Performance of screening mammography among women with and without a first-degree relative with breast cancer.

BACKGROUND: Although it is recommended that women with a family history of breast cancer begin screening mammography at a younger age than average-risk women, few studies have evaluated the performance of mammography in this group. OBJECTIVE: To compare the performance of screening mammography in women with a first-degree family history of breast cancer and women of similar age without such history. DESIGN: Cross-sectional. SETTING: Mammography registries in California (n = 1), New Hampshire (n = 1), New Mexico (n = 1), Vermont (n = 1), Washington State n = 2), and Colorado (n = 1). PARTICIPANTS: 389 533 women 30 to 69 years of age who were referred for screening mammography from April 1985 to November 1997. MEASUREMENTS: Risk factors for breast cancer; results of first screening examination captured for a woman by a registry; and any invasive cancer or ductal carcinoma in situ identified by linkage to a pathology database, the Surveillance, Epidemiology, and End Results program, or a state tumor registry. RESULTS: The number of cancer cases per 1000 examinations increased with age and was higher in women with a family history of breast cancer than in those without (3.2 vs. 1.6 for ages 30 to 39 years, 4.7 vs. 2.7 for ages 40 to 49 years, 6.6 vs. 4.6 for ages 50 to 59 years, and 9.3 vs. 6.9 for ages 60 to 69 years). The sensitivity of mammography increased significantly with age (P = 0.001 [chi-square test for trend]) in women with a family history and in those without (63.2% [95% CI, 41. 5% to 84.8%] vs. 69.5% [CI, 57.7% to 81.2%] for ages 30 to 39 years, 70.2% [CI, 61.0% to 79.5%] vs. 77.5% [CI, 73.3% to 81.8%] for ages 40 to 49 years, 81.3% [CI, 73.3% to 89.3%] vs. 80.2% [CI, 76.5% to 83.9%] for ages 50 to 59 years, and 83.8% [CI, 76.8% to 90.9%] vs. 87.7% [CI, 84.8% to 90.7%] for ages 60 to 69 years). Sensitivity was similar for each decade of age regardless of family history. The positive predictive value of mammography was higher in women with a family history than in those without (3.7% vs. 2.9%; P = 0.001). CONCLUSIONS: Cancer detection rates in women who had a first-degree relative with a history of breast cancer were similar to those in women a decade older without such a history. The sensitivity of screening mammography was influenced primarily by age.

Effect of variations in operational definitions on performance estimates for screening mammography.

RATIONALE AND OBJECTIVES: The Mammography Quality Standards Act requires practices to measure limited aspects of their performance. The authors conducted this study to calculate the differences in measurements of sensitivity and specificity due only to differences in the definitions used in the analysis. This included definitions for case inclusion. MATERIALS AND METHODS: Data from the New Mexico Mammography Project for January 1991 to December 1995 on 136,540 women who underwent screening mammography were analyzed. A starting definition was created for each performance measure. The components of the definition were varied, and estimates of sensitivity and specificity for the different definitions were calculated. RESULTS: Sensitivity was lower and specificity was higher when assessed on the basis of the results of all imaging performed in the screening work-up rather than on the initial screening examination alone. Sensitivity was higher and specificity was lower in women who did not undergo rather than in women who did recently undergo a previous examination. When the definition of a positive examination included cases that were recommended for short-term follow-up, the work-up sensitivity was slightly higher and the work-up specificity was considerably lower. Longer follow-up times for determining the diagnosis of cancer were associated with decreasing sensitivity, particularly when the follow-up period extended beyond 12 months. CONCLUSION: Variations in the operational definitions for measures of mammographic performance affect these estimates. To facilitate valid comparisons, reports need to be explicit regarding the definitions and methods used.

Women and tobacco: moving from policy to action.

