Informing breast cancer patients about clinical trials: a randomized clinical trial of an educational booklet.

BACKGROUND: To evaluate the impact of an educational booklet on women's knowledge of and willingness to participate in a randomized clinical trial of treatment for breast cancer. MATERIALS AND METHODS: Women undergoing surgery for newly diagnosed early stage breast cancer were randomized to receive, or not, an information booklet explaining the need for and manner in which randomized trials are conducted. RESULTS: Eighty-three women with newly diagnosed early stage breast cancer completed a questionnaire assessing attitudes to random clinical trials (RCTs) and were randomized to receive usual information treatment options provided from their oncologist, or the educational booklet in addition to usual information from their oncologist (42 usual information, 41 booklet). Fewer women who received the clinical trials booklet (40% versus 47%) would consider participating in the hypothetical clinical trial (P = 0.6). Mean knowledge scores increased for both groups; moreover, women who did not receive the booklet showed similar improvements to women who received the booklet [mean difference 0.09, 95% confidence interval (CI) -0.66 to 0.83]. In a multivariate analysis women who would consider participating in the clinical trial were more anxious [odds ratio (OR) 5.9, P = 0.02] had involved lymph nodes (OR 5.8, P = 0.02) and were less influenced by negative aspects of clinical trials (OR 7.7, P = 0.0001). After adjustment for these variables women who received the educational booklet were significantly less likely to consider trial participation (OR 0.22, P = 0.05). CONCLUSIONS: Educating women about clinical trials in this manner appears ineffective in improving recruitment to RCTs. Women appear to be more influenced by their perception of risk than understanding. This finding has ethical implications for communication of information about RCTs.     

The Feasibility of Women at High Risk for Breast Cancer Participating in Chemoprevention Trials

Abstract

There is significant interest in developing chemoprevention trials for women at high risk for breast cancer, yet it is not clear how acceptable these strategies are. Results of clinical trials with tamoxifen have demonstrated a reduction in the incidence of breast cancer in women at increased risk, but rates of participation in such trials have been lower than expected. No previous studies have assessed the attitudes of high-risk women toward participating in chemoprevention trials using drugs causing ovarian suppression. All women who had attended a large familial cancer clinic in Sydney, New South Wales, between 1994 and 2000 who were eligible for the Raloxifene and Zoladex Research study being piloted in the United Kingdom at the time were approached. Telephone interviews were conducted with the 35 high-risk women willing to participate in this study. Almost half the women surveyed expressed willingness to participate in a randomized trial, and slightly fewer women considered participating in a nonrandomized trial. The women who would consider participating were younger than those who would not. The most frequently mentioned reasons for interest in participating in trials were to aid research, help others, and learn more, which indicates that altruism may have played a significant part in the women's willingness to participate. Most women interviewed were participating in risk reduction and early detection strategies and expressed high interest in research screening tests. Given the interest in randomized trials and the fact that women at high risk for breast cancer consider the side effects as mainly acceptable, undertaking such trials may be worthwhile.     

Performance of diagnostic mammography for women with signs or symptoms of breast cancer

BACKGROUND: The performance of diagnostic mammography for women with signs or symptoms of breast cancer has not been well studied. We evaluated whether age, breast density, self-reported breast lump, and previous mammography influence the performance of diagnostic mammography. METHODS: From January 1996 through March 1998, prospective diagnostic mammography data from women aged 25-89 years with no previous breast cancer were linked to cancer outcomes data in six mammography registries participating in the Breast Cancer Surveillance Consortium. We used the final mammographic assessment at the end of the imaging work-up to determine abnormal mammographic examination rate, positive predictive value (PPV), sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve. We used age, breast density, prior mammogram, and self-reported breast lump jointly as predictors of performance. All statistical tests were two-sided. RESULTS: Of 41 427 diagnostic mammograms, 6279 (15.2%) were judged abnormal. The overall PPV was 21.8%, sensitivity was 85.8%, and specificity was 87.7%. Multivariate analysis showed that sensitivity and specificity generally declined as breast density increased (P =.007 and P<.001, respectively), that previous mammography decreased sensitivity (odds ratio [OR] = 0.52, 95% confidence interval [CI] = 0.36 to 0.74; P<.001) but increased specificity (OR = 1.43, 95% CI = 1.31 to 1.57; P<.001), and that a self-reported breast lump increased sensitivity (OR = 1.64, 95% CI = 1.13 to 2.38; P =.013) but decreased specificity (OR = 0.54, 95% CI = 0.49 to 0.59; P<.001). ROC analysis showed that higher breast density and previous mammography were negatively related to accuracy (P<.001 for both). CONCLUSIONS: Diagnostic mammography in women with signs or symptoms of breast cancer shows higher sensitivity and lower specificity than screening mammography does. Higher breast density and previous mammographic examination appear to impair performance.     

