Breast cancer screening in older women: practices and barriers reported by primary care physicians

The Moderating Role of Clinical Experience in the Relationship Between Patient Characteristics, Attributed Barriers to Mammography, Beliefs About Cancer, and Clinical Decisions: a Study of Israeli Arab Physicians

This study examined whether clinical experience moderates the relationship between three potential physician biases (patient characteristics; cancer-related beliefs, i.e., traditional and fatalistic beliefs; and attributed barriers to mammogram performance) and clinical decisions (recommending and discussing mammography with Arab women patients). A survey was conducted among 146 randomly sampled (cluster sampling) Arab physicians who serve the Arab population in Israel. We found that the least experienced physicians recommended and discussed mammography to a lesser extent than experienced doctors. Less experienced physicians were also less inclined to discuss and recommend mammography to women with specific characteristics (religious women, women with lower education levels, and women who expressed high fatalistic beliefs) and held significantly higher traditional beliefs concerning cancer. The correlation between patient characteristics and clinical decision making was both direct and moderated by clinical experience (stronger for the least experienced and moderately experienced physicians). Cancer-related beliefs had a direct negative effect on recommending and discussing mammography. The findings suggest that greater clinical experience with Arab women patients might reduce physician bias pertaining to patient characteristics among less experienced doctors who serve patients of the same ethnicity. Nonetheless, the findings imply that anti-stigma interventions should not rely on prolonged contact and should be implemented among all physicians, regardless of their clinical experience.

Barriers to obtaining prostate multi-parametric magnetic resonance imaging in African-American men on active surveillance for prostate cancer

Purpose

Magnetic resonance imaging is playing an ever‐bigger role in the management of prostate cancer. This study investigated barriers to obtaining multi‐parametric MRI (mpMRI) in African‐American men on active surveillance for prostate cancer in comparison to white men affected by the same type of cancer.

Materials and Methods

Retrospective review of prostate mpMRI orders from August 2015 to October 2017 at a single health organization treating a diverse population was performed. Data was extracted from the electronic medical records and cancellations were examined based on the documented reason for mpMRI cancellation, race, median zip code household income, and distance from healthcare facility.

Results

Out of 793 prostate mpMRI orders, 201 (25%) went unscanned. Access to care issues accounted for 46% of unscanned orders. Patient cancellations were the most common, followed by difficulty contacting patients, and insurance denials. African‐American patients disproportionately went unscanned because institution staff were unable to contact patients (29% vs 10% in white men, P = 0.0015). Median zip code household income was significantly different between racial groups but did not vary between indication for cancellation.

Conclusions

African‐American prostate cancer patients' access to mpMRI is hindered more by barriers to care than White patients. Urology providers must consider these issues before using prostate mpMRI within their active surveillance pathways.

Robust expression of tumor suppressor miRNA's let-7 and miR-195 detected in plasma of Saudi female breast cancer patients

Background

Female breast cancer is frequently diagnosed at a later stage and the leading cause of cancer deaths world-wide. Levels of cell-free circulating microRNAs (miRNAs) can potentially be used as biomarkers to measure disease progression in breast cancer patients in a non-invasive way and are therefore of high clinical value.

Methods

Using quantitative RT-PCR, circulating miRNAs were measured in blood samples collected from disease-free individuals (n = 34), triple-negative breast tumours (TNBC) (n = 36) and luminal tumours (n = 57). In addition to intergroup comparisons, plasma miRNA expression levels of all groups were analyzed against RNASeq data from cancerous breast tissue via The Cancer Genome Atlas (TCGA).

Results

A differential set of 18 miRNAs were identified in the plasma of breast cancer patients and 10 miRNAs were uniquely identified based on ROC analysis. The most striking findings revealed elevated tumor suppressor let-7 miRNA in luminal breast cancer patients, irrespective of subtype, and elevated miR-195 in plasma of TNBC breast cancer patients. In contrast, hsa-miR-195 and let-7 miRNAs were absent from cancerous TCGA tissue and strongly expressed in surrounding non-tumor tissue indicating that cancerous cells may selectively export tumor suppressor hsa-miR-195 and let-7 miRNAs in order to maintain oncogenesis.

Conclusions

While studies have indicated that the restoration of let-7 and miR-195 may be a potential therapy for cancer, these results suggested that tumor cells may selectively export hsa-miR-195 and let-7 miRNAs thereby neutralizing their potential therapeutic effect. However, in order to facilitate earlier detection of breast cancer, blood based screening of hsa-miR-195 and let-7 may be beneficial in a female patient cohort.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3776-5) contains supplementary material, which is available to authorized users.

Effect of light therapy upon disturbed behaviors in Alzheimer patients

Alzheimer's disease (AD) causes sleep and behavioral disturbares which may be related to abnormalities of circadian rhythms caused by damage of the suprachiasmatic nucleis. Exposure to bright light may compensate for this danlage by improving synchronization, timing and amplijude of circadian rhythms. Three case studies, presented in this paper, demonstrate the beneficial effect of light therapy on sleep and one of the cases also suggests that light therapy may be effective in the treatment of agitated behavior. The clinical observations also suggest a need for increased level of lighting in long term care facilites.

Physician clinical management strategies and reasoning: a cross-sectional survey using clinical vignettes of eight common medical admissions

BACKGROUND

Physicians often select clinical management strategies not strongly supported by evidence or guidelines. Our objective was to examine the likelihood of selecting, and rationale for pursuing, clinical management strategies with more or less guideline support among physicians using clinical vignettes of eight common medical admissions.

METHODS

We conducted a cross-sectional survey using clinical vignettes of attending physicians and housestaff at one internal medicine program in New York City. Each clinical vignette included a brief clinical scenario and a varying number of clinical management strategies: diagnostic tests, consultations, and treatments, some of which had strong evidence or guideline support (Level 1 strategies) while others had limited evidence or guideline support (Level 3 strategies). Likelihood of selecting a given management strategy was assessed using Likert scales and multiple response options were used to indicate rationale(s) for selections.

