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Biomedical subjects

J Mandelblatt

Publications and source records attributed to J Mandelblatt.

At least 19 recordsLinked to original sources
PubMed2001

Advancing age and cervical cancer screening and prognosis.

OBJECTIVES: To determine associations between advancing age and screening behavior and prognosis in long-term members of a prepaid health plan diagnosed with invasive cervical cancer (ICC). DESIGN: Case series. SETTING: Prepaid health plan. PARTICIPANTS: All women diagnosed with ICC at Kaiser Permanente Medical Care Program-Northern California health plan from 1988 to 1994. MEASUREMENTS: From medical records, we recorded participants' age, stage at diagnosis, tumor histology, and results of and reasons for all previous cervical smears. We limited our analysis to women who had been members of the health plan for at least 30 of the 36 months preceding diagnosis (n = 455). RESULTS: Women in older age groups were less likely than younger women to have been screened within the 3 years before diagnosis (P = .005 for trend). Nonadherence to follow-up of abnormal cervical smears was uncommon (17/455, 3.7%) and not age related (P = .932 for trend). The proportions of ICC that were interval cancers, defined as ICC diagnosed within 3 years of a negative screening smear, were highest in women under age 30 (P = .004 for trend). In multivariate analyses controlling for stage at diagnosis, women age 60 and older were not more likely to die of ICC within 3 years of diagnosis than were women younger than age 60 (odds ratio 1.30, 95% confidence interval 0.75-2.28). CONCLUSION: The disproportionate burden of cervical cancer observed in older women appears to be largely attributable to lack of screening within the 3 years before diagnosis.

Adenocarcinoma↗
PubMed2001

Medicare fees and small area variations in breast-conserving surgery among elderly women.

This study used data from Medicare files, the American Hospital Association's Annual Survey of Hospitals, and the 1990 census to investigate whether Medicare fees for breast-conserving surgery (BCS) and mastectomy (MST) affected the rate of BCS across 799 3-digit ZIP code areas in 1994. The full model, which was based on the conceptual framework of the supply of and demand for different treatments, explained 51 percent of the variation in BCS rates. Medicare fees were statistically significant and had the hypothesized effects: a 10 percent higher BCS fee was associated with a 7 to 10 percent higher BCS rate, while a 10 percent higher MST fee was associated with a 2 to 3 percent lower proportion receiving BCS. Other significant economic variables were proximity to a radiation therapy hospital, a teaching hospital or a cancer center, and the percentage of elderly women with incomes below the poverty rate, which were negatively related to the BCS rate. Variations in age, race, and metropolitan populations had small or insignificant effects. The single most important was the percentage of cases with one or more comorbidities.

Aged↗
PubMed2001

The emotional consequences of false positive mammography: African-American women's reactions in their own words.

High false positive rates associated with screening for breast cancer in the United States have an unintended psychological consequence for women (Lerman et al., 1991) that has raised concerns in recent years (Sox, 1998). This study uses inductive qualitative analysis of open-ended interviews with 45 African American women living in New York City who were part of a larger study of women and their experiences after receiving an abnormal mammogram. Themes resulting from the analyses included: inadequate provider-patient communication, anxieties exacerbated by waiting and wondering, and fears of iatrogenic effects of follow-up tests such as biopsies and repeat mammograms. While more research is needed on message-framing strategies for women entering mammographic testing and follow-up, modest changes in service delivery such as improved medical communication can help to alleviate fears and enhance trust.

Adult↗
PubMed2001

Inreach and outreach interventions to improve mammography use.

