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Panis C, Lemos B. Pesticide exposure and increased breast cancer risk in women population studies. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 933:172988. [PMID: 38710391 DOI: 10.1016/j.scitotenv.2024.172988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/08/2024]
Abstract
Pesticide exposure is emerging as a risk factor for various human diseases. Breast cancer (BC) is a multifactorial disease with known genetic and non-genetic risk factors. Most BC cases are attibutable to non-genetic risk factors, with a history of adverse environmental exposures playing a significant role. Pesticide exposure can occur at higher levels in female populations participating in rural activities such as spraying of pesticides in the field, unprotected handling of pesticides at home, and washing of contaminated clothes. Exposure can also be significant in the drinking water of certain populations. Here, we reviewed the literature on women's exposure to pesticides and the risk of BC. We summarize the main links between pesticide exposure and BC and discuss the role of dose and exposure context, as well as potential mechanisms of toxicity. Overall, reports reviewed here have documented stronger associations between higher levels of exposure and BC risk, including documenting direct and acute pesticide exposure in certain female populations. However, discrepancies among studies regarding dose and mode of exposure may result in misunderstandings about the risks posed by pesticide exposure. Plausible mechanisms linking pesticides to breast cancer risk include their impacts as endocrine disruptors, as well as their roles as genotoxic agents, and modulators of the epigenome. Besides establishing links between pesticide exposure and breast cancer, the literature also highlights the critical need to understand the routes and doses of women's exposure to pesticides and the specific associations and mechanisms that are determinants of disease etiology and prognosis.
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Affiliation(s)
- Carolina Panis
- R Ken Coit College of Pharmacy, The University of Arizona, Tucson, AZ, United States; Laboratory of Tumor Biology, State University of Western Paraná, UNIOESTE, Francisco Beltrão, Paraná, Brazil.
| | - Bernardo Lemos
- R Ken Coit College of Pharmacy, The University of Arizona, Tucson, AZ, United States; Coit Center for Longevity and Neurotherapeutics, The University of Arizona, Tucson, AZ, United States.
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Coles CE, Earl H, Anderson BO, Barrios CH, Bienz M, Bliss JM, Cameron DA, Cardoso F, Cui W, Francis PA, Jagsi R, Knaul FM, McIntosh SA, Phillips KA, Radbruch L, Thompson MK, André F, Abraham JE, Bhattacharya IS, Franzoi MA, Drewett L, Fulton A, Kazmi F, Inbah Rajah D, Mutebi M, Ng D, Ng S, Olopade OI, Rosa WE, Rubasingham J, Spence D, Stobart H, Vargas Enciso V, Vaz-Luis I, Villarreal-Garza C. The Lancet Breast Cancer Commission. Lancet 2024; 403:1895-1950. [PMID: 38636533 DOI: 10.1016/s0140-6736(24)00747-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 12/18/2023] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Affiliation(s)
| | - Helena Earl
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Benjamin O Anderson
- Global Breast Cancer Initiative, World Health Organisation and Departments of Surgery and Global Health Medicine, University of Washington, Seattle, WA, USA
| | - Carlos H Barrios
- Oncology Research Center, Hospital São Lucas, Porto Alegre, Brazil
| | - Maya Bienz
- Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust, London, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - David A Cameron
- Institute of Genetics and Cancer and Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - Wanda Cui
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Prudence A Francis
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Reshma Jagsi
- Emory University School of Medicine, Atlanta, GA, USA
| | - Felicia Marie Knaul
- Institute for Advanced Study of the Americas, University of Miami, Miami, FL, USA; Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA; Tómatelo a Pecho, Mexico City, Mexico
| | - Stuart A McIntosh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Kelly-Anne Phillips
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | | | | | - Jean E Abraham
- Department of Oncology, University of Cambridge, Cambridge, UK
| | | | | | - Lynsey Drewett
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | | | - Farasat Kazmi
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | | | - Dianna Ng
- Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Szeyi Ng
- The Institute of Cancer Research, London, UK
| | | | - William E Rosa
- Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | | | | | | | | | | | - Cynthia Villarreal-Garza
- Breast Cancer Center, Hospital Zambrano Hellion TecSalud, Tecnologico de Monterrey, Monterrey, Mexico
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Dunlop KLA, Singh N, Robbins HA, Zahed H, Johansson M, Rankin NM, Cust AE. Implementation considerations for risk-tailored cancer screening in the population: A scoping review. Prev Med 2024; 181:107897. [PMID: 38378124 PMCID: PMC11106520 DOI: 10.1016/j.ypmed.2024.107897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Risk-tailored screening has emerged as a promising approach to optimise the balance of benefits and harms of existing population cancer screening programs. It tailors screening (e.g., eligibility, frequency, interval, test type) to individual risk rather than the current one-size-fits-all approach of most organised population screening programs. However, the implementation of risk-tailored cancer screening in the population is challenging as it requires a change of practice at multiple levels i.e., individual, provider, health system levels. This scoping review aims to synthesise current implementation considerations for risk-tailored cancer screening in the population, identifying barriers, facilitators, and associated implementation outcomes. METHODS Relevant studies were identified via database searches up to February 2023. Results were synthesised using Tierney et al. (2020) guidance for evidence synthesis of implementation outcomes and a multilevel framework. RESULTS Of 4138 titles identified, 74 studies met the inclusion criteria. Most studies in this review focused on the implementation outcomes of acceptability, feasibility, and appropriateness, reflecting the pre-implementation stage of most research to date. Only six studies included an implementation framework. The review identified consistent evidence that risk-tailored screening is largely acceptable across population groups, however reluctance to accept a reduction in screening frequency for low-risk informed by cultural norms, presents a major barrier. Limited studies were identified for cancer types other than breast cancer. CONCLUSIONS Implementation strategies will need to address alternate models of delivery, education of health professionals, communication with the public, screening options for people at low risk of cancer, and inequity in outcomes across cancer types.