RESULTS

Our sample included 79 physicians; 68 (86%) were younger than 40 years of age, 34 (43%) were female. There were 31 attending physicians (39%) and 48 housestaff (61%) and 39 (49%) had or planned to have primarily primary care internal medicine clinical responsibilities. Overall, physicians were more likely to select Level 1 strategies "always" or "most of the time" when compared with Level 3 strategies (82% vs. 43%; p < 0.001), with wide variation across the eight medical admissions. There were no differences between attending and housestaff physician likelihood of selecting Level 3 strategies (47% vs. 45%, p = 0.36). Supportive evidence and local practice patterns were the two most common rationales behind selections; supportive evidence was cited as the most common rationale for selecting Level 1 when compared with Level 3 strategies (63% versus 30%; p < 0.001), whereas ruling out other severe conditions was cited most often for Level 3 strategies.

CONCLUSIONS

For eight common medical admissions, physicians selected more than 80% of management strategies with strong evidence or guideline support, but also selected more than 40% of strategies for which there was limited evidence or guideline support. The promotion of evidence-based care, including the avoidance of care that is not strongly supported by evidence or guidelines, may require better evidence dissemination and educational outreach to physicians.

Enhancing measurement of primary health care indicators using an equity lens: An ethnographic study

Introduction

One important goal of strengthening and renewal in primary healthcare (PHC) is achieving health equity, particularly for vulnerable populations. There has been a flurry of international activity toward the establishment of indicators relevant to measuring and monitoring PHC. Yet, little attention has been paid to whether current indicators: 1) are sensitive enough to detect inequities in processes or outcomes of care, particularly in relation to the health needs of vulnerable groups or 2) adequately capture the complexity of delivering PHC services across diverse groups. The purpose of this paper is to contribute to the discourse regarding what ought to be considered a PHC indicator and to provide some concrete examples illustrating the need for modification and development of new indicators given the goal of PHC achieving health equity.

Methods

Within the context of a larger study of PHC delivery at two Health Centers serving people facing multiple disadvantages, a mixed methods ethnographic design was used. Three sets of data collected included: (a) participant observation data focused on the processes of PHC delivery, (b) interviews with Health Center staff, and (c) interviews with patients.

Results

Thematic analysis suggests there is a disjuncture between clinical work addressing the complex needs of patients facing multiple vulnerabilities such as extreme levels of poverty, multiple chronic conditions, and lack of housing and extant indicators and how they are measured. Items could better measure and monitor performance at the management level including, what is delivered (e.g., focus on social determinants of health) and how services are delivered to socially disadvantaged populations (e.g., effective use of space, expectation for all staff to have welcoming and mutually respectful interactions). New indicators must be developed to capture inputs (e.g., stability of funding sources) and outputs (e.g., whole person care) in ways that better align with care provided to marginalized populations.

Conclusions

The current emphasis on achieving greater equity through PHC, the continued calls for the renewal and strengthening of PHC, and the use of monitoring and performance indicators highlight the relevance of ensuring that there are more accurate methods to capture the complex work of PHC organizations.

Breast cancer screening beliefs among older Korean American women

Korean American women's breast cancer screening rates are low, and the rates among older Korean American women are even lower.This article describes health beliefs related to older Korean American women's screening behaviors, comparing them to beliefs of younger Korean American women. The 73 women age 65 and older had significantly dif-ferent health beliefs than the 114 women between ages 40 and 64. Further, older women's perceptions of the seriousness of the disease and benefits of and barriers to taking action to prevent the disease predated their screening behaviors. Interventions to change the health beliefs of older Korean American women are suggested.

Language use and the receipt of cancer screening recommendations by immigrant Chinese American women

BACKGROUND

Cancer screening rates are low among Chinese American women, a mostly immigrant minority population. This is possibly because they do not receive cancer screening recommendations from their physicians. The objective of this study was to determine if the rate at which physicians recommend cancer screening to older Chinese American women differs according to the language used during visits.

METHODS

Data for the cross-sectional study were collected from a telephone survey of older Chinese American women residing in the Washington, DC, area. A total of 507 asymptomatic Chinese American women aged > or =50 who had a regular physician participated in this study. The main outcome was women's self-reported perception of having received a recommendation from their physician for mammography, Pap tests, or colorectal cancer screening in the past 2 years. The main independent variable was the language used during visits (English vs. Chinese). Patient age, educational level, employment status, cultural views, physician specialty, physician gender, and length of relationship with the physician were included in the multiple logistic regression analyses.

RESULTS

Chinese women who communicated with their physicians in English were 1.71 (95% CI 1.00-2.96) and 1.73 (95% CI 1.00-3.00) times more likely to report having received mammography and colorectal cancer screening recommendations, respectively (p < 0.05). Physicians in family medicine or general practice were 2.11 (95% CI 1.31-3.40) and 1.70 (95% CI 1.06-2.48) times more likely to recommend cancer screening than those in other specialties.

CONCLUSIONS

Chinese American women who conversed with their physicians in Chinese were less likely to perceive receiving cancer screening recommendations. Future research is needed to identify physician-specific knowledge, attitude, and cultural barriers to recommending cancer screening.

Health beliefs and rates of breast cancer screening among Arab women

OBJECTIVES

To examine the relationship between health beliefs and participation in breast cancer screening among Arab women in Israel.

METHODS

A random sample of 568 Arab women, aged 20-60, belonging to three religious groups, Muslim, Christian, and Druze, was recruited. Participants answered a telephone questionnaire regarding attendance for mammography screening and clinical breast examination (CBE) and health beliefs.

RESULTS

Christian women had undergone more mammography screening and CBE than Druze and Muslim women. They perceived more benefits and fewer barriers to screening practices and had greater perception of the severity of breast cancer. Perception of susceptibility was similar across groups. The barriers that were significant for the Druze and Muslim women were feelings of discomfort and embarrassment, the belief that there was no cure in the case of a positive finding, perceiving mammography as hazardous to health, and perceiving CBE as painful. Logistic regression revealed that age, group, and having a first-degree relative with breast cancer predicted participation in early detection screening. Physician's recommendation predicted mammography, and level of participants' religiosity predicted CBE.