OBJECTIVE: to assess the effectiveness of patient-targeted interventions in increasing mammography use when performed outside (outreach) or inside the primary care medical setting (inreach). METHODS: We performed a meta-analysis of controlled interventions to increase mammography use in patients in the United States published between 1980 and February 2001. Interventions were classified by setting (inreach or outreach), mechanism of action (behavioral, cognitive, sociologic, or a combination), type of control group (active or usual care), number of strategies, and mode of delivery (static or interactive). Summary estimates were calculated with DerSimonian and Laird random effects models for each group of interventions. RESULTS: We included 66 studies with 98 separate interventions. Inreach and outreach interventions were equally effective in increasing mammography use. Compared to active controls, behavioral interventions with multiple strategies increased mammography use by 14.0% (95% CI, 8.7-19.2) in inreach and 18.7% (95% CI, 4.9-32.4) in outreach settings. Theory-based educational strategies delivered interactively increased mammography use by 10.7% (95% CI, 6.8-14.7) and 19.9% (95% CI, 10.6-29.1) in inreach and outreach settings, respectively. Interventions that combined behavioral and theory-based educational strategies with usual care controls increased mammography use by 14.0% (95% CI, 7.9-20.2) in inreach and 27.3% (95% CI, 14.7-40.0) in outreach settings. Finally, sociologic interventions increased mammography use by 10.7% (95% CI, 3.4-18.0) and 9.1% (95% CI, 1.7-13.3) in inreach and outreach settings, respectively. CONCLUSIONS: Inreach and outreach interventions to increase mammography use were similarly effective within intervention categories based on mechanism of action, mode of delivery, and type of control group. Ultimate decisions about intervention strategies will depend on the characteristics of the target population, practical considerations, and relative cost-effectiveness.

Breast Neoplasms↗
PubMed2000

The positive predictive value of cervical smears in previously screened postmenopausal women: the Heart and Estrogen/progestin Replacement Study (HERS).

BACKGROUND: The benefits and risks of performing annual cervical smears on postmenopausal women are not well defined. The independent effect of hormone replacement therapy on development of cytologic abnormalities is unknown. OBJECTIVE: To determine the positive predictive value of cervical smears in previously screened postmenopausal women and to determine the effect of oral estrogen plus progestin on incident cervical cytologic abnormalities. DESIGN: Prospective cohort study (incidence) and randomized, double-blind, placebo-controlled trial (hormone therapy). SETTING: 20 U.S. outpatient and community clinical centers. PARTICIPANTS: 2561 women with a uterus and normal cytologic characteristics at baseline. INTERVENTIONS: Annual smears; oral conjugated equine estrogens, 0. 625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d, or identical placebo. MEASUREMENTS: Incident cytologic abnormalities (atypical squamous cells of undetermined significance, atypical glandular cells of undetermined significance, low-grade squamous epithelial lesion, and high-grade squamous epithelial lesion) and final histologic diagnoses. RESULTS: The incidence of new cytologic abnormalities in the 2 years following a normal smear was 110 per 4895 person-years (23 per 1000 person-years [95% CI, 18 to 27 per 1000 person-years]). Among the 103 women with known histologic diagnoses, one had mild to moderate dysplasia. The positive predictive value of any smear abnormality identified 1 year after a normal smear, therefore, was 0% (CI, 0% to 5.0%) (0 of 78 women); the positive predictive value of abnormalities found within 2 years was 0.9% (CI, 0.0% to 3.0%) (1 of 110 women). In hormone-treated compared with non-hormone-treated women, the incidence of cytologic abnormalities was nonsignificantly higher (relative hazard, 1.36 [CI, 0.93 to 1.99]), largely because of a nonsignificant 58% greater incidence of atypical squamous cells of undetermined significance (relative hazard, 1.58 [CI, 0.99 to 2.52]). CONCLUSIONS: Because of a poor positive predictive value, cervical smears should not be performed within 2 years of normal cytologic results in postmenopausal women. Therapy with oral estrogen plus progestin does not significantly affect the incidence of cytologic abnormalities.

Aged↗
PubMed1999

Acculturation and breast cancer screening among Hispanic women in New York City.

