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Stephen H Taplin

Publications and source records attributed to Stephen H Taplin.

At least 19 recordsLinked to original sources
PubMed2006

Reality check: perceived versus actual performance of community mammographers.

OBJECTIVE: Federal regulations mandate that radiologists receive regular albeit limited feedback regarding their interpretive accuracy in mammography. We sought to determine whether radiologists who regularly receive more extensive feedback can report their actual performance in screening mammography accurately. SUBJECTS AND METHODS: Radiologists (n = 105) who routinely interpret screening mammograms in three states (Washington, Colorado, and New Hampshire) completed a mailed survey in 2001. Radiologists were asked to estimate how frequently they recommended additional diagnostic testing after screening mammography and the positive predictive value of their recommendations for biopsy (PPV2). We then used outcomes from 336,128 screening mammography examinations interpreted by the radiologists from 1998 to 2001 to ascertain their true rates of recommendations for diagnostic testing and PPV2. RESULTS: Radiologists' self-reported rate of recommending immediate additional imaging (11.1%) exceeded their actual rate (9.1%) (mean difference, 1.9%; 95% confidence interval [CI], 0.9-3.0%). The mean self-reported rate of recommending short-interval follow-up was 6.2%; the true rate was 1.8% (mean difference, 4.3%; 95% CI, 3.6-5.1%). Similarly, the mean self-reported and true rates of recommending immediate biopsy or surgical evaluation were 3.2% and 0.6%, respectively (mean difference, 2.6%; 95% CI, 1.8-3.4%). Conversely, radiologists' mean self-reported PPV2 (18.3%) was significantly less than their mean true PPV2 (27.6%) (mean difference, -9.3%; 95% CI, -12.4% to -6.2%). CONCLUSION: Despite regular performance feedback, community radiologists may overestimate their true rates of recommending further evaluation after screening mammography and underestimate their true positive predictive value.

Biopsy↗
PubMed2006

Testing the effect of computer-assisted detection on interpretive performance in screening mammography.

OBJECTIVE: The objective of our study was to test whether the use of computer-assisted detection (CAD) improves sensitivity at no cost to specificity for the detection of breast cancer and enables more accurate assessment of fatty breast tissue compared with dense breast tissue. MATERIALS AND METHODS: We created a stratified random sample of screening mammograms weighted with difficult cases split evenly among women with fatty breast tissue and those with dense breast tissue: 114 patients were cancer-free, 114 had cancer 1 year after screening, and 113 had cancer 13-24 months after screening. In test settings 6 months apart, 19 community radiologists interpreted 341 bilateral screening mammograms with and without CAD. We compared the sensitivity and specificity using regression models adjusting for repeated measures. RESULTS: CAD assistance did not affect overall sensitivity (cancer by 1 year: 63.2% without CAD and 62.0% with CAD; cancer in 13-24 months: 33.5% without CAD and 32.3% with CAD), but its effect differed for visible masses that were marked by CAD compared with those that were not marked by CAD (hereafter referred to as "unmarked"). CAD was associated with improved sensitivity for marked visible cancers and decreased sensitivity for unmarked visible masses; the sensitivities without and with CAD, respectively, were as follows: marked cancer by 1 year, 82.7% versus 83.1%; marked cancer in 13-24 months, 44.2% versus 57.9%; unmarked cancer by 1 year, 37.4% versus 30.1%; unmarked cancer in 13-24 months, 29.7% versus 23.0% (p < 0.03 for both interactions between assistance and CAD marking for cancer by 1 year and cancer in 13-24 months). CAD marked 77% (70/91) of the visible cancers by 1 year and 67.3% (37/55) of the visible cancers in 13-24 months. CAD marked more visible calcified lesions (86%) than masses and asymmetric densities (67%) (p < 0.05). Overall specificity was 72% without and 75% with CAD (p < 0.02). CAD had a greater effect on both specificity (p < 0.02) and sensitivity (p < 0.03) among radiologists who interpret more than 50 mammograms per week. The results were the same for fatty breast tissue and dense breast tissue. CONCLUSION: In this experiment, CAD increased interpretive specificity but did not affect sensitivity because visible noncalcified lesions that went unmarked by CAD were less likely to be assessed as abnormal by radiologists. Breast density did not affect CAD's performance.

