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

An exploratory study of patients' views about being at high-risk for breast cancer and risk management beliefs and intentions, before and after risk counselling: Preliminary evidence of the influence of beliefs on post-counselling prevention intentions

OBJECTIVES

1) To describe how women at high-risk for breast cancer (BC) perceive their at-risk status and the options available to manage this risk, before and after risk counselling; 2) to explore the contributions of pre-counselling demographic, clinical, cognitive and emotional factors to post-counselling risk management intentions.

METHODS

58 of 173 eligible patients (34%) enrolled and were asked to fill surveys including measures of 1) subjective risk, 2) illness (being at high-risk for BC) and 3) treatment (surveillance, lifestyle modifications, and chemoprevention) cognitions, 4) BC fear and 5) future risk management intentions, prior to and 3 months after risk consultation.

RESULTS

48 of 58 participants (83%) completed both surveys. Beliefs and emotions about their condition and its management were stable over time. Surveillance and lifestyle were associated with stronger intentions, higher perceived need, and lower concerns than chemoprevention (all ps <0.001). The strongest predictors of intentions strengths were the women's beliefs about the risk reduction methods, especially for lifestyle and chemoprevention (all ps <0.01).

CONCLUSIONS

The findings emphasize the importance of patients' beliefs in risk management decisions.

PRACTICAL IMPLICATIONS

Patients' treatment beliefs appear to influence their choice of BC risk reduction strategies and should be discussed during risk reduction consultations.

Imaging surveillance programs for women at high breast cancer risk in Europe: Are women from ethnic minority groups adequately included? (Review)

Women from ethnic minority groups, including immigrants and refugees are reported to have low breast cancer (BC) screening rates. Active, culturally-sensitive outreach is vital for increasing participation of these women in BC screening programs. Women at high BC risk and who belong to an ethnic minority group are of special concern. Such women could benefit from ongoing trials aimed at optimizing screening strategies for early BC detection among those at increased BC risk. Considering the marked disparities in BC survival in Europe and its enormous and dynamic ethnic diversity, these issues are extremely timely for Europe. We systematically reviewed the literature concerning European surveillance studies that had imaging in the protocol and that targeted women at high BC risk. The aim of the present review was thereby to assess the likelihood that women at high BC risk from minority ethnic groups were adequately included in these surveillance programs. Twenty-seven research groups in Europe reported on their imaging surveillance programs for women at increased BC risk. The benefit of strategies such as inclusion of magnetic resonance imaging and/or more intensive screening was clearly documented for the participating women at increased BC risk. However, none of the reports indicated that sufficient outreach was performed to ensure that women at increased BC risk from minority ethnic groups were adequately included in these surveillance programs. On the basis of this systematic review, we conclude that the specific screening needs of ethnic minority women at increased BC risk have not yet been met in Europe. Active, culturally-sensitive outreach is needed to identify minority women at increased BC risk and to facilitate their inclusion in on-going surveillance programs. It is anticipated that these efforts would be most effective if coordinated with the development of European-wide, population-based approaches to BC screening.

Breast MRI use uncommon among U.S. women

BACKGROUND

The goal of breast cancer screening is to reduce breast cancer mortality. Mammography is the standard screening method for detecting breast cancer early. Breast MRI is recommended to be used in conjunction with mammography for screening subsets of women at high risk for breast cancer. We offer the first study to provide national estimates of breast MRI use among women in the United States.

METHODS

We analyzed data from women who responded to questions about having a breast MRI on the 2010 National Health Interview Survey. We assessed report of having a breast MRI and reasons for it by sociodemographic characteristics and access to health care and computed five-year and lifetime breast cancer risk using the Gail model.

RESULTS

Among 11,222 women who responded, almost 5% reported ever having a breast MRI and 2% reported having an MRI within the 2 years preceding the survey. Less than half of the women who reported having a breast MRI were at increased risk. Approximately 60% of women reported having the breast MRI for diagnostic reasons. Women who ever had a breast MRI were more likely to be older, Black, and insured and to report a usual source of health care as compared with women who reported no MRI.

CONCLUSIONS

Breast MRI use may be underused or overused in certain subgroups of women.

IMPACT

As access to health care improves, the use of breast MRI and the appropriateness of its use for breast cancer detection will be important to monitor.