An educational video to increase clinical trials enrollment among breast cancer patients

Only 3% of women with breast cancer participate in cancer clinical trials nationwide. The lack of awareness about clinical trials is a significant barrier towards clinical trials participation. A study was conducted at a large urban Comprehensive Cancer Center to test (1) the effectiveness of an 18-min educational video on improving attitudes toward clinical trials and trials enrollment among new breast cancer patients seen at the Karmanos Cancer Institute, and (2) to assess racial differences in attitudes regarding clinical trials. Participants were randomized to either the educational intervention prior to their first oncology clinic appointment or to standard care. A baseline and 2-week post-intervention survey to assess attitudes toward clinical trials participation was completed by participants. Of 218 subjects recruited, 196 (55% white vs. 45% African American (AA)) eligible patients were included in the analysis. A small increase in therapeutic clinical trial enrollment was observed in the intervention arm but was not statistically significant (10.4% vs. 6.1%; P = 0.277). The intervention also did not result in a clear improvement in patients’ attitudes toward clinical trials at posttest. However, a lower enrollment rate for the AA women was noted after adjusting for stage (OR = 0.282, P = 0.049). Significantly more negative scores were noted in 3 out of the 5 baseline attitudinal scales for AA women. The educational video did not significantly increase enrollment in breast cancer clinical trials. The findings that AA women had significantly more negative attitudes toward clinical trials than white women may partially explain the racial disparity in enrollment. An educational video remains a simple and cost-effective way to educate patients. Future studies should focus on designing a new educational video to specifically target cultural and attitudinal barriers in the AA population to more effectively change attitudes and increase trial enrollment.     

The impact of mammography on breast cancer detection

Background: Mammography has different effects on the epidemiologyof breast cancer, i.e., while increasing the registered incidenceit can reduce mortality. This study was aimed at obtaining quantitativeestimates of the impact of mammography on breast cancer detection. Subjects and methods: A case-control study was conducted inNorthern Italy between 1985 and 1991 on 2596 cases of histologicallyconfirmed breast cancer and 2005 controls in hospital for acutediseases unrelated to known or suspected risk factors for breastcancer. Results: 15.6% of the patients reported one screening mammographyand 9.7% two or more. The age-adjusted breast cancer diagnosisodds ratios (OR) were 1.3 (95% confidence interval, CI 1.1 to1.5) for one mammography and 2.0 (95% CI 1.6 to 2.6) for twoor more. When allowance was made for major identified potentialdistorting factors, the OR decreased to 1.0 (95% CI 0.8 to 1.2)for one, and 1.3 (95% CI 1.0 to 1.8) for two or more mammographies.In the age-adjusted analysis, the association between screeningmammography and breast cancer detection was apparently strongerfor younger and pre-menopausal women, among more educated womenand those with no history of benign breast disease or breastbiopsy, and among women who had first-degree relatives withhistories of breast cancer. Conclusions: Although the association between mammography andbreast cancer was largely explained by selective screening,confirming at the epidemiological level that the relationshipis incidental, the unadjusted ratios are of public health interest,since they give a measure of the role of mammography in breastcancer detection. breast neoplasms, epidemiology, incidence mammography, risks factors     

Who gets screened, and where: a comparison of organised and opportunistic mammography screening in Geneva, Switzerland

