Lydia E. Pace

Trends in mammography screening rates after publication of the 2009 US Preventive Services Task Force recommendations

In November 2009, the US Preventive Services Task Force (USPSTF) issued new recommendations regarding mammography screening. The Task Force recommended against routine screening for women ages 40 to 49 years and recommended biennial screening for women ages 50 to74 years. The recommendations met great controversy in mass media and medical literature; whether they have had an impact on screening patterns is not known. The objective of this study was to determine whether the 2009 USPSTF recommendations led to changes in screening rates among women ages 40 to 49 years and ages 50 to 74 years.

The impact of out-of-pocket costs on the use of intrauterine contraception among women with employer-sponsored insurance

Background:Long-acting reversible contraception (LARC) is highly effective but also has higher initiation costs than oral contraceptive methods, which may contribute to relatively low use. The Affordable Care Act requires most private insurance plans to cover contraceptive services without patient cost-sharing. Whether this mandate will increase LARC use is unknown. Objective:To assess the relationship between cost-sharing and use of LARC among privately insured women. Design:Cross-sectional analysis using Truven Health MarketScan data from January 2011 to December 2011. Subjects:Women aged 14–45 years with continuous insurance coverage enrolled in health plan products that covered branded and generic oral contraceptive pills (OCPs) and intrauterine devices (IUDs). We selected women using OCPs and IUDs as these are the most commonly used short-acting and long-acting reversible methods, respectively (N=1,682,425). Measures:Multivariable regression was used to assess the association of the level of out-of-pocket costs for IUDs for each patient’s plan and IUD initiation, adjusting for out-of-pocket costs for branded and generic OCPs and patient characteristics. Results:Overall, 5.5% of women initiated an IUD in 2011. After adjustment, IUD initiation was less likely among women with higher versus lower co-pays (adjusted risk ratio=0.65; 95% CI, 0.64–0.67). Women who saw an obstetrician/gynecologist during 2011 were more likely to initiate an IUD (adjusted risk ratio=2.49; 95% CI, 2.45–2.53). Conclusions:Rates of IUD use are low among privately insured women in the United States, and higher cost-sharing is associated with lower rates of IUD use. Together with other measures to promote LARC use, eliminating co-pays for contraception could promote the use of these more effective and cost-effective methods.

Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda

BACKGROUND Breast cancer incidence is increasing in low- and middle-income countries (LMICs). Mortality/incidence ratios in LMICs are higher than in high-income countries, likely at least in part because of delayed diagnoses leading to advanced-stage presentations. In the present study, we investigated the magnitude, impact of, and risk factors for, patient and system delays in breast cancer diagnosis in Rwanda. MATERIALS AND METHODS We interviewed patients with breast complaints at two rural Rwandan hospitals providing cancer care and reviewed their medical records to determine the diagnosis, diagnosis date, and breast cancer stage. RESULTS A total of 144 patients were included in our analysis. Median total delay was 15 months, and median patient and system delays were both 5 months. In multivariate analyses, patient and system delays of ≥6 months were significantly associated with more advanced-stage disease. Adjusting for other social, demographic, and clinical characteristics, a low level of education and seeing a traditional healer first were significantly associated with a longer patient delay. Having made ≥5 health facility visits before the diagnosis was significantly associated with a longer system delay. However, being from the same district as one of the two hospitals was associated with a decreased likelihood of system delay. CONCLUSION Patients with breast cancer in Rwanda experience long patient and system delays before diagnosis; these delays increase the likelihood of more advanced-stage presentations. Educating communities and healthcare providers about breast cancer and facilitating expedited referrals could potentially reduce delays and hence mortality from breast cancer in Rwanda and similar settings. IMPLICATIONS FOR PRACTICE Breast cancer rates are increasing in low- and middle-income countries, and case fatality rates are high, in part because of delayed diagnosis and treatment. This study examined the delays experienced by patients with breast cancer at two rural Rwandan cancer facilities. Both patient delays (the interval between symptom development and the patients first presentation to a healthcare provider) and system delays (the interval between the first presentation and diagnosis) were long. The total delays were the longest reported in published studies. Longer delays were associated with more advanced-stage disease. These findings suggest that an opportunity exists to reduce breast cancer mortality in Rwanda by addressing barriers in the community and healthcare system to promote earlier detection.

Factors influencing time to diagnosis after abnormal mammography in diverse women.

