A pivotal role for the general practitioner in a mixed mammographic screening model

BackgroundA mixed mammographic screening model presents a country or region with a complex problem. Promoting a significant shift within the target population from opportunistic breast cancer screening to participation in an organised screening programme offers many advantages. The objective was to explore the role of GPs as potential mediators by assessing their specific knowledge, attitudes, and experience on breast cancer and mammographic screening.MethodsA detailed questionnaire was mailed in 2007 to 1500 GPs randomly sampled from the GP population in the province of Antwerp, Belgium. Levels of knowledge on epidemiology and screening, opinions and attitudes on systematic mammographic screening, and experience with breast cancer and mammography were evaluated.ResultsWe received 317 completed questionnaires, 21.1% of the contacted GPs. General knowledge on basic concepts of mammographic screening was average, while the response to an open question on the differences between screening and opportunistic mammography was very limited. More than half of the participants had a positive or realistic attitude towards many aspects of systematic screening, and had satisfactory experience with breast cancer patients in their daily practice (about 82% saw one to four new cases a year). Many (72%) were favourably disposed towards systematic screening organised by the government.ConclusionThe answers of the GPs suggest a promising potential with regard to the official breast cancer screening programme. Many participants presented qualifications, which could contribute to a change from the mixed model in favour of the official screening system. A number of gaps, however, need to be filled and there is a continuing need to educate physicians on principles and risks and benefits of systematic screening of the target group.     

Use of patient reminder letters to promote cancer screening services in women: A population-based study in Wisconsin.

BACKGROUND: Patient reminder letters are an effective method of promoting cancer screening services in women; however, information on their actual use in a population setting is lacking. METHODS: Data were obtained from a population-based, random digit dial telephone survey of 896 adult women living in Wisconsin. Respondents were asked if they had received a reminder letter for Pap or mammography screening within the past year. RESULTS: Among women aged >/=18 years, 12.9% (95% confidence interval [95% CI] = 10.1-15. 6) received a Pap test reminder within the past year, while 13.0% (95% CI = 9.3-16.7) of women aged >/=40 years received a mammography reminder. Women without health care coverage were unlikely to receive either type of reminder. Current compliance with screening recommendations was greater among those women who received a reminder letter for Pap tests (94.3 versus 78.1%, P < 0.0001) and for mammography (81.7 versus 59.4%, P < 0.001). In contrast to the infrequent use of cancer screening reminders, 54.2% (95% CI = 50. 1-58.3) and 72.7% (95% CI = 67.6-77.8) of women reported receiving a reminder letter from their dentist or veterinarian, respectively. CONCLUSIONS: Reminder letters for cancer screening services were rarely utilized in this study population. Receipt of a reminder letter was associated with greater compliance with current screening recommendations.     

Physician recommendations for screening mammography: results of a survey using clinical vignettes

BACKGROUND. Although experts estimate that 30% of breast cancer deaths could be prevented if women were screened according to published guidelines, fewer than 50% of physicians follow screening mammography guidelines, and fewer than 30% of women are screened with mammography. METHODS. Physician recommendations for screening mammography were examined in a questionnaire mailed to 300 randomly selected physicians of the Ohio Academy of Family Physicians. Physicians responded with their likelihood of recommending screening mammography to 24 clinical vignettes that high-lighted patient, mammographic, and encounter characteristics. RESULTS. Seventy-one percent responded. Ninety-one percent reported almost always recommending screening mammography to a 55-year-old woman at her yearly examination. They were significantly less likely to recommend mammography to women who were young (40 years old), were old (70 years old), were poor, had small breasts, had painful mammograms, did not want the doctor to look for cancer, lived in a nursing home, or were retarded. Physicians recommended mammography less often when the mammography unit was far away or produced poor quality films or ambiguous interpretations. When physicians ran behind schedule, perceived a more urgent medical problem during the encounter, or saw a woman for an acute visit, they recommended mammography significantly less often. CONCLUSIONS. Patient, mammographic, and encounter characteristics significantly limit physician recommendations for screening mammography as assessed by clinical vignettes. These characteristics must be addressed if breast cancer mortality is to be reduced with early screening.     