It is unclear whether introducing organised mammography screening programmes in a population where opportunistic screening is prevalent results in the two types of screening mainly competing against each other or attracting different groups of women. To compare women who participate in organised screening and those who prefer opportunistic screening, we conducted a prospective study of 932 women followed for 8 months after an invitation to participate in the first round of an organised screening programme in Geneva, Switzerland. All women were aged 50-69 years and were due for a mammogram according to local guideline. Of the 932 participants, 11.6% had an organised and 39.4% an opportunistic mammogram during follow-up. Women who were in the stage of contemplation, had favourable attitude toward mammography screening, and perceived their risk of breast cancer to be high were more likely to have a mammogram (either organised or opportunistic). Compared to women who had an opportunistic mammogram, women with an organised mammogram were less positive about screening, less likely to be in maintenance at baseline (adjusted odds ratio (OR), 3.0; 95% confidence interval (CI), 1.7-5.5), to have a history of benign breast disease (OR, 2.4; 95% CI, 1.2-5.1) and to perceive their financial situation as comfortable (OR, 1.7; 95% CI, 1.1-2.8). Although screening uptake was low, the programme appeared to attract women in lower socio-economic strata who did not usually undergo mammography screening.     

Identification of accrual barriers onto breast cancer prevention clinical trials

BACKGROUND:

The purpose of this study was to examine factors influencing a woman's decision to participate in a breast cancer prevention clinical trial. Nine healthcare organizations in Massachusetts cooperated in the present project.

METHODS:

The authors performed a case‐control study to compare responses between the study group (Study of Tamoxifen and Raloxifene [STAR] trial eligible, but not enrolled) and the control group (STAR trial participants) on 12 factors previously identified as barriers to accrual for clinical trials. Eight hypotheses were tested using multiple logistic regression to estimate the strength of the association for each factor on the dependent variable (study participation).

RESULTS:

The study samples were similar to the general population of eligible breast cancer prevention clinical trial subjects in the counties where the participating organizations were located, the state of Massachusetts, and nationally published STAR trial data. Results of a mailed questionnaire showed that when adjusting for subject demographics, and in the presence of other questions, 4 factors significantly influenced a woman's decision to enroll onto a breast cancer prevention clinical trial more than other eligible subjects: 1) clinician expertise and qualifications (P = .012; odds ratio [OR], 4.903; 95% confidence interval [CI], 1.41‐17.04); 2) personal desire to participate (P = .033; OR, 3.16; 95% CI, 1.10‐9.06); 3) perceived value of the trial (P = .020; OR, 2.92; 95% CI, 1.18‐7.21); and 4) level of trial inconvenience (P = .002; OR, 0.10; 95% CI, 0.02‐0.44).

CONCLUSIONS:

Addressing these issues in the relationship between patients and clinicians should improve accrual to breast cancer prevention clinical trials. Cancer 2010. © 2010 American Cancer Society.     

Use of mammography among women residing in Spanish provinces with breast cancer screening programmes.

The objective of this study was to measure use of mammography and associated factors among women living in Spanish provinces with breast cancer screening programmes. From a cross-sectional population survey in a representative sample of Spanish women aged 40-70 years, we selected all women aged 45-65 living in provinces with breast cancer screening programmes (336 women). The programmes invited women in this age group to have a mammogram every 2 years. Data were collected by oral interviews in 1994. Use of mammography was defined as having received at least one test in the previous 2 years. Factors associated with mammography were studied using a logistic regression model. In the three autonomous communities (totalling 11 provinces) with programmes, the percentage of women receiving the test was 41.1% in Castille-Leon, 41.7% in Castille-La Mancha and 87.6% in Navarre (mean: 55.4%). The programmes began in 1990 in Navarre and between 1992 and 1993 in the other two communities. The most important factors affecting mammography use in the multivariate analysis were: intention to have a mammogram [odds ratio (OR) = 5.52; 95% confidence interval (CI) = 3.17-9.63]; not rejecting the test for fear of cancer diagnosis (OR = 4.23; 95% CI = 1.64-10.9); and physician recommendation of the test (OR = 3.43; 95% CI = 1.88-6.24). In conclusion, although the more established screening programmes have higher mammography use than those more recently implemented, programmes alone may not guarantee that women receive the test. Women's attitudes about mammography, and the role of the physician, are fundamental factors in the use of mammography.     