Breast↗
PubMed2005

Explaining black-white differences in receipt of recommended colon cancer treatment.

BACKGROUND: Black-white disparities exist in receipt of recommended medical care, including colorectal cancer treatment. This retrospective cohort study examines the degree to which health systems (e.g., physician, hospital) factors explain black-white disparities in colon cancer care. METHODS: Data from the Surveillance, Epidemiology, and End Results program; Medicare claims; the American Medical Association Masterfile; and hospital surveys were linked to examine chemotherapy receipt after stage III colon cancer resection among 5294 elderly (> or = 66 years of age) black and white Medicare-insured patients. Logistic regression analysis was used to identify factors associated with black-white differences in chemotherapy use. All statistical tests were two-sided. RESULTS: Black and white patients were equally likely to consult with a medical oncologist, but among patients who had such a consultation, black patients were less likely than white patients (59.3% versus 70.4%, difference = 10.9%, 95% confidence interval [CI] = 5.1% to 16.4%, P < .001) to receive chemotherapy. This black-white disparity was highest among patients aged 66-70 years (black patients 65.7%, white patients 86.3%, difference = 20.6%, 95% CI = 10.7% to 30.4%, P < .001) and decreased with age. The disparity among patients aged 66-70 years also remained statistically significant in the regression analysis. Overall, patient, physician, hospital, and environmental factors accounted for approximately 50% of the disparity in chemotherapy receipt among patients aged 66-70 years; surgical length of stay and neighborhood socioeconomic status accounted for approximately 27% of the disparity in this age group, and health systems factors accounted for 12%. CONCLUSIONS: Black and white Medicare-insured colon cancer patients have an equal opportunity to learn about adjuvant chemotherapy from a medical oncologist but do not receive chemotherapy equally. Little disparity was explained by health systems; more was explained by illness severity, social support, and environment. Further qualitative research is needed to understand the factors that influence the lower receipt of chemotherapy by black patients.

Black or African American↗
PubMed2005

Cervical cancer in women with comprehensive health care access: attributable factors in the screening process.

BACKGROUND: Invasive cervical cancer is highly preventable, yet it continues to occur, even among women who have access to cancer screening and treatment services. To reduce cervical cancer among such women, reasons for its occurrence must be better understood. We examined factors associated with the diagnosis of cervical cancer among women enrolled in health plans. METHODS: We identified all cases of invasive cervical cancer (n = 833) diagnosed from January 1, 1995, through December 31, 2000, among women who were long-term members of seven prepaid comprehensive health plans and reviewed each woman's medical records for the 3 years prior to her cancer diagnosis. Women were classified into one of three categories based on Pap test histories 4-36 months before diagnosis: failure to screen with a Pap test, failure in detection by a Pap test, or failure in follow-up of an abnormal test result. RESULTS: The majority of cases (n = 464; 56%) were in women who had no Pap tests during the period 4-36 months prior to diagnosis. Of the remaining cases, 263 (32%) were attributed to Pap test detection failure and 106 (13%) to follow-up failure. Being older (odds ratio [OR] = 6.48, 95% confidence interval [CI] = 3.89 to 10.79) or living in an area of higher poverty (OR = 1.72, 95% CI = 1.11 to 2.67) or having a lower education level (OR= 1.52; 95% CI = 1.07 to 2.16) was associated with the likelihood of being assigned to the failure to screen category versus either of the other two categories. A total of 375 (81%) of the 464 patients who had not had Pap screening had had at least one outpatient visit 4-36 months prior to cancer diagnosis. The cancer diagnostic process was triggered by a routine screening examination in 44% of patients, whereas 53% of the patients presented with symptoms consistent with cervical cancer; the remaining 3% were identified fortuitously during the course of receiving noncervical care. CONCLUSIONS: To reduce the incidence of invasive cervical cancer among women with access to screening and treatment, Pap screening adherence should be increased. In addition, strategies to improve the accuracy of Pap screening could afford earlier detection of cervical cancer.

Adult↗
PubMed2005

Current realities of delivering mammography services in the community: do challenges with staffing and scheduling exist?

