Screening mammography and breast cancer treatment patterns in older women.

OBJECTIVE: To examine the impact of mammography screening on treatment options received by a cohort of older breast cancer patients. SETTING AND POPULATION: We studied 718 newly diagnosed breast cancer patients, 67 years and over, diagnosed with TNM Stage I and II disease between 1995 and 1997 at 29 hospitals in five regions. METHODS: Data were collected from patients, surgeons, and medical records. A breast cancer diagnosis was considered to have been by screening mammography if so reported by both patient and medical records. Bivariate and logistic regression were used to identify predictors of a women having her cancer detected by screening mammography and the relationships between mode of detection, stage of disease at diagnosis, and local treatment. RESULTS: Women with high school or greater education were 1.75 times (95%, CI 1.11-2.75) more likely to have their cancers diagnosed by screening mammography than women who had not completed high school, controlling for other factors. Screening found earlier stage disease: 96% of women with mammographically diagnosed cancer had T1 lesions, compared to 81% of women diagnosed by other means (p = 0.001). Women with mammography detected lesions were more likely to have ductal cancer, and to be referred to radiation oncologists more than women diagnosed by other means. Controlling for stage and histology, screening remained associated with a higher likelihood of receiving breast conserving surgery (BCS) with radiation (RT) (OR 1.56, 95%, CI 1.10-2.22) than other local therapies. CONCLUSIONS: Beyond the impact on stage, ductal cancers were more likely to be diagnosed by screening. Mammographically detected lesions were associated with referrals to radiation oncologists and higher rates of BCS and RT. Research is needed to explain the residual independent effects of mammography screening on breast cancer treatment.

Effectiveness of interventions to improve follow-up after abnormal cervical cancer screening.

OBJECTIVE: The purpose of this study was to determine the effectiveness of interventions designed to improve follow-up after an abnormal Pap smear. METHODS: We performed a qualitative meta-analysis of interventions designed to improve follow-up after an abnormal Pap smear and included studies that met the following criteria: randomized or concurrently controlled study design, defined outcomes, and data available for abstraction. Interventions were classified as behavioral, cognitive, sociologic, or combined strategies (e.g., behavioral and cognitive). Abnormal Pap smears were defined as any test result requiring additional follow-up. Effectiveness was measured by the rate of compliance with recommended follow-up. RESULTS: Twenty-two interventions in 10 studies met the inclusion criteria. Cognitive interventions utilizing interactive telephone counseling were the most effective, improving compliance by 24 to 31%. Behavioral interventions, such as patient reminders, were also effective, increasing follow-up by up to 18%. Not all of these results achieved statistical significance. The single sociologic intervention we identified used video-taped peer discussions to provide a message about abnormal Pap smears and appropriate follow-up. This intervention was not associated with increased follow-up after an abnormal test. The effectiveness of interventions using multiple types of strategies to improve follow-up was inconsistent. CONCLUSIONS: Cognitive strategies led to the greatest improvement in compliance with follow-up of abnormal Pap smear screening tests. Extension of similar interventions to follow-up of abnormal breast and colon cancer screening, development of physician- and system-targeted interventions, and evaluation of the cost-effectiveness of these strategies are important priorities for future research.

Patterns of breast carcinoma treatment in older women: patient preference and clinical and physical influences.

BACKGROUND: Older women have high rates of breast carcinoma, and there are substantial variations in the patterns of care for this population group. METHODS: The authors studied 718 breast carcinoma patients age 67 years and older who were diagnosed with localized disease between 1995 and 1997 from 29 hospitals in 5 regions. Data were collected from patients, charts, and surgeons. Logistic regression analysis was used to evaluate determinants of treatment. RESULTS: Women who were concerned about body image were 1.8 times more likely (95% confidence interval [95% CI], 1.1-2.8) to receive breast conservation surgery and radiotherapy than women without this preference, controlling for other factors. In contrast, women who preferred receiving no therapy beyond surgery were 3.9 times more likely (95% CI, 2.9-6.1) to undergo mastectomy than other women, after considering other factors. Radiotherapy was omitted after breast conservation 3.4 times more often (95% CI, 2.0-5.6) among women age 80 years and older than among women ages 67-79 years, controlling for covariates. Black women tended to have radiotherapy omitted after breast conservation surgery 2.0 times more often (95% CI, 0.9-4.4) than white women (P = 0.09). Women age 80 years and older also were 70% less likely (odds ratio = 0.3; 95% CI, 0.1-0.8) to receive chemotherapy than women ages 67-79 years, controlling for health, functional status, and other covariates. CONCLUSIONS: After considering other factors, patient preferences and age were found to be associated with breast carcinoma treatment patterns in older women. Further research and training are needed to provide care for the growing population of older women that is both clinically appropriate and consonant with a woman's preferences.

