Black women receive less mammography even with similar use of primary care

Breast cancer screening during the COVID-19 pandemic: moving from disparities to health equity

The COVID-19 pandemic created unprecedented disruptions to routine health care in the United States. Screening mammography, a cornerstone of breast cancer control and prevention, was completely halted in the spring of 2020, and screening programs have continued to face challenges with subsequent COVID-19 waves. Although screening mammography rates decreased for all women during the pandemic, a number of studies have now clearly documented that reductions in screening have been greater for some populations than others. Specifically, minoritized women have been screened at lower rates than White women across studies, although the specific patterns of disparity vary depending on the populations and communities studied. We posit that these disparities are likely due to a variety of structural and contextual factors, including the differential impact of COVID-19 on communities. We also outline key considerations for closing gaps in screening mammography. First, practices, health systems, and communities must measure screening mammography use to identify whether gaps exist and which populations are most affected. Second, we propose that strategies to close disparities in breast cancer screening must be multifaceted, targeting the health system or practice, but also structural factors at the policy level. Health disparities arise from a complex set of conditions, and multimodal solutions that address the complex, multifactorial conditions that lead to disparities may be more likely to succeed and are necessary for promoting health equity.

pessoa idosa na Atenção Primária à Saúde

Introdução: O envelhecimento da população mundial é uma conquista da humanidade, que também se mostra um dos maiores desafios, uma vez que ocasionará novos paradigmas e demandas políticas, sociais, econômicas e de saúde. Desse modo, torna-se essencial discutir os aspectos que envolvem a pessoa idosa e a Atenção Primária à Saúde (APS). Objetivo: Realizar uma análise bibliométrica da produção científica referente aos fatores relacionados com a pessoa idosa e a APS. Métodos: Trata-se de uma revisão bibliométrica que utilizou os termos “primary health care” AND “aged*” na base de dados Web of Science, entre os anos de 1945 e 2016. O estudo analisou os registros com base em revisão de literatura sobre a temática em questão com o auxílio do software HistCite. Resultados: Foram identificados 700 artigos em 313 periódicos, de 2.834 autores vinculados a 1.138 instituições de 61 países, o que totalizou 19.745 referências, com média de aproximadamente 28 referências por artigo. A revista Scandinavian Journal of Primary Health Care possui 4% dos textos e o International Journal of Geriatric Psychiatry, o maior fator de impacto. Os autores mais citados estão reunidos em apenas cinco universidades, com destaque para a Linkoping University, que detém 4% do total de publicações, e três países: Suécia, Brasil e Estados Unidos da América. O Brasil ocupa a primeira colocação, com 2% dos textos. Conclusões: Os estudos revelam aspectos importantes associados à pessoa idosa e à APS, como problemas de inobservância quanto aos cuidados de saúde para essa população, tanto por profissionais quanto pelos próprios idosos, apontando para a desumanização e consequente falta de priorização dessa faixa etária no âmbito da saúde. Com o envelhecimento das populações, é imprescindível que esse tema venha a ser priorizado, ampliando o debate sobre essa transição demográfica e suas consequências para toda a população e visando a alternativas que possam minimizar os impactos dela, bem como a novos paradigmas para produtos e serviços voltados para a população idosa. Isso especialmente na atenção primária, que é porta de entrada para todo o serviço de saúde e principal elo social entre o idoso e a qualidade de vida. Destaca-se ainda a necessidade de educação continuada dos profissionais e de aperfeiçoamento desse nível de atenção para o atendimento a essa população, quantitativamente cada vez maior.

Effect of Out-of-Pocket Costs on Subsequent Mammography Screening

OBJECTIVE

Although the Affordable Care Act eliminated cost sharing for screening mammography, a concern is that grandfathered plans, diagnostic mammograms, and follow-up testing may still lead to out-of-pocket (OOP) spending. Our study examines how OOP spending among women at their baseline screening mammogram may impact the decision to receive subsequent screening.

METHODS

The study included commercially insured women aged 40 to 41 years with a screening mammogram between 2011 and 2014. We estimated multivariate linear probability models of the effect of OOP spending at the baseline mammogram on subsequent screening 12 to 36 months later.

RESULTS

Having any OOP payments for the baseline screening mammogram significantly reduced the probability of screening in the subsequent 12 to 24 months by 3.0 percentage points (pp) (95% confidence interval [CI]: 1.1-4.8 pp decrease). For every $100 increase in the OOP expenses for the baseline mammogram, the likelihood of subsequent screening within 12 to 24 months decreased by 1.9 pp (95% CI: 0.8-3.1 pp decrease). Similarly, any OOP spending for follow-up tests resulting from the baseline screening led to a 2.7 pp lower probability of screening 12 to 24 months later (95% CI: 0.9-4.1 pp decrease). Higher OOP expenses were associated with significantly lower screening 24 to 36 months later (coefficient = -0.014, 95% CI: -0.025 to -0.003).

DISCUSSION

Although cost sharing has been eliminated for screening mammograms, OOP costs may still arise, particularly for diagnostic and follow-up testing services, both of which may reduce rates of subsequent screening. For preventive services, reducing or eliminating cost sharing through policy and legislation may be important to ensuring continued adherence to screening guidelines.

Disparities in Breast Cancer Survivors in Rural West Texas

Objectives

Breast cancer is the second highest female mortality rate in Texas for all races and ethnicities, except for Hispanics. Interestingly, Hale County is a rural underserved county in West Texas which experiences a lower rate of cancer, has higher age-adjusted mortality rates (26.2/100 000), on average, compared to all of Texas (23.1/100 000). The purpose of this study was to determine the relationship between sociodemographic variables and breast cancer outcomes in underserved Hale County which contributed to the highest mortality rate in Texas.

Methods

Hale County breast cancer data (1995–2014) were obtained from the Texas Cancer Registry. Statistical methods independent samples t-test, Kaplan–Meier curve, and Cox proportional hazard were used to describe the significant relationship between survival time, sociodemographic, and prognostic variables.

Results

Women with breast cancer in Hale County were more likely to be White non-Hispanics (n = 266, 65.5%) and had the highest longevity (2753.6 ± 2073.5 days). White Hispanics experienced the worst survival (2369.6 ± 2060.2 days) and were more likely to develop a serious grade of cancer. Significant relationships were found between the stage of cancer and insurance status with survival time for both White non-Hispanics and White Hispanics (P < .001). Patients in grades II and III were found to be significantly (P < .01) associated with breast cancer death, and grades II and III which had around five-fold and eleven-fold increased risk of death, respectively, compared with the referent group, grade I.

Conclusion

Determining the impact of sociodemographic variables on breast cancer outcome is essential to addressing issues of geographic disparities and integrating such variables may guide relevant policy interventions to reduce breast cancer’s incidence in rural underserved communities in West Texans.

