Revisions in the risk-based Breast Cancer Screening Program at Group Health Cooperative

The current status of risk-stratified breast screening

Apart from high-risk scenarios such as the presence of highly penetrant genetic mutations, breast screening typically comprises mammography or tomosynthesis strategies defined by age. However, age-based screening ignores the range of breast cancer risks that individual women may possess and is antithetical to the ambitions of personalised early detection. Whilst screening mammography reduces breast cancer mortality, this is at the risk of potentially significant harms including overdiagnosis with overtreatment, and psychological morbidity associated with false positives. In risk-stratified screening, individualised risk assessment may inform screening intensity/interval, starting age, imaging modality used, or even decisions not to screen. However, clear evidence for its benefits and harms needs to be established. In this scoping review, the authors summarise the established and emerging evidence regarding several critical dependencies for successful risk-stratified breast screening: risk prediction model performance, epidemiological studies, retrospective clinical evaluations, health economic evaluations and qualitative research on feasibility and acceptability. Family history, breast density or reproductive factors are not on their own suitable for precisely estimating risk and risk prediction models increasingly incorporate combinations of demographic, clinical, genetic and imaging-related parameters. Clinical evaluations of risk-stratified screening are currently limited. Epidemiological evidence is sparse, and randomised trials only began in recent years.

Cost-effectiveness of risk-based breast cancer screening: A systematic review

To analyse published evidence on the economic evaluation of risk-based screening (RBS), a full systematic literature review was conducted. After a quality appraisal, we compared the cost-effectiveness of risk-based strategies (low-risk, medium-risk and high-risk) with no screening and age-based screening. Studies were also analysed for modelling, risk stratification methods, input parameters, data sources and harms and benefits. The 10 modelling papers analysed were based on screening performance of film-based mammography (FBM) (three); digital mammography (DM) and FBM (two); DM alone (three); DM, ultrasound (US) and magnetic resonance imaging (one) and DM and US (one). Seven studies did not include the cost of risk-stratification, and one did not consider the cost of diagnosis. Disutility was incorporated in only six studies (one for screening and five for diagnosis). None of the studies reported disutility of risk-stratification (being considered as high-risk). Risk-stratification methods varied from only breast density (BD) to the combination of familial risk, genetic susceptibility, lifestyle, previous biopsies, Jewish ancestry and reproductive history. Less or no screening in low-risk women and more frequent mammography screening in high-risk women was more cost-effective compared to no screening and age-based screening. High-risk women screened annually yielded a higher mortality rate reduction and more quality-adjusted life years at the expense of higher cost and false positives. RBS can be cost effective compared to the alternatives. However, heterogeneity among risk-stratification methods, input parameters, and weaknesses in the methodologies hinder the derivation of robust conclusions. Therefore, further studies are warranted to assess newer technologies and innovative risk-stratification methods.

Trends in BRCA Test Utilization in an Integrated Health System, 2005-2015

BACKGROUND

Genetic testing to determine BRCA status has been available for over two decades, but there are few population-based studies of test diffusion. We report 10-year trends in BRCAtesting in an integrated health-care system with long-standing access to genetic services.

METHODS

A cohort of women aged 18 years and older was created to ascertain BRCA testing (n = 295 087). Annual testing rates between 2005 and 2015 were calculated in all women with and without incident (ie, newly diagnosed) breast and ovarian cancers and in clinically eligible subgroups by family cancer history, personal cancer history, and age at diagnosis. Secular trends were assessed using Poisson regression. Women tested early (2005-2008), midway (2009-2012), and late (2013-2015) in the study period were compared in cross-sectional analyses.

RESULTS

Between 2005 and 2015, annual testing rates increased from 0.6/1000 person-years (pys) (95% confidence interval [CI] = 0.4 to 0.7/1000 pys) to 0.8/1000 pys (95% CI = 0.6 to 1.0/1000 pys) in women without incident breast or ovarian cancers. Rates decreased from 71.5/1000 pys (95% CI = 42.4 to 120.8/1000 pys) to 44.4/1000 pys (95% CI = 35.5 to 55.6/1000 pys) in women with incident diagnoses, despite improvements in provision of timely BRCA testing during this time frame. We found no evidence of secular trends in clinically eligible subgroups including women with family history indicating increased hereditary cancer risk, but no personal cancer history. At the end of the study period, 97.0% (95% CI = 96.6% to 97.3%) of these women remained untested.

CONCLUSION

Many eligible women did not receive BRCA testing despite having insurance coverage and access to specialty genetic services, underscoring challenges to primary and secondary hereditary cancer prevention.

Review of non-clinical risk models to aid prevention of breast cancer

A disease risk model is a statistical method which assesses the probability that an individual will develop one or more diseases within a stated period of time. Such models take into account the presence or absence of specific epidemiological risk factors associated with the disease and thereby potentially identify individuals at higher risk. Such models are currently used clinically to identify people at higher risk, including identifying women who are at increased risk of developing breast cancer. Many genetic and non-genetic breast cancer risk models have been developed previously. We have evaluated existing non-genetic/non-clinical models for breast cancer that incorporate modifiable risk factors. This review focuses on risk models that can be used by women themselves in the community in the absence of clinical risk factors characterization. The inclusion of modifiable factors in these models means that they can be used to improve primary prevention and health education pertinent for breast cancer. Literature searches were conducted using PubMed, ScienceDirect and the Cochrane Database of Systematic Reviews. Fourteen studies were eligible for review with sample sizes ranging from 654 to 248,407 participants. All models reviewed had acceptable calibration measures, with expected/observed (E/O) ratios ranging from 0.79 to 1.17. However, discrimination measures were variable across studies with concordance statistics (C-statistics) ranging from 0.56 to 0.89. We conclude that breast cancer risk models that include modifiable risk factors have been well calibrated but have less ability to discriminate. The latter may be a consequence of the omission of some significant risk factors in the models or from applying models to studies with limited sample sizes. More importantly, external validation is missing for most of the models. Generalization across models is also problematic as some variables may not be considered applicable to some populations and each model performance is conditioned by particular population characteristics. In conclusion, it is clear that there is still a need to develop a more reliable model for estimating breast cancer risk which has a good calibration, ability to accurately discriminate high risk and with better generalizability across populations.

Breast cancer screening outreach effectiveness: Mammogram-specific reminders vs. comprehensive preventive services birthday letters

We compared the effectiveness of two outreach strategies on timely mammography adherence: a mammogram-specific reminder letter (sent just before a woman was due) to a birthday letter (addresses multiple preventive services and not timed around due dates). We evaluated screening mammography adherence following 79,848 mammogram-specific and 151,626 birthday letters mailed between 2002 and 2012 to women aged 40-74years enrolled in Kaiser Permanente Washington. Screening mammogram adherence was specifically tied to due date and was evaluated separately by age group and up-to-date or overdue status at the time of mailing. We used generalized estimating equations to account for correlation between repeated observations, to model the odds of screening mammography adherence by letter type. Among women up-to-date, adherence following birthday letters was 22-76% lower compared to the mammogram-specific reminders, with the greatest decreases in adherence in women aged 70-74. Birthday letters were more effective at activating screening uptake among some subgroups of overdue women aged 50-69 and most overdue women aged 70-74, but universally low adherence rates were observed in overdue women. Increasing number of recommended services for women aged 50-74 who were up-to-date resulted in 12-17% lower mammography adherence, but had no effect in women aged 40-49 or in overdue women. Birthday letters are less effective than mammogram-specific reminder letters at prompting women to undergo timely breast cancer screening, particularly among women up-to-date with screening. Birthday letters may be effective at increasing overall preventive care; however, supplemental outreach may be needed around the due date to increase timely preventive services receipt.

