Impact of a breast cancer screening community intervention

Printed Health Education Materials for Diverse Communities: Suggestions Learned from the Field

Health education materials designed for the general population may be perceived as unattractive, irrelevant, or unclear by members of certain cultural groups. Given the increasingly multicultural demographics of the United States, planners need to be aware of the specific characteristics of a target audience to address cultural differences and similarities in health messages. The authors describe the use of the subjective culture methodology and social marketing to develop health education materials targeted to multicultural populations, illustrate cultural factors that should be considered when designing printed materials, and outline steps in the design of attractive, stimulating, and culturally appropriate materials. The authors describe the challenges and problems in designing printed materials for multiethnic communities, give suggestions for written educational messages, present a summary of the lessons learned in the development of materials for ethnically diverse populations, and give examples of success stories in multiethnic communities.

Pathways to Early Cancer Detection in the Multiethnic Population of the San Francisco Bay Area

The Pathways project studied the relationship of race/ethnicity, socioeconomic status, and culture to breast and cervical cancer screening. A multidisciplinary, multicultural team of investigators assessed the knowledge, attitudes, and practices of women from five race/ethnic groups (N = 4,228) and their barriers to screening utilization. A planning framework guided the development of interventions and analyses of the similarities and differences in screening behaviors across race/ethnic groups. Baseline data for women ages 18 to 74 years showed that levels of screening were higher than national averages for Latina, white, and black women but lower for Chinese and Vietnamese women. Analyses revealed the importance of education and insurance in obtaining recommended screening regardless of race/ethnicity. However, race, ethnicity, and culture are important to the tailoring of effective interventions.

The African American Women and Mass Media (AAMM) campaign in Georgia: quantifying community response to a CDC pilot campaign

PURPOSE

To evaluate whether a culturally appropriate campaign using "Black radio" and print media increased awareness and utilization of local mammography screening services provided by the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program among African American women.

METHODS

The evaluation used a quasi-experimental design involving data collection during and after campaign implementation in two intervention sites in GA (Savannah with radio and print media and Macon with radio only) and one comparison site (Columbus, GA). We used descriptive statistics to compare mammography uptake for African American women during the initial months of the campaign (8/08-1/09) with the latter months (2/09-8/09) and a post-campaign (9/09-12/09) period in each of the study sites. Comparisons of monthly mammogram uptake between cities were performed with multinomial logistic regression. We assumed a p value <0.05 to be significant.

RESULTS

We observed an increase of 46 and 20 % in Savannah and Macon, respectively, from the initial period of the campaign to the later period. However, the increase did not persist in the post-campaign period. Analysis comparing monthly mammogram uptake in Savannah and Macon with Columbus showed a significant increase in uptake from the first to the second period in Savannah only (OR 1.269, 95 % CI (1.005-1.602), p = 0.0449).

CONCLUSIONS

Dissemination of health promotion messages via a culturally appropriate, multicomponent campaign using Black radio and print media was effective in increasing mammogram uptake in Savannah among low-income, African American women. Additional research is needed to quantify the relative contribution of campaign radio, print media, and community components to sustain increased mammography uptake.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

Formative research for a community-based message-framing intervention

OBJECTIVE

To inform a community-based message framing intervention encouraging physical activity and fruit and vegetable consumption among medically underserved adults.

METHOD

Key informant interviews, focus groups, and a survey were conducted with limited-literacy Hispanics in the northeastern United States.

RESULTS

Barriers to healthy lifestyle behaviors exist at individual, community, and policy levels. A strong degree of networking among local organizations and elected officials exists that can be used to encourage healthy lifestyle initiatives.

CONCLUSIONS

Community-based health communication interventions must address neighborhood realities, the literacy levels of the target population, and existing networks of providers and consumers.

The role of physician involvement in Latinas' mammography screening adherence

BACKGROUND

Disparities in breast cancer (BC) screening continue to affect Latinas significantly, but the factors that explain these disparities remain unclear.

