Interval adherence to mammography screening guidelines

The Public's Perception of the Severity and Global Impact at the Start of the SARS-CoV-2 Pandemic: A Crowdsourcing-Based Cross-Sectional Analysis

BACKGROUND

COVID-19 is a rapidly developing threat to most people in the United States and abroad. The behaviors of the public are important to understand, as they may have a tremendous impact on the course of this novel coronavirus pandemic.

OBJECTIVE

This study intends to assess the US population's perception and knowledge of the virus as a threat and the behaviors of the general population in response.

METHODS

A prospective cross-sectional study was conducted with random volunteers recruited through Amazon Mechanical Turk, an internet crowdsourcing service, on March 24, 2020.

RESULTS

A total of 969 participants met the inclusion criteria. It was found that the perceived severity of the COVID-19 pandemic significantly differed between age groups (P<.001) and men and women (P<.001). A majority of study participants were actively adhering to the Centers for Disease Control and Prevention guidelines.

CONCLUSIONS

Though many participants identified COVID-19 as a threat, many failed to place themselves appropriately in the correct categories with respect to risk. This may indicate a need for additional public education for appropriately defining the risk of this novel pandemic.

Screening mammography use in older women according to health status: a systematic review and meta-analysis

Background

The extent to which screening mammography (SM) recommendations in older women incorporate life expectancy factors is not well established.

Objective

The objective of this review was to evaluate evidence on SM utilization in older women by life expectancy factors.

Data sources

We searched Medline, Embase and Web of Science from January 1991 to March 2016.

Study selection

We included studies examining SM utilization in women ages ≥65 years that measured life expectancy using comorbidity, functional limitations or health or prognostic status.

Data extraction and synthesis

ORs and 95% CIs were extracted and grouped by life expectancy category. Findings were aggregated into pooled ORs and 95% CIs and meta-analyzed by life expectancy category.

Main outcomes and measures

The primary outcome was SM utilization within the last 5 years. Life expectancy factors included number of comorbidities, Charlson Comorbidity Index (CCI), activities of daily living, instrumental activities of daily living, self-reported health status and 5-year prognostic indices.

Results

Of 2,606 potential titles, we identified 25 meeting the inclusion criteria (comorbidity: eight studies, functional status: 11 studies and health/prognostic status: 13 studies). Women with higher CCI scores had decreased SM utilization (pooled OR: 0.75, 95% CI: 0.67–0.85), but increased absolute number of comorbidities were weakly associated with increased SM utilization (pooled OR: 1.17, 95% CI: 1.00–1.36). Women with more functional limitations had lower SM use odds than women with no limitations (pooled OR: 0.72, 95% CI: 0.62–0.83). Screening utilization odds were lower among women with poor vs excellent health (pooled OR: 0.85, 95% CI: 0.74–0.96).

Conclusion

Greater CCI score, functional limitations and lower perceived health were associated with decreased SM use, whereas higher absolute number of comorbidities was associated with increased SM use. SM guidelines should consider these factors to improve assessments of potential benefits and harms in older women.

Stereotactic Breast Biopsy With Benign Results Does Not Negatively Affect Future Screening Adherence

PURPOSE

To evaluate whether false-positive stereotactic vacuum-assisted breast biopsy (SVAB) affects subsequent mammographic screening adherence.

MATERIALS AND METHODS

This Institutional Review Board-approved, HIPAA-compliant retrospective review of women with SVAB was performed between 2012 and 2014. Patient age, clinical history, biopsy pathology, and first postbiopsy screening mammogram were reviewed. Statistical analyses were performed using Fisher's exact, Mann-Whitney, and χ² tests.

RESULTS

There were 913 SVABs performed in 2012 to 2014 for imaging detected lesions; of these, malignant or high-risk lesions or biopsies resulting in a recommendation of surgical excision were excluded, leaving 395 SVABs yielding benign pathology in 395 women. Findings were matched with a control population consisting of 45,126 women who had a BI-RADS 1 or 2 screening mammogram and did not undergo breast biopsy. In all, 191 of 395 (48.4%) women with a biopsy with benign results and 22,668 of 45,126 (50.2%) women without biopsy returned for annual follow-up >9 months and ≤18 months after the index examination (P = .479). In addition, 57 of 395 (14.4%) women with a biopsy with benign results and 3,336 of 45,126 (7.4%) women without biopsy returned for annual follow-up >18 months after the index examination (P < .001). Older women, women with personal history of breast cancer, and women with postbiopsy complication after benign SVAB were more likely to return for screening (P = .026, P = .028, and P = .026, respectively).

CONCLUSION

The findings in our study suggest that SVABs with benign results do not negatively impact screening mammography adherence. The previously described "harms" of false-positive mammography and biopsy may be exaggerated.

Physician Recommendation for Colorectal Cancer Screening by Race, Ethnicity, and Health Insurance Status Among Men and Women in the United States, 2000

In this study, the authors examined whether men and women in the United States had received a physician recommendation to get a colorectal cancer screening test, by race, ethnicity, and health insurance status using data from the 2000 National Health Interview Survey. Among men and women who had had a doctor visit in the past year but who had not had a recent fecal occult blood test, about 94.6% (95% CI 94.0-95.2) reported that their doctor had not recommended the test in the past year. African Americans, Hispanics, and American Indians/Alaska Natives were less likely to report receiving a recommendation for endoscopy compared to Whites.

Stages of Adopting Regular Screening Mammography

This study examined whether distinct subgroups of women could be identified within stages of adoption for screening mammography. These subgroups may represent differential readiness to move to the next stage of the adoption continuum. Data were from a baseline survey of 1323 women between the ages of 50 and 74 years who were recruited through a staff- model HMO for an intervention study to increase rates of mammography. Multiple regression models were used to identify correlates of positive decisional balance within each of four stages of adoption, and an index of positive indicators was developed from the significant correlates for each stage. Analysis of variance showed that the number of positive indicators discriminated women within each stage. This information can be used to develop more effective tailored interventions to increase the percentage of women receiving mammograms on a regular schedule.

The relationship of social support concept and repeat mammography among Iranian women

BACKGROUND

Breast cancer ranks as the first most common cancer among the Iranian women. The regular repeat of mammography with 1-2 year intervals leads to the increased efficiency of early detection of breast cancer. The present study examined the predictors of repeat mammography. It was hypothesized that higher social support is connected with mammography repeat.

METHODS

A cross-sectional study was carried out among 400 women 50 years and older in Sanandaj, Iran. Data was collected by the questionnaire including information on socio demographical variables and measuring social support level. Data was analyzed by SPSS16 software. Multiple logistic regression was used to determine the predictive power of demographic variables and dimensions of social support for repeat mammography.

RESULTS

Women aged 50-55 years had three times odds of repeat mammography compared to women aged 56-60 years) OR, 3.02). Married women had greater odds of repeat mammography compared to single women (P < 0.006). The probability of repeat mammography in women with higher social support was 0.93 times greater than the women with lower social support (OR, 0.93; 95 % CI, 0.91-0.95; P < 0.0001).

