Breast cancer risk and participation in mammographic screening.

Within the context of an organized breast cancer screening program we conducted a prospective evaluation of the relation between breast cancer risk and participation in mammographic screening. The influence on participation of known breast cancer risk factors, as well as a summary risk label, (i.e. "high", or "moderate") were examined. The overall participation rate was 71 percent among 2,422 women, 50 to 79 years of age, invited to a centralized clinic. Multivariate analyses showed participation to be somewhat decreased among women with late menopause and definitely increased among women with any of the following factors: 1) increased age; 2) a family history of breast cancer; and 3) a previous breast biopsy. Women in the high-risk group were most likely to participate but the effect of the label was stronger among women ages 50 to 59 compared to women ages 60 to 79. The study results are generally consistent with previous findings that participants in screening programs have higher rates of breast cancer. The results also suggest the possibility that providing breast cancer risk information may encourage participation in screening.     

Predictors of attendance at a relocatable mammography service for rural women

Abstract: This study aimed to identify factors that predicted attendance at a relocatable screening mammography service in a rural centre in Victoria. A cohort design was used whereby 180 women from the target population were interviewed by telephone two weeks before the service moved to the area for a 10–week period of operation. Attendance data were ascertained from service records. Fifty per cent of the sample attended the service. Significant predictors of attendance were: mammographic history, with women who reported previous screening mammography being less likely to attend than women who had not had a previous mammogram (odds ratio (OR) 0.38, 95% confidence interval (CI) 0.17 to 0.83); perception of personal risk for breast cancer, with women who perceived at least some risk being more likely to attend than women who perceived no risk (OR 2.73, CI 1.07 to 6.99); stated intention of attending (OR 2.01, CI 1.49 to 2.71); knowing the correct location of the service (OR 3.08, CI 1.37 to 6.89); and education, with higher education being associated with a lower likelihood of attending (OR 0.65, CI 0.44 to 0.96). Our study raised some issues, including the high prevalence of rural women who reported a previous screening mammogram, although BreastScreen services had not previously been available in their area; factors underlying perceptions of personal risk for breast cancer; and the generalisability of our finding of an inverse relationship between higher education and attendance for screening.     

Is Step Down Assessment of screen‐detected lesions as safe as workup at a Metropolitan Assessment Centre?

Objective: BreastScreen WA offers population mammographic screening via fixed clinics in the metropolitan area and mobile clinics that visit country areas every two years. If an abnormality is suspected following mobile clinic screening, women undergo Step Down Assessment; diagnostic further views are performed at the mobile clinic and if a possibly significant abnormality persists, country women are referred to a Perth Metropolitan Breast Assessment Centre. The purpose of this retrospective cohort study was to determine if Step Down Assessment in country Western Australia offered the same diagnostic effectiveness as screening and assessment in the metropolitan area. Methods: The study included all screening episodes at BreastScreen WA between 1999 and 2008. Screening episodes from metropolitan and mobile clinics were compared according to the primary outcomes of cancer detection rates, recall and further investigations, cancer size, return to screen rates and interval cancers. Results: Cancer detection rate per 1,000 screening episodes was lower for the country program than the metropolitan program (3.07 (2.84–3.31) versus 7.04 (6.82–7.27)). The false negative (interval cancer) rate was lower for Step Down Assessment than for the metropolitan program. The size of cancers detected was similar for both screening services. Return to screen rates were comparable between both groups. Conclusion: The results indicate that the current service model is providing appropriate diagnostic effectiveness, as well as comparable client satisfaction, for country and metropolitan women.     

Population-based mammographic screening: Does Informed choice‘ require any less than full disclosure to individuals of benefits,harms, limitations and consequences?