OBJECTIVE

The objective of this study was to investigate whether physician's instruction on breast examination and mammography recommendations predicted Latinas' adherence to mammography screening above and beyond other influential variables.

METHODS

A cross-sectional, descriptive design was utilized. Convenience and snowball sampling techniques were followed to recruit 344 Latinas aged 41 years and older from predominantly Latino neighborhoods in Denver, Colorado.

MAIN OUTCOME MEASURES

Latinas' adherence to mammography screening recommendations by the American Cancer Society.

RESULTS

Characteristics that were significantly associated with mammography adherence were age, Pap smear adherence, physician's breast examination instructions, and physician's mammography recommendations.

CONCLUSION

The study provides evidence that the BC screening disparities that significantly affect Latinas can be addressed by increasing physician's involvement through BC screening instruction and referral.

"Health is strength": a community health education program to improve breast and cervical cancer screening among Korean American Women in Alameda County, California

BACKGROUND

A 48-month community intervention was conducted to improve breast and cervical cancer (BCC) screening among Korean American (KA) women in Alameda County (AL), California. KA women in Santa Clara (SC) County, California served as a comparison group.

METHODS

Random samples of KA women from each county were surveyed by telephone in 1994 (n=818) and 2002 (n=1084). Propensity score analyses were used to estimate the difference between counties in changes over time in screening (Pap tests, breast self-examinations, clinical breast examinations, and mammography), and to estimate differences in screening between participants and non-participants in an educational workshop among women in AL in 2002.

RESULTS

Mammography screening and clinical breast examinations increased over time in both counties. Pap tests increased in AL but not SC, and breast self-examinations did not change significantly in either county. None of the intervention-comparison group differences over time were significant. In 2002, compared to non-participants, women who attended a workshop were more likely to report a recent Pap test (P<.08).

CONCLUSIONS

Although our overall intervention did not appear to enhance screening practices at the community-level, attendance at a women's health workshop appears to have increased cervical cancer screening.

Colorectal cancer screening: physician recommendation is influential advice to Marylanders

BACKGROUND

In comparison to the United States, Maryland is facing a significantly higher burden of colorectal cancer incidence and mortality. The primary objective of this study was to determine the predictors of colorectal cancer screening use in Maryland.

METHODS

We performed secondary analyses on Maryland Cancer Survey 2002 data from 2994 respondents to investigate important predictors for individual colorectal cancer screening tests. CRC screening outcomes were defined as (1) FOBT within the past year, (2) sigmoidoscopy within the past 5 years, or (3) colonoscopy within the past 10 years.

RESULTS

We found that clinician recommendation for a screening test is the best predictor in both age categories (50-64 years and 65+ years); it is a very strong indicator and consistently improves the odds of use by a factor of at least 8 for any screening test.

CONCLUSIONS

There remains a great need for improved colorectal cancer screening in Maryland. According to our results, it is clear that the most influential way to improve overall colorectal cancer screening for each test and both age groups is to increase clinician recommendation for these tests.

Long-term results from a randomized controlled trial to increase cancer screening among attendees of community health centers

PURPOSE

We assessed whether increased cancer screening rates that were observed with Cancer Screening Office Systems (Cancer SOS) could be maintained at 24 months' follow-up, a period in which clinics were expected to be largely self-sufficient in maintaining the intervention.

METHODS

Eight primary care clinics serving disadvantaged populations in Hills-borough County, Fla, agreed to take part in a cluster-randomized experimental trial. Charts of independent samples of established patients aged 50 to 75 years were abstracted, with data collected at baseline (n = 1,196) and at 24 months' follow-up (n = 1,296). Papanicolaou (Pap) smears, mammography, and fecal occult blood testing were assessed.

RESULTS

At 24 months of follow-up, intervention patients had received a greater number of cancer screening tests (mean 1.17 tests vs 0.94 tests, t test = 4.42, P <.0001). In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms slightly (odds ratio [OR]) = 1.26; 95% confidence interval [CI], 1.02-1.55; P = .03) but had no effect on fecal occult blood tests (OR = 1.17; 95% CI, 0.92-1.48; P =0.19) or Pap smears (OR = 0.88; 95% CI, 0.0.68-1.15; P = .34).

