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Del Vecchio NJ, Beaber EF, Garcia MP, Wheeler CM, Kamineni A, Chao C, Chubak J, Corley DA, Owens CL, Winer RL, Pruitt SL, Raine-Bennett T, Feldman S, Silverberg M. Provider- and Facility-Level Variation in Precancerous Cervical Biopsy Diagnoses. J Low Genit Tract Dis 2023; 27:113-119. [PMID: 36728078 PMCID: PMC10038855 DOI: 10.1097/lgt.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Reproducibility of cervical biopsy diagnoses is low and may vary based on where the diagnostic test is performed and by whom. Our objective was to measure multilevel variation in diagnoses across colposcopists, pathologists, and laboratory facilities. METHODS We cross-sectionally examined variation in cervical biopsy diagnoses within the 5 sites of the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR I) consortium within levels defined by colposcopists, pathologists, and laboratory facilities. Patients aged 18 to 65 years with a colposcopy with biopsy performed were included, with diagnoses categorized as normal, cervical intraepithelial neoplasia grade 1 (CIN1), grade 2 (CIN2), and grade 3 (CIN3). Using Markov Chain Monte-Carlo methods, we fit mixed-effects logistic regression models for biopsy diagnoses and presented median odds ratios (MORs), which reflect the variability within each level. Median odds ratios can be interpreted as the average increased odds a patient would have for a given outcome (e.g., CIN2 or CIN3 vs normal or CIN1) when switching to a provider with higher odds of diagnosing that outcome. The MOR is always 1 or greater, and a value of 1 indicates no variation in outcome for that level, with higher values indicating greater variation. RESULTS A total of 130,110 patients were included who received care across 82 laboratory facilities, 2,620 colposcopists, and 489 pathologists. Substantial variation in biopsy diagnoses was found at each level, with the most occurring between laboratory facilities, followed by pathologists and colposcopists. Substantial variation in biopsy diagnoses of CIN2 or CIN3 (vs normal or CIN1) was present between laboratory facilities (MOR: 1.26; 95% credible interval = 1.19-1.36). CONCLUSIONS Improving consistency in cervical biopsy diagnoses is needed to reduce underdiagnosis, overdiagnosis, and unnecessary treatment resulting from variation in cervical biopsy diagnoses.
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Affiliation(s)
| | - Elisabeth F. Beaber
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Michael P. Garcia
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Chun Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | | | - Rachel L. Winer
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Sandi L. Pruitt
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas; and Harold C. Simmons Cancer Center, Dallas, Texas
| | - Tina Raine-Bennett
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Sarah Feldman
- Division of Gynecologic Oncology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Michael Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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Kamineni A, Doria-Rose VP, Chubak J, Inadomi JM, Corley DA, Haas JS, Kobrin SC, Winer RL, Elston Lafata J, Beaber EF, Yudkin JS, Zheng Y, Skinner CS, Schottinger JE, Ritzwoller DP, Croswell JM, Burnett-Hartman AN. Evaluation of Harms Reporting in U.S. Cancer Screening Guidelines. Ann Intern Med 2022; 175:1582-1590. [PMID: 36162112 PMCID: PMC9903969 DOI: 10.7326/m22-1139] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Cancer screening should be recommended only when the balance between benefits and harms is favorable. This review evaluated how U.S. cancer screening guidelines reported harms, within and across organ-specific processes to screen for cancer. OBJECTIVE To describe current reporting practices and identify opportunities for improvement. DESIGN Review of guidelines. SETTING United States. PATIENTS Patients eligible for screening for breast, cervical, colorectal, lung, or prostate cancer according to U.S. guidelines. MEASUREMENTS Information was abstracted on reporting of patient-level harms associated with screening, diagnostic follow-up, and treatment. The authors classified harms reporting as not mentioned, conceptual, qualitative, or quantitative and noted whether literature was cited when harms were described. Frequency of harms reporting was summarized by organ type. RESULTS Harms reporting was inconsistent across organ types and at each step of the cancer screening process. Guidelines did not report all harms for any specific organ type or for any category of harm across organ types. The most complete harms reporting was for prostate cancer screening guidelines and the least complete for colorectal cancer screening guidelines. Conceptualization of harms and use of quantitative evidence also differed by organ type. LIMITATIONS This review considers only patient-level harms. The authors did not verify accuracy of harms information presented in the guidelines. CONCLUSION The review identified opportunities for improving conceptualization, assessment, and reporting of screening process-related harms in guidelines. Future work should consider nuances associated with each organ-specific process to screen for cancer, including which harms are most salient and where evidence gaps exist, and explicitly explore how to optimally weigh available evidence in determining net screening benefit. Improved harms reporting could aid informed decision making, ultimately improving cancer screening delivery. PRIMARY FUNDING SOURCE National Cancer Institute.
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Affiliation(s)
- Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington (A.K., J.C.)
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (V.P.D., S.C.K., J.M.C.)
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington (A.K., J.C.)
| | - John M Inadomi
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah (J.M.I.)
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California (D.A.C.)
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts (J.S.H.)
| | - Sarah C Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (V.P.D., S.C.K., J.M.C.)
| | - Rachel L Winer
- Department of Epidemiology, University of Washington, Seattle, Washington (R.L.W.)
| | - Jennifer Elston Lafata
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, and Henry Ford Health System, Detroit, Michigan (J.E.L.)
| | - Elisabeth F Beaber
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (E.F.B., Y.Z.)
| | - Joshua S Yudkin
- University of Texas Health Science Center at Houston, Houston, Texas (J.S.Y.)
| | - Yingye Zheng
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (E.F.B., Y.Z.)
| | - Celette Sugg Skinner
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, and Simmons Comprehensive Cancer Center, Dallas, Texas (C.S.S.)
| | - Joanne E Schottinger
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California (J.E.S.)
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado (D.P.R., A.N.B.)
| | - Jennifer M Croswell
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (V.P.D., S.C.K., J.M.C.)
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Chao CR, Chubak J, Beaber EF, Kamineni A, Mao C, Silverberg MJ, Tiro JA, Skinner C, Garcia M, Corley DA, Winer RL, Raine‐Bennett T, Feldman S, Wheeler CM. Gaps in the screening process for women diagnosed with cervical cancer in four diverse US health care settings. Cancer Med 2022; 12:3705-3717. [PMID: 36106421 PMCID: PMC9939213 DOI: 10.1002/cam4.5226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Potential care gaps in the cervical cancer screening process among women diagnosed with cervical cancer in an era with increased human papillomavirus (HPV) testing have not been extensively evaluated. METHODS Women diagnosed with cervical cancer between ages 21 and 65 at four study sites between 2010 and 2014 were included. Screening histories were ascertained from 0.5 to 4 years prior to cervical cancer diagnosis. We identified potential care gaps in the screening history for each woman and classified them into one of three mutually exclusive types: lack of a screening test, screening test failure, and diagnostic/treatment care gap. Distributions of care gaps were tabulated by stage, histology, and study site. Multivariable nominal logistic regression was used to examine the associations between demographic and cancer characteristics and type of care gap. RESULTS Of 499 women evaluated, 46% lacked a screening test in the time window examined, 31% experienced a screening test failure, and 22% experienced a diagnostic/treatment care gap. More than half of the women with advanced cancer and squamous cell carcinoma lacked a screening test compared to 31% and 24% of women with localized cancer and adenocarcinoma, respectively. Women aged 21-29 at diagnosis were more likely to experience screening test failure and diagnostic/treatment care gap, while those aged 50-65 were more likely to lack a screening test, compared to women aged 30-39. CONCLUSIONS Our findings demonstrate a continuing need to develop interventions targeting unscreened and under-screened women and improve detection and diagnosis of adenocarcinoma in women undergoing cervical cancer screening and diagnostic follow-up.