Aromatase inhibitor versus tamoxifen in postmenopausal woman with advanced breast cancer: a literature-based meta-analysis

Clinical trials have reported conflicting results as to whether Aromatase inhibitors (AIs) as first-line hormonal therapy improve outcome over tamoxifen in postmenopausal women with advanced breast cancer. We performed a meta-analysis comparing primary and secondary endpoints of AIs to tamoxifen as first-line hormonal therapy in postmenopausal women with advanced breast cancer. The event-based odds ratio (OR) with 95% confidence interval (95% CI) were derived, and a test of heterogeneity was applied. Six eligible trials (2560 patients) were selected from 488 studies that initially were identified. A significant difference in favoring AIs over tamoxifen was observed in overall response rate (ORR; OR, 1.56; 95% CI, 1.17-2.07; P = .002) and clinical benefit (CB; OR, 1.70; 95% CI, 1.24-2.33; P = .0009).Whereas the trend toward an improved overall survival (OS) rate was not significant (OR, 1.95; 95% CI, 0.88-4.30; P = .10).Toxicities did not differ significantly except vaginal bleeding (OR, 0.30; 95% CI, 0.16-0.56; P = .0002) and thromboembolic event (OR, 0.47; 95% CI, 0.28-0.77; P = .003). AIs appeared to be effective and feasible compared with tamoxifen as first-line hormonal therapy in postmenopausal women with advanced breast cancer. Further prospective, randomized, controlled trials will be necessary.     

10-Year results after sector resection with or without postoperative radiotherapy for stage I breast cancer: a randomized trial.

PURPOSE: To study the long-term effectiveness of postoperative radiotherapy after sector resection for breast cancer in a randomized trial in which mammography is a major pathway to diagnosis. PATIENTS AND METHODS: Three hundred eighty-one women with a unifocal breast cancer < or = 20 mm in diameter on the preoperative mammogram and without histopathologic signs of axillary metastases were treated by sector resection plus axillary dissection. Of these patients, 184 women were randomized to receive postoperative radiotherapy to the breast (XRT group), and 197 women received no further treatment (non-XRT group). RESULTS: The local recurrence rate was 8.5% (95% confidence interval [CI], 3.9% to 13.1%) in the XRT group and 24.0% (95% CI, 17.6% to 30.4%) in the non-XRT group (P =.0001). Survival free from regional and distant recurrence was 83. 3% in the XRT group (95% CI, 77.5% to 89.1%) and 80.0% in the non-XRT group (95% CI, 73.9% to 86.1%) (P =.23). Overall survival was 77.5% in the XRT group (95% CI, 70.9% to 84.1%) and 78% in the non-XRT group (95% CI, 71.7% to 84.3%) (P =.99). A subgroup analysis suggested that women older than 55 years of age without comedo or lobular carcinomas had a low risk of local recurrence of 6.1% (95% CI, 0.1% to 9.1%) in the XRT-group and 11.0% (4.0% to 18.0%) in the non-XRT group (P =.16). CONCLUSION: Sector resection plus radiotherapy resulted in an absolute reduction in local recurrence of 16% at 10 years compared with surgery alone. Women older than 55 years of age without comedo or lobular carcinomas may have a low risk of local recurrence. Postoperative radiotherapy was not shown to reduce distant recurrences or improve overall survival.     

Hormone replacement therapy and the risk of breast cancer. Nested case-control study in a cohort of Swedish women attending mammography screening

There is concern that hormone replacement therapy (HRT) increases the risk of breast cancer. We undertook a case-control study of this risk relationship within a cohort of 40- to 74-year-old women in Uppsala County, Sweden, who participated in mammography screening. Incident cases of breast cancer were ascertained during 5 years of follow-up. In all, 435 cases (87% invasive, 13% in situ cancers) were detected, 313 through screening and 122 through clinical diagnosis. As controls, 1,740 women were selected randomly. Information on risk factors and use of HRT was obtained through interviews before the start of follow-up. Multivariate analyses revealed an increased risk among users of any type of HRT for more than 10 years, the odds ratio (OR) being 2.1 (95% confidence interval [CI] 1.1–4.0), as well as when restricting analyses to cases diagnosed through mammography screening. After stratification for compound type, risk estimates were apparently higher among women reporting estradiol–progestin combined treatment vs. estradiol or conjugated estrogens alone, with ORs for more than 10 years of intake being 2.4 (95% CI 0.7–8.6) and 1.3 (95% CI 0.5–3.7), respectively. Analyses through a model including both compound type and length of hormone intake confirmed a significant excess risk linked to treatment for more than 10 years, OR = 2.6 (95% CI 1.3–5.1). Our results indicate a moderately increased risk of breast cancer after many years of HRT and, hypothetically, a further enhancement of the risk with added progestins. Int. J. Cancer 72:758–761, 1997. © 1997 Wiley-Liss, Inc.     

