Cancer screening by primary care physicians. Can we explain the differences?

BACKGROUND. Physicians perform cancer screening tests less often than recommended. METHODS. Forty primary care physicians were surveyed to assess their knowledge, attitudes, and experiences regarding cancer and cancer screening, and patients' medical records were reviewed to measure physicians' screening rates. RESULTS. Over 80% of physicians believed doctors should urge screening. On average, 23% of their patient visits were scheduled primarily for preventive care interventions. Screening performance scores expressed the percentage of compliance with the American Cancer Society's recommendations and demonstrated the low levels of compliance for six out of seven tests; however, there was substantial variance in performance among physicians. The best predictors of screening performance were (1) the percentage of visits scheduled primarily for prevention (mammography, and pelvic and breast examinations [P less than .05]); and (2) the number of medical journals read regularly (stool occult blood test [P less than .01], sigmoidoscopy [P less than .01], and Papanicolaou smear [P less than .02]). Also, female physicians performed more Papanicolaou smears (P less than .05) and scheduled more visits for preventive care (P less than .001). CONCLUSIONS. A small group of predictors explain large portions of the variance in cancer screening performance.     

Breast cancer screening: effect of physician specialty, practice setting, year of medical school graduation, and sex.

We surveyed physicians of different specialties in a large metropolitan area to determine how their characteristics affected their performance and beliefs about breast cancer screening. Of 664 general internists, obstetrician-gynecologists, and cardiologists surveyed, we received 298 responses (45%). We found significant differences in reported performance of breast cancer screening and physicians' beliefs about mammography screening among practicing obstetrician-gynecologists, internists, and cardiopulmonary specialists. Cardiopulmonary specialists performed the fewest breast examinations and screening mammograms and were most likely to believe annual mammography screening unnecessary even for women in their 50s. We observed no difference between physicians graduating before 1960 and those graduating afterward and no differences according to physician sex. We found similar screening practices and beliefs in the three types of practice settings examined: community-based, private practices, a large health maintenance organization (HMO), and academic medical centers. Obstetrician-gynecologists and internists differed only in the frequency with which they performed breast examinations. Physicians graduating before 1960 in these two groups reported somewhat poorer performance and knowledge of breast cancer screening than those graduating more recently. A majority of all respondents disagreed with American Cancer Society guidelines for mammography screening. Physicians of all specialties reported performing far more breast examinations than screening mammograms on women of all ages, even for those 50-59 years of age. We conclude that all physicians need to improve their screening rates. However, intervention programs should first target those physicians with the greatest deficiencies in breast cancer screening performance and knowledge; these include medical specialists and older physicians in primary care specialties.     

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.     

Factors associated with the use of screening mammography in a primary care setting

Despite consensus recommendations the usse of screening mammography remins low. We examined physician and patient related variables associated with requests to undergo screening mammography in a primary care setting, in order to assess current barriers to screening mammography at the level of the physician-patient interaction. A sample of 261 women over the age of 50, whose primary care was provided by resident physician in a large, urban, academic medical center were examined. Data concerning patients and physicians demographic and clinical chracteristics were abstracted. The data were analyzed by Chi-square and stepwise logistic regression. Forty-five percent of the patients were offered screening mammography within the study year and 53% were offered mammography over the preceding two years. Variables significantly associated with a request for screening included a previous history of breast disease (p<.001) and the severity of the patient's overall medical conditoin. Patients with an overall medical condition rated as mild were more likely to be requested to undergo screening than patients rated as moderately or severely ill (p<.01). Patients with higher educational levels were also more likely to be offered screening (P=.06). First year popstgraduate (PGY 1) physicians requested more mammograms than PGY 2 or PGY 3 physicians (P<.05). A multivariable model utilizing logistic regression confirmed the association of the significant variables above with screening requests. Physicians were more likely to request mammography in patients at higher risk for developing breast cancer and less likely to request it in patients who had co-morbid illness. Increasing physician understanding of the importance and benefits of mammography and further investigation of strategies to ensure ophysician compliance with mammography recommendations are necessary to increase utilization.     

Factors associated with obtaining health screening among women of reproductive age.

Death and disability associated with breast and cervical cancer and hypertension can be reduced by early detection and treatment. The authors examined the rates for having obtained a Papanicolaou (Pap) test or pelvic examination, a breast physical examination, and a blood pressure test within the last 12 months among women of reproductive age in the United States in 1988, as reported by the 8,450 women interviewed for the 1988 National Survey of Family Growth. Overall, the annual rates of screening for women ages 15-44 years for those tests were 67 percent for a Pap test or pelvic examination, 67 percent for a breast examination, and 82 percent for a blood pressure test. Standard recommendations for the frequency of screening and survey data were examined to see whether actual screening practice was consistent with those recommendations. More than 90 percent of women who had a family planning service visit within 12 months received each of the tests, regardless of who provided the service or who paid for the visit. Women who were not sexually active, women with little education or low income, American Indian women, Hispanic women, and women of Asian or Pacific Islander descent had lower rates of screening than others, regardless of their risk status. These findings strongly suggest that the likelihood of having obtained screening among women 15-44 years old is determined primarily by how often a woman uses health care, rather than by her risk of disease.     