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Affiliation(s)
- Kate L A Dunlop
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia; Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.
| | - Nehal Singh
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Hilary A Robbins
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Hana Zahed
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Mattias Johansson
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Nicole M Rankin
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia; Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Anne E Cust
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia; Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
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Laza C, Niño de Guzmán E, Gea M, Plazas M, Posso M, Rué M, Castells X, Román M. "For and against" factors influencing participation in personalized breast cancer screening programs: a qualitative systematic review until March 2022. Arch Public Health 2024; 82:23. [PMID: 38389068 PMCID: PMC10882761 DOI: 10.1186/s13690-024-01248-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/05/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Personalized breast cancer screening is a novel strategy that estimates individual risk based on age, breast density, family history of breast cancer, personal history of benign breast lesions, and polygenic risk. Its goal is to propose personalized early detection recommendations for women in the target population based on their individual risk. Our aim was to synthesize the factors that influence women's decision to participate in personalized breast cancer screening, from the perspective of women and health care professionals. METHODS Systematic review of qualitative evidence on factors influencing participation in personalized Breast Cancer Screening. We searched in Medline, Web of science, Scopus, EMBASE, CINAHL and PsycINFO for qualitative and mixed methods studies published up to March 2022. Two reviewers conducted study selection and extracted main findings. We applied the best-fit framework synthesis and adopted the Multilevel influences on the cancer care continuum model for analysis. After organizing initial codes into the seven levels of the selected model, we followed thematic analysis and developed descriptive and analytical themes. We assessed the methodological quality with the Critical Appraisal Skills Program tool. RESULTS We identified 18 studies published between 2017 and 2022, conducted in developed countries. Nine studies were focused on women (n = 478) and in four studies women had participated in a personalized screening program. Nine studies focused in health care professionals (n = 162) and were conducted in primary care and breast cancer screening program settings. Factors influencing women's decision to participate relate to the women themselves, the type of program (personalized breast cancer screening) and perspective of health care professionals. Factors that determined women participation included persistent beliefs and insufficient knowledge about breast cancer and personalized screening, variable psychological reactions, and negative attitudes towards breast cancer risk estimates. Other factors against participation were insufficient health care professionals knowledge on genetics related to breast cancer and personalized screening process. The factors that were favourable included the women's perceived benefits for themselves and the positive impact on health systems. CONCLUSION We identified the main factors influencing women's decisions to participate in personalized breast cancer screening. Factors related to women, were the most relevant negative factors. A future implementation requires improving health literacy for women and health care professionals, as well as raising awareness of the strategy in society.
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Affiliation(s)
- Celmira Laza
- Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
- Biomedical Research Institute of Lleida Fundació Dr. Pifarré (IRBLleida), Lleida, Spain
| | - Ena Niño de Guzmán
- Cancer Prevention and Control Program, Institut Català d' Oncologia, Barcelona, Spain
| | - Montserrat Gea
- Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
- Biomedical Research Institute of Lleida Fundació Dr. Pifarré (IRBLleida), Lleida, Spain
| | - Merideidy Plazas
- Cochrane Associated Center- University Foundation of Health Sciences, Bogotá, Colombia
| | - Margarita Posso
- Department of Epidemiology and Evaluation, Hospital del Mar Research Institute, Barcelona, Spain
| | - Montserrat Rué
- Biomedical Research Institute of Lleida Fundació Dr. Pifarré (IRBLleida), Lleida, Spain
- Basic Medical Sciences, University of Lleida, Lleida, Spain
| | - Xavier Castells
- Department of Epidemiology and Evaluation, Hospital del Mar Research Institute, Barcelona, Spain
| | - Marta Román
- Department of Epidemiology and Evaluation, Hospital del Mar Research Institute, Barcelona, Spain.
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McCarthy AM, Fernandez Perez C, Beidas RS, Bekelman JE, Blumenthal D, Mack E, Bauer AM, Ehsan S, Conant EF, Wheeler BC, Guerra CE, Nunes LW, Gabriel P, Doucette A, Wileyto EP, Buttenheim AM, Asch DA, Rendle KA, Shelton RC, Fayanju OM, Ware S, Plag M, Hyland S, Gionta T, Shulman LN, Schnoll R. Protocol for a pragmatic stepped wedge cluster randomized clinical trial testing behavioral economic implementation strategies to increase supplemental breast MRI screening among patients with extremely dense breasts. Implement Sci 2023; 18:65. [PMID: 38001506 PMCID: PMC10668465 DOI: 10.1186/s13012-023-01323-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Increased breast density augments breast cancer risk and reduces mammography sensitivity. Supplemental breast MRI screening can significantly increase cancer detection among women with dense breasts. However, few women undergo this exam, and screening is consistently lower among racially minoritized populations. Implementation strategies informed by behavioral economics ("nudges") can promote evidence-based practices by improving clinician decision-making under conditions of uncertainty. Nudges directed toward clinicians and patients may facilitate the implementation of supplemental breast MRI. METHODS Approximately 1600 patients identified as having extremely dense breasts after non-actionable mammograms, along with about 1100 clinicians involved with their care at 32 primary care or OB/GYN clinics across a racially diverse academically based health system, will be enrolled. A 2 × 2 randomized pragmatic trial will test nudges to patients, clinicians, both, or neither to promote supplemental breast MRI screening. Before implementation, rapid cycle approaches informed by clinician and patient experiences and behavioral economics and health equity frameworks guided nudge design. Clinicians will be clustered into clinic groups based on existing administrative departments and care patterns, and these clinic groups will be randomized to have the nudge activated at different times per a stepped wedge design. Clinicians will receive nudges integrated into the routine mammographic report or sent through electronic health record (EHR) in-basket messaging once their clinic group (i.e., wedge) is randomized to receive the intervention. Independently, patients will be randomized to receive text message nudges or not. The primary outcome will be defined as ordering or scheduling supplemental breast MRI. Secondary outcomes include MRI completion, cancer detection rates, and false-positive rates. Patient sociodemographic information and clinic-level variables will be examined as moderators of nudge effectiveness. Qualitative interviews conducted at the trial's conclusion will examine barriers and facilitators to implementation. DISCUSSION This study will add to the growing literature on the effectiveness of behavioral economics-informed implementation strategies to promote evidence-based interventions. The design will facilitate testing the relative effects of nudges to patients and clinicians and the effects of moderators of nudge effectiveness, including key indicators of health disparities. The results may inform the introduction of low-cost, scalable implementation strategies to promote early breast cancer detection. TRIAL REGISTRATION ClinicalTrials.gov NCT05787249. Registered on March 28, 2023.
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Affiliation(s)
- Anne Marie McCarthy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA.
