Stephen H. Taplin

Effectiveness of Interventions to Increase Screening for Breast, Cervical, and Colorectal Cancers Nine Updated Systematic Reviews for the Guide to Community Preventive Services

CONTEXT Screening reduces mortality from breast, cervical, and colorectal cancers. The Guide to Community Preventive Services previously conducted systematic reviews on the effectiveness of 11 interventions to increase screening for these cancers. This article presents results of updated systematic reviews for nine of these interventions. EVIDENCE ACQUISITION Five databases were searched for studies published during January 2004-October 2008. Studies had to (1) be a primary investigation of one or more intervention category; (2) be conducted in a country with a high-income economy; (3) provide information on at least one cancer screening outcome of interest; and (4) include screening use prior to intervention implementation or a concurrent group unexposed to the intervention category of interest. Forty-five studies were included in the reviews. EVIDENCE SYNTHESIS Recommendations were added for one-on-one education to increase screening with fecal occult blood testing (FOBT) and group education to increase mammography screening. Strength of evidence for client reminder interventions to increase FOBT screening was upgraded from sufficient to strong. Previous findings and recommendations for reducing out-of-pocket costs (breast cancer screening); provider assessment and feedback (breast, cervical, and FOBT screening); one-on-one education and client reminders (breast and cervical cancer screening); and reducing structural barriers (breast cancer and FOBT screening) were reaffirmed or unchanged. Evidence remains insufficient to determine effectiveness for the remaining screening tests and intervention categories. CONCLUSIONS Findings indicate new and reaffirmed interventions effective in promoting recommended cancer screening, including colorectal cancer screening. Findings can be used in community and healthcare settings to promote recommended care. Important research gaps also are described.

Performance of Screening Mammography among Women with and without a First-Degree Relative with Breast Cancer