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.     

A study guided by the Health Belief Model of the predictors of breast cancer screening of women ages 40 and older

In late 1987, a total of 852 Rhode Island women ages 40 and older were interviewed by telephone (78 percent response rate) to measure their use of breast cancer screening and to investigate potential predictors of use. Predictors included the women's socioeconomic status, use of medical care, a provider's reported recommendations for screening, and the women's health beliefs about breast cancer and mammography. The Health Belief Model guided the construction of the interview questions and data analysis. Logistic regression was used to identify leading independent predictors of breast cancer screening according to contemporary recommendations: reporting that a medical provider had ever recommended a screening mammogram (odds ratio [OR] = 18.77), having received gynecological care in the previous year (OR = 4.92), having a regular source of gynecological care (OR = 2.63), having ever had a diagnostic mammogram (OR = 2.32), and perceiving mammography as safe enough to have annually (OR = 1.93). The findings suggest that programs intended to increase the use of breast cancer screening should include "inreach" and "outreach" elements; inreach to patients with established patient-provider relationships, by assuring that physicians recommend screening to all eligible patients, and outreach to all eligible women, by helping them overcome barriers to effective primary care, and by promoting mammography, emphasizing its effectiveness and safety. The findings also suggest that socioeconomically disadvantaged women, who are less likely to be screened than other women, should become special targets of inreach and outreach interventions.     

How often should patients be sigmoidoscoped? A mathematical perspective

A simple mathematical model is used to help determine suitable intervals for routine periodic sigmoidoscopy. Although annual examinations have been recommended in the past, our calculations indicate that such frequent examinations may only be needed for high-risk patients or very cautious examiners. Our calculations suggest examinations every 2 or 3 years for asymptomatic persons. These recommendations are intended as guides for physicians in their daily practice. They may not apply to large scale screening programs where costs and logistics factors require consideration.     

Rural physicians' perspectives on cervical and breast cancer screening: a gender-based analysis

Several studies highlight the role of physicians in determining cervical and breast cancer screening rates, and some urban studies report higher screening rates by female physicians. Rural women in North America remain underscreened for breast and cervical cancers. This survey was conducted to determine if there were significant gender differences in practices and perceptions of barriers to breast and cervical cancer screening among rural family physicians in Ontario, Canada. One hundred ninety-one family physicians (response rate 53.1%) who practiced in rural areas, small towns, or small cities completed a mail questionnaire. The physicians' mean age was 44.4 years (SD 9.9), and mean number of years in practice was 16.6 years (SD 10.3). Over 90% of physicians reported that they were very likely to conduct a Pap test and clinical breast examination (CBE) during a periodic health examination, and they had high levels of confidence and comfort in performing these procedures. Male (68%) and female (32%) physicians were similar in their likelihood to conduct screening, levels of confidence and comfort, and knowledge of breast and cervical cancer screening guidelines. However, the self-reported screening rates for Pap tests and CBE performed during last year were higher for female than male physicians (p < 0.01). Male physicians reported they were asked more frequently by patients for a referral to another physician to perform Pap tests and CBE (p < 0.001). Also, male physicians perceived patients' embarrassment as a stronger barrier to performing Pap tests (p < 0.05) and CBE (p < 0.01) than female physicians. No gender differences were observed in screening rates or related barriers to mammography referrals. These findings suggest that physicians' gender plays a role in sex-sensitive examination, such as Pap tests and CBE. There is a need to facilitate physician-patient interactions for sex-sensitive cancer screening examinations by health education initiatives targeting male physicians and women themselves. The feasibility of providing sex-sensitive cancer screening examinations by a same-sex health provider should also be explored.     