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Affiliation(s)
- Chun R. Chao
- Department of Research and EvaluationKaiser Permanente Southern CaliforniaPasadenaCaliforniaUSA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Elisabeth F. Beaber
- Fred Hutchinson Cancer Research Center, Public Health Sciences DivisionSeattleWashingtonUSA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research InstituteSeattleWashingtonUSA
| | - Connie Mao
- Department of Obstetrics and Gynecology, University of WashingtonSeattleWashingtonUSA
| | | | - Jasmin A. Tiro
- Department of Population and Data SciencesUniversity of Texas Southwestern Medical CenterDallasTexasUSA,Harold C. Simmons Comprehensive Cancer CenterDallasTexasUSA
| | - Celette Skinner
- Department of Population and Data SciencesUniversity of Texas Southwestern Medical CenterDallasTexasUSA,Harold C. Simmons Comprehensive Cancer CenterDallasTexasUSA
| | - Michael Garcia
- Fred Hutchinson Cancer Research Center, Public Health Sciences DivisionSeattleWashingtonUSA
| | - Douglas A. Corley
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Rachel L. Winer
- Department of EpidemiologyUniversity of Washington School of Public HealthSeattleWashingtonUSA
| | - Tina Raine‐Bennett
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA,Medicines360San FranciscoCaliforniaUSA
| | - Sarah Feldman
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Cosette M. Wheeler
- Center for HPV PreventionUniversity of New Mexico Comprehensive Cancer CenterAlbuquerqueNew MexicoUSA
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4
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Beaber EF, Kamineni A, Burnett-Hartman AN, Hixon B, Kobrin SC, Li CI, Oliver M, Rendle KA, Skinner CS, Todd K, Zheng Y, Ziebell RA, Breslau ES, Chubak J, Corley DA, Greenlee RT, Haas JS, Halm EA, Honda S, Neslund-Dudas C, Ritzwoller DP, Schottinger JE, Tiro JA, Vachani A, Doria-Rose VP. Evaluating and Improving Cancer Screening Process Quality in a Multilevel Context: The PROSPR II Consortium Design and Research Agenda. Cancer Epidemiol Biomarkers Prev 2022; 31:1521-1531. [PMID: 35916603 PMCID: PMC9350927 DOI: 10.1158/1055-9965.epi-22-0100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/08/2022] [Accepted: 05/06/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Cancer screening is a complex process involving multiple steps and levels of influence (e.g., patient, provider, facility, health care system, community, or neighborhood). We describe the design, methods, and research agenda of the Population-based Research to Optimize the Screening Process (PROSPR II) consortium. PROSPR II Research Centers (PRC), and the Coordinating Center aim to identify opportunities to improve screening processes and reduce disparities through investigation of factors affecting cervical, colorectal, and lung cancer screening in U.S. community health care settings. METHODS We collected multilevel, longitudinal cervical, colorectal, and lung cancer screening process data from clinical and administrative sources on >9 million racially and ethnically diverse individuals across 10 heterogeneous health care systems with cohorts beginning January 1, 2010. To facilitate comparisons across organ types and highlight data breadth, we calculated frequencies of multilevel characteristics and volumes of screening and diagnostic tests/procedures and abnormalities. RESULTS Variations in patient, provider, and facility characteristics reflected the PROSPR II health care systems and differing target populations. PRCs identified incident diagnoses of invasive cancers, in situ cancers, and precancers (invasive: 372 cervical, 24,131 colorectal, 11,205 lung; in situ: 911 colorectal, 32 lung; precancers: 13,838 cervical, 554,499 colorectal). CONCLUSIONS PROSPR II's research agenda aims to advance: (i) conceptualization and measurement of the cancer screening process, its multilevel factors, and quality; (ii) knowledge of cancer disparities; and (iii) evaluation of the COVID-19 pandemic's initial impacts on cancer screening. We invite researchers to collaborate with PROSPR II investigators. IMPACT PROSPR II is a valuable data resource for cancer screening researchers.
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Affiliation(s)
- Elisabeth F. Beaber
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | | | - Brian Hixon
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Sarah C. Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Christopher I. Li
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Malia Oliver
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Katharine A. Rendle
- Departments of Family Medicine and Community Health and of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Celette Sugg Skinner
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX,Simmons Comprehensive Cancer Center, Dallas, TX
| | - Kaitlin Todd
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yingye Zheng
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Erica S. Breslau
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Robert T. Greenlee
- Center for Clinical Epidemiology & Population Health, Marshfield Clinic Research Institute, Marshfield, WI
| | - Jennifer S. Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Ethan A. Halm
- Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Stacey Honda
- Hawaii Permanente Medical Group, Kaiser Permanente Center for Integrated Health Care Research, Honolulu, HI
| | | | | | | | - Jasmin A. Tiro
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX,Simmons Comprehensive Cancer Center, Dallas, TX
| | - Anil Vachani
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - V. Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
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5
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Silver MI, Anderson ML, Beaber EF, Haas JS, Kobrin S, Pocobelli G, Skinner CS, Tiro JA, Kamineni A. De-implementation of cervical cancer screening before age 21. Prev Med 2021; 153:106815. [PMID: 34599920 PMCID: PMC8802556 DOI: 10.1016/j.ypmed.2021.106815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 09/13/2021] [Accepted: 09/26/2021] [Indexed: 11/28/2022]
Abstract
In 2012, United States consensus guidelines were modified to recommend that cervical cancer screening not begin before age 21 and, since 2014, the Health Effectiveness Data and Information Set (HEDIS), a health plan quality measurement too, has included a measure for non-recommended cervical cancer screening among females ages 16-20. Our goal was to describe prevalence over time of cervical cancer screening before age 21 following the 2012 guideline change, and provide information to help understand how rapidly new guidelines may be disseminated and implemented into clinical practice. We used longitudinal clinical and administrative data from three diverse healthcare systems in the Population-based Research to Optimize the Screening Process (PROSPR II) consortium to examine annual trends in screening before age 21. We identified 55,316 average-risk, screening-eligible females ages 18-20 between 2011 and 2017. For each calendar year, we estimated the proportion of females who received a Papanicolaou (Pap) test. We observed a steady decline in the proportion of females under age 21 who received a Pap test, from an average of 8.3% in 2011 to <1% in 2017 across the sites. The observed steady decline suggests growing adherence to the 2012 consensus guidelines. This trend was consistent across diverse geographic regions, healthcare systems, and patient populations, strengthening the generalizability of the results; however, since we only had 1-2 years of study data prior to the consensus guidelines, we cannot discern whether screening under age 21 was already in decline. Nonetheless, these results provide data to compare with other guideline changes to de-implement non-recommended screening practices.
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Affiliation(s)
- Michelle I Silver
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States of America.
| | - Melissa L Anderson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Elisabeth F Beaber
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Sarah Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, United States of America
| | - Gaia Pocobelli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Celette Sugg Skinner
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Simmons Comprehensive Cancer Center, Dallas, TX, United States of America
| | - Jasmin A Tiro
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Simmons Comprehensive Cancer Center, Dallas, TX, United States of America
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
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6
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Barlow WE, Beaber EF, Geller BM, Kamineni A, Zheng Y, Haas JS, Chao CR, Rutter CM, Zauber AG, Sprague BL, Halm EA, Weaver DL, Chubak J, Doria-Rose VP, Kobrin S, Onega T, Quinn VP, Schapira MM, Tosteson ANA, Corley DA, Skinner CS, Schnall MD, Armstrong K, Wheeler CM, Silverberg MJ, Balasubramanian BA, Doubeni CA, McLerran D, Tiro JA. Evaluating Screening Participation, Follow-up, and Outcomes for Breast, Cervical, and Colorectal Cancer in the PROSPR Consortium. J Natl Cancer Inst 2020; 112:238-246. [PMID: 31292633 DOI: 10.1093/jnci/djz137] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/11/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cancer screening is a complex process encompassing risk assessment, the initial screening examination, diagnostic evaluation, and treatment of cancer precursors or early cancers. Metrics that enable comparisons across different screening targets are needed. We present population-based screening metrics for breast, cervical, and colorectal cancers for nine sites participating in the Population-based Research Optimizing Screening through Personalized Regimens consortium. METHODS We describe how selected metrics map to a trans-organ conceptual model of the screening process. For each cancer type, we calculated calendar year 2013 metrics for the screen-eligible target population (breast: ages 40-74 years; cervical: ages 21-64 years; colorectal: ages 50-75 years). Metrics for screening participation, timely diagnostic evaluation, and diagnosed cancers in the screened and total populations are presented for the total eligible population and stratified by age group and cancer type. RESULTS The overall screening-eligible populations in 2013 were 305 568 participants for breast, 3 160 128 for cervical, and 2 363 922 for colorectal cancer screening. Being up-to-date for testing was common for all three cancer types: breast (63.5%), cervical (84.6%), and colorectal (77.5%). The percentage of abnormal screens ranged from 10.7% for breast, 4.4% for cervical, and 4.5% for colorectal cancer screening. Abnormal breast screens were followed up diagnostically in almost all (96.8%) cases, and cervical and colorectal were similar (76.2% and 76.3%, respectively). Cancer rates per 1000 screens were 5.66, 0.17, and 1.46 for breast, cervical, and colorectal cancer, respectively. CONCLUSIONS Comprehensive assessment of metrics by the Population-based Research Optimizing Screening through Personalized Regimens consortium enabled systematic identification of screening process steps in need of improvement. We encourage widespread use of common metrics to allow interventions to be tested across cancer types and health-care settings.