Acute consumption of flavanol-rich cocoa beverage improves attenuated cutaneous microvascular function in healthy young African Americans

Flavanols have beneficial effects on vascular health and we have recently demonstrated that cerebral vasodilatory capacity in healthy young African Americans (AA) is improved with acute flavanol intake relative to aged-matched Caucasian Americans (CA). However, whether the positive benefits of acute flavanol consumption would also be present in the cutaneous microvascular circulation of AA remains unknown. Thus, we hypothesized that acute consumption of flavanol-rich cocoa (FC) would improve the previously reported reduced cutaneous microvascular responses to local heating in young AA. Seven AA and seven CA participated in this double-blind crossover study. Data were collected on two different days, separated by a minimum of one week. Two intradermal microdialysis membranes were inserted in the forearm and each site was randomly assigned to receive lactated Ringer's solution or NO synthase (NOS) inhibitor. Participants were randomly assigned to consume either a non-flavanol containing (NF) beverage or FC beverage. Cutaneous vascular conductance (CVC) was calculated as cutaneous blood flux/mean arterial pressure and normalized as % maximal CVC (%CVCmax). The difference in %CVCmax between the Ringer's site and NOS inhibited site was calculated to assess NO contribution (Δ %CVCmax). In the Ringer's site, acute consumption of FC beverage improved %CVCmax during 39 °C heating when compared to NF beverage in AA (NF: 36 ± 6 vs. FC: 47 ± 5%CVCmax; P < .01) while there was similar %CVCmax during 39 °C heating between beverages in CA (NF: 55 ± 4 vs. FC: 59 ± 5%CVCmax; P = .40). During 39 °C heating, NO contribution was significantly higher with FC beverage than NF beverage in AA (NF: 27 ± 5 vs. FC: 35 ± 4 Δ %CVCmax; P = .03) while there was similar NO contribution between beverages in CA (NF: 42 ± 4 vs. FC: 45 ± 4 Δ %CVCmax; P = .36). This data suggests that acute consumption of FC could be a therapeutic solution to improve an attenuated microvascular function in young AA.

Preferences for physician weight status among women with overweight

BACKGROUND

Women with overweight experience stigma in clinical interactions. Emerging evidence suggests that one near-term approach to offset the negative consequences of weight stigma could be to capitalize on benefits of patient-physician weight concordance. However, it is likely that patient attitudes towards physicians with overweight are complicated and multifaceted and may include stigmatization of providers with overweight.

METHODS

Two-hundred ninety-eight women with overweight completed an online questionnaire and indicated preference for a physician who is 'overweight', 'not overweight', or indicated no preference. Participants provided reasons for their choice and answered questions about their weight-related beliefs and experiences.

RESULTS

The majority of women indicated no weight preference (63%), and a portion (36%) of the sample explicitly preferred physicians who are not overweight. Reasons provided for these preferences were primarily based on stereotyped notions of physician aptitude based on weight. Compared with having no preference, those who preferred physicians who are not overweight had fewer previous negative weight-related physician interactions and had increased beliefs about the controllability of weight.

CONCLUSIONS

These findings elucidate patient attitudes towards physicians with overweight in a sample at increased risk for weight stigmatization. Findings underscore the need for stigma-reducing interventions so that clinical experiences for both women and physicians with overweight can be improved.

Stepped-Care, Community Clinic Interventions to Promote Mammography Use among Low-Income Rural African American Women

Few studies have investigated community clinic-based interventions to promote mammography screening among rural African American women. This study randomized older low-income rural African American women who had not participated in screening in the previous 2 years to a theory-based, personalized letter or usual care; no group differences in mammography rate were evident at 6-month follow-up. Women who had not obtained a mammogram were then randomized to a tailored call delivered by community health care workers or a tailored letter. There were no group differences in mammography rates after the second 6-month follow-up. However, among women who had never had a mammogram, the tailored call was more effective in promoting mammography use. Tailored counseling may be an effective screening promotion strategy for hard-to-reach rural African American women with no history of screening. Further research into this strategy may facilitate efforts to reduce health disparities in underserved low-income rural African American populations.

Mammography Screening for Older Minority Women

This project facilitated access to mammography screening for older ethnic minority women through health education and coordination of service networks for aging and health care services. Health education sessions were held in senior centers, followed by a mammography screening in a mammography van or at a health care facility. Of the participants in the education sessions, 38% received a mammogram. More women who did not obtain a mammogram believed that cancer treatments were worse than the disease. Also, more African American and White women than Hispanic women did not recognize age as a risk factor for cancer Of the Hispanic women, 30% believed that early diagnosis did not make a difference in one's outcome, compared with 20% of White women and 8% of African American women.

Racial disparities in the use of blood transfusion in major surgery

BACKGROUND

Racial disparities in healthcare in the United States are widespread and have been well documented. However, it is unknown whether racial disparities exist in the use of blood transfusion for patients undergoing major surgery.

METHODS

We used the University HealthSystem Consortium database (2009-2011) to examine racial disparities in perioperative red blood cells (RBCs) transfusion in patients undergoing coronary artery bypass surgery (CABG), total hip replacement (THR), and colectomy. We estimated multivariable logistic regressions to examine whether black patients are more likely than white patients to receive perioperative RBC transfusion, and to investigate potential sources of racial disparities.

RESULTS

After adjusting for patient-level factors, black patients were more likely to receive RBC transfusions for CABG (AOR = 1.41, 95% CI: [1.13, 1.76], p = 0.002) and THR (AOR = 1.39, 95% CI: [1.20, 1.62], p < 0.001), but not for colectomy (AOR = 1.08, 95% CI: [0.90, 1.30], p = 0.40). Black-white disparities in blood transfusion persisted after controlling for patient insurance and hospital effects (CABG: AOR = 1.42, 95% CI: [1.30, 1.56], p < 0.001; THR: AOR = 1.43, 95% CI: [1.29, 1.58], p < 0.001).

CONCLUSIONS

We detected racial disparities in the use of blood transfusion for CABG and THR (black patients tended to receive more transfusions compared with whites), but not for colectomy. Reporting racial disparities in contemporary transfusion practices may help reduce potentially unnecessary blood transfusions in minority patients.

The role of social capital in African-American women's use of mammography

Black/African-American women are more likely to get breast cancer at a young age and/or be diagnosed at a late disease stage, pointing to a greater need to promote mammography for Black women at earlier ages than are currently recommended. This study explores how perceived neighborhood social capital, that is, perceptions of how tight-knit a neighborhood is and what power that confers to neighborhood members, relates to use of mammography for Black women in Philadelphia. Living in a community with tight social ties (social cohesion) or that have a collective motivation for community change (collective efficacy) may increase the likelihood that an individual woman in that community will hear health messages from other community members and neighbors (diffusion of information) and will have access to health-related resources that allow them to engage in healthy behaviors. No prior studies have explored the role of social capital in decisions for mammography use. Using multilevel logistic regression, we analyzed self-report of mammography in the past year for 2586, Black women over age 40 across 381 Philadelphia, Pennsylvania USA census tracts. Our study included individual demographic and aggregates of individual-level social capital data from the Public Health Management Corporation's 2004, 2006, and 2008 Community Health Database waves, and 2000 US Census sociodemographic characteristics. Individual perceptions that a Black woman's neighborhood had high social capital, specifically collective efficacy, had a positive and statistically significant association with mammography use (OR = 1.40, CI: 1.05, 1.85). Our findings suggest that an individual woman's perception of greater neighborhood social capital may be related to increased mammography use. Although this analysis could not determine the direction of causality, it suggests that social capital may play a role in cancer preventive screening for African-American women in Philadelphia, which warrants further study.