Transdisciplinary training in cancer prevention: reflections on two decades of training

Education in cancer prevention and control calls for training that spans disciplines to bring a broad range of skills together to develop future leaders who can speed research and delivery of effective prevention and control programs. We review the history of the Harvard Cancer Prevention Education Program as one example and summarize approaches to transdisciplinary training from the early 1990s onwards. From backgrounds in traditional public health disciplines (epidemiology, behavioral science, health policy, decision sciences, biostatistics, and environmental health) and clinical training, we encouraged common vocabulary, teamwork, and application of knowledge to the prevention of cancer with a population health perspective. While the evaluation of training programs is necessarily tied to the career trajectories of trainees, spanning decades, we present some early evidence of broad applications of training across research and delivery in government and not for profit sectors.

Does a Family History of Male Breast Cancer Influence Risk Perception and Use of Genetic Testing?

We sought to determine differences in risk perception and use of genetic testing in these individuals compared with those with a family history of female breast cancer (FHxFBC) in a population-based cohort. Data from the 2005 National Health Interview Survey were used to assess risk perception and use of genetic counseling in individuals with a family history of male breast cancer (FHxMBC) versus those with a FHxFBC. Of the 2429 individuals with a first-degree relative with breast cancer surveyed, 21 (0.7%) had a FHxMBC, whereas 2408 (99.3%) had a FHxFBC. Women who had a FHxMBC perceived themselves as being at higher risk for developing breast cancer than those with a FHxFBC (61.5 vs 46.5%, P = 0.011). Fewer individuals with a FHxMBC had heard about genetic testing than those with a FHxFBC (38.4 vs 50.8%, P = 0.322). Of these, none of the individuals with a FHxMBC discussed this with their physician (vs 13% of individuals with a FHxFBC, P = 0.004) and none underwent genetic testing (vs 3% of individuals with a FHxFBC, P = 0.009). Women with a FHxMBC perceive this as being associated with increased cancer risk, but few discuss this with their physicians. Physicians should be proactive in discussing risk with these patients.

Racial and ethnic differences in mammography use among U.S. women younger than age 40

OBJECTIVE

Evidence-based recommendations for routine breast cancer screening suggest that women begin mammography at age 40, although some women receive a mammogram before that age. Little is known about mammography use among younger women, especially with respect to race and ethnicity.

METHODS

We used data from the 2005 National Health Interview Survey to examine racial/ethnic differences in mammography use among U.S. women ages 30-39. We examined descriptive characteristics of women who reported ever having a mammogram, and used logistic regression to estimate associations between race/ethnicity and mammography use among women at average risk for breast cancer.

RESULTS

Our sample comprised 3,098 women (18% Hispanic, 13% non-Hispanic [NH] black, 69% NH white), of whom 29% reported having ever had a mammogram. NH black women were more likely than NH white women to report ever having a mammogram and receiving multiple mammograms before age 40 among women of average risk. Patterns of mammography use for Hispanic women compared to NH white women varied.

CONCLUSION

Findings suggest differential utilization of mammograms by race/ethnicity among women outside current recommendations and of average risk. Future studies should examine the role of practice patterns and patient-provider communication.

Family history of breast cancer and compliance with mammography in Israel: findings of the National Health Survey 2003-2004 (EUROHIS)

A positive family history of breast cancer is an established risk factor for the disease. In Israel, screening is recommended annually for high-risk women aged > or =40 years and biennially for average-risk women aged > or =50 years. The current study aimed to assess the effect of having a positive breast cancer family history on performing screening mammography in Israeli women. This study is a cross-sectional survey based on a random sample of the Israeli population, conducted in 2003. The study was carried out by means of telephone interviews that included questions on the use of preventive medical services. The current study population consists of 1605 Israeli women aged 40-74 years. A positive family history for breast cancer was reported by 153 (9.5%) of the participants. A mammogram in the previous year was reported by 43.1 and 24.7% of the positive and negative family history subgroups, respectively (P<0.0001). Rates increased with age. Among women with a positive family history, only being married was a significant correlate for a mammography in the previous year. Over 60% and around 55% of high-risk women aged 40-49 and > or =50 years, respectively, are inadequately screened for breast cancer. Screening rates are not optimal in the average-risk group as well.

Which women aren’t getting mammograms and why? (United States)

OBJECTIVE

This study investigates why women who reported no recent mammogram did not get the test.

METHODS

Using data from the 2000 National Health Interview Survey (NHIS), we examine correlates of mammography use among women 40 years and older (n = 10,212), with particular focus on the 30% (n = 3,188) who reported no recent mammogram. Non-screening is examined in the context of two important correlates of mammography use-access to health care and a physician's recommendation to get a mammogram.

