Validation of self-reported screening mammography histories among women with and without breast cancer

Diagnostic chest X-rays and breast cancer risk among women with a hereditary predisposition to breast cancer unexplained by a BRCA1 or BRCA2 mutation

Background

Diagnostic ionizing radiation is a risk factor for breast cancer (BC). BC risk increases with increased dose to the chest and decreases with increased age at exposure, with possible effect modification related to familial or genetic predisposition. While chest X-rays increase the BC risk of BRCA1/2 mutation carriers compared to non-carriers, little is known for women with a hereditary predisposition to BC but who tested negative for a BRCA1 or BRCA2 (BRCA1/2) mutation.

Methods

We evaluated the effect of chest X-rays from diagnostic medical procedures in a dataset composed of 1552 BC cases identified through French family cancer clinics and 1363 unrelated controls. Participants reported their history of X-ray exposures in a detailed questionnaire and were tested for 113 DNA repair genes. Logistic regression and multinomial logistic regression models were used to assess the association with BC.

Results

Chest X-ray exposure doubled BC risk. A 3% increased BC risk per additional exposure was observed. Being 20 years old or younger at first exposure or being exposed before first full-term pregnancy did not seem to modify this risk. Birth after 1960 or carrying a rare likely deleterious coding variant in a DNA repair gene other than BRCA1/2 modified the effect of chest X-ray exposure.

Conclusion

Ever/never chest X-ray exposure increases BC risk 2-fold regardless of age at first exposure and, by up to 5-fold when carrying 3 or more rare variants in a DNA repair gene.

Further studies are needed to evaluate other DNA repair genes or variants to identify those which could modify radiation sensitivity. Identification of subpopulations that are more or less susceptible to ionizing radiation is important and potentially clinically relevant.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13058-021-01456-1.

Lack of validity of self-reported mammography data

This qualitative literature review aimed to describe the totality of peer-reviewed scientific evidence from 1990 to 2017 concerning validity of self-reported mammography. This review included articles about mammography containing the words accuracy, validity, specificity, sensitivity, reliability or reproducibility; titles containing self-report, recall or patient reports, and breast or 'mammo'; and references of identified citations focusing on evaluation of 2-year self-reports. Of 45 publications meeting the eligibility criteria, 2 conducted in 1993 and 1995 at health maintenance organisations in Western USA which primarily served highly educated whites provided support for self-reports of mammography over 2 years. Methodological concerns about validity of self-reports included (1) telescoping, (2) biased overestimates particularly among black women, (3) failure to distinguish screening and diagnostic mammography, and (4) failure to address episodic versus consistent mammography use. The current totality of evidence supports the need for research to reconsider the validity of self-reported mammography data as well as the feasibility of alternative surveillance data sources to achieve the goals of the Healthy People Initiative.

Validation of self-reported post-treatment mammography surveillance among breast cancer survivors by electronic medical record extraction method

Little is known about validity of self-reported mammography surveillance among breast cancer survivors. Most studies have focused on accuracy among healthy, average-risk populations and none have assessed validity by electronic medical record (EMR) extraction method. To assess validity of survivor-reported mammography post-active treatment care, we surveyed all survivors diagnosed 2004-2009 in an academic hospital cancer registry (n = 1441). We used electronic query and manual review to extract EMR data. Concordance, sensitivity, specificity, positive predictive value, and report-to-records ratio were calculated by comparing survivors' self-reports to data from each extraction method. We also assessed average difference in months between mammography dates by source and correlates of concordance. Agreement between the two EMR extraction methods was high (concordance 0.90; kappa 0.70), with electronic query identifying more mammograms. Sensitivity was excellent (0.99) regardless of extraction method; concordance and positive predictive value were good; however, specificity was poor (manual review 0.20, electronic query 0.31). Report-to-records ratios were both over 1 suggesting over-reporting. We observed slight forward telescoping for survivors reporting mammograms 7-12 months prior to survey date. Higher educational attainment and less time since mammogram receipt were associated with greater concordance. Accuracy of survivors' self-reported mammograms was generally high with slight forward telescoping among those recalling their mammograms between 7 and 12 months prior to the survey date. Results are encouraging for clinicians and practitioners relying on survivor reports for surveillance care delivery and as a screening tool for inclusion in interventions promoting adherence to surveillance guidelines.

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.

Risk adjustment for smoking identified through tobacco use diagnoses in hospital data: a validation study

Adjustment for the differing risk profiles of patients is essential to the use of administrative hospital data for epidemiological research. Smoking is an important factor to include in such adjustments, but the accuracy of the diagnostic codes denoting smoking in hospital records is unknown. The aims of this study were to measure the validity of current smoking and ever smoked status identified from diagnoses in hospital records using a range of algorithms, relative to self-reported smoking status; and to examine whether the misclassification of smoking identified through hospital data is differential or non-differential with respect to common exposures and outcomes. Data from the baseline questionnaire of the 45 and Up Study, completed by 267,153 residents of New South Wales (NSW), Australia, aged 45 years and older, were linked to the NSW Admitted Patient Data Collection. Patients who had been admitted to hospital for an overnight stay between 1 July 2005 and the date of completion of the questionnaire (1 January 2006 to 2 March 2009) were included. Smokers were identified by applying a range of algorithms to hospital admission histories, and compared against self-reported smoking in the questionnaire (‘gold standard’). Sensitivities for current smoking ranged from 59% to 84%, while specificities were 94% to 98%. Sensitivities for ever smoked ranged from 45% to 74% and specificities were 93% to 97%. For the majority of algorithms, sensitivities and/or specificities differed significantly according to principal diagnosis, number of comorbidities, socioeconomic status, residential remoteness, Indigenous status, 28 day readmission and 365 day mortality. The identification of smoking through diagnoses in hospital data results in differential misclassification. Risk adjustment based on smoking identified from these data will yield potentially misleading results. Systematic capture of information about smoking in hospital records using a mandatory item would increase the utility of administrative data for epidemiological research.