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Affiliation(s)
| | - Elisabeth F Beaber
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Berta M Geller
- Departments of Family Medicine, and the University of Vermont Cancer Center, University of Vermont, Burlington, VT
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Yingye Zheng
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Dana Farber, Harvard Cancer Institute, Harvard School of Public Health, Boston, MA
| | - Chun R Chao
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brian L Sprague
- Departments of Surgery and Radiology, University of Vermont, Burlington, VT
| | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.,Simmons Comprehensive Cancer Center, Dallas, TX
| | - Donald L Weaver
- Department of Pathology and the UVM Cancer Center, University of Vermont, Burlington, VT
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - V Paul Doria-Rose
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.,Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Sarah Kobrin
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Tracy Onega
- Departments of Biomedical Data Science, Epidemiology, and the Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Marilyn M Schapira
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, and CMC VA Medical Center, Philadelphia, PA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Celette Sugg Skinner
- Simmons Comprehensive Cancer Center, Dallas, TX.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mitchell D Schnall
- Department of Radiology, University of Pennsylvania, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Katrina Armstrong
- General Medicine Division, MA General Hospital, Harvard Medical School, Boston, MA
| | - Cosette M Wheeler
- Departments of Pathology and Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM.,University of New Mexico Comprehensive Cancer Center, Albuquerque, NM
| | | | - Bijal A Balasubramanian
- Simmons Comprehensive Cancer Center, Dallas, TX.,UTHealth School of Public Health, Dallas, TX
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Dale McLerran
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jasmin A Tiro
- Simmons Comprehensive Cancer Center, Dallas, TX.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX
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7
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Conant EF, Barlow WE, Herschorn SD, Weaver DL, Beaber EF, Tosteson ANA, Haas JS, Lowry KP, Stout NK, Trentham-Dietz A, diFlorio-Alexander RM, Li CI, Schnall MD, Onega T, Sprague BL. Association of Digital Breast Tomosynthesis vs Digital Mammography With Cancer Detection and Recall Rates by Age and Breast Density. JAMA Oncol 2020; 5:635-642. [PMID: 30816931 DOI: 10.1001/jamaoncol.2018.7078] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance Breast cancer screening examinations using digital breast tomosynthesis (DBT) has been shown to be associated with decreased false-positive test results and increased breast cancer detection compared with digital mammography (DM). Little is known regarding the size and stage of breast cancer types detected and their association with age and breast density. Objective To determine whether screening examinations using DBT detect breast cancers that are associated with an improved prognosis and to compare the detection rates by patient age and breast density. Design, Setting, and Participants This retrospective analysis of prospective cohort data from 3 research centers in the Population-based Research Optimizing Screening Through Personalized Regimens (PROSPR) consortium included data of women aged 40 to 74 years who underwent screening examinations using DM and DBT from January 1, 2011, through September 30, 2014. Statistical analysis was performed from November 8, 2017, to August 14, 2018. Exposures Use of DBT as a supplement to DM at breast cancer screening examination. Main Outcomes and Measures Recall rate, cancer detection rate, positive predictive value, biopsy rate, and distribution of invasive cancer subtypes. Results Among 96 269 women (mean [SD] patient age for all examinations, 55.9 [9.0] years), patient age was 56.4 (9.0) years for DM and 54.6 (8.9) years for DBT. Of 180 340 breast cancer screening examinations, 129 369 examinations (71.7%) used DM and 50 971 examinations (28.3%) used DBT. Screening examination with DBT (73 of 99 women [73.7%]) was associated with the detection of smaller, more often node-negative, HER2-negative, invasive cancers compared with DM (276 of 422 women [65.4%]). Screening examination with DBT was also associated with lower recall (odds ratio, 0.64; 95% CI, 0.57-0.72; P < .001) and higher cancer detection (odds ratio, 1.41; 95% CI, 1.05-1.89; P = .02) compared with DM for all age groups even when stratified by breast density. The largest increase in cancer detection rate and the greatest shift toward smaller, node-negative invasive cancers detected with DBT was for women aged 40 to 49 years. For women aged 40 to 49 years with nondense breasts, the cancer detection rate for examinations using DBT was 1.70 per 1000 women higher compared with the rate using DM; for women with dense breasts, the cancer detection rate was 2.27 per 1000 women higher for DBT. For these younger women, screening with DBT was associated with only 7 of 28 breast cancers (25.0%) categorized as poor prognosis compared with 19 of 47 breast cancers (40.4%) when screening with DM. Conclusions and Relevance The findings suggest that screening with DBT is associated with increased specificity and an increased proportion of breast cancers detected with better prognosis compared with DM. In the subgroup of women aged 40 to 49 years, routine DBT screening may have a favorable risk-benefit ratio.
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Affiliation(s)
- Emily F Conant
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Sally D Herschorn
- Department of Radiology, University of Vermont, Burlington.,University of Vermont Cancer Center, University of Vermont, Burlington
| | - Donald L Weaver
- University of Vermont Cancer Center, University of Vermont, Burlington.,Department of Pathology, University of Vermont, Burlington
| | - Elisabeth F Beaber
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Anna N A Tosteson
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Jennifer S Haas
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Amy Trentham-Dietz
- Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin, Madison
| | | | - Christopher I Li
- Translational Research Program, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mitchell D Schnall
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Tracy Onega
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Brian L Sprague
- Department of Radiology, University of Vermont, Burlington.,University of Vermont Cancer Center, University of Vermont, Burlington.,Department of Surgery, University of Vermont, Burlington
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8
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Rendle KA, Burnett-Hartman AN, Neslund-Dudas C, Greenlee RT, Honda S, Elston Lafata J, Marcus PM, Cooley ME, Vachani A, Meza R, Oshiro C, Simoff MJ, Schnall MD, Beaber EF, Doria-Rose VP, Doubeni CA, Ritzwoller DP. Evaluating Lung Cancer Screening Across Diverse Healthcare Systems: A Process Model from the Lung PROSPR Consortium. Cancer Prev Res (Phila) 2020; 13:129-136. [PMID: 31871221 PMCID: PMC7010351 DOI: 10.1158/1940-6207.capr-19-0378] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/18/2019] [Accepted: 12/18/2019] [Indexed: 02/07/2023]
Abstract
Numerous organizations, including the United States Preventive Services Task Force, recommend annual lung cancer screening (LCS) with low-dose CT for high risk adults who meet specific criteria. Despite recommendations and national coverage for screening eligible adults through the Centers for Medicare and Medicaid Services, LCS uptake in the United States remains low (<4%). In recognition of the need to improve and understand LCS across the population, as part of the larger Population-based Research to Optimize the Screening PRocess (PROSPR) consortium, the NCI (Bethesda, MD) funded the Lung PROSPR Research Consortium consisting of five diverse healthcare systems in Colorado, Hawaii, Michigan, Pennsylvania, and Wisconsin. Using various methods and data sources, the center aims to examine utilization and outcomes of LCS across diverse populations, and assess how variations in the implementation of LCS programs shape outcomes across the screening process. This commentary presents the PROSPR LCS process model, which outlines the interrelated steps needed to complete the screening process from risk assessment to treatment. In addition to guiding planned projects within the Lung PROSPR Research Consortium, this model provides insights on the complex steps needed to implement, evaluate, and improve LCS outcomes in community practice.
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Affiliation(s)
- Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | | | | | | | - Stacey Honda
- Center for Health Research, Hawaii Permanente Medical Group, Kaiser Permanente Hawaii, Oahu, Hawaii
| | - Jennifer Elston Lafata
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, Michigan
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Pamela M Marcus
- Division of Cancer Control and Population Sciences, NCI, Bethesda, Maryland
| | | | - Anil Vachani
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Rafael Meza
- School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Caryn Oshiro
- Center for Health Research, Hawaii Permanente Medical Group, Kaiser Permanente Hawaii, Oahu, Hawaii
| | - Michael J Simoff
- Henry Ford Health System and Henry Ford Cancer Institute, Detroit, Michigan
| | - Mitchell D Schnall
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, NCI, Bethesda, Maryland
| | - Chyke A Doubeni
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
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9
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Breen N, Skinner CS, Zheng Y, Inrig S, Corley DA, Beaber EF, Garcia M, Chubak J, Doubeni C, Quinn VP, Haas JS, Li CI, Wernli KJ, Klabunde CN. Time to Follow-up After Colorectal Cancer Screening by Health Insurance Type. Am J Prev Med 2019; 56:e143-e152. [PMID: 31003603 PMCID: PMC6820676 DOI: 10.1016/j.amepre.2019.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 01/28/2023]
Abstract
INTRODUCTION The purpose of this study was to test the hypothesis that patients with Medicaid insurance or Medicaid-like coverage would have longer times to follow-up and be less likely to complete colonoscopy compared with patients with commercial insurance within the same healthcare systems. METHODS A total of 35,009 patients aged 50-64years with a positive fecal immunochemical test were evaluated in Northern and Southern California Kaiser Permanente systems and in a North Texas safety-net system between 2011 and 2012. Kaplan-Meier estimation was used between 2016 and 2017 to calculate the probability of having follow-up colonoscopy by coverage type. Among Kaiser Permanente patients, Cox regression was used to estimate hazard ratios and 95% CIs for the association between coverage type and receipt of follow-up, adjusting for sociodemographics and health status. RESULTS Even within the same integrated system with organized follow-up, patients with Medicaid were 24% less likely to complete follow-up as those with commercial insurance. Percentage receiving colonoscopy within 3 months after a positive fecal immunochemical test was 74.6% for commercial insurance, 63.10% for Medicaid only, and 37.5% for patients served by the integrated safety-net system. CONCLUSIONS This study found that patients with Medicaid were less likely than those with commercial insurance to complete follow-up colonoscopy after a positive fecal immunochemical test and had longer average times to follow-up. With the future of coverage mechanisms uncertain, it is important and timely to assess influences of health insurance coverage on likelihood of follow-up colonoscopy and identify potential disparities in screening completion.
