Mammographic screening of women with increased risk of breast cancer

Compliance with Breast and Cervical Cancer Screening Programs in Women: Results from a Population-Based Study

Aims and background

Women's adherence to mammography and PAP test screening guidelines is a fundamental topic regarding women's health. The aim of the study was to evaluate the knowledge and compliance to breast and cervical cancer screening programs in women living in three Italian towns, where a public screening program, consisting of free mammography every two years and free PAP test every three years, is ongoing.

Methods

An anonymous survey was mailed to a random sample of women. Eight 120-min focus discussions with groups of women exploring perceptions, knowledge and practices were carried out after analysis of the returned surveys.

Results

Replies were received from 1345 women (response rate, 27%). Almost every woman knew of the screening program, but women's practice of mammography was age-dependent: up to 72% of the women performed it before the age of 50. Conversely, the age of the first PAP test was rather late: up to 70% of the women performed it at over 30 years of age. Women with a lower educational level reported being screened less than those with a higher level. During the group discussions, women's perceptions, knowledge and beliefs regarding cancer and screening, together with aspects of the health care system, appeared to strongly influence the preventive practices. Many women deplored being infrequently instructed by health professionals.

Conclusions

Despite the limitations of the study due to the low response rate, we believe that health professionals should invest on encouraging factors and reduce the deterring factors to optimize screening practices.

Predictors of Breast Cancer Worry in a Hispanic and Predominantly Immigrant Mammography Screening Population

OBJECTIVE

Worry about developing breast cancer (BC) has been associated with participation in screening and genetic testing and with follow-up of abnormal screening results. Little is known about the scope and predictors of BC worry in Hispanic and immigrant populations.

METHODS

We collected in-person interview data from 250 self-identified Hispanic women recruited from an urban mammography facility (average age 50.4 years; 82% foreign-born). Women reported whether they worried about developing breast cancer rarely/never (low worry), sometimes (moderate worry), or often/all the time (high worry). We examined whether sociocultural and psychological factors (e.g., acculturation, education, perceived risk), and risk factors and objective risk for BC (e.g., family history, Gail model 5-year risk estimates, parity) predicted BC worry using multinomial and logistic regression.

RESULTS

In multivariable models, women who perceived higher absolute BC risk (odds ratio, 1.66 [95% confidence interval, 1.28-2.14] for a one-unit increase in perceived lifetime risk) and comparative BC risk (e.g., odds ratio, 2.73, 95% confidence interval, 1.23-6.06) were more likely to report high BC worry than moderate or low BC worry. There were no associations between BC worry and indicators of objective risk or acculturation.

CONCLUSIONS

In Hispanic women undergoing screening mammography, higher perceptions of BC risk, in both absolute and comparative terms, were associated independently with high BC worry, and were stronger predictors of BC worry than indicators of objective BC risk, including family history, mammographic density, and personal BC risk estimates.

Predictors of breast cancer screening behavior in women with a strong family history of the disease

This study applied the self-regulation model to examine cognitive and emotional predictors of screening in unaffected women with a strong family history of breast cancer. 748 unaffected female members of an Australian registry of multiple-case breast cancer families formed the sample. Participants completed a baseline psychosocial questionnaire and a screening questionnaire 3 years later. Multinomial logistic regression was employed to determine predictors of under- and over-screening according to national guidelines. At follow-up 16% of women under-screened and 10% over-screened with mammography; 55% under-screened with clinical breast examination (CBE); and 9% over-screened with breast self-examination (BSE). Of the women found screening according to guidelines for mammography 72% reported ever having received specific recommendations for mammography screening from a health professional. Compared to appropriate screeners, under-screeners on mammography were less likely to have received a screening recommendation (as were under-screeners on CBE), were younger and reported lower perceived breast cancer risk, but were at higher relative risk (RR) of breast cancer and were more likely to report elevated depression. Over-screeners on mammography were more likely to be younger and have a lower RR of breast cancer. Over-screeners on BSE reported elevated cancer-specific anxiety, were less likely to be university educated and more likely to have received a recommendation for BSE. Under- and over-screening is common in women with a strong family history of breast cancer. Evaluation of interventions targeting perceived risk of breast cancer, anxiety and depression are needed to ensure women obtain accurate advice from relevant specialists and enact screening recommendations.

Predicting regular breast cancer screening in African-American women with a family history of breast cancer

OBJECTIVE

To evaluate the impact of socioeconomic, personal and affective factors on regular breast cancer screening in at-risk African-American women.

METHODS

The study was a cross-sectional analysis assessing socioeconomic and affective predictors of breast cancer screening practices. Unaffected African-American women ages 40-64 with a family history of breast cancer were recruited from community settings. The main outcome measures were recent mammography, regular mammography and regular breast self-examinations.

RESULTS

The majority of women reported having a recent mammogram (73%) and yearly mammograms (71%). More than half (56%) reported monthly breast self-examinations (BSEs). Available health insurance and risk perception had significant independent associations with regular mammography screening so that women having a mammogram every 6-12 months were more likely to have health insurance [odds ratio (OR)=4.99, 95% confidence interval (CI): 1.05-23.52], and women not engaged in regular screenings were less likely to perceive future breast cancer risk (OR=0.10, 95% CI: 0.01-0.96). Access to regular healthcare had a significant independent association with recent mammography so that women having a mammogram in the past 12 months were more likely to have access to regular healthcare (OR=6.59, 95% CI: 1.01-42.79).

CONCLUSIONS

A significant majority of this subset of African-American women engage in repeat mammography screenings with cognitive and economic factors predicting noncompliance. Additional research with repeat mammography users is required so that regular screening practices can be encouraged among all at-risk women.

Breast self-examination in long-term breast cancer survivors

INTRODUCTION

For many breast cancer survivors, continued surveillance will be necessary to increase the possibility of finding a new diagnosis in an early stage. One such surveillance approach, breast self-examination, has not been studied specifically in breast cancer survivors. The current study was designed to assess the practice of BSE in a sample of long-term breast cancer survivors, and to examine the personal, emotional, cognitive, and health-care provider factors that may contribute to its performance.

METHODS

Three hundred forty-five breast cancer survivors (34% response rate, 345/1,001) diagnosed with in situ-stage II breast cancer between 1997-2004 at a community hospital provided answers to a mailed, self-report questionnaire.

RESULTS

Seventy-six percent of respondents reported that they had performed a BSE in the last 30-days. Forty percent reported performing BSE once/month, 39% more than once/month, and 21% less than once/month since their diagnosis. Most of the women (90%) reported that a doctor or nurse told them to perform a BSE once/month since their diagnosis, although only 69% had actually been shown how to perform a BSE. Consistently, the perception of increased barriers to BSE performance was associated with performance of BSE less than once/month (OR = 1.4, 95% CI 1.2, 1.6; OR = 0.8, 95% CI 0.8, 0.9). In addition, depending on the model, age (OR = 1.1, 95% CI 1.0, 1.2), perceived effectiveness of cancer treatments (OR = 0.7, 95% CI 0.5, 0.9), and perceived benefits of BSE (OR = 0.8, 95% CI 0.7, 0.9) also was associated with differences in BSE performance.