CONCLUSIONS

Iranian women are less likely repeat mammography than other Asian women. Identifying the associations between perceived social support and repeat mammography may offer detailed information to allow for future study and guide the development of interventions not only for Iranian women but also for similar cultural that received pay too little attention to date in the breast cancer literature.

Recent trends in adherence to continuous screening for breast cancer among Medicare beneficiaries

OBJECTIVE

The aim of this study is to examine recent trends in adherence to continuous screening, especially the rate of subsequent screening mammography following an initial screening before and after the U.S. Preventive Services Task Force (USPSTF) revised its guidelines on breast cancer in November 2009.

METHODS

We retrospectively analyzed Medicare fee-for-service claims data to: 1) compare rate of subsequent screening mammography over 27 month periods for 317,150 women screened in either 2004 or 2009; and 2) examine patterns of subsequent screening by age and race.

RESULTS

When adjusted for age, race, state of residence, county-level covariates, and clustered on ordering provider, the rate of subsequent screening decreased in 2009 relative to 2004 (OR=0.75; 95% CI: 0.74-0.76). Adjusted odds ratios are similar for alternative follow-up windows (15 months, 0.71; 24 months, 0.70; 30 months 0.75). The decline was mostly attributable to women 75 and older who are now less likely to return for a subsequent screening. Although USPSTF guidelines call for 24 months, approximately half of women continue screening at 12-month intervals in both cohorts.

CONCLUSIONS

The rate of subsequent screening mammography has declined after 2009. Older women seem to follow the revised USPSTF guideline, but confusion by physicians and patients about competing guidelines may be contributing to these findings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors influencing adherence to mammography screening guidelines in Appalachian women participating in a mobile mammography program

The objectives of this study were to evaluate the characteristics (demographic, access to care, health-related behavioral, self and family medical history, psychosocial) of women age 40 years and above who participated in a mobile mammography screening program conducted throughout West Virginia (WV) to determine the factors influencing their self-reported adherence to mammography screening guidelines. Data were analyzed using the Andersen Behavioral Model of Healthcare Utilization framework to determine the factors associated with adherence to mammography screening guidelines in these women. Of the 686 women included in the analysis, 46.2% reported having had a mammogram in the past 2 years. Bivariate analyses showed predisposing factors such as older age and unemployed status, visit to a obstetrician/gynecologist (OB/GYN) in the past year (an enabling factor) and need-related factors such as having a family history of breast cancer (BC), having had breast problems in the past, having had breast biopsy in the past, having had a Pap test in past 2 years, and having had all the screenings for cholesterol, blood glucose, bone mineral density and high blood pressure in past 2 years to be significant predictors of self-reported adherence to mammography guidelines. In the final model, being above 50 years (OR=2.132), being morbidly obese (OR=2.358), having BC-related events and low knowledge about mammography were significant predictors of self-reported adherence. Breast cancer related events seem to be associated with mammography screening adherence in this rural Appalachian population. Increasing adherence to mammography screening may require targeted, community-based educational interventions that precede and complement visits by the mobile mammography unit.

The impact of family history of breast cancer on knowledge, attitudes, and early detection practices of Mexican women along the Mexico-US border

Rates of breast cancer (BC) have increased in Mexico, with the highest incidence and mortality rates observed in the northern Mexican states. This study aimed to describe the BC knowledge, attitudes and screening practices among Mexican women with and without a family history of BC residing along the Mexico-US border, and identify factors associated with screening behaviors. One hundred and twenty eight Mexican women aged 40 and older completed an interviewer-administered questionnaire on sociodemographic characteristics, knowledge, family history, and screening practices. There were no significant differences between Mexican women with and without a family history. Over 60% of women in both groups had never had a mammogram/breast ultrasound, and more than 50% had never obtained a clinical breast exam. Age, marital status, insurance, and breast cancer knowledge significantly influenced BC screening behaviors among Mexican women. Further research is needed to examine other key factors associated with screening utilization, in effort of improving BC rates.

A national study of out-of-pocket expenditures for mammography screening

OBJECTIVES

To identify variations in screening mammography expenditures, primarily out-of-pocket and total expenditures, of women 40-64 years of age in the United States and factors associated with variations.

METHODS

Retrospective analysis of data collected from the 2007 and 2008 Medical Expenditure Panel Survey (MEPS). The sample included 2020 women 40-64 years of age who received one mammogram in 2007 or 2008. Ordinary least squares regression was used to describe relationships among out-of-pocket mammography expenditures, total mammography expenditures, and out-of-pocket mammography expenditures as a percentage of total mammography expenditures and such independent variables as insurance status and type, income, region of the United States, and type of facility where a mammogram was received.

RESULTS

The average out-of-pocket expenditure for a mammogram in 2007 or 2008 was $33, representing 14.1% of the total mammogram expenditure ($266). After controlling for demographic and health factors, women who were uninsured, were from the Midwest, and had a mammogram at an office-based facility had greater out-of-pocket mammography expenditures. Women who were uninsured, lived in the South, and received their mammogram at an office-based facility had out-of-pocket mammography expenditures that represented a greater proportion of the total mammography expenditures.

CONCLUSIONS

Large variations in out-of-pocket expenditures were observed among women with and without insurance and between insurance types, geographic regions of the United States, and types of facilities where mammograms were received. A higher financial burden of mammography screening among some subgroups of women may act as a barrier to future mammography screening.

Breast cancer knowledge, attitudes, and early detection practices in United States-Mexico border Latinas

INTRODUCTION

Evidence suggests Latinas residing along the United States-Mexico border face higher breast cancer mortality rates compared to Latinas in the interior of either country. The purpose of this study was to investigate breast cancer knowledge, attitudes, and use of breast cancer preventive screening among U.S. Latina and Mexican women residing along the U.S.-Mexico border.

METHODS

For this binational cross-sectional study, 265 participants completed an interviewer-administered questionnaire that obtained information on sociodemographic characteristics, knowledge, attitudes, family history, and screening practices. Differences between Mexican (n=128) and U.S. Latina (n=137) participants were assessed by Pearson's chi-square, Fischer's exact test, t tests, and multivariate regression analyses.

RESULTS

U.S. Latinas had significantly increased odds of having ever received a mammogram/breast ultrasound (adjusted odds ratio [OR]=2.95) and clinical breast examination (OR=2.67) compared to Mexican participants. A significantly greater proportion of Mexican women had high knowledge levels (54.8%) compared to U.S. Latinas (45.2%, p<0.05). Age, education, and insurance status were significantly associated with breast cancer screening use.

CONCLUSIONS

Despite having higher levels of breast cancer knowledge than U.S. Latinas, Mexican women along the U.S.-Mexico border are not receiving the recommended breast cancer screening procedures. Although U.S. border Latinas had higher breast cancer screening levels than their Mexican counterparts, these levels are lower than those seen among the general U.S. Latina population. Our findings underscore the lack of access to breast cancer prevention screening services and emphasize the need to ensure that existing breast cancer screening programs are effective in reaching women along the U.S.-Mexico border.