CONCLUSIONS

Diversity in health beliefs and behaviors exists in religious subgroups. Health communications should be modified to suit women in different groups in order to increase participation in screening. In addition, physicians have to be made keenly aware of their pivotal role in motivating women to participate in early detection screening.

Older adults' attitudes about continuing cancer screening later in life: a pilot study interviewing residents of two continuing care communities

Background

Individualized decision making has been recommended for cancer screening decisions in older adults. Because older adults' preferences are central to individualized decisions, we assessed older adults' perspectives about continuing cancer screening later in life.

Methods

Face to face interviews with 116 residents age 70 or over from two long-term care retirement communities. Interview content included questions about whether participants had discussed cancer screening with their physicians since turning age 70, their attitudes about information important for individualized decisions, and their attitudes about continuing cancer screening later in life.

Results

Forty-nine percent of participants reported that they had an opportunity to discuss cancer screening with their physician since turning age 70; 89% would have preferred to have had these discussions. Sixty-two percent believed their own life expectancy was not important for decision making, and 48% preferred not to discuss life expectancy. Attitudes about continuing cancer screening were favorable. Most participants reported that they would continue screening throughout their lives and 43% would consider getting screened even if their doctors recommended against it. Only 13% thought that they would not live long enough to benefit from cancer screening tests. Factors important to consider stopping include: age, deteriorating or poor health, concerns about the effectiveness of the tests, and doctors recommendations.

Conclusion

This select group of older adults held positive attitudes about continuing cancer screening later in life, and many may have had unrealistic expectations. Individualized decision making could help clarify how life expectancy affects the potential survival benefits of cancer screening. Future research is needed to determine whether educating older adults about the importance of longevity in screening decisions would be acceptable, affect older adults' attitudes about screening, or change their screening behavior.

Women with disabilities: general practitioners and breast cancer screening

BACKGROUND

Because they undergo breast cancer screening (BCS) relatively infrequently, women with physical or mental impairments may be at higher risk of late-stage breast cancer than women without impairments. A panel of 600 general practitioners (GPs) in Provence (southeastern France) provided information from which barriers potentially associated with BCS practices for women with disabilities were evaluated.

METHODS

In 2002, a telephone questionnaire collected data about GPs' personal and professional characteristics and their attitudes and practices regarding patients with disabilities. Analysis in 2003 used simple and multiple logistic regressions.

RESULTS

More than a quarter of the GPs reported apparently inadequate BCS practices for people with disabilities. Feelings of discomfort when treating people with disabilities, lack of assistance, and communication difficulties were inversely associated with BCS for women with mental and physical impairments. General practitioners' information-seeking strategies were associated with BCS for women with mental impairments, and nursing home work experience was inversely associated with BCS for women with physical impairments.

CONCLUSIONS

Appropriate training sessions should be made available to improve primary health care quality and prevention practices and to reduce GPs' misperceptions of people with disabilities.

Barriers to cancer screening by rural Appalachian primary care providers

CONTEXT

Rural Appalachia has significantly higher overall cancer mortality compared with national rates, and lack of cancer screening is believed to be one of the contributing factors. Reducing the cancer disparity in this region must include strategies to address suboptimal cancer screening practices by rural Appalachian primary care providers (PCPs).

PURPOSE

To identify and investigate barriers to recommending and/or performing cancer screening among rural Appalachian PCPs.

METHODS

A semistructured focus group research design was used to elicit perceived barriers to recommending and/or performing cancer screening from 36 rural Appalachian PCPs (in 5 groups), including physicians, nurse practitioners, and a physician assistant.

FINDINGS

Findings indicate that rural Appalachian PCPs may not be performing recommended cancer screenings for a number of reasons. Time constraints, conflicting guidelines, and perceptions that patients do not value prevention were reported barriers to cancer screening. The PCPs in this study expressed frustration in attempting to encourage cancer screening and cited patient factors such as socioeconomic status, Appalachian culture, and cancer fatalism as barriers to cancer screening.

CONCLUSIONS

Rural Appalachian PCPs encounter various barriers, such as lack of time and multiple cancer screening guidelines, to incorporating cancer screening into their practice routine. The findings underscore the negative impact of some cultural factors on preventive care delivered by PCPs. Increased provider education is needed on how best to encourage cancer screening within a cultural context and should include clarification and understanding of current cancer screening guidelines.

Screening rarely screened women: time-to-service and 24-month outcomes of tailored interventions

BACKGROUND

Managed care organizations and others reaching out to underscreened women seek strategies to encourage mammogram and Pap screening.

METHODS

Female HMO members aged 50-69 years and overdue for a mammogram and a Pap test (n = 501) were followed for 24 months after interventions began. An Outreach intervention (tailored letters and motivational telephone interviews), an Inreach intervention (motivational interview delivered in clinics), and a Combined Inreach/Outreach intervention were compared to Usual Care at 24 months. Logistic regression and Cox hazard models examined predictors of obtaining screening services and time-to-service, respectively.

RESULTS

Compared with Usual Care, the odds of Outreach women aged 50-64 obtaining a mammogram (OR = 2.06; 95% CI = 1.59-5.29), a Pap test (OR = 1.97; 95% CI = 1.12-3.53), or both (OR = 2.53; 95% CI = 1.40-4.63) remained significantly increased at 24 months. The average time-to-service for Outreach women was reduced by 4 months. Outreach effects persisted despite intensive, ongoing health plan efforts to improve screening of all women.

CONCLUSIONS

This brief, tailored outreach intervention was an effective strategy for encouraging cervical and breast cancer screening among women overdue for both screening services. It also shortened time-to-service, an important benefit for early detection and treatment. Alternative strategies are needed for women who remain unscreened.