OBJECTIVES: This study investigated whether acculturation was associated with the receipt of clinical breast examinations and mammograms among Colombian, Ecuadorian, Dominican, and Puerto Rican women aged 18 to 74 years in New York City in 1992. METHODS: A bilingual, targeted, random-digit-dialed telephone survey was conducted among 908 Hispanic women from a population-based quota sample. Outcome measures included ever and recent use of clinical breast examinations and mammograms. Multivariate logistic regression models were used to assess the effect of acculturation on screening use. RESULTS: When demographic, socioeconomic, and health system characteristics and cancer attitudes and beliefs were controlled for, women who were more acculturated had significantly higher odds of ever and recently receiving a clinical breast examination (P < or = .01) and of ever (P < or = .01) and recently (P < or = .05) receiving a mammogram than did less acculturated women. For all screening measures, there was a linear increase in the adjusted probability of being screened as a function of acculturation. CONCLUSIONS: Neighborhood and health system interventions to increase screening among Hispanic women should target the less acculturated.

Acculturation↗
PubMed1998

Cigarette smoking and cervical dysplasia among non-Hispanic black women.

This is the first case-control study to determine whether smoking is associated with cervical dysplasia, after adjustment for human papillomavirus (HPV) infection, among a group of non-Hispanic black women. Subjects were interviewed and asked questions about smoking and other risk factors for cervical cancer. HPV infection was determined by hybrid capture. Thirty-two women with histologically confirmed incident dysplasia and 113 control women with normal cytologic smears were enrolled; all women were HIV negative. Smoking was more strongly associated with dysplasia among women with high-grade lesions than among all case women combined. After adjustment, women with high-grade lesions were roughly four times more likely to be ever (odds ratio [OR]: 3.8; 95% confidence interval [CI]: 0.76-18.4) or current (OR: 4.3; 95% CI: 0.83-21.9) smokers, compared with control women. Larger studies among black women that control for HPV infection are needed to confirm these findings and to explore associations among black women with low-grade lesions.

Adult↗
PubMed1998

Dietary intake and blood levels of lycopene: association with cervical dysplasia among non-Hispanic, black women.

We examined whether elevated levels of retinoids, carotenoids, folate, and vitamin E protected against cervical dysplasia among non-Hispanic, black women. We enrolled 32 women with incident cervical dysplasia, including cervical intraepithelial neoplasia (CIN) I, CIN II, and CIN III/carcinoma in situ, and 113 control women with normal cervical cytology in case-control study. Micronutrient levels were estimated from a food-frequency questionnaire (FFQ) and measured from blood samples. Information on risk factors for cervical neoplasia was elicited by interview. Hybrid capture was used to determine infection with human papillomavirus. After adjustment for potential confounders, analysis of micronutrient levels estimated from the FFQ suggested that women in the upper tertile of lycopene and vitamin A intake were one-third (odds ratio = 0.32, 95% confidence interval = 0.8-1.3) and one-fourth (odds ratio = 0.24, 95% confidence interval = 0.05-1.2) as likely, respectively, to have dysplasia as women in the lower tertile. Borderline protective trends (p < or = 0.10) were apparent. Elevated levels of serum lycopene also suggested some protection against dysplasia. Results were not significant at alpha = 0.05 because of the small number of case women enrolled. Overall, correlations between estimates from the FFQ and serum levels were poor. This study indicates that, among black women, lycopene and perhaps vitamin A may play a protective role in the early stages of cervical carcinogenesis.

Adolescent↗
PubMed1997

Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community.