Underutilization of radiation therapy in patients with glioblastoma: predictive factors and outcomes

BACKGROUND

Randomized trials have demonstrated that radiation improves survival in patients with glioblastoma. The purpose of this study was to characterize the risk factors and impact of omission of radiation therapy in such patients.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) program was used to identify 22,777 patients diagnosed with glioblastoma between 1988 and 2007. Multivariable logistic regression was employed to identify predictors associated with omission of radiation. Cox regression was used to characterize the impact of omitting radiation on all-cause mortality.

RESULTS

Among the entire cohort, 16,863 of 22,777 patients (74%) received radiation, whereas 5914 of 22,777 patients (26%) did not. Factors associated with omission of radiation included older age (OR=1.048 per year increase, 95% CI=1.046-1.051, P<.001), lower annual income (OR=0.93 per $10,000 increase, 95% CI=0.90-0.96, P<.001), African American race (reference=white, OR=1.19, 95% CI=1.03-1.37, P=.02), Hispanic race (OR=1.34, 95% CI=1.19-1.50, P< .001), Asian American race (OR=1.24, 95% CI=1.04-1.48, P<.001), unmarried status (OR=1.71, 95% CI=1.60-1.83, P< .001), and subtotal resection/biopsy (OR=1.82, 95% CI=1.69-1.96, P<.001). The use of radiation was significantly associated with improved overall survival (2-year survival: 14.6% versus 4.2%, P<.001; adjusted HR=2.09, 95% CI=2.02-2.16, P<.001). When the population was restricted to patients <50 years old, these findings remained largely unchanged.

CONCLUSIONS

Radiation therapy is associated with survival benefit in patients with glioblastoma, and sociodemographic factors play a significant role in the underutilization of radiation. The underlying causes for these disparities in care require further research.

Racial differences in outcomes of triple-negative breast cancer

African American (AA) women have a higher incidence of triple-negative breast cancer (TNBC: negative for the expression of estrogen receptor, progesterone receptor, and HER2 gene amplification) than Caucasian (CA) women, explaining in part their higher breast cancer mortality. However, there have been inconsistent data in the literature regarding survival outcomes of TNBC in AA versus CA women. We performed a retrospective chart review on 493 patients with TNBC first seen at the Washington University Breast Oncology Clinic (WUBOC) between January 2006 and December 2010. Analysis was done on 490 women (30 % AA) for whom follow-up data was available. The median age at diagnosis was 53 (23-98) years and follow-up time was 27.2 months. There was no significant difference between AA and CA women in the age of diagnosis, median time from abnormal imaging to breast biopsy and from biopsy diagnosis to surgery, duration of follow-up, tumor stage, grade, and frequency of receiving neoadjuvant or adjuvant chemotherapy and pathologic complete response rate to neoadjuvant chemotherapy. There was no difference in disease free survival (DFS) and overall survival (OS) between AA and CA groups by either univariate or multivariate analysis that included age, race, and stage. The hazard ratio for AA women was 1.19 (CI 0.80-1.78, p = 0.39) and 0.91 (CI 0.62-1.35, p = 0.64) for OS and DFS, respectively. Among the 158 patients who developed recurrence or presented with stage IV disease (AA: n = 36, CA: n = 122), no racial differences in OS were observed. We conclude that race did not significantly affect the clinical presentation and outcome of TNBC in this single center study where patients received similar therapy and follow-up.

Racial/ethnic minority access to end-of-life care: a conceptual framework

Minority underutilization of hospice care has been well-documented; however, explanations addressing disparities have failed to examine the scope of factors in operation. Drawing from previous health care access models, a framework is proposed in which access to end-of-life care results from an interaction between patient-level, system-level, and societal-level barriers with provider-level mediators. The proposed framework introduces an innovative mediating factor missing in previous models, provider personal characteristics, to better explain care access disparities. This article offers a synthesis of previous research and proposes a framework that is useful to researchers and clinicians working with minorities at end of life.

A simulation model approach to analysis of the business case for eliminating health care disparities

BACKGROUND

Purchasers can play an important role in eliminating racial and ethnic disparities in health care. A need exists to develop a compelling "business case" from the employer perspective to put, and keep, the issue of racial/ethnic disparities in health care on the quality improvement agenda for health plans and providers.

METHODS

To illustrate a method for calculating an employer business case for disparity reduction and to compare the business case in two clinical areas, we conducted analyses of the direct (medical care costs paid by employers) and indirect (absenteeism, productivity) effects of eliminating known racial/ethnic disparities in mammography screening and appropriate medication use for patients with asthma. We used Markov simulation models to estimate the consequences, for defined populations of African-American employees or health plan members, of a 10% increase in HEDIS mammography rates or a 10% increase in appropriate medication use among either adults or children/adolescents with asthma.

RESULTS

The savings per employed African-American woman aged 50-65 associated with a 10% increase in HEDIS mammography rate, from direct medical expenses and indirect costs (absenteeism, productivity) combined, was $50. The findings for asthma were more favorable from an employer point of view at approximately $1,660 per person if raising medication adherence rates in African-American employees or dependents by 10%.

CONCLUSIONS

For the employer business case, both clinical scenarios modeled showed positive results. There is a greater potential financial gain related to eliminating a disparity in asthma medications than there is for eliminating a disparity in mammography rates.

Women's cognitive and affective reactions to breast cancer survivor stories: a structural equation analysis

OBJECTIVE

Compare the immediate affective and cognitive reactions to cancer survivor stories about mammography and breast cancer vs. a didactic, informational approach.

METHODS

Participants (N=489) were African American women age 40 years and older (mean=61). Most had ≤high school education (67%), annual household income ≤$20,000 (77%), and a prior mammogram (89%). Participants completed surveys before and after watching the narrative or informational video. We used structural equation modeling to examine the large number of inter-related latent constructs.

RESULTS

Women who watched the narrative video experienced more positive and negative emotions, found it easier to understand the video, had more positive evaluations of the video, reported stronger identification with the message source (i.e., perceived similarity, trust, liking), and were more engaged with the video.

