Michael S. O'Malley

The Association of Race/Ethnicity, Socioeconomic Status, and Physician Recommendation for Mammography: Who Gets the Message About Breast Cancer Screening?

OBJECTIVES This study investigated the association between physician recommendation for mammography and race/ethnicity, socioeconomic status, and other characteristics in a rural population. METHODS In 1993 through 1994, we surveyed 1933 Black women and White women 52 years and older in 10 rural counties. RESULTS Fifty-three percent of the women reported a physician recommendation in the past year. White women reported recommendations significantly more often than did Black women (55% vs 45%; odds ratio = 1.49). Controlling for educational attainment and income eliminated the apparent racial/ethnic difference. After control for 5 personal, 4 health, and 3 access characteristics, recommendation for mammography was found to be more frequent among women who had access to the health care system (i.e., had a regular physician and health insurance). Recommendation was less frequent among women who were vulnerable (i.e., were older, had lower educational attainment, had lower annual family income). CONCLUSIONS Socioeconomic status, age, and other characteristics--but not race/ethnicity--were related to reports of a physician recommendation, a precursor strongly associated with mammography use. Efforts to increase physician recommendation should include complementary efforts to help women address socioeconomic and other barriers to mammography use.

Increasing Use of Mammography Among Older, Rural African American Women: Results From a Community Trial

OBJECTIVES A community trial was undertaken to evaluate the effectiveness of the North Carolina Breast Cancer Screening Program, a lay health advisor network intervention intended to increase screening among rural African American women 50 years and older. METHODS A stratified random sample of 801 African American women completed baseline (1993-1994) and follow-up (1996-1997) surveys. The primary outcome was self-reported mammography use in the previous 2 years. RESULTS The intervention was associated with an overall 6 percentage point increase (95% confidence interval [CI] = -1, 14) in community-wide mammography use. Low-income women in intervention counties showed an 11 percentage point increase (95% CI = 2, 21) in use above that exhibited by low-income women in comparison counties. Adjustment for potentially confounding characteristics did not change the results. CONCLUSIONS A lay health advisor intervention appears to be an effective public health approach to increasing use of screening mammography among low-income, rural populations.

The North Carolina Breast Cancer Screening Program: foundations and design of a model for reaching older, minority, rural women

SummaryBreast cancer screening programs do not reach all women at the same rate. Screening mammography use varies according to sociodemographic characteristics; mammography utilization is highest among women in their fifties but then decreases with age. In North Carolina, breast cancer is a particular burden for Black and lower-income women. Black women are more likely to be diagnosed with late stage disease, and their rate of breast cancer mortality is higher than it is for White women even though the incidence in White women is greater. Older, Black, and low-income women are less likely to obtain screening by mammography and clinical breast examination. The Black-White gap is even more pronounced among rural women, in part because they are more likely to be poor.The North Carolina Breast Cancer Screening Program (NC-BCSP) was established to increase the rate of regular mammography screening by an absolute 20% in 3 years among older Black women ages 50 and older in five rural counties in the eastern part of the state. In this paper, we describe the genesis of this comprehensive community intervention model, highlighting the behavioral science constructs, health education principles, and theories of behavioral and organizational change that form its conceptual foundation. NC-BCSPs theoretical foundations include the social ecological perspective, the PRECEDE model of health promotion, the Health Belief Model of individual change, and the “stages of change” transtheoretical model. We also review the experiences and lessons learned from two previous outreach initiatives in North Carolina that provided valuable “lessons” in the development of the NC-BCSP intervention model. In the second half of the paper, we describe the actual NC-BCSP interventions, activities, and evaluation tools, citing specific examples of how the underlying theories are implemented.NC-BCSPs goal goes beyond individual behavior change to raise low mammography screening rates among Black women in rural North Carolina. Its ultimate objective is to create linkages across agencies, and between agencies and communities, that will endure after the research project ends.Breast cancer screening programs do not reach all women at the same rate. Screening mammography use varies according to sociodemographic characteristics; mammography utilization is highest among women in their fifties but then decreases with age. In North Carolina, breast cancer is a particular burden for Black and lower-income women. Black women are more likely to be diagnosed with late stage disease, and their rate of breast cancer mortality is higher than it is for White women even though the incidence in White women is greater. Older, Black, and low-income women are less likely to obtain screening by mammography and clinical breast examination. The Black-White gap is even more pronounced among rural women, in part because they are more likely to be poor. The North Carolina Breast Cancer Screening Program (NC-BCSP) was established to increase the rate of regular mammography screening by an absolute 20% in 3 years among older Black women ages 50 and older in five rural counties in the eastern part of the state. In this paper, we describe the genesis of this comprehensive community intervention model, highlighting the behavioral science constructs, health education principles, and theories of behavioral and organizational change that form its conceptual foundation. NC-BCSPs theoretical foundations include the social ecological perspective, the PRECEDE model of health promotion, the Health Belief Model of individual change, and the “stages of change” transtheoretical model. We also review the experiences and lessons learned from two previous outreach initiatives in North Carolina that provided valuable “lessons” in the development of the NC-BCSP intervention model. In the second half of the paper, we describe the actual NC-BCSP interventions, activities, and evaluation tools, citing specific examples of how the underlying theories are implemented. NC-BCSPs goal goes beyond individual behavior change to raise low mammography screening rates among Black women in rural North Carolina. Its ultimate objective is to create linkages across agencies, and between agencies and communities, that will endure after the research project ends.