Increased mammography use and its impact on earlier breast cancer detection in Vermont, 1975-1999

BACKGROUND: A trend toward earlier breast carcinoma detection in the United States has been attributed to screening mammography, although direct evidence linking this trend to the increased use of mammography in a general population is lacking. This study examined the effects of mammography on tumor size and axillary lymph node metastasis in Vermont over 25 years. METHODS: Pathology and mammography data from 3499 Vermont women who were diagnosed with invasive breast carcinoma during 1975-1984, 1989-1990, and 1995-1999 were compared. Logistic regression analysis was used to estimate the effects of age, mammography use, and period on the odds of a tumor < or = 2 cm and the odds of negative lymph nodes. RESULTS: The proportion of breast tumors that were detected by screening mammography increased from 2% during 1974-1984 to 36% during 1995-1999 (P < 0.001), and these tumors were more likely to measure < or = 2 cm than tumors that were detected by other methods. Among women age > 50 years, the odds ratio (OR) was 4.5, with a 95% confidence interval (95% CI) of 3.5-6.4. The effect was smaller in younger women (OR, 1.8; 95% CI, 1.1-3.0). Mammographic detection increased the odds of negative lymph nodes by a similar amount in both age groups, although women age > 50 years were more likely to have negative lymph nodes than younger women (OR, 1.3; 95% CI, 1.1-1.6). Tumor size and lymph node metastasis also were related to the number of mammograms and to the mammographic interval. CONCLUSIONS: Most of the trend toward earlier detection in Vermont was due to mammography. Mammography had a lesser effect on tumor size among younger women, which may be related to less frequent screening, although its effect on lymph node metastasis was not age dependent. Women age < 50 years were more likely to have positive lymph nodes, independent of the method of detection or the frequency of mammography.     

Patterns and predictors of mammography utilization among breast cancer survivors

BACKGROUND: Improvements in cancer detection and treatment have resulted in increasing numbers of breast cancer survivors. Information regarding the use of mammography by breast cancer survivors is limited. METHODS: The use of surveillance mammography was examined over a 5-year period in a retrospective cohort of women age>or=55 years who were diagnosed with incident primary breast cancer (1996-1997) while enrolled in 1 of 4 geographically diverse integrated health systems. RESULTS: Of the 797 women included in the study, 80% (n=636) underwent mammograms during the first year after treatment for breast cancer. The percentage of women having mammograms during each yearly period decreased significantly over time. In multivariable analyses, older women with comorbid illnesses or those with late-stage disease were less likely to undergo mammograms, whereas those who underwent breast-conserving therapy (adjusted odds ratio [OR] of 1.38 [95% confidence interval (95% CI), 1.09-1.75]) were more likely to have mammograms. Women who had outpatient visits with a gynecologist (adjusted OR of 3.49 [95% CI, 2.55-4.79]), or a primary care physician (adjusted OR of 2.21 [95% CI, 1.73-2.82]) during the year were more likely to undergo mammograms in that year. CONCLUSIONS: The use of mammography among breast cancer survivors declines over time. Efforts are needed to increase awareness among healthcare providers and breast cancer survivors of the value of follow-up mammography. The current findings highlight the importance of maintaining ongoing contact with primary care physicians and gynecologists.     

