Reported drop in mammography : is this cause for concern?

Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries

This article presents global cancer statistics by world region for the year 2022 based on updated estimates from the International Agency for Research on Cancer (IARC). There were close to 20 million new cases of cancer in the year 2022 (including nonmelanoma skin cancers [NMSCs]) alongside 9.7 million deaths from cancer (including NMSC). The estimates suggest that approximately one in five men or women develop cancer in a lifetime, whereas around one in nine men and one in 12 women die from it. Lung cancer was the most frequently diagnosed cancer in 2022, responsible for almost 2.5 million new cases, or one in eight cancers worldwide (12.4% of all cancers globally), followed by cancers of the female breast (11.6%), colorectum (9.6%), prostate (7.3%), and stomach (4.9%). Lung cancer was also the leading cause of cancer death, with an estimated 1.8 million deaths (18.7%), followed by colorectal (9.3%), liver (7.8%), female breast (6.9%), and stomach (6.8%) cancers. Breast cancer and lung cancer were the most frequent cancers in women and men, respectively (both cases and deaths). Incidence rates (including NMSC) varied from four-fold to five-fold across world regions, from over 500 in Australia/New Zealand (507.9 per 100,000) to under 100 in Western Africa (97.1 per 100,000) among men, and from over 400 in Australia/New Zealand (410.5 per 100,000) to close to 100 in South-Central Asia (103.3 per 100,000) among women. The authors examine the geographic variability across 20 world regions for the 10 leading cancer types, discussing recent trends, the underlying determinants, and the prospects for global cancer prevention and control. With demographics-based predictions indicating that the number of new cases of cancer will reach 35 million by 2050, investments in prevention, including the targeting of key risk factors for cancer (including smoking, overweight and obesity, and infection), could avert millions of future cancer diagnoses and save many lives worldwide, bringing huge economic as well as societal dividends to countries over the forthcoming decades.

Screening Mammography Utilization in the United States

Breast cancer is the second leading cause of cancer mortality in adult women in the United States. Screening mammography reduces breast cancer mortality between 22% and 48%; however, screening mammography remains underutilized. Screening mammography utilization data are available from insurance claims, electronic medical records, and patient self-report via surveys, and each data source has unique benefits and challenges. Numerous barriers exist that adversely affect the use of screening mammography in the United States. This article will review screening mammography utilization in the United States, explore factors that impact utilization, and briefly discuss strategies to improve utilization.

Urbanicity, Income, and Mammography-Use Disparities Among American Indian Women

INTRODUCTION

Reported breast cancer screening among American Indian women is consistently below that of White women. The last claims-based trends were from 1991 to 2001. This study updates mammography trends for American Indian women and examines the impact of race, urbanicity, and income on long-term mammography use.

METHODS

This was a multi-year (2005-2019), retrospective study of women aged 40-89 years using a 5% sample of Medicare fee-for-service beneficiaries residing in Arizona, California, New Mexico, Oklahoma, and Washington. This study used multivariable logistic regression to examine the impact of urbanicity and income on receiving mammography for American Indian women compared with that for White women. Analyses were conducted in 2022.

RESULTS

Overall, annual age-adjusted mammography use declined from 205 per 1,000 in 2005 to 165 per 1,000 in 2019. The slope of these declines was significantly steeper (difference = -2.41, p<0.001) for White women (-3.06) than for American Indian women (-0.65). Mammography-use odds across all urbanicity categories were less for American Indian women than for White women compared with those of their respective metropolitan counterparts (e.g., rural: 0.96, 95% CI=0.77, 1.20 for American Indian women and 1.47, 99% CI=1.39, 1.57 for White women). Although residing in higher-income communities was not associated with mammography use for American Indian women, it was 31% higher for White women (OR=1.31, 99% CI=1.28, 1.34).

CONCLUSIONS

The disparity in annual age-adjusted mammography use between American Indian and White women narrowed between 2005 and 2019. However, the association of urbanicity and community income on mammography use differs substantially between American Indian and White women. Policies to reduce disparities need to consider these differences.

Women 75 Years Old or Older: To Screen or Not to Screen?

Breast cancer is the most common cancer in women, with the incidence rising substantially with age. Older women are a vulnerable population at increased risk of developing and dying from breast cancer. However, women aged 75 years and older were excluded from all randomized controlled screening trials, so the best available data regarding screening benefits and risks in this age group are from observational studies and modeling predictions. Benefits of screening in older women are the same as those in younger women: early detection of smaller lower-stage cancers, resulting in less invasive treatment and lower morbidity and mortality. Mammography performs significantly better in older women with higher sensitivity, specificity, cancer detection rate, and positive predictive values, accompanied by lower recall rates and false positives. The overdiagnosis rate is low, with benefits outweighing risks until age 90 years. Although there are conflicting national and international guidelines about whether to continue screening mammography in women beyond age 74 years, clinicians can use shared decision making to help women make decisions about screening and fully engage them in the screening process. For women aged 75 years and older in good health, continuing annual screening mammography will save the most lives. An informed discussion of the benefits and risks of screening mammography in older women needs to include each woman's individual values, overall health status, and comorbidities. This article will review the benefits, risks, and controversies surrounding screening mammography in women 75 years old and older and compare the current recommendations for screening this population from national and international professional organizations. ^©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

Tendência Temporal da Cobertura de Mamografias no Sistema Único de Saúde, Brasil, 2010-2019

Introdução: O câncer de mama no Brasil apresenta elevadas taxas de incidência e mortalidade apesar da tendência de redução da mortalidade em algumas Regiões. Objetivo: Descrever a tendência da cobertura de mamografias de rastreamento nas Macrorregiões e Estados brasileiros e identificar a influência de Políticas Nacionais voltadas ao controle do câncer de mama entre 2010-2019. Método: Foi calculada a razão entre mamografias de rastreamento na faixa etária de 50-69 anos por local de residência e subtraída a população das residentes com plano de saúde na faixa etária e no período referidos. A tendência foi avaliada pelo modelo de regressão Joinpoint. Resultados: A cobertura aumentou no Brasil de 2010-2014 e apresentou queda de 2014-2019, com aumento na proporção de exames realizados na população-alvo. Esse padrão foi observado nas demais Regiões, exceto na Centro-Oeste, porém com ano de mudança da tendência diferente. Foram identificados dois pontos de mudança no país: de 2010-2014, com tendência crescente (APC 8,7, IC 95% 6,2; 11,3), e de 2014-2019, com tendência decrescente (APC -4,2, IC 95% -5,7; -2,7), ambos significantes. A Região Nordeste foi a única com três pontos de mudança de tendência: 2010-2012 (APC 30,3, IC 95% 22,9; 38,2), 2012-2017 (APC 4,7, IC 95% 3,0; 6,4) e 2017-2019 (APC -14,9, IC 95% -19,7; - 9,8). Não foi identificada tendência para a Região Centro-Oeste. Conclusão: Houve crescimento na proporção de mamografias de rastreamento realizadas na população-alvo no período, para Brasil e Regiões, e tendência de redução na cobertura da mamografia a partir de 2014. Esses resultados indicam priorização da população-alvo do programa nas ações de rastreamento.