Evidence for Detection Bias by Medication Use in a Cohort Study of Breast Cancer Survivors

In previous studies, we found modestly decreased and increased risks of second breast cancer events with the use of statins and antibiotics, respectively, after adjustment for surveillance mammography. We evaluated detection bias by comparing receipt of surveillance mammography among users of these 2 disparate classes of medication. Adult women diagnosed with early-stage breast cancer during 1990-2008 (n = 3,965) while enrolled in an integrated health-care plan (Group Health Cooperative; Washington State) were followed for up to 10 years in the Commonly Used Medications and Breast Cancer Outcomes (COMBO) Study. Categories of antibiotic use included infrequent (1-3 dispensings/12 months) and frequent (≥4 dispensings/12 months) use, and categories of statin use included less adherent (1 dispensing/6 months) and adherent (≥2 dispensings/6 months). We examined associations between medication use and surveillance mammography using multivariable generalized estimating equations and evaluated the impact of adjusting for surveillance within Cox proportional hazard models. Frequent antibiotic users were less likely to receive surveillance mammography (odds ratio (OR) = 0.90, 95% confidence interval (CI): 0.82, 0.99) than were nonusers; no association was found among infrequent users (OR = 0.96, 95% CI: 0.90, 1.03). Adherent statin use was associated with more surveillance compared with nonuse (OR = 1.11, 95% CI: 1.01, 1.25), but less adherent statin use was not (OR = 1.03, 95% CI: 0.81, 1.31). No difference in associations between medications of interest and second breast cancer events was observed when surveillance was removed from otherwise adjusted models. The influence of detection bias by medication use warrants further exploration.

Identification of genetic and non-genetic risk factors for nasopharyngeal carcinoma in a Southeast Asian population

BACKGROUND

Nasopharyngeal carcinoma (NPC) is endemic in Southern Chinese and Southeast Asian populations. Geographical and ethnic clustering of the cancer is due to genetic, environmental, and lifestyle risk factors. This case-control study aimed to identify or confirm both genetic and non-genetic risk factors for NPC in one of the endemic countries, Malaysia.

MATERIALS AND METHOD

A panel of 768 single-nucleotide polymorphisms (SNPs) previously associated with various cancers and known non-genetic risk factors for NPC were selected and analyzed for their associations with NPC in a case-control study.

RESULTS

Statistical analysis identified 40 SNPs associated with NPC risk in our population, including 5 documented previously by genome-wide association studies (GWAS) and other case-control studies; the associations of the remaining 35 SNPs with NPC were novel. In addition, consistent with previous studies, exposure to occupational hazards, overconsumption of salt-cured foods, red meat, as well as low intake of fruits and vegetables were also associated with NPC risk.

CONCLUSIONS

In short, this study confirmed and/or identified genetic, environmental and dietary risk factors associated with NPC susceptibility in a Southeast Asian population.

Predictors of preoperative MRI for breast cancer: differences by data source

AIM

Investigate how the results of predictive models of preoperative MRI for breast cancer change based on available data.

MATERIALS & METHODS

A total of 1919 insured women aged ≥18 with stage 0-III breast cancer diagnosed 2002-2009. Four models were compared using nested multivariable logistic, backwards stepwise regression; model fit was assessed via area under the curve (AUC), R2.

RESULTS

MRI recipients (n = 245) were more recently diagnosed, younger, less comorbid, with higher stage disease. Significant variables included: Model 1/Claims (AUC = 0.76, R2 = 0.10): year, age, location, income; Model 2/Cancer Registry (AUC = 0.78, R2 = 0.12): stage, breast density, imaging indication; Model 3/Medical Record (AUC = 0.80, R2 = 0.13): radiologic recommendations; Model 4/Risk Factor Survey (AUC = 0.81, R2 = 0.14): procedure count.

CONCLUSION

Clinical variables accounted for little of the observed variability compared with claims data.

A risk prediction model for smoking experimentation in Mexican American youth

BACKGROUND

Smoking experimentation in Mexican American youth is problematic. In light of the research showing that preventing smoking experimentation is a valid strategy for smoking prevention, there is a need to identify Mexican American youth at high risk for experimentation.

METHODS

A prospective population-based cohort of 1,179 adolescents of Mexican descent was followed for 5 years starting in 2005-06. Participants completed a baseline interview at a home visit followed by three telephone interviews at intervals of approximately 6 months and additional interviews at two home visits in 2008-09 and 2010-11. The primary endpoint of interest in this study was smoking experimentation. Information about social, cultural, and behavioral factors (e.g., acculturation, susceptibility to experimentation, home characteristics, and household influences) was collected at baseline using validated questionnaires.

RESULTS

Age, sex, cognitive susceptibility, household smoking behavior, peer influence, neighborhood influence, acculturation, work characteristics, positive outcome expectations, family cohesion, degree of tension, ability to concentrate, and school discipline were found to be associated with smoking experimentation. In a validation dataset, the proposed risk prediction model had an area under the receiver operating characteristic curve (AUC) of 0.719 (95% confidence interval, 0.637-0.801) for predicting absolute risk for smoking experimentation within 1 year.

CONCLUSIONS

The proposed risk prediction model is able to quantify the risk of smoking experimentation in Mexican American adolescents.

IMPACT

Accurately identifying Mexican American adolescents who are at higher risk for smoking experimentation who can be intervened will substantially reduce the incidence of smoking and thereby subsequent health risks.

Cancer screening and genetics: a tale of two paradigms

The long-standing medical tradition to "first do no harm" is reflected in population-wide evidence-based recommendations for cancer screening tests that focus primarily on reducing morbidity and mortality. The conventional cancer screening process is predicated on finding early-stage disease that can be treated effectively; yet emerging genetic and genomic testing technologies have moved the target earlier in the disease development process to identify a probabilistic predisposition to disease. Genetic risk information can have varying implications for the health and well-being of patients and their relatives, and has raised important questions about the evaluation and value of risk information. This article explores the paradigms that are being applied to the evaluation of conventional cancer screening tests and emerging genetic and genomic tests of cancer susceptibility, and how these perspectives are shifting and evolving in response to advances in our ability to detect cancer risks. We consider several challenges germane to the evaluation of both categories of tests, including defining benefits and harms in terms of personal and clinical utility, addressing healthcare consumers' information preferences, and managing scientific uncertainty. We encourage research and dialogue aimed at developing a better understanding of the value of all risk information, nongenetic and genetic, to people's lives. Cancer Epidemiol Biomarkers Prev; 23(6); 909-16. ©2014 AACR.

Factors associated with long-term adherence to annual surveillance mammography among breast cancer survivors

Clinical practice guidelines recommend yearly surveillance mammography for breast cancer survivors, yet many women do not receive this service. The objective of this study was to evaluate factors related to long-term surveillance mammography adherence among breast cancer survivors. We conducted a retrospective cohort study among women ≥ 18 years, diagnosed with incident stage I or II breast cancer between 1990 and 2008. We used medical record and administrative health plan data to ascertain covariates and receipt of surveillance mammography for up to 10 years after completing breast cancer treatment. Surveillance included post-diagnosis screening exams among asymptomatic women. We used multivariable repeated measures generalized estimating equation regression models to estimate odds ratios and robust 95 % confidence intervals to examine factors related to the annual receipt of surveillance mammography. The analysis included 3,965 women followed for a median of six surveillance years; 79 % received surveillance mammograms in year 1 but decreased to 63 % in year 10. In multivariable analyses, women, who were < 40 years or 80+ years of age (compared to 50-59 years), current smokers, had greater comorbidity, were diagnosed more recently, had stage II cancer, or were treated with mastectomy or breast conserving surgery without radiation, were less likely than other women to receive surveillance mammography. Women with outpatient visits during the year to primary care providers, oncologists, or both were more likely to undergo surveillance. In this large cohort study of women diagnosed with early-stage invasive breast cancer, we found that important subgroups of women are at high risk for non-adherence to surveillance recommendations, even among younger breast cancer survivors. Efforts should be undertaken to actively engage breast cancer survivors in managing long-term surveillance care.

Measurement in comparative effectiveness research

Comparative effectiveness research (CER) on preventive services can shape policy and help patients, their providers, and public health practitioners select regimens and programs for disease prevention. Patients and providers need information about the relative effectiveness of various regimens they may choose. Decision makers need information about the relative effectiveness of various programs to offer or recommend. The goal of this paper is to define and differentiate measures of relative effectiveness of regimens and programs for disease prevention. Cancer screening is used to demonstrate how these measures differ in an example of two hypothetical screening regimens and programs. Conceptually and algebraically defined measures of relative regimen and program effectiveness also are presented. The measures evaluate preventive services that range from individual tests through organized, population-wide prevention programs. Examples illustrate how effective screening regimens may not result in effective screening programs and how measures can vary across subgroups and settings. Both regimen and program relative effectiveness measures assess benefits of prevention services in real-world settings, but each addresses different scientific and policy questions. As the body of CER grows, a common lexicon for various measures of relative effectiveness becomes increasingly important to facilitate communication and shared understanding among researchers, healthcare providers, patients, and policymakers.