Mammographic screening is a public health intervention with benefits, harms and consequences. Assuming technical excellence and at least 70% participation, mammographic screening of women aged 50 years or over will reduce breast cancer mortality by 24%. Before the introduction of mammographic screening in Australia, the mortality rate from breast cancer for women in the target age group was 69.0 per 100,000. On the basis of this relative risk reduction, breast cancer mortality would be reduced to 46 per 100,000. However, for every breast cancer death averted, 10 additional cases of breast cancer will be diagnosed. As it is unknowable who will benefit from mammographic screening, it is unethical to claim that any given individual has been 'saved' through participation, especially in the absence of evidence that all-cause mortality will change. As women misunderstand their risks of breast cancer and the benefits and limitations of mammographic screening, public education is needed. As an individual's choice about screening is affected by the way benefits are framed, our public messages must be carefully scrutinised. It is impossible otherwise to assert that women are making an 'informed choice'. The decision of women who decline to participate must be respected. Public health expertise is crucial to ensure the rhetoric of 'informed choice' in cancer screening is realised.     

Breast Cancer Screening Among Korean Americans: A Systematic Review

Cancer is the leading cause of death for Korean Americans (KAs). Breast cancer (BC) is the most commonly occurring cancer among KA women, and its rate has been rapidly increasing. Low BC screening rates for KAs puts them at greater risk for late-stage breast cancer. We conducted a systematic review of the published literature on cancer screening among KAs, and identified 38 eligible studies. Despite significant increases in mammogram utilization over the past two decades, KAs have consistently lower rates of mammogram screening than other American populations. KA women also report lower rates of clinical breast examination and breast self-examination. Screening rates are higher among adults with higher socioeconomic status, greater acculturation to the United States, more cancer knowledge, higher perceived susceptibility to BC, more social support, and better access to health services. However, fear of finding something wrong, fear of embarrassment or lack of modesty, not knowing where to go for screening, believing that mammography is only necessary when symptoms are present, and perceived time and cost difficulties in accessing mammography were reported as barriers to mammogram screening. Coordinated efforts from clinicians, public health workers, KA cultural and religious organizations, and the broader breast cancer advocacy and awareness community are necessary for improving BC screening among KAs.     

Breast cancer screening in regional Hispanic populations

Although Hispanics' use of breast cancer screening services has been investigated, to date there have been no published studies of distinct Hispanic populations in different areas of the country. Using the diverse populations and sites involved in the National Hispanic Leadership Initiative on Cancer 'En Acción', this study examines ethno-regional differences in breast cancer screening rates among these groups and explores the correlates of screening participation. Data collected through telephone surveys were analyzed for women 40 years of age and older (n = 2082). After controlling for demographic variables traditionally related to breast cancer screening rates, it was found that ethno-regional differences in breast cancer screening practices clearly persisted. In addition to traditional demographic factors, other variables evidently underlie differences in Hispanics' utilization of breast cancer screening services. These variables may be cultural and should be investigated in future research. Meanwhile, researchers should not refer to the 'Hispanic' population at large without identifying, addressing and clarifying the ethno-regional characteristics of their samples.     

Trusting technology: women aged 40-49 years participating in screening for breast cancer--an exploratory study

OBJECTIVE: This paper reports key findings from an exploratory study of factors associated with women's decision to participate in mass mammography screening in Tasmania. In particular, we explored factors that contribute to the choice to participate in screening by women who are outside the primary target group, and for whom the evidence of benefit remains contentious. METHODS: Semi-structured interviews were conducted with a small sample of women aged between 40 and 49 years in rural Tasmania who had participated in mammography screening. RESULTS: Key ideas that appeared to shape participation included the fear of breast cancer, trust in technology, and taking responsibility for health. Information provision is also an important factor in shaping participation patterns. CONCLUSIONS AND IMPLICATIONS: In order to facilitate informed consent, information provision in this area should take account of the dominant ideas that shape the decision to participate in breast cancer screening.     

Exploring breast cancer screening barriers among Barbadian women: a focus group study of mammography in a resource-constrained setting