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA.
| | | | - Rinad S Beidas
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Justin E Bekelman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Daniel Blumenthal
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth Mack
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna-Marika Bauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah Ehsan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily F Conant
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Carmen E Guerra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Linda W Nunes
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter Gabriel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Abigail Doucette
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - E Paul Wileyto
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Alison M Buttenheim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Rachel C Shelton
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Oluwadamilola M Fayanju
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Sue Ware
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
| | - Martina Plag
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Hyland
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tracy Gionta
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lawrence N Shulman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
| | - Robert Schnoll
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA, USA
- Center for Interdisciplinary Research On Nicotine Addiction, University of Pennsylvania, Philadelphia, PA, USA
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Blakeslee SB, Gunn CM, Parker PA, Fagerlin A, Battaglia T, Bevers TB, Bandos H, McCaskill-Stevens W, Kennedy JW, Holmberg C. Talking numbers: how women and providers use risk scores during and after risk counseling - a qualitative investigation from the NRG Oncology/NSABP DMP-1 study. BMJ Open 2023; 13:e073138. [PMID: 37984961 PMCID: PMC10660821 DOI: 10.1136/bmjopen-2023-073138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 09/29/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVES Little research exists on how risk scores are used in counselling. We examined (a) how Breast Cancer Risk Assessment Tool (BCRAT) scores are presented during counselling; (b) how women react and (c) discuss them afterwards. DESIGN Consultations were video-recorded and participants were interviewed after the consultation as part of the NRG Oncology/National Surgical Adjuvant Breast and Bowel Project Decision-Making Project 1 (NSABP DMP-1). SETTING Two NSABP DMP-1 breast cancer care centres in the USA: one large comprehensive cancer centre serving a high-risk population and an academic safety-net medical centre in an urban setting. PARTICIPANTS Thirty women evaluated for breast cancer risk and their counselling providers were included. METHODS Participants who were identified as at increased risk of breast cancer were recruited to participate in qualitative study with a video-recorded consultation and subsequent semi-structured interview that included giving feedback and input after viewing their own consultation. Consultation videos were summarised jointly and inductively as a team.tThe interview material was searched deductively for text segments that contained the inductively derived themes related to risk assessment. Subgroup analysis according to demographic variables such as age and Gail score were conducted, investigating reactions to risk scores and contrasting and comparing them with the pertinent video analysis data. From this, four descriptive categories of reactions to risk scores emerged. The descriptive categories were clearly defined after 19 interviews; all 30 interviews fit principally into one of the four descriptive categories. RESULTS Risk scores were individualised and given meaning by providers through: (a) presenting thresholds, (b) making comparisons and (c) emphasising or minimising the calculated risk. The risk score information elicited little reaction from participants during consultations, though some added to, agreed with or qualified the provider's information. During interviews, participants reacted to the numbers in four primary ways: (a) engaging easily with numbers; (b) expressing greater anxiety after discussing the risk score; (c) accepting the risk score and (d) not talking about the risk score. CONCLUSIONS Our study highlights the necessity that patients' experiences must be understood and put into relation to risk assessment information to become a meaningful treatment decision-making tool, for instance by categorising patients' information engagement into types. TRIAL REGISTRATION NUMBER NCT01399359.
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Affiliation(s)
- Sarah B Blakeslee
- Research Group: Prevention, Integrative Medicine and Health Promotion in Pediatrics, Department of Pediatrics, Division of Oncology and Hematology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christine M Gunn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Cancer Center, Dartmouth College, Hanover and Lebanon, New Hampshire, USA
| | - Patricia A Parker
- Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah, USA
| | - Tracy Battaglia
- Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Therese B Bevers
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hanna Bandos
- NRG Oncology SDMC, and the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Worta McCaskill-Stevens
- Community Oncology and Prevention Trials Research Group, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, UK
| | - Jennifer W Kennedy
- Institute of Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christine Holmberg
- Institute of Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
- Institute of Social Medicine and Epidemiology, Brandenburg Medical School Theodor Fontane, Brandenburg/Havel, Germany
- Faculty of Health Sciences, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
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Manna EDF, Serrano D, Aurilio G, Bonanni B, Lazzeroni M. Chemoprevention and Lifestyle Modifications for Risk Reduction in Sporadic and Hereditary Breast Cancer. Healthcare (Basel) 2023; 11:2360. [PMID: 37628558 PMCID: PMC10454363 DOI: 10.3390/healthcare11162360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023] Open
Abstract
Female breast cancer is the most commonly diagnosed malignancy worldwide. Risk assessment helps to identify women at increased risk of breast cancer and allows the adoption of a comprehensive approach to reducing breast cancer incidence through personalized interventions, including lifestyle modification, chemoprevention, intensified surveillance with breast imaging, genetic counseling, and testing. Primary prevention means acting on modifiable risk factors to reduce breast cancer occurrence. Chemoprevention with tamoxifen, raloxifene, anastrozole, and exemestane has already shown benefits in decreasing breast cancer incidence in women at an increased risk for breast cancer. For healthy women carrying BRCA 1 or BRCA 2 pathogenic/likely pathogenic (P/LP) germline variants, the efficacy of chemoprevention is still controversial. Adopting chemoprevention strategies and the choice among agents should depend on the safety profile and risk-benefit ratio. Unfortunately, the uptake of these agents has been low. Lifestyle modifications can reduce breast cancer incidence, and the recommendations for BRCA 1 or BRCA 2 P/LP germline variant carriers are comparable to the general population. This review summarizes the most recent evidence regarding the efficacy of chemoprevention and lifestyle interventions in women with sporadic and hereditary breast cancer.
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Affiliation(s)
- Eliza Del Fiol Manna
- Division of Cancer Prevention and Genetics, IEO European Institute of Oncology IRCCS, 20141 Milan, Italy; (D.S.); (G.A.); (B.B.); (M.L.)
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Archer S, Donoso FS, Carver T, Yue A, Cunningham AP, Ficorella L, Tischkowitz M, Easton DF, Antoniou AC, Emery J, Usher-Smith J, Walter FM. Exploring the barriers to and facilitators of implementing CanRisk in primary care: a qualitative thematic framework analysis. Br J Gen Pract 2023:BJGP.2022.0643. [PMID: 37308304 PMCID: PMC10285688 DOI: 10.3399/bjgp.2022.0643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/27/2023] [Accepted: 02/28/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND The CanRisk tool enables the collection of risk factor information and calculation of estimated future breast cancer risks based on the multifactorial Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) model. Despite BOADICEA being recommended in National Institute for Health and Care Excellence (NICE) guidelines and CanRisk being freely available for use, the CanRisk tool has not yet been widely implemented in primary care. AIM To explore the barriers to and facilitators of the implementation of the CanRisk tool in primary care. DESIGN AND SETTING A multi-methods study was conducted with primary care practitioners (PCPs) in the East of England. METHOD Participants used the CanRisk tool to complete two vignette-based case studies; semi-structured interviews gained feedback about the tool; and questionnaires collected demographic details and information about the structural characteristics of the practices. RESULTS Sixteen PCPs (eight GPs and eight nurses) completed the study. The main barriers to implementation included: time needed to complete the tool; competing priorities; IT infrastructure; and PCPs' lack of confidence and knowledge to use the tool. Main facilitators included: easy navigation of the tool; its potential clinical impact; and the increasing availability of and expectation to use risk prediction tools. CONCLUSION There is now a greater understanding of the barriers and facilitators that exist when using CanRisk in primary care. The study has highlighted that future implementation activities should focus on reducing the time needed to complete a CanRisk calculation, integrating the CanRisk tool into existing IT infrastructure, and identifying appropriate contexts in which to conduct a CanRisk calculation. PCPs may also benefit from information about cancer risk assessment and CanRisk-specific training.