Body mass index, tumor characteristics, and prognosis following diagnosis of early-stage breast cancer in a mammographically screened population

PURPOSE

Many studies suggest increased body mass index (BMI) is associated with worse breast cancer outcomes, but few account for variability in screening, access to treatment, and tumor differences. We examined the association between BMI and risk of breast cancer recurrence, breast cancer-specific mortality, and all-cause mortality, and evaluated whether tumor characteristics differ by BMI among a mammographically screened population with access to treatment.

METHODS

Using a retrospective cohort study design, we followed 485 women aged ≥40 years diagnosed with stage I/II breast cancer within 24 months of a screening mammogram occurring between 1988 and 1993 for 10-year outcomes. BMI before diagnosis was categorized as normal (<25 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (≥30 kg/m(2)). Tumor marker expression was assessed via immunohistochemistry using tissue collected before adjuvant treatment. Medical records were abstracted to identify treatment, recurrence, and mortality. We used Cox proportional hazards to separately model the hazard ratios (HR) of our three outcomes by BMI while adjusting for age, stage, and tamoxifen use.

RESULTS

Relative to normal-weight women, obese women experienced increased risk of recurrence (HR 2.43; 95 % CI 1.34-4.41) and breast cancer death (HR 2.41; 95 % CI 1.00-5.81) within 10 years of diagnosis. There was no association between BMI and all-cause mortality. Obese women had significantly faster growing tumors, as measured by Ki-67.

CONCLUSIONS

Our findings add to the growing evidence that obesity may contribute to poorer breast cancer outcomes, and also suggest that increased tumor proliferation among obese women is a pathway that explains part of their excess risk of adverse outcomes.

Comparative effectiveness of mailed reminder letters on mammography screening compliance

OBJECTIVE

Reminder letters are effective at prompting women to schedule mammograms. Less well studied are reminders addressing multiple preventive service recommendations. We compared the effectiveness of a mammogram-specific reminder sent when a woman was due for a mammogram to a reminder letter addressing multiple preventive services and sent on a woman's birthday on mammography receipt.

METHODS

The study included 48,583 women 52-74 years enrolled in Group Health Cooperative, a health plan in Washington State. From 2005 to 2009, women were mailed 88,605 mammogram-specific or birthday letters. In this one group pretest-posttest study, we modeled the odds of obtaining a screening mammogram after receiving a letter by reminder type using logistic regression, controlling for demographic and healthcare use characteristics and stratifying by whether women were overdue or up-to-date with mammography at the mailing.

RESULTS

Among women up-to-date with screening, birthday letters were negatively associated with mammography receipt compared to mammogram-specific letters (birthday letters with 1-2 recommendations: OR=0.73; 95% CI:0.68-0.79; 3 recommendations: OR=0.74; 95% CI:0.69-0.78; 4-8 recommendations: OR=0.62 95% CI:0.55-0.68) after. Among overdue women, birthday letters with 4-8 recommendations were negatively associated with mammography receipt.

CONCLUSIONS

Transitioning from mammogram-specific reminder letters to multiple preventive service birthday letters was associated with decreased mammography receipt.

Prophylactic oophorectomy rates in relation to a guideline update on referral to genetic counseling

OBJECTIVE

We sought to determine whether prophylactic oophorectomy rates changed after the introduction of a 2007 health plan clinical guideline recommending systematic referral to a genetic counselor for women with a personal or family history suggestive of an inherited susceptibility to breast/ovarian cancer.

METHODS

We conducted a retrospective cohort study of female members of Group Health, an integrated delivery system in Washington State. Subjects were women aged ≥ 35 years during 2004-2009 who reported a personal or family history consistent with an inherited susceptibility to breast/ovarian cancer. Personal and family history information was collected on a questionnaire completed when the women had a mammogram. We ascertained oophorectomies from automated claims data and determined whether surgeries were prophylactic by medical chart review. Rates were age-adjusted and age-adjusted incidence rate ratios (IRR) and 95% confidence intervals (CI) were computed using Poisson regression.

RESULTS

Prophylactic oophorectomy rates were relatively unchanged after compared to before the guideline change, 1.0 versus 0.8/1000 person-years, (IRR=1.2; 95% CI: 0.7-2.0), whereas bilateral oophorectomy rates for other indications decreased. Genetic counseling receipt rates doubled after the guideline change (95% CI: 1.7-2.4) from 5.1 to 10.2/1000 person-years. During the study, bilateral oophorectomy rates were appreciably greater in women who saw a genetic counselor compared to those who did not regardless of whether they received genetic testing as part of their counseling.

CONCLUSION

A doubling in genetic counseling receipt rates lends support to the idea that the guideline issuance contributed to sustained rates of prophylactic oophorectomies in more recent years.

Relationship between Obesity, Depression, and Disability in Middle-Aged Women

BACKGROUND: Obesity and depression are closely linked, and each has been associated with disability. However, few studies have assessed inter-relationships between these conditions. DESIGN AND METHODS: In this study, 4 641 women aged 40-65 completed a structured telephone interview including self-reported height and weight, the Patient Health Questionnaire (PHQ) assessment of depression, and the World Health Organization Disability Assessment Schedule II (WHODAS II). The survey response rate was 62%. We used multivariable regression models to assess relationships between obesity, depression, and disability. RESULTS: The mean age was 52 years; 82% were white; and 80% were currently employed. One percent were underweight, 39% normal weight, 27% overweight, and 34% obese. Mild depressive symptoms were present in 23% and moderate-to-severe symptoms were present in 13%. After multivariable adjustment, depression was a strong independent predictor of worse disability in all 7 domains (cognition, mobility, self-care, social interaction, role functioning, household, and work), but obesity was only a significant predictor of greater mobility, role-functioning, household, and work limitations (P<0.05) (overweight was not significantly associated with any disability domain). Overall, the effect on disability was stronger and more pervasive for depression than obesity, and there was no significant interaction between the two conditions (P>0.05). Overweight and obesity were associated with 5 760 days of absenteeism per 1 000 person-years, and depression was associated with 18 240 days of absenteeism per 1 000 person-years. CONCLUSIONS: The strong relationships between depression, obesity and disability suggest that these conditions should be routinely screened and treated among middle-aged women.

Obesity, depression, and health services costs among middle-aged women

BACKGROUND

Both obesity and depression have been associated with significant increases in health care costs. Previous research has not examined whether cost increases associated with obesity could be explained by confounding effects of depression.

OBJECTIVE

Examine whether the association between obesity and health care costs is explained by co-occurring depression.

DESIGN

Cross-sectional study including telephone survey and linkage to health plan records.

PARTICIPANTS

4462 women aged 40 to 65 enrolled in prepaid health plan in the Pacific Northwest.

MAIN MEASURES

The telephone survey included self-report of height and weight and measurement of depression by the Patient Health Questionnaire (PHQ9). Survey data were linked to health plan cost accounting records.

KEY RESULTS

Compared to women with BMI less than 25, proportional increases in health care costs were 65% (95% CI 41% to 93%) for women with BMI 30 to 35 and 157% (95% CI 91% to 246%) for women with BMI of 35 or more. Adjustment for co-occurring symptoms of depression reduced these proportional differences to 40% (95% CI 18% to 66%) and 87% (95% CI 42% to 147%), respectively. Cost increases associated with obesity were spread across all major categories of health services (primary care visits, outpatient prescriptions, inpatient medical services, and specialty mental health care).

CONCLUSIONS

Among middle-aged women, both obesity and depression are independently associated with substantially higher health care costs. These cost increases are spread across the full range of outpatient and inpatient health services. Given the high prevalence of obesity, cost increases of this magnitude have major policy and public health importance.

The association between obesity, depression, and educational attainment in women: the mediating role of body image dissatisfaction

OBJECTIVE

We examine the mediating role of body image dissatisfaction (BID) on the association between obesity and depression and the variation of this association as a function of years of education among a population-based sample of women aged 40-65 years.