Many guidelines recommend that women at high risk for breast cancer undergo regular screening mammography at a younger age than those at average risk (1). However, few studies have evaluated the performance of screening mammography among younger women at increased risk for breast cancer. One group reported that the positive predictive value of mammography was two- to threefold higher (2) but the sensitivity was slightly lower (3) in women who had at least one first-degree relative with a history of breast cancer compared with those who did not. No randomized, controlled trials or subgroup analyses of data from existing randomized, controlled trials of screening mammography have evaluated the efficacy of the test in women with a family history of breast cancer. Understanding whether a family history of breast cancer influences the test performance characteristics of mammography may be important in developing screening strategies. This may be especially true for younger women, in whom the positive predictive value of mammography is low and the likelihood of associated diagnostic procedures to evaluate an abnormal result is high (2, 4, 5). We pooled data from seven mammography registries in order to provide a more stable estimate of the accuracy of screening mammography among women with a first-degree family history of breast cancer. We also compared the accuracy of the test in these women and in women of similar age without a family history. In this study, we report the rate of cancer, cancer yield per breast biopsy, and positive predictive value and sensitivity of mammography according to family history and decade of age. Methods Participants and Data Sources Our study sample included women 30 to 69 years of age who underwent screening mammography from April 1985 to November 1997. Data were pooled from seven mammography registries that participate in the National Cancer Institute Breast Cancer Surveillance Consortium (BCSC) (6). The seven registries, which are funded by the National Cancer Institute or the Department of Defense, are the San Francisco Mammography Registry (SFMR), San Francisco, California; Group Health Cooperative (GHC), Seattle, Washington; Fred Hutchinson Cancer Research Center (FHCRC), Seattle, Washington; New Mexico Mammography Project (NMMP), Albuquerque, New Mexico; Vermont Mammography Registry (VMR), Burlington, Vermont; Colorado Mammography Advocacy Project (CMAP), Denver, Colorado; and New Hampshire Mammography Network (NHMN), Hanover, New Hampshire. The SFMR provided data from April 1985 to December 1993, the GHC provided data from January 1986 to December 1993, the FHCRC provided data from December 1987 to December 1996, the NMMP provided data from June 1992 to December 1995, the VMR provided data from January 1994 to December 1996, the CMAP provided data from August 1994 to December 1996, and the NHMN provided data from May 1996 to November 1997. One mammographic examination per woman was included in the pooled analysis. If a woman had more than one mammographic examination in a mammography registry, results from her earliest dated examination were included and results from any subsequent screening examinations were excluded. We excluded women with a previous diagnosis of breast cancer and those with a palpable breast mass by history or on physical examination. Women whose ZIP codes were outside the catchment areas of their regional Surveillance, Epidemiology, and End Results (SEER) program or state tumor registry were also excluded to minimize incomplete follow-up information. The University of California, San Francisco, Committee on Human Research approved the study. Measurements We obtained a self-reported risk profile for breast cancer for each woman, as well as a mammographic assessment of two standard screening views per breast. The risk profile for breast cancer included questions about family history of breast cancer in a first-degree relative. Women were considered to have a family history of breast cancer if they reported having at least one first-degree relative (mother, sister, or daughter) with breast cancer. Results of initial screening examinations were classified as normal or abnormal. In mammography registries that used the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) (7) or terminology consistent with BI-RADS to assign mammographic assessment categories (SFMR, FHCRC, NMMP, VMR, NHMN, and CMAP), findings considered negative (category 1) or benign (category 2) were classified as normal. Examinations reported with any of the following BI-RADS assessments were categorized as abnormal: 1) probably benign (category 3); 2) incomplete, needs additional imaging evaluation (category 0), 3) suspicious (category 4), and 4) highly suggestive of malignancy (category 5). Before using BI-RADS, GHC used three mammographic assessment codes: negative, indeterminate, and positive. Negative and indeterminate assessments (for which follow-up in 1 year was recommended) were classified as normal; indeterminate assessments (for which 6-month follow-up examinations, additional imaging, or biopsy was recommended) and all positive assessments were classified as abnormal. Follow-up Breast biopsies performed to evaluate an abnormal mammography result were identified by contacting the womans personal physician, performing data linkage with a pathology database, or performing data linkage with a radiology database, depending on the study site. Breast biopsies included excisional and core biopsies. Women who had screening examinations were linked by computer to a pathology database (VMR, NHMN), to SEER (GHC, SFMR, NMMP, FHCRC), or to a state tumor registry (VMR, NHMN, CMAP) that collects population-based cancer data. To maintain participant confidentiality, procedures for linkage were performed according to protocols for human subjects research. Women were linked by using their full names, birth dates, addresses, ZIP codes, and Social Security numbers, when available, by using a probability-matching software program (Automatch, Vality Technology, Inc., Boston, Massachusetts) (VMR, NHMN, SFMR) or a comparable software program developed for linkage by a mammography registry (GHC, FHCRC, NMMP, CMAP). To allow adequate time for breast cancer to be reported to a tumor registry after a normal mammography result, we included only women who were screened through November 1997. Women were considered to have breast cancer if reports from a breast pathology database, SEER program, or state tumor registry showed any invasive carcinoma or ductal carcinoma in situ. Women with lobular carcinoma in situ only were excluded. Results for all cases of breast cancer and results for invasive cancer are presented separately. Definitions If breast cancer was diagnosed within 12 months of a normal mammography result, the examination was considered to be a false negative. If breast cancer was not diagnosed within 12 months of a normal mammography result, the examination was considered to be a true negative. If breast cancer was diagnosed within 12 months of an abnormal mammography result, the examination was considered to be a true positive. If breast cancer was not diagnosed within 12 months of an abnormal mammography result, the examination was considered to be a false positive. The diagnosis date was the date reported by a SEER program, the date reported by a state tumor registry, or the biopsy date recorded in a pathology database. Statistical Analysis The positive predictive value of screening mammography was calculated as the percentage of women with abnormal screening examinations who received a diagnosis of breast cancer within 12 months of the screening examination. Since the positive predictive value of mammography is influenced by the criteria used to define an examination as abnormal, we also reported the number of cases of breast cancer detected per 1000 screening examinations (normal and abnormal combined) when breast cancer was diagnosed within 1 year of the screening examination. The cancer yield per breast biopsy was calculated as the percentage of women who had a breast biopsy and received a diagnosis of breast cancer within 12 months of the screening examination. The sensitivity of mammography was calculated as the number of true-positive examinations divided by the number of true-positive examinations plus the number of false-negative examinations. The specificity of mammography was calculated as the number of true-negative examinations divided by the number of false-positive examinations plus the number of true-negative examinations. The chi-square test and the Fisher exact test were used for comparison of proportions. The chi-square test for trend and the chi-square test for homogeneity were used to compare proportions stratified by age. All Pvalues were two sided. Role of the Funding Sources The funding sources had no role in the collection, analysis, or interpretation of the data or in the decision to submit the paper for publication. Results A total of 389 533 screening examinations were performed among seven mammography registries. Of these, 50 834 (13.0%) were performed in women with a family history of breast cancer. Five registries record self-reported previous use of mammography. In data from these registries, previous use was similar among women with a family history of breast cancer (81.7% [28 574 of 34 973]) and among those without (80.2% [170 505 of 212 729]). Abnormal Mammography Results Among women without a family history of breast cancer, the overall frequency of abnormal examination results was 10.8% (95% CI, 10.7% to 11.0%). The frequency of abnormal results ranged from 8.8% to 11.3% across age groups and was lowest for women 30 to 39 years of age (Table 1). The frequency of abnormal examination results was higher among women with a family history of breast cancer than among those without (12.7% vs. 10.8%; P<0.001 [chi-square test]); these differe

