Investing in early detection versus intensive treatment for breast cancer: a study of the Israeli public priorities

Objective  Public opinion has become one of the main inputs in setting priorities, rationing and allocating health resources. The present study focuses on the priorities of the Israeli public in allocating marginal breast cancer funds between early detection in the healthy majority of the population and intensive treatment of the sick minority in need.
Design  A sample of 2030 individuals representing the Israeli Jewish urban population aged 45–75 was interviewed in 1993/4. A full sit-down interview collected information on several health related issues.
Results  Sixty-one per cent chose to direct the funds to early detection efforts and 35% chose to direct the funds to treating the sick. Four per cent of the population could not decide. Higher education and better health are related to choosing early detection; religious observance is related to choosing the treatment option; and men and older persons tend, more than women and younger respondents, to be undecided.
Conclusions  Whilst the majority of the population tend to follow a cost-effectiveness rationale in the marginal use of breast cancer funds, for more than a third of the population efficiency is not thus important, and they adhere to entitlement based upon a need-equity principle in allocating health resources.     

Decision-making role preferences and information needs: a comparison of colorectal and breast cancer

Objective  An exploratory study has been carried out to examine decision-making role preferences and information needs for a sample of people with colorectal cancer ( n =48). The work replicated a larger study carried out for women with breast cancer ( n =150), and this paper compares and contrasts findings for both disease groups.
Design  A cross-sectional design was employed, involving structured interviews. The main variables investigated were decision-making preference (using a decisional role preference card sort), perceived decisional role and information need (using an information needs questionnaire).
Results  The majority (78%) of the colorectal cancer patients preferred to play a passive role in decision making, in contrast to 52% of women with breast cancer in previous work. Eighty per cent of the colorectal sample and 61% of the women with breast cancer perceived that the doctor had made treatment decisions. Priority information needs for both groups related to cure, spread of disease and treatment options.
Conclusions  The two most striking findings from the comparison between the two disease groups relate to the differences in decision-making role preferences and the similarities in information needs. The process of involving people with colorectal cancer in treatment decision making warrants further investigation. The similarity in information needs of the two disease groups has implications for health care professionals providing information to people with cancer.     

Who wants to know if their care is rationed? Views of citizens and service informants

Objective  To explore the views of citizens and service informants about whether they would want to know about any rationing of their own health care.
Design  In-depth interviews using a semistructured schedule. Data were analysed using the methods of constant comparison.
Setting and participants  Citizens and service informants.
Main variables studied  Issues around health care rationing were explored within the context of the United Kingdom health care system.
Results  The views of citizens and service informants were very similar in terms of whether they, personally, wanted to know about any rationing of their own care, with the vast majority wanting to be given this information. Informants were also similar in terms of their reasons for wanting to know about rationing: to be given a 'good explanation' to enable them to judge whether the decision made had been correct; and to enable them to change the decision if necessary, either through protest or payment. Many informants suggested that they would indeed be likely to react either by challenging the decision or by paying for care.
Conclusions  The findings suggest that policies to be open with people about the rationing of care would be welcomed, but also indicate that if protest follows such openness, it may be difficult for the health service to cope with greater explicitness. Further research is needed among patient groups actually facing this situation.     

Medical tests: women's reported and preferred decision-making roles and preferences for information on benefits, side-effects and false results

Objective To determine women's preferences for and reported experience with medical test decision‐making. Design Computer‐assisted telephone survey. Setting and participants Six hundred and fifty‐two women resident in households randomly selected from the New South Wales electronic white pages. Main outcome measures Reported and preferred test and treatment (for comparison) decision‐making, satisfaction with and anxiety about information on false results and side‐effects; and effect of anxiety on desire for such information. Results Overall most women preferred to share test (94.6%) and treatment (91.2%) decision‐making equally with their doctor, or to take a more active role, with only 5.4–8.9% reporting they wanted the doctor to make these decisions on their behalf. This pattern was consistent across all age groups. In general, women reported experiencing a decision‐making role that was consistent with their preference. Women who had a usual doctor were more likely to report experiencing an active role in decision‐making. More women reported receiving as much information as they wanted about the benefits of tests and treatment than about the side‐effects of tests and treatment. Most women wanted information about the possibility of false test results (91.5%) and test side‐effects (95.6%), but many reported the doctor never provided this information (false results = 40.0% and side‐effects = 31.3%). A substantial proportion said this information would make them anxious (false results = 56.6% and side‐effects = 43.1%), but reported they wanted the information anyway (false results = 77.6% and side‐effects = 88.1%). Conclusions Women prefer an active role in test and treatment decision‐making. Many women reported receiving inadequate information. If so, this may jeopardize informed decision‐making.     