Effect of appointment scheduling and reminder postcards on adherence to mammography recommendations

A brief, simple intervention designed to increase the adherence of female patients to their physicians' recommendations for screening mammograms was tested in several midwestern sites. Compared with a control group in which women were examined, told about mammography, and instructed to make an appointment for themselves, an intervention that scheduled appointments for women on the spot and followed up with a reminder postcard increased adherence at every site. Such an intervention, if implemented on a wide scale, would augment the value of screening mammography in controlling breast cancer.     

Cost-effectiveness of a tailored intervention designed to increase breast cancer screening among a non-adherent population: a randomized controlled trial

ABSTRACT: BACKGROUND: Although the percentage of women who initiate breast cancer screening is rising, the rate of continued adherence is poor. The purpose of this study was to examine the effectiveness and cost-effectiveness of a tailored print intervention compared with a non-tailored print intervention for increasing the breast cancer screening rate among a non-adherent population. METHODS: In total, 1859 participants aged 51--59 years (except those aged 55 years) were recruited from a Japanese urban community setting. Participants were randomly assigned to receive either a tailored print reminder (tailored intervention group) or non-tailored print reminder (non-tailored intervention group). The primary outcome was improvement in the breast cancer screening rate. The screening rates and cost-effectiveness were examined for each treatment group (tailored vs. non-tailored) and each intervention subgroup during a follow-up period of five months. All analyses followed the intention-to-treat principle. RESULTS: The number of women who underwent a screening mammogram following the reminder was 277 (19.9%) in the tailored reminder group and 27 (5.8%) in the non-tailored reminder group. A logistic regression model revealed that the odds of a woman who received a tailored print reminder undergoing mammography was 4.02 times those of a women who had received a non-tailored print reminder (95% confidence interval, 2.67--6.06). The cost of one mammography screening increase was 2,544 JPY or 30 USD in the tailored intervention group and 4,366 JPY or 52 USD in the non-tailored intervention group. CONCLUSIONS: Providing a tailored print reminder was an effective and cost-effective strategy for improving breast cancer screening rates among non-adherent women.     

Methodology for targeting physicians for interventions to improve breast cancer screening

INTRODUCTION: Uneven increases in mammography utilization rates call for methods to efficiently target educational interventions to women who do not regularly use mammography and physicians who do not adhere to national guidelines for breast cancer screening. This paper discusses a method for identifying physicians who are nonadherers to breast cancer screening guidelines or in need of continuing medical education (CME) in this area. METHODS: A 1995 community-based telephone survey of randomly selected women aged 50-80, residing in four Long Island, NY, townships was used to identify women who underuse mammography and their regular physicians. Community-based surveys of physicians permitted identification of nonadherent providers. Nonadherence to breast cancer screening recommendations was the primary criterion, but because of anticipated physician reluctance to self report nonadherence with screening guidelines, additional criteria were developed to identify physicians with educational needs relating to breast cancer screening. These criteria included lack of office reminder systems and knowledge relating to breast cancer screening, and lack of confidence in patient counseling and clinical breast examination skills. RESULTS: Overall response rates were 77% for women's survey, and 66% for the physician survey. 3427 women were classified as underusers (38.5%) and 87% of underusers provided the name and address of their regular physicians. By physician self report, 45% of physicians were classified as nonadherers and 42% were identified as having related educational needs. CONCLUSION: A feasible method for identifying physicians who are nonadherers to breast cancer screening recommendations or in need of CME about this is described, permitting efficient targeting of educational interventions to those with patients who underuse mammography. The method is not dependent on access to a specific provider or patient population.     

An ecological study of the effectiveness of mammography in reducing breast cancer mortality.