PURPOSE: To evaluate the current (2001-2002) capacity of community-based mammography facilities to deliver screening and diagnostic services in the United States. MATERIALS AND METHODS: Institutional review board approvals and patient consent were obtained. A mailed survey was sent to 53 eligible mammography facilities in three states (Washington, New Hampshire, and Colorado). Survey questions assessed equipment and staffing availability, as well as appointment waiting times for screening and diagnostic mammography services. Criterion-related content and construct validity were obtained first by means of a national advisory committee of academic, scientific, and clinical colleagues in mammography that reviewed literature on existing surveys and second by pilot testing a series of draft surveys among community mammography facilities not inclusive of the study facilities. The final survey results were independently double entered into a relational database with programmed data checks. The data were sent encrypted by means of file transfer protocol to a central analytical center at Group Health Cooperative. A two-sided P value with alpha = .05 was considered to show statistical significance in all analyses. RESULTS: Forty-five of 53 eligible mammography facilities (85%) returned the survey. Shortages of radiologists relative to the mammographic volume were found in 44% of mammography facilities overall, with shortages of radiologists higher in not-for-profit versus for-profit facilities (60% vs 28% reported). Shortages of Mammography Quality Standards Act-qualified technologists were reported by 20% of facilities, with 46% reporting some level of difficulty in maintaining qualified technologists. Waiting times for diagnostic mammography ranged from less than 1 week to 4 weeks, with 85% performed within 1 week. Waiting times for screening mammography ranged from less than 1 week to 8 weeks, with 59% performed between 1 week and 4 weeks. Waiting times for both diagnostic and screening services were two to three times higher in high-volume compared with low-volume facilities. CONCLUSION: Survey results show shortages of radiologists and certified mammography technologists.

Breast Neoplasms↗
PubMed2005

Previous pregnancy outcome and breast density (United States).

OBJECTIVE: We evaluated the association of pre-term delivery (PTD), low birth weight (LBW), and fetal death with breast density by age at mammogram and years since birth. METHODS: Subjects were women aged < or =55 years who had a screening mammogram between 1 June 1996 and 1 August 1997 in Seattle, Washington, and whose records were linked to their previous state birth (1 January 1968 to 1 August 1997) or fetal death (1/1/1984-8/1/1997) records. We used unconditional logistic regression, adjusting for age at mammogram, body mass index, age at first birth, and menopausal status, to calculate the odds of dense (extremely or heterogeneously dense by BI-RADS) (n=3593) versus fatty breasts (scattered fibroglandular tissue or almost entirely fat) (n=2378) for women with a prior PTD (< 34, 34-36 versus > or =37 weeks gestation), LBW (< 2500 versus > or =2500 g), or fetal death (stillborn 20 weeks gestation versus live birth). RESULTS: The odds for denser breasts increased among women with PTD at <34 weeks gestation who were < or =45 years at time of mammogram (odds ratio (OR) and 95 confidence interval (CI)=2.8 (1.3-6.1)) and for whom <10 years had elapsed since pregnancy (OR=8.8 (1.7-45.8)). We observed similar increases in density among women with LBW (OR=3.3 (1.3-8.2)) when <10 years had elapsed. CONCLUSIONS: PTD and LBW may have a transitory effect on breast density.

Adult↗
PubMed2005

Building a research consortium of large health systems: the Cancer Research Network.

Critical questions about cancer prevention, care, and outcomes increasingly require research involving large patient populations and their care delivery organizations. The Cancer Research Network (CRN) includes 11 integrated health systems funded by the National Cancer Institute (NCI) to conduct collaborative cancer research. This article describes the challenges of constructing a productive consortium of large health systems, and explores the CRN's responses. The CRN was initially funded through an NCI cooperative agreement in 1999 and has since received a second 4-year grant. Leadership and policy development are provided through a steering committee, subcommittees, and an external advisory committee. The CRN includes integral and affiliated research projects supported by a Scientific and Data Resources Core. Three characteristics of the CRN intensified the general challenges of consortium research: 1) its members are large health systems with legitimate concerns about confidentiality of data about enrollees, providers, and the organization; 2) CRN research projects often generate highly sensitive data about quality of care; and therefore 3) each participating organization wants a strong voice in CRN direction. CRN experience to date confirms that a consortium of health systems with internal research capacity can address a range of important cancer research questions that would be difficult to study in other venues. The advantages and challenges of consortium research are explored, with suggestions for the development, execution, and management of multisystem population laboratories.

Biomedical Research↗
PubMed2005

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

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

Aged↗
PubMed2005

Association between mammography timing and measures of screening performance in the United States.