Taking charge of self: breast health practices of older rural women

The purpose of this grounded theory study was to explore breast health practices of older Vermont women residing in rural communities. Although the three components of breast health-mammography, clinical breast exam, and self-breast exam-are recommended for women 40 years and over, minimal research has empirically analyzed the breast health practices of healthy women to ascertain if, in fact, these procedures are followed, and if so, what the motivation is for doing so. Twelve women, 50-64 years, participated in face-to-face, audiotaped interviews. Data analysis, including line-by-line and constant comparative approaches, occurred concurrently with data collection. Taking Charge of Self, the generated theory, describes participants' engagement in a process of learning how to take charge of their lives. The analysis indicates that health care providers have a powerful role in the lives of women in this age group. With an increasing emphasis on health promotion and disease prevention, health care providers are positioned to cultivate and support women's development of the personal or internal motivation for health and well-being.

Screening mammography: Is it suitably targeted to older women who are most likely to benefit?

OBJECTIVES

To determine whether screening mammography is suitably targeted to older women who are most likely to benefit.

DESIGN

Prospective cohort study.

SETTING

New Haven County, Connecticut.

PARTICIPANTS

Eight hundred forty-four community-dwelling older women were interviewed as part of the 1990 New Haven Established Populations for the Epidemiologic Study of the Elderly (EPESE) program.

MEASUREMENTS

Mammography use was ascertained from Medicare Part B claims data. A four-level prognostic mortality index was developed using items previously shown to be predictive of mortality. Mammography use and all-cause mortality were evaluated by prognostic stage over a 5-year period, January 1, 1991, to December 31, 1995.

RESULTS

Five-year mortality increased steadily with each prognostic stage (12% to 68%, P = .001), whereas the 5-year mammography use rate declined (48% to 7%, P = .001). Over half the women (53%) in the most favorable prognostic group did not receive a mammogram, whereas 13% in the two worst prognostic groups received at least one mammogram.

CONCLUSION

Screening mammography may be underutilized among older women who are the most likely to benefit and overutilized among those who are unlikely to benefit.

The effects of message framing and ethnic targeting on mammography use among low-income women

The authors examined the effects that differently framed and targeted health messages have on persuading low-income women to obtain screening mammograms. The authors recruited 752 women over 40 years of age from community health clinics and public housing developments and assigned the women randomly to view videos that were either gain or loss framed and either targeted specifically to their ethnic groups or multicultural. Loss-framed, multicultural messages were most persuasive. The advantage of loss-framed, multicultural messages was especially apparent for Anglo women and Latinas but not for African American women. These effects were stronger after 6 months than after 12 months.

Barriers to mammography and Pap smear screening among women who recently had neither, one or both types of screening

There is legitimate concern about whether cancer screening programs and other types of prevention and early detection programs are designed to reach those most in need of services. Previous research on barriers to screening has generally addressed screening for specific cancers. The purpose of this study was to evaluate and compare the types and strengths of barriers to both mammography and Pap smear screening experienced by three groups of women. Five hundred and twenty-two women, aged 52-69, who were members of a large health maintenance organization (HMO), completed a survey about cancer screening and associated barriers. Women with no mammogram in the preceding 2 years and with no Pap smear in 3 years were classified into a "safety net" program. We classified women as falling into both (Pap smear and mammography), one (Pap smear or mammography), or neither safety nets. Results consistently revealed that women needing both tests had more numerous and more intense barriers than other women to both types of screening. Factor analyses and descriptive analyses both showed that the types of barriers experienced were very similar for mammography and Pap smear screening. The discussion addresses intervention implications and the additional research needed on women who need both mammogram and Pap smear screening and who have much higher cancer risk than other women.

The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: who gets the message about breast cancer screening?

OBJECTIVES

This study investigated the association between physician recommendation for mammography and race/ethnicity, socioeconomic status, and other characteristics in a rural population.

METHODS

In 1993 through 1994, we surveyed 1933 Black women and White women 52 years and older in 10 rural counties.

RESULTS

Fifty-three percent of the women reported a physician recommendation in the past year. White women reported recommendations significantly more often than did Black women (55% vs 45%; odds ratio = 1.49). Controlling for educational attainment and income eliminated the apparent racial/ethnic difference. After control for 5 personal, 4 health, and 3 access characteristics, recommendation for mammography was found to be more frequent among women who had access to the health care system (i.e., had a regular physician and health insurance). Recommendation was less frequent among women who were vulnerable (i.e., were older, had lower educational attainment, had lower annual family income).

CONCLUSIONS

Socioeconomic status, age, and other characteristics--but not race/ethnicity--were related to reports of a physician recommendation, a precursor strongly associated with mammography use. Efforts to increase physician recommendation should include complementary efforts to help women address socioeconomic and other barriers to mammography use.

A systems model of clinical preventive care: the case of breast cancer screening among older women. For the NCI Breast Cancer Screening Consortium

BACKGROUND

In older women covered by Medicare, relationships among physician recommendation, mammography in the past 2 years, and clinical breast examination (CBE) in the past year were systematically explored with a variety of predisposing, enabling, and situational factors identified in the Systems Model of Clinical Preventive Care.

METHODS

A population-based survey of women age 65 years and older was conducted in five National Cancer Institute's Breast Cancer Screening Consortium geographic areas. Analyses focused on women with a regular physician and site of care (n = 5318).

RESULTS

Physician recommendation and mammography use declined with women's increasing age and increased with income, education, and insurance. CBE and mammography increased with number of physicians and breast cancer family history; mammography use decreased with worsening health status. Recommendations were higher among physicians who were younger, female, and internists. Family practitioners were older and male; women who saw family practitioners reported characteristics associated with decreased screening-lower income, education, and insurance-and seeing only one physician.

CONCLUSIONS

Public policy and health system changes that create a uniform system of finance and service performance expectations may reduce the persistent discrepancy in physician recommendation and mammography use due to sociodemographics and physician specialty.

Breast cancer screening for older women in a primary care practice

OBJECTIVE

To determine rates of breast cancer screening for older women cared for in a primary care practice and to identify associations between patient and physician characteristics and breast cancer screening.