Reported drop in mammography : is this cause for concern?

Timely screening with mammography can prevent a substantial number of deaths from breast cancer. The objective of this brief was to ascertain whether recent use of mammography has dropped nationally.

A test of an expanded theory of reasoned action to predict mammography participation

This paper presents the results of a prospective study testing an expanded theory of reasoned action (TRA) to predict mammography participation. A questionnaire was developed to measure each of the expanded TRA model components. A sample was identified of 946 women age 40 and above who were invited to obtain a mammogram at the Group Health Cooperative of Puget Sound Breast Cancer Screening Program (BCSP). The sample was stratified by risk category as determined by the screening program. The study questionnaire was administered to all women in the sample within 2 weeks after they were sent the invitation to obtain a mammogram. Mammography participation was obtained from the BCSP data base 6 months after the invitation. Regression analyses found attitude, affect, subjective norm, and facilitating conditions to all be significantly associated with participation. The expanded TRA model explained 39% of the variance in womens intentions and 20% of the variance in participation behavior. A stepwise hierarchical regression found that no other psychosocial measures were able to improve the model predictions of behavior. An interaction between habit and intention was found such that women with larger numbers of previous mammograms were less likely to carry out their intentions than women with fewer previous mammograms. Contrary to expectations, some demographic characteristics did significantly improve prediction. The need for further work investigating the roles of fear and experience is discussed.

Comparative Effectiveness of Digital Versus Film-Screen Mammography in Community Practice in the United States: A Cohort Study