What Factors are Associated with Where Women Undergo Clinical Breast Examination? Results from the 2005 National Health Interview Survey

BACKGROUND

Recent studies have suggested that clinical breast examination (CBE) rates may vary according to patient, provider and health care system characteristics.

OBJECTIVE

To examine the locations where U.S. women received a CBE and other general preventive health, and to examine predictors of location of receipt of general preventive health care (including a recent CBE).

DESIGN

Age-specific and age-adjusted rates of CBE use were calculated using Statistical Analysis Software (SAS) and SUDAAN. A multivariate analysis was carried out using logistic regression techniques.

PARTICIPANTS

Women aged 40 years and older (n = 10,002) who participated in the 2005 National Health Interview Survey (NHIS).

MEASUREMENTS

Recent CBE use was defined as within the past two years.

RESULTS

Among all women, 65% reported a CBE within two years. The highest rate was found among women receiving routine care from doctors' offices and health maintenance organizations (HMOs) (68.5%). CBE use was somewhat lower among women receiving routine care from clinics or health centers (62.9%), and substantially lower among women receiving care from "other" locations (28.4%) or not reporting receiving preventive care (25.3%). Low income women (p < .01) and those with less than a high school education (p < .01) are more likely to go to a hospital than higher SES women. Women with health insurance are much more likely than women without health insurance to go to a doctor's office or HMO, and less likely to be seen at a clinic or health center (p < .01 in both instances). In multivariate analysis, women who received routine care in a location other than a clinic or health center, doctor's office or HMO, or hospital outpatient department (OPD) were less likely to have received a CBE within the past two years (adjusted OR = 0.4, 95% CI = 0.3, 0.7) compared to those at a doctor's office or HMO.

CONCLUSIONS

After adjusting for patient factors, clinics/health centers and hospital OPDs performed as well as doctors' offices/HMOs in delivering CBE. However, women receiving care in other locations were less likely to report CBE.

Breast cancer knowledge and early detection among Hispanic women with a family history of breast cancer along the U.S.-Mexico border

BACKGROUND

Breast cancer is the leading cause of cancer-related death among U.S. Hispanic women. Hispanics are less likely than non-Hispanic White women to be diagnosed at an early stage and survive breast cancer.

METHODS

For this cross-sectional study, we assessed differences in breast cancer knowledge, attitudes, and screening practices between Hispanic women with (FH+) and without (FH-) a family history of breast cancer in three U.S.-Mexico border counties.

RESULTS

Among 137 Hispanic women age 40 and older, FH+ women had levels of knowledge and attitudes about breast cancer similar to those of FH- women. FH+ participants were more likely to have ever performed breast self-examinations, although levels of compliance with screening guidelines did not significantly differ between FH+ and FH- groups.

CONCLUSION

U.S. Hispanic women with a family history of breast cancer constitute an at-risk group for which adhering to preventive screening guidelines could substantially reduce breast cancer mortality.

Does health status influence intention regarding screening mammography?

OBJECTIVE

We analyzed information surveyed from a community-based sample of Korean women older than 40 years of age to understand the relationships between health status and screening behavior.

METHODS

In a cross-sectional population-based study, a two-stage, geographically stratified household-based sampling design was used for assembly of a probability sample of women aged 40-69 years living in Gunpo in Korea, resulting in a total sample size of 503 women. The primary outcome variable for this analysis was the respondent's intention to obtain a mammogram. Predictor variables included health status and other factors known to influence the use of cancer screening, such as age, education, income, marital status and the presence of co-morbid illnesses. Health status was assessed by using the EuroQol (EQ-5D).

RESULTS

The median EQ visual analogue scale score was 75.0, ranging from 20 to 100. In bivariate analyses, the percentage of women reporting to have intention toward mammography use decreased with worsening health status. Women who had problems with mobility or anxiety/depression showed lower intention to undergo future screening mammography. Multivariate logistic regression confirmed that health status was significantly associated with intention toward mammography use. Anxiety or depression was an independent predictor of future screening mammography use.

CONCLUSIONS

Health status is significantly associated with intention regarding screening mammography use. Physicians or other health professionals should be aware that health status is an important component for health promotion, and should pay more attention to clients' possible vulnerability in screening mammography use due to their poor health status.

Computational analysis of non-adherence and non-attendance using the text of narrative physician notes in the electronic medical record

Non-adherence to physician recommendations is common and is thought to lead to poor clinical outcomes. However, no techniques exist for a large-scale assessment of this phenomenon. We evaluated a computational approach that quantifies patient non-adherence from an analysis of the text of physician notes. Index of non-adherence (INA) was computed based on the number of non-adherence word tags detected in physician notes. INA was evaluated by comparing the results to a manual patient record review at the individual sentence and patient level. The relationship between INA and frequency of Emergency Department visits was determined. The positive predictive value of identification of individual non-adherence word tags was 93.3%. The Pearson correlation coefficient between the INA and the number of documented instances of non-adherence identified by manual review was 0.62. The frequency of ED visits was more than twice as high for patients with INA in the highest quartile (least adherent) than for patients with INA in the lowest (most adherent) quartile (p < 0.0001). We have described the design and evaluation of a novel approach that allows quantification of patient non-adherence with physician recommendations through an analysis of physician notes. This approach has been validated at several levels and demonstrated to correlate with clinical outcomes.

Predisposing factors associated with compliance to biennial breast screening among centers with and without nurses

BACKGROUND

Previous research suggests that predisposing factors such as previous screening experience, participation in preventive health behaviors, and knowledge/beliefs about breast cancer and screening influence a woman's decision to make a timely return for a second screen.

METHODS

A stratified random sample of compliers and noncompliers to biennial screening were selected from a cohort of 51,242 women ages 50 to 65 years who had their initial screen at the Ontario Breast Screening Program. In total, 1,901 women were telephone-interviewed. The associations between predisposing factors and compliance were estimated separately for centers with and without nurses using logistic regression analyses adjusted for demographics and smoking status.

RESULTS

Women screened at nurse centers were less likely to comply if they thought women should stop having mammograms before age 70 years [odds ratio (OR), 0.39; 95% confidence interval (95% CI), 0.19-0.79], did not consider mammograms very likely to find cancer (OR, 0.73; 95% CI, 0.56-0.95), felt their likeliness of getting breast cancer was below average (OR, 0.69; 95% CI, 0.54-0.89), or believed a high-fat diet was not an important risk factor for breast cancer (OR, 0.59; 95% CI, 0.36-0.97). Women attending nurse centers were significantly more likely to comply if they sometimes had thoughts or worries about developing breast cancer (OR, 1.40; 95% CI, 1.10-1.80).