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Affiliation(s)
- Stephanie Archer
- Department of Public Health and Primary Care, Department of Psychology
- Department of Public Health and Primary Care
- Department of Public Health and Primary Care
- Department of Public Health and Primary Care
- Department of Public Health and Primary Care
- Department of Public Health and Primary Care
- Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre
- Department of Public Health and Primary Care
- Department of Public Health and Primary Care, University of Cambridge, Cambridge
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Australia
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Wolfson Institute of Population Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Francisca Stutzin Donoso
- Department of Public Health and Primary Care, Department of Psychology
- Department of Public Health and Primary Care
- Department of Public Health and Primary Care
- Department of Public Health and Primary Care
- Department of Public Health and Primary Care
- Department of Public Health and Primary Care
- Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre
- Department of Public Health and Primary Care
- Department of Public Health and Primary Care, University of Cambridge, Cambridge
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Australia
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Wolfson Institute of Population Health, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
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Morrell BL, Morrell MB, Ball JA, Ochoa AC, Seewaldt VL. Disparities in the use of screening breast magnetic resonance imaging persist in Louisiana after the Affordable Care Act: A question of access, policy, institutional support, or something else? Cancer 2023; 129:829-833. [PMID: 36632769 DOI: 10.1002/cncr.34605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/31/2022] [Accepted: 11/28/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Louisiana continues to have one of the highest breast cancer mortality rates in the nation, and Black women are disproportionally affected. Louisiana has made advances in improving access to breast cancer screening through the expansion of Medicaid. There remains, however, broad underuse of advanced imaging technology such as screening breast magnetic resonance imaging (MRI), particularly for Black women. METHODS Breast MRI has been proven to be very sensitive for the early detection of breast cancer in women at high risk. MRI is more sensitive than mammography for aggressive, invasive breast cancer types, which disproportionally affect Black women. Here the authors identify potential barriers to breast MRI screening in Black women, propose strategies to address disparities in access, and advocate for specific recommendations for change. RESULTS Cost was identified as one of the greatest barriers to screening breast MRI. The authors propose implementation of cost-saving, abbreviated protocols to address cost along with lobbying for further expansion of the Affordable Care Act (ACA) to include coverage for screening breast MRI. In addition, addressing gaps in communication and knowledge and facilitating providers' ability to readily identify women who might benefit from MRI could be particularly impactful for high-risk Black women in Louisiana communities. CONCLUSIONS Since the adoption of the ACA in Louisiana, Black women have continued to have disproportionally high breast cancer mortality rates. This persistent disparity provides evidence that additional change is needed. This change should include exploring innovative ways to make advanced imaging technology such as breast MRI more accessible and expanding research to specifically address community and culturally specific barriers.
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Affiliation(s)
- Brooke L Morrell
- Stanley S. Scott Cancer Center, Louisiana State University, New Orleans, Louisiana, USA
| | - Mignonne B Morrell
- Stanley S. Scott Cancer Center, Louisiana State University, New Orleans, Louisiana, USA
| | - Jane A Ball
- Stanley S. Scott Cancer Center, Louisiana State University, New Orleans, Louisiana, USA
| | - Augusto C Ochoa
- Stanley S. Scott Cancer Center, Louisiana State University, New Orleans, Louisiana, USA
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10
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Taylor LC, Law K, Hutchinson A, Dennison RA, Usher-Smith JA. Acceptability of risk stratification within population-based cancer screening from the perspective of healthcare professionals: A mixed methods systematic review and recommendations to support implementation. PLoS One 2023; 18:e0279201. [PMID: 36827432 PMCID: PMC9956883 DOI: 10.1371/journal.pone.0279201] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 12/01/2022] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Introduction of risk stratification within population-based cancer screening programmes has the potential to optimise resource allocation by targeting screening towards members of the population who will benefit from it most. Endorsement from healthcare professionals is necessary to facilitate successful development and implementation of risk-stratified interventions. Therefore, this review aims to explore whether using risk stratification within population-based cancer screening programmes is acceptable to healthcare professionals and to identify any requirements for successful implementation. METHODS We searched four electronic databases from January 2010 to October 2021 for quantitative, qualitative, or primary mixed methods studies reporting healthcare professional and/or other stakeholder opinions on acceptability of risk-stratified population-based cancer screening. Quality of the included studies was assessed using the Mixed Methods Appraisal Tool. Data were analysed using the Joanna Briggs Institute convergent integrated approach to mixed methods analysis and mapped onto the Consolidated Framework for Implementation Research using a 'best fit' approach. PROSPERO record CRD42021286667. RESULTS A total of 12,039 papers were identified through the literature search and seven papers were included in the review, six in the context of breast cancer screening and one considering screening for ovarian cancer. Risk stratification was broadly considered acceptable, with the findings covering all five domains of the framework: intervention characteristics, outer setting, inner setting, characteristics of individuals, and process. Across these five domains, key areas that were identified as needing further consideration to support implementation were: a need for greater evidence, particularly for de-intensifying screening; resource limitations; need for staff training and clear communication; and the importance of public involvement. CONCLUSIONS Risk stratification of population-based cancer screening programmes is largely acceptable to healthcare professionals, but support and training will be required to successfully facilitate implementation. Future research should focus on strengthening the evidence base for risk stratification, particularly in relation to reducing screening frequency among low-risk cohorts and the acceptability of this approach across different cancer types.
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Affiliation(s)
- Lily C. Taylor
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Katie Law
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Alison Hutchinson
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Rebecca A. Dennison
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Juliet A. Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
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11
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Usher-Smith JA, Hindmarch S, French DP, Tischkowitz M, Moorthie S, Walter FM, Dennison RA, Stutzin Donoso F, Archer S, Taylor L, Emery J, Morris S, Easton DF, Antoniou AC. Proactive breast cancer risk assessment in primary care: a review based on the principles of screening. Br J Cancer 2023; 128:1636-1646. [PMID: 36737659 PMCID: PMC9897164 DOI: 10.1038/s41416-023-02145-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
In the UK, the National Institute for Health and Care Excellence (NICE) recommends that women at moderate or high risk of breast cancer be offered risk-reducing medication and enhanced breast screening/surveillance. In June 2022, NICE withdrew a statement recommending assessment of risk in primary care only when women present with concerns. This shift to the proactive assessment of risk substantially changes the role of primary care, in effect paving the way for a primary care-based screening programme to identify those at moderate or high risk of breast cancer. In this article, we review the literature surrounding proactive breast cancer risk assessment within primary care against the consolidated framework for screening. We find that risk assessment for women under 50 years currently satisfies many of the standard principles for screening. Most notably, there are large numbers of women at moderate or high risk currently unidentified, risk models exist that can identify those women with reasonable accuracy, and management options offer the opportunity to reduce breast cancer incidence and mortality in that group. However, there remain a number of uncertainties and research gaps, particularly around the programme/system requirements, that need to be addressed before these benefits can be realised.