CONCLUSION

Narratives elicited immediate reactions consistent with theorized pathways of how communication affects behavior. Future studies should examine whether and how these immediate outcomes act as mediators of the longer term effects of narratives on affect, cognitions, and behavior.

PRACTICE IMPLICATIONS

Stories of other women's experiences may be more powerful than a didactic presentation when encouraging African American women to get a mammogram.

Factors that influence the incidence of breast cancer in Arica, Chile (Review)

Breast cancer is a common disease estimated to occur in 1 in 9 women over their lifetime. Epidemiological research has identified a number of risk factors for breast cancer. Racial and ethnic differences in breast cancer mortality rates have been difficult to ascertain. The present review reports that there was an increase in the incidence of breast cancer in Arica, Chile, from 1997 to 2007, particularly in 2005, reaching 55.1% per 100,000 women, while the percentage decreased in 2006 and 2007. A greater percentage of breast cancer was found in individuals between 46 and 65 years of age when the population was distributed by age. The Indian population, Aymara, had only a 13.9% incidence of the disease. The incidence for breast cancer for patients with no family background reached approximately 88%, with or without Indian ethnicity, and 98.4% of these women did not have prior hormonal therapy. When the stage of the disease and the number of pregnancies were considered, results showed that there was an increase in the progression of the disease from stage I to stage III in women that had 1-3 pregnancies. Results also showed that 20.9 and 33.2% who received prior tamoxifen treatment were in stages I and IIA, respectively. The breast cancer incidence reached 42.4% when patients had a sister with the disease. It can be concluded that important differences in the risk factors of breast cancer should be identified in the future for a comparison with other biological factors, such as genetic and molecular factors. This may provide greater insight into breast cancer aetiology in different populations.

The frequency of early repeat tests after colonoscopy in elderly medicare recipients

BACKGROUND

The frequency of early repeat and follow-up tests (RAFTs) occurring after colonoscopy has not been previously examined in the literature. RAFTs incur cost, discomfort, and inconvenience to patients who have undergone colonoscopic examination; therefore, it is important to identify factors associated with their use.

METHODS

We identified elderly Medicare recipients who had colonoscopy performed in 1999 from the 5% Medicare administrative files (N = 69,282). We determined the number of early RAFTs (repeat colonoscopy, barium enema, flexible sigmoidoscopy) occurring within the year of initial colonoscopy.

RESULTS

Of the study sample, 8.3% required at least one RAFT during the year. Using multivariable analysis, we found that RAFTs varied significantly with age, race, sex, income, comorbidity, provider type, and place of service. RAFTs were 22% higher in African Americans compared to whites. Gastroenterologists used 20-35% fewer RAFTs than the other provider types performing colonoscopy.

CONCLUSIONS

The frequency of early RAFTs after colonoscopy occurs in 8.3% of the Medicare population. Important differences exist in the frequency of RAFTs by race and provider type.

Healthcare access, socioeconomic factors and late-stage cancer diagnosis: an exploratory spatial analysis and public policy implication

Patients diagnosed with late-stage cancer have lower survival rates than those with early-stage cancer. This paper examines possible associations between several risk factors and late-stage diagnosis for four types of cancer in Illinois: breast cancer, prostate cancer, colorectal cancer, and lung cancer. Potential risk factors are composed of spatial factors and nonspatial factors. The spatial factors include accessibility to primary healthcare and distance or travel time to the nearest cancer screening facility. A set of demographic and socioeconomic variables are consolidated into three nonspatial factors by factor analysis. The Bayesian model with convolution priors is utilised to analyse the relationship between the above risk factors and each type of late-stage cancer while controlling for spatial autocorrelation. The results for breast cancer suggest that people living in neighbourhoods with socioeconomic disadvantages and cultural barriers are more likely to be diagnosed at a late stage. In regard to prostate cancer, people in regions with low socioeconomic status are also more likely to be diagnosed at a late stage. Diagnosis of late-stage colorectal or lung cancer is not significantly associated with any of the abovementioned risk factors. The results have important implications in public policy.

Impact of androgen deprivation therapy on racial/ethnic disparities in the survival of older men treated for locoregional prostate cancer

BACKGROUND

Racial disparities persist in prostate cancer (CaP) treatment and survival, but disparities in androgen deprivation therapy (ADT) and the degree to which it affects racial differences in survival remains to be fully assessed.

METHODS

Using the Surveillance, Epidemiology and End Results-Medicare linked data, we examined a large cohort of men (N = 64,475) diagnosed with locoregional CaP during 1992 to 1999 and followed through 2003. The effects of ADT and race on survival were analyzed using a Cox proportional hazards model.

RESULTS

The receipt of ADT was significantly lower in African Americans (24%) relative to Caucasians (27%), Asians (34%), and Hispanics (28.7%) (P < .05). Compared with Caucasian race, African American race was associated with a statistically significant increased mortality (HR = 1.26, 95% CI = 1.21-1.32), which remained significant after adjusting for ADT but was substantially decreased after controlling for primary therapies such as radical prostatectomy, radiation, and watchful waiting (HR = 1.06, 95% CI = 1.01-1.10) and was no longer statistically significant after controlling for comorbidities (HR = 0.98, 95% CI = 0.94-1.03).

CONCLUSIONS

There were marked racial variations in the receipt of ADT, primary therapies (namely surgery and surgery combined with radiation), and comorbidities. However, racial disparities in survival were not affected by racial variations in ADT but were explained by racial variations in primary therapies and by racial differences in comorbidities.

African-American and low-socioeconomic status patients have a worse prognosis for invasive ductal and lobular breast carcinoma: do screening criteria need to change?

BACKGROUND

Determine the effect of race, socioeconomic status (SES) and other demographic variables on outcomes of patients with invasive ductal and lobular breast cancer.

STUDY DESIGN

Florida cancer registry and inpatient hospital data were queried for patients diagnosed with invasive breast cancer from 1998 to 2002.

RESULTS

A total of 63,472 patients with breast cancer were identified. Overall, 90.5% of patients were Caucasian, 7.6% African American, and 8.7% Hispanic. African-American patients presented at a younger age and with more-advanced disease, 10.5% presented with breast cancer before the age of 40 years, and 22.4% before 45 years of age. African-American patients were less likely to undergo operations. Similarly, low-SES patients were less likely to have operations and presented more often with larger tumors. Stepwise multivariate analysis revealed a substantial drop in the hazard ratio for African-American patients once correction for stage of presentation was made, suggesting that disparities in breast cancer outcomes are, in part, a result of advanced stage at presentation. Race and low SES were independent predictors of worse prognosis when controlling for patient comorbidities and treatment.

CONCLUSIONS

Dramatic disparities by patient race and SES exist in breast cancer. Our study integrates previous smaller studies, providing comprehensive insight into African-American patients and their outcomes for breast cancer. Earlier screening programs and greater access to cancer care for the poor and African Americans are needed. Successful institution of such programs will not completely erase disparities in outcomes for breast cancer in African-American patients.