Counselling needs of women with a maternal history of breast cancer

Thirty-nine women with a maternal history of breast cancer were interviewed to determine their needs, concerns, and health practices pertaining to breast cancer. Each said they had been profoundly affected by their mother's illness. Many had feelings of guilt and anxiety, which had arisen after the diagnosis of their mother's breast cancer. Although most subjects (79%) practiced breast self-examination (BSE), both examiners and nonexaminers felt that their emotional reactions to breast cancer might keep them from performing an adequate examination. Subjects sought frequent breast examinations from a health professional--59% had two or more examinations a year--and found they helped to relieve anxiety. Most of the subjects (82%) though their risk of breast cancer was increased because of their maternal history of breast cancer. They were also concerned about the effects of birth control pills, radiation, and other factors on their breast cancer risk. Although subjects were concerned about risk, they had only vague, and sometimes incorrect, information about the magnitude of the risk. Based on these findings, we suggest that, beginning at the time of their mother's diagnosis, women whose mothers have breast cancer would benefit from ongoing counseling on emotional issues from a service that provides information and counselling about breast cancer risk, from receiving instruction in BSE and from having regularly scheduled examinations from a health care professional.     

Disclosure of a cancer diagnosis in Thai patients treated with radiotherapy

Although radiotherapy usually implies a cancer diagnosis, no available study has been reported as to what proportion of Thai patients treated with radiotherapy know their diagnosis and how they want related information revealed. We questioned 106 patients in order to determine the proportion who knew their cancer diagnosis, and interviewed patients who knew the diagnosis and relatives of patients both who knew and did not know it with semi-structured questionnaires concerning how they wanted to be told. Sixty-seven patients (63.2%) knew their cancer diagnosis. Multivariate analysis showed that the patients with the following characteristics were inclined to know their diagnosis: younger than 70 years old, head and neck or gynecological cancer, no previous treatment before radiotherapy, no accompanying relatives during the treatment, and patients with relatives who wanted to disclose the information. 97.0% of patients who knew the diagnosis indicated that they had really wanted to know, 89.5% and 73.3%, respectively of relatives who accompanied patients who knew and did not know it expressed the same wish. No demographic factors could predict who wanted to be told the diagnosis. The majority of patients and relatives who wanted the diagnosis disclosed wanted to know all related information before treatment. They wanted to hear this directly from the doctor in the presence of their relatives.     

Attitudes of women toward the gynecologic examination

This study was undertaken to determine why patients feel uncomfortable during the gynecologic examination, to assess general knowledge about the procedures, and to find out what would make the patient feel better about the examination. Nine hundred seventy-seven women sampled in 14 different health care facilities in the Salt Lake area in Utah filled out a two-page, self-administered questionnaire while waiting for a medical appointment. Results show that women feel less comfortable during the pelvic examination than they do during the breast examination; physical discomfort of the pelvic examination is the reason most frequently cited. There were 77.1 percent who stated they would feel better about the examination if the physician told them what was going to happen. Over 70 percent wanted to know more about their female organs, normal sexual functions and emotions, and reasons and procedures for the pelvic examination; 68.3 percent felt that knowing more would make them more comfortable. There were 46.5 percent who thought the use of a mirror for the woman to observe the examination was a good idea. Only 28.9 percent knew the rectum was examined. This study shows that women need and want to be educated about the gynecologic examination.     