BACKGROUND Few studies have examined the comparative effectiveness of digital versus film-screen mammography in U.S. community practice. OBJECTIVE To determine whether the interpretive performance of digital and film-screen mammography differs. DESIGN Prospective cohort study. SETTING Mammography facilities in the Breast Cancer Surveillance Consortium. PARTICIPANTS 329,261 women aged 40 to 79 years underwent 869 286 mammograms (231 034 digital; 638 252 film-screen). MEASUREMENTS Invasive cancer or ductal carcinoma in situ diagnosed within 12 months of a digital or film-screen examination and calculation of mammography sensitivity, specificity, cancer detection rates, and tumor outcomes. RESULTS Overall, cancer detection rates and tumor characteristics were similar for digital and film-screen mammography, but the sensitivity and specificity of each modality varied by age, tumor characteristics, breast density, and menopausal status. Compared with film-screen mammography, the sensitivity of digital mammography was significantly higher for women aged 60 to 69 years (89.9% vs. 83.0%; P = 0.014) and those with estrogen receptor-negative cancer (78.5% vs. 65.8%; P = 0.016); borderline significantly higher for women aged 40 to 49 years (82.4% vs. 75.6%; P = 0.071), those with extremely dense breasts (83.6% vs. 68.1%; P = 0.051), and pre- or perimenopausal women (87.1% vs. 81.7%; P = 0.057); and borderline significantly lower for women aged 50 to 59 years (80.5% vs. 85.1%; P = 0.097). The specificity of digital and film-screen mammography was similar by decade of age, except for women aged 40 to 49 years (88.0% vs. 89.7%; P < 0.001). LIMITATION Statistical power for subgroup analyses was limited. CONCLUSION Overall, cancer detection with digital or film-screen mammography is similar in U.S. women aged 50 to 79 years undergoing screening mammography. Women aged 40 to 49 years are more likely to have extremely dense breasts and estrogen receptor-negative tumors; if they are offered mammography screening, they may choose to undergo digital mammography to optimize cancer detection. PRIMARY FUNDING SOURCE National Cancer Institute.

Quality of life of 5-10 year breast cancer survivors diagnosed between age 40 and 49.

BackgroundThe purpose of this report is to examine the correlates of quality of life (QOL) of a well-defined group of long-term breast cancer survivors diagnosed between the ages of 40 and 49.MethodsWomen were eligible if they were diagnosed with invasive breast cancer or ductal carcinoma in situ 5 to 10 years before June 30, 1998 and were enrolled at Group Health Cooperative, a health maintenance organization in western Washington State. A questionnaire was mailed to 290 women; 216 were included in this analysis. The questionnaire included standardized measures of QOL [e.g., the Cancer Rehabilitation Evaluation System (CARES-SF) and SF-36] as well as general demographic and medical information. ANOVA and logistic regression were used to estimate correlates of self-reported QOL.ResultsThe mean age at diagnosis was 44.4 years, and the average time since diagnosis was 7.3 years. Women reported high levels of functioning across several standardized QOL scales; mild impairment was found on the CARES-SF Sexual Scale. The presence of breast-related symptoms at survey, use of adjuvant therapy, having lower income, and type of breast surgery were significantly associated with lower QOL 5 to 10 years post-diagnosis on one or more of the scales.ConclusionsOur results emphasize that younger long-term survivors of breast cancer have a high QOL across several standardized measures. However, the long-term consequences of adjuvant therapy and the management of long-term breast-related symptoms are two areas that may be important for clinicians and women with breast cancer in understanding and optimizing long-term QOL.

Introduction: Understanding and Influencing Multilevel Factors Across the Cancer Care Continuum

Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. There is, therefore, a need to consider our approach to health-care delivery. Cancer care is a good example for consideration because it spans the continuum of health-care issues from primary prevention through long-term survival and end-of-life care. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. To achieve health-care delivery consistent with the Institute of Medicines six quality aims (safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity), we must influence multiple levels of that multilevel system. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a well-established ecological view. This view has been used to analyze health-care delivery and health disparities. However, experience considering multilevel interventions in health care is much less robust. This monograph includes 13 chapters relevant to expanding the foundation of research for multilevel interventions in health-care delivery. Subjects include clinical cases of multilevel thinking in health-care delivery, the state of knowledge regarding multilevel interventions, study design and measurement considerations, methods for combining interventions, time as a consideration in the evaluation of effects, measurement of effects, simulations, application of multilevel thinking to health-care systems and disparities, and implementation of the Affordable Care Act of 2010. Our goal is to outline an agenda to proceed with multilevel intervention research, not because it guarantees improvement in our current approach to health care, but because ignoring the complexity of the multilevel environment in which care occurs has not achieved the desired improvements in care quality outlined by the Institute of Medicine at the turn of the millennium.