Measuring mammography and breast cancer beliefs in African American women

Although intervention trials have demonstrated significant improvement in mammography adherence for African American women, many of the current measurement tools used in these interventions have not been assessed for validity and reliability in ethnic minorities. This study assessed the validity and reliability of Health Belief Model (HBM) variables that are often the target of mammography interventions. Scale validity and reliability was assessed for HBM scales in a sample of 344 low-income African American women. Validity was supported through exploratory factor analysis and theoretical prediction of relationships. Internal consistency reliability was .73 or above for all scales.

Socioeconomic disparities in breast cancer screening among US women: trends from 2000 to 2005

OBJECTIVES

This study describes trends in the socioeconomic disparities in breast cancer screening among US women aged 40 or over, from 2000 to 2005. We assessed 1) the disparities in each socioeconomic dimension; 2) the changes in screening mammography rates over time according to income, education, and race; and 3) the sizes and trends of the disparities over time.

METHODS

Using data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2000 to 2005, we calculated the age-adjusted screening rate according to relative household income, education level, health insurance, and race. Odds ratios and the relative inequality index (RII) were also calculated, controlling for age.

RESULTS

Women in their 40s and those with lower relative incomes were less likely to undergo screening mammography. The disparity based on relative income was greater than that based on education or race (the RII among low-income women across the survey years was 3.00 to 3.48). The overall participation rate and absolute differences among socioeconomic groups changed little or decreased slightly across the survey years. However, the degree of each socioeconomic disparity and the relative inequality among socioeconomic positions remained quite consistent.

CONCLUSIONS

These findings suggest that the trend of the disparity in breast cancer screening varied by socioeconomic dimension. Continued differences in breast cancer screening rates related to income level should be considered in future efforts to decrease the disparities in breast cancer among socioeconomic groups. More focused interventions, as well as the monitoring of trends in cancer screening participation by income and education, are needed in different social settings.

Can America's urban safety net systems be a solution to unequal treatment?

Eliminating disparities in care for racial and ethnic minorities remains a challenge in achieving overall quality health care. One approach to resolving issues of inequity involves utilizing an urban safety-net system to address preventive and chronic care disparities. An analysis was undertaken at Denver Health (DH), an urban safety net which serves 150,000 patients annually, of which 78% are minorities and 50% uninsured. Medical charts for 4,795 randomly selected adult patients at ten DH-associated community health centers were reviewed between July 1999 and December 2001. Logistic regression was used to identify differences between racial/ethnic groups in cancer screening, blood pressure control, and diabetes management. No disparities in care were found, and in most instances, the quality of care met or exceeded available benchmarks, leading us to conclude that treatment in urban integrated safety net systems committed to caring for minority populations may represent one approach to reducing disparity.

Can primary care visits reduce hospital utilization among Medicare beneficiaries at the end of life?

BACKGROUND

Medical care at the end of life is often expensive and ineffective.

OBJECTIVE

To explore associations between primary care and hospital utilization at the end of life.

DESIGN

Retrospective analysis of Medicare data. We measured hospital utilization during the final 6 months of life and the number of primary care physician visits in the 12 preceding months. Multivariate cluster analysis adjusted for the effects of demographics, comorbidities, and geography in end-of-life healthcare utilization.

SUBJECTS

National random sample of 78,356 Medicare beneficiaries aged 66+ who died in 2001. Non-whites were over-sampled. All subjects with complete Medicare data for 18 months prior to death were retained, except for those in the End Stage Renal Disease program.

MEASUREMENTS

Hospital days, costs, in-hospital death, and presence of two types of preventable hospital admissions (Ambulatory Care Sensitive Conditions) during the final 6 months of life.

RESULTS

Sample characteristics: 38% had 0 primary care visits; 22%, 1-2; 19%, 3-5; 10%, 6-8; and 11%, 9+ visits. More primary care visits in the preceding year were associated with fewer hospital days at end of life (15.3 days for those with no primary care visits vs. 13.4 for those with > or = 9 visits, P < 0.001), lower costs ($24,400 vs. $23,400, P < 0.05), less in-hospital death (44% vs. 40%, P < 0.01), and fewer preventable hospitalizations for those with congestive heart failure (adjusted odds ratio, aOR = 0.82, P < 0.001) and chronic obstructive pulmonary disease (aOR = 0.81, P = 0.02).

CONCLUSIONS

Primary care visits in the preceding year are associated with less, and less costly, end-of-life hospital utilization. Increased primary care access for Medicare beneficiaries may decrease costs and improve quality at the end of life.

Racial and ethnic differences in breast cancer survival: how much is explained by screening, tumor severity, biology, treatment, comorbidities, and demographics?

BACKGROUND

The reasons for race/ethnicity (R/E) differences in breast cancer survival have been difficult to disentangle.

METHODS

Surveillance, Epidemiology, and End Results (SEER)-Medicare data were used to identify 41,020 women aged > or =68 years with incident breast cancer between 1994-1999 including African American (2479), Hispanic (1172), Asian/Pacific Island (1086), and white women (35,878). A Cox proportional hazards model assessed overall and stage-specific (0/I, II/III, and IV) R/E differences in breast cancer survival after adjusting for mammography screening, tumor characteristics at diagnosis, biologic markers, treatment, comorbidity, and demographics.

RESULTS

African American women had worse survival than white women, although controlling for predictor variables reduced this difference among all stage breast cancer (hazards ratio [HR], 1.08; 95% confidence interval [95% CI], 0.97-1.20). Adjustment for predictors reduced, but did not eliminate, disparities in the analysis limited to women diagnosed with stage II/III disease (HR, 1.30; 95% CI, 1.10-1.54). Screening mammography, tumor characteristics at diagnosis, biologic markers, and treatment each produced a similar reduction in HRs for women with stage II/III cancers. Asian and Pacific Island women had better survival than white women before and after accounting for all predictors (adjusted all stages HR, 0.61 [95% CI, 0.47-0.79]; adjusted stage II/III HR, 0.61 [95% CI, 0.47-0.79]). Hispanic women had better survival than white women in all and stage II/III analysis (all stage HR, 0.88; 95% CI, 0.75-1.04) and stage II/III analysis (HR, 0.88; 95% CI, 0.75-1.04), although these findings did not reach statistical significance. There was no significant difference in survival by R/E noted among women diagnosed with stage IV disease.

CONCLUSIONS

Predictor variables contribute to, but do not fully explain, R/E differences in breast cancer survival for elderly American women. Future analyses should further investigate the role of biology, demographics, and disparities in quality of care.

How does social integration influence breast cancer control among urban African-American women? Results from a cross-sectional survey

BACKGROUND

Although social integration is a well-established influence on health, less is known about how the specific types of social connection (social roles, social networks, and social support) influence knowledge, attitudes, and practices for specific prevention goals, and how to utilize these influences in interventions with priority populations. This research examined the prevalence of social roles, networks and support among 576 urban African-American women age 45-93 in East Baltimore, Maryland, and the association of these social factors with breast cancer related knowledge, attitudes, and practices.