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Affiliation(s)
- Juliet A. Usher-Smith
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Hindmarch
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - David P. French
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Marc Tischkowitz
- grid.5335.00000000121885934Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Sowmiya Moorthie
- grid.5335.00000000121885934PHG Foundation, University of Cambridge, Cambridge, UK
| | - Fiona M. Walter
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Rebecca A. Dennison
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Francisca Stutzin Donoso
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Psychology, University of Cambridge, Cambridge, UK
| | - Lily Taylor
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jon Emery
- grid.1008.90000 0001 2179 088XCentre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, VIC Australia
| | - Stephen Morris
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Douglas F. Easton
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Antonis C. Antoniou
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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12
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Beidler LB, Kressin NR, Wormwood JB, Battaglia TA, Slanetz PJ, Gunn CM. Perceptions of Breast Cancer Risks Among Women Receiving Mammograph Screening. JAMA Netw Open 2023; 6:e2252209. [PMID: 36689223 PMCID: PMC9871800 DOI: 10.1001/jamanetworkopen.2022.52209] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/02/2022] [Indexed: 01/24/2023] Open
Abstract
Importance Breast density is an independent risk factor for breast cancer. Despite the proliferation of mandated written notifications about breast density following mammography, there is little understanding of how women perceive the relative breast cancer risk associated with breast density. Objective To assess women's perception of breast density compared with other breast cancer risks and explore their understanding of risk reduction. Design, Setting, and Participants This mixed-methods qualitative study used telephone surveys and semistructured interviews to investigate perceptions about breast cancer risk among a nationally representative, population-based sample of women. Eligible study participants were aged 40 to 76 years, reported having recently undergone mammography, had no history of prior breast cancer, and had heard of breast density. Survey participants who had been informed of their personal breast density were invited for a qualitative interview. Survey administration spanned July 1, 2019, to April 30, 2020, with 2306 women completing the survey. Qualitative interviews were conducted from February 1 to May 30, 2020. Main Outcomes and Measures Respondents compared the breast cancer risk associated with breast density with 5 other risk factors. Participants qualitatively described what they thought contributed to breast cancer risk and ways to reduce risk. Results Of the 2306 women who completed the survey, 1858 (166 [9%] Asian, 503 [27%] Black, 268 [14%] Hispanic, 792 [43%] White, and 128 [7%] other race or ethnicity; 358 [19%] aged 40-49 years, 906 [49%] aged 50-64 years, and 594 [32%] aged ≥65 years) completed the revised risk perception questions and were included in the analysis. Half of respondents thought breast density to be a greater risk than not having children (957 [52%]), having more than 1 alcoholic drink per day (975 [53%]), or having a prior breast biopsy (867 [48%]). Most respondents felt breast density was a lesser risk than having a first-degree relative with breast cancer (1706 [93%]) or being overweight or obese (1188 [65%]). Of the 61 women who were interviewed, 6 (10%) described breast density as contributing to breast cancer risk, and 43 (70%) emphasized family history as a breast cancer risk factor. Of the interviewed women, 17 (28%) stated they did not know whether it was possible to reduce their breast cancer risk. Conclusions and Relevance In this qualitative study of women of breast cancer screening age, family history was perceived as the primary breast cancer risk factor. Most interviewees did not identify breast density as a risk factor and did not feel confident about actions to mitigate breast cancer risk. Comprehensive education about breast cancer risks and prevention strategies is needed.
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Affiliation(s)
- Laura B. Beidler
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Nancy R. Kressin
- Section of General Internal Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts
| | | | - Tracy A. Battaglia
- Section of General Internal Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts
| | - Priscilla J. Slanetz
- Department of Radiology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Christine M. Gunn
- Dartmouth Cancer Center, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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13
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Devi G, Fish L, Bennion A, Sawin G, Weaver S, Tran A. Assessing Knowledge and Barriers at the Primary Care Provider Level that Contribute to Disparities in Inflammatory Breast Cancer Diagnosis and Treatment. RESEARCH SQUARE 2022:rs.3.rs-2302308. [PMID: 36523410 PMCID: PMC9753779 DOI: 10.21203/rs.3.rs-2302308/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Purpose The purpose of this study was to evaluate knowledge gaps and barriers related to diagnosis and care of inflammatory breast cancer (IBC), a rare but most lethal breast cancer subtype, amongst Primary Care Providers (PCP) as they are often the first point of contact when patients notice initial symptoms. Methods PCP participants within Duke University Health System, federally qualified health center, corporate employee health and community practices, nearby academic medical center, Duke physician assistant, and nurse leadership program alumni were first selected in a convenience sample (n=11) for semi-structured interviews (n=11). Based on these data, an online survey tool was developed and disseminated (n=78) to assess salient measures of IBC diagnosis, health disparity factors, referral and care coordination practices, COVID impact, and continued medical education (CME). Results PCP reported access to care and knowledge gaps in symptom recognition (mean = 3.3, range 1-7) as major barriers. Only 31% reported ever suspecting IBC in a patient. PCP (n=49) responded being challenged with referral delays in diagnostic imaging. Additionally, since the COVID-19 pandemic started, 63% reported breast cancer referral delays, and 33% reported diagnosing less breast cancer. PCP stated interest in CME in their practice for improved diagnosis and patient care, which included online (53%), lunch time or other in-service training (33%), patient and provider-facing websites (32%). Conclusions Challenges communicating rare cancer information, gaps in confidence in diagnosing IBC, and timely follow-up with patients and specialists underscores the need for developing PCP educational modules to improve guideline-concordant care.
