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Introducing screening for prostate cancer requires evidence that this would do more good than harm. Current evidence about the impact and natural history of prostate cancer, screening and diagnostic tests, and the effectiveness of treatments is reviewed below.
OBJECTIVES: The purpose of this study was to determine whether referral to a primary physician led to an increase in screening for cervical cancer among women enrolled in Delaware Medicaid. METHODS: Medicaid claims data were used to compare annual Papanicolaou (Pap) test rates for women referred to a primary care physician or obstetrician (n = 365) with rates for age-matched comparison women who were not referred (n = 1799). RESULTS: Thirty-eight percent of referred women and 27% of comparison women underwent Pap tests (adjusted odds ratio = 1.71; 95% confidence interval = 1.33, 2.20). CONCLUSIONS: Referral to a primary physician had a positive impact on cervical cancer screening among the study participants.
This article reviews screening for breast cancer in older women from the perspective of the primary care physician. Although breast cancer is a leading cause of cancer in women, the diagnosis of breast cancer in an asymptomatic woman is an uncommon occurrence for the individual physician. Physician compliance with breast cancer screening recommendations is less than optimum: physicians report higher compliance in survey studies than is demonstrated by performance audits. The low yield of screening, cost concerns, concerns about the reliability of radiology reports, concerns about patient compliance, lack of time, and forgetfulness are reasons cited for poor provider compliance with screening recommendations. In general there is no reason not to recommend mammography for older women unless individual factors including biologic age, life expectancy, comorbidities, or patient preference appear to make screening not worthwhile. The decision to stop recommending mammography for an older woman should be made in conjunction with the patient.
Studies have suggested that women with low incomes residing in metropolitan areas might be less likely to be screened for breast cancer than more affluent women residing in the same areas. However, few studies have examined the associations between breast cancer screening and both individual and area-based measures of socioeconomic status (SES) among women in metropolitan areas. To examine these associations, CDC analyzed the percentage of women who had a mammogram by using individual data (i.e., household income and education level) from the 2000 and 2002 Behavioral Risk Factor Surveillance System (BRFSS) surveys and area-based data (i.e., percentages classified as living in poverty or at a low education level) from the 2000 U.S. Census. This report summarizes the results of those analyses, which suggested that, among women in 35 metropolitan statistical areas (MSAs), those with annual household incomes of <15,000 dollars were less likely to have had a mammogram than more affluent women (especially in areas where a greater proportion of women were affluent) and those without a high school education were less likely to have had a mammogram than women with more education (especially in areas where a greater proportion of women had higher education levels). Studies are needed to determine how to increase the percentage of women having mammograms among women in low-income and low-education populations.
PURPOSE: To clarify whether the benefit of a reduced effective scan width obtained using a smaller pitch outweighs the disadvantage of increased noise in the application of a subsecond helical CT to mass screenings for lung cancer. MATERIALS AND METHODS: Twenty-two helical CT scans of the lung were obtained in 11 healthy subjects using the following parameters: 1) scan 1 was performed at 120 kVp, 50 mA, 10-mm collimation, 1-second/rotation, helical pitch of 2.0; and 2) scan 2 was performed at 120 kVp, 50 mA, 10-mm collimation, 0.75-second/rotation, helical pitch of 1.5. Computer-generated nodules measuring 10 mm and 6 mm in diameter showing ground-glass opacity were superimposed on these images. The detectability of each nodule was evaluated by six blinded readers using ROC analysis. RESULTS: Detectability of the 6-mm nodules was significantly higher in scan 2 than in scan 1. Detectability of the 10-mm nodules was not significantly different between scans 1 and 2. CONCLUSION: The use of a smaller pitch by employing a subsecond rotation scan in a helical CT for lung cancer screenings improves the detection of small lesions without increasing either the scanning time or radiation dose.
BACKGROUND: The identification of effective strategies for the prevention, diagnosis, and treatment of cancer is a high priority for the nation, yet relatively little is known about how cancer is diagnosed in primary care. This study was undertaken to describe practitioner beliefs about cancer screening and to determine whether beliefs and intentions about cancer screening are associated with actual cancer detection rates among asymptomatic patients cared for by family physicians. METHODS: A self-administered questionnaire on cancer screening beliefs and practices was completed by members of the Michigan Research Network (MIRNET) in January 1990 and again in December of 1990. Thirty-one practitioners prospectively identified all patients with a new diagnosis of cancer during 1990. RESULTS: One hundred sixteen cancer cases were identified. Only 31% of the 77 cancers considered to be potentially detectable by routine screening were actually identified by screening. Physicians reporting more aggressive screening practices identified greater percentages of asymptomatic cancers and a greater number of breast and colon cancers. CONCLUSIONS: Low percentages of cancers were detected in asymptomatic patients in this population. Practitioner attitudes about the need for cancer screening appear to be an important component of cancer detection.