STUDY DESIGN

A retrospective cohort study of older women.

SETTING

An urban hospital-based academic general medicine practice. This practice uses a computerized medical record and office procedures that facilitate tracking and ordering of mammograms.

PARTICIPANTS

A random sample of 130 women aged 65 to 80 who receive primary care at a hospital-based general medicine practice.

MEASUREMENTS

Data were collected from the hospital's computerized medical record. We recorded all clinical breast exams and mammograms performed or recommended during the 2-year study period.

RESULTS

The median age of the 130 women studied was 71, and 21% of the women were black. Most patients had no serious comorbid illness (69%) and were independent in their activities of daily living (92%). During the 2-year study period, mammography was recommended for 95% of women and completed for 84%, and clinical breast exam was performed on 75%. Patients of male physicians had higher rates of mammography than patients of female physicians (89% vs. 75%, P = .045). Patients of faculty physicians had higher rates of clinical breast exam than patients of house officers or fellows (83% vs. 56%, P = .001).

CONCLUSIONS

We report a very high rate of mammography for women cared for at a hospital-based primary care practice. The systems in place to facilitate ordering and tracking of mammograms probably contributed to the unusually high rate of mammography observed.

Mammography use among women as a function of age and patient involvement in decision-making

OBJECTIVE

To assess the extent to which self-reported patient involvement in decision-making for initiation of mammography differs with age.

DESIGN

Data from the 1992 National Health Interview Survey (NHIS) Cancer Control Supplement were evaluated. Prevalences were weighted and variances were adjusted using SUDAAN software to account for the complex, multistage sampling probability design of the NHIS. Logistic regression was used to evaluate the relative likelihood of self-reported involvement in the decision to have a mammogram within the preceding year as a function of age and other covariates.

PARTICIPANTS

Mammography use was assessed among 3,863 NHIS female respondents 40 years of age or older. The analysis of decision-making was restricted to the subgroup of 1,064 women who reported a screening mammogram within the preceding year and who provided information on the other relevant variables.

MEASUREMENTS AND MAIN RESULTS

The probability of reported mammography use within the preceding year declines among older groups of interviewees. Among women with a mammogram in the preceding year, the weighted percentage of women reporting active involvement in the decision (patient decision or decided jointly with a physician) declines from 51% among women 40 to 45 years of age to 19% among those aged 75 years or older. The adjusted odds ratio comparing the likelihood of participating in the decision to have a mammogram for the oldest women, compared with the youngest, was 0.31 (95% confidence interval 0.15 to 0.61).

CONCLUSIONS

Older women are substantially less likely than younger women to report active involvement in the mammography decision-making process. Increased use of screening mammography among older women will require greater promotion by physicians. Other interventions, such as directed educational efforts, may also be needed to increase mammography demand among older women.

Cancer surgery in the elderly

The incidence of most cancers increases with age. Although the risk for surgery increases in elderly patients who have comorbidities, evaluations of risk can allow interventions that may decrease morbidity and mortality. Appropriate treatments should be offered to the elderly until studies demonstrate the elderly can safely be managed differently from younger patients. The elderly should not be denied adequate treatment simply because of age.

The effect of a multifaceted physician office-based intervention on older women's mammography use

BACKGROUND

In response to identified low mammography use among older women in three geographic areas in Connecticut, a physician office-based mammography intervention was initiated under the Health Care Financing Administration's Health Care Quality Improvement Program.

OBJECTIVE

To evaluate the intervention's impact on older women's mammography use.

DESIGN

A quasi-experimental design comparing mammography rates for women in the intervention program with a randomly selected control sample.

SETTING

Community-based physician offices.

PATIENTS

Female Medicare beneficiaries aged 65 to 74 years seen by participating and control physicians for at least one primary care visit in 1995 (baseline) and 1996 (follow-up). In the baseline period, 1720 women in the intervention sample and 2761 women in the control sample were included in the study.

INTERVENTION

The recruitment strategies included the use of physician opinion leaders and modified academic detailing. The multifaceted intervention incorporated patient education, physician reminders, and audit-with-feedback

MEASUREMENTS

Biennial mammography rates. Patient adherence to physician mammography referral was evaluated in a restricted cohort of women selected from the intervention sample.

RESULTS

The mammography rate for the intervention sample increased from 62.7% (baseline) to 73.1% (follow-up), (P<.001), whereas the control sample's rate remained essentially unchanged (68.3 to 69.5%), (P = .34). The intervention patients were 48% more likely than controls to experience an increase in biennial mammography use (OR = 1.48; 95% CI, 1.22-1.79) after adjustment for patient race and income and physician gender, specialty, and age. The proportion of women who adhered to their physicians' mammography referral was 70.6%.

CONCLUSIONS

These data demonstrate the effectiveness of a multifaceted intervention program administered in the setting of community physician practices. The relatively low rate of patients' acceptance of their physicians' mammography recommendations has identified the need to address more effectively older women's concerns about mammography screening.

The impact of a physician intervention program on older women's mammography use

The Mammography Optimum Referral Effort (MORE) is a physician office-based intervention program initiated by the Connecticut Peer Review Organization (CPRO) to increase mammography use among older women in Connecticut. Three locales in the state were targeted for the MORE intervention based on identified low mammography rates in women aged 65 years and older. Thirty-seven physicians participated from March 1, 1996, to August 31, 1996. Annual mammography rates were derived by merging Medicare Part B mammography claims with a database from the Connecticut Tumor Registry. This strategy allowed us to exclude women with a prior history of breast cancer from the analysis, in order to estimate screening rates. The MORE intervention was associated with an absolute increase of 5.9%, which represents a relative increase of 15.4%, in annual mammography use. Our findings suggest that a multifaceted physician intervention is capable of increasing mammography use among older women.