CONCLUSIONS

Nurses at screening centers may reinforce a woman's knowledge or beliefs about breast cancer or screening and as a result increase their compliance to biennial breast screening.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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

BACKGROUND AND OBJECTIVE

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

DESIGN

Cross-sectional study using 2000 National Health Interview Survey.

PARTICIPANTS

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

MEASUREMENTS AND ANALYSIS

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

RESULTS

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

CONCLUSIONS

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

Mammography utilization in Canadian women aged 50 to 69: identification of factors that predict initiation and adherence

OBJECTIVE

To identify factors that predict initiation of mammography and adherence with biennial screening among Canadian women aged 50-69 years.

METHODS

Using data from a longitudinal panel of Canadian women interviewed in the National Population Health Survey (NPHS) in 1994/95 and 2 and 4 years later, we estimated the relative risks (RR) of mammography initiation and adherence according to socio-demographic, health and lifestyle characteristics.

RESULTS

Among 505 women with no history of mammography use at baseline, 23.0% and 41.4% initiated mammography by 2 and 4 years, respectively. Urban residence (RR = 2.85) was most strongly associated with initiation by 2 years; younger age (50-54) and lower education also predicted initiation by 2 years. Younger age, birthplace outside Canada, and having a recent (< 2 years) blood pressure check were associated with initiation by 4 years. Among 873 women reporting a recent (< 2 years) mammogram at baseline, 88.7% also reported a recent mammogram within 2 years while 73.0% reported one at both the 2- and 4-year follow-up. Being a non-smoker was the strongest predictor of maintaining adherence both at the 2- (RR = 1.18) and the 4-year (RR = 1.37) follow-up.

INTERPRETATION

Previously identified underserved groups of Canadian women (e.g., those with lower educational levels or born outside of Canada) were most likely to initiate mammography. Approximately 1 in 6 women aged 50 to 69 years remained never-users during follow-up, and fewer than half reported recent mammograms at all three survey cycles, suggesting the need to reinforce regular screening participation.

Randomized controlled trial of a repeat mammography intervention: effect of adherence definitions on results

BACKGROUND

As overall mammography rates approach national goals, mammography promotion efforts must increasingly focus on repeat adherence. This randomized controlled trial examined the effect of two interventions on repeat mammography utilization using various adherence definitions.

METHODS

1,558 women aged 40-63 receiving a mammogram through a federally funded screening program were randomized to three groups: mailed reminder (minimum group); mailed thank you card, newsletters, and reminder (maximum group); no mailings (control). The primary outcome (repeat mammogram) was assessed 13, 15, 18, and 24 months after the qualifying mammogram using administrative data.

RESULTS

The proportions receiving a repeat mammogram within 13 months were 0.28, 0.30, and 0.32 for control, minimum, and maximum groups, respectively. The corresponding proportions were 0.38, 0.43, and 0.45 at 15 months; 0.43, 0.49, and 0.51 at 18 months; and 0.47, 0.52, and 0.54 at 24 months. There were no significant differences across study groups at 13 months. The differences between control and maximum subjects at 15, 18, and 24 months were statistically significant. The differences between control and minimum subjects were significant only at 18 months.

CONCLUSIONS

The two low-cost mailed interventions evaluated modestly increased repeat mammography utilization. However, effects were not visible until at least 15 months after the qualifying mammogram.

Physician Recommendation for Papanicolaou Testing Among U.S. Women, 2000

OBJECTIVE

Many women in the U.S. undergo routine cervical cancer screening, but some women have rarely or never had a Papanicolaou (Pap) test. Studies of other cancer screening tests (for example, mammograms) have shown that physician recommendation to get a screening test is one of the strongest predictors of cancer screening.

METHODS

In this study, we examined whether women in the U.S. had received a physician recommendation to get a Pap test using data from the 2000 National Health Interview Survey. Reported reasons for not receiving a Pap test were also explored.

RESULTS

Among women aged > or =18 years who had no history of hysterectomy, 83.3% [95% confidence interval (CI), 82.4-84.1%] of the 13,636 women in this sample had had a Pap test in the last 3 years. Among 2,310 women who had not had a recent Pap test, reported reasons for not receiving a Pap test included: "No reason/never thought about it" (48.0%; 95% CI, 45.5-50.7), "Doctor didn't order it" (10.3%; 95% CI, 8.7-12.0), "Didn't need it/didn't know I needed this type of test" (8.1%; 95% CI, 6.7-9.6), "Haven't had any problems" (9.0%; 95% CI, 7.6-10.5), "Put it off" (7.4%; 95% CI, 6.2-8.7), "Too expensive/no insurance" (8.7%; 95% CI, 7.3-10.2), "Too painful, unpleasant, embarrassing" (3.5%; 95% CI, 2.5-4.6), and "Don't have doctor" (1.7%; 95% CI, 1.2-2.4). Among women who had had a doctor visit in the last year but who had not had a recent Pap test, about 86.7% (95% CI, 84.5-88.6) reported that their doctor had not recommended a Pap test in the last year. African-American women were as likely as White women to have received a doctor recommendation to get a Pap test. Hispanic women were as likely as non-Hispanic women to have received a doctor recommendation to get a Pap test. In multivariate analysis, factors positively associated with doctor recommendation to get a Pap test included being aged 30 to 64 years, having been born in the U.S., and having seen a specialist or general doctor in the past year.

CONCLUSION

These findings suggest that lack of a physician recommendation contributes to underuse of Pap screening by many eligible women. Given research that shows the effectiveness of physician recommendations in improving use, increased physician recommendations could contribute significantly to increased Pap screening use in the U.S.

The influence of breast self-examination on subsequent mammography participation

OBJECTIVES

We evaluated whether breast self-examination (BSE) influences subsequent mammography participation.

METHODS

We evaluated associations between BSE and subsequent mammography participation, adjusting for baseline screening behaviors and sociodemographic, health, and lifestyle characteristics, among women aged 40 years and older using data from the longitudinal Canadian National Population Health Survey.

RESULTS

Regular performance of BSE at baseline was not associated with receipt of a recent mammogram at follow-up among all women (adjusted odds ratio [OR]=1.01; 95% confidence interval [CI]= 0.75, 1.35) or with mammography uptake among the subgroup of women reporting never use at baseline (adjusted OR=0.78; 95% CI=0.50, 1.22).

CONCLUSIONS

The lack of association between performance of BSE and subsequent mammography participation suggests that not recommending BSE is unlikely to influence mammography participation.

Office systems and their influence on mammography use in rural and urban primary care

CONTEXT

Breast cancer screening rates are lower in rural communities. Although studies have addressed barriers to mammography for rural residents, physician practice barriers have received less attention.

PURPOSE

Controlled clinical trials have shown that the use of office reminder systems in primary care practices is related to increased clinical care rates. Therefore, we compared office systems use in primary care practices located in rural and urban communities and assessed the impact of these systems on rural-urban differences in mammography utilization.