Breast cancer affects women worldwide. Early detection strategies, notably mammography, aim to reduce mortality from breast cancer. However, mammography is a costly screening tool, generates controversy in terms of its impact and adverse effects, and its uptake remains low among some populations. This qualitative study (12 focus groups with 110 participants) explored experiences with mammography among Barbadian women by investigating how barriers are negotiated in a setting of resource-constrained health care provision without a national screening programme. The study findings indicate that, firstly, Barbadian women have to actively seek understanding of both breast cancer and the mammography process. Women described how, with little public awareness and knowledge, they borrow from available public health information on diabetes and HIV/AIDS to give meaning to mammographic screening. Secondly, many women expressed their fear about mammography and its potential consequences, such as experiencing social stigma and losing a romantic relationship after diagnosis. Thirdly, the cost of screening for women who opted for the more reliable private facilities was discussed, along with the potential cost of health care following a diagnosis and the emotional cost of enduring the societal taboo of breast cancer. If breast cancer screening is to be acceptable for this or similar populations, there should be provision of additional services to ensure better access to free screening or alternative strategies, as well as post-diagnostic social and financial support. The policies to develop these services must also address women’s concerns about screening and breast cancer, and provide comprehensive information to allow informed decisions about screening.     

The influence of socio-cultural factors on breast cancer screening behaviors in Lagos,Nigeria

Culture has been shown to influence health beliefs and health-related behaviors by influencing the type of health information to which women have been exposed and shapes health and illness perceptions and practices. To increase screening rates, cultural influences should be considered as important correlates of screening behaviors for breast cancer. This study used semi-structured interviews of women attending a cancer screening facility in Lagos, Nigeria guided by the PEN-3 model to describe culturally relevant factors that shape attitudes toward breast cancer and breast cancer screening. Religion was the most prominent theme and was shown to have positive, negative and existential effect on breast cancer perceptions. Other major themes observed were related to family and traditional beliefs. The results from this study could be used to develop and implement culturally relevant cancer prevention interventions, strategies, and recommendations to overcome screening barriers in an effort to increase breast cancer participation and awareness among Nigerian women.     

Mammographic parenchymal patterns as indicators of breast cancer risk

Mammographic parenchymal patterns have been suggested as indicators of breast cancer risk. However, few well-controlled studies have used prediagnostic mammograms to determine the pattern classification. The authors studied 266 cases of breast cancer and 301 controls from 25 screening centers of the Breast Cancer Detection and Demonstration Project, a nationwide screening program conducted between 1973 and 1980 to evaluate the risk associated with mammographic patterns using mammograms taken four years before the detection of breast cancer. Mammograms of the cancerous breast of cases and of the ipsilateral breast in the control matched to each case were blindly assessed by one of the investigators (J.N.W.), originator of the mammographic pattern classification. The breast cancer odds ratio among women with the combined P2 + DY patterns, compared with women with the N1 pattern, was 2.8 (95% confidence interval (CI): 1.6-5.1). This estimate of relative risk was comparable with the risk associated with other recognized breast cancer risk factors. The odds ratio among P2 + DY women with a first-degree family history of breast cancer was 5.5 (95% CI: 2.6-11.8) compared with N1 women without a family history. These data provide additional evidence that mammographic patterns are indicators for subsequent development of breast cancer, particularly among women with a first-degree family history of this malignancy.     

Barriers to breast cancer screening for low-income Mexican and Dominican women in New York City

The proportion of Mexican and Dominican women has increased rapidly in New York City and in other urban areas, and breast cancer screening rates continue to be lower for Latina women as a whole, but particularly for some nationality sub-groups. The current analysis explored the reasons why Mexican and Dominican women from medically underserved communities in New York City do not seek breast cancer screening. Data were collected through interviews with 298 Mexican and Dominican women aged 40–88 years; the interviews included an open-ended question on the barriers women face in seeking screening. The three most commonly cited barriers were not taking care of oneself (descuido) (52.3%), lack of information (49.3%), and fear (44.6%). Women who had been screened cited fear, pain, or other personal barriers more often, but women who had never had a mammogram cited cost or other logistical barriers. Responses from Dominican and Mexican women were significantly different, with Mexican women more often citing shame or embrarrassment and Dominican women more often citing fear. The dependent variable, barriers to screening, was grouped into major categories. When sociodemographic factors were controlled for, the effect of ethnicity disappeared. Multivariate logistic regression revealed that women with a source of health care were less likely to cite any logistical barriers, but significantly more likely to report only personal barriers (such as fear ordescuido). The analysis indicated that personal barriers were very prevalent in the communities studied. It may not be sufficient merely to increase access to breast cancer screening services for low-income Latinas: even when women have a source of health care, personal barriers may prevent many women from seeking screening. Outreach programs need to be tailored to the target communities as there are significant differences among groups of Latinas. Targeted outreach programs must work in tandem with programs to increase access to ensure that both personal and logistical barriers to screening are addressed.     

