Report of the International Workshop on Screening for Breast Cancer.

BACKGROUND: Over the past 30 years, eight major randomized controlled trials of breast cancer screening--with mammography and/or clinical breast examination--have been conducted. Results from several trials have been updated during the past year, and initial results of three other trials have been reported. PURPOSE: The National Cancer Institute held an International Workshop on Screening for Breast Cancer in February 1993 to conduct a thorough and objective critical review of the world's most recent clinical trial data on breast cancer screening, consider the new evidence, assess the current state of knowledge, and identify issues needing further research. METHODS: Investigators representing the eight randomized controlled trials of breast cancer screening in women aged 40-74 presented published and unpublished data. Evidence relating to the effectiveness of breast cancer screening in different age groups, especially women aged 40-49, was presented. RESULTS: For women aged 40-49, randomized controlled trials consistently demonstrated no benefit from screening in the first 5-7 years after study entry. A meta-analysis of six trials found a relative risk of 1.08 (95% confidence interval = 0.85-1.39) after 7 years' follow-up. After 10-12 years of follow-up, none of four trials have found a statistically significant benefit in mortality; a combined analysis of Swedish studies showed a statistically insignificant 13% decrease in mortality at 12 years. Only one trial (Health Insurance Plan) has data beyond 12 years of follow-up, and results show a 25% decrease in mortality at 10-18 years. Statistical significance of this result is disputed, however. In women aged 50-69, all studies show mortality reductions; three of four studies show reductions of about 30% at 10-12 years after study entry. Results from two of these trials were statistically significant. Too few women over age 70 have been included in studies for adequate analysis. CONCLUSIONS: For women aged 40-49, randomized controlled trials of breast cancer screening show no benefit 5-7 years after entry. At 10-12 years, benefit is uncertain and, if present, marginal; thereafter, it is unknown. For women aged 50-69, screening reduces breast cancer mortality by about a third. Currently available data for women age 70 or older are inadequate to judge the effectiveness of screening. IMPLICATIONS: Randomized trials have provided stronger scientific evidence regarding the effectiveness of screening for breast cancer than for any other cancer. However, much still needs to be learned. Periodic gatherings of scientists in the field should speed the process.

Silicone controversy: a survey of women with breast cancer and silicone implants.

BACKGROUND: During the past 3 years, there has been a highly publicized debate concerning the potential medical complications of silicone breast implants. There have been no studies that have addressed the effect of this controversy on women with a history of breast cancer who have undergone breast reconstruction with silicone implants. PURPOSE: This study was undertaken to understand the concerns of such women regarding their breast reconstructions and to assess what impact the silicone implant controversy had on them. METHODS: One hundred seventy-four randomly selected women who had undergone reconstructive surgery with silicone implants subsequent to mastectomy for treatment of breast cancer were interviewed by telephone from February through May 1992. (A moratorium on use of silicone breast implants, imposed by the Food and Drug Administration, extended from January through April 1992.) These women, a subset of 359 mastectomy/reconstruction patients of one university-based plastic surgeon, had their first permanent prostheses placed between 1985 and 1990. The interview included questions designed to elicit information about women's experiences with reconstruction and reactions to the controversy. RESULTS: All study participants were aware of the controversy surrounding silicone implants. Seventy-six percent stated that breast reconstruction helped them cope with cancer, and only 16% had regrets about reconstruction. Many respondents had misconceptions about the nature of possible complications from silicone implants. Fifty-five percent were worried about the implants, yet only 13% considered having them removed as a result of the controversy. Only 27% indicated they would be completely likely to choose silicone implants again. The majority of women were unwilling to accept substantial risks of complications from implants, but there was variability in the level of risk that respondents would tolerate. CONCLUSIONS: A majority of women who have had breast reconstruction using silicone implants after treatment of breast cancer believe that implants helped them cope with the cancer. However, a sizeable proportion of such women are worried about possible medical complications that may develop as a consequence of silicone breast implants. Many would likely not choose these implants today. IMPLICATIONS: The true risks associated with silicone implants will ultimately be known. In the meantime, health care providers need to address patients' concerns about these implants. Information and guidance regarding the potential benefits and risks of breast implant devices should be provided to women with breast cancer who are considering treatment options.

Cancer risk notification: psychosocial and ethical implications.