METHODS

We identified female Kansas Medicare beneficiaries aged 65 to 79 from Medicare claims data (N = 24,030) and determined which beneficiaries received a mammogram between April 1, 1999, and March 31, 2001. We linked beneficiaries to their primary care providers and obtained surveys from 180 primary care practices on their use of office reminder systems.

FINDINGS

Mammography rates ranged from 20% to 92% (mean = 65%) among the 180 practices. Flowsheets with a mammography prompt were used by 33% of the practices, 38% utilized nonphysician staff to identify women due for mammograms, and 15% used computerized reminder systems. Urban practices used flowsheets more often than rural practices (44% versus 16%, P < 0.001). A multivariable regression model demonstrated higher mammography rates in urban practices, group practices, and practices using mammography flowsheets.

CONCLUSIONS

Despite success in randomized controlled trials, reminder systems are not used often by primary care providers and are used even less often in rural compared to urban practices. Consistent implementation may be a major barrier to the successful adaptation of flowsheets by primary care offices.

The effect of area HMO market share on cancer screening

OBJECTIVE

Managed care may have widespread impacts on health care delivery for all patients in the areas where they operate. We examine the relationship between area managed care activity and screening for breast, cervical, and prostate cancer among patients enrolled in more managed care plans and patients who are enrolled in less managed plans.

DATA AND METHODS

Data on cancer screening from the 1996 Medical Expenditure Panel Survey (MEPS) were linked to data on health maintenance organization (HMO) and preferred provider organization (PPO) market share and HMO competition at the metropolitan statistical area (MSA) level. Logistic regression analysis was used to examine the relationship between area managed care prevalence and the use of mammography, clinical breast examination, Pap smear, and prostate cancer screening in the past two years, controlling for important covariates.

RESULTS

Among all patients, increases in area-level HMO market share are associated with increases in the appropriate use of mammography, clinical breast exam, and Pap smear (OR for high relative to low managed care areas are 1.75, p < .01, for mammography, 1.58, p < .05, for clinical breast exam, and 1.71, p < .01, for Pap smear). In analyses of subgroups, the relationship is significant only for individuals who are enrolled in the nonmanaged plans; there is no relationship for individuals in more managed plans. No relationship is observed between area HMO market share and prostate cancer screening in any analysis. Neither the level of competition between area HMOs nor area PPO market share is associated with screening rates.

CONCLUSIONS

Area-level managed care activity can influence preventive care treatment patterns.

A Prospective Study of Perceived Susceptibility to Breast Cancer and Nonadherence to Mammography Screening Guidelines in African American and White Women Ages 40 to 79 Years

This prospective study examined the influence of perceived susceptibility to breast cancer on nonadherence to recommended mammography screening guidelines. The study population included 1,229 African American and White women ages 40 to 79 years who obtained an index mammography screening examination at one of five urban hospitals in Connecticut between October 1996 and January 1998. Information on perceived susceptibility to breast cancer and on multiple covariates was obtained by telephone interview on average 1.5 months after the index screening. Subsequent adherence to mammography screening guidelines was ascertained by follow-up interview on average 29 months after the index exam. Across race, age, and family breast cancer history, women who believed that their susceptibility was high (i.e., “very likely” to develop breast cancer) were less likely to adhere to screening guidelines than women who believed that their susceptibility was moderate [adjusted odds ratio (OR), 2.83; 95% confidence interval (CI), 1.51-5.30], but the effect was stronger in older women. Women ages 40 to 49 years (but not ages 50-79 years) who believed that their susceptibility was low (i.e., “not likely” or “a little likely” to develop breast cancer) were also less likely to adhere to guidelines than those who reported moderate susceptibility (adjusted OR, 3.07; 95% CI, 1.66-5.68, and adjusted OR, 2.78; 95% CI, 1.63-4.73). In contrast to most previous studies that found a positive linear relationship between perceived susceptibility to breast cancer and mammography screening, these findings suggest a more complex relationship that should be considered when developing interventions to improve adherence to mammography screening guidelines.

Empowering factors in repeat mammography: insights from the stories of underserved women

Screening mammography can reduce breast cancer mortality. Although a significant percentage of underserved women obtain low income, minority mammograms regularly women underutilize mammography and rates of regular screening are also very low in the general population. By structuring focus groups around constructs from the Precede-Proceed Model, our study explored how these underserved women overcame barriers to be screened on a regular basis. Twenty-eight items were categorized as personal factors that helped them overcome the barriers: awareness and knowledge of risk factors (age and family history); knowledge and trust in early detection and treatment processes; personal responsibility about own health and well-being; and pride in self and satisfaction with one's own actions.

Breast cancer screening in women aged 80 and older: results from a national survey

OBJECTIVES

To estimate the national rates of mammography screening in women aged 80 and older and examine the relationship between health status and screening within the previous 2 years.

DESIGN

Population-based survey.

SETTING

United States.

PARTICIPANTS

Eight hundred eighty-two women aged 80 and older who responded to the 2000 National Health Interview Survey, representing an estimated 3.83 million noninstitutionalized women nationally.

MEASUREMENTS

Screening mammography, disease burden, and functional status were assessed using a questionnaire.

RESULTS

Of the 882 women, 41.5% were aged 85 and older; 19.6% had two or more significant diseases; and 12.1% were dependent in at least one activity of daily living (ADL). More than half (50.8%) had received a screening mammogram within the previous 2 years. Women with two or more significant diseases were less likely to have received screening than those without significant disease, but the difference was not statistically significant (43.9% vs 54.0%, P=.152). Women dependent in at least one ADL were less likely to receive screening mammography than women without functional impairment (37.2% vs 55.9%, P<.001). After adjustment, the likelihood of screening remained lower in women with two or more significant diseases (adjusted odds ratio (AOR)=0.63, 95% confidence interval (CI)=0.40-1.05) and in women with at least one ADL dependency (AOR=0.44, 95% CI=0.22-0.88). Of 294 women likely to have life expectancies of less than 5 years because of poor health, 39.4% received screening mammography.

CONCLUSION

More than half of women aged 80 and older in the United States receive screening mammograms. Nearly 40% of women very unlikely to benefit because of poor health received screening mammography.

The effect of access and satisfaction on regular mammogram and Papanicolaou test screening in a multiethnic population

BACKGROUND

Access and satisfaction are determinants of preventive service use, but few studies have evaluated their role in breast and cervical cancer screening in multiethnic populations.

OBJECTIVES

We sought to investigate the relationship between race/ethnicity, access, satisfaction, and regular mammogram and Papanicolaou test receipt in 5 racial/ethnic groups.

RESEARCH DESIGN

We conducted a telephone survey in 4 languages.

SUBJECTS

Our subjects were black, Chinese, Filipino, Latino, or white women aged 40 to 74 residing in Alameda County, California.

MEASURES

OUTCOME

regular mammograms (last test within 15 months and another within 2 years prior) and Papanicolaou tests (36 months and 3 years, respectively). Independent: race/ethnicity, sociodemographic variables, access (health insurance, usual site of care, regular doctor, check-up within 12 months, knowing where to go, copayment for tests), and satisfaction (overall satisfaction scale, waiting times, test-related pain and embarrassment, test satisfaction).