Molecular profiles of screen detected vs. symptomatic breast cancer and their impact on survival: results from a clinical series

BACKGROUND

Stage shift is widely considered a major determinant of the survival benefit conferred by breast cancer screening. However, factors and mechanisms underlying such a prognostic advantage need further clarification. We sought to compare the molecular characteristics of screen detected vs. symptomatic breast cancers and assess whether differences in tumour biology might translate into survival benefit.

METHODS

In a clinical series of 448 women with operable breast cancer, the Kaplan-Meier method and the log-rank test were used to estimate the likelihood of cancer recurrence and death. The Cox proportional hazard model was used for the multivariate analyses including mode of detection, age at diagnosis, tumour size, and lymph node status. These same models were applied to subgroups defined by molecular subtypes.

RESULTS

Screen detected breast cancers tended to show more favourable clinicopathological features and survival outcomes compared to symptomatic cancers. The luminal A subtype was more common in women with mammography detected tumours than in symptomatic patients (68.5 vs. 59.0%, p=0.04). Data analysis across categories of molecular subtypes revealed significantly longer disease free and overall survival for screen detected cancers with a luminal A subtype only (p=0.01 and 0.02, respectively). For women with a luminal A subtype, the independent prognostic role of mode of detection on recurrence was confirmed in Cox proportional hazard models (p=0.03). An independent role of modality of detection on survival was also suggested (p=0.05).

CONCLUSIONS

Molecular subtypes did not substantially explain the differences in survival outcomes between screened and symptomatic patients. However, our results suggest that molecular profiles might play a role in interpreting such differences at least partially.Further studies are warranted to reinterpret the efficacy of screening programmes in the light of tumour biology.

Exposure to diagnostic radiation and risk of breast cancer among carriers of BRCA1/2 mutations: retrospective cohort study (GENE-RAD-RISK)

OBJECTIVE

To estimate the risk of breast cancer associated with diagnostic radiation in carriers of BRCA1/2 mutations.

DESIGN

Retrospective cohort study (GENE-RAD-RISK).

SETTING

Three nationwide studies (GENEPSO, EMBRACE, HEBON) in France, United Kingdom, and the Netherlands,

PARTICIPANTS

1993 female carriers of BRCA1/2 mutations recruited in 2006-09.

MAIN OUTCOME MEASURE

Risk of breast cancer estimated with a weighted Cox proportional hazards model with a time dependent individually estimated cumulative breast dose, based on nominal estimates of organ dose and frequency of self reported diagnostic procedures. To correct for potential survival bias, the analysis excluded carriers who were diagnosed more than five years before completion of the study questionnaire.

RESULTS

In carriers of BRCA1/2 mutations any exposure to diagnostic radiation before the age of 30 was associated with an increased risk of breast cancer (hazard ratio 1.90, 95% confidence interval 1.20 to 3.00), with a dose-response pattern. The risks by quarter of estimated cumulative dose <0.0020 Gy, ≥ 0.0020-0.0065 Gy, ≥ 0.0066-0.0173 Gy, and ≥ 0.0174 Gy were 1.63 (0.96 to 2.77), 1.78 (0.88 to 3.58), 1.75 (0.72 to 4.25), and 3.84 (1.67 to 8.79), respectively. Analyses on the different types of diagnostic procedures showed a pattern of increasing risk with increasing number of radiographs before age 20 and before age 30 compared with no exposure. A history of mammography before age 30 was also associated with an increased risk of breast cancer (hazard ratio 1.43, 0.85 to 2.40). Sensitivity analysis showed that this finding was not caused by confounding by indication of family history.

CONCLUSION

In this large European study among carriers of BRCA1/2 mutations, exposure to diagnostic radiation before age 30 was associated with an increased risk of breast cancer at dose levels considerably lower than those at which increases have been found in other cohorts exposed to radiation. The results of this study support the use of non-ionising radiation imaging techniques (such as magnetic resonance imaging) as the main tool for surveillance in young women with BRCA1/2 mutations.

Validation study suggested no differential misclassification of self-reported mammography history in BRCA1/2 mutation carriers

OBJECTIVES

We assessed accuracy of self-reported lifetime mammography history by BRCA1/2 mutation carriers with and without breast cancer.

STUDY DESIGN AND SETTING

Within the framework of the HEBON study (The Netherlands Collaborative Group on Hereditary Breast Cancer), 218 Dutch BRCA1/2 mutation carriers had completed a risk factor questionnaire between 2006 and 2007. Accuracy of self-reported lifetime mammography history was assessed by medical record review and calculated by proportion agreement and Cohen's kappa coefficient (κ).

RESULTS

For 177 (81%) carriers, validation could be completed. Accuracy of reporting of ever/never exposure was excellent (i.e., agreement ≥ 93%, κ ≥ 0.81) for all time frames (lifetime, before age 30, and at ages 30-39). Accuracy of age at first mammogram was poor to moderate (i.e., 39%, κ=0.37) for exact agreement and improved to almost excellent (i.e., 70%, κ=0.69) for agreement within 1 year, indicating that differences were small. Although cases more often tended to underestimate their exact age at first mammogram, whereas unaffected carriers tended to overestimate, this difference in the direction of inaccuracy was not statistically significant (P=0.237). Accuracy of age at last mammogram was moderate and improved to excellent for agreement within 1 year. Carriers tended to underreport the time since last mammogram ("telescoping") and overreported the number of mammograms.