Frequency and adequacy of breast cancer screening among elderly hispanic women

Studies have demonstrated that Hispanic (relative to Anglo) women are at greater risk for late-stage breast cancer diagnosis. Screening irregularity may be a factor contributing to late-stage diagnosis, yet virtually nothing is known about the breast cancer-screening behavior of Hispanic women. We interviewed 600 elderly Hispanic women residing in Los Angeles to collect information on frequency of physician breast examinations and mammography and on regularity and competence of breast self-examination. Predictors of screening were also examined. Fifty percent of our sample indicated that they had had a breast exam within the past year; 12.5% had had a mammogram within the past year (74% never had had a mammogram); and 47% reported that they had performed breast self-examination within the past month. Few of the women were able to demonstrate adequate breast self-examination technique on a foam breast model, and only 1% found all five lumps present. Thus, although the observed frequency of screening and self-examination is comparable to national norms, it is unlikely that our subjects' attempts at self-examination would lead to early breast cancer detection. Age, educational level, emotional reactions to screening, and media cues predicted screening behavior. Physician instruction in breast self-examination increased the frequency and adequacy of self-examination. Perceived susceptibility to cancer, perceived benefits of early detection, and level of acculturation were not strong predictors. The extent to which our results generalize to other subpopulations of Hispanic women is discussed.     

Urban black women's perceptions of breast cancer and mammography

The purpose of this study was to examine differences in perceptions of breast cancer and mammography between black women who wanted a mammogram and those who did not. The subjects were 186 low socioeconomic black women who attended an inner city community health clinic (83% response rate). There were no significant differences on the demographic and background variables between women who did (N=139) and did not (N=47) want a mammogram. The knowledge level of both groups regarding breast cancer was poor. Those who desired a mammogram perceived themselves as more susceptible to breast cancer, and considered breast cancer more severe than those who did not want a mammogram. Neither group identified many barriers to obtaining a mammogram. The majority (at least 88 percent of those who wanted a mammogram and at least 55 percent of those who did not) agreed with each of the five benefit items. Eighty-five percent of both groups agreed they would receive a mammogram if their physician told them to do so. The two Health Belief Model components which accounted for the largest percentage of the variance between women who wanted a mammogram and those who did not were perceived benefits (13 percent) and perceived susceptibility (3 percent).James H. Price is Professor of Health Promotion, Department of Health Promotion, University of Toledo, Toledo, OH 43606, Sharon M. Desmond, Assistant Professor of Health Education, Department of Health Education, University of Maryland, College Park, MD 20742, Suzanne Slenker is Assistant Professor of Health Behavior, Department of Health Education and Health Behavior, School of Public Health, Boston University, Boston, MA 02215, Daisy Smith is Health Education Coordinator, Cordelia Martin Health Center, and Paula Stewart is Executive Director of the Cordelia Martin Health Center, 905 Nebraska Avenue, Toledo, OH 43607.Funded by a grant from Ohio Department of Health, Division of Chronic Diseases.     

Work of female rural doctors

Objectives: To identify the impact of family life on the ways women practice rural medicine and the changes needed to attract women to rural practice.
Design: Census of women rural doctors in Victoria in 2000, using a self-completed postal survey.
Setting: General and specialist practice.
Subjects: Two hundred and seventy-one female general practitioners and 31 female specialists practising in Rural, Remote and Metropolitan Area Classifications 3–7. General practitioners are those doctors with a primary medical degree and without additional specialist qualifications. Main outcome measure: Interaction of hours and type of work with family responsibilities.
Results: Generalist and specialist women rural doctors carry the main responsibility for family care. This is reflected in the number of hours they work in clinical and non-clinical professional practice, availability for oncall and hospital work, and preference for the responsibilities of practice partnership or the flexibility of salaried positions. Most of the doctors had established a satisfactory balance between work and family responsibilities, although a substantial number were overworked in order to provide an income for their families or meet the needs of their communities. Thirty-six percent of female rural general practitioners and 56% of female rural specialists preferred to work fewer hours. Female general practitioners with responsibility for children were more than twice as likely as female general practitioners without children to be in a salaried position and less likely to be a practice partner. The changes needed to attract and retain women in rural practice include a place for everyone in the doctor's family, flexible practice structures, mentoring by women doctors and financial and personal recognition.     