METHODS

Using data from 1997-1998 in-home interviews, we developed indices of six possible social roles, social networks of family, neighborhood and church, and instrumental and emotional social support. In multivariate models adjusting for age, education, and medical care, we examined the association of each social influence on breast cancer knowledge, attitudes, screening recency and intention, and treatment preferences.

RESULTS

We found substantial variation in social integration among these women, with social integration positively associated with overall health and well-being. Social roles and networks were positively associated with screening knowledge, and emotional support and church networks were positively associated with attitudes conducive to early detection and treatment. In regard to screening behaviors, family networks were associated with both screening recency and intention. Women with greater church networks and emotional support held more conservative attitudes towards lumpectomy, reconstruction, and clinical trials.

CONCLUSION

Overall, social integration is a positive influence on breast cancer control and should be utilized where possible in interventions, including identifying surrogate mechanisms for support for subgroups without existing social resources.

Cultural Values and Secondary Prevention of Breast Cancer in African American Women

Background

Improving mammography initiation and maintenance among African American women has been suggested as a strategy for reducing breast cancer mortality in this population.

Methods

We examined cultural values in relation to self-reported breast cancer screening among 572 low-income, urban, African American women. Cultural values examined included time orientation, family authority, employment aspirations, value of past vs modern life, and reliance on medical professionals. Also, implications for continued development of culturally tailored health interventions and opportunities for the consideration of cultural values in health communication are discussed.

Results

Bivariate analyses showed that more traditional values were associated with worse screening histories and lower intentions for future screening. In multivariate analyses, two interactions were observed between cultural values and age: for younger women, more traditional values were associated with lower odds of having ever received a mammogram, and for older women, more traditional values were associated with lower odds of intentions to receive a mammogram in the next 2 years.

Conclusions

This study adds to the evidence that cultural constructs, such as values, are associated with secondary prevention of breast cancer and supports the consideration of cultural constructs as important in increasing mammography and reducing breast cancer disparities for African American women.

Differences in the quality of the patient-physician relationship among terminally ill African-American and white patients: impact on advance care planning and treatment preferences

BACKGROUND

Little is known about the quality of the patient-physician relationship for terminally ill African Americans.

OBJECTIVE

To compare the quality of the patient-physician relationship between African-American and white patients and examine the extent to which relationship quality contributes to differences in advance care planning (ACP) and preferences for intensive life-sustaining treatment (LST).

DESIGN

Cross sectional survey of 803 terminally ill African-American and white patients.

MEASUREMENTS

Patient-reported quality of the patient-physician relationship (degree of trust, perceived respect, and joint decision making; skill in breaking bad news and listening; help in navigating the medical system), ACP, preferences for LST (cardiopulmonary resuscitation, major surgery, mechanical ventilation, and dialysis).

RESULTS

The quality of the patient-physician relationship was worse for African Americans than for white patients by all measures except trust. African Americans were less likely to have an ACP (adjusted relative risk [aRR] = 0.66, 95%CI = 0.52-0.84), and were more likely to have a preference for cardiopulmonary resuscitation and dialysis (aRR = 1.28, 95%CI = 1.03-1.58; aRR = 1.25, 95%CI = 1.07-1.47, respectively). Additional adjustment for the quality of the patient-physician relationship had no impact on the differences in ACP and treatment preferences.

CONCLUSIONS

Lower reported patient-physician relationship quality for African-American patients does not explain the observed differences between African Americans and whites in ACP and preferences for LST.

Race and mortality after acute renal failure

Black patients receiving dialysis for end-stage renal disease in the United States have lower mortality rates than white patients. Whether racial differences exist in mortality after acute renal failure is not known. We studied acute renal failure in patients hospitalized between 2000 and 2003 using the Nationwide Inpatient Sample and found that black patients had an 18% (95% confidence interval [CI] 16 to 21%) lower odds of death than white patients after adjusting for age, sex, comorbidity, and the need for mechanical ventilation. Similarly, among those with acute renal failure requiring dialysis, black patients had a 16% (95% CI 10 to 22%) lower odds of death than white patients. In stratified analyses of patients with acute renal failure, black patients had significantly lower adjusted odds of death than white patients in settings of coronary artery bypass grafting, cardiac catheterization, acute myocardial infarction, congestive heart failure, pneumonia, sepsis, and gastrointestinal hemorrhage. Black patients were more likely than white patients to be treated in hospitals that care for a larger number of patients with acute renal failure, and black patients had lower in-hospital mortality than white patients in all four quartiles of hospital volume. In conclusion, in-hospital mortality is lower for black patients with acute renal failure than white patients. Future studies should assess the reasons for this difference.

Common psychosocial factors underlying breast cancer screening and breast cancer treatment adherence: a conceptual review and synthesis

In this paper, we review the literature on psychosocial influences on breast cancer screening and treatment adherence with an eye to identifying common cognitive, emotional, and social network factors that may lead to poor screening adherence and suboptimal treatment in the case of diagnosed breast cancer. Nonadherence to breast cancer screening and treatment guidelines can significantly and negatively impact the prospects for prevention and control of breast cancer. Psychosocial factors are an especially important focus for research, inasmuch as belief structures and psychosocial characteristics (such as patterns of emotion regulation and the quality of social relations) are modifiable and are, thus, eminently suitable to intervention.

Collaborative Breast Health Intervention for African American Women of Lower Socioeconomic Status

PURPOSE/OBJECTIVES

To describe all phases of a collaborative breast health intervention delivered by paraprofessionals or specially trained community health advisors (CHAs) for African American women designed to increase mammography screening.

DESIGN

Collaborative pretest, post-test breast health intervention.

SETTING

Large city in Ohio.

SAMPLE

68 African American women with a median age of 57.8 (SD = 5.28) obtained mammography screening and participated in the breast health intervention.

METHODS

Specially trained CHAs used aggressive recruitment strategies to increase mammography screening and knowledge of breast health and mammography screening in African American women aged 50 and older.

MAIN RESEARCH VARIABLES

Knowledge scores of breast health and mammography screening.

FINDINGS

Ninety women (81%) met the inclusion criteria and were recruited into the intervention, but only 68 (76%) obtained mammography screening. The women demonstrated increased knowledge by change in pre- to post-test scores. Several questions were statistically significant.

CONCLUSIONS

Collaborative breast health interventions delivered by trained CHAs are effective in increasing screenings as well as knowledge of breast health and mammography screening in African American women. The unique role of the CHA is especially important in recruitment of hard-to-reach women and was vital to the success of the educational intervention. Most importantly, the women valued the individualized attention to their breast health and agreed to share the information with significant others. Further collaborative interventions designed to increase screenings and increase knowledge of breast health and mammography screening are needed to reduce the health disparities of later-stage detection and poorer survival of breast cancer in African American women.

