Impact of a community-based breast cancer screening program on Hopi women

Objective

To examine changes in breast cancer knowledge, attitudes, beliefs and behaviors following implementation of a tribal run CDC Breast and Cervical Cancer Program (BCCP), we report 2006 survey results from Hopi women and contrast findings with 1993 survey data and BCCP reports.

Methods

Community meetings, focus groups, and researchers jointly developed a culturally appropriate survey instrument. Hopi women randomly selected from Tribal enrollment lists were interviewed in-person by Hopi interviewers; 250 women ≥ age 18 participated (87% response) between June and December, 2006.

Results

Among women 40+, 77.5% reported ever having had a mammogram and 68.9% reported having done so within the past 2 years, an increase from 45.2% and 46% self-reported in 1993. Compared to 1993, more women in 2006 (88.1% vs. 59%) believed that a mammogram can detect cancer and more than 90% now believe that early detection of cancer can save lives. Women reported a preference (60%) for receiving health care at the Hopi BCCP. Survey results were validated using programmatic data which estimated 76.6% of Hopi women had received mammography screening.

Conclusion

Implementation of a tribal run BCCP has resulted in a substantial increase in mammography screening on the Hopi reservation.     

How do we achieve informed choice for women considering breast screening?

Objective

In current medical literature, mammography and other cancer screening programs are subject to controversy because of debate about the magnitude and nature of the benefits and harms. This paper discusses the issues around informed choice for women considering breast screening.

Method

We discuss qualitative and quantitative studies of women’s attitudes to breast screening and informed choice.

Results

Women view breast screening as a way of avoiding potential regret, and reassurance from normal results is highly valued. Screening participants acknowledge anxiety about false positives but awareness regarding potential overdetection of indolent breast cancer is minimal, and research is needed to assess how better understanding of screening downsides may affect women’s views. In any case, weighing up screening advantages and disadvantages is sensitive to personal preferences.

Conclusions

Communicators have an ethical obligation to make balanced information available to women, which is flexible enough to respond to the level of detail and involvement desired by each individual. Many women want to know more and to participate more actively in screening decisions. Techniques have been developed to present balanced information and support individual decision making in ways that are accessible and empowering for the wider community. Evaluations of breast cancer screening must integrate clinical data with evidence on the perspectives of women themselves.     

How many deaths are attributable to smoking in the United States? Comparison of methods for estimating smoking-attributable mortality when smoking prevalence changes

Background

The number of smoking-attributable deaths is commonly estimated using current and former smoking prevalences or lung cancer mortality as an indirect metric of cumulative population smoking. Neither method accounts for differences in the timing with which relative risks (RRs) for different diseases change following smoking initiation and cessation. We aimed to develop a method to account for time-dependent RRs.

Methods

We used birth cohort lung cancer mortality and its change over time to characterize time-varying cumulative smoking exposure. We analyzed data from the American Cancer Society Cancer Prevention Study II to estimate RRs for disease-specific mortality associated with current and former smoking, and change in RRs over time after cessation.

Results

When lung cancer was used to measure cumulative smoking exposure, 254,700 male and 227,000 female deaths were attributed to smoking in the US in 2005. A modified method in which RRs for different diseases decreased at different rates after cessation yielded similar but slightly lower estimates [251,900 (male) and 221,100 (female)]. The lowest estimates resulted from the method based on smoking prevalence [225,800 (male) and 163,700 (female)].

Conclusions

Although all methods estimated a large number of smoking attributable deaths, future efforts should account for temporal changes in smoking prevalence and in accumulation/reversibility of disease-specific risks.     

Overdiagnosis in breast cancer: design and methods of estimation in observational studies

Objectives

In recent years observational epidemiological studies have been used to estimate overdiagnosis in breast cancer screening. These estimates vary widely. In this paper we present some of the methodological issues which explain the large variability of the reported findings.

Methods

Different types of observational studies were identified according to study design, definition of the population, adjustment for breast cancer risk and adjustment for lead time.

Results

The majority of observational studies that have estimated breast cancer overdiagnosis have analyzed temporal trends or geographical differences in breast cancer incidence. Estimates of overdiagnosis in a dynamic population vary widely, from 4% to 52%. Only a few studies have used the cohort approach and they found estimates varying from 1% to 5%.