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Affiliation(s)
- Nancy Breen
- Office of Science Planning, Policy, Analysis, Reporting and Data, National Institute on Minority Health and Health Disparities, NIH, Bethesda, Maryland.
| | - Celette Sugg Skinner
- Department of Clinical Sciences, Parkland Health and Hospital System/University of Texas Southwestern Medical Center, Dallas, Texas; Department of Population Sciences, Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Yingye Zheng
- Department of Biostatistics, Public Health Science Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Stephen Inrig
- Department of Clinical Sciences, Parkland Health and Hospital System/University of Texas Southwestern Medical Center, Dallas, Texas
| | - Douglas A Corley
- Division of Research, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Elisabeth F Beaber
- Department of Biostatistics, Public Health Science Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mike Garcia
- Department of Biostatistics, Public Health Science Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Chyke Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, Universityof Pennsylvania, Philadelphia, Pennsylvania
| | - Virginia P Quinn
- Research and Evaluation, Kaiser Permanente Southern California, Los Angeles, California
| | - Jennifer S Haas
- Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Christopher I Li
- Department of Biostatistics, Public Health Science Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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10
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Kamineni A, Tiro JA, Beaber EF, Silverberg MJ, Wheeler CM, Chao CR, Chubak J, Skinner CS, Corley DA, Kim JJ, Balasubramanian BA, Paul Doria-Rose V. Cervical cancer screening research in the PROSPR I consortium: Rationale, methods and baseline findings from a US cohort. Int J Cancer 2018; 144:1460-1473. [PMID: 30353911 DOI: 10.1002/ijc.31940] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 09/24/2018] [Accepted: 09/28/2018] [Indexed: 11/09/2022]
Abstract
Little is known about the effect of evolving risk-based cervical cancer screening and management guidelines on United States (US) clinical practice and patient outcomes. We describe the National Cancer Institute's Population-based Research Optimizing Screening through Personalized Regimens (PROSPR I) consortium, methods and baseline findings from its cervical sites: Kaiser Permanente Washington, Kaiser Permanente Northern California, Kaiser Permanente Southern California, Parkland Health & Hospital System/University of Texas Southwestern (Parkland-UTSW) and New Mexico HPV Pap Registry housed by University of New Mexico (UNM-NMHPVPR). Across these diverse healthcare settings, we collected data on human papillomavirus (HPV) vaccinations, screening tests/results, diagnostic and treatment procedures/results and cancer diagnoses on nearly 4.7 million women aged 18-89 years from 2010 to 2014. We calculated baseline (2012 for UNM-NMHPVPR; 2010 for other sites) frequencies for sociodemographics, cervical cancer risk factors and key screening process measures for each site's cohort. Healthcare delivery settings, cervical cancer screening strategy, race/ethnicity and insurance status varied among sites. The proportion of women receiving a Pap test during the baseline year was similar across sites (26.1-36.1%). Most high-risk HPV tests were performed either reflexively or as cotests, and utilization pattern varied by site. Prevalence of colposcopy or biopsy was higher at Parkland-UTSW (3.6%) than other sites (1.3-1.4%). Incident cervical cancer was rare. HPV vaccination among age-eligible women not already immunized was modest across sites (0.1-7.2%). Cervical PROSPR I makes available high-quality, multilevel, longitudinal screening process data from a large and diverse cohort of women to evaluate and improve the effectiveness of US cervical cancer screening delivery.
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Affiliation(s)
- Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Jasmin A Tiro
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX.,Simmons Comprehensive Cancer Center, Dallas, TX
| | - Elisabeth F Beaber
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Cosette M Wheeler
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM
| | - Chun R Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Celette Sugg Skinner
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX.,Simmons Comprehensive Cancer Center, Dallas, TX
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jane J Kim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Bijal A Balasubramanian
- Simmons Comprehensive Cancer Center, Dallas, TX.,UTHealth School of Public Health in Dallas, Dallas, TX
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
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11
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Beaber EF, Sprague BL, Tosteson ANA, Haas JS, Onega T, Schapira MM, McCarthy AM, Li CI, Herschorn SD, Lehman CD, Wernli KJ, Barlow WE. Multilevel Predictors of Continued Adherence to Breast Cancer Screening Among Women Ages 50-74 Years in a Screening Population. J Womens Health (Larchmt) 2018; 28:1051-1059. [PMID: 30481098 DOI: 10.1089/jwh.2018.6997] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: U.S. women of ages 50-74 years are recommended to receive screening mammography at least biennially. Our objective was to evaluate multilevel predictors of nonadherence among screened women, as these are not well known. Materials and Methods: A cohort study was conducted among women of ages 50-74 years with a screening mammogram in 2011 with a negative finding (Breast Imaging-Reporting and Data System 1 or 2) within Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium research centers. We evaluated the association between woman-level factors, radiology facility, and PROSPR research center, and nonadherence to breast cancer screening guidelines, defined as not receiving breast imaging within 27 months of an index screening mammogram. Multilevel mixed-effects logistic regression was used to calculate odds ratios and 95% confidence intervals. Results: Nonadherence to guideline-recommended screening interval was 15.5% among 51,241 women with a screening mammogram. Non-Hispanic Asian/Pacific Islander women, women of other races, heavier women, and women of ages 50-59 years had a greater odds of nonadherence. There was no association with ZIP code median income. Nonadherence varied by research center and radiology facility (variance = 0.10, standard error = 0.03). Adjusted radiology facility nonadherence rates ranged from 10.0% to 26.5%. One research center evaluated radiology facility communication practices for screening reminders and scheduling, but these were not associated with nonadherence. Conclusions: Breast cancer screening interval nonadherence rates in screened women varied across radiology facilities even after adjustment for woman-level characteristics and research center. Future studies should investigate other characteristics of facilities, practices, and health systems to determine factors integral to increasing continued adherence to breast cancer screening.
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Affiliation(s)
- Elisabeth F Beaber
- 1Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Brian L Sprague
- 2Department of Surgery, University of Vermont Cancer Center, University of Vermont, Burlington, Vermont.,3Department of Radiology, University of Vermont Cancer Center, University of Vermont, Burlington, Vermont
| | - Anna N A Tosteson
- 4The Dartmouth Institute for Health Policy and Clinical Practice, Department of Medicine, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Jennifer S Haas
- 5Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tracy Onega
- 6Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.,7Department of Epidemiology, The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Marilyn M Schapira
- 8Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne Marie McCarthy
- 9Department of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher I Li
- 1Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Sally D Herschorn
- 10Department of Radiology, University of Vermont Cancer Center, University of Vermont, Burlington, Vermont
| | - Constance D Lehman
- 11Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Karen J Wernli
- 12Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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12
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Chubak J, McLerran D, Zheng Y, Singal AG, Corley DA, Doria-Rose VP, Doubeni CA, Kamineni A, Haas JS, Halm EA, Skinner CS, Zauber AG, Wernli KJ, Beaber EF. Receipt of Colonoscopy Following Diagnosis of Advanced Adenomas: An Analysis within Integrated Healthcare Delivery Systems. Cancer Epidemiol Biomarkers Prev 2018; 28:91-98. [PMID: 30459208 DOI: 10.1158/1055-9965.epi-18-0452] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 07/06/2018] [Accepted: 09/04/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND To reduce colorectal cancer incidence and mortality, experts recommend surveillance colonoscopy 3 years after advanced adenoma removal. Little is known about adherence to that interval. METHODS We describe patterns of and factors associated with subsequent colonoscopy among persons with ≥3 adenomas and/or ≥1 adenoma with villous/tubulovillous histology in four U.S. integrated healthcare delivery systems. We report Kaplan-Meier estimators of the cumulative percentage of patients undergoing colonoscopy 6 months to 3.5 years after an index colonoscopy with high-risk findings. Combining data from three healthcare systems, we used multivariable logistic regression with inverse probability of censoring weights to estimate ORs and 95% confidence intervals (CI) for associations between patient characteristics and receipt of subsequent colonoscopy. RESULTS Among 6,909 persons with advanced adenomas, the percent receiving a subsequent colonoscopy 6 months to 3.5 years later ranged from 18.3% (95% CI: 11.7%-27.8%) to 59.5% (95% CI: 53.8%-65.2%) across healthcare systems. Differences remained significant in the multivariable model. Patients with ≥3 adenomas were more likely than those with 1 to 2 villous/tubulovillous adenomas to undergo subsequent colonoscopy. Subsequent colonoscopy was also more common for patients ages 60-74 and less common for patients ages 80 to 89 compared with those ages 50 to 54 years at their index colonoscopy. Sex, race/ethnicity, and comorbidity index score were generally not associated with subsequent colonoscopy receipt. CONCLUSIONS Colonoscopy within the recommended interval following advanced adenoma was underutilized and varied by healthcare system, age, and number of adenomas. IMPACT Strategies to improve adherence to surveillance colonoscopy following advanced adenomas are needed.