Informing Women and Their Physicians about Recommendations for Adjunct Breast MRI Screening: A Cohort Study

It is unclear how best to communicate recommendations for breast cancer screening with MRI as an adjunct to mammography for women at high risk. This study compares the rates of breast MRI screening for two different methods of communication. The retrospective IRB-approved cohort study was conducted at Invision Sally Jobe Breast Centers (ISJBC). ISJBC provided Gail model risk assessment to all women presenting for screening mammography. Women with scores ≥ 19.6% were considered to be high risk. Over 2 years, ISJBC used two different methods to inform women at elevated lifetime risk and their physicians about recommendations for adjunct MRI screening (N = 561, mean age = 52 years, s.d. = 8.7). During Window A, information was sent to referring physicians as a part of the dictated imaging report, while later, in Window B, the information was sent to referring physicians as well as to the women themselves in a letter. Analyses were stratified by mammography screening frequency. One-time screeners presented in only Window A or Window B. Repeat screeners came both in Window A and in Window B. Breast MRI screening rates were significantly higher in Window B than in Window A (one-time screeners, N = 459, 9.8% vs. 14.4%, p = 0.047; repeat screeners, N = 102, 0% vs. 6.9%, p = 0.016). Although an observational study cannot assess causality, direct communication of risk-based recommendations for adjunct breast MRI screening to women and to their referring physicians was associated with an increased rate of screening breast MRI completion at the same clinic at which the women underwent mammography.     

Effect of continuing medical education and cost reduction on physician compliance with mammography screening guidelines

BACKGROUND. Primary care physicians perform breast cancer screening in women aged 50 years and older less frequently than recommended by national guidelines. METHODS. A multimethod continuing medical education (CME) intervention was tested in an attempt to increase breast cancer screening practices in a predominantly fee-for-service practice community in New York State. Preintervention and postintervention surveys of primary care physicians were conducted in 1988 and 1990, respectively. Project-initiated, low-cost mammography in one town and the unanticipated provision of free mammography services in another town under nonproject auspices permitted a comparison to be made between these towns and towns where mammography screening was provided at the prevailing fees to determine the impact that cost has on physicians' referral of women patients for mammography. RESULTS. Physicians practicing in the towns in which the CME intervention was provided showed a significant increase, consistent across specialty groups and greatest among family physicians, in the number of reported mammography referrals of asymptomatic women aged 50 to 75 years. Changes in the CME control town were smaller and not statistically significant for the sample size available. The increase in compliance was as large in the CME-intervention towns, one without (19%) and one with low-cost mammography (20%), as the increase in the town with free mammography alone (18%). There were no significant increases in reported performance of breast examination. CONCLUSIONS. A multimethod program of CME is a feasible approach to increasing community physician compliance with mammography screening guidelines, particularly among family physicians, and can enhance the impact of reduced cost or have at least the equivalent effect of free mammography services.     

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.     

Mammography referrals for elderly women: is Medicare reimbursement likely to make a difference?

Data from a survey of primary care physicians practicing in Long Island, New York in 1990 show that physicians report that they are less likely to refer all of their elderly female patients--those 75 years of age and older--for routine screening mammograms than their patients age 50 to 75. According to physicians' self-reports, out-of-pocket costs to the patient for screening mammography are not considered a major deterrent to referrals in this age group. Physicians' decisions to refer elderly patients are affected by the patients' state of health and are associated with the specialty of the physician: obstetrician/gynecologists (OBGYNs) are more likely to make routine referrals of elderly patients for screening mammography than are family practitioners and general internists. The results of this analysis suggest that the new Medicare reimbursement for biennial screening mammograms will not result in immediate increases in utilization by elderly women, unless their physicians become more convinced of the utility of widespread mammographic screening for the elderly patient.     

Physicians’ recommendations for colon cancer screening in women: Too much of a good thing?

Background:Expert groups support periodic colorectal cancer (CRC) screening for persons aged 50 and older but not for persons younger than 50. We were interested in community primary care physicians’ recommendations to women for fecal occult blood tests (FOBT), flexible sigmoidoscopy (SIG), and colonoscopy (COL).Methods:In a mailed survey of 1,292 community primary care physicians in North Carolina, we queried physicians regarding their recommendations to women for CRC screening.Results:Analysis was performed on 508 respondents (39%). Recommendation for FOBT (96%) and SIG (69%) for women >50 years old was high among all subgroups of physicians. Recommendation for women < 50 years old was high for FOBT (82%) but lower for SIG (28%). Overall, 19% of physicians recommended COL. Recommendation for FOBT, SIG, and COL varied by physician specialty, physician age, perceived patient demand, physician need for additional CRC screening information, practice size, and location.Conclusions:Although increasing physician recommendation for CRC screening is important, primary care physicians report recommending earlier and more aggressive screening than that supported by national guidelines.     