CONCLUSION

Accuracy of self-reported lifetime mammography history in carriers highly varied, depending on the measure under investigation. However, the extent of the observed misclassification was small and mostly nondifferential.

Use of evidence-based strategies to promote mammography among medically underserved women

BACKGROUND

Several web-based resources recommend effective intervention strategies to promote use of mammography but there is limited information on whether the strategies are used, particularly by organizations that serve medically underserved women.

PURPOSE

In 2010, data collected by the Avon Breast Health Outreach Program (BHOP) were analyzed to examine the diffusion of evidence-based intervention strategies among funded organizations.

METHODS

Data on intervention strategies were obtained from a 2009 survey of Avon BHOP organizations funded during 2006-2009. Self-reported use of mammography was reported from annual intake forms administered to medically underserved women aged ≥40 years, excluding those with a history of breast cancer or initial enrollees not exposed to the strategies. Strategies reflected interventions reviewed in the Guide to Community Preventive Services. Those recommended to increase demand and use of mammography included (1) client reminders; (2) small media; (3) one-to-one education; (4) removal of structural barriers to rescreening; and (5) group education-and one that lacked sufficient evidence to warrant a recommendation (6) client incentives.

RESULTS

Among 86 organizations, 96% used three or more intervention strategies. The most common strategies were group education (91%) and client reminders (83%). The overall crude-percentage of recent mammography use was 84%. This percentage was similar for clinical sites and nonclinical sites, despite the disproportionate enrollment of medically underserved women in nonclinical sites.

CONCLUSIONS

The wide use of evidence-based strategies among Avon BHOP-funded organizations and high percentage of recent mammography use among women exposed to the strategies suggests that medically underserved women are benefiting from effective interventions to increase use of mammography.

Cultural views, English proficiency and regular cervical cancer screening among older Chinese American women

OBJECTIVE

The purpose of this study was to investigate the association between cultural views, English proficiency, and regular cervical cancer screening among older Chinese women.

METHODS

The study sample consisted of 473 asymptomatic Chinese participants aged 50 and older recruited from community organizations. The study outcome was regular receipt of Pap tests, defined as having a recent test in the past 3 years and another within 3 years before the present test. Eastern cultural views were measured by a 30-item scale that assessed beliefs about illness and cancer. Sociodemographics, cancer worry, physician recommendation, health insurance, and access barriers were included as covariates in multiple logistic regression models.

RESULTS

A total of 239 (50.5%) Chinese American women had regular Pap tests. Findings indicate that 1) women who held more traditional Chinese cultural views were less likely to be a regular screener (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.94-0.99); 2) women with higher English proficiency were 1.39 times more likely to have received regular Pap tests than women with lower proficiency (OR, 1.39; 95% CI, 1.13-1.72).

CONCLUSION

Cultural views and English proficiency were significant predictors of older Chinese American women regular receipt of Pap tests. Future research is needed to identify and design culturally and linguistically competent programs to promote cervical cancer screening.

Reliability of self-reported diagnostic radiation history in BRCA1/2 mutation carriers

We assessed reliability of self-reported diagnostic radiation history in BRCA1/2 mutation carriers with and without breast cancer. Within the frame-work of the HEBON study, 401 BRCA1/2 mutation carriers completed a baseline (1999-2004) and a follow-up questionnaire (2006-2007). Test-retest reliability of self-reported exposure to chest X-rays, fluoroscopies and mammograms was assessed for the entire study population and by case status.Overall proportion agreement on reporting ever/never exposure was good ([75%), while the corresponding kappa coefficients were between 0.40 and 0.75, indicating at least moderate reliability beyond chance. Reliability of number of exposures was also good ([75%). Proportion agreement on reporting age at first mammogram was low(40%) for exact consistency and moderate (60%) for consistency +/- 1 year. Reliability of age at first mammogram was higher for cases than for unaffected carriers(P\0.001) but this difference disappeared when excluding diagnostic mammograms (P = 0.60). In unaffected carriers proportion agreement on age at last mammogram was 50%. In general, the direction of disagreement on all items was equally distributed. More consistent reporting was mainly determined by a younger age at questionnaire completion. In conclusion, inconsistent self-report of diagnostic radiation by BRCA1/2 mutation carriers was mainly non-differential by disease status.

[Prevalence of non-utilization of mammography and associated factors in elderly women]

This study analyzes the prevalence of non-utilization of mammography among older women, according to socio-demographic variables, health status, and use of preventive health services. This was a cross-sectional study including women 60 years or older. We interviewed 4,621 women 60 to 106 years of age; the majority were widows (51.8%) and had little or no schooling (53.8%). Most (89%) reported health problems, and 66.4% used private medical care. Prevalence of self-reported mammography was 72.1%. Gynecological visits (PR = 2.39; 95%CI: 2.04-2.80), Pap smear (PR = 3.24; 95%CI: 2.89-3.63), years of schooling (PR = 1.07; 95%CI: 1.02-1.12), health care insurance (PR = 1.16; 95%CI: 1.11-1.20), physician visits (PR = 1.23; 95%CI: 1.11-1.37), age (PR = 1.12; 95%CI: 1.08-1.17), marital status (PR = 1.05; 95%CI: 1.00-1.09), and barriers to health services (PR = 0.94; 95%CI: 0.89-0.98) were also associated with non-utilization of mammography. These associations may be partially explained by lack of knowledge, poor access to public health services, and cultural factors related to the aging process and reproductive incapacity.

Sensitivity of self-report mammography use in older women

BACKGROUND

Recent survey evidence indicates a decline in mammography use among older women.

PURPOSE

The objective of this study was to detect sensitivity of self-reported mammography use and pose evidence-based suggestions to increase survey accuracy.