Utility of incorporating a gene-based lung cancer risk test on uptake and adherence in a community-based lung cancer screening pilot study

Based on the results of randomized control trials, screening for lung cancer using computed tomography (CT) is now widely recommended. However, adherence to screening remains an issue outside the clinical trial setting. This study examines the utility of biomarker-based risk assessment on uptake and subsequent adherence in a community screening study.

In a single arm pilot study, current or former smokers > 50 years old with 20 + pack year history were recruited following local advertising. One hundred and fifty seven participants volunteered to participate in the study that offered an optional gene-based lung cancer risk assessment followed by low-dose CT according to a standardised screening protocol.

All 157 volunteers who attended visit 1 underwent the gene-based risk assessment comprising of a clinical questionnaire and buccal swab. Of this group, 154 subsequently attended for CT screening (98%) and were followed prospectively for a median of 2.7 years. A participant’s adherence to screening was influenced by their baseline lung cancer risk category, with overall adherence in those with a positive scan being significantly greater in the “very high” risk group compared to “moderate” and “high” risk categories (71% vs 52%, Odds ratio = 2.27, 95% confidence interval of 1.02–5.05, P = 0.047). Those in the “moderate” risk group were not different to those in the “high” risk group (52% and 52%, P > 0.05).

In this proof-of-concept study, personalised gene-based lung cancer risk assessment was well accepted, associated with a 98% uptake for screening and increased adherence for those in the highest risk group.

Role of Breast Imaging Radiologists as Advocates for Screening Mammography

The objective of this article is to outline opportunities for breast imaging radiologists to advocate for screening mammography. Despite breast cancer being the second most common cancer in women and screening mammography's ability to reduce mortality from this disease, there remains suboptimal utilization in the community. The different guidelines for screening presented by respected organizations has created confusion for patients and referring clinicians and the eventual underutilization of screening mammography. As experts in the value of early detection, breast radiologists are well suited to take on the role of screening advocates. Using specific action steps and examples, we create a template for a radiologist to utilize in the promotion of screening among the breast imaging team, clinicians, administrators, and the community at large. By deliberately filling the role of screening mammography advocate, one can satisfy the mandate for radiologists to bring increased value to the health care team while contributing to community health and patient satisfaction.

The Controversial History of Hormone Replacement Therapy

The history of hormone replacement therapy (HRT) started in the 1960s, with very high popularity in the 1990s. The first clinical trials on HRT and chronic postmenopausal conditions were started in the USA in the late 1990s. After the announcement of the first results of the Women’s Health Initiative (WHI) in 2002, which showed that HRT had more detrimental than beneficial effects, HRT use dropped. The negative results of the study received wide publicity, creating panic among some users and new guidance for doctors on prescribing HRT. The clear message from the media was that HRT had more risks than benefits for all women. In the following years, a reanalysis of the WHI trial was performed, and new studies showed that the use of HRT in younger women or in early postmenopausal women had a beneficial effect on the cardiovascular system, reducing coronary disease and all-cause mortality. Notwithstanding this, the public opinion on HRT has not changed yet, leading to important negative consequences for women’s health and quality of life.

Patient-Assisted Compression in Screening Mammography: Patient Experience and Image Quality

OBJECTIVE

Screening mammography is critical to reduce breast cancer mortality, yet many women cite pain from compression as a reason they avoid this test. We evaluated patient experience and image quality in screening patients opting for a handheld patient-assisted compression (PAC) device.

METHODS

After institutional review board approval, women screened between February and July 2018 with a synthetic 2D/tomosynthesis mammography unit were offered use of a handheld PAC device. Patient experience through survey, image quality, compression thickness, compression force, and average glandular dose were evaluated and compared between women opting for PAC and women opting for technologist-controlled compression (TC). Multivariable ordinal logistic and linear regression models were estimated to control for age and breast density. In addition, for women opting for PAC, image quality obtained with their current PAC mammogram was compared with that obtained with their prior TC mammogram, by using Wilcoxon/Pearson tests.

RESULTS

Seventy-three percent of women preferred their mammogram experience with PAC compared with their prior mammogram without PAC. Women using PAC reported decreased anxiety compared with those using TC, after controlling for age and breast density (adjusted odds ratio [aOR] 0.22 [95% confidence interval (CI): 0.09-0.49]). There were no significant differences in image quality, compression thickness, or average glandular dose in exams for women using PAC compared with exams for women using TC. Women using PAC had significantly more compression force than women using TC had (P = 0.012).

CONCLUSIONS

Mammography with PAC improves patient experience and results in similar image quality compared with mammography with TC.

The Effect of Digital Breast Tomosynthesis Adoption on Facility-Level Breast Cancer Screening Volume

OBJECTIVE

The purpose of this study was to determine whether digital breast tomosynthesis (DBT) adoption was associated with a decrease in screening mammography capacity across Breast Cancer Screening Consortium facilities, given concerns about increasing imaging and interpretation times associated with DBT.

SUBJECTS AND METHODS

Facility characteristics and examination volume data were collected prospectively from Breast Cancer Screening Consortium facilities that adopted DBT between 2011 and 2014. Interrupted time series analyses using Poisson regression models in which facility was considered a random effect were used to evaluate differences between monthly screening volumes during the 12-month preadoption period and the 12-month postadoption period (with the two periods separated by a 3-month lag) and to test for changes in month-to-month facility-level screening volume during the preadoption and postadoption periods.

RESULTS

Across five regional breast imaging registries, 15 of 83 facilities (18.1%) adopted DBT for screening between 2011 and 2014. Most had no academic affiliation (73.3% [11/15]), were nonprofit (80.0% [12/15]), and were general radiology practices (66.7% [10/15]). Facility-level monthly screening volumes were slightly higher during the postadoption versus preadoption periods (relative risk [RR], 1.09; 95% CI, 1.06-1.11). Monthly screening volumes remained relatively stable within the preadoption period (RR, 1.00 per month; 95% CI 1.00-1.01 per month) and the postadoption period (RR, 1.00; 95% CI, 1.00-1.01 per month).

CONCLUSION

In a cohort of facilities with varied characteristics, monthly screening examination volumes did not decrease after DBT adoption.

Breast and Cervical Cancer Screening Among Medicaid Beneficiaries: The Role of Physician Payment and Managed Care

Medicaid-insured women have low rates of cancer screening. There are multiple policy levers that may influence access to preventive services such as screening, including physician payment and managed care. We examine the relationship between each of these factors and breast and cervical cancer screening among nonelderly nondisabled adult Medicaid enrollees. We combine individual-level data on Medicaid enrollment, demographics, and use of screening services from the Medicaid Analytic eXtract files with data on states' Medicaid-to-Medicare fee ratios and estimate their impact on screening services. Higher physician fees are associated with greater screening for comprehensive managed care enrollees; for enrollees in fee-for-service Medicaid, the findings are mixed. Patient participation in primary care case management is a significant moderator of the relationship between physician fees and the rate of screening, as interactions between enrollee primary care case management status and the Medicaid fee ratio are consistently positive across models of screening.