METHODS

A series of sample-weighted logistic regression models were used to estimate the associations between obesity, BID, and depression, stratified by educational attainment. Data were obtained from a structured telephone interview of 4543 female health plan enrollees, including self-reported height and weight, the Patient Health Questionnaire assessment of depression, and a single-item measure of BID.

RESULTS

Among those with <16 years of education, in both the unadjusted and adjusted models, obesity and BID were significantly associated with depression. Similarly, among those with ≥ 16 years of education, obesity and BID were significantly associated with depression in the unadjusted models. However, in the adjusted model, only BID was associated with depression. A formal test for mediation suggests that the association between obesity and depression was mediated by BID regardless of level of education.

CONCLUSIONS

Our data suggest that BID-mediated the obesity-depression association. In addition, obesity and BID may be salient risk factors for depression among middle-aged women as a function of the level of education.

Cost of breast-related care in the year following false positive screening mammograms

OBJECTIVE

We sought to estimate the direct cost, from the perspective of the health insurer or purchaser, of breast-care services in the year following a false positive screening mammogram compared with a true negative examination.

DESIGN

We identified 21,125 women aged 40 to 80 years enrolled in an integrated healthcare delivery system in Washington State, who participated in screening mammography between January 1, 1998 and July 30, 2002. Pathology and cancer registry data were used to identify breast cancer diagnoses in the year following the screening mammogram. A positive examination was defined as a Breast Imaging Reporting and Data System assessment of 0, 4, or 5. Women with a positive screening mammogram but no breast cancer diagnosed within 1 year were classified as false positives. We used diagnostic and procedure codes in automated health plan data to identify services received in the year following the screening mammogram. Medicare reimbursement rates were applied to all services. We used ordinary least-squares linear regression to estimate the difference in costs following a false positive versus true negative screening mammogram.

RESULTS

False positive results occurred in 9.9% of women; most false positives (87.3%) were followed by breast imaging only. The mean cost of breast-care following a false positive mammogram was $527. This was $503 (95% confidence interval, $490-$515) more than the cost of breast-care services for true negative women.

CONCLUSIONS

The direct costs for breast-related procedures following false positive screening mammograms may contribute substantially to US healthcare spending.

Short-term (1-2 mo) hormone therapy cessation before mammography

OBJECTIVE

Some healthcare providers recommend hormone therapy (HT) cessation before mammography to improve performance. Our objective was to evaluate characteristics of women willing to consider HT cessation before screening mammography.

METHODS

We performed a randomized clinical trial, the Radiological Evaluation and Breast Density study, within an integrated health plan (2004-2007). Women aged 45 to 80 years who used HT at their most recent screening (index) mammogram, who were due for a screening (study) mammogram, and who were still using HT were invited to participate. Randomization groups were: (1) no, (2) 1-month, or (3) 2-month cessation. Women's willingness to participate was evaluated by age, race, ethnicity, education, hysterectomy, type of HT (unopposed estrogen and estrogen plus progestin), duration of HT use, body mass index, breast cancer risk, and breast density.

RESULTS

A total of 5,861 women were invited to participate; 2,999 refused. An additional 169 women agreed to participate but withdrew before data collection. Compared with women who participated (n = 1,535), nonparticipants (n = 3,168; 2,999 + 169; 54%) were older, were less educated, and had lower body mass index (all P < 0.05). Among nonparticipants, 1,876 (59.2%) were unwilling to stop HT. Among estrogen-plus-progestin users, women with a first-degree relative with a history of breast cancer had lower odds of refusal than women without a family history of breast cancer (adjusted odds ratio, 0.71; 95% CI, 0.54-0.93).

CONCLUSIONS

Most women were unwilling to stop HT, even for a short period, when the intent was to improve mammographic accuracy, and even when informed that they could restart HT at any time during the 2-month study. Some factors predicted willingness to stop HT; the magnitude of the differences may not be clinically meaningful.

Does the association between depression and smoking vary by body mass index (BMI) category?

OBJECTIVE

The purpose of this study was to explore how weight might influence the relationship between depression and smoking.

METHODS

Data were obtained from a cross-sectional survey representative of women age 40-65 enrolled in Group Health Cooperative, a health plan serving members in Washington and northern Idaho (n=4640). We examined the relationships between depression and smoking in normal weight, overweight, and obese women using weighted multiple logistic regression with both minimal and full adjustment.

RESULTS

Current depression was significantly associated with current smoking in obese women (adjusted odds ratio=2.48, 95% confidence interval=1.26-4.88) but not in underweight/normal or overweight women. Among ever smokers, obese women, but not other groups, were significantly less likely to have quit smoking in the past.

CONCLUSIONS

In our preliminary study, the association between smoking and depression in middle-aged women appears to be limited to the obese subset and may stem from a lesser likelihood of obese ever smokers to have quit. This population represents an important target for preventive medicine efforts.

Statin use and female reproductive organ cancer risk in a large population-based setting

OBJECTIVE

Statins are an effective and commonly used cholesterol-lowering medication class, but their hypothesized effects on cancer risk remain uncertain. We evaluated the association between statin use and endometrial as well as ovarian cancer risks.

METHODS

We conducted a retrospective study with two cohorts of women aged 45-89 years during 1990-2004 within an integrated healthcare delivery system. Information on statin use and covariates were obtained from automated databases. We identified cancer cases through the Surveillance, Epidemiology, and End Results registry. Multivariable Cox proportional hazards models were used to estimate the hazard ratios (HR) and 95% confidence intervals (CI) for incident invasive endometrial and ovarian cancers among statin users compared to nonusers.

RESULTS

Women were followed for a median of about six years. Among 73,336 women studied, 568 endometrial cancer cases were identified. During the study period, 6% of women used statins for at least one year and the median duration of use was 3.1 years. Although not statistically significant, we found a reduction in endometrial cancer risk among statin users (HR = 0.67; 95% CI: 0.39-1.17) compared to nonusers. We identified 326 ovarian cancer cases in a cohort of 93,619 women. There was also a nonsignificant decrease in ovarian cancer risk among statin users (HR = 0.69; 95% CI: 0.32-1.49).

CONCLUSION

Our study does not support an association between statin use and endometrial as well as ovarian cancers, but a reduced risk cannot be ruled out.

A logistic regression model based on the national mammography database format to aid breast cancer diagnosis

OBJECTIVE

The purpose of our study was to create a breast cancer risk estimation model based on the descriptors of the National Mammography Database using logistic regression that can aid in decision making for the early detection of breast cancer.

MATERIALS AND METHODS

We created two logistic regression models based on the mammography features and demographic data for 62,219 consecutive mammography records from 48,744 studies in 18,269 [corrected] patients reported using the Breast Imaging Reporting and Data System (BI-RADS) lexicon and the National Mammography Database format between April 5, 1999 and February 9, 2004. State cancer registry outcomes matched with our data served as the reference standard. The probability of cancer was the outcome in both models. Model 2 was built using all variables in Model 1 plus radiologists' BI-RADS assessment categories. We used 10-fold cross-validation to train and test the model and to calculate the area under the receiver operating characteristic curves (A(z)) to measure the performance. Both models were compared with the radiologists' BI-RADS assessments.

RESULTS

Radiologists achieved an A(z) value of 0.939 +/- 0.011. The A(z) was 0.927 +/- 0.015 for Model 1 and 0.963 +/- 0.009 for Model 2. At 90% specificity, the sensitivity of Model 2 (90%) was significantly better (p < 0.001) than that of radiologists (82%) and Model 1 (83%). At 85% sensitivity, the specificity of Model 2 (96%) was significantly better (p < 0.001) than that of radiologists (88%) and Model 1 (87%).

CONCLUSION

Our logistic regression model can effectively discriminate between benign and malignant breast disease and can identify the most important features associated with breast cancer.

Associations of child sexual and physical abuse with obesity and depression in middle-aged women

OBJECTIVE

Examine whether (1) childhood maltreatment is associated with subsequent obesity and depression in middle-age; (2) maltreatment explains the associations between obesity and depression; and (3) binge eating or body dissatisfaction mediate associations between childhood maltreatment and subsequent obesity.