METHODS

Using the 1991-2006 Medicare Current Beneficiary Survey, 15,357 women, aged > or =65 years, were selected based on use of mammography services. The women were interviewed in the community setting at random periods after screening and asked, Have you had a mammogram or breast X-ray since [today's date or previous supplement round interview date] a year ago? Statistical analyses were conducted between March 11 and April 28 of 2008. This study tested whether sensitivity (i.e., probability of an affirmative response) was dependent on length of the recall period and on respondent demographic and socioeconomic characteristics.

RESULTS

Overall, 90.4% of the older women self-reported use; however, sensitivity decreased as the recall period lengthened (90% at 6 months, 80% at 12 months). This time effect was significantly higher among older, economically disadvantaged women. Sensitivity also decreased an additional 13.8% if the event occurred in the previous calendar year, and 3.5% if conducted in a non-English language or by proxy.

CONCLUSIONS

Greatest sensitivity occurred during the 6-month period after service without straddling calendar years. These findings may aid the tailoring of future surveys for older adults, improving the recall of preventive services.

Validity of self-reported Pap smear history in Norwegian women

OBJECTIVES

To assess the validity of self-reported Papanicolau (Pap) smear history in Norwegian women and to identify characteristics that influence the validity.

METHODS

Interview data from a sample of 16,574 Norwegian women, aged 18-45, in 2004-2005, was compared with information from the population-based cytology register. Crude validity in the self-reports with respect to ever/never having taken a Pap smear was summarized. The validity of the reported interval since last Pap smear was assessed by a smoothed distribution of the reported interval, stratified by the registered interval. Characteristics of influence on validity were identified by logistic regression for true positives (sensitivity and positive predictive value), true negatives (specificity and negative predictive value) and for more than one year discrepancy in time since last Pap smear, between reported and registered interval.

RESULTS

Overall validity was summarized by: concordance = 0.9, sensitivity = 0.97, positive predictive value = 0.92, specificity = 0.55, negative predictive value = 0.78 and report-to-records ratio = 1.51. The variance in the reported interval increased proportionally with the registered interval, and women tended to underestimate the interval (telescoping). Age and registered number of years since last Pap smear had the strongest influence on ever/never and time interval validity, respectively.

CONCLUSIONS

Estimated screening rates, based on self-reporting without organized screening, are biased. Telescoping leads to increased risk for developing invasive disease, because women will postpone their next Pap smear.

Lifetime asymptomatic for back pain: the validity of self-report measures in soldiers

STUDY DESIGN

A 5-year prospective observational study in US Army Reserve soldiers.

OBJECTIVES

The aims of this study were 2-fold: to evaluate the prevalence of soldiers reporting no previous back pain (BP) on 3 consecutive annual assessments, and to compare these findings to those obtained from a subsequent monthly detailed BP assessment.

SUMMARY OF BACKGROUND DATA

BP history is a risk factor for future BP and disability. Conversely, subjects reporting a negative history of back troubles are thought to be at low risk for future BP events. Reporting of previous BP is assumed to have high validity. Few studies have critically evaluated the validity of the self-reported "lifetime asymptomatic" status in civilian or military populations.

METHODS

Two hundred eighty-five special operations reserve soldiers were queried annually using standardized US Army Medical Questionnaires, among whom 154 (54%) reported no BP or history thereof over 3 consecutive years. Over the next 18 months these soldiers completed annual US Army Medical Questionnaires, as well as monthly numerical rating scale pain scores, Oswestry Disability Indexes, and questions regarding back injuries. At the study's conclusion, soldiers again completed the annual medical certificate, and the results of this final BP assessment were compared with those from monthly surveillance reports.

RESULTS

During monthly surveillance of purported "lifetime asymptomatic" soldiers, the 18-month cumulative percentages reporting BP scores > or = 2, > or = 4, and > or = 6 were 84%, 64%, and 14%, respectively. For Oswestry Disability Index scores, these percentages were 25% for scores > or = 10, and 12% for scores > or = 20. Yet, at the conclusion of the 5-year study, 97% soldiers still described themselves as being "asymptomatic for BP problems."

CONCLUSION

In physically active soldiers self-identified as without back problems, the report of BP using frequent surveillance tools is extremely common. The overwhelming majority of these soldiers appeared to have high resilience to common BP episodes (i.e., returned to usual duties). Episodic BP should be considered a normative rather than exceptional occurrence. Similar to other conditions, long-interval surveys of BP history may underestimate the true prevalence of BP.

Cultural views, language ability, and mammography use in Chinese American women

Mammography screening rates among Chinese American women have been reported to be low. This study examines whether and how culture views and language ability influence mammography adherence in this mostly immigrant population. Asymptomatic Chinese American women (n = 466) aged 50 and older, recruited from the Washington, D.C. area, completed a telephone interview. Regular mammography was defined as having two mammograms at age-appropriate recommended intervals. Cultural views were assessed by 30 items, and language ability measured women's ability in reading, writing, speaking, and listening to English. After controlling for risk perception, worry, physician recommendation, family encouragement, and access barriers, women holding a more Chinese/Eastern cultural view were significantly less likely to have had regular mammograms than those having a Western cultural view. English ability was positively associated with mammography adherence. The authors' results imply that culturally sensitive and language-appropriate educational interventions are likely to improve mammography adherence in this population.

Accuracy of self-reported cancer-screening histories: a meta-analysis

BACKGROUND

Survey data used to study trends in cancer screening may overestimate screening utilization while potentially underestimating existing disparities in use.