OBJECTIVE: To examine how continuity of care affects the use of breast and cervical cancer screening in a multiethnic population. METHODS: All data came from a structured telephone survey of a population-based quota sample designed to determine the cancer prevention needs of multiethnic blacks and Hispanics in New York, NY, in 1992. The study included 1420 women of 7 racial/ethnic groups: US-born blacks, English-speaking Caribbean-born blacks, Haitian blacks, and Puerto Rican, Dominican, Colombian, and Ecuadorian Hispanics. The main outcome measures were ever and recently having had a Papanicolaou smear, clinical breast examination (CBE), or mammogram. RESULTS: Among respondents who qualified for the survey on the basis of age and ethnicity, the refusal rate for completing the interview was 2.1%. Compared with women without a usual site of care, those with a usual site, but no regular clinician, were 1.56, 2.45 (P < or = .01), and 2.32 (P < or = .05) times as likely ever to have received a Papanicolaou smear, CBE, or mammogram, respectively and 1.84, 1.92 (P < or = .05), and 1.75 times as likely to have received a recent Papanicolaou smear, CBE, or mammogram, respectively. Compared with women without a usual site of care, women with a regular clinician at that usual site of care were 2.63 (P < or = .01), 2.83 (P < or = .01), and 2.30 (P < or = .05) times as likely ever to have received a Papanicolaou smear, CBE, or mammogram, and were 2.00 (P < or = .05), 2.65 (P < or = .01), and 1.40 times as likely to have recently received a Papanicolaou smear, CBE, or mammogram, respectively (adjusted odds ratios). For uninsured women, presence of a usual site of care was associated with increases in recent use of cancer screening for all screening tests. CONCLUSIONS: There is a linear trend in increasing breast and cervical cancer screening rates when one goes from having no usual source of care, to having a usual source, and to having a regular clinician at that usual source. Emphasis on continuity of care, especially on usual source of care, may help to bridge the gap in access to cancer prevention services faced by minority women.

Adult↗
PubMed1997

The costs and effects of cervical and breast cancer screening in a public hospital emergency room. The Cancer Control Center of Harlem.

OBJECTIVES: This study assessed the cost-effectiveness of cervix and breast cancer screening in a public hospital emergency room. METHODS: Age-eligible women with nonurgent conditions and without recent screening were offered screening by a nurse. A decision analysis compared the costs and outcomes of emergency room screening and standard hospital screening efforts. RESULTS: The undiscounted cost-effectiveness results for establishing new programs were $4050 (cervical cancer), $403,203 (breast cancer), and $4375 (joint cervix and breast cancer) per year of life saved. If screening is added to an existing program, results are more favorable ($429, $21,324, and $479 per year of life saved for cervix, breast, and joint screening, respectively). Results were most sensitive to volume and probability of receiving treatment after an abnormal screen. CONCLUSIONS: Emergency room screening was cost-effective for cervical cancer; breast cancer screening was relatively expensive given the low number of women reached. More intensive recruitment and follow-up strategies are needed to maximize the cost-effectiveness of such programs.

Breast Neoplasms↗
PubMed1996

Implementation of a breast and cervical cancer screening program in a public hospital emergency department. Cancer Control Center of Harlem.

STUDY OBJECTIVE: To assess the feasibility and yields of screening for breast and cervical cancer in an urban public hospital emergency department. METHODS: Women who presented to the ED of a large, urban public hospital during the study period with nonurgent conditions were eligible for a Papanicolaou test (Pap smear) and a clinical breast examination (CBE) if they were 18 years of age or older and for a mammogram if they were 40 years of age or older, provided they had not had the screening examination within the past year. The Pap smear and CBE were performed by a nurse, and mammography was scheduled for a later date. Women with gynecologic complaints were excluded. RESULTS: On the basis of screening history, medical status, and age, 1,850 (32%) of the 5,830 women seen in the ER during the 23-month study period were eligible for both mammography and CBE, and 2,361 (41%) were eligible for Pap smears. Of these women, 116 (6%) completed mammography and CBE, and 644 (27%) received Pap smears. Among screened women, 10 (9%) and 20 (3%), respectively, had results that were suspicious or positive for breast or cervical cancer. Follow-up rates were low: 20% for breast screening and 50% for Pap smears. Among those receiving follow-up, 1 woman was found to have breast cancer and 8 were found to have cervical neoplasia. CONCLUSION: ED cancer screening was feasible and yielded a high rate of cancer detection. Program efficiency was hampered by low volume and high numbers of patients lost to follow-up after abnormal screening results. Greater integration into the acute care setting and more intensive recruitment and follow-up strategies are needed to maximize the potential yield and cost effectiveness of such programs.

