Azadeh Stark

Communicating Side Effect Risks in a Tamoxifen Prophylaxis Decision Aid: The Debiasing Influence of Pictographs

OBJECTIVE To experimentally test whether using pictographs (image matrices), incremental risk formats, and varied risk denominators would influence perceptions and comprehension of side effect risks in an online decision aid about prophylactic use of tamoxifen to prevent primary breast cancers. METHODS We recruited 631 women with elevated breast cancer risk from two healthcare organizations. Participants saw tailored estimates of the risks of 5 side effects: endometrial cancer, blood clotting, cataracts, hormonal symptoms, and sexual problems. Presentation format was randomly varied in a three factor design: (A) risk information was displayed either in pictographs or numeric text; (B) presentations either reported total risks with and without tamoxifen or highlighted the incremental risk most relevant for decision making; and (C) risk estimates used 100 or 1000 person denominators. Primary outcome measures included risk perceptions and gist knowledge. RESULTS Incremental risk formats consistently lowered perceived risk of side effects but resulted in low knowledge when displayed by numeric text only. Adding pictographs, however, produced significantly higher comprehension levels. CONCLUSIONS Pictographs make risk statistics easier to interpret, reducing biases associated with incremental risk presentations. PRACTICE IMPLICATIONS Including graphs in risk communications is essential to support an informed treatment decision-making process.

Testing whether decision aids introduce cognitive biases: Results of a randomized trial

OBJECTIVE Women at high risk of breast cancer face a difficult decision whether to take medications like tamoxifen to prevent a first breast cancer diagnosis. Decision aids (DAs) offer a promising method of helping them make this decision. But concern lingers that DAs might introduce cognitive biases. METHODS We recruited 663 women at high risk of breast cancer and presented them with a DA designed to experimentally test potential methods of identifying and reducing cognitive biases that could influence this decision, by varying specific aspects of the DA across participants in a factorial design. RESULTS Participants were susceptible to a cognitive bias - an order effect - such that those who learned first about the risks of tamoxifen thought more favorably of the drug than women who learned first about the benefits. This order effect was eliminated among women who received additional information about competing health risks. CONCLUSION We discovered that the order of risk/benefit information influenced womens perceptions of tamoxifen. This bias was eliminated by providing contextual information about competing health risks. PRACTICE IMPLICATIONS We have demonstrated the feasibility of using factorial experimental designs to test whether DAs introduce cognitive biases, and whether specific elements of DAs can reduce such biases.

Human papillomavirus, cervical cancer and women's knowledge

BACKGROUND Human papillomavirus (HPV) is the major risk factor for cervical cancer. METHODS We implemented a retrospective case-series study to discern HPV knowledge accuracy among women diagnosed with and treated for cervical cancer. Cases (n=1174), identified from the Pathology database, were diagnosed and treated for cervical cancer at the same institution. Data were collected using self-administered questionnaires and by reviewing medical records. RESULTS A total of 328 (27.9%) women returned the completed forms. Only 19% of the respondents had identified HPV as the primary risk factor for cervical cancer. Environmental pollutants, radiation exposure, poor dietary habits, excessive physical activity and family history of cervical cancer were listed as risk factors among many others. Multivariate analysis was performed to determine variables that were best associated with HPV knowledge accuracy. Age and education were the two variables that were statistically associated with the outcome. Younger and more educated women who participated in this study were more likely to know about the association between HPV infection and the risk of cervical cancer. CONCLUSIONS Cervical cancer risk factor knowledge, especially knowledge about HPV is low, even among women with the history of cervical cancer. Younger and more educated women are more likely to have HPV and cervical cancer knowledge accuracy. The importance of personal health practices and the focus on health education should be equally emphasized to achieve successful cancer prevention through vaccination.