How best to teach women breast self-examination. A randomized controlled trial

OBJECTIVE To compare three methods for teaching breast self-examination. DESIGN Randomized controlled trial with factorial design. SETTING A general medicine group practice in a university hospital. PATIENTS Continuing-care patients from 40 to 68 years of age. Of 456 eligible women, 156 refused participation, 300 were randomly assigned, 269 completed assigned interventions, and 260 completed the post-test 1 year later. INTERVENTIONS One third of patients received nurse instruction stressing tactile skills (Mammacare group) (Mammatech Corporation, Gainesville, Florida); one third, traditional nurse instruction emphasizing technique (traditional group); and one third, no nurse instruction (control group). Half of each group received physician encouragement. MEASUREMENTS AND MAIN RESULTS One year later, women in the Mammacare group found more lumps (mean, 57%; 95% CI, 54% to 60%) in manufactured breast models than did those in the traditional (mean, 47%; CI, 44% to 51%) and control (mean, 45%; CI, 42% to 48%) groups. Lump detection specificity was unaffected. Self-reported examination frequency rose in all groups, to 5.1 times per 6 months in the traditional group, 4.2 in the Mammacare group, and 3.9 in the control group. Physician encouragement did not improve sensitivity, specificity, or overall frequency. Women in the Mammacare group used more of seven examination techniques (4.9) than did those in the traditional (3.9) or control (3.2) groups (P less than 0.001). No group increased health care use or reported more overall worry about breast cancer. CONCLUSIONS Mammacare instruction resulted in more long-term improved lump detection and examination technique use than did traditional instruction or physician encouragement. Breast self-examination instruction should emphasize lump detection skills.

Communicating results of diagnostic mammography: What do patients think?

RATIONALE AND OBJECTIVES The purpose of this study was to investigate womens preferences for who (radiologist or referring physician) should communicate the results of diagnostic mammography. MATERIALS AND METHODS Data from 153 women presenting to two sites for diagnostic mammography between February and June 1995 were collected with a 24-item, self-administered, closed-ended survey. For both normal and abnormal hypothetical results, contingency tables with chi2 tests and multiple logistic regression were used to determine the association, if any, between womens characteristics and their preferences. RESULTS Women undergoing diagnostic mammography preferred that their radiologists disclose their normal (90%) and abnormal (88%) mammogram results to them immediately after their examination, rather than have their referring physicians disclose results at a later time. In the case of normal findings, women whose regular physicians were specialists were less likely to want to hear first from their radiologists (odds ratio [OR] = 0.06; 95% confidence interval [CI] = 0.01, 0.77; P = .03), but women who were nervous about learning their results were more likely to want to hear first from their radiologists (OR = 4.5; 95% CI = 1.2, 17.3; P = .03). CONCLUSION Radiologists may want to consider assessing womens preferences for who communicates their mammogram results, as most women in this study preferred to hear these results from their radiologists rather than waiting to hear from their referring physicians.