OBJECTIVES: The purpose of this study was to determine the relation of screening mammography to breast cancer incidence and case fatality. METHODS: In a sample of White female Medicare beneficiaries hospitalized in 1990-1991, age-adjusted breast cancer incidence and 2-year case fatality rates were estimated and compared with the frequency of mammographic screening from a population-based survey. RESULTS: The average rates for incidence, case fatality, and mammography within 5 years in 29 states were 414/100,000, 18.8%, and 59.2%, respectively. There was a positive state-level correlation between mammography rates and incidence and an inverse correlation between mammography and case fatality. CONCLUSIONS: High screening mammography rates in some states are associated with reduced breast cancer case fatality rates, presumably as a result of diagnosis of earlier stage cancers.     

Screening and early diagnosis of breast cancer

Long-term survival in breast cancer currently rests on detection and appropriate therapy at the earliest possible stage, with survival being excellent in patients whose cancers are discovered at a small size and without dissemination. Discovery of lesions at the smallest possible size is therefore desirable. Of the available imaging modalities, only modern mammography has been shown consistently to detect small breast lesions. The efficacy of screening mammography in asymptomatic women has been demonstrated in large-scale trials in women older than 49 years of age and has been strongly supported by follow-up results in the Breast Cancer Detection and Demonstration Project in women aged 40 to 50 years. Mammographic screening has been advocated by the American Cancer Society (ACS) beginning at 40 years of age, while the National Cancer Institute recommends mammographic screening beginning at 50 years of age. The ACS recommends also that breast self-examination begin at 20 years of age. Unfortunately, a great majority of women do not practice breast self-examination, nor do they know that mammography is useful in detecting breast cancer. Further, only a minority of physicians recommend screening mammography, although most recommend breast self-examination and perform physical examination of the breast. Physicians are therefore urged to recommend regular screening to their patients.     

Results of mammographic screening at the Mammary Center of Debrecen in 1999 and 2000

INTRODUCTION: The screening mammography decreases the mortality of female breast cancer. METHODS: A complex, independent centre of screening mammography has been operating in Debrecen since 1999. RESULTS: The number of the examinations were 10,399 in 1999 and 13,800 in 2000. The number of explored breast cancer cases were 43 (0.41%) in 1999 and 62 (0.45%) in 2000. CONCLUSION: Although the mortality reduction can be exactly measured after several years, we are convinced that the chances for a better life of these 107 women operated on with breast cancer in early state increased thanks to our project. The results of the breast cancer screening program in Debrecen fulfilled the professional requirements of mammographic service-screening.     

Men's and women's knowledge and perceptions of breast cancer and mammography screening

BACKGROUND: Although most men are not directly affected by breast cancer, they participate in decisions influencing breast cancer screening and contribute to shaping the social norm on mammography screening. This study tested the hypothesis that men may be less knowledgeable than women about breast cancer and mammography and have less favorable perceptions of mammography screening. METHODS: A survey was mailed to 952 women and 370 men aged 40 to 80 years, randomly selected from the general population of Geneva, Switzerland. Information collected included knowledge and perceptions about breast cancer and mammography, familiarity with screening recommendations, and perceived usefulness of an organized screening program. RESULTS: Men were almost as knowledgeable as women about breast cancer (difference in z-scores: -0.12; 95% CI: -0.25, 0.02; P = 0.10) and breast cancer screening (difference: -0.12; 95% CI: -0.25, 0.02; P = 0.09). Both men and women perceived mammography screening to be useful, but men had significantly higher z-scores of positive attitude toward mammography than women (difference: 0.28; 95% CI: 0.14, 0.42; P < 0.001). Younger and more educated respondents of either sex were both more knowledgeable and more favorably inclined toward screening. CONCLUSION: Men were as knowledgeable about breast cancer and mammography screening as women but had more favorable attitudes toward breast cancer screening than women. Actions to strengthen community support for mammography screening programs should primarily target older and less educated persons of either sex.     