Equitable access to cancer services: A review of barriers to quality care.

BACKGROUND: Barriers to cancer care have been documented in nearly all settings and populations; such barriers represent potentially avoidable morbidity or mortality. A conceptual framework was used to describe patient, provider, and system barriers to cancer services. METHODS: A review of the English language literature on cancer care from 1980-1998 was conducted; key research was summarized for each domain in the conceptual model. RESULTS: Key patient barriers are related to old age, minority race, and low socioeconomic class; the common pathways by which these sociodemographic factors appear to mediate cancer outcomes include social class and race-related or class-related attitudes. Providers are often ill-prepared to communicate the complexities of cancer care to their diverse patient populations; constraints of the medical care system also can impede the delivery of care. To the authors' knowledge the impact of the rapid growth in managed care organizations (MCOs) on access to care has yet to be evaluated fully. Although MCOs historically have provided high levels of cancer screening in healthy populations, to the authors' knowledge there are fewer data regarding outcomes for elderly and poor populations and for treatment services. CONCLUSIONS: Additional research is needed to develop and test interventions to overcome barriers to care and evaluate the impact of the growth of managed care on access to cancer care for diverse populations.

The effect of race and sex on physicians' recommendations for cardiac catheterization.

BACKGROUND: Epidemiologic studies have reported differences in the use of cardiovascular procedures according to the race and sex of the patient. Whether the differences stem from differences in the recommendations of physicians remains uncertain. METHODS: We developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with particular characteristics in scripted interviews about their symptoms. A total of 720 physicians at two national meetings of organizations of primary care physicians participated in the survey. Each physician viewed a recorded interview and was given other data about a hypothetical patient. He or she then made recommendations about that patient's care. We used multivariate logistic-regression analysis to assess the effects of the race and sex of the patients on treatment recommendations, while controlling for the physicians' assessment of the probability of coronary artery disease as well as for the age of the patient, the level of coronary risk, the type of chest pain, and the results of an exercise stress test. RESULTS: The physicians' mean (+/-SD) estimates of the probability of coronary artery disease were lower for women (probability, 64.1+/-19.3 percent, vs. 69.2+/-18.2 percent for men; P<0.001), younger patients (63.8+/-19.5 percent for patients who were 55 years old, vs. 69.5+/-17.9 percent for patients who were 70 years old; P<0.001), and patients with nonanginal pain (58.3+/-19.0 percent, vs. 64.4+/-18.3 percent for patients with possible angina and 77.1+/-14.0 percent for those with definite angina; P=0.001). Logistic-regression analysis indicated that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and whites, respectively. Analysis of race-sex interactions showed that black women were significantly less likely to be referred for catheterization than white men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004). CONCLUSIONS: Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain.

Are we getting the message out to all? Health information sources and ethnicity.

BACKGROUND: Over 80% of the excess deaths in minority and economically disadvantaged populations are from diseases with preventable or controllable contributing factors. However, mainstream health education targeting behavior change often fails to reach minority populations. OBJECTIVE: To identify the health and cancer information sources used by a multi-ethnic population and to determine whether information sources differ by ethnic group, age, gender, and socioeconomic status. METHODS: A multilingual, random-digit dial telephone survey of 2,462 Hispanic (Colombian, Dominican, Ecuadorian, and Puerto Rican) and black (Caribbean, Haitian, and U.S.-born) persons, aged 18-80 years, from a population-based quota sample, New York City, 1992. RESULTS: All ethnic and age groups cited a health professional as the most common source of health information (40% overall). The next most commonly cited sources overall were: television (21%), hospitals or doctor's offices (18%), books (17%), magazines (15%), brochures/pamphlets (11%), and radio (8%). Responses on sources of cancer information followed a similar pattern. Black subgroups were all significantly more likely than Hispanic subgroups to get their health information from a doctor or other health professional (p = 0.001). Use of the radio as a source of health information was highest among Haitians (20.8%) and Colombians (12.5%), and lowest among U.S.-born blacks (4.2%) (p = 0.001), but there was no difference in the use of television. Among immigrants, as the proportion of life spent in mainland U.S. rose, increasing percentages cited magazines (p = 0.001) and decreasing percentages cited radio (p = 0.025) as a health information source. Less educated persons and more recent immigrants were most likely to report inability to get health information (p = 0.001). CONCLUSIONS: Given the variation in sources of health and cancer information, identification of those most commonly used is important to health educators' and public health practitioners' efforts to target hard-to-reach ethnic minorities.