Breast cancer anxiety's associations with responses to a chemoprevention decision aid

Few studies have examined how specific emotions may affect decision-making processes. Anxiety may be especially relevant in health decisions such as those related to cancer in which thoughts of illness or death may be abundant. We examined associations between womens anxiety about developing breast cancer and variables related to their decision to take a medication that could reduce their chances of the disease. Six-hundred and thirty-two American women, who had an increased risk of breast cancer, reviewed a web-based decision aid about tamoxifen. We examined associations between their baseline, self-reported anxiety about developing the disease and post decision aid measures including knowledge about tamoxifen, attitude toward the medication, and behavioral intentions to look for more information and take the medication. Results showed that anxiety was not associated with knowledge about tamoxifen, but it was associated with attitude toward the medication such that women who were more anxious about developing breast cancer were more likely to think the benefits were worth the risks. Greater anxiety was also associated with greater behavioral intentions to look for additional information and take the medication in the next few months. Secondary analyses showed that behavioral intentions were related to knowledge of tamoxifen and attitude toward the medication only for women who were reporting low levels of anxiety. Overall, the findings suggest that anxiety about breast cancer may motivate interest in tamoxifen and not necessarily through affecting knowledge or attitudes.

The pen and the scalpel: effect of diffusion of information on nonclinical variations in surgical treatment.

Background:As information is disseminated about best practices, variations in patterns of care should diminish over time. Objective:To test the hypotheses that differences in rates of a surgical procedure are associated with type of insurance in an era of evolving practice guidelines and that insurance and site differences diminish with time as consensus guidelines disseminate among the medical community. Methods:We use lymph node dissection among women with ductal carcinoma in situ (DCIS) as an example of a procedure with uncertain benefit. Using a sample of 1051 women diagnosed from 1985 through 2000 at 2 geographic sites, we collected detailed demographic, clinical, pathologic, and treatment information through abstraction of multiple medical records. We specified multivariate logistic models with flexible functions of time and time interactions with insurance and treatment site to test hypotheses. Results:Lymph node dissection rates varied significantly according to site of treatment and insurance status after controlling for clinical, pathologic, treatment, and demographic characteristics. Rates of lymph node dissection decreased over time, and differences in lymph node dissection rates according to site and generosity of insurance were no longer significant by the end of the study period. Conclusions:We have demonstrated that rates of a discretionary surgical procedure differ according to nonclinical factors, such as treatment site and type of insurance, and that such unwarranted variation decreases over time with diminishing uncertainty and in an era of diffusion of clinical guidelines.

Prevalence of colonoscopy before age 50

OBJECTIVE Describe the prevalence of colonoscopy before age 50, when guidelines recommend initiation of colorectal cancer screening for average risk individuals. METHOD We assembled administrative health records that captured receipt of colonoscopy between 40 and 49-years of age for a cohort of 204,758 50-year-old members of four US health plans and used backward recurrence time models to estimate trends in receipt of colonoscopy before age 50 and variation in early colonoscopy by age and sex. We also used self-reported receipt of colonoscopy from 27,157 40- to 49-year-old respondents to the 2010 National Health Interview Survey (NHIS) to estimate the association between early colonoscopy and sex, race/ethnicity, and geographic location based on logistic regression models that accounted for the complex NHIS sampling design. RESULTS About 5% of the health plan cohort had a record of colonoscopy before age 50. Receipt of early colonoscopy increased significantly from 1999 to 2010 (test for linear trend, p<0.0001), was more likely among women than men (RR=1.9, 95% CI 1.14-1.24) and in the east coast health plan compared to west coast and Hawaii plans. The NHIS analysis found that early colonoscopy was more likely in Northeastern residents compared to residents in the West (odds ratio=1.75, 95% CI 1.28-2.39). CONCLUSION Colonoscopy before age 50 is increasingly common.

Effects of transitioning from conventional methods to liquid-based methods on unsatisfactory Papanicolaou tests: results from a multicenter US study

Papanicolaou (Pap) testing has transitioned from conventional preparations (CPs) to liquid‐based preparations (LBPs) because of the perceived superiority of LBPs. Many studies conclude that LBPs reduce unsatisfactory Pap tests; however, some believe that the evidence substantiating this claim is weak. The authors studied the effect of the transition from CPs to LBPs on the proportion of unsatisfactory Pap tests in 4 health care systems in the United States participating in the National Institutes of Health‐funded Screening Effectiveness and Research in Community‐Based Healthcare (SEARCH) project.