METHODS

Data were obtained through a population-based survey of 4641 women (mean age=52 years) enrolled in a large health plan in the Pacific Northwest. A telephone survey assessed child sexual and physical abuse, obesity (BMI>or=30), depressive symptoms, binge eating, and body dissatisfaction. Data were analyzed using logistic regression models incorporating sampling weights.

RESULTS

Both child sexual and physical abuse were associated with a doubling of the odds of both obesity and depression, although child physical abuse was not associated with depression for the African American/Hispanic/American Indian subgroup. The association between obesity and depression (unadjusted OR=2.82; 95% CI=2.20-3.62) was reduced somewhat after controlling for sexual abuse (adjusted OR=2.54; 1.96-3.29) and for physical abuse (adjusted OR=2.63; 2.03-3.42). Controlling for potential mediators failed to substantially attenuate associations between childhood maltreatment and obesity.

CONCLUSIONS

This study is the first to our knowledge that compares associations of child abuse with both depression and obesity in adults. Although the study is limited by its cross-sectional design and brief assessments, the fact that child abuse predicted two debilitating conditions in middle-aged women indicates the potential long-term consequences of these experiences.

Quality of life valuations of mammography screening

OBJECTIVE

To obtain quality-of-life (QOL) valuations associated with mammography screening and breast cancer treatment that are suitable for use in cost-effectiveness analyses.

METHODS

Subjects comprised 131 women (age range 50-79 years) randomly sampled from a breast cancer screening program. In an in-person or telephone interview, women rated the QOL impact of 14 clinical scenarios (ranging from mammography to end-of-life care for breast cancer) using a visual analogue scale anchored by death (0) and perfect health/quality of life (100).

RESULTS

Women rated the scenarios describing true negative results, false positive results, and routine screening mammography at 80 or above on a scale of 0-100, suggesting that they perceive these states as being close to perfect health. They rated adjuvant chemotherapy (39.7; range 10-90), palliation/end-of-life care (35.8; range 0-100), and recurrence at 1 year (33.0; range 0-95) the lowest, suggesting that these health states are perceived as compromised. Women rated receiving news of a breast cancer diagnosis (true positive) (45.7; range 5-100) and receiving delayed news of a breast cancer diagnosis (false negative) (48.5; range 5-100) as being comparable to undergoing mastectomy (48.3; range 10-100) and radiation therapy (46.2; range 5-100) for breast cancer.

CONCLUSIONS

These data can be used to update cost analyses of mammography screening that wish to take into account the QOL impact of screening.

Population-based estimates of the relation between breast cancer risk, tumor subtype, and family history

OBJECTIVE

Many studies that have estimated the breast cancer risk attributable to family history have been based on data collected within family units. Use of this study design has likely overestimated risks for the general population. We provide population-based estimates of breast cancer risk and different tumor subtypes in relation to the degree, number, and age at diagnosis of affected relatives.

METHODS

Cox Proportional Hazards to calculate risks (hazard ratios; 95% confidence interval) of breast cancer and tumor subtypes for women with a family history of breast cancer relative to women without a family history among a cohort of 75,189 women age >or=40 years of whom 1,087 were diagnosed with breast cancer from June 1, 2001-December 31, 2005 (median follow-up 3.16 years).

RESULTS

Breast cancer risk was highest for women with a first-degree family history (1.54; 1.34-1.77); and did not differ substantially by the affected relative's age at diagnosis or by number of affected first-degree relatives. A second-degree family history only was not associated with a significantly increased breast cancer risk (1.15; 0.98-1.35). There was a suggestion that a positive family history was associated with risk of triple positive (Estrogen+/Progesterone+/HER2+) and HER2-overexpressing tumors.

CONCLUSIONS

While a family history of breast cancer in first-degree relatives is an important risk factor for breast cancer, gathering information such as the age at diagnosis of affected relatives or information on second-degree relative history may be unnecessary in assessing personal breast cancer risk among women age >or=40 years.

Does clinical depression affect the accuracy of self-reported height and weight in obese women?

OBJECTIVE

Recent research from a self-report survey showed a strong association between obesity and clinical depression in women. The present analysis assessed whether differential bias in self-reports of height and weight as a function of depression influences the apparent strength of the association.

METHODS

Accuracy of self-reported height and weight was assessed in 250 obese (mean BMI=38.7 kg/m(2)) women, 135 of whom met the American Psychiatric Association DSM-IV diagnostic criteria for clinical depression.

RESULTS

Depressed and non-depressed women underreported their weight by 1.5 and 1.2 kg, respectively. They underreported their height by 0.002 and 0.003 m, respectively.

DISCUSSION

Bias in self-reports of body weight and height is similar in depressed and non-depressed obese women. The underreporting of weight in both groups is similar in magnitude to that seen in normal weight women. Thus, using self-reports of height and weight seems unlikely to bias estimates of the association between obesity and clinical depression in women.

Association between obesity and depression in middle-aged women

OBJECTIVE

Evaluate the association between obesity and depression among middle-aged women.

METHODS

A total of 4641 female health plan enrollees aged 40-65 years completed a structured telephone interview including self-reported height and weight, the Patient Health Questionnaire (PHQ) assessment of depression; a brief measure of rate was 62%.

RESULTS

Prevalence of moderate or severe depression increased from 6.5% among those with body mass index (BMI) under 25 to 25.9% among those with BMI over 35. Prevalence of obesity increased from 25.4% among those with no depressive symptoms to 57.8% among those with moderate to severe depression. Independent of obesity, depression was associated with significant reductions in frequency of moderate (4.6 vs. 5.4 times per week) or vigorous (2.8 vs. 3.7 times per week) physical activity. Depression was associated with significantly higher daily caloric intake (1831 vs. 1543) among those with BMI over 30.

CONCLUSIONS

Among middle-aged women, depression is strongly and consistently associated with obesity, lower physical activity and (among the obese) higher caloric intake. Public health approaches to reducing the burden of obesity or depression must consider the strong association between these two common conditions.

Concordance of population-based estimates of mammography screening

OBJECTIVE

Estimates of adherence to mammography screening guidelines vary, in part, due to lack of consensus on defining adherence. This study estimated adherence to repeat (two successive on-time screenings) and regular screening (three or more successive screenings) and evaluated the impact of varying operational definitions and evaluation periods.

METHODS

The study included women aged 50-80 without a history of breast cancer who: were on a biennial screening cycle and due for a screening mammogram between 1995 and 1996; underwent screening (index date) in response to a reminder letter; and belonged to Group Health, an integrated health care delivery system in Washington State, for 6 or more years after the index date. Automated records provided information on enrollment, health care utilization, and procedures.

RESULTS

Among 1336 women, 67-82% experienced a repeat screen. Adherence to regular screening over the 6-year evaluation period was 42-84%--and higher with longer allowable intervals between screenings, when definitions did not require on-schedule screenings, when intervals were reset after a diagnostic mammogram, and for shorter evaluation periods.

CONCLUSION

Estimates of adherence to screening guidelines varied by the operational definition of "success" and time period of evaluation. Consensus in definitions and terminology is needed to compare evaluations.

Relation of body mass index to depression and weighing frequency in overweight women

OBJECTIVE

Research suggests that overweight and obesity are associated with depressive symptoms, particularly among women. Evidence from weight control trials suggests that higher weighing frequency is associated with greater weight loss or less weight gain. As limited data exist on the effects of self-weighing on body mass index (BMI) among overweight adults with or without depression, this study seeks to examine this issue using data from a population-based epidemiologic survey.

METHODS

Data from a large population-based survey of 4655 women ages 40-65 in the greater Seattle area, surveyed from November 2003 to February 2005, were used to examine associations of depression and weight self-monitoring with BMI. Sample-weighted regression models were used to examine associations of depression, self-weighing frequency, and BMI, with demographic factors (race/ethnicity, employment status, smoking status, age, martial status, educational attainment) entered as covariates.

RESULTS

Regression models indicated that higher self-weighing frequency and negative depression status were independently associated with lower BMI, with no interaction observed between depression and self-weighing.

CONCLUSION

Frequent self-weighing appears to be associated with lower BMI in both depressed and non-depressed overweight women.