METHODS

We did a literature review and meta-analysis of validation studies examining the accuracy of self-reported cancer-screening histories. We calculated summary random-effects estimates for sensitivity and specificity, separately for mammography, clinical breast exam (CBE), Pap smear, prostate-specific antigen testing (PSA), digital rectal exam, fecal occult blood testing, and colorectal endoscopy.

RESULTS

Sensitivity was highest for mammogram, CBE, and Pap smear (0.95, 0.94, and 0.93, respectively) and lowest for PSA and digital rectal exam histories (0.71 and 0.75). Specificity was highest for endoscopy, fecal occult blood testing, and PSA (0.90, 0.78, and 0.73, respectively) and lowest for CBE, Pap smear, and mammogram histories (0.26, 0.48, and 0.61, respectively). Sensitivity and specificity summary estimates tended to be lower in predominantly Black and Hispanic samples compared with predominantly White samples. When estimates of self-report accuracy from this meta-analysis were applied to cancer-screening prevalence estimates from the National Health Interview Survey, results suggested that prevalence estimates are artificially increased and disparities in prevalence are artificially decreased by inaccurate self-reports.

CONCLUSIONS

National survey data are overestimating cancer-screening utilization for several common procedures and may be masking disparities in screening due to racial/ethnic differences in reporting accuracy.

Protection of mammography screening against death from breast cancer in women aged 40-64 years

OBJECTIVE

This study assessed the efficacy of community-based screening mammography in protecting against breast cancer death, asking whether age differences in efficacy persisted in the 1990s.

METHODS

In a case-control study with follow-up, odds ratios (OR) were used to estimate the relative mortality rates from invasive breast cancer among women with at least one screening mammogram in the two years prior to a baseline reference date compared to non-screened women, adjusting for potential confounding. The multicenter population-based study included 553 black and white women diagnosed during 1994-1998 who died in the following five years, and 4016 controls without breast cancer.

RESULTS

Efficacy for reducing the rate of breast cancer death within five years after diagnosis was greater at ages 50-64 years (OR = 0.47, 95% confidence interval (CI) 0.35-0.63) than at ages 40-49 (OR = 0.89, 95% CI 0.65-1.23), and greater among postmenopausal (OR = 0.45, 95% CI 0.33-0.62) than premenopausal women (OR = 0.74, 95% CI 0.53-1.04). Estimates of efficacy were conservative, as shown by sensitivity analyses addressing whether cancer was discovered by a screening mammogram, age at which screening was received, the length of the screening observation window, and years of follow-up after diagnosis.

CONCLUSIONS

Despite the persistence of age differences in efficacy of mammography screening, with greater observed benefit for women aged 50-64 years, these findings support current screening recommendations for women 40-64 years old.

The black:white disparity in breast cancer mortality: the example of Chicago

OBJECTIVE

The black:white disparity in breast cancer mortality has been increasing in the U.S. In order to gain insight into this disparity in Chicago, we examined mortality data together with other important measures associated with breast cancer.

METHODS

Trends in black:white female breast cancer mortality, incidence, stage at diagnosis, and mammography screening in Chicago were examined using data from the Illinois State Cancer Registry, Illinois Department of Public Health Vital Records, and the Illinois Behavioral Risk Factor Surveillance System.

RESULTS

The breast cancer mortality rate for black women in Chicago for 1999-2003 was 49% higher than that of white women, but the disparity is a recent phenomenon that is increasing rapidly. In 2003 the black rate was 68% higher than the white rate. Mortality rates were similar in the 1980's and only started to diverge in the 1990's as a result of a sharp improvement in mortality among white women contrasted with no improvement for black women. This lack of progress for black women is perplexing given that self-reported mammography screening rates have been the same for blacks and whites in Chicago since at least 1996 and that the early detection of breast cancer for black women has been increasing.

CONCLUSIONS

There has been no improvement in mortality from breast cancer for black women in Chicago in 23 years. This study, along with a review of the literature, lends support to the hypothesis that the disparities in breast cancer mortality are due to differential access to mammography, differential quality in mammography, and differential access to treatment for breast cancer. Fortunately, all three are amenable to intervention, which would help ameliorate this unacceptable disparity.

Are Tri-Ethnic Low-Income Women with Breast Cancer Effective Teachers of the Importance of Breast Cancer Screening to Their First-Degree Relatives? Results from a Randomized Clinical Trial

The purpose of this study was to determine the efficacy of women with breast cancer as teachers of the importance of breast cancer screening to their first-degree female relatives. The sample was restricted to low-income working age women recruited from four hospitals. The study design was a randomized clinical trial. At each hospital, breast cancer patients (probands) were randomized into one of two study groups: (i) intensive, individual educational training on breast cancer screening or (ii) standard clinic education on breast cancer screening. The probands were instructed to teach at least one of their first-degree female relatives (21+ years of age) about breast cancer screening techniques. Three to six months after the enrollment of the probands, their relatives were contacted by telephone to determine breast cancer screening practices. A total of 79 probands and 96 relatives participated in the study. Relatives in the education group when compared with the control group were: 1.25 times more likely to have clinical breast examination (p = 0.005), 2.83 times more likely to have scheduled a clinical breast examination (p = 0.046), and, 1.36 times more likely to have been told about performing breast self-examination (p = 0.05). Additionally, relatives in the education group were more likely to have received a pamphlet on breast cancer screening (RR = 1.58, p = 0.009) and have discussed the importance of breast cancer screening (RR = 1.33, p = 0.020) from the proband. Special education training did not impact mammography utilization of the relatives. From these findings, a tri-ethnic group of low-income women with breast cancer can be effective teachers of breast cancer screening practices, at least for promoting clinical breast examination and transmitting messaging for performance of breast self-examination if given the adequate training.