BACKGROUND: Rural residence, access to healthcare facilities, and multiple roles of farmwomen may pose barriers to cervical cancer screening among women living in southern farm states. OBJECTIVES: To compare the proportion of women failing to obtain cervical cancer screening in three Southern states to state-level Behavioral Risk Factor Surveillance System (BRFSS) data and to identify factors contributing to cervical cancer screening and detection behaviors. METHODS: A cross-sectional study design was used. Data were collected using several Farm Family Health and Injury Prevention surveys via telephone interviews in three southern states. Farmwomen (N = 2,324) from three states comprised the sample on Pap testing. Data were used from summary reports of the BRFSS for each state to compare the proportion of farmwomen >or=18 years of age who had failed to obtain a Pap test within the past 3 years to failure to obtain Pap tests statewide. Multiple logistic regression analyses were conducted to examine the predictors of failure to obtain early screening. RESULTS: Pap testing did not meet Healthy People 2010 target goal of 90%. Farm lifestyle predicting failure to obtain cervical cancer screening included having a house on the farm and engaging in no off-farm work and minimal involvement in farm tasks. The risk of failing to obtain Pap testing increased with age and decreased with education. The only health access variable contributing to failure to obtain Pap testing was women with no insurance. Positive preventive risk factors contributing to compliance with up-to-date status were previous mammogram and previous breast exam. Being married was a positive risk factor. DISCUSSION: Although the failure to obtain Pap testing in Texas was comparable to state BRFSS rates, failure to obtain Pap testing rates in Kentucky and Louisiana were at least 6% greater for farmwomen than women living in the state. Farmwomen, a subgroup of the rural population, have unique barriers to obtaining screening services. Geographical isolation and minimal role involvement on the farm may contribute to the likelihood that women are not seeking cervical cancer screening.
UNLABELLED: OBJECTIVES The study tested a behavioral and structural barriers model of breast cancer screening, while seeking to determine age effects of behavioral barriers, in order to identify the factors that inhibit screening among older, minority women. METHODS: 405 older African-American women eligible for a federally funded cancer screening program were enrolled in the study. Participants were administered an intake questionnaire and followed for 3 months to determine mammography use. RESULTS: Three months after enrollment in the program, 79% had not received breast cancer screening. The oldest cohort had significantly lower rates of mammography (just 16% of screened women were > or = 60, p<0.05). Behavioral barriers (knowledge/information deficits, cancer risk perception, cancer fears) inhibited mammography in the oldest group; their breast cancer information deficits included less knowledge of breast cancer risk, treatment, and survivability (all p<0.001). CONCLUSIONS: Older women, with greater breast cancer risk than younger cohorts, should be targeted as a high need population for cancer screening. Even when financial and insurance barriers are removed mammography rates are 1/3 those of women <50. Since failure to be screened is related to knowledge and information barriers, health care providers have the potential to educate their older patients and subsequently increase the likelihood they will have regular cancer screening.
CHEK2, a serine-threonine kinase, is activated in response to agents, such as ionizing radiation, which induce DNA double-strand breaks. Activation of CHEK2 can result in cell cycle checkpoint arrest or apoptosis. One specific variant, CHEK2*1100delC, has been associated with an increased risk of breast cancer. In this population-based study, we screened 2,311 female breast cancer cases and 496 general population controls enrolled in the Ontario and Northern California Breast Cancer Family Registries for this variant (all controls were Canadian). Overall, 30 cases and one control carried the 1100delC allele. In Ontario, the weighted mutation carrier frequency among cases and controls was 1.34% and 0.20%, respectively [odds ratio (OR), 6.65; 95% confidence interval (95% CI), 2.37-18.68]. In California, the weighted population mutation carrier frequency in cases was 0.40%. Across all cases, 1 of 524 non-Caucasians (0.19%) and 29 of 1,775 Caucasians (1.63%) were mutation carriers (OR, 0.12; 95% CI, 0.02-0.89). Among Caucasian cases >45 years age at diagnosis, carrier status was associated with history of benign breast disease (OR, 3.18; 95% CI, 1.30-7.80) and exposure to diagnostic ionizing radiation (excluding mammography; OR, 3.21; 95% CI, 1.13-9.14); compared with women without exposure to ionizing radiation, the association was strongest among women exposed >15 years before diagnosis (OR, 4.28; 95% CI, 1.50-12.20) and among those who received two or more chest X-rays (OR, 3.63; 95% CI, 1.25-10.52). These data supporting the biological relevance of CHEK2 in breast carcinogenesis suggest that further studies examining the joint roles of CHEK2*1100delC carrier status and radiation exposure may be warranted.