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Affiliation(s)
| | | | | | | | | | - Anh Tran
- Duke University School of Medicine
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14
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Taylor G, McWilliams L, Woof VG, Evans DG, French DP. What are the views of three key stakeholder groups on extending the breast screening interval for low-risk women? A secondary qualitative analysis. Health Expect 2022; 25:3287-3296. [PMID: 36305519 PMCID: PMC9700144 DOI: 10.1111/hex.13637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/14/2022] [Accepted: 10/16/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION There is increasing interest in risk-stratified breast screening, whereby the prevention and early detection offers vary by a woman's estimated risk of breast cancer. To date, more focus has been directed towards high-risk screening pathways rather than considering women at lower risk, who may be eligible for extended screening intervals. This secondary data analysis aimed to compare the views of three key stakeholder groups on how extending screening intervals for low-risk women should be implemented and communicated as part of a national breast screening programme. METHODS Secondary data analysis of three qualitative studies exploring the views of distinct stakeholder groups was conducted. Interviews took place with 23 low-risk women (identified from the BC-Predict study) and 17 national screening figures, who were involved in policy-making and implementation. In addition, three focus groups and two interviews were conducted with 26 healthcare professionals. A multiperspective thematic analysis was conducted to identify similarities and differences between stakeholders. FINDINGS Three themes were produced: Questionable assumptions about negative consequences, highlighting how other stakeholders lack trust in how women are likely to understand extended screening intervals; Preserving the integrity of the programme, centring on decision-making and maintaining a positive reputation of breast screening and Negotiating a communication pathway highlighting communication expectations and public campaign importance. CONCLUSIONS A risk-stratified screening programme should consider how best to engage women assessed as having a low risk of breast cancer to ensure mutual trust, balance the practicality of change whilst ensuring acceptability, and carefully develop multilevel inclusive communication strategies. PATIENT AND PUBLIC CONTRIBUTION The research within this paper involved patient/public contributors throughout including study design and materials input.
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Affiliation(s)
- Grace Taylor
- School of Health Sciences, Manchester Centre of Health Psychology, Division of Psychology and Mental HealthUniversity of ManchesterManchesterUK
| | - Lorna McWilliams
- School of Health Sciences, Manchester Centre of Health Psychology, Division of Psychology and Mental HealthUniversity of ManchesterManchesterUK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science CentreCentral Manchester University Hospitals NHS Foundation TrustManchesterUK
| | - Victoria G. Woof
- School of Health Sciences, Manchester Centre of Health Psychology, Division of Psychology and Mental HealthUniversity of ManchesterManchesterUK
| | - D. Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science CentreCentral Manchester University Hospitals NHS Foundation TrustManchesterUK
- The Nightingale and Prevent Breast Cancer CentreManchester University NHS Foundation TrustManchesterUK
- Manchester Breast Centre, Manchester Cancer Research CentreUniversity of ManchesterManchesterUK
- Genomic Medicine, Division of Evolution and Genomic Sciences, St Mary's Hospital, Manchester University NHS Foundation TrustThe University of ManchesterManchesterUK
| | - David P. French
- School of Health Sciences, Manchester Centre of Health Psychology, Division of Psychology and Mental HealthUniversity of ManchesterManchesterUK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science CentreCentral Manchester University Hospitals NHS Foundation TrustManchesterUK
- Manchester Breast Centre, Manchester Cancer Research CentreUniversity of ManchesterManchesterUK
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15
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"It Will Lead You to Make Better Decisions about Your Health"-A Focus Group and Survey Study on Women's Attitudes towards Risk-Based Breast Cancer Screening and Personalised Risk Assessments. Curr Oncol 2022; 29:9181-9198. [PMID: 36547133 PMCID: PMC9776908 DOI: 10.3390/curroncol29120719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 11/22/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Singapore launched a population-based organised mammography screening (MAM) programme in 2002. However, uptake is low. A better understanding of breast cancer (BC) risk factors has generated interest in shifting from a one-size-fits-all to a risk-based screening approach. However, public acceptability of the change is lacking. Focus group discussions (FGD) were conducted with 54 women (median age 37.5 years) with no BC history. Eight online sessions were transcribed, coded, and thematically analysed. Additionally, we surveyed 993 participants in a risk-based MAM study on how they felt in anticipation of receiving their risk profiles. Attitudes towards MAM (e.g., fear, low perceived risk) have remained unchanged for ~25 years. However, FGD participants reported that they would be more likely to attend routine mammography after having their BC risks assessed, despite uncertainty and concerns about risk-based screening. This insight was reinforced by the survey participants reporting more positive than negative feelings before receiving their risk reports. There is enthusiasm in knowing personal disease risk but concerns about the level of support for individuals learning they are at higher risk for breast cancer. Our results support the empowering of Singaporean women with personal health information to improve MAM uptake.
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16
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Hawkins R, McWilliams L, Ulph F, Evans DG, French DP. Healthcare professionals' views following implementation of risk stratification into a national breast cancer screening programme. BMC Cancer 2022; 22:1058. [PMID: 36224549 PMCID: PMC9555254 DOI: 10.1186/s12885-022-10134-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/14/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background It is crucial to determine feasibility of risk-stratified screening to facilitate successful implementation. We introduced risk-stratification (BC-Predict) into the NHS Breast Screening Programme (NHSBSP) at three screening sites in north-west England from 2019 to 2021. The present study investigated the views of healthcare professionals (HCPs) on acceptability, barriers, and facilitators of the BC-Predict intervention and on the wider implementation of risk-based screening after BC-Predict was implemented in their screening site. Methods Fourteen semi-structured interviews were conducted with HCPs working across the breast screening pathway at three NHSBSP sites that implemented BC-Predict. Thematic analysis interpreted the data. Results Three pre-decided themes were produced. (1) Acceptability of risk-based screening: risk-stratification was perceived as a beneficial step for both services and women. HCPs across the pathway reported low burden of running the BC-Predict trial on routine tasks, but with some residual concerns; (2) Barriers to implementation: comprised capacity constraints of services including the inadequacy of current IT systems to manage women with different risk profiles and, (3) Facilitators to implementation: included the continuation of stakeholder consultation across the pathway to inform implementation and need for dedicated risk screening admin staff, a push for mammography staff recruitment and guidance for screening services. Telephone helplines, integrating primary care, and supporting access for all language needs was emphasised. Conclusion Risk-stratified breast screening was viewed as a progressive step providing it does not worsen inequalities for women. Implementation of risk-stratified breast screening requires staff to be reassured that there will be systems in place to support implementation and that it will not further burden their workload. Next steps require a comprehensive assessment of the resource needed for risk-stratification versus current resource availability, upgrades to screening IT and building screening infrastructure. The role of primary care needs to be determined. Simplification and clarification of risk-based screening pathways is needed to support HCPs agency and facilitate implementation. Forthcoming evidence from ongoing randomised controlled trials assessing effectiveness of breast cancer risk-stratification will also determine implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-10134-0.