CONCLUSIONS

The Cancer SOS intervention had persistent, although modest, effects on screening at 24 months' follow-up, an effect that had clearly diminished from results reported at 12 months' follow-up. Further study is needed to develop successful intervention strategies that are either self-sustaining or that are able to produce long-term changes in screening behavior.

Promoting cancer screening: Learning from experience

This article provides an overview of behavioral and social science cancer screening intervention research and introduces the scope of topics addressed in this supplement to Cancer. The authors identify and address issues to consider before conducting interventions to promote the uptake of screening tests, such as the benefits and harms associated with screening. Trends in the use of cancer screening tests are discussed in the context of their efficacy and adoption over time. Both the development and breadth of social and behavioral intervention research intended to increase the use of effective tests are reviewed as background for the articles that follow. The application of the lessons from this extensive knowledge base not only should accelerate the uptake of the effective cancer screening tests currently available, but also can guide future directions for research.

Issues in the meta-analysis of cluster randomized trials

Meta-analyses involving the synthesis of evidence from cluster randomization trials are being increasingly reported. These analyses raise challenging methodologic issues beyond those raised by meta-analyses which include only individually randomized trials. In this paper we review and comment on a selected number of these issues, including problems of study heterogeneity, difficulties in estimating design effects from individual trials and the choice of statistical methods.

Evaluation of a community breast screening promotion program

BACKGROUND

This study reports results of a controlled evaluation of a comprehensive community breast screening promotion program. This program promoted increased use of mammography, clinical breast examination, and breast self-examination through community organization, physician training, and public education.

METHODS

The program was conducted in one of three matched Florida study areas, with before and after assessment of breast screening behaviors, beliefs, and perceptions of women ages 40 and older. Baseline measures in 1990 were obtained by combining telephone and household survey data; follow-up measures using similar combined data were conducted with 4,096 women in 1997.

RESULTS

. There was no evidence that the breast screening promotion program achieved higher levels of screening among women ages 40 and older in the program area. Mammography use and supportive beliefs and perceptions of mammography increased in all three study areas between 1990 and 1997.

CONCLUSIONS

Among factors that may have reduced the differential impact of the program were public attention to breast cancer screening in the late 1980s throughout the U.S., effects of managed care, and limited penetration of a key program component. While the program was well received and served the community, its impact was overwhelmed by temporal trends observed in this study.

Community-based cancer screening for underserved women: design and baseline findings from the Breast and Cervical Cancer Intervention Study

BACKGROUND

Underutilization of breast and cervical cancer screening has been observed in many ethnic groups and underserved populations. Effective community-based interventions are needed to eliminate disparities in screening rates and thus to improve prospects for survival.

METHODS

The Breast and Cervical Cancer Intervention Study was a controlled trial of three interventions in the San Francisco Bay Area from 1993 to 1996: (1) community-based lay health worker outreach; (2) clinic-based provider training and reminder system; and (3) patient navigator for follow-up of abnormal screening results. Study design and a description of the interventions are reported along with baseline results of a household survey conducted in four languages among 1599 women, aged 40-75.

RESULTS

Seventy-six percent of women ages 40 and over had had at least one mammogram, and most had had a clinical breast examination (88%) and Pap smear (89%). Rates were significantly lower for non-English-speaking Latinas and Chinese women (56 and 32%, respectively, for mammography), and maintenance screening (three mammograms in the past 5 years) varied from 7% (non-English-speaking Chinese) to 53% (Blacks). Pap smear screening in the past 3 years was low among non-English-speaking Latinas (72%) and markedly lower among non-English-speaking Chinese women (24%). The strongest predictors of screening behavior were having private health insurance and frequent use of medical services. Having a regular clinic and speaking English were also important. Race/ethnicity, education, household income, and employment status were, overall, not significant predictors of screening behavior.