PURPOSE: To evaluate whether there is an association between the number of months since previous mammography (MSPM) and performance measures (sensitivity, specificity, recall rate, cancer detection rate, and positive predictive value) in women who underwent U.S. community-based screening mammography. MATERIALS AND METHODS: Data from seven registries (Breast Cancer Surveillance Consortium) and mammographic data and cancer outcome in regard to 1 213 754 screening mammographic examinations performed in 680 641 women who were 40-89 years old for the years 1996-2000 were used in this study. These data are submitted annually in a standard format to a central statistical coordinating center that is subject to institutional review board approval, quality control, and confidentiality standards. Performance measures were calculated for first and subsequent screening mammography. For subsequent mammography, performance measures were calculated according to categories of MSPM (9-15, 16-20, 21-27, and >/=28 months). Receiver operating characteristic and multivariable logistic regression analyses were conducted to test the association between the number of MSPM and performance measures. RESULTS: With increasing MSPM in each category from 9-15 to 28 months or more and for first mammographic examinations, respectively, there was increased sensitivity (70.9%, 75.7%, 85.4%, 82.5%, and 88.6%), decreased specificity (93.3%, 92.7%, 91.6%, 91.0%, and 85.9%), increased recall rate (7.0%, 7.6%, 8.8%, 9.4%, and 14.7%), and increased cancer detection rates (3.2, 3.5, 4.5, 4.6, and 6.1 per 1000 mammographic examinations). When the category of 9-15 MSPM was compared with that of 21-27 MSPM, there was a slight increase in positive predictive value from 4.6% to 5.1%. Confidence intervals were narrow and did not overlap. Age affected these associations for all performance measures except sensitivity. CONCLUSION: Performance measures increased as MSPM increased, except for specificity, which decreased. Time between mammograms is an important factor to consider when audits are reviewed or screening performance measures are compared.

Adult↗
PubMed2005

Does litigation influence medical practice? The influence of community radiologists' medical malpractice perceptions and experience on screening mammography.

PURPOSE: To assess the relationship between radiologists' perception of and experience with medical malpractice and their patient-recall rates in actual community-based clinical settings. MATERIALS AND METHODS: All study activities were approved by the institutional review boards of the involved institutions, and patient and radiologist informed consent was obtained where necessary. This study was performed in three regions of the United States (Washington, Colorado, and New Hampshire). Radiologists who routinely interpret mammograms completed a mailed survey that included questions on demographic data, practice environment, and medical malpractice. Survey responses were linked to interpretive performance for all screening mammography examinations performed between January 1, 1996, and December 31, 2001. The odds of recall were modeled by using logistic regression analysis based on generalized estimating equations that adjust for study region. RESULTS: Of 181 eligible radiologists, 139 (76.8%) returned the survey with full consent. The analysis included 124 radiologists who had interpreted a total of 557 143 screening mammograms. Approximately half (64 of 122 [52.4%]) of the radiologists reported a prior malpractice claim, with 18 (14.8%) reporting mammography-related claims. The majority (n = 51 [81.0%]) of the 63 radiologists who responded to a question regarding the degree of stress caused by a medical malpractice claim described the experience as very or extremely stressful. More than three of every four radiologists (ie, 94 [76.4%] of 123) expressed concern about the impact medical malpractice has on mammography practice, with over half (72 [58.5%] of 123) indicating that their concern moderately to greatly increased the number of their recommendations for breast biopsies. Radiologists' estimates of their future malpractice risk were substantially higher than the actual historical risk. Almost one of every three radiologists (43 of 122 [35.3%]) had considered withdrawing from mammogram interpretation because of malpractice concerns. No significant association was found between recall rates and radiologists' experiences or perceptions of medical malpractice. CONCLUSION: U.S. radiologists are extremely concerned about medical malpractice and report that this concern affects their recall rates and biopsy recommendations. However, medical malpractice experience and concerns were not associated with recall or false-positive rates. Heightened concern of almost all radiologists may be a key reason that recall rates are higher in the United States than in other countries, but this hypothesis requires further study.

Adult↗
PubMed2005

Community-based mammography practice: services, charges, and interpretation methods.