CONCLUSION

The current study suggests that breast cancer survivors between 4 and 11 years from diagnosis practice BSE, although their perception of the barriers to conducting BSE influences the frequency of this behavior. Further examination is needed to understand why some survivors perceive greater barriers to BSE performance than others. Also needed is a prospective examination of BSE performance using behavioral measures in relation to self-report.

IMPLICATIONS FOR CANCER SURVIVORS

Increased attention should be paid to this particular screening behavior performed by a majority of breast cancer survivors by both researchers and health-care providers alike. Whether survivors perform the behavior correctly and the impact it has on their emotional and cognitive well-being should be further explored.

Family matters in mammography screening among African-American women age > 40

PURPOSE

To examine how family history of cancer influences the mammography screening behaviors of asymptomatic African-American women.

METHODS

Using the National Health Interview Survey's 2000 Cancer Control Module, the authors performed bivariate analyses and multivariate logistic regressions with SAS/SUDAAN due to the complex sampling design.

RESULTS

Of the 1,531 African-American women in the final sample, 38% had a family history of cancer. Women with a family history of cancer were 39% more likely to have a recent mammogram compared to women with no family history of cancer (OR = 1.39; 95% CI: 1.06-1.81; p < 0.05). Eighty-five percent of African-American women aged > 40 with a family history of cancer indicated having a mammogram in the past compared to nearly 70% of African-American women without a family history of cancer.

CONCLUSION

Family history of any cancer independently and positively predicted mammography screening behaviors among asymptomatic African-American women. This suggests that African-American women with a history of cancer in their family are more likely (and perhaps more motivated) to engage in early cancer detection practices.

Predictors of non-attendance from BreastScreen NSW in women who report current mammography screening

OBJECTIVE

To identify among self-reported current screeners: (1) predictors of never attendance at BreastScreen NSW (BSNSW); (2) predictors of late or lapsed attendance to BSNSW (attendance to alternative providers).

METHODS

Random samples of women aged 50-69 years were selected from the BSNSW database and NSW electoral roll as: current attenders to BSNSW (<27 months since last screen); late or lapsed attenders to BSNSW (>27 months since last screen); or women who had never attended BSNSW. The response rate was 71% (3,104) for a telephone interview that asked questions concerning demographics, medical status and health service usage, and opinions and behaviours related to mammography.

RESULTS

Never attendance at BSNSW was predicted by higher income, advice from a doctor or nurse to have their last mammogram, recent clinical breast examination and belief that a referral letter is necessary. Late or lapsed attendance to BSNSW (and attendance to alternate providers) was associated with higher education, health insurance coverage, recent clinical breast examination and a family history of breast cancer.

CONCLUSIONS

Currently screened women who do not attend BSNSW, or who are late or lapsed for a mammogram, appear to be influenced by referral patterns of their health care providers and their higher socio-economic status.

IMPLICATIONS

BSNSW should be promoted to eligible women and general practitioners as a specialty mammography screening service that does not require a referral.

BRCA1/2 testing in hereditary breast and ovarian cancer families III: Risk perception and screening

This study aimed to ascertain whether cancer risk perception changed following the offer and subsequent receipt of BRCA1/2 results and to evaluate breast and ovarian screening practices in testers and non-testers. Members of thirteen HBOC families were offered BRCA1/2 testing for a known family mutation. Perceived risk for developing breast cancer, ovarian cancer or for carrying the familial BRCA1/2 mutation, was assessed at baseline and again at 6-9 months following the receipt of test results. Breast and ovarian cancer screening data were obtained at both time-points. A total of 138 women participated and 120 (87%) chose to be tested for a known familial mutation. Twenty-eight women (24%) were identified as carriers and their perceived ovarian cancer risk and their perception of being a mutation carrier increased (P = 0.01 for both). Those testing negatives had a significant decrease in all dimensions of risk perception (P < 0.01). Regression analysis showed test results to be strong predictors of follow-up risk perception (P = 0.001), however, they were not predictors of screening practices at follow-up. Testers were more likely to have completed a clinical breast exam following testing than decliners. Mammography was positively associated with baseline adherence, age, and intrusive thoughts. Ovarian cancer worries only predicted pelvic ultrasound screening post-testing. Baseline practices and psychological factors appear to be stronger predictors of health behavior than test results.

Development and Psychometric Testing of the Coping With Breast Cancer Threat Instrument

Women with a positive family history of breast cancer have a higher relative breast cancer risk. Research pertinent to this “at-risk” population has focused primarily on the early detection measures of breast self-exam, clinical breast exam, and mammography. Other specific primary prevention coping behaviors have received little research attention and, while there are instruments that measure general coping behaviors in the face of illness threat, there are no known instruments that measure coping behaviors specific to dealing with breast cancer threat. This study tested the psychometric properties of the Coping with Breast Cancer Threat instrument (CBCT). The CBCT was designed to measure primary prevention and early detection coping strategies used by women with family histories of breast cancer in response to their appraised breast cancer threat. The tool’s format was modeled after the Jalowiec Coping Scale (JCS) and included use and effectiveness scales. Internal consistency reliabilities and content and construct validity of the CBCT were assessed in a sample of 209 women with a family history of breast cancer. Alpha coefficients for the CBCT’s total use and effectiveness scales were .70 and .76, respectively. Principal components factor analysis with a varimax rotation revealed three conceptually relevant subcales that accounted for 52% of the variance in breast cancer threat coping behaviors. The CBCT was shown to be a reliable and valid measure of coping with breast cancer threat in a well-educated, European Amercian sample of middle-aged women.

Awareness and concern about ovarian cancer among women at risk because of a family history of breast or ovarian cancer

Research on women at risk for breast cancer because of family history suggests that a substantial proportion need education and counseling to assist them in their efforts to understand their risk of breast cancer and that some do not get appropriate breast cancer screening. Although women at high genetic risk for breast cancer are at elevated risk for ovarian cancer as well, few studies have examined these women's needs for education and counseling about ovarian cancer risk. This study examined awareness of ovarian cancer, perceived risk of breast and ovarian cancer, interest in genetic testing, and use of screening for breast and ovarian cancer in a population-based sample of women at high risk for breast and ovarian cancer because of a strong family history of cancer at one or both sites. We found that most high-risk women are not getting the information and care they need with respect to their risk for ovarian cancer. Almost 75% have not heard much about their risk for ovarian cancer. More than 90% failed to use 1 or another of 2 possible tests used for ovarian cancer screening regularly.