Mammography in New Hampshire: Characteristics of the Women and the Exams They Receive

New Hampshire (NH) is one of two states that has developed a population-based mammography registry. The purpose of this paper is to describe what we have learned about mammography use in New Hampshire. After collecting data for 20 months, the database contains almost 110,000 mammographic encounters representing 101,679 NH women, who range in age from 18 to 97 with a mean of 56.7 years (SD=10.91). Education levels are high with 92% having a high school education and 59% with some college. Forty-six percent report their primary insurance is private, 29% report HMO/PPO coverage, and 25% receive federal health care assistance. Risk factors represented in the database include (categories not mutually exclusive) advancing age (60% over age 50), hormone replacement therapy use by menopausal women (40.6%), and a family history of breast cancer (29%). Penetration of mammography relative to the NH population is higher for younger age groups (40–48% for those aged 44–64) than older age groups (34–39% for those aged 65–84). The majority of mammographic encounters are routine screening exams (86%), often interpreted as negative or normal with benign findings (88%). Use of comparison films to interpret either diagnostic or screening mammography occurred in 86% of encounters. We have matched 3,877 breast pathology records to these mammographic encounters. The distribution of pathology outcomes for diagnostic exams was very similar to that for screening exams (approximately 65% benign, 17% invasive breast cancer, and 6% noninvasive breast cancer). Overall, we have designed a system that is well accepted by the NH community. Challenges include careful monitoring of data for coding errors, and a limitation of linking variables in mammography and pathology data. Data represented in this registry are a critical resource for research in mammographic screening and breast cancer early detection.     

Breast cancer screening among relatives of women with breast cancer.

BACKGROUND. National surveys indicate that only 15% to 30% of all women in the general population 50 years of age or older have an annual mammogram. METHODS. We studied first-degree female relatives of women with breast cancer, who are at elevated risk of disease, to describe the breast cancer screening practices of these relatives and to improve their practices through a program of intensive education. We report here the screening behaviors of 2471 relatives of women with breast cancer. RESULTS. Self-reported behaviors were as follows: 49% performed monthly breast self-examination and 70% had annual breast examinations by a medical professional. Of 983 women 50 years of age or older, 49% had had a mammogram, but only 14% have a mammogram annually. Of women 50 years of age or older who had never had a mammogram, 92% reported never having had one recommended by a medical professional. CONCLUSIONS. Our findings indicate that screening behaviors in relatives of breast cancer patients are not substantially different from those of women in the general population. Enhanced efforts both to educate medical professionals and to encourage women to demand screening mammography are necessary to reduce breast cancer mortality.     

Perceived sensitivity of mammographic screening: women's views on test accuracy and financial compensation for missed cancers

OBJECTIVES: To estimate women's expectations of the accuracy of screening mammography and to explore attitudes towards compensation for missed cancers. DESIGN: Cross sectional survey (by telephone). SETTING: Australia; population-based survey conducted in April 1996. PARTICIPANTS: Random sample of women aged 30-69 years. A total of 2935 women completed the Breast Health Survey (adjusted response rate 65%). A random sample of 115 completed this sub-survey on perceived sensitivity of mammographic screening and compensation for missed cancers. RESULTS: About one third of women (32.2%, 95% CI 23.7, 40.7) had an unrealistically high expectation of the sensitivity of screening mammography, reporting it to be 95% or higher. Approximately 40% of the women (43.5%, 95% CI 34.4, 52.6) thought that screening mammography should pick up all cancers (should have a sensitivity of 100%). Just under half the women (45.2%, 95% CI 36.1, 54.3) said financial compensation should be awarded for a cancer missed by screening mammography even if the cancer was missed as a consequence of the small failure rate of the test. Younger women living in metropolitan areas and women who had realistic expectations of the accuracy of the tests were more likely to favour financial compensation. CONCLUSION: Unrealistically high expectations of the sensitivity of screening mammography were common in this group of women. Many women favoured financial compensation for missed cancers even if the cancer was missed solely because of the failure rate of the test. Public education is required to inform women of the limited sensitivity of breast cancer tests but this may not reduce claims for financial compensation when cancers are missed.     