Mammographic breast density, dense area, and breast area differences by phase in the menstrual cycle

BACKGROUND

Mammographic breast density may be greater in the luteal phase (days 15-30) than the follicular phase (days 1-14) of the menstrual cycle; this may have implications for when mammography screening should occur.

OBJECTIVE

Examine whether percent breast density, breast area, or dense area differ by menstrual phase.

METHODS

We identified 204 premenopausal women with regular periods who were <55 years (mean = 45.0 years) and had two screening mammograms within 9 to 18 months, with one screening between days 9 and 14, and one screening between days 22 and 35 of the menstrual cycle. We measured percent breast density, breast area, and dense area using the Cumulus software. We used linear regression to test for differences in breast density, breast area, and dense area from follicular to luteal phase, adjusting for change in weight and time between exams.

RESULTS

The mean (SD) percent breast density was 35.8% (21.3) in the follicular phase and 36.7% (21.3) in the luteal phase. Multivariable analyses showed small but not statistically significant increases in percent density [1.1%; 95% confidence interval (95% CI), -0.2% to 2.3%] and breast area (16.7 cm(2); 95% CI, -2.8 to 36.2) and a statistically significant increase in dense area (13.1 cm(2); 95% CI, 0.1-26.1) in the luteal compared with the follicular phase.

CONCLUSIONS

Breast density, breast area, and dense area have small, but probably not clinically meaningful, increases in the luteal phase of the menstrual cycle. However, there are other factors that may differ by menstrual cycle phase that we were unable to assess (e.g., breast compression), which may ultimately influence mammographic sensitivity by menstrual cycle phase.

Statin use and breast cancer risk in a large population-based setting

BACKGROUND

Mechanistic studies suggest that 3-hydroxy-3-methylglutaryl CoA inhibitors (statins) reduce the risk of breast cancer. Observational studies offer mixed results.

METHODS

To evaluate the relation between statin use and breast cancer risk, we conducted a cohort study among women ages 45 to 89 years within an integrated health care delivery system. Information on statin use and covariates were obtained from automated databases. We identified breast cancer cases through the Surveillance, Epidemiology, and End Results registry. We used Cox proportional hazards models to estimate the hazard ratios (HR) and 95% confidence intervals (95% CI) for invasive breast cancer among statin users compared with nonusers.

RESULTS

Among 92,788 women studied from 1990 to 2004, median follow-up time was 6.4 years, and 2,707 breast cancer cases were identified. During the study period, 7.4% of women used statins for at least 1 year, and the median duration of use was 3.1 years. We found no difference in breast cancer risk among statin users (HR, 1.07; 95% CI, 0.88-1.29) compared with nonusers. Risk of breast cancer did not differ by duration of use (1-2.9, 3-4.9, or >or=5 years) or hydrophobic statin use. We found a suggestive increased risk of breast cancer among statin users of >or=5 years (HR, 1.27; 95% CI, 0.89-1.81 for any statins and HR, 1.47; 95% CI, 0.89-2.44 for hydrophobic statins) and of estrogen receptor-negative tumors with increasing duration of statin use (1-2.9 years: HR, 1.33; 95% CI, 0.64-2.77; 3-4.9 years: HR, 1.68; 95% CI, 0.72-3.92; >or=5 years: HR, 1.81; 95% CI, 0.75-4.36).

CONCLUSION

This study does not support an association between statin use and breast cancer risk.

Lung cancer risk prediction: a tool for early detection

Although 45% of men and 39% of women will be diagnosed with cancer in their lifetime, it is difficult to predict which individuals will be affected. For some cancers, substantial progress in individual risk estimation has already been made. However, relatively few models have been developed to predict lung cancer risk beyond effects of age and smoking. This paper reviews published models for lung cancer risk prediction, discusses their potential contribution to clinical and research settings and suggests improvements to the risk modeling strategy for lung cancer. The sensitivity and specificity of existing cancer risk models is less than optimal. Improvement in individual risk prediction is important for selection of individuals for prevention or early detection interventions. In addition to smoking, factors related to occupational exposure, personal medical history and family history of cancer can add to the predictive power. A good risk prediction model is one that can identify a small fraction of the population in which a large proportion of the disease cases will occur. In the future, genetic and other biological markers are likely to be useful, although they will require rigorous evaluation. Validation is essential to establish the predictive effect and for ongoing monitoring of the model's continued relevance.

Varying levels of family history of breast cancer in relation to mammographic breast density (United States)

OBJECTIVE

We examined the relationship between breast cancer family history and mammographic breast density.

METHODS

Participants included 35,019 postmenopausal women aged >or=40 years enrolled in a population-based mammography screening program. We collected data on the number and type of 1st and 2nd degree female relatives with a history of breast cancer and their ages at diagnosis. We used the Breast Imaging Reporting and Data System breast density categories to identify women with fatty (1 = almost entirely fatty or 2 = scattered fibroglandular tissue) and dense (3 = heterogeneously dense or 4 = extremely dense) breasts. We used logistic regression to calculate odds ratios (OR) and 95% confidence intervals for dense (N = 18,111) compared to fatty breasts (N = 16,908).

RESULTS

The odds of having dense breasts were 17% greater for women with affected 1st degree relatives than women with no family history. The odds increased with more affected 1st degree relatives [>or=3 vs. none (OR = 1.46; 1.05-2.01)] and among women with >or=1 affected 1st degree relative diagnosed <50 years (OR = 1.22; 1.10-1.34).

CONCLUSIONS

Having a family history of breast cancer was more strongly associated with mammographic breast density when the affected relatives were more genetically similar. There may be common, yet undiscovered, genetic elements that affect breast cancer and mammographic breast density.

Do breast cancer risk factors modify the association between hormone therapy and mammographic breast density? (United States)

OBJECTIVE

To evaluate whether the association between hormone therapy (HT) and breast density differs by levels of breast cancer risk factors.

METHODS

We evaluated 80,867 screening mammograms from 39,296 postmenopausal women from Washington State. We estimated odds ratios and 95% confidence intervals for dense breasts (Breast Imaging Reporting and Data System categories 3 "heterogeneously dense" and 4 "extremely dense") compared to fatty breasts (categories 1 "almost entirely fat" and 2 "scattered fibroglandular") among HT users compared to never users. We separately examined former HT use and current HT use by type (estrogen plus progestin therapy (EPT) and estrogen-only therapy (ET)). We stratified the associations by age, BMI, race, family history, and reproductive and menopausal factors.

RESULTS

Current EPT users had a 98% (1.87-2.09) greater odds of having dense breasts and current ET users had a 71% (1.56-1.87) greater odds compared to never users. Current HT users were more likely to have dense breasts if they were older, had more children, or younger at first birth compared to never users; these associations were stronger among EPT users than ET users.

CONCLUSIONS

HT, particularly EPT, may reduce protective effects of older age, parity, and younger age at first birth on mammographic density.

Effects of a telephone counseling intervention on sisters of young women with breast cancer

OBJECTIVE

Women that have a first-degree relative diagnosed with breast cancer at an early age are at increased risk of the disease, yet they often lack information about their personal risk of breast cancer and early detection measures. An intervention to provide objective risk information, reduce worries, and promote screening and healthy behaviors was developed.

METHOD

In 1999-2002, a randomized pre-post design was used to test a tailored telephone counseling intervention with a sample of 163 women whose sisters were diagnosed with breast cancer at age 50 or younger in the San Francisco Bay Area. Participants were interviewed by telephone regarding their breast cancer risk factors, perceived risk, worries, lifestyle factors, and screening behavior. A modified Gail model was used to compute an objective measure of individualized lifetime risk.

RESULTS

Risk overestimates averaged 25 percentage points. The intervention was effective in reducing overestimates in women age 50 and over but not in those under 50. The intervention was effective in increasing physical activity and reinforcing the conviction to maintain good breast health, but not in decreasing worries or increasing screening.

CONCLUSION

Telephone counseling appears to be a viable tool for reducing risk overestimates and promoting healthy behaviors among sisters of women with breast cancer.