Breast carcinoma screening and risk perception among women at increased risk for breast carcinoma: results from a national survey

BACKGROUND: The Gail model is validated to estimate breast carcinoma risk. The authors assessed the association of Gail risk scores with screening and cancer risk perception. METHODS: Using the 2000 National Health Interview Survey, the authors studied women ages 41-70 without a cancer history. Gail scores > or = 1.66% defined increased risk. The authors used logistic regression to assess associations between breast carcinoma risk and previous and recent (< or = 1 year) mammography and clinical breast examination (CBE). RESULTS: Of 6410 women, 15.7% had increased risk. High-risk women more frequently reported previous mammograms (94% vs. 85%; P < 0.0001), previous CBE (93% vs. 88%; P < 0.0001), recent mammograms (70% vs. 54%; P < 0.0001), recent CBE (71% vs. 61%; P < 0.0001), and high cancer risk perception (20% vs. 9%; P < 0.0001). However, 30% of high-risk women had not received a recent mammogram. After adjustment for sociodemographic factors, access to care factors, and cancer risk perception, high-risk women remained more likely to have received recent mammography (adjusted odds ratio [OR], 1.45, 95% confidence interval [95% CI], 1.19-1.77), recent CBE (OR, 1.32; 95% CI, 1.08-1.61]), and previous mammography than average-risk women. The authors observed an interaction between risk and age, with women ages 41-49 years more frequently reporting previous mammography (OR, 4.79; 95% CI, 1.55-4.81) than average-risk, same-age women. For women age > or = 50 years, the odds of previous mammography were similar regardless of risk. CONCLUSIONS: In a nationally representative sample, 15.7% of women had increased breast carcinoma risk using the Gail model. High-risk women perceived higher cancer risk and more often received screening. However, nearly one in three high-risk women did not receive recent screening and most of these women did not perceive increased risk.     

Barriers and Attitudes toward Breast Cancer Screening among Omani Women

Background: Breast cancer (BC) is the most common cancer accounting for 24.5% of Omani female cancer. Early detection of BC through regular breast cancer screening (BCS) has been found to decrease mortality rates. The aim of this study was to identify knowledge, attitudes and barriers of Omani women toward BCS. Methods: A cross-sectional study was conducted among adult Omani women attending the Sultan Qaboos University Hospital (SQUH). Results: A total of 358 Omani women participated from 420 invited (response rate = 85.2%). Most women (92.1%) thought that BC could be cured if detected early, but less than half (46.8%) thought that they were at risk of BC if a relative had BC. The majority (81.1%) were aware that BCS was available in Oman, though less than half (48.5%) knew where to go for BCS and most (83.8%) had not undergone BCS before. The most common personal-related barriers to BCS were fear of BC diagnosis (40.8%), fear of treatment (52.1%) and embarrassment of the breast examination (46.6%). The most perceived system-related barriers to BCS were the concern over the availability of a male doctor (46.6%) or a non-Arabic speaking doctor (38.7%) and not recommended by the doctor (46.3%). Univariate binary logistic regression showed that attitudes toward BCS were influenced by their previous experiences of BCS (odds ratio [OR] = 2.28; 95% confidence interval [CI]: 1.18-4.41) and their willingness to participate in the future BCS [OR = 1.96; 95% CI: 1.14-3.37). Conclusion: Although Omani women showed an interest toward BCS, few had undergone BCS. Several cultural, practical and personal-related barriers were noted to interfere with BCS in Oman. Addressing these concerns through involving healthcare providers to reassure the women and implementing a national strategy of BCS could improve BCS screenings and early diagnosis of BC.     

Characteristics of women refusing follow-up for tests or symptoms suggestive of breast cancer