The costs and benefits of breast cancer screening can be placed in the framework usually used for sensitivity and specificity. All those screened incur the costs associated with the test. In addition, only the segment of the true positives who, in the absence of screening, would die of their disease but with screening will survive to die of another cause truly benefit; all other true positives acquire lead time without benefit. In the Canadian National Breast Screening Study, simpler treatment of screen-detected cancer was not achieved. The true negatives benefited from reassurance, but the majority were not at risk of breast cancer anyway. The false negatives were disadvantaged from false reassurance, but in practice the percentage is low, and the consequences are not dire. There are major costs associated with the false positive state, including anxiety, unnecessary biopsies, and residual scarring; major endeavors are justified to reduce them and improve the specificity of screening. In practice, with no benefit demonstrated for women 40-49 years of age, the costs are too great to justify continuation of screening this age group merely in the hope that benefits will eventually be demonstrated. For women older than 50, the degree of benefit may have been overestimated, especially in an era when improvements in therapy affect screen-detected and nonscreen-detected cases alike. We may have overestimated the benefit-cost ratio of screening this age group also; thus, careful monitoring of the outcome of ongoing programs over the next few years is essential.
OBJECTIVE: To examine factors affecting cervical cancer screening behaviors. DESIGN: Qualitative, descriptive. SETTING: Interviews were conducted in participants' homes. PARTICIPANTS: Purposive sample of 20 Hispanic women 18 to 65 years of age. RESULTS: Participants accessed the health care system primarily during times of illness or in association with impending marriage, obtaining birth control, or childbearing. Barriers to screening participation included personal/cultural and provider/ system factors. Motivators included personal experience with others having cervical cancer, perceived importance of the Pap smear in maintaining health, reduction of financial barriers, and access to culturally appropriate health care. CONCLUSIONS: Factors affecting cervical cancer screening behavior among Hispanic women are identifiable and describable. Knowledge of barriers and motivators can be utilized to design effective nursing interventions and community-based programs.
BACKGROUND: Decision aids are currently being developed and evaluated for use in cancer-screening decisional settings. PURPOSE: The purpose of this article is to review and discuss the theoretical basis of interventions to promote informed decision making in cancer screening. METHODS: We reviewed interventions cited in Briss et al. and Rimer et al. to identify their theoretical basis, intervention content, measurement strategies, and outcomes. RESULTS: Few interventions had a strong, decision-oriented conceptual basis. This was apparent in their intervention content, the measurement strategy, and the choice of outcomes for the study. CONCLUSIONS: We recommend that more research occur into the basis of decision making in cancer screening and that future interventions use this research to rigorously design and evaluate decision aids to help people make choices about cancer screening.
PURPOSE: The purpose of this report is to educate healthcare professionals about the legal risks of conducting cancer screening examinations and necessary risk reduction practices. OVERVIEW: The authors describe the elements of a medical malpractice claim, the healthcare professionals' legal standard of care, theories of malpractice liability, common factors related to missed or delayed diagnoses, malpractice defenses, and risk reduction practices. CLINICAL IMPLICATIONS: Healthcare professionals, including physicians, physician assistants, advanced practice nurses, and social workers, have been shown to be clinically effective in cancer screening, and early detection of many cancers leads to improved long-term survival rates. Healthcare professionals who conduct cancer early detection examinations and counsel patients in cancer screening programs need to be aware of the common legal theories under which lawsuits are brought related to cancer detection examinations. Important steps in reducing the risk of malpractice include developing creative strategies to address the theories of liability in the area of cancer screening and early detection; keeping abreast of changes in national and international cancer screening recommendations; monitoring the literature for approaches to decrease liability; and scrupulously maintaining documentation of all findings and interactions among providers and between providers and patients.
BACKGROUND: Few African American men participate in prostate cancer screening, although they have higher prostate cancer incidence and mortality rates. METHODS: This study documents the benefits of two educational methods; the peer-educator method and the client-navigator method, in increasing their participation. RESULTS: Sixty-one percent of the 1,211 African American men who received an educational program on prostate cancer participated in the free prostate cancer screening. Men who received the peer-educator method intervention, which included a testimony in support of prostate cancer screening given by an African American man, were more likely to participate, p = 0.04, than were men who received a standard educational program. Also, men who received the client-navigator method intervention, which included 1) a phone call aimed at overcoming screening barriers and 2) reminders for screening, were more likely to participate, p = 0.0001. CONCLUSIONS: More African American men will participate in prostate cancer screening following the peer-education and client-navigator interventions.
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.