Breast carcinoma screening and risk perception among women at increased risk for breast carcinoma

BACKGROUND

The Gail model is validated to estimate breast carcinoma risk. The authors assessed the association of Gail risk scores with screening and cancer risk perception.

METHODS

Using the 2000 National Health Interview Survey, the authors studied women ages 41-70 without a cancer history. Gail scores > or = 1.66% defined increased risk. The authors used logistic regression to assess associations between breast carcinoma risk and previous and recent (< or = 1 year) mammography and clinical breast examination (CBE).

RESULTS

Of 6410 women, 15.7% had increased risk. High-risk women more frequently reported previous mammograms (94% vs. 85%; P < 0.0001), previous CBE (93% vs. 88%; P < 0.0001), recent mammograms (70% vs. 54%; P < 0.0001), recent CBE (71% vs. 61%; P < 0.0001), and high cancer risk perception (20% vs. 9%; P < 0.0001). However, 30% of high-risk women had not received a recent mammogram. After adjustment for sociodemographic factors, access to care factors, and cancer risk perception, high-risk women remained more likely to have received recent mammography (adjusted odds ratio [OR], 1.45, 95% confidence interval [95% CI], 1.19-1.77), recent CBE (OR, 1.32; 95% CI, 1.08-1.61]), and previous mammography than average-risk women. The authors observed an interaction between risk and age, with women ages 41-49 years more frequently reporting previous mammography (OR, 4.79; 95% CI, 1.55-4.81) than average-risk, same-age women. For women age > or = 50 years, the odds of previous mammography were similar regardless of risk.

CONCLUSIONS

In a nationally representative sample, 15.7% of women had increased breast carcinoma risk using the Gail model. High-risk women perceived higher cancer risk and more often received screening. However, nearly one in three high-risk women did not receive recent screening and most of these women did not perceive increased risk.

The relationship between perceived risk, affect, and health behaviors

In this study, we examined the relationship between affect and health behaviors. The study participants were women (n = 1366), aged 18-74 years, who had not been previously diagnosed with breast cancer, who had a working telephone number and address, who spoke English, who planned to be in their present residence for at least 1 year, and who were willing to complete the survey requirements. General anxiety was a significant predictor of eating a low-fat diet, in a quadratic manner (p < .05). General anxiety and breast cancer worry were significant predictors of breast self-examination, in a quadratic fashion (p < .05). None of four independent variables, perceived risk, cancer worry, general anxiety, and general depression scores, were significantly related to mammography use, physical activity, or fruit and vegetable consumption. We must look beyond risk perceptions and family history to understand motivations for health behaviors.

The Impact of a Family History of Breast Cancer on Screening Practices and Attitudes in Low-Income, Rural, African American Women

BACKGROUND

Women with a family history of breast cancer are at increased risk for developing cancer and, therefore, might be expected to engage in early detection practices more actively than women without a family history. Alternatively, women with a family history may avoid thinking about cancer and have attitudes and practices that do not promote early detection.

METHODS

This study examined breast cancer attitudes and practices among African American women aged >or=50 who had not had a mammogram in the last 2 years.

RESULTS

Phone survey data from 320 female clients of low-income, rural primary care clinics (91% African American) indicated that 15% self-reported a family history of breast cancer (FH(+)). Half of the FH(+) women did not know their relative risk of developing breast cancer. Of those providing a risk estimate, 67% perceived themselves at low risk compared with other women their age. Perceived relative risk was comparable between FH(+) and FH(-) women. Further, FH(+) women did not indicate greater worry about breast cancer, nor did they have more accurate knowledge of mammography recommendations than FH(-) women. Two thirds of FH(+) women had never had a mammogram. Monthly breast self-examination did not differ between FH(+) and FH(-) women.

CONCLUSIONS

Thus, neither knowledge of a positive family history nor perceived relative risk of breast cancer was associated with either increased or decreased early detection practices among these low-income, rural, African American women who have underused mammography. Furthermore, a substantial proportion of FH(+) women had not ever participated in screening mammography. Interventions to increase mammography rates in this population of underusers are indicated.

Experience with breast cancer, pre-screening perceived susceptibility and the psychological impact of screening

This prospective study examined whether the psychological impact of organized mammography screening is influenced by women's pre-existing experience with breast cancer and perceived susceptibility (PS) to the disease. From a target population of 16,886, a random sample of women with a normal screening finding and all women with a false positive or a benign biopsy finding were included (N=1942). Data were collected with postal questionnaires 1-month before screening invitation and 2 and 12 months after screening. Response rate was 63% at baseline; 86, and 80% of the baseline participants responded to the follow-ups. Psychological impact was measured as anxiety (STAI-S), depression (BDI), health-related concerns (IAS), and breast cancer-specific beliefs and concerns. Data was analyzed with repeated measures analyses of variance, with estimates of effect size based on Eta-squared. Women with breast cancer experience had higher risk perception already before screening invitation; after screening they were also more distressed. Women with high PS were more distressed than women with low PS also at pre-invitation. The distress was not alleviated by screening, but instead remained even after normal mammograms. Experience and PS did not influence responses to different screening findings. Of the finding groups, false positives experienced most adverse effects: their risk perception increased and they reported most post-screening breast cancer-specific concerns. Furthermore, they became more frequent in breast self-examination (BSE) despite a simultaneous decrease in BSE self-efficacy. Our findings suggest that women with high PS and women with false positive screening finding may need individualized counseling and follow-up as much as women with a family history of breast cancer. Besides medical risk factors, women's own perceptions of susceptibility should be discussed during the screening process.

Reports of information and support needs of daughters and sisters of women with breast cancer

The aim of this study was to describe the information and support needs of women who have primary relatives with breast cancer. The Information and Support Needs Questionnaire (ISNQ) was developed and revised from previous qualitative and pilot studies. The ISNQ addressed concepts of the importance of, and the degree to which, 29 information and support needs related to breast cancer had been met. The study sample consisted of 261 community-residing women who had mothers, sisters, or a mother and sister(s) with breast cancer. Data were collected using a mailed survey. In addition to the ISNQ, additional items addressed family and health history, breast self-care practices, perception of the impact of the relative's breast cancer and other variables. Also included were established and well-validated measures of anxiety and depression. The findings document women's priority information and support needs. The information need most frequently identified as very important was information about personal risk of breast cancer. Other highly rated needs addressed risk factors for breast cancer and early detection measures. Generally, the women perceived that their information and support needs were not well met. These findings illuminate needs of women for more information and support when they have close family relatives with breast cancer and opportunities for primary care providers to assist women in addressing their needs.