Prostate and Colon Cancer Screening Messages in Popular Magazines

AbstractOBJECTIVES: To 1) compare the number of articles published about prostate, colon, and breast cancer in popular magazines during the past 2 decades, and 2) evaluate the content of indepth prostate and colon cancer screening articles identified from 1996 to 2001. DESIGN: We used a searchable database to identify the number of prostate, colon, and breast cancer articles published in three magazines with the highest circulation from six categories. In addition, we performed a systematic review on the in-depth (≥2 pages) articles on prostate and colon cancer screening that appeared from 1996 through 2001. RESULTS: Although the number of magazine articles on prostate and colon cancer published in the 1990s increased compared to the 1980s, the number of articles is approximately one third of breast cancer articles. There were 36 in-depth articles from 1996 to 2001 in which prostate or colon cancer screening were mentioned. Over 90% of the articles recommended screening. However, of those articles, only 76% (25/33; 95% confidence interval [CI], 58% to 89%) cited screening guidelines. The benefits of screening were mentioned in 89% (32/36; 95% CI, 74% to 97%) but the harms were only found in 58% (21/36; 95% CI, 41% to 75%). Only 28% (10/36; 95% CI, 14% to 45%) of the articles provided all the necessary information needed for the reader to make an informed decision. CONCLUSIONS: In-depth articles about prostate and colon cancer in popular magazines do not appear as frequently as articles about breast cancer. The available articles on prostate and colon cancer screening often do not provide the information necessary for the reader to make an informed decision about screening.

How consistently do women report lifetime mammograms at successive interviews

BACKGROUND Little data exist on the reliability of self-reported regular mammography use measures. We used data from two successive interviews of 892 women aged 50 to 74 years without a history of abnormal mammograms to investigate how consistently women report their lifetime number of mammograms. METHODS We added an estimated number of mammograms obtained between interviews to the baseline report to create a revised baseline report for comparison with the follow-up report. We then examined the correlation in paired reports, the level of agreement between paired reports, and factors associated with consistent reporting. RESULTS Spearman rank correlation between paired reports was 0.73. Agreement between paired reports dropped with increasing lifetime number of mammograms. After adjustment for mammography use, womens characteristics did not appear to be strongly associated with consistent reporting. CONCLUSIONS Self-reported lifetime number of mammograms is a reasonably consistent measure for younger women or women with less mammography experience, but it is less reliable for women with long mammography histories. In these women, it may be useful to distinguish those who obtain regular screening from those who do not. Assessing reliability as well as validity for other measures of regular mammography use will allow additional measures to be identified.

The practices and attitudes of primary care nurse practitioners and physician assistants with respect to colorectal cancer screening

The practices and attitudes of primary care nurse practitioners and physician assistants with respect to colorectal cancer screening

Serum Factors Releasing Serotonin from Normal Platelets: Relation to the Manifestations of Systemic Lupus Erythematosus

In 13 patients with systemic lupus erythematosus, globulin fractions of sera from serial bleedings were assayed for the induction of serotonin release from normal platelets. Releasing activity appeared at some time in the sera of seven patients, five of whom had episodes of thrombocytopenia. Conversely, only one patient manifested thrombocytopenia without the occurrence of serotonin releasing activity at any time. In three patients with episodes of thrombocytopenia, increases in serotonin releasing activity temporally coincided with drops in platelet count. These data show that levels of circulating platelet serotonin releasing factor(s) vary in the course of systemic lupus erythematosus and these variations may be inversely related to the platelet count in particular patients.

Physicians and the teaching of breast self-examination: implications from a survey at a university teaching hospital.

We surveyed 80 physicians from four specialties (Family Medicine, General Medicine, General Surgery, Ob-Gyn) to investigate how they taught breast self-examination (BSE). Only half reported personally teaching BSE. Few MDs reported routinely using techniques to assess BSE competency. Most (72 per cent) claimed no formal training in teaching BSE; 10 per cent claimed no training at all. Techniques used to teach BSE may vary, and physicians may lack the training to teach BSE.