A gender perspective contributes to a better understanding of the epidemiological trends, social marketing strategies, economic policies, and international actions relating to women and the tobacco epidemic. Evidence is provided in this article for the negative impact of tobacco use by women and of passive smoking on the health of women and children. Use of tobacco by women is increasing and this is related to the tobacco industry's aggressive advertising, sponsorship and promotion strategies. Policy directions are proposed in this article. At all levels, a multi-pronged strategy--including changes in legislation and fiscal policies, improvements in gender-sensitive health services, and cessation programmes--should be considered. Much more gender-specific research on tobacco use is needed, particularly in developing countries. Women's empowerment and leadership should be at the centre of all tobacco control efforts and are essential for the success of national programmes and the recently introduced Framework Convention on Tobacco Control.

Current medicolegal and confidentiality issues in large, multicenter research programs.

The convenience of fast computers and the Internet have encouraged large collaborative research efforts by allowing transfers of data from multiple sites to a single data repository; however, standards for managing data security are needed to protect the confidentiality of participants. Through Dartmouth Medical School, in 1996-1998, the authors conducted a medicolegal analysis of federal laws, state statutes, and institutional policies in eight states and three different types of health care settings, which are part of a breast cancer surveillance consortium contributing data electronically to a centralized data repository. They learned that a variety of state and federal laws are available to protect confidentiality of professional and lay research participants. The strongest protection available is the Federal Certificate of Confidentiality, which supersedes state statutory protection, has been tested in court, and extends protection from forced disclosure (in litigation) to health care providers as well as patients. This paper describes the careful planning necessary to ensure adequate legal protection and data security, which must include a comprehensive understanding of state and federal protections applicable to medical research. Researchers must also develop rules or guidelines to ensure appropriate collection, use, and sharing of data. Finally, systems for the storage of both paper and electronic records must be as secure as possible.

Spit (smokeless) tobacco use by high school baseball athletes in California.

OBJECTIVE: To describe the prevalence, patterns, and correlates of spit (smokeless) tobacco (ST) use in a sample of high school baseball athletes in California. DESIGN: This cross sectional study was a survey of 1226 baseball athletes attending 39 California high schools that were randomly selected from a list of all publicly supported high schools with baseball teams. At a baseball team meeting, athletes who agreed to participate and had parental consent completed the study questionnaire. To enhance the accuracy of self reported ST use status, a saliva sample was collected from each subject. The questionnaires and saliva samples were coded and salivary cotinine assay was performed on a random subsample of 5% of non-users who also were non-smokers. Biochemical assay indicated that 2% tested positive for cotinine inconsistent with self reported ST non-use. RESULTS: Overall, 46% had ever used ST and 15% were current users. Odds ratios and 95% confidence intervals (CI) suggested that, among high school baseball athletes, age, living in a rural area, being white, smoking cigarettes, drinking alcohol, not knowing about the adverse effects of ST, perceiving little personal risk associated with ST use, and believing that friends, role models, teammates, and same age baseball athletes in general used ST, increased the likelihood of being an ST user. CONCLUSION: The findings indicate that considerable experimentation with ST products occurs among high school baseball athletes in California, and many are current users. ST interventions targeting this population are needed to stop the transition from experimental ST use to tobacco dependence. Correlates of ST use for consideration in future intervention studies are identified.

Mortality among women with ductal carcinoma in situ of the breast in the population-based surveillance, epidemiology and end results program.

BACKGROUND: Over 14% of breast cancers diagnosed in the United States annually are ductal carcinomas in situ (DCIS). There are no published population-based reports of the likelihood of breast cancer death among US women with DCIS. METHODS: We used data from the Surveillance, Epidemiology and End Results program to determine the likelihood of breast cancer death at 5 and 10 years among US women aged 40 and older diagnosed with DCIS from 1978 to 1983 (before screening mammography was common; n = 1525) and from 1984 to 1989 (when screening mammography became common; n = 5547). We also calculated standardized mortality ratios (SMRs) to compare observed deaths from breast cancer, cardiovascular disease, and all causes combined among women with DCIS with deaths expected based on general population mortality rates. RESULTS: Among women diagnosed with DCIS from 1978 to 1983, 1.5% died of breast cancer within 5 years and 3.4% within 10 years. Among women diagnosed from 1984 to 1989, 0.7% died of breast cancer within 5 years and 1.9% within 10 years. Relative to the general population, risk of breast cancer death was greater for women diagnosed from 1978 to 1983 (SMR, 3.4; 95% confidence interval [CI], 2.5-4.5) than for women diagnosed from 1984 to 1989 (10-year SMR, 1.9; 95% CI, 1.5-2.3). Women diagnosed from 1984 to 1989 were significantly less likely than women in the general population to have died of cardiovascular diseases (10-year SMR, 0.6; 95% CI, 0.5-0.7) or of all causes combined (SMR, 0.8; 95% CI, 0.7-0.8). CONCLUSIONS: Among women diagnosed with DCIS, risk of death from breast cancer was low, at least within the 10 years following diagnosis. This may reflect the effectiveness of treatment for DCIS, the "benign" nature of DCIS, or both. At 10 years, women diagnosed from 1984 to 1989 were less likely than women diagnosed from 1978 to 1983 to have died of breast cancer, and their risk of dying of all causes combined was lower than that in the general population.