Living with the worry of cancer: health perceptions and behaviors of elderly people with self, vicarious, or no history of cancer

Cancer is a major health threat that has a long-term impact on quality of life and health worries. The present study is focused on two major issues: (1) the impact that a history of cancer has on reactions to other diseases, in addition to cancer and general health worries; and, (2) the impact that having lived with someone who had cancer has on health perceptions and behaviors. All 108 participants had osteoarthritis, a symptomatic but benign disease (49 people have had cancer, 22 had lived with a cancer patient, and 37 had not had any close experience with cancer). Cancer and health worries were lowest among the people with vicarious experience, while monitoring for bodily signs was similar and highest in both cancer experience groups. Reactions to arthritis suggest more vigilance among people who have had self or vicarious experience with cancer, while reactions to ambiguous symptoms suggest vigilance especially among those with a personal history of cancer. Overall, the findings suggest that the effects of self-experience with cancer and of close experience with a cancer patient may be long-term and impact upon both health perceptions and behaviors.

First-degree relatives of breast-cancer patients: cognitive perceptions, coping, and adherence to breast self-examination

The author assessed patterns of breast self-examination (BSE) related to cognitive appraisal, coping, and emotional distress in 80 women with first-degree relatives who were breast-cancer patients and 47 matched controls. Participants with first-degree relatives adhered to BSE better than did women with no family history of breast cancer, and women whose relatives had recurrent or metastatic disease performed more BSE than those whose relatives were currently disease free. Greater adherence to BSE was associated with lower levels of depression, more problem-focused coping, older age, and more education. In the women with first-degree relatives, BSE was also associated with higher perceptions of (a) control over prevention, (b) risk for breast cancer, and (c) higher levels of state anxiety. Perception of control, problem-focused coping, depression, and anxiety predicted 35% of the variance in adherence to BSE. The findings suggest that cognitive appraisal, coping strategies, and levels of emotional distress should be considered in designing programs for enhancing adherence to early detection procedures.

Effecting behavior change: awareness of family history

This article explores the use of family history of disease as a public health tool for risk stratification and improved disease prevention by drawing from previous research on women at moderate risk of developing breast cancer because of a positive family history. About one quarter to one third of women do not appear to be aware of the added risk a family history of breast cancer poses, and many women with a family history overestimate their risk. It is unclear whether risk perceptions are causally related to breast cancer screening in women with a family history. Exaggerated risk perceptions may not hinder breast cancer screening, unless accompanied by distress. Studies suggest that counseling women with a family history of breast cancer about their risk has a small and short-term effect on risk comprehension, a small effect on breast cancer screening, psychological benefits for some women, and unintended negative effects on screening for other women. Future research needs to consider the psychological, individual difference, and cultural variables that moderate counseling effects, recruitment biases, the prospective relationship between perceived risk and breast cancer screening, and whether risk perceptions and comprehension need to match objective risk to be an effective tool to promote screening.

Risk factors and health promotion in families of patients with breast cancer

Women with a family history of breast cancer have an increased risk of developing the disease. Women identified as "high risk" for developing breast cancer have been shown to exhibit increased levels of psychological distress and anxiety related to breast cancer. Oncology nurses can address this barrier and others, such as altered risk perception and lack of physician recommendation for screening. Oncology nurses also can identify high-risk families that may be candidates for genetic testing for breast cancer susceptibility, provide comprehensive teaching about breast self-examination (BSE), and clarify misconceptions about early detection. Primary prevention measures for hereditary breast cancer include prophylactic mastectomy and oophorectomy and chemopreventative agents. Secondary prevention measures include screening and early detection with mammography, clinical breast examinations, and BSE. Nurses have a responsibility to educate families of patients with breast cancer about risk factors, primary and secondary preventive measures, genetic testing, and screening recommendations.

Breast and ovarian cancer screening practices in healthy women with a strong family history of breast or ovarian cancer

Studies in women with a family history of cancer demonstrate a wide variability in the uptake of cancer screening measures. Little data exist regarding the breast and ovarian cancer screening practices of women who are members of hereditary breast cancer families. In order to address this issue, we examined the screening behaviors and the determinants of screening in a clinic based group of 216 women with a strong family history of breast or ovarian cancer who were participating in a free genetic counseling and testing research program. At baseline, prior to obtaining genetic counseling or testing, 50% of women ages 30-39, 83% of those age 40-49, 69% of those 50-64, and 53% of those >65 reported having a mammogram in the prior year. Adherence to mammography recommendations was correlated with age, number of relatives with breast cancer, and income. Twenty percent of participants had at least one CA- 125 performed and 31 % had ever obtained a screening ultrasound. Having at least one relative with ovarian cancer was very strongly associated with ovarian cancer screening [OR = 12.3, 95% CI = 4.6-33 for CA-125; OR=4.9, 95% CI=2.4, 10.1 for ultrasound]. No association between cancer worries/distress and either breast or ovarian cancer screening was found. In conclusion, the breast and ovarian screening uptake in healthy women from hereditary breast cancer families is suboptimal, even for women over age 50, for whom annual mammography is clearly indicated. These findings indicate a need for better education about screening guidelines for high-risk women.

Information and support needs of women with primary relatives with breast cancer: development of the Information and Support Needs Questionnaire

AIMS OF THE STUDY

The aim was to develop and pilot test a newly developed measure, The Information and Support Needs Questionnaire (ISNQ), for use with women with primary relatives with breast cancer.

BACKGROUND/RATIONALE

Breast cancer is a major risk to the health of women in the United Kingdom (UK). Increasingly, research is documenting women's needs for information and support, particularly at the time of diagnosis. However, to date there is little understanding of the information and support needs of women who have a family history of breast cancer. Contributing to the dearth of understanding of female relatives' needs is the lack of valid and reliable instruments for use in descriptive and intervention research with this population.

DESIGN/METHODS

The ISNQ and survey items documenting family history, sources of information and support for breast cancer risk, breast self-care practices, and other variables were pilot tested for the acceptability of the measures, appropriateness of the data collection methods, initial psychometric properties of the ISNQ, and time and financial costs of administration. Data were collected from 39 women living in the North-west of England who had primary relatives with breast cancer using mailed questionnaires and follow-up telephone interviews.

FINDINGS

The items on the ISNQ were reported to be clear, acceptable to women and to yield relevant data. The psychometric properties of the new measure were satisfactory with a high reliability coefficient alpha. Descriptive findings indicate that women had moderate to high needs for information and support, but reported that these needs were not well met.

CONCLUSIONS

The results of this pilot are guiding the development of a larger study in which the information and support needs of women with a family history of breast cancer are explored.