RESULTS

Among women who had ever had a mammogram or Papanicolaou test, 54% and 77%, respectively, received regular screening. In multivariate analyses, regular mammography was positively associated with increased age (odds ratio [OR] 1.05 per year), private insurance (OR 1.7), check-up in the past year (OR 2.3), knowing where to go for mammography (OR 3.0), and greater satisfaction with processes of care (OR 1.04 per unit), and negatively with not knowing copayment amount (OR 0.4), too many forms to fill out (OR 0.5), embarrassment at the last mammogram (OR 0.6), and Filipino race/ethnicity. Similar results were found for regular Papanicolaou tests.

CONCLUSIONS

Access and satisfaction are important predictors of screening but do little to explain racial/ethnic variation. Tailored interventions to improve regular mammography and Papanicolaou test screening in multiethnic populations are needed.

Health beliefs, salience of breast cancer family history, and involvement with breast cancer issues: adherence to annual mammography screening recommendations

Involvement in breast cancer (BC) issues, and the degree to which family history of BC influences perceived risk (salience of family history), have been proposed as additions to the Health Belief Model as applied to mammography adherence. Barriers and benefits of mammography, perceived susceptibility, severity, cues to action, salience of family history, and issue involvement with respect to BC were examined in adherent (n=97) and non-adherent (n=213) women. Adherent women with positive family histories reported greater benefits of mammography, greater response to cues to action, and higher salience of family history than women with negative family histories. Non-adherent women with positive family histories reported fewer benefits of mammography and greater issue involvement, and perceived BC as less severe than those with negative family histories. Benefits (OR=1.51), susceptibility (OR=1.41), issue involvement (OR=1.59), severity (OR=0.66), and cues to action (OR=0.75) were significantly associated with adherence. Results have implications for evidence-based interventions.

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.

Moving beyond the typologies of managed care: the example of health plan predictors of screening mammography

OBJECTIVES

To develop a framework of factors to characterize health plans, to identify how plan characteristics were measured in a national survey, and to apply our findings to an analysis of the predictors of screening mammography.

DATA SOURCE

The primary data were from the 1996 Medical Expenditure Panel Survey.

STUDY DESIGN

Women ages 40+, with private insurance, and no history of breast cancer were included in the study (N = 2,909). We used multivariate logistic regression to estimate mammography utilization in the past two years relative to health plan and demographic factors. Health plan measures included whether there is a defined provider network, whether coverage is restricted to a network, use of gatekeepers, level of cost containment, copayment and deductible amounts, coinsurance rate, and breadth of benefit coverage.

PRINCIPAL FINDINGS

We found no significant difference in reported mammography utilization using a dichotomous comparison of individuals enrolled in managed care versus indemnity plans. However, women in health plans with a defined provider network were more likely to report having received a mammogram in the past two years than those without networks (adjusted OR= 1.21, 95 percent CI = 1.07-1.36), and women in gatekeeper plans were more likely to report receiving mammography than those without gatekeepers (adjusted OR = 1.18, 95 percent CI = 1.03-1.36). Restricted out-of-network coverage, use of cost containment, enrollee cost sharing, and breadth of benefit coverage did not appear to affect mammography use.

CONCLUSIONS

It is important to examine the effect of individual health plan components on the utilization of health care, rather than use the traditional broader categorizations of managed versus nonmanaged care or simple health plan typologies.

Are gatekeeper requirements associated with cancer screening utilization?

OBJECTIVE

There is widespread debate over whether health plans should require enrollees to use "gatekeepers," which are primary care providers that coordinate care and control access to specialists. However, little is known about whether health plan gatekeeper requirements improve or reduce quality-of-care. Our objective was to examine whether gatekeeper requirements are associated with the utilization of cancer screening for breast, cervical, and prostate cancer.

DATA SOURCES

Three linked sources (N = 13,534): (1) 1996 Medical Expenditure Panel Survey (MEPS) Household Survey, a nationally representative, ongoing survey sponsored by the Agency for Healthcare Research and Quality; (2) 1996 MEPS Health Insurance Plan Abstraction, which codes data from health plan booklets obtained from privately insured respondents, and (3) 1995 National Health Interview Survey.

STUDY DESIGN/DATA COLLECTION

Cross-sectional, multivariate logistic regression analysis using secondary data.

PRINCIPAL FINDINGS

We found in multivariate analyses that women in gatekeeper plans were significantly more likely to obtain mammography screening (Odds Ratio [OR] = 1.22, 95 percent Confidence Interval [CI] 1.07-1.40), clinical breast examinations (OR = 1.39, 95 percent CI 1.23-1.57), and Pap smears (OR = 1.33, 95 percent CI 1.16-1.52) than women not in gatekeeper plans. In contrast, gatekeeper requirements were not associated with prostate cancer screening (OR = 1.11, 95 percent CI 0.93-1.33). We found no association between screening utilization and aggregate plan types (HMO, POS, PPO, FFS).

CONCLUSIONS

Gatekeeper requirements are associated with higher utilization of widely recommended cancer screening procedures, but not with utilization of a less uniformly recommended cancer screening procedure. Researchers should consider the analysis of specific plan characteristics rather than aggregate plan types in conducting future research, and insurers and policymakers should consider the potential benefits of gatekeepers with respect to preventive care when designing health plans and legislation.

Patient and Clinical Site Factors Associated With Rescreening Behavior Among Older Multiethnic, Low-Income Women

PURPOSE

Our goal was to identify factors predictive of mammography rescreening within 18 months of baseline screening in multiethnic, low-income older women.

DESIGN AND METHODS

We interviewed a cross-sectional survey of staff of 102 randomly selected clinics that provided screening and diagnostic services. We also surveyed a random sample of 391 older women served by these clinics to retrospectively assess their experiences of the screening process.

RESULTS

We found that 59% of the sample returned for a repeat mammogram. Education level and the belief it is important to get an annual mammogram were significant patient-level predictors of rescreening. Offering pap smears and using hands-on demonstrations with breast models were significant clinic-level variables predictive of rescreening. Of note, among the variables that did not prove significant in the final model were those reflecting ethnicity and income.