Addressing Potential Health Disparities in the Adoption of Advanced Breast Imaging Technologies

With the advent of new screening technologies, including digital breast tomosynthesis, screening ultrasound, and breast magnetic resonance imaging, there is growing concern that existing disparities among traditionally underserved populations will worsen. These newer screening modalities purport improved cancer detection over mammography alone but are not offered at all screening facilities and often require a larger co-pay or out-of-pocket expense. Thus, the potential for worsening disparities with regard to access and appropriate utilization of supplemental screening technologies exists. Currently, there is a dearth of literature on the topic of health disparities related to access and the use of supplemental breast cancer screening and their impact on outcomes. Identifying and addressing explanatory factors for persistent and potentially worsening disparities remain a central focus of efforts to improve equity in breast cancer care. Therefore, this paper provides an overview of factors that may contribute to present and future disparities in breast cancer screening and outcomes, and explores specific relevant topics requiring greater research efforts as more personalized, multimodality breast cancer screening approaches are adopted into clinical practice.

Geographic access to mammography facilities and frequency of mammography screening

PURPOSE

To assess the association between geographic access to mammography facilities and women's mammography utilization frequency.

METHODS

Using data from the population-based 1995-2007 Wisconsin Women's Health study, we used proportional odds and logistic regression to test whether driving times to mammography facilities and the number of mammography facilities within 10 km of women's homes were associated with mammography frequency among women aged 50-74 years and whether associations differed between Rural-Urban Commuting Areas and income and education groups.

RESULTS

We found evidence for nonlinear relationships between geographic access and mammography utilization (nonlinear effects of driving times and facility density, P-values .01 and .005, respectively). Having at least one nearby mammography facility was associated with greater mammography frequency among urban women (1 vs. 0 facilities, odds ratio 1.26, 95% confidence interval, 1.09-1.47), with similar effects among rural women. Adding more facilities had decreasing marginal effects. Long driving times tended to be associated with lower mammography frequency. We found no effect modification by income, education, or urbanicity. In rural settings, mammography nonuse was higher, facility density smaller, and driving times to facilities were longer.

CONCLUSIONS

Having at least one mammography facility near one's home may increase mammography utilization, with decreasing effects per each additional facility.

The Beginning of a Decline in Breast Cancer Incidence in Italy?

The incidence of invasive breast cancer in Turin, Italy, showed a statistically significant decrease during 1999–2003 overall (estimated annual percent change -2.6; 95% CL -8.52; -0.78) and in women aged over 50, similar to the recently documented trend in American data. This represents the first demonstration of a decline in breast cancer incidence in the early years of this decade outside the United States. In our population, the drop in the usage of hormone replacement therapy which occurred after 2002 is unlikely to be at the origin of this declining incidence trend, which is largely explained by a screening effect. This observation may be relevant to other geographical areas where organized or spontaneous screening reached a plateau after an increase in the preceding years.

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

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

Increasing Breast Cancer Screening in Russian Immigrant Women: Identifying Barriers and Providing On-Site Mammography

Background: There has been a significant decline in the use of mammography in the Russian immigrant population. Local Problem: Structural barriers to mammography include lack of or insufficient health insurance and distance to medical facilities. Organizational barriers include difficulty communicating with medical staff and navigating health care systems. The strongest mammography intervention is access. Methods: A Breast Health Tea event, small group discussions, and an on-site mammography event were held within this community to provide education about breast cancer and provide on-site screening mammography. Results: Twenty-seven women received the education and returned the questionnaires. Of these 27, 19 had mammograms. Of the 19, 16 had normal/benign results. Three required follow-up. Of the 3, 1 was positive for breast cancer, 1 was benign, and 1 went elsewhere. Conclusions: Providing access to on-site mammography has been shown to be an effective tool to reach communities that otherwise would not have access to these screenings. Advanced practice registered nurses can partner with public and private organizations and remove barriers to access for breast cancer screening in immigrant communities.

New analysis reexamines the value of cancer care in the United States compared to Western Europe

Despite sharp increases in spending on cancer treatment since 1970 in the United States compared to Western Europe, US cancer mortality rates have decreased only modestly. This has raised questions about the additional value of US cancer care derived from this additional spending. We calculated the number of US cancer deaths averted, compared to the situation in Western Europe, between 1982 and 2010 for twelve cancer types. We also assessed the value of US cancer care, compared to that in Western Europe, by estimating the ratio of additional spending on cancer to the number of quality-adjusted life-years saved. Compared to Western Europe, for three of the four costliest US cancers-breast, colorectal, and prostate-there were approximately 67,000, 265,000, and 60,000 averted US deaths, respectively, and for lung cancer there were roughly 1,120,000 excess deaths in the study period. The ratio of incremental cost to quality-adjusted life-years saved equaled $402,000 for breast cancer, $110,000 for colorectal cancer, and $1,979,000 for prostate cancer-amounts that exceed most accepted thresholds for cost-effective medical care. The United States lost quality-adjusted life-years despite additional spending for lung cancer: -$19,000 per quality-adjusted life-year saved. Our results suggest that cancer care in the United States may provide less value than corresponding cancer care in Western Europe for many leading cancers.

Multilevel factors associated with long-term adherence to screening mammography in older women in the U.S

In the U.S., guidelines recommend that women continue mammography screening until at least age 74, but recent evidence suggests declining screening rates in older women. We estimated adherence to screening mammography and multilevel factors associated with adherence in a longitudinal cohort of older women. Women aged 66-75years receiving screening mammography within the Breast Cancer Surveillance Consortium were linked to Medicare claims (2005-2010). Claims data identified baseline adherence, defined as receiving subsequent mammography within approximately 2years, and length of time adherent to guidelines. Characteristics associated with adherence were investigated using logistic and Cox proportional hazards regression models. Analyses were stratified by age to investigate variation in relationships between patient factors and adherence. Among 49,775 women, 89% were adherent at baseline. Among women 66-70years, those with less than a high school education were more likely to be non-adherent at baseline (odds ratio [OR] 1.96; 95% confidence interval [CI] 1.65-2.33) and remain adherent for less time (hazard ratio [HR] 1.41; 95% CI 1.11-1.80) compared to women with a college degree. Women with ≥1 versus no Charlson co-morbidities were more likely to be non-adherent at baseline (OR 1.46; 95% CI 1.31-1.62) and remain adherent for less time (HR 1.44; 95% CI 1.24-1.66). Women aged 71-75 had lower adherence overall, but factors associated with non-adherence were similar. In summary, adherence to guidelines is high among Medicare-enrolled women in the U.S. receiving screening mammography. Efforts are needed to ensure that vulnerable populations attain these same high levels of adherence.

Breast Cancer After Use of Estrogen Plus Progestin and Estrogen Alone: Analyses of Data From 2 Women's Health Initiative Randomized Clinical Trials

IMPORTANCE

The use of menopausal hormone therapy (HT) continues in clinical practice, but reports are conflicting concerning the longer-term breast cancer effects of relatively short-term use.

OBJECTIVE

To report the longer-term influence of menopausal HT on breast cancer incidence in the 2 Women's Health Initiative (WHI) randomized clinical trials.