Use of antidepressant medications in relation to the incidence of breast cancer

Although associations have been reported between antidepressant use and risk of breast cancer, the findings have been inconsistent. We conducted a population-based case-control study among women enrolled in Group Health Cooperative (GHC), a health maintenance organization in Washington State. Women with a first primary breast cancer diagnosed between 1990 and 2001 were identified (N = 2904) and five controls were selected for each case (N = 14396). Information on antidepressant use was ascertained through the GHC pharmacy database and on breast cancer risk factors and screening mammograms from GHC records. Prior to one year before diagnosis of breast cancer, about 20% of cases and controls had used tricyclic antidepressants (adjusted odds ratio = 1.06, 95% CI 0.94-1.19) and 6% of each group had used selective serotonin reuptake inhibitors (OR = 0.98, 95% CI 0.80-1.18). There also were no differences between cases and controls with regard to the number of prescriptions filled or the timing of use. Taken as a whole, the results from this and other studies to date do not indicate an altered risk of breast cancer associated with the use of antidepressants overall, by class, or for individual antidepressants.

Breast self-examination: self-reported frequency, quality, and associated outcomes

BACKGROUND

There is little information on the quality of breast self-examination (BSE) and associated outcomes.

METHOD

We conducted a retrospective cohort study of 27,421 women enrolled in a Pacific Northwest health plan. We linked responses regarding BSE quality from a questionnaire to subsequent screening and diagnostic efforts.

RESULTS

A total of 75% of the women performed BSE. We rated BSE quality as adequate in 27%. Women who reported higher BSE duration, frequency, and quality were more likely to have diagnostic mammograms. Participants ultimately diagnosed with breast cancer (N = 300) were significantly less likely to report performing BSE. Tumor size and stage were not associated with BSE behavior.

CONCLUSION

A high proportion of women perform BSE, but few do so adequately. We found no evidence for benefit of BSE. It is time to ask whether systematic BSE performance should continue to be encouraged.

Previous pregnancy outcome and breast density (United States)

OBJECTIVE

We evaluated the association of pre-term delivery (PTD), low birth weight (LBW), and fetal death with breast density by age at mammogram and years since birth.

METHODS

Subjects were women aged < or =55 years who had a screening mammogram between 1 June 1996 and 1 August 1997 in Seattle, Washington, and whose records were linked to their previous state birth (1 January 1968 to 1 August 1997) or fetal death (1/1/1984-8/1/1997) records. We used unconditional logistic regression, adjusting for age at mammogram, body mass index, age at first birth, and menopausal status, to calculate the odds of dense (extremely or heterogeneously dense by BI-RADS) (n=3593) versus fatty breasts (scattered fibroglandular tissue or almost entirely fat) (n=2378) for women with a prior PTD (< 34, 34-36 versus > or =37 weeks gestation), LBW (< 2500 versus > or =2500 g), or fetal death (stillborn 20 weeks gestation versus live birth).

RESULTS

The odds for denser breasts increased among women with PTD at <34 weeks gestation who were < or =45 years at time of mammogram (odds ratio (OR) and 95 confidence interval (CI)=2.8 (1.3-6.1)) and for whom <10 years had elapsed since pregnancy (OR=8.8 (1.7-45.8)). We observed similar increases in density among women with LBW (OR=3.3 (1.3-8.2)) when <10 years had elapsed.

CONCLUSIONS

PTD and LBW may have a transitory effect on breast density.

In a randomized controlled trial, patients preferred electronic data collection of breast cancer risk-factor information in a mammography setting

BACKGROUND AND OBJECTIVE

We evaluated patient acceptance of an electronic questionnaire to collect breast cancer risk-factor data in a mammography setting.

METHODS

We developed an electronic questionnaire on a tablet computer incorporating prefilled answers and skip patterns. Using a randomized controlled study design, we tested the survey in a mammography clinic that administers a paper risk-factor questionnaire to every woman at her screening mammogram. We randomized 160 women to use the electronic survey (experimental group, n = 86) or paper survey (control group, n = 74). We evaluated patient acceptance and data completeness.

RESULTS

Overall, 70.4% of the experimental group women thought the survey was very easy to use, compared to 55.6% of women in the control group. Ninety percent of experimental group women preferred using the tablet, compared to the paper questionnaire. Preference for the tablet did not differ by age; however, women > or = 60 years did not find the tablet as easy to use as did women < 60 years. The proportion of missing data was significantly lower on the tablet compared to the paper questionnaire (4.6% vs. 6.2%, P = .04).

CONCLUSION

Electronic questionnaires are feasible to use in a mammography setting, can improve data quality, and are preferred by women regardless of age.

An empirical assessment of high-performing medical groups: results from a national study

The performance of medical groups is receiving increased attention. Relatively little conceptual or empirical work exists that examines the various dimensions of medical group performance. Using a national database of 693 medical groups, this article develops a scorecard approach to assessing group performance and presents a theory-driven framework for differentiating between high-performing versus low-performing medical groups. The clinical quality of care, financial performance, and organizational learning capability of medical groups are assessed in relation to environmental forces, resource acquisition and resource deployment factors, and a quality-centered culture. Findings support the utility of the performance scorecard approach and identification of a number of key factors differentiating high-performing from low-performing groups including, in particular, the importance of a quality-centered culture and the requirement of outside reporting from third party organizations. The findings hold a number of important implications for policy and practice, and the framework presented provides a foundation for future research.

[Application of the Gail method of calculating risk in the population of Valencia]

BACKGROUND

The objective of this study was to verify whether the method defined by Gail is applicable and predictive in a population of women in Valencia (Spain).

POPULATION AND METHODS

Of the 685 patients diagnosed with breast cancer and attended-to in 2000-2001, 186 incident cases were identified. The variables studied were obtained from a specific questionnaire which included characteristics of reproductive history, number of biopsies and contraceptive pill consumption prior to the diagnosis. Using the model of the National Surgical Adjuvant Breast and Bowel Project (NSABP), an adaptation of the Gail model, the risk of developing breast cancer at 5 years was estimated.

RESULTS

Only 40% of those women diagnosed as having breast cancer would have been identified as a high-risk patient by the Gail method. With our population group, the method detected the elderly women with a medical history of breast cancer who developed advanced stage disease.

CONCLUSIONS

The Gail method does not adapt well to the study population of Valencia. It would be necessary to add other risk-factors to the Gail method so as to identify more patients in our area.

Cancer risk prediction models: a workshop on development, evaluation, and application

Cancer researchers, clinicians, and the public are increasingly interested in statistical models designed to predict the occurrence of cancer. As the number and sophistication of cancer risk prediction models have grown, so too has interest in ensuring that they are appropriately applied, correctly developed, and rigorously evaluated. On May 20-21, 2004, the National Cancer Institute sponsored a workshop in which experts identified strengths and limitations of cancer and genetic susceptibility prediction models that were currently in use and under development and explored methodologic issues related to their development, evaluation, and validation. Participants also identified research priorities and resources in the areas of 1) revising existing breast cancer risk assessment models and developing new models, 2) encouraging the development of new risk models, 3) obtaining data to develop more accurate risk models, 4) supporting validation mechanisms and resources, 5) strengthening model development efforts and encouraging coordination, and 6) promoting effective cancer risk communication and decision-making.

A population-based osteoporosis screening program: who does not participate, and what are the consequences?

OBJECTIVES

To describe differences in osteoporosis risk factors and rates of fracture and antiresorptive therapy use in women who did and did not participate in an osteoporosis screening program.

SETTING

Group Health Cooperative, a health maintenance organization in western Washington state.

PARTICIPANTS

A total of 9,268 women (aged 60-80) who were not using any antiresorptive therapy were invited to participate in an osteoporosis screening program. This study compares the 35% who participated with the 65% who did not.

DESIGN

This observational cohort study of women invited to participate in a randomized, controlled trial of an osteoporosis screening program provided all participants with personalized feedback on their risk of osteoporosis. Some participants also received bone density testing. Automated administrative data were used to examine differences between participants and nonparticipants in fracture outcomes and medication initiation before and after invitation.

RESULTS

Baseline fracture rates did not differ between participants and nonparticipants. After age adjustment, nonparticipants had a higher hip fracture rate (14.1 vs 8.3 per 1,000) and a lower rate of initiating any antiresorptive therapy (10.3 vs 17.9 per 100) than participants after an average of 28 to 29 months of follow-up.