Moving in between mammography: screening decisions of American Indian women in Vermont

Breast cancer is a leading cause of cancer death among American Indian women, with mammography screening rates below the national average for this population. A grounded theory study, conducted with Vermont American Indian women, explicated factors that influence mammography decision making. The authors examined mammography decision making across the breast cancer screening continuum: women with a history of consistent annual mammograms, women who were under users or nonusers of mammography, and women who were breast cancer survivors. The generated theory, Moving in Between Mammography, describes the decision-making process and factors that influenced women's participation in routine mammography screening. Specific influencing factors addressed include Connecting to Nativeness, Taking Care of Self, Financing Health Care, and (Mis)Trusting the Health Care System. Implications and directions for future research are addressed.     

Does mammographic density reflect ethnic differences in breast cancer incidence rates?

Breast cancer incidence rates in the United States are substantially lower among Asian-American women than among White or African-American women. The authors determined whether mammographic density reflects these ethnic differences by evaluating mammograms from 442 White, African-American, and Asian-American women without breast cancer who served as controls in one of two population-based, breast cancer case-control studies conducted in Los Angeles, California, in 1994-1998. Absolute and percent mammographic densities were determined with a previously developed and validated computer-assisted method. Data were analyzed using multiple regression methods. Mean age-adjusted percent mammographic density was significantly higher in Asian Americans (35.9%) than in African Americans (27.8%, p < 0.05) but was no longer significant after further adjustment for body mass index. After adjustment for age, body mass index, selected menstrual/reproductive factors, and family history, absolute mammographic density was statistically significantly lower in Asian Americans than in African Americans (p < 0.05) but not than in Whites. The ethnic difference in absolute mammographic density was particularly evident among women older than age 50 years. Additional adjustment for breast size reduced these ethnic differences. This study suggests that absolute but not percent mammographic density reflects the lower breast cancer incidence rates of Asian Americans in relation to those of African Americans and Whites.     

Reliability and validity of women's recall of mammographic screening

Objective : To assess the reliability and validity of self‐reported attendance for mammographic screening. Methods : To assess reliability of recall of attendance for a screening mammogram, 100 women selected at random were interviewed twice (approximately one week apart). To assess validity, 127 women who reported having a mammogram within the national breast screening program (BreastScreen Australia) consented to having their reports verified by the national program. Results : Test‐retest reliability for the question “Have you ever had a mammogram?” was perfect (agreement 100%, kappa 1). Validity was also high. About one‐quarter of women (24.4%) recalled the exact date of their last mammogram and a further third (39.4%) correctly reported the month in which the mammogram was done. Almost all (91.3%) women reported the mammogram date accurately to within 12 months of the recorded date. Conclusions : These data suggest that Australian women provide reliable and valid information in relation to mammographic screening attendance. Implications : Self‐reported data about attendance for mammographic screening are likely to provide reliable and valid estimates for research and health services evaluation purposes.     

Projections of the breast cancer burden to U.S. women: 1990-2000

Although breast cancer incidence rates in the United States have been climbing for the last 40 years, recent trends have shown a more dramatic increase since 1982. This recent rise has been the subject of much study, and it is likely due in part to increased mammographic screening. A mathematical model incorporating the long-term incidence trend estimated from the Connecticut Tumor Registry and recent increases in availability of dedicated mammography machines is described and used to project incidence rates. Projections of breast cancer incidence rates among U.S. women ages 50 and over from 1990 to the year 2000 are developed. It appears that breast cancer incidence rates will continue to rise until about 1990 and then decline as screening rates stabilize.     