RESULTS

In total, 80% of non-screeners who reported having access to healthcare did not receive a recommendation for a mammogram. Women age 65 years and older were more likely than younger women to report not receiving a recommendation (OR 1.77, 95% CI 1.25-2.50). For women who reported having access, non-screening was significantly more likely among younger women (40-49), those with less education, incomes less than 20,000 dollars, residence outside Metropolitan Statistical Areas (MSAs) and no family history of breast cancer. Among women with access problems, those who had not visited a primary care provider in the past year were much more likely to be non-screeners (80%) compared with those who had seen a provider (46%). Among women with access, those who reported put it off as the main reason for non-screening were significantly more likely to be younger and to be born in the U.S. than women who said that they didn't know they needed a mammogram.

CONCLUSIONS

Most non-screeners report not receiving a physician recommendation for mammography. Although a minority reported access problems, the effect of lacking access on utilization was strong and is accentuated when women without access do not see a doctor. These findings confirm the importance of a mammography recommendation and raise questions concerning whether this information is being conveyed by physicians or heard by patients.

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.

Reducing racial/ethnic disparities in female breast cancer: screening rates and stage at diagnosis

OBJECTIVES

We assessed whether population rates of mammography screening, and their changes over time, were associated with improvements in breast cancer stage at diagnosis and whether the strength of this association varied by race/ethnicity.

METHODS

We analyzed state cancer registry data linked to socioeconomic characteristics of patients' areas of residence for 1990-1998 time trends in the likelihood of early stage diagnosis. We appended each cancer registry record with matching subgroup estimates of self-reported mammography screening.

RESULTS

Trends in screening and stage at diagnosis were consistent within groups, but African American women had a significantly lower proportion of early stage cancers despite an advantage in screening. Population screening rates were significantly associated with early diagnosis, with a weaker association in African American women than White women (odds ratio [OR] = 1.70; P<.0001 vs OR=2.02; P<.0001, respectively).

CONCLUSIONS

Improvements in screening rates during the 1990s across racial/ethnic groups appear to have contributed significantly to earlier diagnosis within each group, but a smaller effect in African American women should raise concerns. A key health policy challenge is to ensure that screening effectively translates into earlier diagnosis.

Prospective breast cancer risk prediction model for women undergoing screening mammography

BACKGROUND

Risk prediction models for breast cancer can be improved by the addition of recently identified risk factors, including breast density and use of hormone therapy. We used prospective risk information to predict a diagnosis of breast cancer in a cohort of 1 million women undergoing screening mammography.

METHODS

There were 2,392,998 eligible screening mammograms from women without previously diagnosed breast cancer who had had a prior mammogram in the preceding 5 years. Within 1 year of the screening mammogram, 11,638 women were diagnosed with breast cancer. Separate logistic regression risk models were constructed for premenopausal and postmenopausal examinations by use of a stringent (P<.0001) criterion for the inclusion of risk factors. Risk models were constructed with 75% of the data and validated with the remaining 25%. Concordance of the predicted with the observed outcomes was assessed by a concordance (c) statistic after logistic regression model fit. All statistical tests were two-sided.

RESULTS

Statistically significant risk factors for breast cancer diagnosis among premenopausal women included age, breast density, family history of breast cancer, and a prior breast procedure. For postmenopausal women, the statistically significant factors included age, breast density, race, ethnicity, family history of breast cancer, a prior breast procedure, body mass index, natural menopause, hormone therapy, and a prior false-positive mammogram. The model may identify high-risk women better than the Gail model, although predictive accuracy was only moderate. The c statistics were 0.631 (95% confidence interval [CI] = 0.618 to 0.644) for premenopausal women and 0.624 (95% CI = 0.619 to 0.630) for postmenopausal women.

CONCLUSION

Breast density is a strong additional risk factor for breast cancer, although it is unknown whether reduction in breast density would reduce risk. Our risk model may be able to identify women at high risk for breast cancer for preventive interventions or more intensive surveillance.

Breast cancer risk and provider recommendation for mammography among recently unscreened women in the United States

BACKGROUND AND OBJECTIVE

Many women with increased breast cancer risk have not been screened recently. Provider recommendation for mammography is an important reason many women undergo screening. We examined the association between breast cancer risk and reported provider recommendation for mammography in recently unscreened women.