Risk perception and risk communication for cancer screening behaviors: a review

This review summarizes and synthesizes research findings on risk perception and risk communication related to cancer screening behaviors. The focus is on cancers for which there is evidence that screening reduces mortality, i.e., cervical, breast, and colorectal cancers. The following questions are addressed: 1) Is perceived risk associated with relevant cancer screening behaviors? 2) What factors are associated with perceived risk? 3) Is the relationship between perceived risk and cancer screening behaviors modified by other factors? 4) Have interventions to change perceived risk been effective in modifying risk perceptions? 5) Are these changes related to subsequent cancer screening behaviors? Methodologic issues are discussed, and future research needs are identified. There was consistent evidence that perceived risk was associated with mammography screening, but there were insufficient data on these associations for cervical or colorectal cancer screening behaviors. There was some evidence that perceived risk mediated the association between other variables and screening behaviors; however, because of the small number of studies, the findings are best viewed as hypothesis generating. Studies of interventions to modify risk perceptions provided some support for the view that they are modifiable, but there was conflicting evidence that these changes were related to subsequent cancer screening. Methodologic studies of how best to measure perceived risk are needed. Because most data on the correlates of perceived risk were cross-sectional, it is difficult to determine whether perceived risk is a cause or an effect in relation to cancer screening. Longitudinal studies that measure perceived risk in defined populations with different cancer screening histories and that include follow-up for screening and repeated measurements of risk perception are needed to clarify this relationship.

A supportive-expressive group intervention for women with a family history of breast cancer: results of a phase II study

BACKGROUND

Evidence suggests that there are significant psychological and behavioural sequelae associated with having a family history of breast cancer (BC) which can interfere with comprehension of risk estimates.

PURPOSE

The purpose of this study was to develop, standardize and do preliminary testing of a group intervention designed to address the emotional impact of having a family history of BC.

METHODS

This study is a single-arm pilot design with pre- and post-measures of perceived risk, psychosocial distress, knowledge and screening practices.

RESULTS

The primary study outcome measure of risk comprehension was significantly improved by 70%, according to our predetermined criteria for success. In addition, the most important secondary measures of psychosocial functioning, such as cancer-related distress (p=0.025), depression (p=0.05), anxiety (p=0.005) and unresolved grief (p=0.034) were significantly improved.

CONCLUSION

The results of this initial pilot study are encouraging; however, further research is required, using a randomized controlled study design to evaluate the relative contribution of this intervention to the successful modification of risk comprehension, enhanced psychological functioning, and to promote optimal screening adherence.

Breast cancer screening uptake in women at increased risk of developing hereditary breast cancer

This multicenter study assessed breast cancer screening uptake in 461 unaffected women at increased risk of developing breast cancer on the basis of family history who approached familial cancer clinics for advice about surveillance options. At the time of attending the clinic, 89% and 90% of participants were vigilant with respect to age- and risk-specific recommendations for mammography and clinical breast examination, respectively, and 51% reported practicing breast self-examination monthly or more frequently. The degree to which health outcomes are perceived to be under one's personal control (chi2 = -2.09, p = 0.0037) and breast cancer anxiety (chi2 = 8.11, p = 0.044) were both associated with monthly or more frequent breast self-examination, while there were no associations with sociodemographic characteristics. A significantly lower percentage (56%) of women aged <30 were vigilant with respect to mammography recommendations, compared to 77%, 96% and 98% of women aged 30-39, 40-49 and >50, respectively (chi2 = 37.2, p < 0.0001). These relatively low rates of mammographic screening in young women may reflect concerns about increased cancer risk associated with early and repeated radiation exposure or lack of sensitivity in young women with radiographically dense breasts. If mammographic screening is ultimately shown to lower mortality in women at high risk, there will be a strong case to promote screening in young women. The need for regular mammographic screening would then need to be highlighted and reinforced amongst young women and their referring physicians. Awareness amongst general practitioners, who are largely responsible for referral to screening services, would also need to be increased.

Patterns of breast cancer screening among lesbians at increased risk for breast cancer

BACKGROUND

Women with a family history of breast cancer (i.e., in a mother, sister or daughter) are at increased risk for this disease. Previous data also suggest that lesbians are at increased risk for breast cancer. While the screening behaviors of women with a family history have been described, little is known about factors that influence screening behaviors of lesbians with the same risk factor profile.

PURPOSE

The purpose of this study was to characterize the perceptions of susceptibility to breast cancer and describe factors that influence adherence to breast cancer screening guidelines in a sample of lesbians with a first-degree relative with a diagnosis of breast cancer.

METHODS

Structured telephone interviews were conducted on a sample of 139 self-identified lesbians who had a first-degree relative with a diagnosis of breast cancer, were between the ages of 35 to 75 and had no previous history of cancer. Cross-sectional data obtained, included socio-demographics, breast cancer risk factors, breast cancer screening patterns, breast cancer perceptions, worries, and knowledge, and barriers and access to health care factors. Individual subject characteristics were examined for their association with adherence to mammography guidelines followed by a multivariate analysis to evaluate the most important combinations of factors. Outcome measures were age-specific adherence to ACS guidelines for both mammography and overall adherence (i.e., mammography, clinical breast examination and breast self-examination).

RESULTS

The 139 lesbians interviewed for this study were young (mean age = 43), almost exclusively white (94%), highly educated (78% = college graduate and beyond), and partnered (68%). In the bivariate analysis of individual factors, being employed and reporting breast cancer worries were significantly and positively associated with adherence to mammography guidelines. Higher income and insurance type were significantly associated with mammography adherence. No factors were significantly associated with overall adherence. Multivariate logistic regression analyses revealed that only income level and degree of breast cancer worries were significantly and positively associated with mammography adherence. However, since there was a high correlation between income level and employment status, a regression model with employment status and worry was also significantly related to mammography adherence.

CONCLUSIONS

In lesbians who are at an increased risk for breast cancer because of family history, breast cancer worries may motivate, rather than deter, adherence for mammography use. High income levels also appear to enable adherence in this population.

IMPLICATIONS

Additional studies are needed to validate these findings, identify the prevalence of lesbians in general samples of women at increased risk for breast cancer, and prospectively test lesbian sensitive educational intervention strategies designed to facilitate adherence to mammography screening guidelines in this population.

Tailored risk notification for women with a family history of breast cancer

BACKGROUND

Evidence indicates that although first-degree relatives of breast cancer cases are at increased risk of developing the disease themselves, they may be underutilizing screening mammography. Therefore, interventions to increase the use of mammography in this group are urgently needed.

METHODS

A randomized two-group design was used to evaluate an intervention to increase mammography use among women (N = 901) with at least one first-degree relative with breast cancer. A statewide cancer registry was used to obtain a random sample of breast cancer cases who identified eligible relatives. The mailed intervention consisted of personalized risk notification and other theoretically driven materials tailored for high-risk women.