BACKGROUND Abnormal mammograms are common, and the risk of false positives is high. We surveyed women in order to understand the factors influencing the efficiency of the evaluation of an abnormal mammogram. METHODS Women aged 40-80 years, identified from lists with Breast Imaging Reporting and Data System (BIRADS) classifications of 0, 3, 4, or 5, were surveyed. Telephone surveys asked about the process of evaluation, and medical records were reviewed for tests and timing of evaluation. RESULTS In this study, 970 women were surveyed, and 951 had chart reviews. Overall, 36% were college graduates, 68% were members of a group model health plan, 18% were Latinas, 25% were African Americans, 15% were Asian, and 43% were white. Of the 352 women who underwent biopsies, 151 were diagnosed with cancer (93 invasive). Median time to diagnosis was 183 days for BIRADS 3 compared to 29 days for BIRADS 4/5 and 27 days for BIRADS 0. At 60 days, 84% of BIRADS 4/5 women had a diagnosis. Being African American (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.49-0.97, p=0.03), income < 

New Guidelines for Breast Cancer Screening in US Women

10,000 (HR 0.55, 95% CI 0.31-0.98, p<0.04), perceived discrimination (HR 0.22, 95% CI 0.09-0.52, p<0.001), not fully understanding the results of the index mammogram (HR 0.49, 95% CI 0.32-0.75, p=0.001), and being notified by letter (HR 0.66, 95% CI 0.48-0.90, p=0.01) or telephone (HR 0.62, 95% CI 0.42-0.92, p=0.02) rather than in person were all associated with significant delays in diagnosis. CONCLUSIONS Evaluation of BIRADS 0, 4, or 5 abnormal mammograms was completed in most women within the recommended 60 days. Even within effective systems, correctible communication factors may adversely affect time to diagnosis.

Breast Cancer in Sub-Saharan Africa: Challenges and Opportunities to Reduce Mortality

Despite the substantial interest and investment in research on breast cancer screening, there is uncertainty about the magnitude of mammography’s benefits and harms and how to select patients and screening strategies to optimize the balance between benefits and harms. In the face of such uncertainty, thoughtful, evidence-based guidelines can play a powerful role in shaping policy and practice, supporting decision making by clinicians and patients, and identifying key research priorities. In this issue of JAMA, Oeffinger et al1 present updated breast cancer screening recommendations from the American Cancer Society(ACS),aninfluentialvoiceincancerpolicyandclinicalcare in the United States for more than 100 years.2 Since last issuing breast cancer screening recommendations in 2003, the ACS revised its guideline development procedures to ensure a more transparent, consistent, and rigorous process.3 This effort was an important step forward in guideline development. In 2003, the ACS recommended annual mammography screening for all women starting at age 40 years and continuing as long as a woman remains in good health and clinical breast examination (CBE) periodically for women in their 20s and 30s and annually for women 40 years and older. The new guideline, which addresses screening among average-risk women, recommends annual mammography for women aged 45 to 54 years and biennial mammography for women 55 years and older, as long as they are healthy and have a life expectancy of at least 10 years. The guideline recommends against routine CBE for any woman. The authors give the starting age of 45 years a strong recommendation, while their guidance on screening intervals, screening in older women, and CBE earns qualified recommendations. Several aspects of this new guideline will be particularly striking to patients, clinicians, and others involved in health care: (1) the more conservative starting age for mammography (45 vs 40 years), which brings the ACS recommendations closer to the US Preventive Services Task Force (USPSTF) guidelines (both the 20094 guideline and the April 2015 draft recommendation statement5), which endorse biennial screening for women aged 50 to 74 years; (2) the proposal for more frequent—annual—screening intervals among women aged 45 to 54 years; (3) the recommendation against routine screening CBE, a marked deviation from prior ACS guidelines and a stronger statement than that of the USPSTF, which in 2009 concluded that the evidence was insufficient to recommend for or against CBE; and (4) the recommendation to stop screening among women with a life expectancy of less than 10 years (the USPSTF concluded that evidence is insufficient to assess benefits and harms in women aged ≥75 years). Oeffinger and colleagues,1 the authors of the guideline, and Myers and colleagues,6 the group conducting the accompanying thorough evidence review, made several methodological decisions that led to these novel recommendations. First, the review extensively featured recent observational studies in assessing the benefits of mammography. This provided a wider range of estimates for breast cancer mortality relative risk reductions associated with screening mammography, which tend to be larger for observational studies than for randomized trials. In fact, the guideline provides estimates of number needed to screen for women in their 40s based on an estimated mortality reduction ranging from 20% to 40%,1 much greater than the 15% estimated from randomized trials.7 The authors acknowledge the limitations of observational studies,1 which include potentially noncomparable control groups, lead-time and length-time bias, and challenges differentiating effects of screening from changes in diagnosis and treatments over time. However, the authors also cite the limitations of the existing randomized trials, which were heterogeneous with regard to mammography exposure and whose findings are increasingly outdated.1 Second, challenging the conventional strategy of estimating mammography’s benefits and harms using 10-year age groups, the authors of the guideline describe the burden of breast cancer using Surveillance, Epidemiology, and End Results data categorized in 5-year age groups, noting that both the absolute risk and distribution of breast cancer deaths are more similar among women aged 45-49 years and 50-54 years than among women aged 45-59 years and 40-44 years. Thus, even though falsepositive mammograms are more frequent among younger women, the authors conclude that the ratio of benefits to harms associatedwithscreening45-to49-year-oldwomencouldberegarded as closer to the ratio among 50to 54-year-old women. A third key decision of the guideline’s authors was to commission an analysis by the Breast Cancer Surveillance Consortium (BCSC) assessing annual vs biennial screening.8 The study assessed the association of screening interval with tumor characteristics among 15 440 women aged 40 to 85 years diagnosed with breast cancer within 1 year of an annual screening mammogram or 2 years of a biennial screening mammogram from 1996 to 2012. The investigators found that the proportion of tumors that were stage IIB or higher and larger than 15 mm was greater for biennial screeners than annual screeners among premenopausal but not postmenopausal women. These findings influenced the guideline recommendation that among women aged 45 to 54 years, screening should occur annually. Earlier work from the BCSC also suggested potential benefits of annual vs biennial screening in identifying smaller tuAuthor Audio Interview at jama.com

