited knowledge of BD and little experience discussing BD with women. There were mixed views on notification of BD with some GPs believing this information would help informed decision making about breast health and that women have the right to know any information about their bodies. While others were concerned about causing unnecessary anxiety and were worried about the uncertainty about what to advise women to do with this information, particularly in relation to supplemental breast screening. The need for an equitable system where all women are either notified or not, and also provided with publicly funded supplemental screening was raised by GPs. Overall, there was high interest in education, training and support around the topic of BD.

CONCLUSIONS

Australian GPs require education, support and evidence-based guidelines to have discussions with women with dense breasts and help manage their risk, especially if widespread notification is to be introduced in population-based screening programmes.

Breast Cancer Risk Assessment and Primary Prevention Advice in Primary Care: A Systematic Review of Provider Attitudes and Routine Behaviours

Implementing risk-stratified breast cancer screening is being considered internationally. It has been suggested that primary care will need to take a role in delivering this service, including risk assessment and provision of primary prevention advice. This systematic review aimed to assess the acceptability of these tasks to primary care providers. Five databases were searched up to July-August 2020, yielding 29 eligible studies, of which 27 were narratively synthesised. The review was pre-registered (PROSPERO: CRD42020197676). Primary care providers report frequently collecting breast cancer family history information, but rarely using quantitative tools integrating additional risk factors. Primary care providers reported high levels of discomfort and low confidence with respect to risk-reducing medications although very few reported doubts about the evidence base underpinning their use. Insufficient education/training and perceived discomfort conducting both tasks were notable barriers. Primary care providers are more likely to accept an increased role in breast cancer risk assessment than advising on risk-reducing medications. To realise the benefits of risk-based screening and prevention at a population level, primary care will need to proactively assess breast cancer risk and advise on risk-reducing medications. To facilitate this, adaptations to infrastructure such as integrated tools are necessary in addition to provision of education.

Breast Density Notification: A Systematic Review of the Impact on Primary Care Practitioners

Background: In the last decade, there has been an unprecedented amount of advocacy and attention surrounding the issue of breast density (BD) in relation to mammography screening. It is largely unknown what impact notifying women of their BD has had on clinical practice for PCPs. This systematic review aimed to synthesize evidence from existing studies to understand the impact of BD notification on primary care practitioners' (PCPs) knowledge, attitudes, and practice implications. Methods: Empirical studies were identified through relevant database searches (database inception to May 2020). Two authors evaluated the eligibility of studies, extracted and crosschecked data, and assessed the risk of bias. Results were synthesized in a narrative form. Results: Six studies of the 232 titles identified and screened were included. All studies were undertaken in the United States, with five conducted postlegislation in their respective states, and one study conducted in states that were both prelegislation and postlegislation. Five studies were quantitative, including four cross-sectional surveys, and one study was qualitative. Findings consistently demonstrated PCPs' overall lack of knowledge about BD, low level of comfort in discussing and managing patients in relation to dense breasts, and limited consensus on the most appropriate approach for managing women with dense breasts, particularly in relation to supplemental screening. Conclusions: This review highlights important gaps in PCPs' understanding of BD and confidence in having discussions with women about the implications of dense breasts. It identifies the need for high-quality research and the development of evidence-based guidelines to better support PCPs.