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Affiliation(s)
- Rachel Hawkins
- The Christie NHS Foundation Trust, Wilmslow Rd, Manchester, M20 4BX, UK. .,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, England.
| | - Lorna McWilliams
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, England
| | - Fiona Ulph
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - D Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, England.,Nightingale & Prevent Breast Cancer Research Unit, Manchester University NHS Foundation Trust, Southmoor Road, M23 9LT, Wythenshawe, Manchester, UK.,Department of Genomic Medicine, Division of Evolution and Genomic Science, Manchester Academic Health Science Centre, University of Manchester, Manchester University NHS Foundation Trust, Oxford Road, M13 9WL, Manchester, UK
| | - David P French
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, England
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17
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McWilliams L, Evans DG, Payne K, Harrison F, Howell A, Howell SJ, French DP. Implementing Risk-Stratified Breast Screening in England: An Agenda Setting Meeting. Cancers (Basel) 2022; 14:cancers14194636. [PMID: 36230559 PMCID: PMC9563640 DOI: 10.3390/cancers14194636] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
It is now possible to accurately assess breast cancer risk at routine NHS Breast Screening Programme (NHSBSP) appointments, provide risk feedback and offer risk management strategies to women at higher risk. These strategies include National Institute for Health and Care Excellence (NICE) approved additional breast screening and risk-reducing medication. However, the NHSBSP invites nearly all women three-yearly, regardless of risk. In March 2022, a one-day agenda setting meeting took place in Manchester to discuss the feasibility and desirability of implementation of risk-stratified screening in the NHSBSP. Fifty-eight individuals participated (38 face-to-face, 20 virtual) with relevant expertise from academic, clinical and/or policy-making perspectives. Key findings were presented from the PROCAS2 NIHR programme grant regarding feasibility of risk-stratified screening in the NHSBSP. Participants discussed key uncertainties in seven groups, followed by a plenary session. Discussions were audio-recorded and thematically analysed to produce descriptive themes. Five themes were developed: (i) risk and health economic modelling; (ii) health inequalities and communication with women; (iii); extending screening intervals for low-risk women; (iv) integration with existing NHSBSP; and (v) potential new service models. Most attendees expected some form of risk-stratified breast screening to be implemented in England and collectively identified key issues to be resolved to facilitate this.
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Affiliation(s)
- Lorna McWilliams
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Correspondence:
| | - D. Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Genomic Medicine, Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary’s Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Nightingale & Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
| | - Katherine Payne
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Manchester Centre for Health Economics, School of Health Sciences, Faculty of Biology Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | | | - Anthony Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Nightingale & Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Sacha J. Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Nightingale & Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - David P. French
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
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Charron M, Kaiser B, Dauge A, Gallois H, Lapointe J, Dorval M, Nabi H, Joly Y. Integrating hereditary breast and ovarian cancer genetic counselling and testing into mainstream clinical practice: Legal and ethical challenges. Crit Rev Oncol Hematol 2022; 178:103797. [PMID: 36031172 DOI: 10.1016/j.critrevonc.2022.103797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/07/2022] [Accepted: 08/21/2022] [Indexed: 11/30/2022] Open
Abstract
Health professionals not specialized in genetics are expected to take an increasing role in genetic services delivery. This article aims to identify legal and ethical challenges related to a collaborative oncogenetics service model, where non-genetic health professionals provide genetic services to patients. Through a scoping literature review, we identified issues to the provision of hereditary breast and ovarian cancer, or other hereditary adult cancers, genetic testing under this model. Concerns that arose in the literature were informed consent, lack of adherence to best practice guidelines, lack of education of non-genetic health professionals on the provision of genetic services, psychological impacts of genetic testing, continuity of care, the complexity of genetic test results, confidentiality, risks of medical mismanagement, and the associated medical responsibility liabilities. Despite these challenges, there is a growing consensus towards the feasibility of cancer genetic testing being undertaken by non-genetic healthcare professionals in a collaborative oncogenetics service model.
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Affiliation(s)
- Marilou Charron
- Centre of Genomics and Policy (CGP), McGill University, Montreal, Québec, Canada.
| | - Beatrice Kaiser
- Centre of Genomics and Policy (CGP), McGill University, Montreal, Québec, Canada
| | - Aurélie Dauge
- Centre of Genomics and Policy (CGP), McGill University, Montreal, Québec, Canada
| | - Hortense Gallois
- Centre of Genomics and Policy (CGP), McGill University, Montreal, Québec, Canada
| | - Julie Lapointe
- Oncology Division, CHU de Québec - Université Laval Research Center, Québec, Canada
| | - Michel Dorval
- Faculty of Pharmacy, Université Laval, Researcher Oncology Division, CHU de Québec - Université Laval Research Center, Canada
| | - Hermann Nabi
- Faculty of Medicine, Université Laval, Researcher Oncology Division, CHU de Québec - Université Laval Research Center, Canada
| | - Yann Joly
- Centre of Genomics and Policy (CGP), McGill University, Montreal, Québec, Canada
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19
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Roux A, Cholerton R, Sicsic J, Moumjid N, French DP, Giorgi Rossi P, Balleyguier C, Guindy M, Gilbert FJ, Burrion JB, Castells X, Ritchie D, Keatley D, Baron C, Delaloge S, de Montgolfier S. Study protocol comparing the ethical, psychological and socio-economic impact of personalised breast cancer screening to that of standard screening in the "My Personal Breast Screening" (MyPeBS) randomised clinical trial. BMC Cancer 2022; 22:507. [PMID: 35524202 PMCID: PMC9073478 DOI: 10.1186/s12885-022-09484-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/02/2022] [Indexed: 12/11/2022] Open
Abstract
Background The MyPeBS study is an ongoing randomised controlled trial testing whether a risk-stratified breast cancer screening strategy is non-inferior, or eventually superior, to standard age-based screening at reducing incidence of stage 2 or more cancers. This large European Commission-funded initiative aims to include 85,000 women aged 40 to 70 years, without prior breast cancer and not previously identified at high risk in six countries (Belgium, France, Italy, Israel, Spain, UK). A specific work package within MyPeBS examines psychological, socio-economic and ethical aspects of this new screening strategy. It compares women’s reported data and outcomes in both trial arms on the following issues: general anxiety, cancer-related worry, understanding of breast cancer screening strategy and information-seeking behaviour, socio-demographic and economic characteristics, quality of life, risk perception, intention to change health-related behaviours, satisfaction with the trial. Methods At inclusion, 3-months, 1-year and 4-years, each woman participating in MyPeBS is asked to fill online questionnaires. Descriptive statistics, bivariate analyses, subgroup comparisons and analysis of variations over time will be performed with appropriate tests to assess differences between arms. Multivariate regression models will allow modelling of different patient reported data and outcomes such as comprehension of the information provided, general anxiety or cancer worry, and information seeking behaviour. In addition, a qualitative study (48 semi-structured interviews conducted in France and in the UK with women randomised in the risk-stratified arm), will help further understand participants’ acceptability and comprehension of the trial, and their experience of risk assessment. Discussion Beyond the scientific and medical objectives of this clinical study, it is critical to acknowledge the consequences of such a paradigm shift for women. Indeed, introducing a risk-based screening relying on individual biological differences also implies addressing non-biological differences (e.g. social status or health literacy) from an ethical perspective, to ensure equal access to healthcare. The results of the present study will facilitate making recommendations on implementation at the end of the trial to accompany any potential change in screening strategy. Trial registration Study sponsor: UNICANCER. My personalised breast screening (MyPeBS). Clinicaltrials.gov (2018) available at: https://clinicaltrials.gov/ct2/show/NCT03672331 Contact: Cécile VISSAC SABATIER, PhD, + 33 (0)1 73 79 77 58 ext + 330,142,114,293, contact@mypebs.eu. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09484-6.