Attitudes, beliefs, and knowledge as predictors of nonattendance in a Swedish population-based mammography screening program

BACKGROUND: The effectiveness of mammography screening could be improved if factors that influence nonattendance were better understood. METHODS: We examined attitudes, beliefs, and knowledge in relation to nonattendance in a population-based mammography screening program, using a case-control design. Data were collected from November 1997 to March 1998 through telephone interviews with 434 nonattenders and 515 attenders identified in a population-based mammography register in central Sweden. The questions asked drew primarily upon the components constituting the Health Belief Model. RESULTS: Multivariate analysis showed that nonattendance was most common among women within the highest quartile of perceived emotional barriers, compared to women within the lowest quartile (OR = 4.81; 95% CI 2.96-7.82). Women who worried most about breast cancer were more likely to attend than those who worried least (OR = 0.09; 95% CI 0.02-0.31). Women with the highest scores of perceived benefits were more likely to attend than women with the lowest ones (OR = 0.35; 95% CI 0.08-0.75). Other factors associated with nonattendance were less knowledge about mammography and breast cancer, lack of advice from a health professional to participate, and very poor trust in health care. CONCLUSIONS: Our findings suggest that increased participation in outreach mammography screening programs can be achieved through enhancement of breast cancer awareness and possibly by reducing some of the modifiable barriers. mammography; mass screening; breast cancer; attitudes; Sweden.     

Breast cancer screening controversies

BACKGROUND: The Cochrane Collaborative, a respected independent review body, recently published a meta-analysis of the effectiveness of screening mammography in decreasing breast cancer mortality. Based on the results of two controlled trials they judged to be of medium validity, they concluded that screening mammography was unjustified. In contrast, the US Preventive Services Task Force recently updated their screening recommendations, and based on a meta-analysis of the same randomized controlled trials, they recommended screening mammography for all women starting at age 40 years. Additionally the Canadian Task Force on Preventive Health Care no longer recommends breast self-examination (BSE). This article reviews the controversies regarding breast cancer screening. METHODS: We performed a systematic review of the literature using keywords and cross-referencing articles. We also used automated data from the Breast Cancer Screening Program at Group Health Cooperative to determine the sensitivity of the clinical breast examination (CBE) at our institution. For the latter we included all cancers diagnosed within 1 year of a screening examination and then determined which of those had been found by CBE. RESULTS: Although most screening studies have shown that mammography decreases breast cancer death, there are controversies about the validity of some of the randomized controlled screening mammography trials. These controversies have led to different conclusions about the efficacy of screening mammography. Evidence is limited about the optimal interval for screening mammography. No studies have directly tested the efficacy of the CBE in decreasing breast cancer mortality. At Group Health Cooperative, 8% of all diagnosed breast cancers were found by the CBE alone (negative mammogram). Whether this 8% incremental increase in case finding leads to decreased breast cancer deaths is unknown. There is good evidence that training women to perform BSE does not increase breast cancer diagnoses or decrease breast cancer deaths. CONCLUSION: There are limitations to randomized controlled trials and meta-analyses. The balance of the evidence still favors screening mammography in women aged 40 years and older at least every 2 years. The independent incremental benefit of the CBE, when added to mammography, in decreasing breast cancer mortality is unknown. Population-based education and training to do BSE are unlikely to lead to decreased breast cancer deaths. Many women find their own breast cancers, so women need to pay attention to symptoms or changes in their breasts.     

A general practice-based recruitment strategy for colorectal cancer screening

OBJECTIVE: To determine whether a screening recruitment strategy for first degree relatives of people with colorectal cancer is effective in enabling eligible relatives to request screening from their general practitioner (GP) and to assess acceptability to GPs and patients. METHODS: Thirty GPs, from 26 practices, and 303 of their patients aged over 50 who were first degree relatives of a person with colorectal cancer, participated in a randomised controlled trial of a GP-based recruitment strategy, in the Newcastle Area of New South Wales, Australia. RESULTS: The proportion of relatives requesting screening was statistically significantly higher in the intervention group than in the control group (18% compared to 4%, respectively; p = 0.01). CONCLUSIONS: Interest in the study by GPs was low, however for GPs who were involved, the recruitment strategy did prompt first degree relatives to discuss screening. The strategy may be even more effective when combined with other interventions such as a media campaign. The results may be generalizable to feasibility studies of general population screening for colorectal cancer in Australia. IMPLICATIONS: The results of this work are potentially informative to public health practice in Australia given the ensuing pilot programs of colorectal cancer screening.     