CONCLUSIONS

These baseline results support the importance of cancer screening interventions targeted to persons of foreign origin, particularly those less acculturated.

Promoting breast and cervical cancer screening at the workplace: results from the Woman to Woman Study

OBJECTIVES

This article reports findings from a peer-delivered intervention designed to increase use of breast and cervical cancer screening.

METHODS

Twenty-six worksites were randomly assigned to the intervention or comparison group. The 16-month intervention consisted of group discussions, outreach, and educational campaigns. Data were collected from a random sample of women employees stratified by age (baseline n = 2943; final n = 2747). Cross-sectional analyses were conducted to evaluate the impact of the intervention on screening behaviors.

RESULTS

Relative to comparison worksites, the intervention group experienced greater increases in the percentage of women who reported a recent mammogram (7.2% vs 5.6%), clinical breast examination (5.8% vs 2.1%), and Papanicolaou (Pap) test (4.7% vs 1.9%). After worksite cluster and age strata were controlled for, the observed increase in Pap tests was significantly greater in the intervention group (odds ratio [OR] = 1.28; 95% confidence interval [CI] = 1.01, 1.62); however, differences in mammography screening rates (OR = 1.14; 95% CI = 0.90, 1.44) and clinical breast examination (OR = 1.19; 95% CI = 0.96, 1.49) were not statistically significant.

CONCLUSIONS

Intervention activities produced a modest increase in cervical cancer screening, but they did not accelerate breast cancer screening rates above the observed secular trend.

Implementation of outreach telephone counseling to promote mammography participation

To increase mammography participation, the authors implemented an outreach intervention translating concepts from expectancy value theory into a motivational interviewing telephone intervention that included the opportunity to schedule a screening appointment. Process data are presented from 491 women who had not scheduled a mammogram within 2 months of receiving a mailed invitation from a managed care organization's centralized breast cancer screening program. A total of 83% of targeted women accepted the counseling calls. Counselors rated 84% of completed calls as either receptive or neutral in tone. Women with prior mammography experience were more likely to be receptive and to schedule a screening appointment during the calls than were women with no prior experience. Topics discussed during the calls also differed between women with and without prior mammography experience. Implications for dissemination of counseling interventions in health care organizations are discussed.

Mammogram utilization among farm women

Utilization of preventive health care services is lower in rural populations than in urban populations, possibly as a result of barriers to preventive health care that are characteristic of rural settings. This study was conducted to identify factors associated with mammogram utilization among farm women. Mammogram utilization among farm women from six southern Minnesota counties was examined as part of a larger community-based cancer intervention study. Farm women aged 40 and older were randomly selected from a list of farm households and interviewed by telephone to determine mammogram utilization and factors related to utilization. Of the 606 respondents, 78 percent reported ever having a mammogram and 49 percent reported a mammogram within the past year. Physician recommendation for a screening mammogram and family history of breast cancer were found to be associated with ever having a mammogram. Correct knowledge of mammogram screening guidelines was associated with a mammogram within the past 12 months. Overall, physician recommendation was the most influential determinant of utilization. As more emphasis is placed on prevention, patient education by physicians can have the greatest impact on mammogram utilization.

Clinical breast examination in primary care: perceptions and predictors among three specialties

To assess predictors of reported performance of screening clinical breast examination (CBE) by internists, family physicians, and obstetrician/gynecologists, we surveyed members of these specialties in four counties of Washington State. We contacted all physicians in the counties and identified 334 providers who saw women ages 50-75 and provided primary care as their principal activity. Seventy-five percent (252 of 334) responded. Physicians were mailed a survey and contacted for telephone completion if they did not respond in writing. The survey inquired about their current performance of CBE and factors that might predispose, enable, or reinforce its use. Differences across specialties were assessed using the chi-square statistic. Factors associated with reported performance of screening CBE in > or =90% of women were evaluated using logistic regression. Fifty-one percent of physicians reported that they perform regular CBE on > or =90% of their patients, although the proportion varied across specialty type. Beliefs about the benefit of CBE were positive and similar across specialties. Twelve percent of male physicians, but no female physicians, reported that women's embarrassment affected their use of screening CBE. In a multivariate model, male gender, family practice specialty, and the perception of patient embarrassment were all associated with lower reported rates of performing regular CBE (p < 0.05). Work to increase the performance of CBE should consider the role of male physician embarrassment and family physician training. Ways to facilitate delivery of preventive care and factors influencing the women themselves may also be important to increased use of CBE.