Conclusions

The cohort approach is preferable to the analysis of a dynamic population because it allows the follow-up of a group of women who have had the opportunity for screening and evaluates if there is sufficient follow-up after the last screen.     

Population studies of the effectiveness of mammographic screening

Objective

To examine population data to see whether survival from breast cancer has improved differentially in screened and unscreened women and examine published studies on mammographic screening to determine whether there is evidence that screening is no longer effective.

Methods

Data was reviewed on trends in breast cancer specific survival among women participating and not participating in the British Columbia Breast Screening Program. Population studies of mammographic screening published between 2000 and 2010 with breast cancer mortality as the outcome were also reviewed.

Results

Breast cancer specific survival in British Columbia improved more in screening participants than non-participants, HR = 0.74 (0.58,0.93) between the periods 1990-4 and 2000-4. Among the published studies of mortality between 2000 and 2010 selected from different jurisdictions all had found a reduction in breast cancer mortality although this was not always statistically different from zero. Studies had used a range of designs and evaluative methods which may have contributed to the magnitude of the effect reported.

Conclusion

No evidence was found in the British Columbia data and the published studies reviewed, that treatment or other changes, had caused mammographic screening to become ineffective.     

The impact of advances in treatment on the efficacy of mammography screening

Objective

The objective of this commentary is to argue that advances in therapy are diminishing the efficacy of mammography screening.

Method

Key studies which demonstrate this effect are briefly reviewed.

Results

The author argues that, for screening to be beneficial, the treatment of screen-detected cancers must be more effective than that of clinically-detected cancers. If there was no effective therapy for breast cancer, then screening would offer no benefit. Furthermore, as breast cancer treatments improve over time, both the absolute and relative benefits of screening will diminish. This is evident in the overview of the nine successive mammography screening trials, which have shown a decrease in the benefit of mammography screening over time, with the three most recent trials showing no benefit at all. Breast cancer adjuvant therapy was widely available in the three most recent mammography screening trials, but not the earlier trials. Additionally, population-based studies seem to suggest that the benefit of mammography screening is diminishing as treatments continue to improve.

Conclusion

Thus, in the years ahead, further declines in breast cancer mortality will likely be fueled by advances in therapy, and not by improvements in screening technology.     

Socioeconomic factors affecting colorectal, breast and cervical cancer screening in an Asian urban low-income setting at baseline and post-intervention

Background

Inequalities in cancer screening are little studied in Asian societies. We determined whether area and individual measures of socio-economic status (SES) affected cancer screening participation in Singapore and prospectively evaluated an access-enhancing community-based intervention.

Methods

The study population involved all residents aged > 40 years in two housing estates comprising of owner-occupied (high-SES area) and rental (low-SES area) flats. From 2009 to 2011, non-adherents to regular screening for colorectal/breast/cervical cancer were offered free convenient screening over six months. Pre- and post-intervention screening rates were compared with McNemar's test. Multi-level logistic regression identified factors of regular screening at baseline; Cox regression analysis identified predictors of screening post-intervention.

Results

Participation was 78.2% (1081/1383). In the low-SES area, 7.7% (33/427), 20.4% (44/216), and 14.3% (46/321) had regular colorectal, cervical and breast cancer screening respectively. Post-intervention, screening rates in the low-SES area rose significantly to 19.0% (81/427), 25.4% (55/216), and 34.3% (74/216) respectively (p < 0.001). Area SES was more consistently associated with screening than individual SES at baseline. Post-intervention, for colorectal cancer screening, those with higher education were more likely to attend (p = 0.004); for female cancer screening, the higher-income were less likely to attend (p = 0.032).

Conclusions

Access-enhancing community-based interventions improve participation among disadvantaged strata of Asian societies.     

The importance of socio-economic variables in cancer screening participation: a comparison between population-based and opportunistic screening in the EU-15

Objectives

To investigate differences in participation with breast and cervical cancer screening related to individual socio-economic characteristics, across population-based versus opportunistic screening programmes.