BACKGROUND: Delay in diagnosis of breast cancer can occur at several points on the diagnostic pathway. We examined characteristics of women with breast cancer who before diagnosis actively refused recommended follow-up of tests or symptoms suggestive of breast cancer. METHODS: We identified women aged 50 years or older diagnosed with late-stage (metastatic disease or tumors > or = 3 cm at diagnosis) and a matched sample of women with early-stage (tumors < 3 cm) breast cancer from 1995 to 1999. Using medical records, we investigated clinical characteristics, use of health care, and documentation of care refusal during the 3 years before diagnosis. We used logistic regression models to compare refusers to nonrefusers. RESULTS: Of the 2694 women studied, 7.2% refused provider follow-up advice during the 3 years. These women were more likely to have late-stage breast cancer at diagnosis than were nonrefusers (odds ratio [OR] = 1.9, 95% confidence interval [CI] = 1.4 to 2.6). They were more likely to be aged 75 years or older (OR = 1.9, 95% CI = 1.4 to 2.7 compared with age 50-64) or to have six or more children (OR = 2.3, 95% CI = 1.3 to 4.2 compared to women with one to two children). Clinical factors associated with refusal included low use of mammography, high use of clinical breast exam, and missed appointments. A minority of women who refused had a reason documented in the medical record; the most frequent reasons were avoidance-denial-fatalism, fear of diagnostic tests, and fear of surgery or disfigurement. CONCLUSIONS: Our results suggest that certain demographic and clinical characteristics are associated with women's refusal of diagnostic testing for breast cancer. Further study is needed on refusers' characteristics and on how such refusals affect outcomes. Efforts aimed at identifying and counseling women with abnormal results who refuse follow-up are warranted.     

Factors associated with low screening for breast cancer in the Palestinian authority

BACKGROUND:

The current study was conducted to assess screening behaviors in relation to cultural and environmental barriers among Palestinian women in the West Bank.

METHODS:

The participants were 397 women, ages 30 to 65 years, residing in the Palestinian Authority, and a stratified sample method was used (98.3% participation rate). The participants completed questionnaires on breast examination behaviors and knowledge, on perceived cancer fatalism and health beliefs, and on environmental barriers scales.

RESULTS:

Greater than 70% of the women had never undergone mammography or clinical breast examination (CBE), whereas 62% performed self breast examination (SBE). Women were more likely to undergo mammography if they were less religious (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.47‐0.81) and if they expressed lower personal barriers (OR, 0.59; 95% CI, 0.29‐0.76) and lower fatalism (OR, 0.39; 95% CI, 0.28‐0.63). A higher likelihood for CBE was related to being Christian (OR, 2.91; 95% CI, 1.49‐5.73) and being less religious (OR, 0.32; 95% CI, 0.13‐0.78), to perceived higher effectiveness of CBE (OR, 1.46; 95% CI, 1.20‐1.79), and to perceived lower cancer fatalism (OR, 0.35; 95% CI, 0.28‐0.60). Women were more likely to perform SBE if they were more educated, resided in cities, were Christian, were less religious, had a first‐degree relative with breast cancer, perceived higher effectiveness and benefits of SBE, and perceived lower barriers and fatalism.

CONCLUSIONS:

Participants reported a combination of personal, cultural, and environmental barriers, which should be addressed by educational programs and followed by the allocation of resources for early detection and treatment of breast cancer. Cancer 2010. © 2010 American Cancer Society.     

Prognosis of premenopausal breast cancer and childbirth prior to diagnosis.

PURPOSE: The time interval between last childbirth and subsequent breast cancer diagnosis is emerging as an important prognostic factor for premenopausal women. PATIENTS AND METHODS: We studied, prospectively, 750 women diagnosed with primary invasive breast cancer before age 45 years who participated in the population-based Australian Breast Cancer Family Study (ABCFS). RESULTS: Median follow-up time was 4.9 years (range, 0.8 to 10.8 years). Compared with nulliparous women, women who gave birth within 2 years prior to diagnosis were more likely to have axillary node-positive (58% v 41%; P =.01), and estrogen receptor-negative (58% v 39%; P =.005) tumors. The unadjusted hazard ratios for death were 2.3 (95% CI, 1.3 to 3.8; P =.002), 1.7 (95% CI, 1.1 to 2.6; P =.03), and 0.9 (95% CI, 0.6 to 1.5; P =.8) for patients who gave birth less than 2 years, 2 to 5 years, and 5 or more years before diagnosis, respectively. After adjusting for tumor characteristics, these hazard ratios were reduced to 1.9 (95%CI, 1.1 to 3.2; P =.02), 1.3 (95% CI, 0.8 to 2.1; P =.3), and 0.9 (95%CI, 0.5 to 1.4; P =.5). Modeling showed that, compared with nulliparous women, the mortality hazard ratio in parous women was 1.9, decreasing by 8% (95%CI, 4% to 13%; P <.001) for each year between last birth and breast cancer diagnosis. CONCLUSION: Proximity of last childbirth to subsequent breast cancer diagnosis is a predictor of mortality independent of histopathological tumor characteristics. Clinicians should be aware that women diagnosed with breast cancer within a few years following childbirth may have a worse outcome than that suggested solely by the standard histopathological prognostic factors of their cancer.     