Cigarette smoking, alcohol consumption, and screening mammography among women ages 50 and older

BACKGROUND

The associations among cigarette smoking and alcohol consumption with recent screening mammograms were evaluated among women ages 50 years and older.

METHODS

The sample included 946 white and African-American women ages 50 years and older from the 1995 Maryland Behavioral Risk Factor Survey. Bivariate and logistic regression analyses were performed to evaluate the associations between current cigarette smoking and alcohol consumption in the past month (none, 1-7 drinks, >7 drinks) with obtaining a screening mammogram in the past 2 years (recent mammogram), controlling for sociodemographic and health variables.

RESULTS

Seventy-eight percent of respondents had recent mammograms, 15% smoked cigarettes, 18% reported 1-7 drinks, and 12% reported >7 drinks in the past month. Smokers had lower mammography rates than nonsmokers (odds ratio (OR) = 0.47, 95% confidence interval (CI) = 0.30-0.75). Women who drank alcoholic beverages had higher mammography rates than nondrinkers (OR = 1.37, 95% CI = 1.03-1.83). Smokers had the lowest mammography rates, regardless of their consumption of alcohol. An interaction was observed among white but not African-American women: nonsmokers who consumed moderate amounts of alcohol (1-7 drinks) had the highest mammography rates in this subgroup.

CONCLUSIONS

To reduce breast cancer mortality, it is important to increase screening mammography among all women over age 50 and especially among smokers and the oldest women.

Increasing mammography among women aged 40-74 by use of a stage-matched, tailored intervention

BACKGROUND

Tailoring is a promising technique for encouraging greater performance of health-related behaviors. Tailored interventions are designed to be more individualized to personal characteristics, in contrast to "standard" interventions where all participants receive the same materials.

METHODS

A total of N = 1864 women aged 40-74 were recruited from a staff model HMO and randomly assigned to one of three intervention groups: (a) No Educational Materials, (b) Standard Materials, and (c) Stage-Matched Materials. A provider-directed component was common across all three conditions. The Standard and Stage-Matched groups each received two mailed educational packets after baseline and follow-up telephone interviews. The Stage-Matched intervention was based on the Transtheoretical Model of behavior change.

RESULTS

Analyses of n = 1397 women (after all attrition) showed that receipt of mammography after the baseline interview was higher for the Stage-Matched group (63.6%) than for the No Materials group (54.9%; OR = 1.43, 95% CI = 1.10, 1.86). The Standard intervention group was intermediate (58. 5%). The Standard group did not differ from the No Materials group, but did differ from the Stage-Matched group in multivariate analysis.

CONCLUSIONS

Stage-matched, tailored materials may be a means to encourage screening mammography. Such interventions can be implemented by telephone and mail.

Behavioral research contributions and needs in cancer prevention and control: adherence to cancer screening advice

BACKGROUND

Research has been critical in understanding human behavior related to the early detection of cancer.

METHODS

Based on the literature and the author's experience, this paper reviews behavioral research accomplishments in the past decade and needs for the future.

RESULTS

Accomplishments have included an improved understanding of the barriers to screening, methods to improve the provision of tests by practitioners, and progress in the development and application of community interventions. Outstanding needs are summarized in 12 areas that include a continued focus on underserved populations and an examination of the use of screening tests in the presence of incomplete evidence of efficacy, translational research that explores the behavioral consequences of genetic susceptibility testing, continued development and use of computer-based technologies in the delivery of preventive services, and studies of the potential negative consequences of screening. Critical changes in the delivery of health care in the era of managed care call for increased behavioral research in health services and health care policy.