Methods

Data from Eurobarometer 66.2 “Health in the European Union” 2006 on self-reported breast and cervical cancer screening participation in the preceding 12 months within the EU 15 was obtained The sample was restricted to those eligible for screening based on the screening age within each country. Observations for 2214 and 5025 individuals respectively for breast and cervical cancer screening were available. Data on marital status, self-reported health, socio-economic group and years of education were also available. Screening programmes were categorised as population-based or opportunistic and logistic regression analysis used to examine the relationship between participation, individual characteristics and programme type.

Results

Differences in participation related to socio-economic status were observed in opportunistic screening programmes for breast cancer (OR = 0.63* and OR = 0.51**) and cervical cancer (OR = 0.75** and OR = 0.64**). Differences related to socio-economic characteristics were not found with respect to participation in population-based programmes.

Conclusions

In opportunistic programmes, differences in participation across socio-economic groups are evident in respect of both breast and cervical cancer screening. These differences may have implications for treatment and outcomes across socio-economic groups. Such differences were not evident in population-based programmes.     

Divergences et surdiagnostics dans le dépistage organisé du cancer du sein. Une revue systématique « méthodologique » de la littérature

Background

The risk-benefit ratio of breast cancer organized screening is the focus of much scientific controversy, especially about overdiagnosis. The aim of this study was to relate methodological discrepancies to variations in rates of overdiagnosis to help build future decision aids and to better communicate with patients.

Carbohydrate Intake and Overweight and Obesity among Healthy Adults

Background

Little is known about the dietary habits of people with optimal body weight in communities with high overweight and obesity prevalence.

Objective

To evaluate carbohydrate intake in relation to overweight and obesity in healthy, free-living adults.

Design

We used a cross-sectional analysis.

Subjects/setting

The Canadian Community Health Survey Cycle 2.2 is a cross-sectional survey of Canadians conducted in 2004-2005. There were 4,451 participants aged 18 years and older with anthropometric and dietary data and no comorbid conditions in this analysis.

Main outcome measures

Outcome variables were body mass index (BMI; calculated as kg/m²) and overweight or obesity status (dichotomous) defined as BMI ≥25 compared with BMI <25 based on measured height and weight. Diet was evaluated by 24-hour dietary recall based on the Automated Multi-Pass Method.

Statistical analyses performed

Weighted regression models with bootstrapping and cubic splines were used. Outcome variables were BMI and overweight or obesity, and predictors were daily nutrient intake. Adjustment for total energy intake, age, leisure time energy expenditure, sex, smoking, education, and income adequacy was performed.

Results

Risk of overweight and obesity was decreased in all quartiles of carbohydrate intake compared to the lowest intake category (multivariate odds ratio quartile 2=0.63; 95% confidence interval: 0.49 to 0.90; odds ratio quartile 3=0.58; 95% confidence interval: 0.41 to 0.82; odds ratio quartile 4=0.60; 95% confidence interval: 0.42 to 0.85). Spline analyses revealed lowest risk among those consuming 290 to 310 g/day carbohydrates.

Conclusions

Consuming a low-carbohydrate (approximately <47% energy) diet is associated with greater likelihood of being overweight or obese among healthy, free-living adults. Lowest risk may be obtained by consuming 47% to 64% energy from carbohydrates.     

Intrauterine device use among women with ovarian cancer: a systematic review

Background

Fertility-sparing treatment may be an option for women with early stage ovarian cancer and certain tumor types. This systematic review evaluated the evidence on the safety of intrauterine device (IUD) use by women with ovarian cancer.

Study Design

We searched the PubMed database for peer-reviewed articles relevant to IUD (copper or levonorgestrel-releasing) use and ovarian cancer published in any language from database inception through August 2009. We sought studies that examined outcomes among women using an IUD at or after ovarian cancer diagnosis.

Results

Of the 250 articles identified by our search strategy, none provided evidence (direct or indirect) regarding the safety of IUD use among women with ovarian cancer.

Conclusions

No evidence on the safety of IUD use among women with ovarian cancer was identified. While there are some theoretical concerns that IUD use might affect monitoring of disease progression of sex cord-stromal tumors, or increase risk of pelvic infection or vaginal bleeding among women undergoing chemotherapy, we did not find any data to suggest that IUD use would lead to worsening of primary ovarian cancer.     