DESIGN, SETTING, AND PARTICIPANTS

A total of 27,347 postmenopausal women aged 50 to 79 years were enrolled at 40 US centers from 1993 to 1998 and followed up for a median of 13 years through September 2010.

INTERVENTIONS

A total of 16,608 women with a uterus were randomized to conjugated equine estrogens (0.625 mg/d [estrogen]) plus medroxyprogesterone acetate (2.5 mg/d [progestin]) (E + P) or placebo with a median intervention duration of 5.6 years, and 10,739 women with prior hysterectomy were randomized to conjugated equine estrogens alone (0.625 mg/d) or placebo with a median intervention duration of 7.2 years.

MAIN OUTCOMES AND MEASURES

Time-specific invasive breast cancer incidence rates and exploratory analyses of breast cancer characteristics by intervention and postintervention phases in the 2 HT trials.

RESULTS

In the E + P trial, hazard ratios (HRs) for the influence of combined HT on breast cancer were lower than 1 for 2 years (HR, 0.71; 95% CI, 0.47-1.08) and steadily increased throughout intervention, becoming significantly increased for the entire intervention phase (HR, 1.24; 95% CI, 1.01-1.53). In the early postintervention phase (within 2.75 years from intervention), there was a sharp decrease in breast cancer incidence in the combined HT group, though the HR remained higher than 1 (HR, 1.23; 95% CI, 0.90-1.70). During the late postintervention phase (requiring patient re-consent), the HR for breast cancer risk remained higher than 1 through 5.5 years (median) of additional follow-up (HR, 1.37; 95% CI, 1.06-1.77). In the estrogen alone trial, the HR for invasive breast cancer risk was lower than 1 throughout the intervention phase (HR, 0.79; 95% CI, 0.61-1.02) and remained lower than 1 in the early postintervention phase (HR, 0.55; 95% CI, 0.34-0.89), but risk reduction was not observed during the late postintervention follow-up (HR, 1.17; 95% CI, 0.73-1.87). Characteristics of breast cancers diagnosed during early and late postintervention phases differed in both trials.

CONCLUSIONS AND RELEVANCE

In the E + P trial, the higher breast cancer risk seen during intervention was followed by a substantial drop in risk in the early postintervention phase, but a higher breast cancer risk remained during the late postintervention follow-up. In the estrogen alone trial, the lower breast cancer risk seen during intervention was sustained in the early postintervention phase but was not evident during the late postintervention follow-up.

Cancer statistics for Hispanics/Latinos, 2015

Cancer is the leading cause of death among Hispanics/Latinos, who represent the largest racial/ethnic minority group in the United States, accounting for 17.4% (55.4 million/318 million) of the total US population in 2014. Every 3 years, the American Cancer Society reports on cancer statistics for Hispanics based on incidence data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. Among Hispanics in 2015, there will be an estimated 125,900 new cancer cases diagnosed and 37,800 cancer deaths. For all cancers combined, Hispanics have 20% lower incidence rates and 30% lower death rates compared with non-Hispanic whites (NHWs); however, death rates are slightly higher among Hispanics during adolescence (aged 15-19 years). Hispanic cancer rates vary by country of origin and are generally lowest in Mexicans, with the exception of infection-associated cancers. Liver cancer incidence rates in Hispanic men, which are twice those in NHW men, doubled from 1992 to 2012; however, rates in men aged younger than 50 years declined by 43% since 2003, perhaps a bellwether of future trends for this highly fatal cancer. Variations in cancer risk between Hispanics and NHWs, as well as between subpopulations, are driven by differences in exposure to cancer-causing infectious agents, rates of screening, and lifestyle patterns. Strategies for reducing cancer risk in Hispanic populations include increasing the uptake of preventive services (e.g., screening and vaccination) and targeted interventions to reduce obesity, tobacco use, and alcohol consumption.

Bias in Observational Studies of the Association between Menopausal Hormone Therapy and Breast Cancer

Background

During the period 1985-2000 the breast cancer incidence rates increased 50% in the age group invited to mammography screening in Norway and Sweden. Simultaneously, use of hormone replacement treatment therapy (HT) increased 5 times. Several influential observational studies showed that HT was associated with 50% to 100% increased risk of breast cancer and most for those using combined (estrogen plus progestin) hormone replacement therapy (CHT). In contrast, the randomized WHI trial reported that CHT increased the risk by 10% for those not having previously used hormones and 24% when including previous users in the analyses. In another randomized trial, estrogen use only was not associated with any increased risk at all. After the WHI trial was published in 2003, use of HT dropped 70% within 5 years in Norway and Sweden while breast cancer rates were essentially unchanged. After 2008, HT use has dropped further and breast cancer incidence rates have started increasing again. The study objective is to calculate and to explain potential bias in the observational study design.

Methods and Findings

Here we use data from the randomized WHI trial and analyze these data as done in the observational studies to calculate the magnitude of the potential biases in the observational study design. Time varying effect of hormones and categorization of the follow-up time may increase the hazard ratio for long-term users from 1.10 to 1.48. Selective retrospective reporting of hormone use may further increase the hazard ratio to 1.68.

Conclusions

We suggest that the mechanism causing higher hazard ratio of breast cancer (compared to the observational studies) is the time-varying effect of CHT on the breast cancer risk and selective retrospective reporting of hormone use. Other risk factors for the increase in breast cancer risk in the age group 50-69 years should be considered, for example, overdiagnosis.

Trends and variations in breast and colorectal cancer incidence from 1995 to 2011: a comparative study between Texas Cancer Registry and National Cancer Institute's Surveillance, Epidemiology and End Results data

Few studies have examined the cancer incidence trends in the state of Texas, and no study has ever been conducted to compare the temporal trends of breast and colorectal cancer incidence in Texas with those of the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) in the United States. This study aimed to conduct a parallel comparison between the Texas Cancer Registry and the National Cancer Institute's SEER on cancer incidence from 1995 to 2011. A total of 951,899 breast and colorectal cancer patients were included. Age-adjusted breast cancer incidence was 134.74 per 100,000 in Texas and 131.78 per 100,000 in SEER in 1995-2011, whereas age-adjusted colorectal cancer incidence was 50.52 per 100,000 in Texas and 49.44 per 100,000 in SEER. Breast cancer incidence increased from 1995 to 2001, decreased from 2002 to 2006, and then remained relatively stable from 2007 to 2011. For colorectal cancer, the incidence increased in 1995-1997, and then decreased continuously from 1998 to 2011 in Texas and SEER areas. Incidence rates and relative risks by age, gender and ethnicity were identical between Texas and SEER.