DESIGN

Cross-sectional study using 2000 National Health Interview Survey.

PARTICIPANTS

In all, 1673 women ages 40 to 75 years without cancer who saw a health care provider in the prior year and had no mammogram within 2 years.

MEASUREMENTS AND ANALYSIS

We assessed breast cancer risk by Gail score and risk factors. We used multivariable logistic regression models in SUDAAN adjusted for age, race and illness burden, to examine the association between risk and reported recommendation for mammography within 1 year for all women and women ages 50 to 75 years.

RESULTS

Of 1673 recently unscreened women, 29% reported a recommendation. Twelve percent of women had increased Gail risk and of these recently unscreened, high-risk women, 25% reported a recommendation. After adjustment, high-risk women were not more likely to report a recommendation than average-risk women. Results were similar for women 50 to 75 years old. No individual breast cancer factors other than age were associated with reporting a recommendation.

CONCLUSIONS

Approximately 70% of recently unscreened women seen by a health care provider in the prior year reported no recommendation for mammography, regardless of breast cancer risk. This did not include women who received a recommendation and were screened. Increasing reported recommendation rates may represent an opportunity to increase screening participation among recently unscreened women, particularly for women with increased breast cancer risk.

The relation between projected breast cancer risk, perceived cancer risk, and mammography use. Results from the National Health Interview Survey

BACKGROUND

Although the use of mammography on at regular intervals can save lives, not all women obtain the repeat mammography recommended in guidelines.

OBJECTIVE

To assess the associations between routine mammography use, perceived cancer risk, and actual projected cancer risk.

METHODS

We include women who were 45 to 75 years of age and who had responded to the 2000 National Health Interview Survey. Women who reported that they believed their risk of getting cancer in the future was "medium" or "high" were considered jointly as "medium/high-risk perception.""Routine mammography use" was defined as having > or =3 mammograms in the previous 6 years. We used logistic regression to determine the independent relation between cancer risk perception, projected breast cancer risk, and routine mammography use.

RESULTS

Of the 6,002 women who met our inclusion criteria, 63.1% reported routine mammography use. About 76% of women in the highest quartile of projected breast cancer risk reported routine mammography use, compared with only 68%, 64%, and 51% in the third, second, and first quartiles, respectively (P<.001 chi-square test for trend). After adjusting for indicators of access to care, sociodemographic and behavioral factors, and perceived cancer risk, women in the highest quartiles of projected cancer risk were significantly more likely to report routine mammogram use than women in the lowest quartile (odds ratio [OR] of women in third and fourth quartiles were 1.57 [1.24 to 1.99], and 2.23 [1.73 to 2.87] vs the lowest quartile, respectively). Women with a higher perceived cancer risk were significantly more likely to undergo routine mammography (adjusted OR: 1.29 [1.12 to 1.48] P=.001). Cancer risk perceptions tended to be higher among women who were younger age, obese, smokers, depressed, or reported one of the following breast cancer risk factors: family breast cancer history, prior abnormal mammogram, and early age at menarche.

CONCLUSION

Actual and perceived risk were independent predictors of routine mammography use, suggesting that efforts to incorporate risk profiles into clinical decision making may need to involve more than just relaying information about projected risks to patients, but also to explore how risk perceptions can be affected by this information.

Health beliefs of women with and without breast cancer seeking genetic cancer risk assessment

Genetic cancer risk assessment (GCRA) is increasingly being incorporated into clinical care. Planning supportive nursing care for women seeking GCRA requires knowledge of their health beliefs. We described and compared the cancer risk-related beliefs of 134 women with a personal history of breast cancer (affected group) and 80 women without breast cancer who had a family history of the disease (unaffected group), prior to risk assessment, using a mailed survey. This article reports their demographics, health characteristics, family history, and beliefs about cancer risk, risk factors, and genetic testing. Most participants were in their 40s (mean age = 47.9), Caucasian (79%), married (66%), and college-educated (60%), and had children (78%). Most women (87%) had a close relative with breast cancer and/or ovarian cancer. In general, both groups greatly overestimated near-term and lifetime cancer risk. Significantly more unaffected women believed they were at higher risk for breast cancer than affected women. Both groups expressed desire for, but lacked knowledge of, genetic testing. Nurses are in a prime position to assist women seeking GCRA by providing accurate information and emotional support regarding cancer risk, risk factors, and genetic testing.