OBJECTIVE: The purpose of our study was to accurately describe facility characteristics among community-based screening and diagnostic mammography practices in the United States. MATERIALS AND METHODS: A survey was developed and applied to community-based facilities providing screening mammography in three geographically distinct locations in the states of Washington, Colorado, and New Hampshire. The facility survey was conducted between December 2001 and September 2002. Characteristics surveyed included facility type, services offered, charges for screening and diagnostic mammography, information systems, and interpretation methods, including the frequency of double interpretation. RESULTS: Among 45 responding facilities, services offered included screening mammography at all facilities, diagnostic mammography at 34 facilities (76%), breast sonography at 30 (67%), breast MRI at seven (16%), and nuclear medicine breast scanning at seven (16%). Most facilities surveyed were radiology practices in nonhospital settings. Eight facilities (18%) reported performing clinical breast examinations routinely along with screening mammography. Only five screening sites (11%) used computer-aided detection (CAD) and only two (5%) used digital mammography. Nearly two thirds of facilities interpreted screening mammography examinations on-site, whereas 91% of facilities interpreted diagnostic examinations on-site. Only three facilities (7%) interpreted screening examinations on line as they were performed. Approximately half of facilities reported using some type of double interpretation, although the methods of double interpretation and the fraction of cases double-interpreted varied widely across facilities. On average, approximately 15% of screening examinations and 10% of diagnostic examinations were reported as being double-interpreted. CONCLUSION: Comparison of this survey's results with those collected a decade earlier indicates dramatic changes in the practice of mammography, including a clear distinction between screening and diagnostic mammography, batch interpretation of screening mammograms, and improved quality assurance and medical audit tools. Diffusion of new technologies such as CAD and digital mammography was not widespread. The methods of double-interpretation and the fraction of cases double-interpreted varied widely across study sites.

Breast Neoplasms↗
PubMed2004

Accuracy of screening mammography interpretation by characteristics of radiologists.

BACKGROUND: Radiologists differ in their ability to interpret screening mammograms accurately. We investigated the relationship of radiologist characteristics to actual performance from 1996 to 2001. METHODS: Screening mammograms (n = 469,512) interpreted by 124 radiologists were linked to cancer outcome data. The radiologists completed a survey that included questions on demographics, malpractice concerns, years of experience interpreting mammograms, and the number of mammograms read annually. We used receiver operating characteristics (ROC) analysis to analyze variables associated with sensitivity, specificity, and the combination of the two, adjusting for patient variables that affect performance. All P values are two-sided. RESULTS: Within 1 year of the mammogram, 2402 breast cancers were identified. Relative to low annual interpretive volume (< or =1000 mammograms), greater interpretive volume was associated with higher sensitivity (P = .001; odds ratio [OR] for moderate volume [1001-2000] = 1.68, 95% CI = 1.18 to 2.39; OR for high volume [>2000] = 1.89, 95% CI = 1.36 to 2.63). Specificity decreased with volume (OR for 1001-2000 = 0.65, 95% CI = 0.52 to 0.83; OR for more than 2000 = 0.76, 95% CI = 0.60 to 0.96), compared with 1000 or less (P = .002). Greater number of years of experience interpreting mammograms was associated with lower sensitivity (P = .001), but higher specificity (P = .003). ROC analysis using the ordinal BI-RADS interpretation showed an association between accuracy and both previous mammographic history (P = .012) and breast density (P<.001). No association was observed between accuracy and years interpreting mammograms (P = .34) or mammography volume (P = .94), after adjusting for variables that affect the threshold for calling a mammogram positive. CONCLUSIONS: We found no evidence that greater volume or experience at interpreting mammograms is associated with better performance. However, they may affect sensitivity and specificity, possibly by determining the threshold for calling a mammogram positive. Increasing volume requirements is unlikely to improve overall mammography performance.

Adult↗
PubMed2004

Biennial versus annual mammography and the risk of late-stage breast cancer.