IMPLICATIONS FOR NURSING

Oncology nurses should build on the findings and deliver further outreach programs to increase mammography screening and knowledge of breast health in a larger number of women of lower socioeconomic status. Future research is needed to determine the influence of reminder phone calls for mammography screening. Oncology nurses should incorporate evaluation strategies at baseline and periodically throughout an intervention to provide more comprehensive data and enhance the credibility of findings. To maximize success, oncology nurses should work collaboratively with other healthcare professionals such as certified x-ray technicians and influential people in the community to increase knowledge of breast health and mammography screening.

Mammography utilization rates among young white and black women in the USA

OBJECTIVE

To determine mammography utilization rates for randomly selected white and black women in the USA.

STUDY DESIGN

This was an observational study using data from 1988 to 2000. Data were extracted from the Behavioral Risk Factor Surveillance System, an annual self-report telephone survey conducted nationally by the Centers for Disease Control and Prevention.

METHODS

The main outcome measure was the mammography utilization rates of women ages 18-40 years responding to 'Have you ever had a mammogram?'. In total, 354097 women were included in this study [310336 (87.6%) white women and 43761 (12.4%) black women].

RESULTS

In women ages 18-33, black women showed consistently higher mammography utilization rates than white women. Utilization rates among women ages 18-23 years were 20.0% and 11.0% for black and white women, respectively. Among women ages 24-29 years, rates were 22.2% and 11.5% for black and white women, respectively. For women ages 30-33 years, rates were 25.7% and 18.1% for black and white women, respectively. Utilization rates were similar in black and white women over 33 years of age.

CONCLUSIONS

This study found that young black women were receiving more mammography screening than young white women between 1988-2000. This may be due to the increased risk of fibroid masses in young black women.

Physician and patient characteristics associated with outpatient breast cancer screening recommendations in the United States: analysis of the National Ambulatory Medical Care Survey Data 1996–2004

BACKGROUND

The primary goal of breast cancer screening tests is to find cancer at an early stage before a person has any symptoms. Evidence suggests that screening examinations such as mammography and clinical breast examinations (CBE) are effective in early detection of breast cancer. Physician recommendation is an important reason many women undergo screening. This study examined the physician and patients related factors associated with physician recommendations for breast cancer screening in the United States (US) outpatient settings.

METHODS

This cross-sectional study used data from the National Ambulatory Medical Care Survey (NAMCS) from 1996-2004. Women aged >or=40 years were included in the study sample. Multivariate logistic regression analyses were used to study the objectives.

RESULTS

Weighted analysis indicated that physicians performed 198 million CBEs and made 110 million mammography recommendations over the study period (1996-2004). Patients' age, duration of visits, history of previous breast cancer diagnosis, and source of insurance were significant predictors of screening recommendations in this population. Obstetricians and gynecologists were more likely to perform a CBE and recommend mammography than other specialty physicians.

CONCLUSIONS

These findings indicated that there were certain disparities regarding the physician recommendations of breast cancer screening for women in the US outpatient settings.

Racial and ethnic disparities in breast cancer mortality: are we doing enough to address the root causes?

Breast cancer is the most common noncutaneous malignancy and the second most lethal form of cancer among women in the United States. Mortality from breast cancer has declined since the late 1980s, but this decline has been steeper among white women compared with black women. As a result, the black:white mortality rate ratio has increased over the last two decades. Other ethnic minorities also suffer from disproportionately high breast cancer mortality rates. This review discusses the causes of racial and ethnic disparities in breast cancer mortality and describes the most common approaches to reducing these disparities. The literature suggests that outcome disparities are related to patient-, provider-, and health system-level factors. Lack of insurance, fear of testing, delay in seeking care, and unfavorable tumor characteristics all contribute to disparities at the patient level. At the provider level, insufficient screening, poor follow-up of abnormal screening tests, and nonadherence to guideline-based treatments add to outcome disparities. High copayment requirements, lack of a usual source of care, fragmentation of care, and uneven distribution of screening and treatment resources exacerbate disparities at the health system level. Although pilot programs have increased breast cancer screening among select populations, persistent disparities in mortality suggest that changes are needed at the policy level to address the root causes of these disparities.

Time spent in the united states and breast cancer screening behaviors among ethnically diverse immigrant women: Evidence for acculturation?

The current study was designed to investigate the relations between time spent in the United States and breast cancer screening in a large sample (N=915) of ethnically diverse immigrant women living in New York City. Previous research among Hispanic women has suggested that acculturation positively influences health beliefs and preventive health behaviors. However, research has not yet extended to other growing immigrant groups, including women from Haiti and the English-speaking Caribbean, and has not tested whether time spent in the United States differentially impacts breast screening across groups that are known to vary in their health beliefs. As expected, time spent in the United States was associated with a greater number of mammograms and clinical breast exams. Importantly, these relations held even when controlling for (a) age, income, education, marital status; (b) morbidity, health insurance, physician's recommendation, physical exams; and (c) ethnicity. Moreover, time spent in the United States interacted with being Haitian to predict the number of clinical breast exams. Even though Haitians were less likely to utilize breast cancer screening overall, time spent in the United States had a stronger effect on the number of clinical breast exams for Haitian women. Results are discussed in terms of the ethnic-specificity of health beliefs, how they may change over time and their implications for preventive health behaviors.

Factors related to underuse of surveillance mammography among breast cancer survivors

PURPOSE

Many older breast cancer survivors do not undergo annual mammography despite guideline recommendations. We identified factors associated with underuse of surveillance mammography and examined whether variation was explained by differences in follow-up care.

PATIENTS AND METHODS

We used Surveillance, Epidemiology, and End Results-Medicare data to identify a population-based sample of 44,511 women fee-for-service Medicare enrollees aged > or = 65 years who were diagnosed with stage I or II breast cancer in 1992 to 1999 who underwent primary surgical therapy. We assessed factors associated with mammography during months 7 to 18, 19 to 30, and 31 to 42 after breast cancer diagnosis using repeated-measures logistic regression; and we examined whether follow-up care with providers of various specialties explained variation in mammography use.

RESULTS

Only three quarters of women (77.6%) underwent mammography during months 7 to 18 after diagnosis, and only 56.7% had mammography yearly over 3 years. In multivariable analyses, women who were older, black, unmarried, and living in certain regions were less likely than other women to undergo surveillance mammography (all P < .05). Patients with more visits and patients who continued to see a medical oncologist, radiation oncologist, or surgeon were most likely to have mammograms (P < .001); however, adjusting for visits with providers did not explain the lower mammography rates based on age, race, marital status, and geographic region.

CONCLUSION

Many elderly breast cancer survivors do not undergo annual surveillance mammography, particularly women who are older, black, and unmarried, and this underuse was not explained by access to follow-up care. New strategies are needed to increase use of surveillance mammography and decrease variations based on nonclinical factors that are likely unrelated to appropriateness of medical care.