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Affiliation(s)
- Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington. .,Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington
| | - Dale McLerran
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yingye Zheng
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Amit G Singal
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - V Paul Doria-Rose
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Jennifer S Haas
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ethan A Halm
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Celette Sugg Skinner
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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13
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Schapira MM, Barlow WE, Conant EF, Sprague BL, Tosteson AN, Haas JS, Onega T, Beaber EF, Goodrich M, McCarthy AM, Herschorn SD, Skinner CS, Harrington TO, Geller B. Communication Practices of Mammography Facilities and Timely Follow-up of a Screening Mammogram with a BI-RADS 0 Assessment. Acad Radiol 2018; 25:1118-1127. [PMID: 29433892 DOI: 10.1016/j.acra.2017.12.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/15/2017] [Accepted: 12/27/2017] [Indexed: 12/15/2022]
Abstract
RATIONALE AND OBJECTIVES The objective of this study was to evaluate the association of communication practices with timely follow-up of screening mammograms read as Breast Imaging Reporting and Data Systems (BI-RADS) 0 in the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. MATERIALS AND METHODS A radiology facility survey was conducted in 2015 with responses linked to screening mammograms obtained in 2011-2014. We considered timely follow-up to be within 15 days of the screening mammogram. Generalized estimating equation models were used to evaluate the association between modes of communication with patients and providers and timely follow-up, adjusting for PROSPR site, patient age, and race and ethnicity. RESULTS The analysis included 34,680 mammography examinations with a BI-RADS 0 assessment among 28 facilities. Across facilities, 85.6% of examinations had a follow-up within 15 days. Patients in a facility where routine practice was to contact the patient by phone if follow-up imaging was recommended were more likely to have timely follow-up (odds ratio [OR] 4.63, 95% confidence interval [CI] 2.76-7.76), whereas standard use of mail was associated with reduced timely follow-up (OR 0.47, 95% CI 0.30-0.75). Facilities that had standard use of electronic medical records to report the need for follow-up imaging to a provider had less timely follow-up (OR 0.56, 95% CI 0.35-0.90). Facilities that routinely contacted patients by mail if they missed a follow-up imaging visit were more likely to have timely follow-up (OR 1.65, 95% CI 1.02-2.69). CONCLUSIONS Our findings support the value of telephone communication to patients in relation to timely follow-up. Future research is needed to evaluate the role of communication in completing the breast cancer screening episode.
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14
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Haas JS, Barlow WE, Schapira MM, MacLean CD, Klabunde CN, Sprague BL, Beaber EF, Chen JS, Bitton A, Onega T, Harris K, Tosteson ANA. Primary Care Providers' Beliefs and Recommendations and Use of Screening Mammography by their Patients. J Gen Intern Med 2017; 32:449-457. [PMID: 28070772 PMCID: PMC5377895 DOI: 10.1007/s11606-016-3973-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 12/12/2016] [Accepted: 12/15/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Revised breast cancer screening guidelines have fueled debate about the effectiveness and frequency of screening mammography, encouraging discussion between women and their providers. OBJECTIVE To examine whether primary care providers' (PCPs') beliefs about the effectiveness and frequency of screening mammography are associated with utilization by their patients. DESIGN Cross-sectional survey data from PCPs (2014) from three primary care networks affiliated with the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium, linked with data about their patients' mammography use (2011-2014). PARTICIPANTS PCPs (n = 209) and their female patients age 40-89 years without breast cancer (n = 30,233). MAIN MEASURES Outcomes included whether (1) women received a screening mammogram during a 2-year period; and (2) screened women had >1 mammogram during that period, reflecting annual screening. Principal independent variables were PCP beliefs about the effectiveness of mammography and their recommendations for screening frequency. KEY RESULTS Overall 65.2% of women received >1 screening mammogram. For women 40-48 years, mammography use was modestly lower for those cared for by PCPs who believed that screening was ineffective compared with those who believed it was somewhat or very effective (59.1%, 62.3%, and 64.7%; p = 0.019 after controlling for patient characteristics). Of women with PCPs who reported they did not recommend screening before age 50, 48.1% were nonetheless screened. For women age 49-74 years, the vast majority were cared for by providers who believed that screening was effective. Provider recommendations were not associated with screening frequency. For women ≥75 years, those cared for by providers who were uncertain about effectiveness had higher screening use (50.7%) than those cared for by providers who believed it was somewhat effective (42.8%). Patients of providers who did not recommend screening were less likely to be screened than were those whose providers recommended annual screening, yet 37.1% of patients whose providers recommended against screening still received screening. CONCLUSIONS PCP beliefs about mammography effectiveness and screening recommendations are only modestly associated with use, suggesting other likely influences on patient participation in mammography.
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Affiliation(s)
- Jennifer S Haas
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA. .,Harvard Medical School, Boston, MA, USA. .,Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | | | - Marilyn M Schapira
- University of Pennsylvania and the Philadelphia VA Medical Center, Philadelphia, PA, USA
| | | | - Carrie N Klabunde
- Office of Disease Prevention, Office of the Director, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Jane S Chen
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Asaf Bitton
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.,Harvard Medical School, Boston, MA, USA
| | - Tracy Onega
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Kimberly Harris
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Anna N A Tosteson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
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15
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Weiss JE, Goodrich M, Harris KA, Chicoine RE, Synnestvedt MB, Pyle SJ, Chen JS, Herschorn SD, Beaber EF, Haas JS, Tosteson ANA, Onega T. Challenges With Identifying Indication for Examination in Breast Imaging as a Key Clinical Attribute in Practice, Research, and Policy. J Am Coll Radiol 2016; 14:198-207.e2. [PMID: 27744009 DOI: 10.1016/j.jacr.2016.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/16/2016] [Accepted: 08/19/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess indication for examination for four breast imaging modalities and describe the complexity and heterogeneity of data sources and ascertainment methods. METHODS Indication was evaluated among the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) breast cancer research centers (PRCs). Indication data were reported overall and separately for four breast imaging modalities: digital mammography (DM), digital breast tomosynthesis (DBT), ultrasound (US), and magnetic resonance imaging (MRI). RESULTS The breast PRCs contributed 236,262 women with 607,735 breast imaging records from 31 radiology facilities. We found a high degree of heterogeneity for indication within and across six data sources. Structured codes within a data source were used most often to identify indication for mammography (59% DM, 85% DBT) and text analytics for US (45%) and MRI (44%). Indication could not be identified for 17% of US and 26% of MRI compared with 2% of mammography examinations (1% DM, 3% DBT). CONCLUSIONS Multiple and diverse data sources, heterogeneity of ascertainment methods, and nonstandardization of codes within and across data systems for determining indication were found. Consideration of data sources and standardized methodology for determining indication is needed to assure accurate measurement of cancer screening rates and performance in clinical practice and research.
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Affiliation(s)
- Julie E Weiss
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire.