Opportunities and challenges for the use of large-scale surveys in public health research: a comparison of the assessment of cancer screening behaviors

Large-scale surveys that assess cancer prevention and control behaviors are a readily available, rich resource for public health researchers. Although these data are used by a subset of researchers who are familiar with them, their potential is not fully realized by the research community for reasons including lack of awareness of the data and limited understanding of their content, methodology, and utility. Until now, no comprehensive resource existed to describe and facilitate use of these data. To address this gap and maximize use of these data, we catalogued the characteristics and content of four surveys that assessed cancer screening behaviors in 2005, the most recent year with concurrent periods of data collection: the National Health Interview Survey, Health Information National Trends Survey, Behavioral Risk Factor Surveillance System, and California Health Interview Survey. We documented each survey's characteristics, measures of cancer screening, and relevant correlates; examined how published studies (n = 78) have used the surveys' cancer screening data; and reviewed new cancer screening constructs measured in recent years. This information can guide researchers in deciding how to capitalize on the opportunities presented by these data resources.

Clinical outcome of Turkish metastatic breast cancer patients with currently available treatment modalities--single center experience

BACKGROUND

Breast cancer is the most common malignancy and the second leading cause of cancer-related death among women in the developed countries. Despite advances in screening, improved local therapies and adjuvant systemic treatments, median survival of metastatic breast cancer patients (MBC) is in the range of 2-3 years at most. We aimed to investigate whether the prognostic factors and therapeutic responses of our Turkish patients are similar to those in the literature.

MATERIALS AND METHODS

We reviewed the medical records of MBC patients who had been treated in our institution between 1999-2009 and analyzed their clinicopathological features and survival outcomes retrospectively.

RESULTS

A hundred and sixty patients were included. Median age was 47 (23-82), median follow up was 24 (2-186) months. At the time of diagnosis 59% of patients were under the age of 50 and 46% were postmenopausal. The majority (37%) had multiple sites of metastases. Forty percent received endocrine therapy and 40% chemotherapy as first line metastatic treatment. Thirty (20%) patients were treated with molecular targeting agents like trastuzumab, lapatinib and sunitinib, frequently combined with a chemotherapy agent. Five-year overall survival (OS) was 32% and median OS was 38 months for the whole group. Five year progression free survival (PFS) was 10% and median PFS was 10 months. Menopausal status, hormone receptor expression and disease free status had a significant impact on overall survival in the multivariate analysis (p 0.018, p 0.018 and p:0.003, respectively).

CONCLUSIONS

All our patients were treated with the modern oncologic therapies recommended by the international guidelines. From our data, MBC patients live up to 3-4 years, indicating that further improvement beyond that requires development of new treatment modalities. The survival outcomes of our patients were consistent with the data reported in the literature.

Validating self-reported mammography use in vulnerable communities: findings and recommendations

BACKGROUND

Most health surveys ask women whether they have had a recent mammogram, all of which report mammography use (past 2 years) at about 70% to 80% regardless of race or residence. We examined the potential extent of overreporting of mammography use in low income African-American and Latina women, and whether self-report inaccuracies might bias estimated associations between patient characteristics and mammography use.

METHODS

Using venue-based sampling in two poor communities on the west side of Chicago, we asked eligible women living in two west side communities of Chicago to complete a survey about breast health (n = 2,200) and to provide consent to view their medical record. Of the 1,909 women who screened eligible for medical record review, 1,566 consented (82%). We obtained medical records of all women who provided both permission and a valid local mammography facility (n = 1,221). We compared the self-reported responses from the survey with the imaging reports found in the medical record (documented). To account for missing data, we conducted multiple imputations for key demographic variables and report standard measures of accuracy.

RESULTS

Although 73% of women self-reported a mammogram in the last 2 years, only 44% of self-reports were documented. Overreporting of mammography use was observed for all three ethnic groups.

CONCLUSIONS

These results suggest considerable overestimation of prevalence of use in these vulnerable populations.

IMPACT

Relying on known faulty self-reported mammography data as a measure of mammography use provides an overly optimistic picture of utilization, a problem that may be exacerbated in vulnerable minority communities.

Randomized trial of DVD, telephone, and usual care for increasing mammography adherence

The purpose of this study was to test an intervention to increase mammography screening in women 51-75 years of age who had not received a mammogram in the last 15 months. A total of 1681 women were randomized to (1) a mailed tailored interactive DVD, (2) a computer-tailored telephone counseling, or (3) usual care. Women with income below US$75,000 who were in the interactive DVD group had significantly more mammograms than women in usual care. Women with income above US$75,000 had significantly fewer mammograms than women with income less than US$75,000 regardless of group. Further investigation is needed to understand why women with income above US$75,000 did not show the same benefit of the intervention.

U.S. Preventive Services Task Force recommendations and cancer screening among female Medicare beneficiaries

BACKGROUND

Medicare covers several cancer screening tests not currently recommended by the U.S. Preventive Services Task Force (Task Force). In September 2002, the Task Force relaxed the upper age limit of 70 years for breast cancer screening recommendations, and in March 2003 an upper age limit of 65 years was introduced for cervical cancer screening recommendations. We assessed whether mammogram and Pap test utilization among women with Medicare coverage is influenced by changes in the Task Force's recommendations for screening.

METHODS

We identified female Medicare beneficiaries aged 66-80 years and used bivariate probit regression to examine the receipt of breast (mammogram) and cervical (Pap test) cancer screening reflecting changes in the Task Force recommendations. We analyzed 9,760 Medicare Current Beneficiary Survey responses from 2001 to 2007.

RESULTS

More than two-thirds reported receiving a mammogram and more than one-third a Pap test in the previous 2 years. Lack of recommendation was given as a reason for not getting screened among the majority (51% for mammogram and 75% for Pap). After controlling for beneficiary-level socioeconomic characteristics and access to care factors, we did not observe a significant change in breast and cervical cancer screening patterns following the changes in Task Force recommendations.

CONCLUSIONS

Although there is evidence that many Medicare beneficiaries adhere to screening guidelines, some women may be receiving non-recommended screening services covered by Medicare.

Crowdsourcing awareness: exploration of the ovarian cancer knowledge gap through Amazon Mechanical Turk

Background

Ovarian cancer is the most lethal gynecologic disease in the United States, with more women dying from this cancer than all gynecological cancers combined. Ovarian cancer has been termed the “silent killer” because some patients do not show clear symptoms at an early stage. Currently, there is a lack of approved and effective early diagnostic tools for ovarian cancer. There is also an apparent severe knowledge gap of ovarian cancer in general and of its indicative symptoms among both public and many health professionals. These factors have significantly contributed to the late stage diagnosis of most ovarian cancer patients (63% are diagnosed at Stage III or above), where the 5-year survival rate is less than 30%. The paucity of knowledge concerning ovarian cancer in the United States is unknown.

Methods

The present investigation examined current public awareness and knowledge about ovarian cancer. The study implemented design strategies to develop an unbiased survey with quality control measures, including the modern application of multiple statistical analyses. The survey assessed a reasonable proxy of the US population by crowdsourcing participants through the online task marketplace Amazon Mechanical Turk, at a highly condensed rate of cost and time compared to traditional recruitment methods.

Conclusion

Knowledge of ovarian cancer was compared to that of breast cancer using repeated measures, bias control and other quality control measures in the survey design. Analyses included multinomial logistic regression and categorical data analysis procedures such as correspondence analysis, among other statistics. We confirmed the relatively poor public knowledge of ovarian cancer among the US population. The simple, yet novel design should set an example for designing surveys to obtain quality data via Amazon Mechanical Turk with the associated analyses.