Mammography screening in six diverse communities in Chicago—A population study

BACKGROUND

Despite the fact that recent studies suggest a narrowing in access to mammography, Black women are much more likely to die from breast cancer than White women. Data at the community level regarding mammography screening can help explain health disparities and inform plans for improved screening efforts.

METHODS

In 2002-2003, a comprehensive household health survey in English or Spanish was conducted in six community areas with 1700 households. The module on mammography was based on a state-based nationwide health survey and included questions on frequency of mammography, repeat screenings, and several demographic variables.

RESULTS

The proportion of women >or=40 years (n=482) who received a mammogram in the past 2 years ranged from 74% to 90% across the six communities. The community with the highest screening proportion was predominantly Mexican and included recent immigrants. The screening proportion in the poorest community area, which was all Black, was 77%. Women with health insurance, higher income, and more education were more likely to receive a mammogram. Proportions for women >or=50 years (n=286) were slightly higher but similar. Repeat screening, which is recommended, occurred at lower levels.

CONCLUSIONS

Access to and utilization of mammography have grown in recent years so that even these vulnerable communities had screening proportions at or even higher than the national average and the Healthy People Year 2010 objective. Nonetheless, repeat screening sequences were lower and may require attention if mammography screening efforts are to have a greater impact on female breast cancer mortality.

Benefit of screening mammography in reducing the rate of late-stage breast cancer diagnoses (United States)

OBJECTIVE

We studied the benefit of modern mammography screening in community settings, evaluating age-related differences in rates of late-stage breast cancer detection.

METHODS

Our multicenter population-based case-control study included 931 black and white women with incident breast cancer (American Joint Commission on Cancer Stage IIB or higher) diagnosed 1994-1998 and 4,016 randomly sampled controls never diagnosed with breast cancer. Adjusted odds ratios (ORs) estimated the relative rate of late-stage diagnosis in screened and non-screened women.

RESULTS

Women aged 50-64 at diagnosis with at least one screening mammogram in the previous 2 years were significantly less likely to have late-stage diagnosis (OR = 0.41, 95% CI 0.33-0.52). Results for women aged 40-49 were consistent with a screening benefit, although the confidence interval marginally overlapped the null (OR = 0.81, 95% CI 0.64-1.02). Mammography screening was associated with lower rates of late-stage breast cancer among both premenopausal (OR = 0.64, 95% CI 0.50-0.81) and postmenopausal (OR = 0.44, 95% CI 0.35-0.56) women.

CONCLUSIONS

With modern mammography in the community, rates of late-stage breast cancer diagnoses are lower in screened compared to non-screened women ages 40 and older, but age-related differences persist.

Impact of women's experiences during mammography on adherence to rescreening (United States)

OBJECTIVE

To examine the relationship between womens' experiences during mammography and their likelihood of being rescreened after receiving a negative or benign mammogram.

METHODS

Telephone interview and medical record data were collected from a random sample of enrollees from four states in a national screening program targeting uninsured and underinsured women at least 30 months after they had undergone an index mammogram in 1997. We calculated 30-month rescreening rates by prior mammography characteristics including pain and embarrassment, worry, convenience of appointment time, treatment by staff, and financial considerations.

RESULTS

Of the 2,000 women in the sampling frame, 1,895 (93.6%) were located, 1,685 (88.6%) were interviewed and 1,680 provided data required for our analysis. Overall, 81.5% of the women had undergone rescreening. More than 90% of the women reported being 'satisfied' or 'very satisfied' with treatment by facility staff, facility location and wait time during the appointment. Statistically significant decreased rescreening rates were seen for women who reported feeling embarrassed and for women reporting dissatisfaction with ability to schedule a convenient appointment time.

CONCLUSION

These results suggest that providing additional reassurance and privacy may increase rescreening rates.

Measuring screening intensity in case-control studies of the efficacy of mammography

Of great interest in studies of screening for breast cancer is the relative efficacy of different screening frequencies (intensities). Prior work has suggested that estimates of the association between screening intensity and outcome in case-control studies would not produce valid results and that only binary indicators (no screens vs. one or more) of exposure can be used. Using case-control studies drawn from simulated cohorts of 30,000-40,000 women, the authors found that biases demonstrated in prior studies can be explained by 1) misclassification of true exposure groups by observed screening history, and 2) differential exposure misclassification of cases and controls. Binary as well as ordered categorical and interval measures can be biased unless they account for misclassification. By combining measurements of screening history from multiple periods of observation of varying lengths and using repeated-measures logistic regression models, the effect of screening intensity can be estimated in the presence of misclassification. Assessing the effect of screening intensity in case-control studies of mammography is possible if principles and methods for misclassification and measurement error guide the analysis.

Screening mammography in the American elderly

BACKGROUND

Substantial differences exist in estimates of the proportion of elderly women who undergo screening mammography and the impact of race and ethnicity on mammography usage.

METHODS

A representative 5% sample of elderly women living in 11 Surveillance, Epidemiology, and End Results areas from 1991 to 2001 was constructed using Medicare data. Biennial rates of screening mammography (at least one mammogram within each 2-year period) were calculated for overlapping 2-year periods, adjusting to a 2000-2001 age and race distribution. Multivariate repeated-measures logistic regression was used to examine predictors of screening usage.

RESULTS

The sample included 146,669 women. Between 1991 and 2001 the age- and race-adjusted proportion of women aged 65 years and older who underwent at least biennial screening mammography increased from 35.8% to 47.9%. Mammography screening increased for all racial and ethnic groups, but remained significantly higher for non-Hispanic white women as compared with all other groups. The biennial screening rate in 2000-2001 was 50.6% for non-Hispanic white, 40.5% for African-American, 34.7% for Asian-American, 36.3% for Hispanic, and 12.5% for Native-American women. After controlling for age, site, physician access, comorbidities, education, and income, African Americans (odds ratio [OR] = 0.80, 95% confidence interval [CI] = 0.78-0.83), Asian Americans (OR=0.53, CI = 0.51-0.55), Hispanics (OR = 0.70, CI = 0.67-0.74), and Native Americans (OR=0.37, CI=0.29-0.46) were still all less likely than non-Hispanic white women to undergo screening.