Tobacco use among multi-ethnic Latino populations.

OBJECTIVES: To examine tobacco use among New York City resident Latin Americans from different countries of origin and with different levels of acculturation reflected by language use. DESIGN: Effective health promotion programs, particularly those aimed at smoking cessation and prevention, require careful investigation into possible cultural and societal factors influencing predictors and barriers to preventive health behavior. National data characterizing cigarette smoking behavior among broadly defined racial/ethnic groups (e.g., black, Hispanic) have rarely examined the extent or importance of cultural variation and acculturation within and among ethnic groups. This report addresses these issues. METHODS: In this study, we examine self-reported cigarette smoking behavior from a 1992 telephone survey of a quota sample of Puerto Rican, Dominican, Colombian, and Ecuadorian Hispanics living in New York City. We compare results from these data with results from a random sample of New York City Hispanics from the Tobacco Use Supplement to the 1992-93 Current Population Survey. RESULTS: Both data sets demonstrated that Puerto Ricans were significantly more likely to be current smokers and ever smokers than the other three Latino groups. Among Hispanic women in the quota sample, those who chose to complete the interview in English were much more likely to report ever smoking than those women who chose to complete the interview in Spanish. CONCLUSIONS: The relationship between smoking behavior and acculturation (as measured by language usage) appears to be complex and sensitive to methodological issues of sampling and interview language.

Ever vs never smoking among an urban, multiethnic sample of Haitian-, Caribbean-, and U.S.-born blacks.

BACKGROUND: Despite the high rate of current smoking among blacks in the United States, to date there have been no studies comparing smoking rates or predictors of smoking among adults from different black ethnic groups living in the United States. If cancer control programs are to successfully reduce the risk of smoking-related cancers within black communities, more extensive data on demographics, knowledge, attitudes, beliefs, and practices within ethnic groups are needed. METHODS: We conducted a structured telephone interview to assess smoking status, alcohol use, cancer-related attitudes and beliefs, and demographic information among Haitian-born (N = 165), Caribbean-born (N = 354), and U.S.-born (N = 402) blacks living in New York City in 1992. RESULTS: Relative to U.S.-born participants, both Caribbean- and Haitian-born participants were significantly less likely to have ever smoked. Although both groups of foreign-born men were much more likely to have ever smoked relative to their female counterparts, U.S.-born men and women were equally likely to have ever smoked. Alcohol use was consistently related to smoking across ethnic and gender groups, and this association was enhanced among older drinkers. The belief that smoking is not related to cancer was associated with an almost twofold increase of ever smoking. CONCLUSIONS: The rate of ever smoking among urban, foreign-born blacks is considerably lower than among U.S.-born blacks; among the foreign-born participants, ever smoking was lower among women relative to men. Alcohol use is an important predictor of smoking status, particularly among older drinkers.

Partnerships for the delivery of cancer care.

Academic oncologists representing prominent academic medical centers and medical directors representing a variety of HMOs have been meeting to confront the issues separating these two groups. Collaborations for Fostering Quality Cancer Care: Examining Partnerships Between Managed Care Organizations and Academic Medical Centers and Partnerships for the Delivery of Cancer Care were conferences jointly sponsored by the Lombardi Cancer Center of Georgetown University and the Xerox Corporation which looked at the obstacles to successful joint efforts and at successful existing partnerships between academic centers and HMOs. During these sessions it became apparent that there is real concern about the survival of the academic cancer centers and for their research, education and patient care missions. But successful partnerships between academic medical centers and HMOs do exist. These offer a model of working relationships that can incorporate both the traditional missions of the academic medical centers and the need for cost-effectiveness which HMOs champion.

Breast cancer prevention and control among the medically underserved.

In 1986, the National Cancer Institute published its cancer control objectives for the nation, which included projected reductions in breast cancer mortality. The reductions were estimated to be 25.0% from reducing fat, 16.0% from expanding use of breast cancer screening services, and 14.3% from expanding access to state-of-the-art breast cancer treatment. During the same decade, the U.S. population aged and became significantly more ethnically diverse, and accompanying this increase in ethnic diversity was endemic poverty, disproportionately experienced by black and Hispanic minorities. These populations may be seen as medically underserved. With respect to breast cancer, as well as many other cancers, the medically underserved are understudied, not well understood by many in the medical and academic research community, and attended by health care institutions that are under-funded and often do not have the resources necessary to ensure access to state-of-the-art cancer screening, clinical follow-up, diagnosis, and treatment. At the same time, medically underserved women are more likely to be diagnosed with late-stage breast cancer, and some groups (e.g. black women) bear the greatest breast cancer mortality burden in the nation. In this special issue of Breast Cancer Research and Treatment, eight papers describe what we know and what we don't about breast cancer prevention and control in medically underserved populations.