Prognostic Characteristics of Breast Cancer Among Postmenopausal Hormone Users in a Screened Population

PURPOSE We determined the risk of breast cancer and tumor characteristics among current postmenopausal hormone therapy users compared with nonusers, by duration of use. METHODS From January 1996 to December 2000, data were collected prospectively on 374,465 postmenopausal women aged 50 to 79 years who underwent screening mammography. We calculated the relative risk (RR) of breast cancer (invasive or ductal carcinoma-in-situ) and type of breast cancer within 12 months of postmenopausal therapy use among current hormone users with a uterus (proxy for estrogen and progestin use) and without a uterus (proxy for estrogen use), compared with nonusers. RESULTS Compared with nonusers, women using estrogen and progestin for >/= 5 years were at increased risk of breast tumors of stage 0 or I (RR, 1.51; 95% CI, 1.37 to 1.66), stage II or higher (RR, 1.46; 95% CI, 1.30 to 1.63), size </= 20 mm (RR, 1.59; 95% CI, 1.43 to 1.76), size greater than 20 mm (RR, 1.24; 95% CI, 1.09 to 1.42), grade 1 or 2 (RR, 1.60; 95% CI, 1.44 to 1.77), grade 3 or 4 (RR, 1.54; 95% CI, 1.37 to 1.73), and estrogen receptor-positive (RR, 1.72; 95% CI, 1.55 to 1.90). Estrogen-only users were slightly more likely to have estrogen receptor-positive breast cancer compared with nonusers (RR, 1.14; 95% CI, 1.06 to 1.23). CONCLUSION Use of estrogen and progestin postmenopausal hormone therapy for five years or more increased the likelihood of developing breast cancer, including both tumors with favorable prognostic features and tumors with unfavorable prognostic features.

Early Detection of Breast Cancer in Countries with Limited Resources

Abstract:  Breast cancer is commonly diagnosed at late stages in countries with limited resources. Efforts aimed at early detection can reduce the stage at diagnosis, potentially improving the odds of survival and cure, and enabling simpler and more cost‐effective treatment. Early detection of breast cancer entails both early diagnosis in symptomatic women and screening in asymptomatic women. Key prerequisites for early detection are ensuring that women are supported in seeking care and that they have access to appropriate, affordable diagnostic tests and treatment. We therefore propose the following sequential action plan: 1) promote the empowerment of women to obtain health care, 2) develop infrastructure for the diagnosis and treatment of breast cancer, 3) begin early detection efforts through breast cancer education and awareness, and 4) when resources permit, expand early detection efforts to include mammographic screening. Public education and awareness can promote earlier diagnosis, and these goals can be achieved in simple and cost‐effective ways, such as dissemination of messages through mass media. All women have the right to education about breast cancer, but it must be culturally appropriate and targeted and tailored to the specific population. When resources become available for screening, they should be invested in screening mammography, as it is the only modality that has thus far been shown to reduce breast cancer mortality. Clinical breast examination (CBE) and breast self‐examination (BSE) are important components of routine breast care in countries with access to mammography and are important for general breast health education in all countries. However, the evidence does not support the use of CBE and BSE as lifesaving screening methods at this time, recognizing that data from countries with very limited resource are lacking. When widespread screening is not possible, screening can begin in an institution, city, or region, or by targeting screening to women at highest risk. A pilot program can be an ideal way to define the best approach to screening. To succeed, early detection efforts must include the health care providers with whom women have contact; these providers may be physicians, nurses, midwives, traditional healers, or others. There are tremendous differences among and within countries, and a program to promote early detection must be tailored to each countrys unique situation. 

The expanding role of primary care in cancer control

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.