RESULTS

An overall significant intervention effect was observed (8% intervention group advantage) in mammography at post-test. There was an interaction of the intervention with age such that there was no effect among women <50 years of age and a fairly large (20% advantage) effect among women 50+ and 65+. Health insurance, education, and having had a mammogram in the year before baseline assessment were positive predictors of mammography at post-test. Perceived risk, calculated risk, and relationship to index cancer case were not associated with mammography receipt.

CONCLUSION

The intervention was successful in increasing mammography rates among high-risk women 50+ years of age. Further work is needed to determine why it was ineffective among younger women.

Anxiety and adherence to breast self-examination in women with a family history of breast cancer

OBJECTIVE

Previous research has indicated low rates of adherence to monthly breast self-examination (BSE) in women with a family history of breast cancer, and anxiety has been identified as a major factor that may interfere with regular self-examination. However, the direction of the relationship between anxiety and BSE frequency remains unclear, with some studies indicating that high anxiety promotes adherence and others indicating that it leads to avoidance. The aim of the present study was to clarify the relationship between anxiety and adherence to breast self-examination by comparing the impact of general anxiety with that of cancer-specific anxiety on BSE frequency.

METHODS

A sample of at-risk women (N=833) completed a questionnaire regarding BSE frequency, general anxiety, breast cancer worries, perceived risk of breast cancer, and family history of breast cancer. Women who self-examined infrequently (N=211), appropriately (N=462), or excessively (N=156) were compared on these variables.

RESULTS

Statistical analyses indicated that general anxiety differentiated only between excessive self-examiners and less frequent self-examiners, with excessive self-examiners reporting significantly higher general anxiety. Breast cancer worries differentiated between all three groups in a linear fashion, with increasing cancer worries associated with higher levels of BSE.

CONCLUSIONS

In some at-risk women, high cancer anxiety may lead to high general anxiety and precipitate hypervigilant breast self-examination rather than avoidance. These findings are discussed in relation to psychoeducational interventions and genetic counseling services for women with a family history of breast cancer.

Promoting cancer screening among the first-degree relatives of breast and colorectal cancer patients: the design of two randomized trials

BACKGROUND

In this paper two large nationwide trials are described, both of which will test a comparable telephone-based counseling intervention to promote cancer screening among the first-degree relatives (FDRs) of breast and colorectal cancer patients. The unit of randomization will be the family unit of eligible FDRs. Access to FDRs will be obtained from their relatives with cancer. Selected intervention and design issues are reviewed, including how both projects will respond to FDRs who exhibit significant levels of cancer-specific anxiety or distress and how potential high-risk cancer families will be accommodated.

METHODS

Pursuant to the development of both studies, two feasibility surveys were conducted to determine whether patients would grant access to their FDRs and whether the FDRS identified by these patients would be receptive to the telephone intervention.

RESULTS

Approximately 80% (106 of 132) of breast cancer patients agreed to provide access to their eligible FDRs when contacted on-site at participating hospitals and clinics. Of those subsequently selected for telephone follow-up (n = 95 or 90%), 80% (n = 76) were successfully contacted by telephone, and of these 97% (n = 74) provided the names and telephone numbers of their FDRs. Among colorectal cancer patients contacted on-site (n = 46), 96% (n = 44) agreed to provide access to their FDRs, and of those contacted by telephone (n = 33 or 75%), 91% (n = 30) provided the requested information about their FDRs. Once contacted, 95% of breast cancer FDRs (55 of 58) and 91% of colorectal cancer patients (51 of 56) endorsed the intervention strategy.

CONCLUSIONS

It is argued that this intervention, if proven effective, could provide an exportable strategy for reaching large numbers of high-risk individuals to promote cancer screening.

A group therapy approach to facilitate integration of risk information for women at risk for breast cancer

OBJECTIVE

To describe and illustrate elements of a group counselling approach designed to enhance the communication of risk information on breast cancer (BC) to women with a family history of this disease. Breast cancer is a leading cause of female cancer death. The most important risk factor for BC is a positive family history in at least 1 first-degree relative, and approximately one-third of women with BC have a family history of the disease. Recent evidence suggests that there is a significant psychological impact associated with having a family history of BC, and this may influence the psychological adjustment and response to being counselled for personal risk. New counselling approaches are required.

METHOD

This paper describes a group therapy approach that incorporates principles of supportive-expressive therapy designed to address the emotional impact of being at risk for BC and to promote accuracy of perceived risk. The key elements of the intervention are described along with clinical illustrations from groups that are part of an ongoing study to develop and standardize the group therapy.

CONCLUSION

Qualitative data from the groups suggest that this model of therapy is both feasible and effective.

Estimation of breast cancer risk by women aged 40 and over: a population-based study

OBJECTIVE

Identify factors associated with knowledge of breast cancer and estimation of risk.

METHODS

Telephone survey of 412 women aged 40 and over, living in Montreal and selected by random digit dialing.

RESULTS

The majority of the respondents had recently been exposed to some information on breast cancer, but only a third quoted the average lifetime probability estimate of about 1 in 10. Older individuals systematically considered themselves at low risk (odds ratio (OR) of perceiving risk as lower than average for women aged 50 or over versus under 50: 2.6, 95% confidence interval: (1.5, 4.6)). In addition, both a first-degree family history of breast cancer (OR: 5.3 (1.7, 17.0)) and a recent mammogram (OR: 3.0 (1.4, 6.2)) were strongly associated with a woman's probability of perceiving herself at high risk.

CONCLUSIONS

Information campaigns should emphasize the frequency of breast cancer in different age groups and the strength of the established associations with specific risk factors. Better knowledge of risk could promote sustained participation in breast screening programs.

Psychological issues in cancer genetics

OBJECTIVES

To review the behavioral research that addresses the impact of hereditary cancer on the family and the psychological aspects of choosing whether or not to undergo susceptibility testing.

DATA SOURCES

Scientific articles and book chapters in the professional literature pertaining to the psychological aspects of cancer genetics and susceptibility testing.

CONCLUSIONS

Susceptibility gene testing for a variety of rare hereditary cancer syndromes and familial cancers will offer new options and challenges to members of cancer families.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses will be involved in the identification of hereditary cancer families at risk assessment and counseling, the offer of susceptibility testing to those who may benefit, and the provision of follow-up support and referral.

The influence of risk factors on breast carcinoma screening of Medicare-insured older women. National Cancer Institute Breast Cancer Screening Consortium

BACKGROUND

It is not certain whether older women with additional breast carcinoma risk factors are adequately screened or whether they are more likely to undergo screening than other older women. This study was conducted to determine whether selected risk factors influence the breast carcinoma screening rates of Medicare-insured older women (i.e., age 65 years or older).