Expanding access to cancer screening and clinical follow-up among the medically underserved.

Blacks have the highest cancer incidences and mortality rates in the United States. Higher mortality rates appear due to higher incidence in some sites and to later-stage diagnoses in others. To address these problems, expanded cancer screening in an inner-city public hospital and a patient navigator intervention were proposed. Patient navigators acted as patient advocates for patients with abnormal screening findings. One thousand thirty-four females and 102 males were screened from July 1990 through November 1992; seven breast cancers and one cervical cancer were found. Patient navigators were significantly more likely to have seen patients with suspicious findings than patients with non-suspicious findings. However, even among those with suspicious findings, almost 70% were not seen by a patient navigator. Of those navigated, 87.5% completed recommended breast biopsies, compared with 56.6% of the non-navigated patients. Among those with a biopsy, navigated patients did so in significantly less time than those not navigated. Navigation is one of three phases proposed to reduce cancer mortality among medically underserved populations.

Cancer control planning and establishment of priorities for intervention by a state health department.

A number of data sources routinely available to State health departments were analyzed as part of a State health department cancer control planning effort. This planning effort consisted of seven steps; the most challenging one was the establishment of priorities for cancer control interventions. Using data from available sources, however, a framework for prioritizing potential cancer control interventions as well as choosing a geographic area in which to implement selected interventions was developed. Factors considered in this framework for setting intervention priorities included the magnitude of the problem; the existence of scientific consensus regarding the efficacy of intervention techniques; the availability of data needed to plan, implement, and evaluate an intervention; the availability of resources within communities to implement an intervention; and the existence of public demand for the intervention. The development and use of this cancer control planning model and framework for setting cancer control intervention priorities in New York State are described in this paper. In using this planning model and framework for setting priorities, quantitative elements were found to be most necessary to define problems, but qualitative elements were most crucial for decision making.

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.

A national survey of attitudes and practices of primary-care physicians relating to nutrition: strategies for enhancing the use of clinical nutrition in medical practice.

A nationwide mail survey was used to determine the degree to which primary-care physicians indicated that they practice the "core competencies" in clinical nutrition identified by Young et al (Am J Clin Nutr 1983;38:800-10). We also surveyed the nutrition-related attitudes of these physicians. Although the 3416 physicians who responded to the survey tended to report favorable attitudes toward using nutrition in their practice, these favorable attitudes were not consistent with their own reports of clinical performance. Neither the positive- or negative-attitude score correlated highly with the reported behavior-practice score. The clinical practices reported by those surveyed are well below the minimum level defined by the Young et al essential core competencies in clinical nutrition. The attitudes, practices, and demographic characteristics associated with the clinical performance variables suggest educational strategies for improving the competence of primary-care physicians and medical students in clinical nutrition.

Predictors of smoking prevalence among New York Latino youth.

BACKGROUND: We examined prevalence rates and risk factors for smoking among Latino adolescents, using a multiethnic sample of sixth- and seventh-grade students (n = 3129) in 47 New York City public and parochial schools. METHODS: The students completed questionnaires; self-reported smoking data were collected by means of the "bogus pipeline" technique. The largest group of Latino students (43%) was Puerto Rican; 20% were of Dominican background, 7% were Colombian, and 7% were Ecuadorian. "Current smoking" was defined as smoking at least once per month. RESULTS: A series of logistic regression analyses indicated that peer influence was the strongest predictor of smoking. Family influence was important as well. CONCLUSIONS: The results are discussed in terms of their implications for prevention.

Geographically-based cancer control: methods for targeting and evaluating the impact of screening interventions on defined populations.

Successful implementation of cancer control programs depends on efficient targeting to those at highest risk of developing and dying from the disease. This study presents a methodology for targeting cancer screening on the basis of population and disease variation among small geographic areas. Techniques for quantifying the impact of targeting on the predictive value of a positive test are demonstrated, using 329 New York City health areas. Age-truncated crude incidence, late-stage incidence and mortality rates for breast, cervix, and colorectal cancer are used, using site-specific truncation points relevant to the age groups appropriate for screening. Coefficient alpha was used to determine rate stability with 2, 3, 5 and 7 years of data. The stability of most small area rates was found to reach acceptable levels only with 5 and 7 years of data. Targeting into areas where breast cancer prevalence was high increased the expected predictive value of a positive test by as much as 50% when compared with areas of average prevalence. Geographic targeting will be most useful where between-area variability in prevalence is large and within-area variability is small. The implications of these results are discussed and future studies are suggested.