Janet Kay Bobo

Clinical Breast Examination: Practical Recommendations for Optimizing Performance and Reporting

Clinical breast examination (CBE) seeks to detect breast abnormalities or evaluate patient reports of symptoms to find palpable breast cancers at an earlier stage of progression. Treatment options for earlier‐stage cancers are generally more numerous, include less toxic alternatives, and are usually more effective than treatments for later‐stage cancers. For average‐risk women aged 40 and younger, earlier detection of palpable tumors identified by CBE can lead to earlier therapy. After age 40, when mammography is recommended, CBE is regarded as an adjunct to mammography. Recent debate, however, has questioned the contributions of CBE to the detection of breast cancer in asymptomatic women and particularly to improved survival and reduced mortality rates. Clinicians remain widely divided about the level of evidence supporting CBE and their confidence in the examination. Yet, CBE is practiced extensively in the United States and continues to be recommended by many leading health organizations. It is in this context that this report provides a brief review of evidence for CBEs role in the earlier detection of breast cancer, highlights current practice issues, and presents recommendations that, when implemented, could contribute to greater standardization of the practice and reporting of CBE. These recommendations may also lead to improved evidence of the nature and extent of CBEs contribution to the earlier detection of breast cancer.

Breast cancer screening practices among women in the United States, 2000

Results from recent studies indicate that many women in the US undergo routine screening for breast cancer, but some groups of women are under-screened. In this study, we examined the breast cancer screening practices of white and black women in the United States, according to Hispanic ethnicity and other factors, using data from the 2000 National Health Interview Survey. Among women aged ≥40 years, 71.2% (95% confidence interval, CI: 70.0–72.4%) of the 8201 white women and 67.6% (95% CI: 64.5–70.6%) of the 1474 black women in this sample reported having a mammogram in the past two years. About 60.3% (95% CI: 56.7–70.3%) of 970 Hispanic women (including those who reported they were white or black) and 71.5% (95% CI: 70.3–72.7%) of 8705 non-Hispanic women reported having a mammogram in the past two years. About 74.8% (95% CI: 73.8–76.8%) of 8176 white women and 73.8% (95% CI: 71.1–76.6%) of 1471 black women aged ≥40 years had received a clinical breast examination in the past two years. About 60.1% (95% CI: 56.1–64.0%) of 969 Hispanic women (including those who reported they were white or black) and 75.6% (95% CI: 74.6–76.6%) of 8678 non-Hispanic women had received a clinical breast examination in the past two years. Women with lower incomes, those with less education, and recent immigrants were less likely to be screened. Women who had a usual source of health care and those with health insurance coverage were more likely to have been screened. These results underscore the need for continued efforts to ensure that uninsured women and those who are medically underserved have access to cancer screening services.

Mammography and breast cancer detection by race and Hispanic ethnicity: results from a national program (United States).

AbstractObjective: Some of the racial and ethnic variation in breast cancer incidence rates may reflect differential use of mammography. We report breast cancer rates using mammography and diagnostic data from five race/ethnicity groups. Methods: Mammography data were analyzed for 573,751 women who received breast cancer screening between July 1991 and March 1998 from the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Abnormal mammography rates, breast cancer detection rates, and cancer stage distribution data are presented by race/ethnicity and screening round (first or subsequent). Results: For the first screening round, percentages of abnormal mammographies ranged from 7.3% among black women to 9.3% among Asian/Pacific Islander women. Cancer detection rates ranged from 4.9 cancers per 1000 mammograms for Hispanic and American Indian/Alaska Native (AI/AN) women to 7.7 per 1000 for white women. Subsequent round rates were lower but varied similarly. AI/AN women had the highest percentage (68%) of first-round cancers detected in the early stage (range for the other groups: 52–63%). Conclusions: Breast cancer detection rates for racial and ethnic groups in this program varied less than published population-based incidence rates. Differential use of mammography among these groups may account for some of the variation reported for breast cancer incidence.

The effect of caregiving on women in families with Duchenne/Becker muscular dystrophy.