Explaining black-white differences in receipt of recommended colon cancer treatment

BACKGROUND

Black-white disparities exist in receipt of recommended medical care, including colorectal cancer treatment. This retrospective cohort study examines the degree to which health systems (e.g., physician, hospital) factors explain black-white disparities in colon cancer care.

METHODS

Data from the Surveillance, Epidemiology, and End Results program; Medicare claims; the American Medical Association Masterfile; and hospital surveys were linked to examine chemotherapy receipt after stage III colon cancer resection among 5294 elderly (> or = 66 years of age) black and white Medicare-insured patients. Logistic regression analysis was used to identify factors associated with black-white differences in chemotherapy use. All statistical tests were two-sided.

RESULTS

Black and white patients were equally likely to consult with a medical oncologist, but among patients who had such a consultation, black patients were less likely than white patients (59.3% versus 70.4%, difference = 10.9%, 95% confidence interval [CI] = 5.1% to 16.4%, P < .001) to receive chemotherapy. This black-white disparity was highest among patients aged 66-70 years (black patients 65.7%, white patients 86.3%, difference = 20.6%, 95% CI = 10.7% to 30.4%, P < .001) and decreased with age. The disparity among patients aged 66-70 years also remained statistically significant in the regression analysis. Overall, patient, physician, hospital, and environmental factors accounted for approximately 50% of the disparity in chemotherapy receipt among patients aged 66-70 years; surgical length of stay and neighborhood socioeconomic status accounted for approximately 27% of the disparity in this age group, and health systems factors accounted for 12%.

CONCLUSIONS

Black and white Medicare-insured colon cancer patients have an equal opportunity to learn about adjuvant chemotherapy from a medical oncologist but do not receive chemotherapy equally. Little disparity was explained by health systems; more was explained by illness severity, social support, and environment. Further qualitative research is needed to understand the factors that influence the lower receipt of chemotherapy by black patients.

Disparities across the breast cancer continuum

OBJECTIVE

We performed a structured review of the literature to identify areas of greater and lesser knowledge of the nature of disparities across the breast cancer continuum from risk and prevention to treatment and mortality.

METHODS

We searched OvidMedline and PubMed to identify published studies from January 1990 to March 2004 that address disparities in breast cancer. We read the abstracts of the identified articles and then reviewed the articles if they were in English, were limited to American populations, limited to women, and described quantitative outcomes. We designated the articles as addressing one or more disparities across one or more of the domains of the breast cancer continuum.

RESULTS

Substantial research exists on racial disparities in breast cancer screening, diagnosis, treatment, and survival. Disparities in screening and treatment exist across other domains of disparities including age, insurance status, and socioeconomic position. Several gaps were identified including how factors interact.

CONCLUSION

A structured review of breast cancer disparities suggests that research in other domains of social inequality and levels of the cancer continuum may uncover further disparities. A multidisciplinary and multi-pronged approach is needed to translate the knowledge from existing research into interventions to reduce or eliminate disparities.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Toward a system of cancer screening in the United States: trends and opportunities

The hard work of public health officials, physicians, and disease advocacy groups to educate Americans about the importance of early detection has resulted in uptake of screening tests at levels equivalent to or higher than in countries with organized cancer screening programs. However, the societal costs of high screening rates are larger in the United States than in other countries, including higher prices for screening, more unnecessary testing, and inefficiencies in delivery, especially in small practices. Further, screening rates are not evenly distributed across population groups, and the national expenditure on clinical and community research to promote cancer screening among individuals has not been matched by research efforts that focus on policy or clinical systems to increase screening widely throughout the population. We identify opportunities for organizational change that improve access to use, improve quality, and promote cost effectiveness in cancer screening delivery.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Racial Inequities in the Timing of Breast Cancer Detection, Diagnosis, and Initiation of Treatment

BACKGROUND

Recent studies suggest differences in quality and timeliness of care received may be major contributing sources to the racial disparity in breast cancer detection and related outcomes.

METHODS

Female patients with breast cancer diagnosed during 1985-1993 (n=400) and followed through June 20, 2001, were included in this retrospective cohort study. Three white patients were selected randomly and matched to each black patient by year of diagnosis. Method and timing of diagnosis and timing of treatment were abstracted from medical records. Initial staging and subsequent breast cancer recurrence and vital status were obtained from the Hospital and Connecticut State Tumor Registry.

RESULTS

Black women were more likely than white women to be diagnosed after a patient-noted abnormality. Black women were less likely than white women to have completed a diagnostic evaluation within 30 days after a patient-noted abnormality (P <0.01) or after having an abnormality noted on screening mammogram (P=0.0001) and were less likely to have initiated treatment within 30 days of diagnosis (P=0.0001). Women diagnosed after a patient-noted abnormality were more likely to have subsequent breast cancer recurrence and/or death due to breast cancer compared with women diagnosed after a screening mammogram (56% versus 24%, respectively, P <0.05).

CONCLUSIONS

Racial differences were identified at each step in the evaluation and treatment clinical pathway, including method of detection, timing from first symptoms of cancer to pathologic diagnosis, and timing from diagnosis to initiation of treatment. The findings highlight the need to provide equal opportunity for timely medical care and treatment.

The association of ambulatory care with breast cancer stage at diagnosis among Medicare beneficiaries

OBJECTIVE

Although nearly all elderly Americans are insured through Medicare, there is substantial variation in their use of services, which may influence detection of serious illnesses. We examined outpatient care in the 2 years before breast cancer diagnosis to identify women at high risk for limited care and assess the relationship of the physicians seen and number of visits with stage at diagnosis.

DESIGN

Retrospective cohort study using cancer registry and Medicare claims data.

PATIENTS

Population-based sample of 11,291 women aged > or =67 diagnosed with breast cancer during 1995 to 1996.

MEASUREMENTS AND MAIN RESULTS

Ten percent of women had no visits or saw only physicians other than primary care physicians or medical specialists in the 2 years before diagnosis. Such women were more often unmarried, living in urban areas or areas with low median incomes (all P> or =.01). Overall, 11.2% were diagnosed with advanced (stage III/IV) cancer. The adjusted rate was highest among women with no visits (36.2%) or with visits to physicians other than primary care physicians or medical specialists (15.3%) compared to women with visits to either a primary care physician (8.6%) or medical specialist (9.4%) or both (7.8%) (P<.001). The rate of advanced cancer also decreased with increasing number of visits (P<.001).

CONCLUSIONS

Even within this insured population, many elderly women had limited or no outpatient care in the 2 years before breast cancer diagnosis, and these women had a markedly increased risk of advanced-stage diagnosis. These women, many of whom were unmarried and living in poor and urban areas, may benefit from targeted outreach or coverage for preventive care visits.