Jeanne S. Mandelblatt

EFFECTS OF MAMMOGRAPHY SCREENING UNDER DIFFERENT SCREENING SCHEDULES: MODEL ESTIMATES OF POTENTIAL BENEFITS AND HARMS

To inform the USPSTF recommendations about breast cancer screening, Mandelblatt and colleagues developed 6 models of breast cancer incidence and mortality in the United States and estimated benefit...

Patient navigation: State of the art or is it science?†

First implemented in 1990, patient navigation interventions are emerging today as an approach to reduce cancer disparities. However, there is lack of consensus about how patient navigation is defined, what patient navigators do, and what their qualifications should be. Little is known about the efficacy and cost‐effectiveness of patient navigation. For this review, the authors conducted a qualitative synthesis of published literature on cancer patient navigation. By using the keywords ‘navigator’ or ‘navigation’ and ‘cancer,’ 45 articles were identified in the PubMed database and from reference searches that were published or in press through October 2007. Sixteen studies provided data on the efficacy of navigation in improving timeliness and receipt of cancer screening, diagnostic follow‐up care, and treatment. Patient navigation services were defined and differentiated from other outreach services. Overall, there was evidence of some degree of efficacy for patient navigation in increasing participation in cancer screening and adherence to diagnostic follow‐up care after the detection of an abnormality. The reported increases in screening ranged from 10.8% to 17.1%, and increases in adherence to diagnostic follow‐up care ranged from 21% to 29.2% compared with control patients. There was less evidence regarding the efficacy of patient navigation in reducing either late‐stage cancer diagnosis or delays in the initiation of cancer treatment or improving outcomes during cancer survivorship. There were methodological limitations in most studies, such as a lack of control groups, small sample sizes, and contamination with other interventions. Although cancer‐related patient navigation interventions are being adopted increasingly across the United States and Canada, further research will be necessary to evaluate their efficacy and cost‐effectiveness in improving cancer care. Cancer 2008.

Patterns of breast carcinoma treatment in older women: Patient preference and clinical and physician influences

Older women have high rates of breast carcinoma, and there are substantial variations in the patterns of care for this population group.

Risk Factors for Breast Cancer for Women Aged 40 to 49 Years: A Systematic Review and Meta-analysis

BACKGROUND Identifying risk factors for breast cancer specific to women in their 40s could inform screening decisions. PURPOSE To determine what factors increase risk for breast cancer in women aged 40 to 49 years and the magnitude of risk for each factor. DATA SOURCES MEDLINE (January 1996 to the second week of November 2011), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (fourth quarter of 2011), Scopus, reference lists of published studies, and the Breast Cancer Surveillance Consortium. STUDY SELECTION English-language studies and systematic reviews of risk factors for breast cancer in women aged 40 to 49 years. Additional inclusion criteria were applied for each risk factor. DATA EXTRACTION Data on participants, study design, analysis, follow-up, and outcomes were abstracted. Study quality was rated by using established criteria, and only studies rated as good or fair were included. Results were summarized by using meta-analysis when sufficient studies were available or from the best evidence based on study quality, size, and applicability when meta-analysis was not possible. Data from the Breast Cancer Surveillance Consortium were analyzed with proportional hazards models by using partly conditional Cox regression. Reference groups for comparisons were set at U.S. population means. DATA SYNTHESIS Sixty-six studies provided data for estimates. Extremely dense breasts on mammography or first-degree relatives with breast cancer were associated with at least a 2-fold increase in risk for breast cancer. Prior breast biopsy, second-degree relatives with breast cancer, or heterogeneously dense breasts were associated with a 1.5- to 2.0-fold increased risk; current use of oral contraceptives, nulliparity, and age 30 years or older at first birth were associated with a 1.0- to 1.5-fold increased risk. LIMITATIONS Studies varied by measures, reference groups, and adjustment for confounders, which could bias combined estimates. Effects of multiple risk factors were not considered. CONCLUSION Extremely dense breasts and first-degree relatives with breast cancer were each associated with at least a 2-fold increase in risk for breast cancer in women aged 40 to 49 years. Identification of these risk factors may be useful for personalized mammography screening. PRIMARY FUNDING SOURCE National Cancer Institute.