Changes in the availability of screening mammography, 2000-2010

BACKGROUND

Rates of screening mammography have plateaued, and the number of mammography facilities has declined in the past decade. The objective of this study was to assess changes over time and geographic disparities in the availability of mammography services.

METHODS

Using information from the US Food and Drug Administration and the US Census, county-level mammography capacity was defined as the number of mammography machines per 10,000 women aged ≥ 40 years. Cross-sectional variation and longitudinal changes in capacity were examined in relation to county characteristics.

RESULTS

Between 2000 and 2010, the number of mammography facilities declined 10% from 9434 to 8469, the number of mammography machines declined 10% from 13,100 to 11,762, and the median county mammography capacity decreased nearly 20% from 1.77 to 1.42 machines per 10,000 women aged ≥ 40 years. In cross-sectional analysis, counties with greater percentages of uninsured residents, less educated residents, greater population density, and higher managed care penetration had lower mammography capacity. Conversely, counties with more hospital beds per 100,000 population had higher capacity. High initial mammography capacity, growth in both the percentage of the population aged ≥ 65 years and the percentage living in poverty, and increased managed care penetration were all associated with a decrease in mammography capacity between 2000 and 2010. Only the percentage of rural residents was associated with an increase in capacity.

CONCLUSIONS

Geographic variation in mammography capacity and declines in capacity over time are associated with demographic, socioeconomic, and health care market characteristics. Maldistribution of mammography resources may explain geographic disparities in breast cancer screening rates.

Hormone replacement therapy and breast cancer: heterogeneous risks by race, weight, and breast density

BACKGROUND

Although studies have demonstrated a positive association between hormone replacement therapy (HRT) and breast cancer risk, this association may vary by patient factors.

METHODS

We analyzed 1642824 screening mammograms with 9300 breast cancer cases in postmenopausal women aged 45 years or older derived from the Breast Cancer Surveillance Consortium, a longitudinal registry of mammography screening in the United States. Multiple imputation methods were used to accommodate missing data for HRT use (14%) and other covariables. We performed logistic regression to estimate odds ratios (ORs) for breast cancer associated with HRT use within strata of race/ethnicity, age, body mass index (BMI), and breast density, with two-way interaction terms between HRT use and each key covariable of interest. P values for assessing possible interactions were computed from Wald z statistics. All statistical tests were two-sided.

RESULTS

HRT use was associated with greater than 20% increased risk in white (OR = 1.21; 95% CI = 1.14 to 1.28), Asian (OR = 1.58; 95% CI = 1.18 to 2.11), and Hispanic women (OR = 1.35; 95% CI = 1.09 to 1.67) but not black women (OR = 0.91; 95% CI = 0.72 to 1.14; P interaction = .04). In women with low/normal BMI and extremely dense breasts, HRT use was associated with the highest breast cancer risk (OR = 1.49; 95% CI = 1.21 to 1.83), compared with nonusers. In overweight/obese women with less-dense breasts, no excess risk was associated with HRT use (adjusted ORs = 0.96 to 1.03).

CONCLUSIONS

The impact of HRT use on breast cancer risk varies according to race/ethnicity, BMI, and breast density. This risk stratification could help in advising HRT use for the relief of menopausal symptoms.

Breast Arterial Calcification: a New Marker of Cardiovascular Risk?

Mammographically-detected breast arterial calcifications (BAC) are considered to be an incidental finding without clinical importance since they are not associated with increased risk of breast cancer. The goal of this article is to review existing evidence that the presence of BAC on mammography correlates with several (but not all) traditional cardiovascular disease (CVD) risk factors and with prevalent and incident CVD. Thus, BAC detected during routine mammography is a noteworthy finding that could be valuable in identifying asymptomatic women at increased future CVD risk that may be candidates for more aggressive management. In addition, there are notable differences in measures of subclinical atherosclerosis burden in women (ie, coronary artery calcification) by race/ethnic background, and the same appears to be true for BAC, although data are very limited. Another noteworthy limitation of prior research on BAC is the reliance on absence vs presence of BAC; no study to date has determined gradation of BAC. Further research is thus required to elucidate the role of BAC gradation in the prediction of CVD outcomes and to determine whether adding BAC gradation to prediction models based on traditional risk factors improves classification of CVD risk.

Changes in access to screening mammography, 2008-2011

Screening mammography is a cornerstone of preventive health care for adult women in the United States. As rates of screening mammography have declined and plateaued in the past decade, access to services remains a concern. In 2011, we repeated a survey of mammography facilities initially surveyed in 2008 in six states. The availability of digital mammography increased and appointment wait times generally improved between the two survey periods, but more facilities required payment upfront. Provisions of the federal healthcare reform law that eliminate cost sharing for selected preventive health services may improve access to screening mammography and prevent further declines in the rate of breast cancer screening.

The link between women's body image disturbances and body-focused cancer screening behaviors: a critical review of the literature and a new integrated model for women

A large body of literature demonstrates the association between body image disturbances and health compromising behaviors among women (e.g., pathological eating, substance use, inappropriate exercise). However, given that disturbed body image is a pervasive problem, it is likely inversely related to health maintenance behaviors. Cancer screenings for breast, skin, and cervical cancer represent an important type of health maintenance behavior, yet adherence rates are low. Given the body-focused nature of these screenings, body image may be a salient predictor. This paper reviews the literature on the relationship between body image disturbances and cancer screening behaviors among women culminating in the proposal of a theoretical model. This model posits that body shame and body avoidance predict performance of cancer screenings and that variables drawn from the cancer literature, including risk perception, health anxiety, subjective norms, and self-efficacy, may moderate this relationship. Clinical implications and suggestions for research are discussed.

Racial differences in breast cancer stage at diagnosis in the mammography era

OBJECTIVES

We assessed racial differences in breast cancer mortality by stage at diagnosis, since mammography became available.

METHODS

We calculated adjusted odds of distant (versus local or regional) tumors for 143,249 White and 13,571 Black women aged 50 to 69 years, diagnosed with breast cancer between 1982 and 2007 and living in a Surveillance, Epidemiology, and End Results region. We compared linear trends in stage at diagnosis before and after 1998.

RESULTS

Distant-stage cancer was diagnosed in 5.8% of White and 10.2% of Black participants. The Black-White disparity in distant tumors narrowed until 1998 (1998 adjusted difference = 0.65%), before increasing. Between 1982 and 1997, the proportion of distant tumors decreased for Blacks (adjusted odds ratio [AOR]/y = 0.973; 95% confidence interval [CI] = 0.960, 0.987) and Whites (AOR/y = 0.978; 95% CI = 0.973, 0.983), with no racial differences (P = .47). From 1998 to 2007, the odds of distant versus local or regional tumors increased for Blacks (AOR/y = 1.036; 95% CI = 1.013, 1.060) and Whites (AOR/y = 1.011; 95% CI = 1.002, 1.021); the rate of increase was greater for Blacks than Whites (P = .04).

CONCLUSIONS

In the mammography era, racial disparities remain in stage at diagnosis.