CONCLUSIONS

Elderly women undergo significantly less mammography screening than is suggested by self-reported surveys. All groups of non-white women undergo less screening than do white women. The magnitude of the difference in screening rates comparing Asian-American and Hispanic women with white women is especially large; however, other studies have questioned the sensitivity of Medicare data for identifying people of Asian and Hispanic ethnicity. For African-American women, the magnitude of the gap is smaller, but it is of concern that the gap in screening as compared with white women has grown over time.

How important are psychosocial predictors of mammography receipt among older women when immediate access is provided via on-site service?

PURPOSE

The purpose of the study was to examine the relative importance of psychosocial variables (i.e., health beliefs, knowledge, barriers) in predicting mammogram receipt compared with providing access through a mobile mammography unit among older women who participated in a mobile mammography intervention.

DESIGN

The data were collected during a randomized trial involving 499 women (60 to 84 years old) recruited from 60 community sites.

SETTING

The study was conducted at 60 sites in Los Angeles where seniors gather, including meal sites, senior centers, and recreational clubs.

SUBJECTS

Participants were older women (60 to 84 years old) who spoke English or Spanish, had a telephone, had no significant cognitive deficits, and had not received a mammogram during the past 12 months.

MEASURES

The baseline survey assessed demographics and psychosocial factors (i.e., health beliefs, knowledge, barriers). A follow-up telephone survey at 3 months assessed mammography receipt.

RESULTS

Results support the importance of behavioral intentions in predicting mammogram receipt, even among women able to access a mammogram through the mobile unit. However, other recognized psychosocial factors failed to predict screening receipt among women randomized to the mobile mammography intervention. Results suggest that the importance of psychosocial predictors might be diminished when a major access barrier has been removed, and they highlight the importance of convenience.

CONCLUSION

Future interventions should focus on not only removing obvious concrete and psychosocial barriers but also on enhancing convenience.

Can Medicare billing claims data be used to assess mammography utilization among women ages 65 and older?

BACKGROUND

Medicare data may be a useful source for determining the utilization of mammography among elderly women, but the accuracy of these data has not been established.

OBJECTIVE

We determined whether Medicare physician billing claims are an accurate reflection of mammography utilization among women ages 65 and older and whether they can be used to assess the use of screening as compared with diagnostic mammography.

DATA SOURCES

Mammography use was assessed using Medicare billing claims and radiology reports from 2 mammography registries; the San Francisco Mammography Registry and the New Mexico Mammography Registry.

METHODS

Completeness of the Medicare data was assessed by comparing mammography use based on Medicare, with radiology reports from the mammography registries, which served as the referent standard. Capture rates for Medicare claims for individual mammograms were examined, and women were characterized as having undergone at least 1 mammogram within each 2-year period based on the Medicare data, and these rates were compared with the referent standard. To determine whether Medicare data can distinguish between screening and diagnostic mammography, we performed a classification analysis using the mammography registries screening/diagnostic designation as the referent standard (dependent variable) and Medicare claim information as the independent/predictor variable. On the basis of the mammogram level classification analysis, women were categorized as having been frequently screened (at least 2 screening mammograms spaced by 12 to 36 months), screened (at least 1 screening mammogram), or not screened.

SUBJECTS

Women ages 65 and older, diagnosed with breast cancer between 1992-1999, who had at least 1 mammogram between 1992-1999 were examined.

RESULTS

A total of 3340 mammograms were obtained in 1371 women between 1992 and 1999. Overall, 83% of mammograms obtained by these women had a corresponding billing claim in Medicare. This increased from 65% in 1992 to 90% in 1999. Of women who underwent at least 1 mammogram during each 2-year period per the referent standard, 94% of women were accurately classified by Medicare claims as also having undergone mammography during the same 2-year period. In multivariable analysis, a mammogram was more likely to be associated with a billing claim over time, for women 80 years or older, and for white and Asian as compared with Hispanic women. Neither socioeconomic status nor screening/diagnostic designation affected the likelihood that a mammogram would be associated with a billing claim. The Medicare data accurately categorized a given mammogram as screening or diagnostic for 87.5% of mammograms. Lastly, there was moderate to substantial agreement in the categorization of women as frequently screened, screened or not screened between the 2 data sets (weighted kappa 0.74, 95% confidence interval 0.70-0.78).

CONCLUSION

Medicare administrative claims are reliable for assessment of mammography utilization and have become more accurate over time. Medicare claims data also provide a mechanism for designating mammography as screening or diagnostic, which subsequently may allow accurate description of a woman's screening history.

Body mass index and use of mammography screening in the United States

BACKGROUND

Obese and underweight women may be less likely to seek cancer screening because of health status, self-perception, and body image related to non-desirable weight. This study examined the relationship between body mass index (BMI) and mammography screening, using the data from the year 2000 United States National Health Interview Survey.

METHODS

This study included 7692 white and 1496 black female participants aged 40-80, who were randomly selected. Body mass index (kg/m2), based on self-reported weight and height, was compared between women with and without a mammogram in the past 2 years using logistic regression.