IMPLICATIONS

Individual and health-care-delivery-system factors play important roles in the obtaining of regular mammograms by low-income women. These findings highlight the importance of both factors in improving rescreening rates among older women.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Repeat mammography: Prevalence estimates and considerations for assessment

Despite recent controversies in mammography efficacy, encouraging women to obtain regular screenings is still an important public health priority. Published articles about repeat or regular screening were reviewed to determine trends in rates of mammography adherence. A search of MEDLINE and PsycINFO from January 1990 to December 2001 identified 45 empirical articles of U.S. samples that reported, or provided sufficient data to calculate, the percentage of women 50 years of age and older who obtained 2 or more consecutive, on-schedule mammograms. Keywords used in the searches included pairing mammography with regular, repeat, adherence, compliance, annual, rescreen, and maintenance. The weighted average repeat mammography percentage across all eventually included studies (N = 37) was 46.1% (confidence interval: 39.4%, 52.8%). There was no substantial difference in the average repeat screening percentages comparing studies that collected data from 1995 to 2001 versus 1991 to 1994. Within each of 3 time periods of data collection (pre-1991, 1991-1994, 1995-2001), there was substantial variation in repeat rates. This variation appears to be due to several characteristics of study design and sampling, including the definition/methods of collecting data about the adherence measure, prior mammography status, and use of an upper age limit at recruitment. Consensus is needed regarding the definition of repeat mammography. National surveys must include items to assess repeat mammography in order to have estimates that accurately represent population-level rates. Although this study involved mammography, similar challenges in assessing prevalence rates can occur with other screening behaviors.

Primary care cancer control interventions including Latinos: a review

BACKGROUND

Even though 86% of adult Latinos have a usual source of care, there is a paucity of literature on primary care-based interventions to promote cancer prevention and control in this population. This systematic review examines published primary care-based cancer control interventions that included Latinos.

METHODS

MEDLINE, the Cochrane Registry, and EMBASE were searched from January 1985 to January 2003. Any primary care-based intervention using a controlled trial, quasi-experimental, or pre-post design that targeted breast, cervical, or colorectal cancer was included if at least 5% of the sample was Latino.

RESULTS

A total of 14 intervention studies met inclusion criteria. Seven of the 14 studies described patient or provider reminder interventions. Other interventions incorporated into the primary care setting one of the following: community health educators, culturally sensitive videos, audit with feedback, materials from the "Put Prevention Into Practice" campaign, and vouchers for free screenings. The heterogeneity of designs and outcome variables and the low number of Latinos presented obstacles to combining data to estimate the overall effectiveness of primary care interventions for this population. Qualitatively, patient and physician reminders and management systems strategies including audit with feedback for providers appear to result in improved screening utilization.

CONCLUSIONS

There is a paucity of data on the effectiveness of primary care cancer control interventions directed at Latinos. Primary care-based interventions that have been effective in non-Latinos could incorporate culturally appropriate elements and lessons from community-based research and could be applied to Latinos so that their effectiveness can be assessed in this group.

Knowledge, attitudes, and practices surrounding breast cancer screening in educated Appalachian women

PURPOSE/OBJECTIVES

To determine how and what women learn about breast cancer and screening practices and which factors influence women's breast cancer screening practices.

DESIGN

Descriptive analysis of questionnaire data collected at the time of enrollment in a clinical trial.

SETTING

Breast care center of a mid-Atlantic academic health sciences center.

SAMPLE

185 women in a predominantly Appalachian, entirely rural state.

METHODS

Participants completed the Modified Toronto Breast Self-Examination Inventory and questions related to personal mammography practices at the time of enrollment before randomization in a longitudinal clinical intervention study.

MAIN RESEARCH VARIABLES

Women's demographics, knowledge of breast cancer screening practices, adherence to breast cancer screening guidelines, and motivation, knowledge, and practice proficiency surrounding breast cancer screening.

FINDINGS

These educated women had knowledge deficits about breast cancer, breast cancer risk factors, and screening guidelines, particularly the timing and practice behaviors of breast self-examination. Women who had received healthcare and cancer-screening instruction by healthcare providers, including advanced practice nurses, had greater knowledge of breast cancer and detection practices.

CONCLUSIONS

Women still have knowledge deficits about breast cancer, breast cancer detection, and personal risk factors. In addition, some educated women in this study failed to practice breast cancer screening according to current guidelines.

IMPLICATIONS FOR NURSING

Practitioners must continue to remind and update women about breast disease, and women's cancer-screening practices must be reinforced. All levels of providers should improve their rates of performing clinical breast examinations with physical examinations. Nurses, who greatly influence women's health care, must remain current in their knowledge of breast disease, screening, and treatment.

Mammography screening and breast cancer biology in African American women--a review

This review examines some of the key issues in early detection and breast cancer biology for African American (AA) women which contribute to their diagnoses at more advanced stages than white women, and poorer long-term prognoses. While screening mammography is considered an essential factor in eliminating these disparities, its optimal application for AAs is not fully understood. There is a paucity of information on the success with which mammography screening programs are maintained over time in the AA population, and on screening guidelines with regard to age of initiation and frequency. No randomized clinical trials targeting AA women have been reported. This type of information is critical since breast cancer in AA women occurs at younger ages, and frequently demonstrates aggressive tumor biology at diagnosis. Studies are required to determine the incidence of interval cancers in current screening programs, and the influence of the biological characteristics which are known to differ in the breast tumors of AA and white women. Recognition of molecular and cellular characteristics which identify the potential invasiveness of ductal carcinomas in situ is also required. These studies would assist in establishing the criteria for identifying the subpopulation of younger pre-menopausal AA women who would benefit from early initiation of screening. Finally, the epidemiology and biology of mammographic densities, a risk factor for breast cancer and, perhaps, markers of aggressive disease require further study in both AA and white women.

5-Year mammography rates and associated factors for older women

BACKGROUND

Major national interventions occurred in the early and mid-1990s to increase mammography screening rates among older women. The current study examined mammography utilization by older women during this period. Relation between mammography utilization and demographic measures and health care-related factors also were examined.

METHODS

A cross-sectional design examined variations in mammography during the 5 years between 1993 to 1997 in a representative sample of 10,000 female Medicare beneficiaries in Michigan age >or= 65 years in 1993. Medicare and census data were used. Separate analyses were performed for having undergone any mammogram and, for the 5680 women who had undergone a mammogram, the number of mammograms. Relations were examined between mammography utilization and 15 demographic variables (e.g., age and African-American race) and health care-related variables (e.g., inpatient admissions and number of physicians involved in care).

RESULTS

In the 5 years 43% of older women had no evidence of having undergone a mammogram. Those with any mammogram averaged 2.8 mammograms. Meaningful independent predictors of both having undergone a mammogram and having more than one mammogram were more physicians involved in care, fewer inpatient admissions, and younger age. Having undergone a mammogram also was found to be associated with seeing an obstetrician/gynecologist.

CONCLUSIONS

Even with screening mammography as a covered benefit and after several national informational campaigns, the current study found that in 5 years, 60% of older women either had not undergone a mammogram or had undergone only 1. Intervention efforts should emphasize screening based on functional status, not age. This message should be targeted to physicians as well as to older women without claims for recent mammograms and who are likely to be in good health.

Mammography screening among Chinese-American women

BACKGROUND

Breast carcinoma is the most common major malignancy among several Asian-American populations. This study surveyed mammography screening knowledge and practices among Chinese-American women.

METHODS

In 1999, the authors conducted a cross-sectional, community-based survey in Seattle, Washington. Bilingual and bicultural interviewers administered surveys in Mandarin, Cantonese, or English at participants' homes.