Factors associated with repeat adherence to breast cancer screening

This study identified barriers and facilitators of repeat participation in mammography and breast physical examination among women ages 50 years and over. Telephone interviews were conducted with 910 women in this age group. Forty percent of respondents had never had a mammogram. Only 38% had had one in the past 12 months. Of women who had a prior mammogram, 43% had had only one. Only 60% of women had had a breast exam in the past 12 months. A physician recommendation was the single best predictor of adherence to mammography. However, only 60% of women reported that their physicians had ever recommended mammography. Several other barriers to mammography were revealed, including anxiety, embarrassment, and concerns about cost and radiation. Both a family history of breast cancer and heightened perceived vulnerability to breast cancer were associated positively with repeat mammography participation; anxiety about screening reduced the likelihood of this outcome. These findings suggest that physicians can play a powerful role in motivating women to participate in initial and subsequent breast cancer screening. Reassurance may reduce women's anxiety and embarrassment and increase utilization further.     

Flexible sigmoidoscopy training and its impact on colorectal cancer screening by primary care physicians

BACKGROUND: Colorectal cancer is an ideal disease for prevention with screening programs. Efforts to increase compliance with screening recommendations have included training primary care physicians to perform flexible sigmoidoscopy. OBJECTIVE: To assess the impact of flexible sigmoidoscopy training on compliance with current screening recommendations. METHODS: We performed a cross-sectional study of 232 patients cared for by physicians in a primary care network. MAIN OUTCOME MEASURES: Rates of screening for colorectal cancer and rates of undergoing flexible sigmoidoscopy were compared across patient groups according to the physician's training and whether the physician performs flexible sigmoidoscopy in his or her practice. RESULTS: Among 217 patients included in the analysis, 122 (56%) were cared for by physicians who were trained in flexible sigmoidoscopy, of whom 79 (36%) were cared for by physicians who perform flexible sigmoidoscopy in their practice. Patients cared for by physicians trained in flexible sigmoidoscopy were not significantly more likely to receive any colorectal cancer screening than were patients cared for by physicians not trained in flexible sigmoidoscopy (odds ratio, 1.16; 95% confidence interval, 0.67-2.01). However, patients cared for by physicians who perform flexible sigmoidoscopy in their practice were more likely to have undergone any colorectal cancer screening (odds ratio, 1.73; 95% confidence interval, 1.02-2.95) and flexible sigmoidoscopy (odds ratio, 2.69; 95% confidence interval, 1.14-6.36). CONCLUSION: Performance of flexible sigmoidoscopy by primary care physicians has the potential to increase the rate of colorectal cancer screening with flexible sigmoidoscopy.     

Improving the periodic health examination: use of a screening flow chart for patients and physicians

An attempt was made to improve periodic health examinations in a family practice department. Both physicians and patients were instructed in the use of a screening flow sheet that listed the clinic's minimum recommendations for the periodic health examination. Both groups were also educated about the evidence against ordering other tests routinely, such as x-ray examinations and blood tests. Audits were performed before and after physician and patient education on a total of 384 charts. Compliance with all of the screening flow-sheet recommendations improved with education. Significant improvements occurred with the ordering of the tetanus-diphtheria booster and proctosigmoidoscopy examinations. Compliance for most procedures, however, remained well below the recommended level. Unnecessary testing was not decreased by the educational effort. The complete blood count was actually ordered significantly more often after patient education despite the lack of evidence of its value in screening. Although physician and patient education in the use of the screening flow sheet did result in some improvement in the ordering of recommended tests, the optimal method of improving periodic health examinations has yet to be found.     

Implementing preventive health measures: a pilot study

OBJECTIVE: Implementation of preventive services guidelines is performed inconsistently. In an attempt to reduce variation in guideline implementation, we developed a patient questionnaire based on the US Preventive Services Task Force Guide and the Health Plan Employer Data and Information Set 3.0 performance measures of the National Committee on Quality Assurance. SUBJECTS: 100 hospitalized patients of five primary-care physicians. METHODS: In a pilot study, 100 hospitalized patients of five primary-care physicians were questioned about their compliance with evidence-based, preventive healthcare recommendations. Information was requested on blood pressure measurement, cholesterol screening, fecal occult blood testing, smoking-cessation counseling, Pap testing, mammography, postmenopausal hormonal replacement therapy counseling, prostate examination and prostate-specific antigen (PSA) testing, use of aspirin and beta-blockers following an acute myocardial infarction, testing of diabetics for hemoglobin A1c and retinal eye examinations, questioning of the elderly for auditory and visual problems, and receipt of influenza and pneumococcal vaccines. Information on variations from the recommended preventive service was fed back to their physicians. Six months after the initial survey, the patients were requestioned to determine if compliance had improved with the recommendations. RESULTS: We found significant improvement in fecal occult blood testing, smoking cessation, Pap smear testing, mammography use, prostate examinations and PSA testing, hemoglobin A1c testing, seeing or hearing loss follow-up, and the administration of influenza and pneumococcal vaccines. CONCLUSIONS: Improving implementation of preventive services recommendations is a challenge. This pilot study suggests that involving the patient more in the process and informing the physician of the results may improve the process.