The Latina Breast Cancer Control Study, year one: factors predicting screening mammography utilization by urban Latina women in Massachusetts

This study identifies factors associated with screening mammography utilization for Latina women age 40 and older in two Massachusetts cities, who are predominantly of Caribbean origin. It is a cross-sectional survey based on an area probability sample, using bilingual Latina interviewers. Sixty-one percent of the sample was Latina, 99% of whom were interviewed in Spanish. Ethnicity, educational attainment, and acculturation were unrelated to recent screening. While distinct healing traditions were found among some Latinas, their use was unrelated to screening. Higher fatalism scores had a bivariate association with lower probability of screening. In a logistic regression, predictors were having health insurance or access to free care; having discussed mammography with a physician in the past 2 years; the difference between 67 and respondent's age (negative coefficient); and city of residence. Having a regular source of care was a predictor when substituted for insurance status. Insurance status and age principally determine whether subjects are screened, mediated by access to physician services and whether physicians recommend screening. Results suggest that universal medical insurance, and efforts to influence physician practices, are key to promoting screening mammography among this population.

Cancer screening of older women : a primary care issue

PURPOSE

The purpose of this retrospective chart review was to examine whether family practice physicians and residents were screening older women for breast, gynecologic, and colorectal cancers as recommended by the American Cancer Society, the Guide to Clinical Preventive Services, and Healthy People 2000.

METHODS

A retrospective chart review of women 60 years and older who were seen at least twice between July 1, 1992, and June 30, 1993, in a midwestern family practice residency program was completed. From the original sample of 660 potential subjects, a systematic random selection of every third chart was identified for review, resulting in a sample of 201. Analysis of the data was performed by descriptive statistics and chi-square tests. A series of multiple regression models using age, number of visits, type and gender of provider, and personal or family history of cancer as predictor variables was performed.

RESULTS

Breast cancer screening was offered to approximately 70% of the sample, with only about one third of the older women receiving mammography or clinical breast examination. Recommendations for gynecologic cancer screening were given to 63% of the sample, with less than one third receiving Papanicolaou smears. Recommendations for digital rectal examination, fecal occult blood test, and flexible sigmoidoscopy were 58%, 59%, and 30%, respectively. The percentages of patients who actually received these tests were considerably lower.

CLINICAL IMPLICATIONS

Barriers for appropriate cancer screening for older women exist for both the provider and the patient; however, many of these obstacles can be overcome. Improving the resident's exposure to the current recommendations, increasing geriatric content in the training program, and initiating a reminder system may reduce some of the provider barriers. The use of midlevel providers may increase the preventive services offered to older women as well as educate and empower these women to become responsible for their own healthcare. Together, physicians and midlevel providers can become patient advocates through political activism, encouraging legislation that guarantees payment for cancer screening tests. Finally, primary care providers can become actively engaged in research that explores the healthcare concerns of older women.

Acceptability of mobile mammography among community-dwelling older women

OBJECTIVE

To test the acceptability of mobile mammography among community-dwelling older women and to identify factors predictive of mobile mammography acceptance.

DESIGN

Case series.

SETTING

Twelve community meal sites sponsored by the City of Los Angeles Area on Aging.

PARTICIPANTS

Two hundred fifty-five volunteers aged 60 to 84 years who attended community meal sites.

INTERVENTION

On-site mammography offered to women who had not had a mammogram within the last year.

MEASUREMENTS

Mammography acceptance rates, reasons for accepting or declining the mammogram, and breast cancer knowledge, beliefs, and intentions.

MAIN RESULTS

One hundred seven of the 255 (42%) women were ineligible because they had received mammograms within the last year. Of the 148 women eligible, 57% accepted the mammograms and 43% declined; moreover, 20 of the 42 (48%) women who had not had a mammogram within the last 5 years or who never had a mammogram also accepted on-site mammography in the mobile van. Variables identified as predictive of mammogram acceptance included Asian American status, not being an HMO member, being married, a reported willingness to accept a screening mammogram if recommended by a physician, and previous mammogram screening history.

CONCLUSION

Mobile mammography is acceptable to many older community-dwelling women. Although mobile mammography does not eliminate all barriers that inhibit a woman from receiving a mammogram, it may substantially increase screening for some groups.

Predictors of mammography use in the past year among elderly women

Thirty-two personal characteristics were examined as potential predictors of mammography use in the past year in a geriatric clinic. Interviews assessed demographic, health status, health service utilization, health belief, and psychological and social variables (n = 242, mean age = 76 years). Four variables were independently associated with mammography use in logistic regression analysis: age, historical mammography use, perceived severity, and perceived barriers. The inverse relationship between age and mammography use in the past year was not modified by health status, functional status, and the other independently predictive variables. The authors conclude that geriatrics specialty care does not eliminate the age-associated decline in mammography use that has been previously described. The factors associated with mammography use in this sample were similar to those that have been described in younger populations of women. Variables examined because of specific gerontologic considerations were not independently associated with mammography use in the past year.

Breast self-examination proficiency in older women: measuring the efficacy of video self-instruction kits

Older women represent the highest risk group for breast cancer but do not use screening at recommended frequencies. Age-sensitive screening programs addressing the developmental issues, unique value systems, and problems of access for all older women are critically needed. Television is an ideal medium for reaching isolated older women with health information and educational programs. This research explored the efficacy of using video self-instruction kits to increase breast self-examination (BSE) proficiency and knowledge about breast cancer among a sample of 62 women > 60 years of age. Participants were given breast health kits containing an instructional video, printed educational materials, a miniature lump model, and BSE skill checks. Before using the kits and 30 days later they were tested on measures of BSE proficiency and knowledge about breast cancer. Results indicate that the self-instruction programs had significant and positive impacts on the two BSE proficiency measures: skill demonstrations (t = 7.32, p < 0.0001) and lump detection using a simulation model (t = 4.23, p < 0.0001). Knowledge about breast cancer scores also improved from pretest to posttest. Implications for cancer nurses and direct outcomes from the research including newly designed instructional media materials are discussed.

Patient factors associated with breast cancer screening among older women

OBJECTIVES

To identify patient factors that influence physicians' decisions to recommend screening mammograms for older women.