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Affiliation(s)
- Alexandra Roux
- IRIS (UMR8156 CNRS & U997 INSERM), Paris 13 University, Aubervilliers, France
| | | | | | - Nora Moumjid
- Université Lyon 1, P2S EA 4129, Centre Léon Bérard, F-69373, Lyon, France
| | | | | | | | - Michal Guindy
- Assuta Medical Centers, Tel Aviv, Israel.,Ben Gurion University, Beersheba, Israel
| | | | | | - Xavier Castells
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | | | | | | | - Suzette Delaloge
- Institut Gustave Roussy, Villejuif, France.,Unicancer, Paris, France
| | - Sandrine de Montgolfier
- IRIS (UMR8156 CNRS & U997 INSERM), Paris 13 University, Aubervilliers, France. .,Paris Est Creteil University, Créteil, France.
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20
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Pons-Rodriguez A, Marzo-Castillejo M, Cruz-Esteve I, Galindo-Ortego G, Hernández-Leal MJ, Rué M. [Moving toward personalized breast cancer screening: The role of Primary Care]. Aten Primaria 2022; 54:102288. [PMID: 35477080 PMCID: PMC9061619 DOI: 10.1016/j.aprim.2022.102288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/11/2022] [Indexed: 11/02/2022] Open
Abstract
Breast cancer is the leading cause of death in the world among women. The Spanish National Health System (SNHS) introduced population-based breast cancer screening in 2006. As in most European programs, risk is identified on the basis of age and a mammogram is offered every two years to women aged 50-69 years. Scientific evidence is moving toward personalized screening, based on individual risk. This article presents the clinical trials that will evaluate the efficacy of personalized screening and some studies carried out in our environment on the effect of informing women of the benefits and adverse effects of screening or the acceptability and feasibility of offering personalized screening, in the Shared Decision Making context. The Preventive Activities and Health Promotion Program can help transform screening in our SNHS.
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Affiliation(s)
| | - Mercè Marzo-Castillejo
- Unitat de Suport a la Recerca Metropolitana Sud, IDIAP Jordi Gol, Direcció d'Atenció Primària Costa de Ponent, Institut Català de la Salut, Barcelona, España
| | | | | | - Maria José Hernández-Leal
- Departament d'Economia, Universitat Rovira i Virgili, Reus, España; Centre de Recerca en Economia i Sostenibilitat (ECO-SOS), Tarragona, España; Grup de Recerca en Anàlisi Estadística i Econòmica en Salut (GRAEES), Lleida y Reus, España
| | - Montserrat Rué
- Grup de Recerca en Anàlisi Estadística i Econòmica en Salut (GRAEES), Lleida y Reus, España; Departament de Ciències Mèdiques Bàsiques, Universitat de Lleida - Institut de Recerca Biomèdica de Lleida (IRB Lleida), Lleida, España.
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21
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Laza-Vásquez C, Codern-Bové N, Cardona-Cardona À, Hernández-Leal MJ, Pérez-Lacasta MJ, Carles-Lavila M, Rué M. Views of health professionals on risk-based breast cancer screening and its implementation in the Spanish National Health System: A qualitative discussion group study. PLoS One 2022; 17:e0263788. [PMID: 35120169 PMCID: PMC8815913 DOI: 10.1371/journal.pone.0263788] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 01/26/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND With the aim of increasing benefits and decreasing harms, risk-based breast cancer screening has been proposed as an alternative to age-based screening. This study explores barriers and facilitators to implementing a risk-based breast cancer screening program from the perspective of health professionals, in the context of a National Health Service. METHODS Socio-constructivist qualitative research carried out in Catalonia (Spain), in the year 2019. Four discussion groups were conducted, with a total of 29 health professionals from primary care, breast cancer screening programs, hospital breast units, epidemiology units, and clinical specialties. A descriptive-interpretive thematic analysis was performed. RESULTS Identified barriers included resistance to reducing the number of screening exams for low-risk women; resistance to change for health professionals; difficulties in risk communication; lack of conclusive evidence of the benefits of risk-based screening; limited economic resources; and organizational transformation. Facilitators include benefits of risk-based strategies for high and low-risk women; women's active role in their health care; proximity of women and primary care professionals; experience of health professionals in other screening programs; and greater efficiency of a risk-based screening program. Organizational and administrative changes in the health system, commitment by policy makers, training of health professionals, and educational interventions addressed to the general population will be required. CONCLUSIONS Despite the expressed difficulties, participants supported the implementation of risk-based screening. They highlighted its benefits, especially for women at high risk of breast cancer and those under 50 years of age, and assumed a greater efficiency of the risk-based program compared to the aged-based one. Future studies should assess the efficiency and feasibility of risk-based breast cancer screening for its transfer to clinical practice.
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Affiliation(s)
- Celmira Laza-Vásquez
- Department of Nursing and Physiotherapy, University of Lleida-IRBLleida, Lleida, Spain
- Health Care Research Group (GRECS), Lleida, Spain
| | - Núria Codern-Bové
- Escola Universitària d’Infermeria i Teràpia Ocupacional de Terrassa, Universitat Autònoma de Barcelona, Terrassa, Spain
- Health, Participation, Occupation and Care Research Group (GrEUIT), Terrassa, Spain
- ÀreaQ, Evaluation and Qualitative Research, Barcelona, Spain
| | | | - Maria José Hernández-Leal
- Department of Economics and Research Centre on Economics and Sustainability (ECO-SOS), Rovira i Virgili University (URV), Tarragona, Spain
- Research Group in Statistical and Economic Analysis in Health (GRAEES), Reus, Spain
| | - Maria José Pérez-Lacasta
- Department of Economics and Research Centre on Economics and Sustainability (ECO-SOS), Rovira i Virgili University (URV), Tarragona, Spain
- Research Group in Statistical and Economic Analysis in Health (GRAEES), Reus, Spain
| | - Misericòrdia Carles-Lavila
- Department of Economics and Research Centre on Economics and Sustainability (ECO-SOS), Rovira i Virgili University (URV), Tarragona, Spain
- Research Group in Statistical and Economic Analysis in Health (GRAEES), Reus, Spain
| | - Montserrat Rué
- Department of Basic Medical Sciences, University of Lleida-IRBLleida, Lleida, Spain
- Research Group in Statistical and Economic Analysis in Health (GRAEES), Lleida, Spain
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