CONCLUSION

Participants had reduced hip fracture rates and increased initiation of antiresorptive therapy compared with nonparticipants. It was not possible to determine whether participating in the screening program, unmeasured confounding, or selection bias accounted for differences in hip fracture or therapy initiation rates. These results suggest that women who do not participate in osteoporosis screening should be pursued to identify individuals who could benefit from primary and secondary osteoporosis prevention.

Association between mammographic breast density and breast cancer tumor characteristics

OBJECTIVE

Few studies have examined the association between breast density and breast cancer tumor characteristics. We examined the association between hormonal, proliferative, and histologic tumor characteristics and mammographic breast density in women with breast cancer.

METHODS

We conducted a cross-sectional analysis in 546 women diagnosed with invasive breast cancer to evaluate the associations between breast density and tumor size, lymph node status, lymphatic or vascular invasion, histologic grade, nuclear grade, tumor differentiation, mitotic index, tumor necrosis, Ki-67 proliferation, estrogen receptor, progesterone receptor, p53, p27, cyclin E, Bcl-2, and C-erb-B2 invasion. Breast density was classified as fatty (Breast Imaging Reporting and Data System code 1 or 2; n = 373) or dense (Breast Imaging Reporting and Data System code 3 or 4; n = 173) for the cancer-free breast. A single pathologist measured all tumor markers. We examined whether the relationships were modified by interval cancer or screen-detected cancer.

RESULTS

Women with a tumor size >1.0 cm were more likely to have dense breasts compared with women with a tumor size < or =1.0 cm after adjusting for confounders (odds ratio, 2.0; 95% confidence interval, 1.2-3.4 for tumor sizes 1.1-2.0 cm; odds ratio, 2.3; 95% confidence interval, 1.3-4.4 for tumor sizes 2.1-10 cm). Tumor size, lymph node status, and lymphatic or vascular invasion were positively associated with breast density among screen-detected cancers. Histologic grade and mitotic index were negatively associated with breast density in women diagnosed with an interval cancer.

CONCLUSIONS

These results suggest that breast density is related to tumor size, lymph node status, and lymphatic or vascular invasion in screen-detected cancers. Additional studies are needed to address whether these associations are due to density masking the detection of some tumors, a biological relationship, or both.

The relationship between breast density and bone mineral density in postmenopausal women

BACKGROUND

It is not well understood whether breast density is a marker of cumulative exposure to estrogen or a marker of recent exposure to estrogen. The authors examined the relationship between bone mineral density (BMD; a marker of lifetime estrogen exposure) and breast density.

METHODS

The authors conducted a cross-sectional analysis among 1800 postmenopausal women > or = 54 years. BMD data were taken from two population-based studies conducted in 1992-1993 (n = 1055) and in 1998-1999 (n = 753). The authors linked BMD data with breast density information collected as part of a mammography screening program. They used linear regression to evaluate the density relationship, adjusted for age, hormone therapy use, body mass index (BMI), and reproductive covariates.

RESULTS

There was a small but significant negative association between BMD and breast density. The negative correlation between density measures was not explained by hormone therapy or age, and BMI was the only covariate that notably influenced the relationship. Stratification by BMI only revealed the negative correlation between bone and breast densities in women with normal BMI. There was no relationship in overweight or obese women. The same relationship was seen for all women who had never used hormone therapy, but it was not significant once stratified by BMI.

CONCLUSIONS

BMD and breast density were not positively associated although both are independently associated with estrogen exposure. It is likely that unique organ responses obscure the relationship between the two as indicators of cumulative estrogen exposure.

Factors Contributing to Mammography Failure in Women Aged 40-49 Years

BACKGROUND

Younger women (40-49 years) have lower mammographic sensitivity (i.e., greater proportion of cancers detected after a negative mammogram) than older women (> or =50 years). We explored the effect of tumor growth rate, breast density, mammographic image quality, and breast cancer risk factors on mammographic sensitivity in younger and older women.

METHODS

We studied 576 women (n = 73 aged 40-49 years and n = 503 aged 50 years or older) who were diagnosed with invasive breast cancer between 1988 and 1993. Interval cancers were defined as those diagnosed within 12 or 24 months after a negative screening mammogram and before a subsequent mammogram. Tumor growth rate was assessed by mitotic figure count and Ki-67 positivity. The main outcome measures were percentage of women with interval cancer (1 -mammographic sensitivity) by age, odds ratio (OR) of interval cancer by age, and excess odds (i.e., the percentage of the odds ratio for age that was explained by individual covariates).

RESULTS

Interval cancers occurred in 27.7% of younger women and 13.9% of older women within 12 months (OR = 2.36, 95% confidence interval [CI] = 1.14 to 4.77) and in 52.1% of younger women and 24.7% of older women within 24 months (OR = 3.58, 95% CI = 2.15 to 5.97). Greater breast density explained 67.6% of the decreased mammographic sensitivity in younger women at 12 months, whereas rapid tumor growth explained 30.6% and breast density explained 37.6% of the decreased sensitivity in younger women at 24 months.

CONCLUSIONS

Breast density largely explained decreased mammographic sensitivity at 12 months, whereas rapid tumor growth contributed to decreased mammographic sensitivity at 24 months. A 12-month versus a 24-month mammography screening interval may therefore reduce the adverse impact of faster growing tumors on mammographic sensitivity in younger women.

Evaluating organized breast cancer screening implementation: the prevention of late-stage disease?

The objective of our study was to evaluate organized breast cancer screening implementation by measuring the association between screening program enrollment and late-stage disease. Our setting was a health plan using mailed mammography reminders to women ages > or = 40. We conducted yearly cross-sectional summaries of mammography experience and late-stage (regional or distant Surveillance Epidemiology and End Results Reporting (SEER) stage) breast cancer occurrence for all of the health-plan women ages > or = 40 (1986-1998). We estimated the odds of late-stage breast cancer among health-plan and surrounding community women because it was too early to compare changes in mortality. We also estimated the odds of late-stage disease (1995-1998) associated with program enrollment and mammography screening among health-plan women. We found that mammography-within-two-years increased within the health plan from 25.9% to 51.2% among women ages 40-49 and from 32.9% to 74.7% among women ages> or = 50. Health-plan late-stage rates were lower than those in the surrounding community [ages 40-49: odds ratio (OR), 0.87; 95% confidence interval (CI), 0.77-0.99; ages 50-79: OR, 0.86; 95% CI, 0.80-0.92] and declined parallel to the community. Among health-plan cancer cases, women ages > or = 43 who were enrolled in the screening program and who had at least one program mammogram were less likely to have late-stage disease compared with the women not enrolled in the program (OR, 0.31; 95% CI, 0.16-0.61) but the odds of late-stage was also reduced among program-enrolled women not receiving program mammograms (OR, 0.45; 95% CI, 0.21-0.95). We concluded that enrollment in organized screening is associated with increased likelihood of mammography and reduced odds of late-stage breast cancer. Addressing the concerns of un-enrolled women and those without mammograms offers an opportunity for further late-stage disease reduction.

Health promotion in physician organizations: results from a national study

BACKGROUND

Health promotion programs can be effective in improving the delivery of clinical preventive services and in improving population health; however, the availability of health promotion programs offered through physician organizations, such as medical groups and independent practice associations, are largely unknown.

METHODS

This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California, Berkeley, to document the extent to which physician organizations offer health promotion programs. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%.

RESULTS

Overall, 60% of physician organizations offer at least one health promotion program targeting one or more of eight areas: prenatal education (42%), smoking cessation (39%), nutrition (39%), weight loss (34%), health risk assessments (25%), stress management (25%), substance abuse (20%), and sexually transmitted disease prevention (16%). Factors positively associated with offering health promotion programs include the following: outside reporting of quality measures, public recognition for quality measures, clinical information technology systems, being a medical group, and ownership by a hospital or health plan.

CONCLUSIONS

Physician organizations in the United States have a long way to go in offering these important programs to their patients. However, our findings also suggest that health plans, purchasers, and policymakers can play a positive role in increasing the use of these programs. By offering recognition and incentives for quality improvement, and by funding the expansion of information technology, the healthcare community can encourage and enable physician organizations to increase the availability of health promotion programs nationally.