DESIGN

A cross-sectional survey including clinical case vignettes.

PARTICIPANTS

Random sample of Massachusetts internists, obstetrician/gynecologists, family/general practice physicians, and geriatricians.

OUTCOME MEASURE

Proportion of screening mammograms recommended for women in different versions of each case vignette.

RESULTS

A total of 482 (65%) of the eligible participants responded to a mailed survey of questions about breast cancer screening practices, attitudes toward ACS guidelines, and four clinical vignettes. Vignettes tested the impact of patient's age, cognitive function, nursing home residence, functional limitations, and comorbidity on the physician's decision to recommend a mammogram. Ninety-four percent of physicians reported often performing periodic clinical breast exams and mammograms for women aged 65 to 74. For women aged 75 to 84, 89% of physicians reported often performing periodic clinical breast exams, and 79% recommend mammograms. Only 48% strongly agreed with ACS guidelines for annual mammography for women over 65. Age, dementia, and nursing home residence were patient factors associated with decreased mammogram use, but limited mobility and chronic medical problems were not. Physicians were more likely to recommend a mammogram for a woman aged 65 to 74 than for a woman 75 to 84. (P = .002) Physicians were more likely to recommend a mammogram for a woman without dementia than for a woman with mild dementia (P < .05) and for a woman living with her daughter than a for a woman living in a nursing home (P < .001).

CONCLUSIONS

Age older than 75, mild dementia, and nursing home residence are factors that negatively influence physicians' decisions to recommend mammography. Presence of chronic medical problems and functional limitations do not. Physicians appear to be using implicit judgments about quality of life and age rather than life expectancy based on comorbidity to determine breast cancer screening practices.

The simultaneous analysis of patient, physician and group practice influences on annual mammography performance

The current study examined the relationship of several variables at the patient (n = 2780), physician (n = 166), and group practice (n = 45) levels for predicting receipt of annual mammography screening. Patient-level variables included constructs from the Triandis Model of Choice; physician-level variables included measures of barriers and receptivity to prevention, as well as demographic information. Hierarchical modeling demonstrated that variables at the patient and physician level reliably predict annual mammography screening, while frequency of screening did not vary across group practices after accounting for patient and physician variables. Patient-level predictors included social norms, perceived consequences and perceived barriers. The only physician-level predictor identified was annual mammography recommendation. These findings add to data which emphasize the importance of public education and social support in health maintenance activities.

Patterns of breast cancer care in the elderly

BACKGROUND

The elderly represent a large proportion of the women with breast cancer. However, there is a lack of information regarding breast cancer care in the elderly.

METHODS

A patient care evaluation survey for breast carcinoma was conducted by the Commission on Cancer of the American College of Surgeons for 1983 and 1990. Data were obtained from hospital tumor registries from all 50 states, Puerto Rico, and Canada. Information regarding presentation, diagnostics, staging, treatment, recurrence, and survival were analyzed. Comparisons were made between women 75 years and older and those younger than 75 years.

RESULTS

Included were 17,029 diagnosed with breast carcinoma during 1983 and 24,004 diagnosed during 1990. In 1983 and 1990, 20.4% and 23.4% of women, respectively, were 75 years or older. Fewer cancers were detected mammographically and needle localized biopsies were performed less often in the elderly. There was no difference in tumor location or histology. Stage at diagnosis appeared more advanced in the elderly. Most women regardless of age, underwent modified radical mastectomy. Of the elderly who did undergo breast conserving surgery in 1983 and 1990, 72% and 39%, respectively, did not receive radiation therapy. No difference was found in the local recurrence rates between the elderly and younger groups. In the elderly, 20% of deaths occurred from causes other than breast cancer. Overall disease specific survival was worse in the elderly but, when analyzed by stage, was significantly different for only certain stages.

CONCLUSIONS

There are several differences in the detection, diagnostic methods, stage at diagnosis, treatment approaches, and outcome of breast cancer in elderly women compared with younger women.

Mammography in older women: one-time and three-year adherence to guidelines

A survey examined self-reported mammography use in a convenience sample of 1,083 women 50 years of age and over. Relationships were examined between ever having mammography; 3-year adherence to mammography guidelines; the predisposing variables of attitudes, knowledge, health history factors, and selected demographics; and the enabling variables of income, health insurance, source of regular medical care, and type of regular physician. Logistic regression analysis for ever having a mammogram identified significant odds ratios (OR) > 1 (p < or = .05) for doctor recommendation for mammography (OR = 14.26), satisfaction with way of living (OR = 2.77), perceived benefits of mammography (OR = 1.35), and knowledge (OR = 1.21). Odds ratios < 1 were found for scaled variables of barriers and control (OR = .81 and .65, respectively). For 3-year adherence, significant odds ratios > 1 were annual Pap tests (OR = 3.36), willingness to pay > or = $50 for mammography (OR = 2.00), benefits (OR = 1.20), and knowledge (OR = 1.18). The odds ratio for control was significant at .85.

A program to increase breast and cervical cancer screening for Cambodian women in a midwestern community

OBJECTIVE

To determine local screening rates for breast and cervical cancer screening among Cambodian women older than 50 years of age who had used the health-care system, to compare these rates with those for non-Cambodian women, to identify barriers to screening among Cambodians, and to implement community screening.

MATERIAL AND METHODS

From review of medical records, cancer screening rates for 1 year among Cambodians (N = 57) were compared with rates for a matched non-Cambodian sample (N = 57). Southeast Asian focus groups identified barriers to screening as a basis for intervention. The intervention included community informational programs in the Cambodian language, group screening appointments, provision of transportation, use of female physicians and interpreters, and an informal clinic setting. Cancer screening rates were compared before and after the intervention.

RESULTS

Initial screening rates for Cambodians were significantly lower than for the non-Cambodians. Expressed barriers included lack of knowledge about cancer, shyness at physical examination, lack of transportation, fear of a large, technical medical center, and individual appointments. After the intervention, community screening rates were almost 5 times higher than at baseline.