BACKGROUND: Mammography screening may reduce breast cancer mortality by detecting cancers at an earlier stage. However, certain questions remain, including the ideal interval between mammograms. METHODS: We conducted an observational study using information collected by seven mammography registries across the United States to investigate whether women diagnosed with breast cancer after having screening mammograms separated by a 2-year interval (n = 2440) are more likely to be diagnosed with late-stage disease (positive lymph nodes or metastases) than women diagnosed with breast cancer after having screening mammograms separated by a 1-year interval (n = 5400). Analyses were stratified by age and breast density to clarify whether groups that have the poorest mammography sensitivity (i.e., women under age 50 years and those with mammographically dense breasts) would benefit most from annual screening. The subjects were women diagnosed with breast cancer between 1996 and 2001 who were 40-89 years old at their index mammographic examination (i.e., the most recent screen at or before breast cancer diagnosis). Data were analyzed by logistic regression, adjusting for race, ethnicity, family history of breast cancer, and mammography registry. RESULTS: Among women age 40-49 years at the index mammogram, those with a 2-year screening interval were more likely to have late-stage disease at diagnosis than those with a 1-year screening interval (28% versus 21%; odds ratio [OR] = 1.35, 95% confidence interval [CI] = 1.01 to 1.81). There was no increase in late-stage disease for women 50 years or older with a 2-year versus a 1-year screening interval (women age 50-59 years at index mammogram: OR = 0.97, 95% CI = 0.75 to 1.25; women age 60-69 years at index mammogram: OR = 0.99, 95% CI = 0.72 to 1.35; women age 70 years or older at index mammogram: OR = 0.88, 95% CI = 0.64 to 1.19). There was no indication that women with dense breasts would benefit more from a 1-year versus 2-year screening interval than women with fatty breasts. CONCLUSION: These findings may be useful for policy decisions about appropriate screening intervals and for use in statistical models that estimate the costs and benefits of mammography by age and screening interval.

Adult↗
PubMed2004

The relationship between breast density and bone mineral density in postmenopausal women.

BACKGROUND: It is not well understood whether breast density is a marker of cumulative exposure to estrogen or a marker of recent exposure to estrogen. The authors examined the relationship between bone mineral density (BMD; a marker of lifetime estrogen exposure) and breast density. METHODS: The authors conducted a cross-sectional analysis among 1800 postmenopausal women > or = 54 years. BMD data were taken from two population-based studies conducted in 1992-1993 (n = 1055) and in 1998-1999 (n = 753). The authors linked BMD data with breast density information collected as part of a mammography screening program. They used linear regression to evaluate the density relationship, adjusted for age, hormone therapy use, body mass index (BMI), and reproductive covariates. RESULTS: There was a small but significant negative association between BMD and breast density. The negative correlation between density measures was not explained by hormone therapy or age, and BMI was the only covariate that notably influenced the relationship. Stratification by BMI only revealed the negative correlation between bone and breast densities in women with normal BMI. There was no relationship in overweight or obese women. The same relationship was seen for all women who had never used hormone therapy, but it was not significant once stratified by BMI. CONCLUSIONS: BMD and breast density were not positively associated although both are independently associated with estrogen exposure. It is likely that unique organ responses obscure the relationship between the two as indicators of cumulative estrogen exposure.

Aged↗
PubMed2004

Reason for late-stage breast cancer: absence of screening or detection, or breakdown in follow-up?

BACKGROUND: Mammography screening increases the detection of early-stage breast cancers. Therefore, implementing screening should reduce the percentage of women who are diagnosed with late-stage disease. However, despite high national mammography screening rates, late-stage breast cancers still occur, possibly because of failures in screening implementation. METHODS: Using data from seven health care plans that included 1.5 million women aged 50 years or older, we conducted retrospective reviews of chart and automated data for 3 years before 1995-1999 diagnoses of late-stage (metastatic and/or tumor size > or =3 cm; case subjects, n = 1347) and early-stage breast cancers (control subjects, n = 1347). We categorized the earliest screening mammogram during the period 13-36 months before diagnosis as none (absence of screening), negative (absence of detection), or positive (potential breakdown in follow-up). We compared the proportion of case and control subjects in each category of screening implementation and estimated the likelihood (odds ratio [OR] with 95% confidence intervals [CIs]) of late-stage breast cancer. We also evaluated demographic characteristics associated with absence of screening in women with late-stage disease. All statistical tests were two-sided. RESULTS: Absence of screening, absence of detection, and potential breakdown in follow-up were distributed differently among case (52.1%, 39.5%, and 8.4%, respectively) and control subjects (34.4%, 56.9%, and 8.8%, respectively) (P = .03). Among all women, the odds of having late-stage cancer were higher among women with an absence of screening (OR = 2.17, 95% CI = 1.84 to 2.56; P<.001). Among case patients, women were more likely to be in the absence-of-screening group if they were aged 75 years or older (OR = 2.77, 95% CI = 2.10 to 3.65), unmarried (OR = 1.78, 95% CI = 1.41 to 2.24), or without a family history of breast cancer (OR = 1.84, 95% CI = 1.45 to 2.34). A higher proportion of women from census blocks with less education (58.5% versus 49.4%; P = .003) or lower median annual income (54.4% versus 42.9%; P = .004) were in the absence-of-screening category compared with the proportion for the other two categories combined. CONCLUSIONS: To reduce late-stage breast cancer occurrence, reaching unscreened women, including elderly, unmarried, low-income, and less educated women, should be made a top priority for screening implementation.