Duchenne/Becker muscular dystrophy (DBMD) is a disorder of progressive muscle weakness that causes an increasing need for assistance with activities of daily living. Our objective was to assess the psychosocial health and contributing factors among female caregivers in families with DBMD. We conducted a survey of adult women among families with DBMD in the United States (US) from June 2006 through January 2007, collecting data related to the care recipient, perception of caregiving demands, personal factors, and socio-ecologic factors. Life satisfaction, stress, and distress were assessed as outcomes. Existing validated instruments were used when available. We received responses from 1238 women who were caring for someone with DBMD, 24.2% of whom were caring for two or more people with DBMD. Caregivers were more likely to be married/cohabitating than women in the general US population, and a high level of resiliency was reported by 89.3% of caregivers. However, the rate of serious psychological distress was significantly higher among caregivers than among the general population. Likewise, 46.4% reported a high level of stress, and only 61.7% reported that they were satisfied with their life. A high level of caregiving demands based on the Zarit Burden Interview (ZBI) was reported by 50.4% of caregivers. The post-ambulatory phase of DBMD was associated with decreased social support and increased ZBI scores. In multivariate logistic regression modelling, life satisfaction was dependent on high social support, high resiliency, high income, and form of DBMD. Distress and high stress were predicted by low resiliency, low social support, and low income. Employment outside of the home was also a predictor of high stress. Interventions focused on resiliency and social support are likely to improve the quality of life of DBMD caregivers, and perhaps caregivers of children with other disabilities or special health care needs as well.

Predicting 10-Year Alcohol Use Trajectories Among Men Age 50 Years and Older

OBJECTIVE To describe common 10-year drinking trajectories followed by men age 50 years or older and identify risk factors for those trajectories. DESIGN Longitudinal data were used to derive a semiparametric group-based model. PARTICIPANTS Men from the Health and Retirement Study age 50-65 years in 1998 who completed three or more of the six interviews conducted from 1998 to 2008, including our 1998 baseline interview. MEASUREMENTS Biannual data on number of drinks per drinking day were used to derive drinking trajectories. Risk factors included baseline age, race, ethnicity, education, marital status, retirement, smoking, binge drinking, vigorous exercise, body mass index, depression, pain, self-reported health, and chronic disease. RESULTS The best-fitting model included consistent infrequent drinkers and nondrinkers (40.6% of cohort), increasing drinkers (5.5%), decreasing drinkers (7.6%), consistent at-risk drinkers (15.6%), and consistent moderate drinkers (30.7%). Adjusted logistic regression models comparing men with similar 1998 drinking levels who subsequently followed different trajectories identified significant risks associated with age, education, smoking, binge drinking, depression, pain, and self-reported health. To illustrate, odds ratios (ORs) and 95% confidence intervals (95% CIs) suggest that baseline infrequent drinkers were less likely to follow an increasing drinkers trajectory if they were older (OR: 0.57, 95% CI: 0.38-0.82) and smoked cigarettes (OR: 0.47, 95% CI: 0.30-0.74). Baseline drinkers were less likely to follow a decreasing trajectory if they reported more than 12 years of education (OR: 0.58, 95% CI: 0.42-0.82) and thought that their health was excellent or very good (OR: 0.54, 95% CI: 0.39-0.76). CONCLUSION Only 30.7% of older men in this cohort were moderate drinkers throughout the follow-up. Many older men may benefit from brief counseling on the risks and benefits of drinking.

TOBACCO CESSATION WITH PATIENTS RECOVERING FROM ALCOHOL AND OTHER SUBSTANCE ABUSE

This article focuses on the problem of tobacco cessation in the patient recovering from alcohol or other substance abuse. The authors review the epidemiology of the problem, specific health risks to this population from continued tobacco use, and recent research findings that address previous treatment concerns. Recommendations for counseling by physicians are made. These include an algorithm for determining the patients stage of readiness for making a quit attempt, specific counseling tasks based on the patients stage, and motivational counseling strategies aimed at increasing the patients motivation to quit.

Alcohol use trajectories in two cohorts of U.S. women aged 50 to 65 at baseline.

OBJECTIVES: To examine drinking trajectories followed by two cohorts of older women over 8 to 10 years of follow‐up.

Increasing and decreasing alcohol use trajectories among older women in the U.S. across a 10-year interval.