Comorbidities and mammography use interact to explain racial/ethnic disparities in breast cancer stage at diagnosis

BACKGROUND:

Interactions with comorbidity burden and comorbidity‐related care have not been examined as potential explanations for racial/ethnic disparities in advanced‐stage breast cancer at diagnosis.

METHODS:

The authors used linked Surveillance, Epidemiology, and End Results‐Medicare data to determine whether comorbidity burden and comorbidity‐related care are associated with stage at diagnosis, whether these associations are mediated by mammography use, and whether they explain racial/ethnic disparities. Stage at diagnosis and mammography use were analyzed in multivariate regression models, adjusting for comorbidity burden and comorbidity‐race interactions among 118,742 women diagnosed with breast cancer during 1993 to 2005.

RESULTS:

Mammography utilization was higher among women with ≥3 stable comorbidities than among those without comorbidities. Advanced stage at diagnosis was associated with black race (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.6‐1.8), Hispanic ethnicity (OR, 1.3; 95% CI, 1.2‐1.5), unstable comorbidity, and age ≥80 years. Mammography was protective in all racial/ethnic groups, but neither mammography use (OR, 0.3; 95% CI, 0.3‐0.3 and OR, 0.2; 95% CI, 0.2‐0.2 for women with 1 and ≥2 prior mammograms, respectively) nor overall physician service use (OR, 0.7; 95% CI, 0.7‐0.8 for women with ≥16 visits) explained the association between race/ethnicity and stage at diagnosis. The black/white OR fell to 1.2 (95% CI, 0.9‐1.5) among women with multiple stable comorbidities who received ≥2 screening mammograms, and 1.0 (95% CI, 0.8‐1.3) among mammography users with unstable comorbidities.

CONCLUSIONS:

Comorbidity burden was associated with regular mammography and earlier stage at diagnosis. Racial/ethnic disparities in late stage disease were reduced among women who received both regular mammograms and comorbidity‐related care. Cancer 2011. © 2011 American Cancer Society.     

Late-stage breast cancer among women with recent negative screening mammography: do clinical encounters offer opportunity for earlier detection?

BACKGROUND: Opportunities to prevent late-stage breast cancer within the course of usual care are needed. We evaluate whether clinical encounters offer such opportunities. METHODS: Within seven health care plans, we identified 1298 women aged more than 50 years with early (<3 cm), late-stage (> or = 3 cm), or metastatic invasive breast cancer diagnosed during 1995-1999, whose first screening mammogram 13-36 months prior to the diagnosis (index) was negative. We audited all care occurring in the health plans up to 36 months prior to the cancer diagnoses. Ordinal logistic regression compared the frequency of events by disease category. We hypothesized that during the 13-36 months prior to diagnosis, women with late-stage or metastatic breast cancer would have more symptoms and be more likely to have breast-related clinical visits but have less breast screening (clinical breast examination [CBE] or mammography) than women with early-stage disease, thereby indicating clinical opportunities for earlier detection. RESULTS: We found no differences in demographic characteristics across breast cancer stage among the 1298 women. Both before and after the negative index mammogram but during the 13-36 months prior to diagnosis, few women had breast symptoms (5% before index, 8% after), but many sought breast care (86% before index, 90% after) and screening CBE (62% before index, 43% after). Only the occurrence of screening CBE (odds ratio [OR] = 0.73, 95% confidence interval [CI] = 0.56 to 0.95) or screening mammograms (OR = 0.74, 95% CI = 0.57 to 0.97) after the negative index mammogram reduced odds of more severe disease at diagnosis. CONCLUSION: Although the mortality benefit of CBE, or one compared to two year mammography has not been established, we found that women with late-stage breast cancers undetected by screening mammography did not experience opportunities for earlier detection except through CBE or additional screening mammography.