METHODS

Self-reported rates of screening mammography and clinical breast examination in the previous year were compared for women with benign breast disease, women with a family history of breast carcinoma, and women lacking these risks, using samples of non-Hispanic white, Medicare-insured women surveyed at the 5 National Cancer Institute Breast Cancer Screening Consortium sites in 1991 (n = 5376, mean age = 69.7 years) and 1994 (n = 5086, mean age = 69.7 years).

RESULTS

In 1993, rates of screening mammography reported in the previous year at the 5 Consortium sites had a range of 46-61% for women with a family history of breast carcinoma, 49-66% for women with benign breast disease, and 31-43% for women lacking these risks. Women with a positive family history or a personal history of benign breast disease were also more likely to report having had a clinical breast examination in the previous year and having received a physician's mammography recommendation. A substantial proportion of older women with a positive family history remain inadequately screened, however. Between 25% and 35% of women in this group had not had a screening mammogram in the previous 2 years, while at some Consortium sites more than 20% reported never having had a mammogram in their lives.

CONCLUSIONS

Older women with additional risk factors are more likely to undergo screening mammography. This is due partly to more frequent physician recommendations for screening and partly to more frequent provision of clinical breast examinations. However, a substantial proportion of high risk older women remain inadequately screened, despite widespread clinical consensus that these women should be regularly screened. Interventions that target older women with risk factors and their physicians appear warranted. Understanding the mechanisms by which risk factors influence screening is an important area for future research.

Familial breast cancer: a controlled study of risk perception, psychological morbidity and health beliefs in women attending for genetic counselling

The present study set out to evaluate perceptions of risk, psychological morbidity and health behaviours in women with a family history of breast cancer who have attended genetic counselling and determine how these differ from general population risk women. Data were collected from 62 genetic counselees (cases) attending the Royal Marsden and Mayday University Hospital genetic counselling services and 62 matched GP attenders (controls). Levels of general psychological morbidity were found to be similar between cases and controls; however, cases reported significantly higher breast cancer-specific distress despite clinic attendance [mean (s.d.) total Impact of Event Scale score, 14.1 (14.3) cases; 2.4 (6.7) controls, P < 0.001]. Although cases perceived themselves to be more susceptible to breast cancer, many women failed correctly to recall risk figures provided by the clinic; 66% could not accurately recall their own lifetime chance. Clinics appeared to have a positive impact on preventive behaviours and cases tended to engage more regularly in breast self-examination (monthly, 66% of cases vs 47% of controls), although few differences were found between groups in terms of health beliefs. We conclude that counselees and GP controls showed considerable similarities on many of the outcome measures, and risk of breast cancer was not predictive of greater psychological morbidity; although cases were more vulnerable to cancer-specific distress. Despite genetic counselling, many cases continued to perceive their risk of breast cancer inaccurately.

Information, support, and communication needs of women with a family history of breast cancer

In this article, the role of information, support, and communication in promoting adaptation to the risk of breast cancer is reported. These variables emerged from an in-depth study of women at risk for breast cancer because of breast cancer in one or more of their primary (first degree) relatives. Fifty-five women with mothers, sisters, mother and sister, or mother and another primary relative were interviewed using in-depth semi-structured, tape-recorded interviews. After transcription, data were analyzed using qualitative analysis procedures. A three-phase process of adaptation to the risk of breast cancer was uncovered, which was subsequently validated with two study participants. Information, support, and communication emerged as important factors in facilitating the adjustment of women throughout the three phases of the process: as women "lived" the breast cancer experience of their relative; as they developed a perception of their personal risk for breast cancer; and finally as they put the risk of breast cancer "in its place." Despite the importance of information and support, most women had difficulty meeting these needs. Also, communication patterns both within the family and with health professionals were generally not helpful for these women. Issues related to the ill relative as "manager" of cancer-related information, the "ownership style" of the woman at risk, and the accessibility and availability of resources influenced women's adaptation to feelings of risk. Women's needs for information, support, and communication and facilitating factors are described in detail, and recommendations for clinical practice and research offered.

Factors related to enrollment in the breast cancer prevention trial at a comprehensive cancer center during the first year of recruitment

BACKGROUND

Using an a priori theoretic model of behavior change, factors predicting enrollment in a randomized chemoprevention trial during the first year of recruitment were assessed prospectively.

METHODS

Eligible participants were asked to complete a 90-item semistructured questionnaire after attendance at an informational meeting. Components of the Health Belief Model (including perceived susceptibility, perceived severity, perceived benefits and barriers, cues to action, and health motivation), health status, preventive health behaviors, and social influence were assessed in relation to enrollment.

RESULTS

Overall, 331 women attended one of the meetings, and 73% completed a questionnaire; 45% enrolled on the trial and 55% did not. In bivariate analyses, all but one of the perceived barriers were associated negatively with enrollment; however, items assessing perceived susceptibility, perceived severity, and perceived benefits were not. Nonparticipants also were more likely to be over 49 years of age, to be currently or to have been on estrogen replacement therapy, and to have had hot flashes. In logistic regression analysis, not being able to take estrogen replacement therapy was the strongest predictor of nonparticipation (odds ratio [OR], 12.13, 95% confidence interval [CI], 3.63, 40.60). Other factors associated with nonparticipation were concern about side effects of tamoxifen (OR, 5.06; CI, 2.37, 10.80); the possibility of getting a placebo (OR, 7.75; CI, 1.51, 39.67); the costs associated with the trial (OR, 3.21; CI, 1.12, 9.24); and absence of concern that significant others would be reassured if the respondent was taking tamoxifen (OR, 2.58; CI, 1.04, 6.41).

CONCLUSIONS

These findings support the view that recruitment efforts for chemoprevention trials should address barriers specific to their circumstances. In addition, increasing the support available from personal social networks may enhance recruitment to chemoprevention trials for breast cancer.

Are patients of women physicians screened more aggressively? A prospective study of physician gender and screening

OBJECTIVE

To determine the effects of physician gender on rates of Pap testing, mammography, and cholesterol testing when identifying and adjusting for demographic, psychosocial, and other patient variables known to influence screening rates.

DESIGN

A prospective design with baseline and six-month follow-up assessments of patients' screening status.

SETTING

Twelve community-based group family practice medicine offices in North Carolina.

PARTICIPANTS

1,850 adult patients, aged 18-75 years (six-month response rate, 83%), each of whom identified one of 37 physicians as being his or her regular care provider.

MAIN RESULTS

Where screening was indicated at baseline, the patients of the women physicians were 47% more likely to get a Pap test [odds ratio (OR) = 1.47, 95% confidence interval (CI) = 1.05, 2.04] and 56% more likely to get a cholesterol test (OR = 1.56, 95% CI = 1.08, 2.24) during the study period than were the patients of the men physicians. For mammography, the younger patients (aged 35-39 years) of the women physicians were screened at a much higher rate than were the younger patients of the men physicians (OR = 2.69, 95% CI = 0.98, 7.34); however, at older ages, the patients of the women and the men physicians had similar rates of screening.