Mammographic screening in women with a family history of breast cancer: some results from the Swedish two-county trial

BACKGROUND: The objective of this study is to compare the effectiveness of mammographic screening in women with a family history of breast cancer to those without. In the invited arm of a randomised trial of breast cancer screening, data on family history of breast cancer were available on 29.179 women aged 40-74 attending for screening. Among those women, 358 were diagnosed with breast cancer during the trial. METHODS: Those with and without a family history were compared with respect to mammographic parenchymal pattern, interval cancer rates, mean sojourn time and sensitivity of screening. In the 358 cancers, the effect of family history was estimated on survival, incidence of advanced cancers and their relationship to screen detection. RESULTS: A significantly higher proportion of high risk mammographic patterns was observed in association with family history among women aged 40-49. Interval cancer rates were higher in women with a family history, and in older women at least, mean sojourn time was shortened in women with a family history (1.89 years compared to 2.70). Survival was better (although not significantly so) in cancers in women with a family history (relative hazard=0.52) independently of detection mode and was significantly poorer in interval cancers then screen detected cancers (relative hazard=2.72) independently of family history. Similarly, interval cancers tended to be larger, and worse malignancy grade in those with and without a family history of breast cancer. CONCLUSIONS: These results suggest that the policy often adopted of annual screening for woman aged 40-49, with a family history of breast cancer, is a reasonable one, and that it may also be necessary to shorten the inter-screening interval to one year in women aged over 50 but with a positive family history.     

Optimizing performance of BreastScreen Norway using value of information in graphical models

This study proposes a method to optimize the performance of BreastScreen Norway through a stratified recommendation of tests including independent double or single reading of the screening mammograms and additional imaging with or without core needle biopsy. This is carefully evaluated by a value of information analysis. An estimated graphical probabilistic model describing the relationship between a set of risk factors and the corresponding risk of breast cancer is used for this analysis, together with a Bayesian network modeling screening test results conditional on the true (but unknown) breast cancer status of a woman. This study contributes towards evaluating a possibility of improving the efficiency of the screening program, where all women aged 50 to 69 are invited every second year, regardless of individual risk factors. Our stratified recommendation of tests is dependent on the probability that an asymptomatic woman has developed breast cancer at the time she is invited to a screening.     

Participation in annual skin cancer screening among women seeking routine mammography

BACKGROUND: Early detection of skin cancer is associated with improved prognosis. The American Cancer Society's current skin cancer screening (SCS) recommendation states that adults over the age of 40 should receive an annual skin examination conducted by a health professional. However, little is known about the psychosocial factors related to participation in annual SCS, which remains relatively low among the general public. METHODS: Data were collected from women, aged 50 and older, seeking routine mammography at a large, urban, breast diagnostic facility. RESULTS: A total of 253 eligible women completed the survey. Overall, 20.2% of women reported receiving annual clinical SCS. Physician recommendation, self-efficacy, perceived susceptibility, and age were significantly associated with participation in annual skin screening. CONCLUSIONS: Similar to previously reported findings in the literature, our rates of participation in annual clinical skin screening were lower than reported rates for other types of cancer screening. Among older women, multiple covariates for participation in annual skin cancer screening were determined and may serve to guide future health education interventions to promote screening. Our findings suggest that participation could improve through increasing physician recommendation, screening self-efficacy, and individuals' sense of perceived susceptibility to skin cancer.     

Influence of Health Care, Cost, and Culture on Breast Cancer Screening: Issues Facing Urban American Indian Women

Background. Breast cancer is the second leading cause of cancer death among American Indian women. Southwestern American Indian women are more likely to have distant spread of the disease, and 5-year survival from breast cancer is poor in comparison to U.S. whites. Mortality from breast cancer could be reduced by more than 30% in American Indian women if current recommendations for screening were followed.Methods. A random household cross-sectional survey was conducted among 519 adult American Indian women in Phoenix, Arizona. Logistic regression was used to identify predictors of recent clinical breast examination and mammogram among those women aged 40 years and older.Results. Just more than half (53.0%) of the women surveyed reported they had received a clinical breast examination in the last year, and 35.7% indicated they had received a mammogram in the last 2 years. Access to care, knowledge of the examinations, and health beliefs were positively associated with breast cancer screening in the multivariate analyses.Conclusions. The cancer screening rates observed in urban American Indian women are far below current national estimates and Healthy People 2000 Objectives. This study confirms the limited access of urban Indians to preventive health services, and supports a role for cancer education in improving screening participation in this special population.