| | - Martha Goodrich
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Kimberly A Harris
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Marie B Synnestvedt
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steve J Pyle
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Jane S Chen
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sally D Herschorn
- University of Vermont and Vermont Cancer Center, Burlington, Vermont; Department of Radiology, University of Vermont, Burlington, Vermont
| | - Elisabeth F Beaber
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jennifer S Haas
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Anna N A Tosteson
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Tracy Onega
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Sprague BL, Conant EF, Onega T, Garcia MP, Beaber EF, Herschorn SD, Lehman CD, Tosteson ANA, Lacson R, Schnall MD, Kontos D, Haas JS, Weaver DL, Barlow WE. Variation in Mammographic Breast Density Assessments Among Radiologists in Clinical Practice: A Multicenter Observational Study. Ann Intern Med 2016; 165:457-464. [PMID: 27428568 PMCID: PMC5050130 DOI: 10.7326/m15-2934] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND About half of the United States has legislation requiring radiology facilities to disclose mammographic breast density information to women, often with language recommending discussion of supplemental screening options for women with dense breasts. OBJECTIVE To examine variation in breast density assessment across radiologists in clinical practice. DESIGN Cross-sectional and longitudinal analyses of prospectively collected observational data. SETTING 30 radiology facilities within the 3 breast cancer screening research centers of the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. PARTICIPANTS Radiologists who interpreted at least 500 screening mammograms during 2011 to 2013 (n = 83). Data on 216 783 screening mammograms from 145 123 women aged 40 to 89 years were included. MEASUREMENTS Mammographic breast density, as clinically recorded using the 4 Breast Imaging Reporting and Data System categories (heterogeneously dense and extremely dense categories were considered "dense" for analyses), and patient age, race, and body mass index (BMI). RESULTS Overall, 36.9% of mammograms were rated as showing dense breasts. Across radiologists, this percentage ranged from 6.3% to 84.5% (median, 38.7% [interquartile range, 28.9% to 50.9%]), with multivariable adjustment for patient characteristics having little effect (interquartile range, 29.9% to 50.8%). Examination of patient subgroups revealed that variation in density assessment across radiologists was pervasive in all but the most extreme patient age and BMI combinations. Among women with consecutive mammograms interpreted by different radiologists, 17.2% (5909 of 34 271) had discordant assessments of dense versus nondense status. LIMITATION Quantitative measures of mammographic breast density were not available for comparison. CONCLUSION There is wide variation in density assessment across radiologists that should be carefully considered by providers and policymakers when considering supplemental screening strategies. The likelihood of a woman being told she has dense breasts varies substantially according to which radiologist interprets her mammogram. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Brian L Sprague
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Emily F Conant
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Tracy Onega
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael P Garcia
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Elisabeth F Beaber
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Sally D Herschorn
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Constance D Lehman
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Anna N A Tosteson
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Ronilda Lacson
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchell D Schnall
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Despina Kontos
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Jennifer S Haas
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Donald L Weaver
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - William E Barlow
- From University of Vermont, Burlington, Vermont; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Fred Hutchinson Cancer Research Center and Cancer Research and Biostatistics, Seattle, Washington; and Massachusetts General Hospital and Brigham and Women's Hospital, Boston, Massachusetts
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Halm EA, Beaber EF, McLerran D, Chubak J, Corley DA, Rutter CM, Doubeni CA, Haas JS, Balasubramanian BA. Association Between Primary Care Visits and Colorectal Cancer Screening Outcomes in the Era of Population Health Outreach. J Gen Intern Med 2016; 31:1190-7. [PMID: 27279097 PMCID: PMC5023609 DOI: 10.1007/s11606-016-3760-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 04/06/2016] [Accepted: 05/24/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown. OBJECTIVE To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT). DESIGN Population-based cohort study. PARTICIPANTS A total of 968,072 patients ages 50-74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. MEASURES Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding. RESULTS Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR = 1.88, 95 % CI: 1.86-1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR = 1.30; 95 % CI: 1.22-1.40). CONCLUSIONS Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening.
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Affiliation(s)
- Ethan A Halm
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Elisabeth F Beaber
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Dale McLerran
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | - Chyke A Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer S Haas
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics & Environmental Sciences, University of Texas School of Public Health, Dallas, TX, USA
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18
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Schapira MM, Sprague BL, Klabunde CN, Tosteson ANA, Bitton A, Chen JS, Beaber EF, Onega T, MacLean CD, Harris K, Howe K, Pearson L, Feldman S, Brawarsky P, Haas JS. Inadequate Systems to Support Breast and Cervical Cancer Screening in Primary Care Practice. J Gen Intern Med 2016; 31:1148-55. [PMID: 27251058 PMCID: PMC5023599 DOI: 10.1007/s11606-016-3726-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/25/2016] [Accepted: 04/22/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND Despite substantial resources devoted to cancer screening nationally, the availability of clinical practice-based systems to support screening guidelines is not known. OBJECTIVE To characterize the prevalence and correlates of practice-based systems to support breast and cervical cancer screening, with a focus on the patient-centered medical home (PCMH). DESIGN Web and mail survey of primary care providers conducted in 2014. The survey assessed provider (gender, training) and facility (size, specialty training, physician report of National Committee for Quality Assurance (NCQA) PCMH recognition, and practice affiliation) characteristics. A hierarchical multivariate analysis clustered by clinical practice was conducted to evaluate characteristics associated with the adoption of practice-based systems and technology to support guideline-adherent screening. PARTICIPANTS Primary care physicians in family medicine, general internal medicine, and obstetrics and gynecology, and nurse practitioners or physician assistants from four clinical care networks affiliated with PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium research centers. MAIN MEASURES The prevalence of routine breast cancer risk assessment, electronic health record (EHR) decision support, comparative performance reports, and panel reports of patients due for routine screening and follow-up. KEY RESULTS There were 385 participants (57.6 % of eligible). Forty-seven percent (47.0 %) of providers reported NCQA recognition as a PCMH. Less than half reported EHR decision support for breast (48.8 %) or cervical cancer (46.2 %) screening. A minority received comparative performance reports for breast (26.2 %) or cervical (19.7 %) cancer screening, automated reports of patients overdue for breast (18.7 %) or cervical (16.4 %) cancer screening, or follow-up of abnormal breast (18.1 %) or cervical (17.6 %) cancer screening tests. In multivariate analysis, reported NCQA recognition as a PCMH was associated with greater use of comparative performance reports of guideline-adherent breast (OR 3.23, 95 % CI 1.58-6.61) or cervical (OR 2.56, 95 % CI 1.32-4.96) cancer screening and automated reports of patients overdue for breast (OR 2.19, 95 % CI 1.15-41.7) or cervical (OR. 2.56, 95 % CI 1.26-5.26) cancer screening. CONCLUSIONS Providers lack systems to support breast and cervical cancer screening. Practice transformation toward a PCMH may support the adoption of systems to achieve guideline-adherent cancer screening in primary care settings.
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Affiliation(s)
- Marilyn M Schapira
- University of Pennsylvania and the Philadelphia VA Medical Center, 1110 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA.
| | | | - Carrie N Klabunde
- Office of Disease Prevention, Office of the Director, National Institutes of Health, Bethesda, MD, USA
| | - Anna N A Tosteson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Asaf Bitton
- Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Jane S Chen
- Brigham and Women's Hospital, Boston, MA, USA
| | | | - Tracy Onega
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | | | | | | | - Loretta Pearson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Sarah Feldman
- Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | | | - Jennifer S Haas
- Division of General Internal Medicine and Primary Care, Brigham and Woman's Hospital, Boston, MA, USA
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19
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McCarthy AM, Kim JJ, Beaber EF, Zheng Y, Burnett-Hartman A, Chubak J, Ghai NR, McLerran D, Breen N, Conant EF, Geller BM, Green BB, Klabunde CN, Inrig S, Skinner CS, Quinn VP, Haas JS, Schnall M, Rutter CM, Barlow WE, Corley DA, Armstrong K, Doubeni CA. Follow-Up of Abnormal Breast and Colorectal Cancer Screening by Race/Ethnicity. Am J Prev Med 2016; 51:507-12. [PMID: 27132628 PMCID: PMC5030116 DOI: 10.1016/j.amepre.2016.03.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/14/2016] [Accepted: 03/14/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Timely follow-up of abnormal tests is critical to the effectiveness of cancer screening, but may vary by screening test, healthcare system, and sociodemographic group. METHODS Timely follow-up of abnormal mammogram and fecal occult blood testing or fecal immunochemical tests (FOBT/FIT) were compared by race/ethnicity using Population-Based Research Optimizing Screening through Personalized Regimens consortium data. Participants were women with an abnormal mammogram (aged 40-75 years) or FOBT/FIT (aged 50-75 years) in 2010-2012. Analyses were performed in 2015. Timely follow-up was defined as colonoscopy ≤3 months following positive FOBT/FIT; additional imaging or biopsy ≤3 months following Breast Imaging Reporting and Data System Category 0, 4, or 5 mammograms; or ≤9 months following Category 3 mammograms. Logistic regression was used to model receipt of timely follow-up adjusting for study site, age, year, insurance, and income. RESULTS Among 166,602 mammograms, 10.7% were abnormal; among 566,781 FOBT/FITs, 4.3% were abnormal. Nearly 96% of patients with abnormal mammograms received timely follow-up versus 68% with abnormal FOBT/FIT. There was greater variability in receipt of follow-up across healthcare systems for positive FOBT/FIT than for abnormal mammograms. For mammography, black women were less likely than whites to receive timely follow-up (91.8% vs 96.0%, OR=0.71, 95% CI=0.51, 0.97). For FOBT/FIT, Hispanics were more likely than whites to receive timely follow-up than whites (70.0% vs 67.6%, OR=1.12, 95% CI=1.04, 1.21). CONCLUSIONS Timely follow-up among women was more likely for abnormal mammograms than FOBT/FITs, with small variations in follow-up rates by race/ethnicity and larger variation across healthcare systems.