Early Impact Of The Affordable Care Act On Oral Contraceptive Cost Sharing, Discontinuation, And Nonadherence

UNLABELLED : The objective of this review is to describe existing data on breast cancer incidence and mortality in low- and middle-income countries (LMICs), in particular in sub-Saharan Africa; identify the limitations of these data; and review what is known about breast cancer control strategies in sub-Saharan African countries and other LMICs. Available estimates demonstrate that breast cancer incidence and mortality are rising in LMICs, including in Africa, although high-quality data from LMICs (and particularly from sub-Saharan Africa) are largely lacking. Case fatality rates from breast cancer appear to be substantially higher in LMICs than in high-income countries. Significant challenges exist to developing breast cancer control programs in LMICs, perhaps particularly in sub-Saharan Africa, and the most effective strategies for treatment and early detection in the context of limited resources are uncertain. High-quality research on breast cancer incidence and mortality and implementation research to guide effective breast cancer control strategies in LMICs are urgently needed. Enhanced investment in breast cancer research and treatment in LMICs should be a global public health priority. IMPLICATIONS FOR PRACTICE The numbers of new cases of breast cancer, and breast cancer deaths per year, in low- and middle-income countries are rising. Engagement by the international breast cancer community is critical to reduce global disparities in breast cancer outcomes. Cancer specialists and institutions in high-income countries can serve as key partners in training initiatives, clinical care, protocol and program development, and research. This article provides an overview of what is known about breast cancer incidence, mortality, and effective strategies for breast cancer control in sub-Saharan Africa and identifies key gaps in the literature. This information can help guide priorities for engagement by the global cancer community.

Early Impact of the Affordable Care Act on Uptake of Long-acting Reversible Contraceptive Methods.

The oral contraceptive pill is the contraceptive method most commonly used by US women, but inconsistent use of the pill is a contributor to high rates of unintended pregnancy. The relationship between consumer cost sharing and consistent use of the pill is not well understood, and the impact of the elimination of cost sharing for oral contraceptive pills in a mandate in the Affordable Care Act (ACA) is not yet known. We analyzed insurance claims for 635,075 women with employer-sponsored insurance who were initiating use of the pill, to examine rates of discontinuation and nonadherence, their relationship with cost sharing, and trends before and during the first year after implementation of the ACA mandate. We found that cost sharing for oral contraceptives decreased markedly following implementation, more significantly for generic than for brand-name versions. Higher copays were associated with greater discontinuation of and nonadherence to generic pills than was the case with zero copayments. Discontinuation of the use of generic or brand-name pills decreased slightly but significantly following ACA implementation, as did nonadherence to brand-name pills. Our findings suggest a modest early impact of the ACA on improving consistent use of oral contraceptives among women initiating their use.

Cost of contraceptive methods to privately insured women in the United States.

Background:The Affordable Care Act (ACA) required most private insurance plans to cover contraceptive services without patient cost-sharing as of January 2013 for most plans. Whether the ACA’s mandate has impacted long-acting reversible contraceptives (LARC) use is unknown. Objective:The aim of this article is to assess trends in LARC cost-sharing and uptake before and one year after implementation of the ACA’s contraceptive mandate. Design:A retrospective cohort study using Truven Health MarketScan claims data from January 2010 to December 2013. Subjects:Women aged 18–45 years with continuous insurance coverage with claims for oral contraceptive pills, patches, rings, injections, or LARC during 2010–2013 (N=3,794,793). Measures:Descriptive statistics were used to assess trends in LARC cost-sharing and uptake from 2010 through 2013. Interrupted time series models were used to assess the association of time, ACA, and time after the ACA on LARC cost-sharing and initiation rates, adjusting for patient and plan characteristics. Results:The proportion of claims with

Benign and Malignant Breast Disease at Rwanda’s First Public Cancer Referral Center

0 cost-sharing for intrauterine devices and implants, respectively, rose from 36.6% and 9.3% in 2010 to 87.6% and 80.5% in 2013. The ACA was associated with a significant increase in these proportions and in their rate of increase (level and slope change both P<0.001). LARC uptake increased over time with no significant change in level of LARC use after ACA implementation in January 2013 (P=0.44) and a slightly slower rate of growth post-ACA than previously reported (&bgr; coefficient for trend, −0.004; P<0.001). Conclusions:The ACA has significantly decreased LARC cost-sharing, but during its first year had not yet increased LARC initiation rates.