CONCLUSION

Although this review of research needs is not exhaustive, it is clear that the challenges and opportunities for behavioral research are substantial, and this effort will be a critical part of the overall national research agenda for cancer control.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The extent of breast cancer screening in older women

Women 65 and older present a unique challenge to health professionals, particularly with respect to breast cancer screening. These women are at the highest risk for developing breast cancer; they represent 50% of all newly diagnosed breast cancers. This group represents 60% of the breast cancer deaths, however, demonstrating how serious a disease breast cancer is in the 65-and-older age group. Moreover, the 65-and-older population cohort is growing rapidly. By 2010, it is estimated that greater than 15% of the population will be older than 65, and, as is the case now, the majority of this group will be women. Therefore, preventing breast cancer deaths in older women is a very significant and pressing issue. Ironically, most studies have reported that screening for breast cancer is less widespread in women older than 65 than in those younger than 65. Regional surveys emphasize a number of barriers, some of which seem to be age-specific--a lower level of knowledge about the usefulness and benefit of mammography, particularly in the absence of symptoms; less of a sense of personal vulnerability; fewer screening recommendations from family, friends, or physicians; and more problems with access (cost, transportation). To improve breast cancer screening rates in older women, sound health education interventions are needed to improve knowledge of and belief and attitudes regarding mammography. These should be targeted not only to older women, but also to their physicians and/or primary care givers. In addition, specific attention should be given to those barriers that are particularly burdensome for the elderly: cost, transportation problems, and loss of mobility.

Screening mammography and older Hispanic women. Current status and issues

BACKGROUND

Little is known about the screening behavior of older minority women, especially Hispanic women. Data from Los Angeles were compared to national data to examine any similarities and unique problems.

METHODS

In 1990, 726 women from Los Angeles older than 65 years of age were surveyed by telephone after being identified through a probability sample or through Medicare listings. Mammography experience and knowledge and attitudes about screening were collected. Differences in mammography experience by racial/ethnic group were computed using the chi-square test.

RESULTS

Hispanic women were not underscreened significantly compared with older white and black women. Approximately three quarters of Hispanics had had a mammogram in the previous 2 years, compared with 84% of blacks and 82% of whites. Income and education levels were more explanatory of underscreening than was race. For example, 50% of whites with incomes of less than $15,000 had been screened in the previous 2 years, compared with 71% of those with higher incomes. Hispanics, however, reported significantly more concerns about screening and getting breast cancer than did whites or blacks despite the Hispanics' lower incidence and mortality rates. Hispanics also reported more health insurance inadequacies and a poorer quality of life that may interfere with maintenance of screening behaviors.

CONCLUSIONS

To maintain equal screening across racial/ethnic groups, national programs should focus on strategies that help Hispanics acculturate to achieve equal educational and other benefits. To decrease screening inequities within races and help realize the National Cancer Institute's Year 2000 goals, income and educational differences will need to be less pronounced.

Early detection of cancer. Psychologic and social dimensions

Major strides in early detection research can be attributed to social and behavioral research. Social scientists have been involved in research determining the epidemiologic basis of and the cost-effectiveness of screening for asymptomatic disease. The availability of well accepted screening tests has been a barrier to early detection research, especially in the area of men's health. Early detection research has focused on the individual and system levels. Theoretical models are being adapted for early detection from smoking research and are a strength of current work. These models explain why people participate in early detection and how behavior change can occur. In studying system barriers to early detection, intervention efforts have been focused in the community and in the medical care delivery system. Methodologic issues are beginning to emerge, including measuring of program outcomes, and the appropriate research designs for community studies. Except for immigrant populations, initial screening rates are high, and the periodicity of screening becomes the outcome of choice. Some of these problems are the direct result of the success of research and public education efforts to increase cancer screening. The following are priorities for the next decade: theory driven research on behavior change and on interventions; the social determinants of physicians' participation in screening; process evaluation to relate community efforts to outcomes; and reductions in the stage at which cancer is diagnosed as an outcome measure.