Trends in Adherence to Recommended Cancer Screening: The US Population and Working Cancer Survivors

INTRODUCTION

Over the past decade the United States (US) has seen a decrease in advanced cancer diagnoses. There has also been an increase in the number of cancer survivors returning to work. Cancer screening behaviors among survivors may play an important role in their return-to-work process. Adherence to a post-treatment cancer screening protocol increases early detection of secondary tumors and reduces potentially limiting side-effects. We compared screening trends among all cancer survivors, working survivors, and the general population over the last decade.

MATERIALS AND METHODS

Trends in adherence to recommended screening were analyzed by site-specific cancer. We used the Healthy People goals as a measure of desired adherence. We selected participants 18+ years from 1997 to 2010 National Health Interview Survey for years where detailed cancer screening information was available. Using the recommendations of the American Cancer Society as a guide, we assessed adherence to cancer screening across the decade. There were 174,393 participants. Analyses included 7,528 working cancer survivors representing 3.8 million US workers, and 119,374 adults representing more than 100 million working Americans with no cancer history.

RESULTS

The US population met the Healthy People 2010 goal for colorectal screening, but declined in all other recommended cancer screening. Cancer survivors met and maintained the HP2010 goal for all, except cervical cancer screening. Survivors had higher screening rates than the general population. Among survivors, white-collar and service occupations had higher screening rates than blue-collar survivors.

CONCLUSION

Cancer survivors report higher screening rates than the general population. Nevertheless, national screening rates are lower than desired, and disparities exist by cancer history and occupation. Understanding existing disparities, and the impact of cancer screening on survivors is crucial as the number of working survivors increases.

Influence of health insurance coverage on breast, cervical, and colorectal cancer screening in rural primary care settings

BACKGROUND

The current study was performed to determine, in rural settings, the relation between the type and status of insurance coverage and being up-to-date for breast, cervical, and colorectal cancer screening.

METHODS

Four primary care practices in 2 rural Oregon communities participated. Medical chart reviews that were conducted between October 2008 and August 2009 assessed insurance coverage and up-to-date status for breast, cervical, and colorectal cancer screening. Inclusion criteria involved having at least 1 health care visit within the past 5 years and being aged ≥ 55 years.

RESULTS

The majority of patients were women aged 55 years to 70 years, employed or retired, and who had private health insurance and an average of 2.5 comorbid conditions. The overall percentage of eligible women who were up-to-date for cervical cancer screening was 30%; approximately 27% of women were up-to-date for clinical breast examination, 37% were up-to-date for mammography, and 19% were up-to-date for both mammography and clinical breast examination. Approximately 38% of men and 35% of women were up-to-date for colorectal cancer screening using any test at appropriate screening intervals. In general, having any insurance versus being uninsured was associated with undergoing cancer screening. For each type of screening, patients who had at least 1 health maintenance visit were significantly more likely to be up-to-date compared with those with no health maintenance visits. A significant interaction was found between having health maintenance visits, having any health insurance, and being up-to-date for cancer screening tests.

CONCLUSIONS

Overall, the percentage of patients who were up-to-date for any cancer screening, especially cervical cancer screening, was found to be very low in rural Oregon. Patients with some form of health insurance were more likely to have had a health maintenance visit within the previous 2 years and to be up-to-date for breast, cervical, and/or colorectal cancer screening.

The "Welcome to Medicare" visit: a missed opportunity for cancer screening among women?

BACKGROUND

On January 1, 2005, Medicare began covering a "Welcome to Medicare" visit (WMV) for new enrollees with fee-for-service (FFS) Medicare (Parts A and B). The new benefit was expected to increase demand for mammography and Pap tests among women transitioning onto Medicare. This study examined whether Medicare's coverage of a WMV influenced the use of mammography and Pap tests among women aged 65 and 66 years with FFS Medicare.

METHODS

Medicare Current Beneficiary Survey (MCBS) data from 2001 to 2007 were linked with Medicare claims. Utilization rates for preventive visits, mammography, and Pap tests were measured among women entering Medicare. Multivariate logistic regressions were estimated to quantify the effects of the new Medicare benefit on the use of these screening tests, controlling for patient characteristics.

RESULTS

Regression-adjusted mammography and Pap test rates did not increase after WMV coverage was introduced. The 2005 reform had nonsignificant trivial effects on the use of both tests, most likely because few of the women who were eligible for a WMV took advantage of it.

CONCLUSIONS

Medicare coverage of a WMV had no impact on mammography screenings or Pap tests among women who were eligible for the benefit.

Cancer statistics for Hispanics/Latinos, 2012

Hispanics/Latinos are the largest and fastest growing major demographic group in the United States, accounting for 16.3% (50.5 million/310 million) of the US population in 2010. In this article, the American Cancer Society updates a previous report on cancer statistics for Hispanics using incidence data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. In 2012, an estimated 112,800 new cases of cancer will be diagnosed and 33,200 cancer deaths will occur among Hispanics. In 2009, the most recent year for which actual data are available, cancer surpassed heart disease as the leading cause of death among Hispanics. Among US Hispanics during the past 10 years of available data (2000-2009), cancer incidence rates declined by 1.7% per year among men and 0.3% per year among women, while cancer death rates declined by 2.3% per year in men and 1.4% per year in women. Hispanics have lower incidence and death rates than non-Hispanic whites for all cancers combined and for the 4 most common cancers (breast, prostate, lung and bronchus, and colorectum). However, Hispanics have higher incidence and mortality rates for cancers of the stomach, liver, uterine cervix, and gallbladder, reflecting greater exposure to cancer-causing infectious agents, lower rates of screening for cervical cancer, differences in lifestyle and dietary patterns, and possibly genetic factors. Strategies for reducing cancer risk among Hispanics include increasing utilization of screening and available vaccines, as well as implementing effective interventions to reduce obesity, alcohol consumption, and tobacco use.

Declining mammography screening in a state Medicaid Fee-for-Service program: 1999-2008

OBJECTIVE

To evaluate and compare annual and biennial mammography screening rates across age, race, and geographic location (rural-urban) and to determine mammography screening persistence over 10 years among women enrolled in the West Virginia (WV) Medicaid Fee-for-Service (FFS) program.

METHODS

The WV Medicaid FFS administrative claims data for women recipients aged 40-64 from 1999 to 2008 were used for study purposes. Annual and biennial screening rates and persistence with screening were determined for women who were continuously enrolled in the WV Medicaid FFS program for respective calendar years.

RESULTS

A steady decline in the annual and biennial screening rates over a 10-year period (1999-2008) was observed among women recipients aged 40-64 years in the WV Medicaid FFS program, and screening persistence was also lower. Both annual and biennial screening rates and persistence varied by different demographic characteristics.

CONCLUSIONS

Although mammography screening services are covered under Medicaid programs, underuse persists as a major concern. The results of this study emphasize the need to identify and address barriers to mammography screening in low-income rural populations.