Knowledge and preference for breast conservation therapy among women without breast cancer.

We interviewed 419 adult women in Minnesota, who were selected at random and without a history of breast cancer, to ascertain what percentage could correctly report that cure was the same for breast conservation therapy and mastectomy, what percentage would state a preference for breast conservation therapy rather than mastectomy, and characteristics associated with these outcomes. Nearly all women (n = 360; 86%) had heard of both mastectomy and breast conservation therapy; among these women, 37% correctly reported that the two treatments were equally efficacious. Given a scenario where they were diagnosed with breast cancer amenable to either treatment, 58% of participants stated a preference for breast conservation therapy. Older women were less likely than younger women to know that cure was the same for breast conservation therapy and mastectomy (adjusted OR = 0.5, 95% CI 0.2, 1.0), and women residing in urban areas were more likely to prefer breast conservation therapy over mastectomy compared to rural residents (adjusted OR = 2.2, 95% CI 1. 3, 3.8). Comparing these findings to women diagnosed with breast cancer in Minnesota, breast conservation therapy was found to be performed less frequently than preference for such therapy among women in our study would suggest. Educating women prior to diagnosis about breast cancer treatment options, and exploring reasons for the gap between actual utilization of breast conservation therapy and prediagnosis preference, may be indicated.     

Breast cancer diagnosis: biographical disruption,emotional experiences and strategic management in Thai women with breast cancer

In this article we draw on Bury's theory of biographical disruption to discuss the meanings of, and emotional experiences related to, being diagnosed with breast cancer among southern Thai women. Qualitative methods, including in‐depth interviewing and drawing methods, were used to collect data from 20 women with breast cancer. The women perceived breast cancer to be a rhok raai; an evil or dread disease. They believed that breast cancer would lead to death. The disruption in their biography occurred when they detected abnormalities indicating breast cancer. The women's narratives revealed their chaotic lives upon this diagnosis and the news precipitated in them shock, fear, anxiety and loss of hope. Although they experienced chaos and disruption, the women cultivated strategies that helped them cope with their experiences by accepting their fate and adhering to Buddhist beliefs and practices. Through their narratives of biographical disruption, the women in our study offer healthcare providers knowledge that could lead to an appreciation of their needs and concerns. This knowledge is crucial for health professionals who wish to provide emotional support to women who have been diagnosed with breast cancer in Thailand and elsewhere.     

Opinion and Participation in the Regional Early Breast Cancer Detection Program in 2007 on the part of family physicians from a health district in the Autonomous Community of Madrid, Spain

BACKGROUND: Mammogram screening is the most effective method for the early detection of breast cancer. The objective of this study is to evaluate the degree of knowledge, the opinion and the participation in the early breast cancer detection program on the part of the family physicians of the Autonomous Community of Madrid. METHODS: The population studied was comprised of family physicians from Madrid Health District Seven. An anonymous, self-administered questionnaire comprised of 30 questions grouped into physicians characteristics and opinion concerning the early breast cancer detection programs. RESULTS: A total of 46% of the physicians replied. A total of 94% of the physicians believed that it is their duty to inform their patients concerning preventive activities, including breast cancer screening, and 95% believed their advice to be useful for convincing women to have a mammogram. A total of 72% believed information to be lacking on this program. During the time when mammograms are being taken at their centres, 24% of the physicians surveyed always or almost always ask the women if they have any doubts or would like further information, 43% having set up appointments for them and 95% advising them to have a mammogram taken. CONCLUSIONS: The family physicians have a good opinion of the early breast cancer detection program and feel their advice to be effective for improving the participation in the program. They report lack of information and inform women about the program to only a small degree.     