Smokeless tobacco cessation intervention for college athletes: results after 1 year.

OBJECTIVES: The purpose of this study was to determine the efficacy of a college-based smokeless tobacco cessation intervention targeting college athletes. METHODS: Sixteen colleges were matched for prevalence of smokeless tobacco use in their combined baseball and football teams and randomly assigned within college pairs to the intervention or the control group. One-year prevalence of cessation among smokeless tobacco users was determined by self-report of abstinence for the previous 30 days. Differences between groups were analyzed in a weighted version of the Fisher 1-sided permutation test for paired samples after adjustment for significant predictors of quitting other than the intervention (i.e., smokeless tobacco uses per week and most frequently used brand). RESULTS: Cessation prevalences were 35% in the intervention colleges and 16% in the control colleges when subjects with unknown quit status were defined as nonquitters. After adjustment for other significant predictors of quitting, the difference of 19% increased to 21%. The intervention effect increased with level of smokeless tobacco use. CONCLUSIONS: This intervention was effective in promoting smokeless tobacco cessation, especially among those who were more frequent users.

Variability and accuracy in mammographic interpretation using the American College of Radiology Breast Imaging Reporting and Data System.

BACKGROUND: Several studies, which were limited by their small sample size and selection of difficult cases for review, have reported substantial variability among radiologists in interpretation of mammographic examinations. We have determined, in the largest study to date, intraobserver and interobserver agreement in interpreting screening mammography and accuracy of mammography by use of the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS). METHODS: The mammographic examinations were randomly selected on the basis of original mammographic interpretation and cancer outcome from 71,713 screening examinations performed by the Mobile Mammography Screening Program of the University of California, San Francisco, during the period from April 1985 through February 1995. The final sample included 786 abnormal examinations with no cancer detected, 267 abnormal examinations with cancer detected, and 1563 normal examinations. Films were read separately by two radiologists according to BI-RADS. Cancer status was determined by contacting women's physicians and by linkage to the regional Surveillance, Epidemiology, and End Results Program. RESULTS: There was moderate agreement between radiologists in reporting the presence of a finding when cancer was present (kappa = 0.54) and substantial agreement when cancer was not present (kappa = 0.62). Agreement was moderate in assigning one of the five assessment categories but was statistically significantly lower when cancer was present relative to when cancer was not present (kappa = 0.46 versus 0.56; two-sided P = .02). Agreement for reporting the presence of a finding and mammographic assessment was two-fold more likely for examinations with less dense breasts. Agreement was higher on repeat readings by the same radiologists than between radiologists. The sensitivity of mammography was lower with BI-RADS than with the original system for mammographic interpretation, but the positive predictive value of mammography was higher. CONCLUSION: Considerable variability in interpretation of mammographic examinations exists; this variability and the accuracy of mammography are neither improved nor diminished with use of BI-RADS.

Birthplace and yield of nipple aspirate fluid in Chinese women.