RESULTS

Compared to women with normal body mass index, underweight and extremely obese women were more likely to have no screening mammograms in the past 2 years (odds ratio (OR) = 1.8, 95% confidence interval (CI), 1.2-2.6 for underweight women; odds ratio = 1.3, 95% confidence interval, 1.0-1.8 for extremely obese women). When data were analyzed by race, the odds ratio estimates were 1.8 for underweight white women (95% confidence interval, 1.3-2.7) and 1.4 for extremely obese white women (95% confidence interval, 1.0-1.9). The corresponding odds ratio estimates were close to 1.0 for black women.

CONCLUSIONS

Underweight and extreme obesity may increase the risk of underusing screening mammography. The association between body mass index especially underweight and underuse of mammography might exist primarily in white women.

Who has regular mammograms? Effects of knowledge, beliefs, socioeconomic status, and health-related factors

BACKGROUND

Breast cancer accounts for the largest proportion of female cancer deaths and new cases in New South Wales (NSW). Biennial screening is recommended for women aged 50-69 years. Objectives were to (1) identify associations between beliefs and knowledge about breast cancer and mammography, socioeconomic (SES) indicators, and health-related factors, and having a mammogram (a) ever and (b) within the last 2 years; and (2) describe utilization of mammography.

METHODS

2974 women aged 50-69 years selected from the BreastScreen NSW (BSNSW) database and the NSW Electoral Roll were administered a structured telephone survey. Associations were assessed using weighted Chi squares and age-adjusted odds ratios from logistic regression with 95% confidence intervals.

RESULTS

Strong positive associations were found between age, married/de facto relationship, knowledge about and belief in the benefits of screening, indicators of health status and service utilization, and whether women had had a mammogram or had one within the recommended period. SES was weakly associated with regularity of mammography. Most respondents (97.4%) reported having had at least one mammogram.

CONCLUSIONS

Specific aspects of knowledge and beliefs about mammograms and individual health-related factors would be important components of initiatives to encourage initial and repeat screening in the targeted age group.

An investigation of the effects of social desirability on the validity of self-reports of cancer screening behaviors

We evaluated 4 approaches to improving the reporting of disease prevention and screening behaviors. The conditions evaluated include (1) the mode in which data are collected, (2) asking the interview subject about her intention to obtain the procedure before asking whether the behavior occurred, (3) asking the interview subject about barriers that might keep respondents from getting the procedure before asking about whether she has received it, and (4) asking the interview subject about exceptions to the regularity with which she might report getting the examination. Data were collected in 2001 from a sample of women aged 50 and older in Champaign-Urbana, Illinois. After completing a telephone or audio computer-assisted self-interview (ACASI), respondents gave permission to abstract their medical records to validate self-reports of Papanicolaou tests, mammograms, and clinical-gynecologic examinations received during the past 3 years. Interviews and matching medical records were available for 588 respondents. Results indicated that first asking about future intentions may be an important design feature that warrants additional consideration. In addition, the use of ACASI may lead to lower quality reporting among women with little computer experience. This study represents the only research to date that reports experimental attempts to address the social desirability biases commonly found in the reporting of cancer screening behaviors.

On-Schedule Mammography Rescreening in the National Breast and Cervical Cancer Early Detection Program

Objective: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides free cancer screening to many low-income, underinsured women annually but does not routinely collect all data necessary for precise estimation of mammography rescreening rates among enrollees. Materials and Methods: To determine the percentages rescreened and to identify factors that encourage on-schedule rescreening, telephone interview and medical record data were collected from 1685 enrollees in Maryland, New York, Ohio, and Texas at least 30 months after their 1997 index mammogram. Results: Overall, 72.4% [95% confidence interval (95% CI) = 70.1–74.7] were rescreened within 18 months and 81.5% (95% CI = 79.6–83.5) within 30 months. At 30 months, the adjusted odds ratios (ORs) for rescreening were higher among Hispanics (OR = 1.95, 95% CI = 1.15–3.28), women with a history of breast cancer before the index mammogram (OR = 3.36, 95% CI = 1.07–10.53), and those who had used hormone replacement therapy before their index mammogram (OR =1.94, 95% CI = 1.30–2.91). The 30-month adjusted ORs were lower for women who reported poor health status (OR = 0.60, 95% CI = 0.42–0.85), did not have a usual source of care (OR = 0.61, 95% CI = 0.40–0.94), did not know if they could have another free mammogram (OR = 0.28, 95% CI = 0.14–0.51), described their index screen as their first mammogram ever (OR for no prior mammograms versus three or more = 0.40, 95% CI = 0.27–0.60), did not recall receiving a rescreening reminder (OR = 0.35, 95% CI = 0.25–0.48), or did not think they had been encouraged to rescreen by their provider (OR = 0.61, 95% CI = 0.44–0.86). Discussion: Rescreening behavior in this sample of NBCCEDP enrollees was comparable with that observed in other populations. To facilitate routine rescreening among low-income women, ongoing efforts are needed to ensure they receive annual reminders and encouragements from their medical providers and that they know how to obtain the services they need.

Some methodologic lessons learned from cancer screening research

Credible and useful methodologic evaluations are essential for increasing the uptake of effective cancer screening tests. In the current article, the authors discuss selected issues that are related to conducting behavior change interventions in cancer screening research and that may assist researchers in better designing future evaluations to increase the credibility and usefulness of such interventions. Selection and measurement of the primary outcome variable (i.e., cancer screening behavior) are discussed in detail. The report also addresses other aspects of study design and execution, including alternatives to the randomized controlled trial, indicators of study quality, and external validity. The authors conclude that the uptake of screening should be the main outcome when evaluating cancer screening strategies; that researchers should agree on definitions and measures of cancer screening behaviors and assess the reliability and validity of these definitions and measures in different populations and settings; and that the development of methods for increasing the external validity of randomized designs and reducing bias in nonrandomized studies is needed.