Adherence of Low-income Women to Cancer Screening Recommendations

BACKGROUND: African-American and low-income women have lower rates of cancer screening and higher rates of late-stage disease than do their counterparts. OBJECTIVE: To examine the effects of primary care, health insurance, and HMO participation on adherence to regular breast, cervical, and colorectal cancer screening. DESIGN: Random-digit-dial and targeted household telephone survey of a population-based sample. SETTING: Washington, D.C. census tracts with ≥30% of households below 200% of federal poverty threshold. PARTICIPANTS: Included in the survey were 1,205 women over age 40, 82% of whom were African American. MAIN OUTCOME MEASURES: Adherence was defined as reported receipt of the last 2 screening tests within recommended intervals for age. RESULTS: The survey completion rate was 85%. Overall, 75% of respondents were adherent to regular Pap smears, 66% to clinical breast exams, 65% to mammography, and 29% to fecal occult blood test recommendations. Continuity with a single primary care practitioner, comprehensive service delivery, and higher patient satisfaction with the relationships with primary care practitioners were associated with higher adherence across the 4 screening tests, after considering other factors. Coordination of care also was associated with screening adherence for women age 65 and over, but not for the younger women. Compared with counterparts in non-HMO plans, women enrolled in health maintenance organizations were also more likely to be adherent to regular screening (e.g., Pap, odds ratio [OR] 1.89, 95% confidence interval [CI] 1.11 to 3.17; clinical breast exam, OR 2.04, 95% CI 1.21 to 3.44; mammogram, OR 1.95, 95% CI 1.15 to 3.31; fecal occult blood test, OR 1.70, 95% CI 1.01 to 2.83.) CONCLUSIONS: Organizing healthcare services to promote continuity with a specific primary care clinician, a comprehensive array of services available at the primary care delivery site, coordination among providers, and better patient-practitioner relationships are likely to improve inner-city, low-income women’s adherence to cancer screening recommendations.

Equitable access to cancer services

Barriers to cancer care have been documented in nearly all settings and populations; such barriers represent potentially avoidable morbidity or mortality. A conceptual framework was used to describe patient, provider, and system barriers to cancer services.

Breast Cancer Screening for Elderly Women with and without Comorbid Conditions: A Decision Analysis Model

OBJECTIVE To determine whether breast cancer screening extends life for women aged 65 years or more with and without comorbid medical conditions. SETTING A provider-patient encounter. DESIGN A decision analysis of the utility of screening for breast cancer. MEASUREMENTS Clinical examination and mammography among four groups of women aged 65 to 85 or more years: average health, mild hypertension, congestive heart failure, and average-health black women. The effects of screening were estimated using the best quality data available. RESULTS Screening saved life at all ages among patients studied. Savings were highest for black women and decreased with increasing age and comorbidity. Screening all average-health women aged 65 or more saved 67,912 years of life. For women who had cancer, screening extended life by 617 days for average-health women between 65 and 69 years of age and 178 days for those aged 85 years or more. Perioperative mortality and test characteristics had little effect on the results. The risks equaled the benefits of screening only when operative mortality was between 27% and 62%. The marginal costs of screening during a routine office visit were

Variations in breast carcinoma treatment in older Medicare beneficiaries: Is it black and white?

138 and increased with advancing age and decreasing test specificity. Benefits persisted after adjustment for changes in long-term quality of life; however, for women aged 85 years and older (with and without comorbidities), the short-term morbidity of anxiety or discomfort associated with screening may have outweighed the benefits. CONCLUSION No inherent reason exists to impose an upper-age limit for breast cancer screening; however, more data are needed on womens preferences for screening strategies.

Is the Promise of Cancer-Screening Programs Being Compromised? Quality of Follow-Up Care after Abnormal Screening Results

To evaluate associations between race and breast carcinoma treatment.

How Do Older Chinese Women View Health and Cancer Screening? Results from Focus Groups and Implications for Interventions

Cancer screening has increased dramatically in the United States, yet in some populations, particularly racial minorities or the poor, advanced disease at diagnosis remains high. One potential explanation is that follow-up of abnormal tests is suboptimal, and the benefits of screening are not being realized. The authors used a conceptual model of access to care and integrated constructs from models of provider and patient health behaviors to review published literature on follow-up care. Most studies reported that fewer than 75 percent of patients received some follow-up care, indicating that the promise of screening may be compromised. They identified pervasive barriers to follow-up at the provider, patient, and health care system levels. Interventions that address these barriers appear to be effective. Improvement of data infrastructure and reporting will be important objectives for policy makers, and further use of conceptual models by researchers may improve intervention development and, ultimately, cancer control.