Variability in measuring (instrumental) activities of daily living functioning and functional decline in hospitalized older medical patients: a systematic review

Objective

To study instruments used and definitions applied in order to measure (instrumental) activities of daily living (I [ADL]) functioning and functional decline in hospitalized older medical patients.

Study Design

We systematically searched Medline, Embase, and the Cochrane Database of Systematic Reviews from 1990 to January 2010. Articles were included if they (1) focused on acute hospitalization for medical illness in older patients; (2) described the instrument used to measure functioning; and (3) outlined the clinical definition of functional decline. Two reviewers independently extracted data.

Results

In total, 28 studies were included in this review. Five different instruments were used to measure functioning: the Katz ADL index, the IADL scale of Lawton and Brody, the Barthel index, Functional Independence Measure, and Care Needs Assessment. Item content and scoring between and within the instruments varied widely. The minimal amount for decline, as defined by the authors, referred to a decrease in functioning between 2.4% and 20.0%.

Conclusion

This review shows there is a large variability in measuring (I)ADL functioning of older hospitalized patients and a large range of clinical definitions of functional decline. These conceptual and clinimetric barriers hamper the interpretation and comparison of functional outcome data of epidemiological and clinical studies.     

Comparative effectiveness of mailed reminder letters on mammography screening compliance

Objective

Reminder letters are effective at prompting women to schedule mammograms. Less well studied are reminders addressing multiple preventive service recommendations. We compared the effectiveness of a mammogram-specific reminder sent when a woman was due for a mammogram to a reminder letter addressing multiple preventive services and sent on a woman's birthday on mammography receipt.

Methods

The study included 48,583 women 52-74 years enrolled in Group Health Cooperative, a health plan in Washington State. From 2005 to 2009, women were mailed 88,605 mammogram-specific or birthday letters. In this one group pretest-posttest study, we modeled the odds of obtaining a screening mammogram after receiving a letter by reminder type using logistic regression, controlling for demographic and healthcare use characteristics and stratifying by whether women were overdue or up-to-date with mammography at the mailing.

Results

Among women up-to-date with screening, birthday letters were negatively associated with mammography receipt compared to mammogram-specific letters (birthday letters with 1-2 recommendations: OR = 0.73; 95% CI:0.68-0.79; 3 recommendations: OR = 0.74; 95% CI:0.69-0.78; 4-8 recommendations: OR = 0.62 95% CI:0.55-0.68) after. Among overdue women, birthday letters with 4-8 recommendations were negatively associated with mammography receipt.

Conclusions

Transitioning from mammogram-specific reminder letters to multiple preventive service birthday letters was associated with decreased mammography receipt.     

Behavioral mediators of colorectal cancer screening in a randomized controlled intervention trial

Background

Understanding mediators for behavioral change is important for the optimization of intervention strategies. This report examines mediators of change in the context of a randomized controlled intervention trial (Los Angeles, 2004-2009) that successfully increased colorectal cancer (CRC) screening among Filipino Americans.

Methods

The intervention, based on the Health Behavior Framework, targeted knowledge/awareness of CRC screening, communication with health care provider, health beliefs, social support and barriers to CRC screening. Health Behavior Framework variables were assessed at baseline and 6-month follow-up (N = 432). Variables targeted for change were tested as potential mediators of the primary outcome, self-reported receipt of CRC screening during the follow-up period, which was previously found to have increased significantly among intervention participants.

Results

Consistent with the Health Behavior Framework, knowledge/awareness of CRC screening and patient-provider communication mediated receipt of screening. Increase in knowledge/awareness of CRC screening accounted for 13% (95% confidence interval 2%-24%) of the total intervention effect size, while patient-provider communication accounted for 20% (5%-36%). Combined, these two variables accounted for 28% (10%-46%) of the total effect size.

Conclusion

Examining the roles of potential mediators in intervention trials may help identify constructs to target in order to enhance the effectiveness of interventions to increase screening.     

Tiempo de viaje y participación en el cribado del cáncer de mama en una región de alta dispersión poblacional

Objective

To analyze the association between travel time and participation in a breast cancer screening program adjusted for contextual variables in the province of Segovia (Spain).