RESULTS

The survey cooperation rate (responses among reachable and eligible households) was 72% with 350 eligible women (age >or= 40 years with no prior history of breast carcinoma or double mastectomy). Seventy-four percent of women reported prior mammography screening, and 61% of women reported screening in the last 2 years. In multivariate analysis, a strong association was found between mammography screening and recommendations by physicians and nurses (prior screening: odds ratio [OR], 16.0; 95% confidence interval [95% CI], 7.8-35.0; recent screening: OR, 7.0; 95% CI, 3.8-13.6). This finding applied to both recent immigrants (< 15 years in the U.S.) and earlier immigrants (>or= 15 years in the U.S.). Thirty-two percent of women reported that the best way to detect breast carcinoma was a modality other than mammogram.

CONCLUSIONS

The authors recommend a multifaceted approach to increase mammography screening by Chinese-American women: recommendations from the provider plus targeted education to address the effectiveness of screening mammography compared with breast self examination and clinical breast examination.

Promoting repeat mammography use: insights from a systematic needs assessment

This article describes the process and outcome of a needs assessment conducted to guide the development of interventions to increase repeat mammography use among participants in a federally funded cancer screening program. Health behavior theory and data from a phone survey are used to uncover key barriers to repeat mammography use and to identify fruitful intervention approaches for modifying them. Estimates of (a) compliance with mammography guidelines, (b) readiness to adopt regular mammography use, (c) the most common reasons for not being rescreened, and (d) population attributable risks associated with various predictors of repeat mammography use are presented and, with guidance from the transtheoretical model of behavior change, used to make inferences about the type of intervention strategies most appropriate for promoting repeat mammography use in this population.

Factors associated with interval adherence to mammography screening in a population-based sample of New Hampshire women

BACKGROUND

Interval adherence to mammography screening continues to be lower than experts advise. The authors evaluated, using a population-based mammography registry, factors associated with adherence to recommended mammography screening intervals.

METHODS

The authors identified and recruited 625 women aged 50 years and older who did and did not adhere to interval mammography screening. Demographic and risk characteristics were ascertained from the registry and were supplemented with responses on a mailed survey to assess knowledge, perceived risk, anxiety regarding breast carcinoma and its detection, and women's experiences with mammography.

RESULTS

The authors found no differences in risk factors or psychologic profiles between adhering and nonadhering women. Women who did not adhere had a statistically higher body mass index than women who did adhere (27.6 versus 26.1, P = 0.003). Exploration of mammographic experiences by group found that care taken by technologists in performing or talking women through the exam was higher in adhering women than nonadhering women (75.6% vs 65.71% for performing the exam, and 71.6% vs 60.8% for talking patients through the exam, respectively, P < 0.05).

CONCLUSIONS

The authors found that previous negative mammographic experiences, particularly those involving mammography technologists, appear to influence interval adherence to screening and that patient body size may be an important factor in this negative experience.

Adherence of low-income women to cancer screening recommendations

BACKGROUND

African-American and low-income women have lower rates of cancer screening and higher rates of late-stage disease than do their counterparts.

OBJECTIVE

To examine the effects of primary care, health insurance, and HMO participation on adherence to regular breast, cervical, and colorectal cancer screening.

DESIGN

Random-digit-dial and targeted household telephone survey of a population-based sample.

SETTING

Washington, D.C. census tracts with > or =30% of households below 200% of federal poverty threshold.

PARTICIPANTS

Included in the survey were 1,205 women over age 40, 82% of whom were African American.

MAIN OUTCOME MEASURES

Adherence was defined as reported receipt of the last 2 screening tests within recommended intervals for age.

RESULTS

The survey completion rate was 85%. Overall, 75% of respondents were adherent to regular Pap smears, 66% to clinical breast exams, 65% to mammography, and 29% to fecal occult blood test recommendations. Continuity with a single primary care practitioner, comprehensive service delivery, and higher patient satisfaction with the relationships with primary care practitioners were associated with higher adherence across the 4 screening tests, after considering other factors. Coordination of care also was associated with screening adherence for women age 65 and over, but not for the younger women. Compared with counterparts in non-HMO plans, women enrolled in health maintenance organizations were also more likely to be adherent to regular screening (e.g., Pap, odds ratio [OR] 1.89, 95% confidence interval [CI] 1.11 to 3.17; clinical breast exam, OR 2.04, 95% CI 1.21 to 3.44; mammogram, OR 1.95, 95% CI 1.15 to 3.31; fecal occult blood test, OR 1.70, 95% CI 1.01 to 2.83.)

CONCLUSIONS

Organizing healthcare services to promote continuity with a specific primary care clinician, a comprehensive array of services available at the primary care delivery site, coordination among providers, and better patient-practitioner relationships are likely to improve inner-city, low-income women's adherence to cancer screening recommendations.

How consistently do women report lifetime mammograms at successive interviews?

BACKGROUND

Little data exist on the reliability of self-reported regular mammography use measures. We used data from two successive interviews of 892 women aged 50 to 74 years without a history of abnormal mammograms to investigate how consistently women report their lifetime number of mammograms.

METHODS

We added an estimated number of mammograms obtained between interviews to the baseline report to create a revised baseline report for comparison with the follow-up report. We then examined the correlation in paired reports, the level of agreement between paired reports, and factors associated with consistent reporting.

RESULTS

Spearman rank correlation between paired reports was 0.73. Agreement between paired reports dropped with increasing lifetime number of mammograms. After adjustment for mammography use, women's characteristics did not appear to be strongly associated with consistent reporting.

CONCLUSIONS

Self-reported lifetime number of mammograms is a reasonably consistent measure for younger women or women with less mammography experience, but it is less reliable for women with long mammography histories. In these women, it may be useful to distinguish those who obtain regular screening from those who do not. Assessing reliability as well as validity for other measures of regular mammography use will allow additional measures to be identified.

Factors associated with continued participation in mammography screening

BACKGROUND

Relatively little is known about factors that predict ongoing participation in mammography screening at regular intervals. Members of managed care plans have access to this preventive service; yet, many still do not receive it routinely.

METHODS

Using administrative data from HIP Health Plan of New York, a group model HMO, 24,215 women ages 50-80 years identified as having a screening mammogram during the baseline period were followed for 2 years to determine demographic and utilization factors that might be related to having a subsequent mammogram within the recommended time interval.

RESULTS

Of the 24,215 women with an index mammogram, 71.8;pc had a subsequent screening mammogram within 2 years. Women ages 65-74 years and those with Medicare coverage had the highest mammogram rates among the age and coverage categories. Number of primary care and gynecology physician visits was strongly related to having a subsequent mammogram. The average (mean) time between index and subsequent mammogram was 14.4 months.

CONCLUSION

The significance of health plan visits in subsequent mammography underscores the importance of physician-patient communication in a managed care plan and the integration of health plan members into the HMO delivery system. Even in this environment with equal access for all types of coverage, Medicaid members were less likely to receive this preventive service.