Age Factors↗
PubMed2004

Factors contributing to mammography failure in women aged 40-49 years.

BACKGROUND: Younger women (40-49 years) have lower mammographic sensitivity (i.e., greater proportion of cancers detected after a negative mammogram) than older women (> or =50 years). We explored the effect of tumor growth rate, breast density, mammographic image quality, and breast cancer risk factors on mammographic sensitivity in younger and older women. METHODS: We studied 576 women (n = 73 aged 40-49 years and n = 503 aged 50 years or older) who were diagnosed with invasive breast cancer between 1988 and 1993. Interval cancers were defined as those diagnosed within 12 or 24 months after a negative screening mammogram and before a subsequent mammogram. Tumor growth rate was assessed by mitotic figure count and Ki-67 positivity. The main outcome measures were percentage of women with interval cancer (1 -mammographic sensitivity) by age, odds ratio (OR) of interval cancer by age, and excess odds (i.e., the percentage of the odds ratio for age that was explained by individual covariates). RESULTS: Interval cancers occurred in 27.7% of younger women and 13.9% of older women within 12 months (OR = 2.36, 95% confidence interval [CI] = 1.14 to 4.77) and in 52.1% of younger women and 24.7% of older women within 24 months (OR = 3.58, 95% CI = 2.15 to 5.97). Greater breast density explained 67.6% of the decreased mammographic sensitivity in younger women at 12 months, whereas rapid tumor growth explained 30.6% and breast density explained 37.6% of the decreased sensitivity in younger women at 24 months. CONCLUSIONS: Breast density largely explained decreased mammographic sensitivity at 12 months, whereas rapid tumor growth contributed to decreased mammographic sensitivity at 24 months. A 12-month versus a 24-month mammography screening interval may therefore reduce the adverse impact of faster growing tumors on mammographic sensitivity in younger women.

Adult↗
PubMed2004

The association between obesity and screening mammography accuracy.

BACKGROUND: Obesity is increasing among American women, especially as they age. The influence of obesity on the accuracy of screening mammography has not been studied extensively. METHODS: We analyzed 100 622 screening mammography examinations performed on members of a nonprofit health plan. The relationship between body mass index (weight in kilograms divided by the square of height in meters) and measures of screening accuracy was assessed. Body mass index was categorized as underweight or normal weight (<25), overweight (25-29), obesity class I (30-34), and obesity classes II to III (> or =35). RESULTS: Compared with underweight or normal weight women, overweight and obese women were more likely to be recalled for additional tests after adjusting for important covariates, including age and breast density (overweight odds ratio [OR], 1.17; 95% confidence interval [CI], 1.11-1.23); obesity class I OR, 1.27; 95% CI, 1.19-1.35; obesity classes II-III OR, 1.31; 95% CI, 1.22-1.41). As body mass index increased, women were more likely to have lower specificity (overweight OR, 0.86; 95% CI, 0.81-0.90; obesity class I OR, 0.79; 95% CI, 0.74-0.84; and obesity classes II-III OR, 0.77; 95% CI, 0.71-0.82). No statistically significant differences were noted in sensitivity. Adjusted receiver operating characteristic analysis showed statistically significant improvement in the area under the curve (AUC) for underweight or normal weight women (AUC = 0.941) vs overweight women (AUC = 0.916, P =.02) and underweight or normal weight women vs obesity classes II and III women (AUC = 0.904, P =.02). CONCLUSIONS: Obese women had more than a 20% increased risk of having false-positive mammography results compared with underweight and normal weight women, although sensitivity was unchanged. Achieving a normal weight may improve screening mammography performance.

Adult↗