Adolescent↗
PubMed1996

Barriers to follow-up of abnormal screening mammograms among low-income minority women. Cancer Control Center of Harlem.

OBJECTIVE: To describe factors related to compliance diagnostic follow-up among minority women of low socioeconomic status with abnormal screening mammograms. METHODS: A retrospective cross-sectional survey using a structured telephone interview. Three cancer screening clinics at an urban inner-city public hospital. All women with abnormal screening mammograms between September 1990 and January 1992 were eligible; women were interviewed in August 1992. Abnormal mammograms were those requiring specific, non-routine clinical follow-up; non-compliance was defined as delayed follow-up (four to six months after the date of the mammogram), or no follow-up at the time of interview (more than 6 months after abnormal). RESULTS: Sixty-two of 442 screened women had abnormal results; the overall rate of non-compliance with follow-up was 50%. Among the 42 (68%) women who agreed to be interviewed, non-compliers were less likely to state that they had been told to receive follow-up than compliers (65% versus 100%; p = 0.008). Non-compliant women were less likely to have suspicious mammography interpretations (p = 0.05), and more likely to report barriers to follow-up, such as cost of lost wages and medical care, system barriers, or fears, than compliant women (61.9% versus 9%, p = 0.01). There were no differences between the two groups for age, education, insurance, source of care, family history, knowledge or attitudes. CONCLUSIONS: These preliminary results suggest that follow-up of low income, minority women with abnormal screening mammograms could be enhanced by improved communication of results. Future studies should extend these findings with larger samples and in other settings and populations.

Adolescent↗
PubMed1996

The late-stage diagnosis of colorectal cancer: demographic and socioeconomic factors.

OBJECTIVES: This study described factors related to colorectal cancer stage at diagnosis. METHODS: Logistic regression analyses were used on data from the New York State Tumor Registry and US Census area-level social class indicators. RESULTS: After the effects of other predictors were controlled for, the odds of late-stage cancer increased as age decreased; women and African Americans were significantly more likely to have late stage than men and Whites; and individuals living in areas of low socioeconomic status (SES) were significantly more likely to be diagnosed at late stage than those living in higher SES areas. Stratified analyses showed that living in a low SES area was the most important determinant of stage for all age, race, gender and source-of-care groups. CONCLUSIONS: While all populations would benefit from the systematic use of screening socioeconomically disadvantaged groups may also benefit from targeted screening.

Adult↗
PubMed1995

Impact of access and social context on breast cancer stage at diagnosis.

This study examined the impact of individual demographic characteristics (age, race/ethnicity, and type of reporting hospital), together with measures of social context, including area of residence socioeconomic status (SES), change in SES, and access to screening (area mammography capacity), on breast cancer stage at diagnosis among New York City residents diagnosed between 1980 and 1985. Three logistic regression models evaluated the impact of individual variables, social context variables, and both classes of variables combined on the outcome of having late-stage (regional or distant) compared to early-stage (local) cancer. The logistic regression models indicated that women aged 50 to 64 years were independently more likely to have late-stage cancer than those younger or older. Controlling for individual and social context variables, African American women were 25 percent more likely than White women to have late-stage breast cancer (p < 0.0001); higher odds seen in the individual model for Hispanic women disappeared after controlling for area SES. In the combined model, women diagnosed from public hospitals were 44 percent more likely to have late-stage disease than those diagnosed in nonpublic settings (p < 0.0001). In both the social context and combined models, area mammography capacity was a significant independent predictor of stage (p = 0.016); area-level SES, but not change in SES, was independently related to late-stage disease (p = 0.002). These data suggest that breast cancer control activities should more actively ensure adequate access to screening, particularly for minorities, populations living in socioeconomically disadvantaged areas, and those cared for in the public sector.