The different rates of breast cancer found between Chinese women in Asia compared with Chinese-born women in the United States suggest that dietary and environmental factors may be of etiological significance. We evaluated the proportion of 480 premenopausal Chinese women who yielded nipple aspirate fluid (NAF) by birthplace in Asia versus the United States and by reproductive and other risk factors. Birthplace was used as a surrogate for presumed differences in exposures during gestation, childhood, and adolescence that might influence yield of NAF in premenopausal women. In United States-born Chinese women compared with Asia-born Chinese women, the proportion yielding NAF was 44 of 95 (46.3%) versus 120 of 385 (31.2%), respectively. The relative risk of yield of NAF in United States-born women compared with Asia-born women was odds ratio = 2.37 (95% confidence interval, 1.26-4.47). Independent positive associations of NAF yield were also found with history of parity and breast feeding, cerumen phenotype, and a negative association with ever use of oral contraceptives. These findings support the hypothesis that early environmental exposures may have long-lasting physiological effects discernible in the breast glands of adult women.

Occurrence of other cancers among patients with prior basal cell and squamous cell skin cancer.

Epidemiological studies suggest that individuals with basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) of the skin are more likely to develop other malignancies; however, the factors responsible for this are unknown. To clarify the risk of other cancers following the occurrence of BCC and SCC, we followed participants in a multicenter skin cancer prevention trial for subsequent malignancies. The study group consisted of 1805 BCC and SCC patients who had enrolled in a trial testing the efficacy of oral beta-carotene. Medical confirmation was sought for all cancers (other than BCC or SCC), which were reported by participants or their next-of-kin over a follow-up period of 10 years. We computed the rate ratio (RR) and 95% confidence interval (CI) of time to first new, primary cancer in relation to history of BCC and SCC, using a proportional hazards model. A total of 235 participants had a new primary invasive cancer during 13,887 person-years of follow up. The risk of other cancers was modestly elevated in patients with one or more previous SCCs compared with those who only had a history of BCC (adjusted RR, 1.37; 95% CI, 0.91-2.07). Risk of other cancers also appeared to be increased among those who had multiple prior BCCs relative to those who had only one prior BCC (adjusted RR, 1.21; 95% CI, 0.91-1.61). Further adjustment for smoking history, Quetelet index, radiotherapy, extent of actinic skin damage, treatment assignment, or baseline beta-carotene concentrations did not appreciably alter the results. Cancer of the respiratory system was most strongly related to previous SCC or multiple BCC [RRs (95% CI), 2.20 (1.05-4.62) and 2.34 (1.14-4.83), respectively]. Our data suggest that unidentified exposures or inherited risk factors may play a common etiological role in the pathogenesis of nonmelanoma skin cancer and other cancers, especially respiratory cancers, although larger studies would be necessary to exclude the role of chance in these findings.

A comparison of two methods to teach smoking-cessation techniques to medical students.

PURPOSE: To evaluate two smoking-cessation practice exercises, one using standardized patients (SPs), the other using role playing by medical students. METHOD: In the spring of 1994 all 120 first-year University of California, San Francisco, School of Medicine Students were given lectures on the health effects of smoking and how physicians can help patients quit. Afterward some of the students were randomly assigned to two groups in which to practice counseling patients: Group 1 (n = 35) used SPs, Group 2 (n = 37) used role playing. Each of the Group 1 students practiced smoking-cessation techniques with an SP; the SP evaluated the student on cognitive and communication skills, assigned an overall rating, and provide feedback using a standardized form. The Group 2 students (as well as the 48 students not assigned to a group) role-played in pairs and used the same form to provide feedback. All the students evaluated their respective practice practices. Two weeks later 24 Group 1 and 31 Group 2 students participated in a clinic-skills-assessment exercise using SPs. As in the Group 1 practice exercise, each student was evaluated by an SP on cognitive and communication skills and assigned an overall rating. Data were analyzed through a number of statistical methods. The cost of the SP program was determined. RESULTS: The Group 1 students rated their practice exercise much more favorably than did the Group 2 students. However, there was no significant difference between the groups in their ratings by the SPs on the clinical-skills-assessment exercise. The use of SPs cost a great deal more than did the use of role playing. CONCLUSION: Although the students rated the SPs higher than they did the role playing, the two tools produced similar levels of skills attainment. The data suggest that having students practice smoking-cessation techniques through role playing may be as effective as using the more extensive SPs.