Older women who routinely drink alcohol may experience health benefits, but they are also at risk for adverse effects. Despite the importance of their drinking patterns, few studies have analyzed longitudinal data on changes in drinking among community-based samples of women ages 50 and older. Reported here are findings from a semi-parametric group-based model that used data from 4,439 randomly sampled U.S. women who enrolled in the Health and Retirement Study (HRS) and completed ≥ 3 biannual alcohol assessments during 1998–2008. The best-fitting model based on the drinks per day data had four trajectories labeled as “Increasing Drinkers” (5.3% of sample), “Decreasing Drinkers” (5.9%), “Stable Drinkers” (24.2%), and “Non/Infrequent Drinkers” (64.6%). Using group assignments generated by the trajectory model, one adjusted logistic regression analysis contrasted the groups with low alcohol intake in 1998 (Increasing Drinkers and Non/Infrequent Drinkers). In this model, baseline education, physical activity, cigarette smoking, and binge drinking were significant factors. Another analysis compared the groups with higher intake in 1998 (Decreasing Drinkers versus Stable Drinkers). In this comparison, baseline depression, cigarette smoking, binge drinking, and retirement status were significant. Findings underscore the need to periodically counsel all older women on the risks and benefits of alcohol use.

Risk factors for failure to detect a cancer during clinical breast examinations (United States)

Background: Although clinical breast examinations (CBEs) provide important opportunities to detect breast cancer, little is known about factors that affect cancer detection during CBEs performed in community settings. To evaluate several potential factors, we analyzed data from 1,056,153 cancer screening records reported to the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Methods: Using case-series methods, we compared 2159 cancers missed during CBEs with 3161 cancers detected during CBEs. Cancers missed during CBE were found by mammography and confirmed by biopsy or fine needle aspiration. Results: After controling for cancer stage, tumor size, and breast symptoms at time of CBE, we found that patient age and CBE history were significantly associated with the likelihood of cancer detection. Compared to women 50–59, women 40–49 were more likely to have their cancer detected during CBE (odds ratio (OR) = 1.84, 95% confidence interval (95% CI) 1.47–2.29), while women 70 and older were less likely to have it detected (OR = 0.74, 95% CI: 0.55–1.00). Among women receiving their first NBCCEDP-funded CBE, 67.5% had their cancer detected by CBE. Among women receiving their second or third CBE, the values were 59.3 and 48.8%, respectively. In an adjusted logistic model, a significant inverse relationship was observed between number of prior CBEs and percent of cancers detected in the index CBE (OR = 0.79, 95% CI: 0.72–0.88). Conclusions: Among women diagnosed with breast cancer, older women and those who have had multiple CBEs were more likely to have their cancer missed during CBE.

A Comparison of Fecal Immunochemical and High-Sensitivity Guaiac Tests for Colorectal Cancer Screening

Objectives:Annual testing using either a high-sensitivity guaiac fecal occult blood test (HS-gFOBT) or a fecal immunochemical test (FIT) is recommended for screening average-risk people for colorectal cancer. We compared the performance characteristics of the HS-gFOBT Hemoccult II SENSA and two FITs (InSure FIT and OC FIT-CHEK) for detecting advanced colorectal neoplasia.Methods:The study included 1,006 asymptomatic patients, aged 50–75 years, who were scheduled to receive a screening colonoscopy at gastroenterology practices in the Minneapolis and Indianapolis metropolitan areas. Each participant was asked to complete all three stool tests before their colonoscopy. Each test’s performance characteristics were evaluated using the screening colonoscopic results as the reference standard.Results:Sensitivity for detecting advanced colorectal neoplasia was highest for InSure FIT (26.3%, 95% confidence interval (CI) 15.9–40.7), followed by OC FIT-CHEK (15.1%, 95% CI 6.7–26.1) and Hemoccult II SENSA (7.4%, 95% CI 1.9–17.0). InSure FIT was statistically significantly more sensitive than both OC FIT-CHEK (absolute difference in sensitivity=11.2%, 95% CI 0.4–24.2) and Hemoccult II SENSA (difference in sensitivity=18.9%, 95% CI 10.2–32.6). Specificities were relatively high for all tests (between 96.8% and 98.6%).Conclusions:Our results suggest that some FITs are more sensitive than the HS-gFOBT Hemoccult II SENSA, but these results need to be confirmed in larger asymptomatic populations. Comparisons between the FITs examined in this study and other FITs are needed to determine the best tests for population screening.