Adult↗
PubMed1995

Effectiveness of interventions to enhance physician screening for breast cancer.

BACKGROUND: Physician recommendation is one of the strongest predictors of mammography use. This study was designed to review research articles assessing the effectiveness of interventions to enhance physician breast cancer screening behavior. METHODS: A MEDLINE search was conducted to identify intervention studies published from January 1980 to April 1993. The search was supplemented by review of all related bibliographic references and recent listings in Current Contents. RESULTS: Effect sizes and 95% confidence intervals were calculated for the 20 controlled trials identified by the search. The majority of studies were conducted in academic settings; two were community-based. Interventions included physician reminder systems, other office systems, audit with feedback, and physician education. The majority of trials included two or more intervention modalities; 65% included physician reminder systems. In university settings, physician reminders and audit with feedback each significantly increased use of mammography and clinical breast examination by approximately 5% to 20%. In community-based settings, the effects of physician education also had a positive impact on mammography and clinical breast examination rates, which ranged from 6% to 14%. Using patient education to influence physician behavior was not effective in university settings, but had a modest impact in community trials. Generally, reminders were more cost-efficient than audit with feedback. CONCLUSIONS: Physician-based interventions can be effective in increasing screening use. Interventions should emphasize community practices and practices caring for underserved and older populations.

Breast Neoplasms↗
PubMed1994

Using census and mortality data to target small areas for breast, colorectal, and cervical cancer screening.

OBJECTIVES: The goal of this study was to develop and validate quantitative models for estimating cancer incidence in small areas. METHODS: The outcome for each cancer site was the incidence of disease that had reached a late stage at the time of diagnosis. Two sets of predictors were used: (1) census-based demographic variables and (2) census-based demographic variables together with the cancer-specific mortality rate. RESULTS: The best models accounted for a substantial percentage of between area variability in late-stage rates for cancer of the breast (46%), cervix (61%), and colon/rectum (58%). A validation procedure indicated that correct identification of small areas with high rates of late-stage disease was two to three times more likely when model-based estimates were used than when areas were selected at random. CONCLUSIONS: Additional testing is needed to establish the generality of the geographic targeting methodology developed in this paper. However, there are strong indications that small-area estimation models will be useful in many regions where planners wish to target cancer screening programs on a geographic basis.

Breast Neoplasms↗
PubMed1993

Targeting breast and cervical cancer screening to elderly poor black women: who will participate? The Harlem Study Team.

BACKGROUND: Factors associated with participation in breast and cervix cancer screening among elderly black women of low socioeconomic status were determined. METHODS: Data from a baseline cross-sectional random survey were used together with data on whether screening was subsequently completed or refused. The subjects were a random sample of women attending an urban public hospital primary care clinic for routine medical care with a birth year of 1924 or earlier. RESULTS: Among the 271 women in the study group, 70% completed screening. Stated intent was the strongest predictor of participation; women who intended to have both mammography and Pap testing were 2.7 times more likely to participate than those who intended to have neither test (95% confidence interval 1.4, 4.9; P < 0.01), controlling for age, insurance status, and level of chronic illness. Women who had more than three chronic illnesses were twice as likely to participate than those with three or fewer illnesses (95% confidence interval 1.1, 3.4 P < 0.02), controlling for the remaining variables. Other variables, including age, history of a recent screening examination, attitudes, or knowledge, were not related to participation. Stated intent was the only variable that predicted compliance with both mammography and Pap smear completion in separate regression models for the individual tests. CONCLUSION: A high proportion of elderly, socioeconomically disadvantaged black women will participate in cancer screening when it is offered in a primary care setting. Further research on behavioral intentions should be conducted to refine interventions designed to enhance the use of early cancer detection among vulnerable population groups.

Black or African American↗