Comparative effectiveness of mailed reminder letters on mammography screening compliance

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Social determinants of breast cancer screening in urban primary care practices: a community-engaged formative study

BACKGROUND

The recent decline in the breast cancer mortality rate can be attributed to intensive screening and early detection efforts. However, studies have documented a decline in self-reported recent mammography use and interventions to enhance mammography utilization have yielded modest improvements. To address the root causes of breast cancer disparities and improve mammography use, interventions need to address multiple layers of patient, provider, and health system factors.

OBJECTIVE

Using community-based participatory research principles, we sought to learn from women receiving care through urban primary care practices about issues surrounding mammography screening and strategies to increase screening.

METHODS

We conducted five focus groups among 41 eligible women who were predominantly African American, recruited using nonprobability purposive sampling methods from urban community health centers in Baltimore, Maryland. Data are reported from three focus groups (n = 28) that provided usable data. We used the social determinants of health perspective to conduct a qualitative content analysis and interpretation of the data.

RESULTS

Major obstacles to obtaining a screening mammogram were individual-level (i.e., pain from the procedure) and structural-level factors (i.e., cost, geography, convenience). Strategies to overcome obstacles could include the creation of structural mechanisms whereby women can receive a host of services during one visit to a healthcare professional's office. Important promoters of screening behavior included social-level factors such as social support, hope, and positive treatment outcomes.

CONCLUSION

The social determinants of health perspective provided a unique perspective to frame barriers and promoters of mammography utilization and insights to develop interventions aimed at improving cancer control among women receiving care at urban primary care health centers.

Relationships between lifestyle, health behaviors, and health status outcomes for underserved adults

PURPOSE

To examine the relationships between lifestyle, health behaviors, and health status for underserved adults.

DATA SOURCES

A convenience sample of 84 adults responded to a questionnaire on lifestyle, health behaviors, health indices, and health status. Health status was measured by the 12-Item Short-Form Health Survey (SF-12).

CONCLUSIONS

The majority of the sample was white, female, ranged in age from 19 to 64 years, and had an annual income range of $0-$25,000. Lifestyle factors reported included smoking (44%), consuming alcohol (59%), using street drugs previously (43%), exercising regularly (45%), and having adequate sleep (M= 7.16 h). Sixty-five percent engaged in at least one screening behavior during the past 12 months and used at least one prescription medication. Data for health indices demonstrated subjects had at least one current symptom (89%), at least one current medical condition (72%), and a body mass index classified as overweight (48%). No significant relationships were found between lifestyle and health status. Findings indicated health indices rather than lifestyle were related to health status.

IMPLICATIONS FOR PRACTICE

Findings provided selective support for the links between lifestyle, health behaviors, and health status. Nurses can use the results as a basis for future assessments and interventions with underserved adults.

Health behaviors among cancer survivors receiving screening mammography

OBJECTIVES

The purpose of this study was to evaluate the prevalence of cancer-related behavioral risk factors among female cancer survivors, relative to women without a previous diagnosis of cancer.

METHODS

In a large cohort of 19,948 women presenting for screening mammography, questionnaires on health behaviors were administered.

RESULTS

A total of 18,510 had detailed history on health behaviors and previous cancer history. Overall 2713 (14.7%) reported a previous cancer history. We found statistically significant results indicating that cancer survivors were less likely than those with no cancer history to: report their overall health as "excellent" (13.6% vs. 21.5%), to engage in moderate or strenuous exercise (56.5% vs. 63.3%), and to use complementary and alternative medicine (57.4% vs. 60.2%). Conversely, cancer survivors were more likely to be current smokers (6.3% vs. 5.5%), rate their overall health as "poor" (15.8% vs. 9.1%), and to report more weight gain over time. Among cancer survivors, differences also emerged by the type of primary cancer. For example, cervical cancer survivors (n = 370) were most likely to report being current smokers (15.7%) and regular alcohol users (71.7%) compared with other survivors. Ovarian (n = 185) and uterine (n = 262) cancer survivors most frequently reported being obese (41% and 34.4%, respectively). Cervical cancer survivors reported the largest weight gain (4.9 lbs at 5 y and 13.4 lbs at 10 y).

CONCLUSIONS

These results suggest opportunities for tailored behavioral health risk factor interventions for specific populations of cancer survivors.

Breast cancer stage at diagnosis: is travel time important?

Recent studies have produced inconsistent results in their examination of the potential association between proximity to healthcare or mammography facilities and breast cancer stage at diagnosis. Using a multistate dataset, we re-examine this issue by investigating whether travel time to a patient's diagnosing facility or nearest mammography facility impacts breast cancer stage at diagnosis. We studied 161,619 women 40 years and older diagnosed with invasive breast cancer from ten state population based cancer registries in the United States. For each woman, we calculated travel time to their diagnosing facility and nearest mammography facility. Logistic multilevel models of late versus early stage were fitted, and odds ratios were calculated for travel times, controlling for age, race/ethnicity, census tract poverty, rural/urban residence, health insurance, and state random effects. Seventy-six percent of women in the study lived less than 20 min from their diagnosing facility, and 93 percent lived less than 20 min from the nearest mammography facility. Late stage at diagnosis was not associated with increasing travel time to diagnosing facility or nearest mammography facility. Diagnosis age under 50, Hispanic and Non-Hispanic Black race/ethnicity, high census tract poverty, and no health insurance were all significantly associated with late stage at diagnosis. Travel time to diagnosing facility or nearest mammography facility was not a determinant of late stage of breast cancer at diagnosis, and better geographic proximity did not assure more favorable stage distributions. Other factors beyond geographic proximity that can affect access should be evaluated more closely, including facility capacity, insurance acceptance, public transportation, and travel costs.

Screening mammography use among current, former, and never hormone therapy users may not explain recent declines in breast cancer incidence

BACKGROUND

Screening mammography and invasive breast cancer and ductal carcinoma in situ (DCIS) rates recently declined in the United States; screening mammography declines among former hormone therapy (HT) users may be an important contributor. We longitudinally examined women and compared mammography use and cancer rates by HT use [current, former, and never users of estrogen + progestin (EPT) and estrogen only (ET)].

METHODS

We studied 163,490 unique women aged 50-79 years enrolled in Group Health (Washington State) between 1994-2009. Electronic data identified HT dispensing, mammography use and incident breast cancer diagnosis. We calculated age-adjusted screening compliance as a time-varying variable (screened-within-the-past-26 months, yes/no).

RESULTS

Before 2002, screening compliance differed significantly by HT with current EPT users having the highest rates (83%) followed by former EPT (77%), current ET (77%), former ET (72%), and never users (56%). After 2002, screening was high (∼81%) among current and former EPT and ET users and significantly increased among never users (∼62%). Invasive breast cancer rates significantly decreased over the whole study period (P(trend) ≤ 0.05) for all HT users, except EPT current users (P(trend) = 0.68); DCIS rates did not change in any group.

CONCLUSIONS

Differential screening mammography rates by HT use do not explain invasive breast cancer incidence declines. Our data suggest discontinuing HT has an immediate effect on breast cancer rates, lending support to the mechanism that cessation leads to tumor regression.

IMPACT

Studies examining the influence of a changing exposure in relation to outcomes should account for varying exposures, individuals' characteristics, as well as screening methods and frequency.