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Affiliation(s)
- Anne Marie McCarthy
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Elisabeth F Beaber
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Yingye Zheng
- Department of Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Andrea Burnett-Hartman
- Division of Epidemiology, Fred Hutchinson Cancer Research Center, Seattle, Washington; Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | | | - Nirupa R Ghai
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Dale McLerran
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Nancy Breen
- Health Systems and Interventions Research Branch, National Cancer Institute, Bethesda, Maryland
| | - Emily F Conant
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, Vermont
| | | | | | - Stephen Inrig
- Department of Health Policy and History of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Health Policy and Management, Mount Saint Mary's University, Los Angeles, California
| | - Celette Sugg Skinner
- Department of Clinical Science and Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Virginia P Quinn
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Jennifer S Haas
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchell Schnall
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - William E Barlow
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Douglas A Corley
- Department of Gastroenterology, Kaiser Permanente Northern California, Oakland, California
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
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20
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Klabunde CN, Zheng Y, Quinn VP, Beaber EF, Rutter CM, Halm EA, Chubak J, Doubeni CA, Haas JS, Kamineni A, Schapira MM, Vacek PM, Garcia MP, Corley DA. Influence of Age and Comorbidity on Colorectal Cancer Screening in the Elderly. Am J Prev Med 2016; 51:e67-75. [PMID: 27344108 PMCID: PMC4992638 DOI: 10.1016/j.amepre.2016.04.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 04/15/2016] [Accepted: 04/15/2016] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Expert recommendations differ for colorectal cancer screening in the elderly. Recent studies suggest that healthy adults aged >75 years may benefit from screening. This study examined screening use and follow-up, and how they varied by health status within age strata, among a large cohort of elderly individuals in community settings. METHODS A population-based, longitudinal cohort study was conducted among health plan members aged 65-89 years enrolled during 2011-2012 in three integrated healthcare systems participating in the Population-Based Research Optimizing Screening through Personalized Regimens consortium. Comorbidity measurements used the Charlson index. Analyses, conducted in 2015, comprised descriptive statistics and multivariable modeling that estimated age by comorbidity-specific percentages of patients for two outcomes: colorectal cancer screening uptake and follow-up of abnormal fecal blood tests. RESULTS Among 846,267 patients, 72% were up-to-date with colorectal cancer screening. Of patients with a positive fecal blood test, 65% received follow-up colonoscopy within 3 months. Likelihood of being up-to-date and receiving timely follow-up was significantly lower for patients aged ≥76 years than their younger counterparts (p<0.001). Comorbidity was less influential than age and more strongly related to timely follow-up than being up-to-date. In all age groups, considerable numbers of patients with no/low comorbidity were not up-to-date or did not receive timely follow-up. CONCLUSIONS In three integrated healthcare systems, many older, relatively healthy patients were not screening up-to-date, and some relatively young, healthy patients did not receive timely follow-up. Findings suggest a need for re-evaluating age-based screening guidelines and improving screening completion among the elderly.
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Affiliation(s)
- Carrie N Klabunde
- Office of Disease Prevention, Office of the Director, NIH, Rockville, Maryland.
| | - Yingye Zheng
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Virginia P Quinn
- Kaiser Permanente Southern California, Research and Evaluation, Pasadena, California
| | - Elisabeth F Beaber
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Ethan A Halm
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Chyke A Doubeni
- Department of Family Medicine and Community Health and Department of Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer S Haas
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Marilyn M Schapira
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania and the Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - Pamela M Vacek
- Medical Biostatistics Unit, University of Vermont College of Medicine, Burlington, Vermont
| | - Michael P Garcia
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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21
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Haas JS, Sprague BL, Klabunde CN, Tosteson ANA, Chen JS, Bitton A, Beaber EF, Onega T, Kim JJ, MacLean CD, Harris K, Yamartino P, Howe K, Pearson L, Feldman S, Brawarsky P, Schapira MM. Provider Attitudes and Screening Practices Following Changes in Breast and Cervical Cancer Screening Guidelines. J Gen Intern Med 2016; 31:52-9. [PMID: 26129780 PMCID: PMC4700005 DOI: 10.1007/s11606-015-3449-5] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Changes to national guidelines for breast and cervical cancer screening have created confusion and controversy for women and their primary care providers. OBJECTIVE To characterize women's primary health care provider attitudes towards screening and changes in practice in response to recent revisions in guidelines for breast and cervical cancer screening. DESIGN, SETTING, PARTICIPANTS In 2014, we distributed a confidential web and mail survey to 668 women's health care providers affiliated with the four clinical care networks participating in the three PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium breast cancer research centers (385 respondents; response rate 57.6 %). MAIN MEASURES We assessed self-reported attitudes toward breast and cervical cancer screening, as well as practice changes in response to the most recent revisions of the U.S. Preventive Services Task Force (USPSTF) recommendations. KEY RESULTS The majority of providers believed that mammography screening was effective for reducing cancer mortality among women ages 40-74 years, and that Papanicolaou (Pap) testing was very effective for women ages 21-64 years. While the USPSTF breast and cervical cancer screening recommendations were widely perceived by the respondents as influential, 75.7 and 41.2 % of providers (for mammography and cervical cancer screening, respectively) reported screening practices in excess of those recommended by USPSTF. Provider-reported barriers to concordance with guideline recommendations included: patient concerns (74 and 36 % for breast and cervical, respectively), provider disagreement with the recommendations (50 and 14 %), health system measurement of a provider's screening practices that use conflicting measurement criteria (40 and 21 %), concern about malpractice risk (33 and 11 %), and lack of time to discuss the benefits and harms with their patients (17 and 8 %). CONCLUSIONS Primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential.
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Affiliation(s)
- Jennifer S Haas
- Brigham and Women's Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Harvard T.H. Chan School of Public Health, Boston, MA, USA. .,Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
| | | | - Carrie N Klabunde
- Office of Disease Prevention, Office of the Director, National Institutes of Health, Bethesda, MD, USA
| | - Anna N A Tosteson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Jane S Chen
- Brigham and Women's Hospital, Boston, MA, USA
| | - Asaf Bitton
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Tracy Onega
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Jane J Kim
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Phillip Yamartino
- University of Pennsylvania and the Philadelphia VA Medical Center, Philadelphia, PA, USA
| | | | - Loretta Pearson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Sarah Feldman
- Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Marilyn M Schapira
- University of Pennsylvania and the Philadelphia VA Medical Center, Philadelphia, PA, USA
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22
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Beaber EF, Kim JJ, Schapira MM, Tosteson ANA, Zauber AG, Geiger AM, Kamineni A, Weaver DL, Tiro JA. Unifying screening processes within the PROSPR consortium: a conceptual model for breast, cervical, and colorectal cancer screening. J Natl Cancer Inst 2015; 107:djv120. [PMID: 25957378 PMCID: PMC4838064 DOI: 10.1093/jnci/djv120] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 02/18/2015] [Accepted: 04/03/2015] [Indexed: 12/13/2022] Open
Abstract
General frameworks of the cancer screening process are available, but none directly compare the process in detail across different organ sites. This limits the ability of medical and public health professionals to develop and evaluate coordinated screening programs that apply resources and population management strategies available for one cancer site to other sites. We present a trans-organ conceptual model that incorporates a single screening episode for breast, cervical, and colorectal cancers into a unified framework based on clinical guidelines and protocols; the model concepts could be expanded to other organ sites. The model covers four types of care in the screening process: risk assessment, detection, diagnosis, and treatment. Interfaces between different provider teams (eg, primary care and specialty care), including communication and transfer of responsibility, may occur when transitioning between types of care. Our model highlights across each organ site similarities and differences in steps, interfaces, and transitions in the screening process and documents the conclusion of a screening episode. This model was developed within the National Cancer Institute-funded consortium Population-based Research Optimizing Screening through Personalized Regimens (PROSPR). PROSPR aims to optimize the screening process for breast, cervical, and colorectal cancer and includes seven research centers and a statistical coordinating center. Given current health care reform initiatives in the United States, this conceptual model can facilitate the development of comprehensive quality metrics for cancer screening and promote trans-organ comparative cancer screening research. PROSPR findings will support the design of interventions that improve screening outcomes across multiple cancer sites.
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Affiliation(s)
- Elisabeth F Beaber
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT).
| | - Jane J Kim
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Marilyn M Schapira
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Anna N A Tosteson
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Ann G Zauber
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Ann M Geiger
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Aruna Kamineni
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Donald L Weaver
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Jasmin A Tiro
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
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Beaber EF, Buist DSM, Barlow WE, Malone KE, Reed SD, Li CI. Recent oral contraceptive use by formulation and breast cancer risk among women 20 to 49 years of age. Cancer Res 2015; 74:4078-89. [PMID: 25085875 DOI: 10.1158/0008-5472.can-13-3400] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Previous studies of oral contraceptives and breast cancer indicate that recent use slightly increases risk, but most studies relied on self-reported use and did not examine contemporary oral contraceptive formulations. This nested case-control study was among female enrollees in a large U.S. integrated health care delivery system. Cases were 1,102 women ages 20 to 49 years diagnosed with invasive breast cancer from 1990 to 2009. Controls were randomly sampled from enrollment records (n = 21,952) and matched to cases on age, year, enrollment length, and medical chart availability. Detailed oral contraceptive use information was ascertained from electronic pharmacy records and analyzed using conditional logistic regression, ORs, and 95% confidence intervals (CI). Recent oral contraceptive use (within the prior year) was associated with an increased breast cancer risk (OR, 1.5; 95% CI, 1.3-1.9) relative to never or former OC use. The association was stronger for estrogen receptor-positive (ER(+); OR, 1.7; 95% CI, 1.3-2.1) than estrogen receptor-negative (ER(-)) disease (OR, 1.2, 95% CI, 0.8-1.8), although not statistically significantly different (P = 0.15). Recent use of oral contraceptives involving high-dose estrogen (OR, 2.7; 95% CI, 1.1-6.2), ethynodiol diacetate (OR, 2.6; 95% CI, 1.4-4.7), or triphasic dosing with an average of 0.75 mg of norethindrone (OR, 3.1; 95% CI, 1.9-5.1; Pheterogeneity compared with using other oral contraceptives = 0.004) was associated with particularly elevated risks, whereas other types, including low-dose estrogen oral contraceptives, were not (OR, 1.0; 95% CI, 0.6-1.7). Our results suggest that recent use of contemporary oral contraceptives is associated with an increased breast cancer risk, which may vary by formulation. If confirmed, consideration of the breast cancer risk associated with different oral contraceptive types could impact discussions weighing recognized health benefits and potential risks.