CONCLUSIONS

In general, the patients of the women physicians were screened at a higher rate than were the patients of the men physicians, even after adjusting for important patient variables. These findings were not limited to gender-specific screening activities (e.g., Pap testing), as in some previous studies. However, the patients of the women physicians were aggressively screened for breast cancer at the youngest ages, where there is little evidence of benefit from mammography. Larger studies are needed to determine whether this pattern of effects reflects a broader phenomenon in primary care.

The impact of genetic counselling on risk perception in women with a family history of breast cancer

Women with a family history of breast cancer generally self-refer because they have a feeling that their risk is high. However, they have, in general, only a hazy notion of the population risk of breast cancer and their own risk in relation to this. It is probable that they are helped by genetic counselling and, if at substantial risk, by annual mammography. However, the psychological impact of assigning true risk and the value of mammography need to be evaluated. We have assessed risk perception by questionnaire in 517 new referrals to a family history clinic and 200 women returning to the clinic at least 1 year after counselling. Correct assignment of population lifetime risk of breast cancer was 16% in the uninformed precounsel group and 33% in the post-counsel group, likewise personal risk was correct in 11% and 41% respectively. Post-counsel women were significantly more likely to retain information if they were sent a post-clinic letter or if they assessed their personal risk as too high initially.

Future challenges in secondary prevention of breast cancer for women at high risk

We are making great progress in singling out those among us who are at high risk of cancer, whether on the basis of epidemiologic characteristics that predict risk in the absence of a firm knowledge of mechanism or, more recently, by specifying the genetic site of a factor that unequivocally puts a specific person in danger. We have been less capable of identifying factors that, given awareness of increased risk, determine whether or not a person adopts an appropriately self-protective behavior. This article reports the experience of female twins whose co-twins have a diagnosis of breast cancer. Such individuals can be assumed to have been presented with incontrovertible evidence of their elevated risk almost as much as if they had been found to have a dangerous gene. Their subsequent actions can shed light on why persons do not always take steps to protect themselves from a clear but future danger. It is evident that cognition is not the sole, or even the most important, determinant of health promoting behavior. Among the others are beliefs about cancer causality and the state of personal health, the details of the medical experience of relatives, and the degree to which perceptions of that experience have intruded into consciousness. The gap between rational and actual efforts to reduce personal risk is great, and if technology is to offer us the benefits promised, we must give priority to narrowing that gap.

Psychological aspects of monitoring high risk women for breast cancer

BACKGROUND

There is a paucity of knowledge pertaining to the attitudes, feelings, and emotions of women who are at increased familial risk for breast cancer and how these concerns will affect their surveillance behavior. A review of the literature shows an unevenness in the conclusions about these matters, with some reports indicating that anxiety aroused in the familial cancer setting may abet surveillance behavior, whereas other data indicates a negative effect.

METHODS

The authors reported anecdotal accounts of such behavior in women from hereditary breast and hereditary breast-ovarian cancer prone families.

RESULTS

Although these responses of fear, anxiety, and apprehension about cancer risk are not unique to this hereditary cohort, they nevertheless must have been tempered by often life-long exposure of cancer occurrences that may have decimated their families.

CONCLUSIONS

All accounts agree with the need to devote more research to the special needs--psychological, social, insurance, and general public health measures--of these high risk women.

The effect of risk on changes in breast cancer screening rates in Los Angeles, 1988-1990

BACKGROUND

Although there have been clear secular trends of increased use of some breast cancer screening modalities, such as mammography, it is less certain that similar trends have occurred among high risk women.

METHODS

Population-based surveys were conducted in three socioeconomically diverse Los Angeles communities in 1988 and 1990. Trends in breast cancer screening behavior and key determinants of screening were compared separately for women with a family history of breast cancer, a personal history of benign breast disease, and for women without these risks.

RESULTS

In two independent samples drawn in 1988 and 1990, women at a higher risk of breast cancer (positive family history) showed smaller increases in the prevalence of self-reported breast cancer screening than a comparison group of women without a family history of breast cancer or a history of benign breast disease. This was especially true for family-history-positive minority women and women aged 65 years and older, for whom screening actually decreased. In 1990, mammograms for the prior year were reported by only 39% of women with a positive family history, 54% of women with benign breast disease, and 35% of women without these risks. Trends in physicians' office visit discussions of breast cancer screening paralleled trends observed in screening behavior.

CONCLUSIONS

Although breast cancer screening increased substantially among lower risk women, rates were unchanged for women at increased risk because of a family history of breast cancer. By identifying and counseling higher risk women, physicians can play an important role in promoting appropriate screening to this group.

Adherence and psychological adjustment among women at high risk for breast cancer

Increasingly, women with a positive family history of breast cancer are being targeted for cancer prevention and control efforts. Two findings have been demonstrated consistently across studies of this high risk population. First, these women often have high levels of psychological distress, as well as persistent and intrusive worries about developing breast cancer. Second, despite their increased risk for developing breast cancer, a substantial proportion of these women do not adhere to recommended breast cancer screening guidelines. There is growing evidence that psychological distress is an important barrier to adherence among high risk women. Despite this, little is known about how to intervene to improve psychological adjustment and adherence in this population. In the present paper, we review the literature on adherence and psychological adjustment in women who are at increased risk for breast cancer because of a positive family history of disease. This review provides the basis for a discussion of potential intervention strategies designed to increase adherence and reduce psychological distress in this population. Finally, we present some of the psychological implications of recent developments in genetic testing for breast cancer susceptibility.

Factors associated with perceived risk of breast cancer among women attending a screening program

A person's perception of the risk of, or susceptibility to, developing a disease is believed to be an important determinant of health-related behavior, yet little is known about the determinants of perceived risk. Knowledge of these correlates may be useful in identifying and addressing barriers to performance of health behaviors such as mammography screening. Data collected from over 36,000 women participating in a breast cancer screening program in Texas were used to examine the associations between perceived risk of ever getting breast cancer and a number of demographic factors, health-related behaviors, and risk factors for breast cancer. There was a strong positive association between family history of breast cancer and risk perception (OR = 11.3, CI = 10.34-12.35). Women who reported other risk factors for breast cancer also reported higher perceived risk, but those associations were of lesser magnitude. Age was inversely associated with perceived risk, and black, but not Hispanic, women were more likely to perceive their risk as high compared with white women. Of the health-related behaviors for the early detection of breast cancer, only having had a prior mammogram was associated with perceived risk. Educational interventions to heighten women's awareness of breast cancer risk factors may increase perceived risk in high risk women and influence their decision to undergo screening mammography.