Methods

We performed an ecological study using the following data sources: the Breast Cancer Early Detection Program of the Primary Care Management of Segovia, the Population and Housing Census for 2001 and the municipal register for 2006-2007. The study period comprised January 2006 to December 2007. Dependent variables consisted of the municipal participation rate and the desired level of municipal participation (greater than or equal to 70%). The key independent variable was travel time from the municipality to the mammography unit. Covariables consisted of the municipalities’ demographic and socioeconomic factors. We performed univariate and multivariate Poisson regression analyses of the participation rate, and logistic regression of the desired participation level.

Results

The sample was composed of 178 municipalities. The mean participation rate was 75.2%. The desired level of participation (≥70%) was achieved in 119 municipalities (67%). In the multivariate Poisson and logistic regression analyses, longer travel time was associated with a lower participation rate and with lower participation after adjustment was made for geographic density, age, socioeconomic status and dependency ratio, with a relative risk index of 0.88 (95% CI: 0.81-0.96) and an odds ratio of 0.22 (95% CI: 0.1-0.47), respectively.

Conclusion

Travel time to the mammography unit may help to explain participation in breast cancer screening programs.     

Long-term projections of the harm-benefit trade-off in prostate cancer screening are more favorable than previous short-term estimates

Objective

To project long-term estimates of the number needed to screen (NNS) and the additional number needed to treat (NNT) to prevent one prostate cancer death with prostate-specific antigen (PSA) screening in Europe and in the United States.

Study Design and Setting

A mathematical model of disease-specific deaths in screened and unscreened men given information on overdiagnosis, disease-specific survival in the absence of screening, screening efficacy, and other-cause mortality is presented. A simulation framework is used to incorporate competing causes of death.

Results

Assuming overdiagnosis and screening efficacy consistent with European Randomized study of Screening for Prostate Cancer (ERSPC) results, we project that, after 25 years, 262 men need to be screened and nine additional men need to be screen detected to prevent one prostate cancer death. Corresponding estimates of the NNS and the additional NNT under a range of overdiagnosis rates that are consistent with U.S. incidence are 186-220 and 2-5.

Conclusions

Long-term estimates of the NNS and the additional NNT are an order of magnitude lower than the short-term estimates published with the results of the ERSPC trial and may be consistent with cost-effective PSA screening in the general U.S. population.     

The effect of phloroglucinol on pain in first-trimester surgical abortion: a double-blind randomized controlled study

Background

First-trimester surgical abortion is a common procedure. Pain control during this procedure is still an unsolved problem.

Study Design

In this randomized, double-blind placebo-controlled study, women presenting for first-trimester surgical abortion received intramuscular phloroglucinol (4 mL) or placebo (normal saline, 4 mL). Visual analog scales (VAS) for pain immediately and 30 min after the procedure and side effects of the drug were recorded.

Results

There was no significant difference between groups in the pain level immediately and 30 min after the procedure; 70.7% of the phloroglucinol group (n=58 cases) and 56.9% of the placebo group (n=58 cases ) reported mild pain; 27.6% and 34.5%, respectively, reported moderate pain; and 1.7% and 8.6%, respectively, reported severe pain. Thirty minutes after the procedure, the median pain score was reduced to 1.3 in both groups. Postoperative side effects were reported, but there was no significant difference between groups for nausea or vomiting and blood pressure.

Conclusion

The use of this dose of phloroglucinol, during first-trimester abortion by suction evacuation under local anesthesia with lidocaine, did not relieve pain, but caused no side effects.     

Oral contraceptives and family history of breast cancer

Background

Questions remain regarding whether oral contraceptive (OC) use among women with a family history of breast cancer increases disease risk.

Study Design

We conducted a systematic review by searching MEDLINE and CENTRAL databases for evidence (in all languages) published in peer-reviewed journals from 1966 to July 2008 that provided estimates of breast cancer risk according to family history. Twelve articles were identified and the quality of each study was assessed using the United States Preventive Services Task Force grading system.

Results

Results from 10 studies and one pooled analysis of 54 studies suggest that the use of OCs does not significantly modify the risk of breast cancer among women with a familial history of breast cancer; however, evidence from four studies shows that some women may be at a greater risk, particularly women who took OCs prior to 1975.

Conclusions

Current evidence shows that women with a family history of breast cancer do not increase their disease risk by using OCs.