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Affiliation(s)
- Elisabeth F Beaber
- Group Health Research Institute, Group Health Cooperative, Seattle, Washington. Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington. Department of Epidemiology, University of Washington, Seattle, Washington.
| | - Diana S M Buist
- Group Health Research Institute, Group Health Cooperative, Seattle, Washington. Department of Epidemiology, University of Washington, Seattle, Washington
| | - William E Barlow
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Kathleen E Malone
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington. Department of Epidemiology, University of Washington, Seattle, Washington
| | - Susan D Reed
- Group Health Research Institute, Group Health Cooperative, Seattle, Washington. Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington. Department of Epidemiology, University of Washington, Seattle, Washington. Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Christopher I Li
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington. Department of Epidemiology, University of Washington, Seattle, Washington
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24
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Onega T, Beaber EF, Sprague BL, Barlow WE, Haas JS, Tosteson ANA, D Schnall M, Armstrong K, Schapira MM, Geller B, Weaver DL, Conant EF. Breast cancer screening in an era of personalized regimens: a conceptual model and National Cancer Institute initiative for risk-based and preference-based approaches at a population level. Cancer 2014; 120:2955-64. [PMID: 24830599 DOI: 10.1002/cncr.28771] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 03/24/2014] [Accepted: 04/03/2014] [Indexed: 12/11/2022]
Abstract
Breast cancer screening holds a prominent place in public health, health care delivery, policy, and women's health care decisions. Several factors are driving shifts in how population-based breast cancer screening is approached, including advanced imaging technologies, health system performance measures, health care reform, concern for "overdiagnosis," and improved understanding of risk. Maximizing benefits while minimizing the harms of screening requires moving from a "1-size-fits-all" guideline paradigm to more personalized strategies. A refined conceptual model for breast cancer screening is needed to align women's risks and preferences with screening regimens. A conceptual model of personalized breast cancer screening is presented herein that emphasizes key domains and transitions throughout the screening process, as well as multilevel perspectives. The key domains of screening awareness, detection, diagnosis, and treatment and survivorship are conceptualized to function at the level of the patient, provider, facility, health care system, and population/policy arena. Personalized breast cancer screening can be assessed across these domains with both process and outcome measures. Identifying, evaluating, and monitoring process measures in screening is a focus of a National Cancer Institute initiative entitled PROSPR (Population-based Research Optimizing Screening through Personalized Regimens), which will provide generalizable evidence for a risk-based model of breast cancer screening, The model presented builds on prior breast cancer screening models and may serve to identify new measures to optimize benefits-to-harms tradeoffs in population-based screening, which is a timely goal in the era of health care reform.
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Affiliation(s)
- Tracy Onega
- Department of Community & Family Medicine and The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire; Norris Cotton Cancer Center, Lebanon, New Hampshire
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25
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Beaber EF, Malone KE, Tang MTC, Barlow WE, Porter PL, Daling JR, Li CI. Oral contraceptives and breast cancer risk overall and by molecular subtype among young women. Cancer Epidemiol Biomarkers Prev 2014; 23:755-64. [PMID: 24633144 DOI: 10.1158/1055-9965.epi-13-0944] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Evidence suggests that recent oral contraceptive (OC) use is associated with a small increased breast cancer risk; yet risks associated with contemporary OC preparations and by molecular subtype are not well characterized. METHODS We conducted a population-based case-control study of invasive breast cancer among women ages 20 to 44 residing in the Seattle-Puget Sound area from 2004 to 2010 (985 cases and 882 controls). We collected information on contraceptive use and participant characteristics via an in-person interview. Multivariable-adjusted logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS Lifetime duration of OC use for ≥ 15 years was associated with an increased breast cancer risk (OR, 1.5; 95% CI, 1.1-2.2). Current OC use (within 1 year of reference date) for ≥ 5 years was associated with an increased risk (OR, 1.6; 95% CI, 1.1-2.5) and there were no statistically significant differences in risk by OC preparation. Risk magnitudes were generally greater among women ages 20 to 39, and for estrogen receptor-negative (ER(-)) and triple-negative breast cancer (current use for ≥ 5 years among ages 20-39: ER(-) OR, 3.5; 95% CI, 1.3-9.0; triple-negative OR, 3.7; 95% CI, 1.2-11.8), although differences between groups were not statistically significant. CONCLUSIONS Long-term use of contemporary OCs and current use for ≥ 5 years was associated with an increased breast cancer risk among women ages 20 to 44. Risk may be greater among younger women and for ER(-) and triple-negative breast cancer, but these findings require confirmation. IMPACT Continued surveillance and pooled analyses of OC use and breast cancer risk by molecular subtype are needed as OC preparations evolve.
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Affiliation(s)
- Elisabeth F Beaber
- Authors' Affiliations: Division of Public Health Sciences, Division of Human Biology, Fred Hutchinson Cancer Research Center; Departments of Epidemiology, Biostatistics, and Pathology, University of Washington, Seattle, Washington
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26
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Li CI, Beaber EF, Tang MTC, Porter PL, Daling JR, Malone KE. Effect of depo-medroxyprogesterone acetate on breast cancer risk among women 20 to 44 years of age. Cancer Res 2012; 72:2028-35. [PMID: 22369929 DOI: 10.1158/0008-5472.can-11-4064] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Depo-medroxyprogesterone acetate (DMPA) is an injectable contraceptive that contains the same progestin as the menopausal hormone therapy regimen found to increase breast cancer risk among postmenopausal women in the Women's Health Initiative clinical trial. However, few studies have evaluated the relationship between DMPA use and breast cancer risk. Here, we conducted a population-based case-control study among 1,028 women ages 20 to 44 years to assess the association between DMPA use and breast cancer risk. Detailed information on DMPA use and other relevant covariates was obtained through structured interviewer-administered in-person questionnaires, and unconditional logistic regression was used to evaluate associations between various aspects of DMPA use and breast cancer risk. We found that recent DMPA use for 12 months or longer was associated with a 2.2-fold [95% confidence interval (CI), 1.2-4.2] increased risk of invasive breast cancer. This risk did not vary appreciably by tumor stage, size, hormone receptor expression, or histologic subtype. Although breast cancer is rare among young women and the elevated risk of breast cancer associated with DMPA appears to dissipate after discontinuation of use, our findings emphasize the importance of identifying the potential risks associated with specific forms of contraceptives given the number of available alternatives.
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Affiliation(s)
- Christopher I Li
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA.
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Beaber EF, Holt VL, Malone KE, Porter PL, Daling JR, Li CI. Reproductive factors, age at maximum height, and risk of three histologic types of breast cancer. Cancer Epidemiol Biomarkers Prev 2009; 17:3427-34. [PMID: 19064558 DOI: 10.1158/1055-9965.epi-08-0641] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Numerous studies have evaluated the association between factors related to maturation and reproduction and breast cancer risk, but few have assessed how these factors are related to different histologic types of breast cancer among postmenopausal women. We used polytomous logistic regression to assess the effect of age at maximum height and reproductive factors on risk of invasive breast cancer by histologic type in three case groups (524 ductal, 324 lobular, and 196 ductal-lobular) and 469 controls enrolled in a population-based case-control study of women ages 55 to 74 years residing in the Seattle-Puget Sound region of Washington State (2000-2004). Histologic type was determined by a centralized tissue review for 83% of cases. Age at menarche and age at maximum height were inversely associated with risk of ductal-lobular carcinoma (P(trend) = 0.04 for both exposures) but not ductal or lobular carcinoma. Relative to nulliparous women, parous women had a 50% reduced risk of all histologic types of breast cancer. We observed similar increases in risk across histologic types associated with having a first live birth at ages > or = 30 years compared with ages < or = 19 years. Compared with parous women who never breast-fed, those who breast-fed had a reduced risk of ductal carcinoma (odds ratio, 0.7; 95% confidence interval, 0.5-0.9) but not lobular or ductal-lobular carcinoma. Further exploration of breast cancer risk by histology is merited to understand differences in the etiology of ductal, lobular, and ductal-lobular carcinoma.
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Affiliation(s)
- Elisabeth F Beaber
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, M4-C308, P.O. Box 19024, Seattle, WA 98109-1024, USA.
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