Beliefs and attitudes about breast cancer and screening practices among Arab women living in Qatar: a cross-sectional study

Background

Despite rising breast cancer incidence and mortality rates, breast cancer screening (BCS) rates among women in Qatar remain low. Previous studies indicate the need to better understand the many complex beliefs, values, and attitudes that influence Arab women’s health seeking behavior for the development of culturally appropriate and effective intervention strategies to address breast cancer in the Middle East. This study investigates beliefs, attitudes, and BCS practices of Arabic-speaking women in Qatar.

Methods

A multicenter, cross-sectional quantitative survey of 1,063 (87.5% response rate) Arabic-speaking female Qatari citizens and non-Qatari residents, 35 years of age or older, was conducted in Qatar from March 2011 to July 2011. Associations between beliefs and BCS practice were estimated using chi-square tests and multivariate logistic regression analyses. Participants who adhered to BCS guidelines (BCS practice?=?Yes) were compared to those who did not (BCS practice?=?No).

Results

In addition to low levels of awareness and low participation rates in BCS, one quarter of the participants stated their doctors talked to them about breast cancer, and less than half of the women interviewed believed breast cancer can be prevented. Women who engaged in BCS practice were more likely to have a doctor who talked to them about breast cancer, to believe they were in good–excellent health, that cancer can be prevented, or that cancer might be hereditary. The majority wanted to know if they had cancer and felt their health care needs were being met. The main reasons given for not planning BCS were lack of a doctor’s recommendation, fear, and embarrassment.

Conclusions

These findings indicate that a variety of channels (health care providers, media, breast cancer survivors, community leaders) should be utilized to create culturally appropriate breast cancer intervention programs and increased awareness of breast cancer, BCS, and the benefits of early detection of breast cancer. Employment of these measures will reduce breast cancer mortality rates among Arabic-speaking women living in the State of Qatar.

     

Consequences of surveying folate awareness

Objectives  To assess women's concerns when interviewed about the association between folate and neural tube defects (NTDs) and to determine how this is affected by time, being folate aware, having seen folate promotional material or being pregnant.
Design  As part of a community randomized trial outcomes evaluation, independent cross-sectional follow-up surveys were carried out in 1997 and 2000.
Setting and participants  Six local government areas in the state of Victoria, Australia; 2431 women aged between 15 and 44 years.
Main variables studied  Whether or not women knew of the association between folate and NTDs (i.e. were folate aware), whether or not women had been concerned by seeing folate/NTD information and if an interview about folate and NTDs had raised any concerns for them.
Results  In the 1997 survey, 36% of women said that the interview had raised concerns and this decreased to 26% in 2000. Women who were folate aware were significantly less likely to have raised concerns than women who were not folate aware (OR_adj= 0.38, 95% CI 0.24–0.60). In general, women who had seen promotional material were less likely to feel concern about the interview than those who had not, although this varied with whether or not the promotional material had raised concerns. These effects were greater in women who were pregnant.
Conclusions  Women had increased concerns having seen folate promotional material and after being interviewed about it. These results are consistent with the proposition that an initial emotional response to sensitive health information is part of an adaptive response appropriate to the process of health-related behaviour change.     

Knowledge of Breast Cancer and Screening Practices Among Iranian Immigrant Women in Toronto

Breast cancer is a leading cause of mortality and morbidity in Canada. Secondary prevention through screening may enable early identification and treatment, but this is suboptimal among all Canadian women, particularly minority immigrant women. This cross-sectional exploratory study assessed breast health knowledge and practices among Iranian immigrant women residing in Toronto. Our sample included 50 adult women with no history of breast cancer. Results showed that, overall, participants had limited knowledge of breast cancer and screening practices. More than two-thirds had low knowledge scores; 22% did not know that the risk of breast cancer increases with age; about 50% did not know the recommended time interval for screening mammography; 72% did not know how frequently to undergo a clinical breast examination. Length of stay in Canada was associated with self-reported breast health practices. These findings highlight the need to educate Iranian immigrants about the role of screening to promote early identification of breast cancer in the absence of symptoms. Culturally sensitive educational materials should be developed to address their specific needs. Healthcare providers should also be educated about how to communicate breast health information effectively to immigrant women. Opportunistic teaching during each health encounter should be encouraged and reinforced.