BACKGROUND: Delayed or incomplete follow-up after abnormal screening results may compromise the effectiveness of breast cancer screening programs, particularly in medically underserved and minority populations. This study examined the role of socioeconomic status, breast cancer risk factors, health care system barriers, and patient cognitive-attitudinal factors in the timing of diagnostic resolution after abnormal breast cancer screening exams among Black women receiving breast cancer screening at three New York city clinics. METHODS: We identified 184 Black women as having an abnormal mammogram or clinical breast exam requiring immediate follow-up and they were interviewed and their medical records examined. Bivariate and multivariate logistic regression analyses were used to assess the association between patient and health care system factors and diagnostic resolution within 3 months of the abnormal finding. RESULTS: Within 3 months, 39% of women were without diagnostic resolution and 28% within 6 months. Neither socioeconomic status nor system barriers were associated with timely diagnostic resolution. Timely resolution was associated with mammogram severity, patients asking questions (OR, 2.73; 95% CI, 1.25-5.96), or receiving next step information (OR, 2.6; 95% CI, 1.08-6.21) at the initial mammogram. Women with prior breast abnormalities were less likely to complete timely diagnostic resolution (OR, 0.42; 95% CI, 0.20-0.85), as were women with higher levels of cancer anxiety (OR, 0.50; 95% CI, 0.27-0.92). CONCLUSIONS: Interventions that address a woman's prior experience with abnormal findings and improve patient/provider communication may improve timely and appropriate follow-up.
The present study attempts to quantitate in an economically and clinically meaningful manner the cost and cost-effectiveness of prostate cancer screening and subsequent treatment, including complications from that treatment. Outcome data from large prostate cancer screening trials using prostate specific antigen (PSA) and digital rectal examination (DRE) and PSA alone were used to construct the screening model. The benefit of screening is expressed in years of life saved by screening, which is calculated by comparing the survival rate of men with prostate cancer to the survival rate of men in the general population. The cost of screening, treatment, and complications were estimated using the Medicare data base and published reports on the cost, morbidity and mortality for radical prostatectomy. The cost per year of life saved by prostate cancer screening with PSA and DRE was $2339-3005 for men aged 50-59, $3905-5070 for men aged 60-69, and $3574-4627 overall for men aged 50-69. The cost per year of life saved by prostate cancer screening with PSA alone for men aged 50-70 was $3822-4956. A sensitivity analysis demonstrates that the cost per year of life saved by prostate cancer screening will not change substantially even if the assumptions in this model have been underestimated or overestimated by 100%. This study quantifies only those parameters which can be reliably compared in concrete terms such as dollars, treatment impact on survival, published complication rates and published treatment costs. Using this type of analysis, prostate cancer screening appears to be a cost-effective intervention. However, the issue of whether prostate cancer screening is cost-effective will be decided definitively only when randomized, controlled trials are available to quantify the costs and benefits of prostate cancer screening.Prostate Cancer and Prostatic Diseases (2001) 4, 138-145.
An extensive body of intervention research to promote breast and cervical cancer screening has accumulated over the last three decades, but its coverage and comprehensiveness have not been assessed. We evaluated published reports of these interventions and propose a framework of critical elements for authors and researchers to use when contributing to this literature. We identified all articles describing breast and cervical cancer screening interventions published between January 1960 and May 1997 in the United States and abstracted specified critical elements in the broad areas of: (a) needs assessment; (b) intervention study design; and (c) analysis methods and study outcomes from each article using a template developed for that purpose. Fifty-eight studies met our criteria for inclusion. Thirty-eight focused exclusively on breast cancer screening, 7 promoted cervical cancer screening, and 13 were designed to promote screening for both cancers. The amount of detail reported varied among the 58 studies. All studies reported the outcome measures used to assess the effectiveness of the intervention, yet only 40% of the studies reported the investigators' original hypotheses or research questions. Needs assessment data were reported in 84% of the studies. Data sources ranged from national surveys to local intervention baseline surveys. Population characteristics reported also varied, with most studies reporting age and race of the study population (78 and 71%, respectively), and fewer studies reporting income and education (53 and 38%, respectively). As the field of behavioral intervention research progressed, we found that more recent studies included and reported many of the parameters we had identified as critical. If this trend continues, it will enhance the reproducibility of studies, enable comparisons between interventions, and provide a reference point for measuring progress in this area. To facilitate this trend toward uniform reporting, we propose an evaluative framework of critical elements for authors to use when developing and reporting their research. The comprehensive assessment of literature that this article provides should be useful background to investigators planning and reporting cancer control interventions, to funding agencies choosing and guiding quality research, and to publishers to help them enhance the quality and utility of their publications.