Repeat mammography among women over 50 years of age.

Mammography decreases mortality among women 50 years of age and older. Although recent surveys show that mammography use has increased since 1983, it continues to be underused by women at risk for breast cancer. The frequency of repeat screening at recommended intervals remains an important unanswered question. This record audit study included all visits from 1986 to 1988 for active female patients, 51-64 years of age, in a family medicine practice. The practice has a disproportionately black patient population, many of whom are on public assistance, characteristics associated with lower compliance with cancer screening guidelines. I reviewed medical records for a physician's recommendation for mammography and also for a radiology report documenting receipt of the mammogram. I also abstracted from the medical record the reason for mammography, a history of breast cancer risk factors, and sociodemographic information. In addition, I noted documentation of a clinical breast examination (CBE) and CBE results. Records for 150 patients were included in the analysis. The results indicate that repeat screening mammography is not common: 3% had three mammograms during the study period; 19% had two; 33% had one; and 44% had none. Physician recommendation for first-time mammography and clinical examination occurred with low frequency. As others report, mammography use is strongly associated with physician recommendation for a mammogram.     

Determinants of Breast, Cervical and Colorectal Cancer Screening Adherence in Mexican–American Women

Despite the effectiveness of cancer screening procedures, its utilization among Latinas remains low. Guided, in part, by the Behavioral Model for Vulnerable Populations, this study examined the associations between predisposing, enabling, and need factors with self-reported breast, cervical, and colorectal cancer screening adherence. Participants were 319 Mexican–American women, from a range of socioeconomic backgrounds, living near the United States-Mexico border. Women were adherent with breast cancer (BC) screening (≥42 years) if they had received at least one mammogram within the last 2 years, with cervical cancer (CC) screening (≥40 years) if they had received at least one Pap exam in the last 3 years, and with colorectal cancer (CRC) screening (≥52 years) if they had undergone one or more of the following: Fecal Occult Blood Test within the last year, or sigmoidoscopy in the last 5 years, or colonoscopy within the last 10 years. BC and CC screenings were higher in the current sample compared to national and state figures: 82% with mammography and 86% adherent with Pap exam screening. However, only 43% were adherent with CRC screening recommendations. Characteristics associated with mammography adherence included CC adherence and usual source of care. BC adherence was associated to CC adherence. Characteristics associated with CRC adherence included BC adherence, being premenopausal, and insurance coverage. A key correlate of cancer screening adherence was adherence to other preventive services. Results underscore the need for continued efforts to ensure that Latinas of all SES levels obtain regular and timely cancer screenings.     

Using physician correspondence and postcard reminders to promote mammography use.

OBJECTIVES. In a health maintenance organization that mails letters to women recommending that they schedule mammograms, we conducted a randomized trial to evaluate simple methods of increasing the use of screening mammography. METHODS. Using a 2 x 2 factorial design, we tested the effects of (1) mailing the recommendation letter from each woman's primary care physician rather than from the program director and (2) sending a subsequent reminder postcard. RESULTS. Sending a reminder postcard nearly doubled the odds that women would get mammograms within 1 year (participate). The letter from the woman's personal physician had no effect. Attending a clinic more than 45 minutes from the screening center, being a current smoker, or being in fair or poor health were negatively associated with subsequently obtaining a mammogram. The odds of participation doubled if women had had previous mammograms. CONCLUSIONS. When preceded by written recommendations to schedule mammograms, reminder postcards effectively increased participation. Future randomized trials to promote use of screening mammography should compare interventions with a reminder condition.