Association Between Benign Breast Disease in African American and White American Women and Subsequent Triple-Negative Breast Cancer

Importance Compared with white American (WA) women, African American (AA) women have a 2-fold higher incidence of breast cancers that are negative for estrogen receptor, progesterone receptor, and ERBB2 (triple-negative breast cancer [TNBC]). Triple-negative breast cancer, compared with non-TNBC, likely arises from different pathogenetic pathways, and benign breast disease (BBD) predicts future non-TNBC. Objective To determine whether AA identity remains associated with TNBC for women with a prior diagnosis of BBD. Design, Setting, and Participants This study is a retrospective analysis of data of a cohort of 2588 AA and 3566 WA women aged between 40 and 70 years with a biopsy-proven BBD diagnosis. The data—obtained from the Pathology Information System of Henry Ford Health System (HFHS), an integrated multihospital and multispecialty health care system headquartered in Detroit, Michigan—include specimens of biopsies performed between January 1, 1994, and December 31, 2005. Data analysis was performed from November 1, 2015, to June 15, 2016. Main Outcomes and Measures Subsequent breast cancer was stratified on the basis of combinations of hormone receptor and ERBB2 expression. Results Case management, follow-up, and outcomes received or obtained by our cohort of 2588 AA and 3566 WA patients were similar, demonstrating that HFHS delivered care equitably. Subsequent breast cancers developed in 103 (4.1%) of AA patients (mean follow-up interval of 6.8 years) and 143 (4.0%) of WA patients (mean follow-up interval of 6.1 years). More than three-quarters of subsequent breast cancers in each subset were ductal carcinoma in situ or stage I. The 10-year probability estimate for developing TNBC was 0.56% (95% CI, 0.32%-1.0%) for AA patients and 0.25% (95% CI, 0.12%-0.53%) for WA patients. Among the 66 AA patients who developed subsequent invasive breast cancer, 16 (24.2%) developed TNBC compared with 7 (7.4%) of the 94 WA patients who developed subsequent invasive breast cancers and had complete biomarker data (P = .01). Conclusions and Relevance This study is the largest analysis to date of TNBC in the context of racial/ethnic identity and BBD as risk factors. The study found that AA identity persisted as a significant risk factor for TNBC. This finding suggests that AA identity is associated with inherent susceptibility for TNBC pathogenetic pathways.

Rejected and Unsatisfactory Specimens: A Comparative Study of Liquid-Based (SurePath) Preparations and Conventional Pap Smears for Cervicovaginal Screening

Background The liquid-based preparation (LBP) has become the primary method for cervicovaginal screening. Methods We conducted a retrospective study with the objective of comparing LBP with the conventional Pap smear (CP). Results Of the smears that were collected using CP, a total of 312 (0.17%) specimens were classified as “Rejected” and 1,040 (0.55%) as “Unsatisfactory.” The proportion of specimens collected using LBP that were categorized as “Rejected” or “Unsatisfactory” were 0.27% (n=369) and 0.22% (n=302), respectively. Independent of the technique, cellular inadequacy (n=1,150, 85.7%) and mis-/no labeling (n=647, 93.8%) were the 2 primary reasons for such classification. With LBP, the laboratory absorbed an additional

Evaluation and Adaptation of a Laboratory-Based cDNA Library Preparation Protocol for Retrospective Sequencing of Archived MicroRNAs from up to 35-Year-Old Clinical FFPE Specimens

2,812.80 in total direct cost. Conclusion Implementation of LBP has yielded a significant decline in the proportion of “Unsatisfactory,” but an increase in the proportion of “Rejected,” specimens. With LBP, the direct cost increased; however, in cost-benefit analysis of health services, all direct and indirect costs should be included.