CONCLUSION

The intervention was successful in overcoming organizational, economic, and cultural barriers to cancer screening among older Cambodian women in this setting.

Breast cancer control among the underserved--an overview

This paper explores barriers to the use of standard screening and breast cancer treatment that result in systematic differences in health outcomes. We review available data on individual, socioeconomic, and health system determinants of access to standard breast cancer care, including screening, diagnostic, and treatment services. Based on this review, we discuss the combination of factors which result in underservice. We argue that a broad framework which considers health system and social class as well as individual factors is useful for analyzing how structures of health care delivery tend to provide less than standard care to women who are older, have less income, or are less educated, black, or Hispanic. Data collection efforts which do not include structural and socioeconomic variables may result in an incomplete or misleading understanding of the determinants of underservice. These factors also need to be considered in the design and evaluation of public health policies and interventions meant to ameliorate the effects of underservice.

Barriers to cancer screening

Many barriers to cancer screening have been summarized and discussed. Barriers have been documented in all patient populations, but some groups such as ethnic minorities and the elderly face unique barriers. The barriers to cancer screening, are multifactorial, but much of the responsibility for change must lie with health care providers and the health care delivery industry. This is not to free the patient of all responsibility, but some significant barriers are beyond their direct control. Take, for example, socioeconomic status, disease knowledge, and culturally related perceptions and myths about cancer detection and treatment. The health care industry must do a better job identifying and overcoming these barriers. The significant effects of provider counseling and advice must not be underestimated. Patients must first be advised, and then further actions must be taken if they reject the screening advice. Did they refuse adherence to recommendations because they do not view themselves as susceptible, because of overwhelming personal barriers, or because of a fatalistic attitude toward cancer detection and treatment? If that is the case, physicians and health care institutions must attempt to change perceptions, educate, and personalize the message so that patients accept their disease susceptibility [table: see text]. Multiple patient and provider risk factors have been identified that can be used to target patients particularly at high risk for inadequate cancer screening and providers at high risk for performing inadequate screening. Research has clearly demonstrated the effectiveness of interventions to improve tracking of patient and physician compliance with screening recommendations. Further research is needed to show the impact of managed-care penetration and payer status on screening efforts, and incentive schemes need to be tested that reward institutions and third-party payers who develop uniform standards and procedures for cancer screening. The greatest responsibility lies with medical and health care institutions and those who determine the priorities of these institutions. Patient and physician barriers to mass cancer screening can be addressed by institutional support. If the quality of care delivered by providers, group practices, managed-care organizations, and HMOs is assessed with priority given to the regularity and consistency with which basic screening procedures are performed, cancer screening will undoubtedly receive greater attention in the clinic. Medical institutions must collaborate to develop standards for cancer screening with attention to the cost-effectiveness of various screening techniques to determine how limited resources can best be spent in cancer control. Such efforts should keep in mind "that a very small change implemented over a broad population may have a greater effect in absolute numbers than a large level of change applied in a small segment of the population."

Physician-reported determinants of screening mammography in older women: the impact of physician and practice characteristics

OBJECTIVE

Despite having markedly higher breast cancer risk, compliance of older women with screening mammography has been poor. This study was undertaken to determine which physician and patient practice characteristics were associated with high self-reported mammography referral rates for older women.

METHODS

Primary care physicians (n = 129) from three socioeconomically diverse communities in Los Angeles were surveyed. Agreement with annual screening and self-reported referral rates were assessed for two groups of women, those 65 to 74 years of age and those 75 years and older. Screening outcomes were compared with physician and patient practice characteristics using bivariate and multivariate techniques.

RESULTS

Although 73% of physicians agreed with annual screening of women aged 65 to 74 years, only 24% of physicians reported actually screening most women seen in this age group. Similarly, 57% of physicians agreed that women age 75 years and older should be screened annually, but only 21% reported recommending mammograms for most women seen in this age group. In multivariate analysis, white physicians (adjusted OR = 9.1), younger physicians (adjusted OR = 3.85), and those who used the American Cancer Society's low cost mammography projects (adjusted OR = 5.01) were more likely to report screening the majority of women seen.

DISCUSSION

This study suggests that although physicians' intentions to screen older women may be relatively high, a gap exists between intentions and what is reported to be accomplished in practice. Race/ethnicity and physician specialty were the two strongest predictors of high self-reported referral rates, suggesting that targeted interventions may be useful.

Implementing annual cancer screenings for elderly women

1. Secondary prevention, in the form of regular screenings, is the most effective approach to early detection of breast and cervical cancer. 2. Women over 50 years of age are at increased risk for breast and cervical cancer, yet a disproportionate number of these women do not receive screening for breast and cervical cancer. 3. A protocol, in the form of a flowchart, can be used as an assessment tool to determine a client's status, needs, progress, and direction for future health care.

A survey of physician beliefs and self-reported practices concerning screening for early detection of cancer

Cancer is the second leading cause of death in the United States. Early detection of cancer greatly improves 5-year survival for many sites, and in 1980 the American Cancer Society (ACS) published recommendations for performing cancer screening with the goal of promoting early cancer detection in asymptomatic persons. This cross-sectional survey examined beliefs and practices related to six cancer screening tests and procedures in a group of 68 primary care physicians in a multi-specialty group practice in Houston, Texas. Constructs from the Health Belief Model and Social Cognitive Theory were used to identify factors that might influence performance of cancer screening. Physicians in this study reported greater compliance with ACS recommendations for performance than has been found in other studies, and there is an indication that some screening tests may be performed even when not indicated based on age-specific criteria. Respondents reported performing digital rectal examination, stool occult blood testing, and sigmoidoscopy more frequently in men than in women. No belief factor emerged as being associated with performance of all screening procedures, and associations that were noted for some procedures were not consistent across patient age and gender groups. Some possible directions for further research and development of programs to promote the appropriate and cost effective use of cancer screening are physician education to include information about age and gender appropriate guidelines for screening and opportunities for skills training and practice workshops for some procedures.