Basic and medical science investigations have identified a growing number of risk factors important in carcinogenesis. By communicating cancer risk information in medical practice, we have the potential to motivate high-risk individuals to adhere to cancer prevention and surveillance protocols. However, cancer screening and risk notification might have adverse psychologic and social consequences as well. In this review, we address the psychosocial and ethical implications of cancer risk notification. The literature on the psychosocial impact of cancer screening programs and programs for notifying workers exposed to occupational carcinogens is reviewed critically. In addition, we examine new concerns and responsibilities raised by the emerging field of cancer genetics. Suggestions for future research and for patient education are addressed.

Why women gain weight with adjuvant chemotherapy for breast cancer.

PURPOSE: Among breast cancer patients receiving adjuvant chemotherapy, weight gain is a common side effect that may decrease quality of life and potentially threaten survival. Weight gain during treatment is a problem that is clinically well appreciated, and one that has been studied by a number of investigators. DESIGN: A literature review was conducted to address each of the following issues: (1) the prevalence and magnitude of weight gain in women receiving adjuvant chemotherapy for early-stage breast cancer, (2) factors that might affect the amount of weight gained, (3) adverse consequences of weight gain, (4) mechanisms potentially responsible for weight gain, and (5) current dietary intervention programs directed toward women receiving adjuvant chemotherapy. RESULTS: Weight gain is associated with a number of adverse effects in breast cancer patients receiving adjuvant chemotherapy. Weight gains are exaggerated in premenopausal women and women receiving multiagent regimens. Little research has been conducted to investigate the underlying mechanisms that contribute to weight gain in this population. CONCLUSION: Interventions to prevent weight gain during adjuvant chemotherapy are underway; however, little research has been conducted to investigate the underlying mechanisms of energy imbalance. Although changes in resting metabolic rate, thermogenesis, physical activity, and dietary intake are all plausible, no firm data exist to support any of these mechanisms. There is a need for research that explores the relative contribution of each of these factors to energy imbalance, so that optimally effective interventions can be created and implemented to combat this problem.

Attitudes, knowledge, and risk perceptions of women with breast and/or ovarian cancer considering testing for BRCA1 and BRCA2.

PURPOSE: This study examined baseline knowledge, beliefs, and risk perceptions among a group of 200 women with breast and/or ovarian cancer who participated in a trial designed to improve decision making about genetic testing for BRCA1 and BRCA2. PATIENTS AND METHODS: Women were identified by self-referral, physician referral, and tumor registry extraction and invited to participate in a randomized trial in which testing for BRCA1 and BRCA2 was offered free of charge. Subjects completed baseline questionnaires and interviews that assessed knowledge, attitudes, and perceptions of risk of having an alteration in BRCA1 or BRCA2. RESULTS: Sixty percent of women overestimated their chances of having a BRCA1 or BRCA2 mutation compared with estimates from a BRCA1/BRCA2 risk model. Women who have at least three relatives with breast or ovarian cancer were one third (95% confidence interval, 0.2 to 0.6) as likely to overestimate their risk of having a BRCA1 or BRCA2 mutation compared with women who have two or fewer affected relatives. Knowledge was limited about BRCA1 and BRCA2 mutations and cancer risk associated with gene mutations. Eighty-four percent of the women indicated a probable or definite interest in testing. CONCLUSION: A high proportion of the high-risk women in this study had knowledge deficits about BRCA1 and BRCA2 and overestimated their risk of having a mutation. Although some degree of caution should be used in generalizing the results of this study to practice settings, the data provide insight into the challenges clinicians will face in communicating with patients about cancer genetics.

Changes in weight, body composition, and factors influencing energy balance among premenopausal breast cancer patients receiving adjuvant chemotherapy.

PURPOSE: Weight gain is a common problem among breast cancer patients who receive adjuvant chemotherapy (CT). We undertook a study to determine the causes of this energy imbalance. PATIENTS AND METHODS: Factors related to energy balance were assessed at baseline (within 3 weeks of diagnosis) and throughout 1 year postdiagnosis among 53 premenopausal women with operable breast carcinoma. Thirty-six patients received CT and 17 received only localized treatment (LT). Measures included body composition (dual energy x-ray absorptiometry), resting energy expenditure (REE; indirect calorimetry), dietary intake (2-day dietary recalls and food frequency questionnaires) and physical activity (physical activity records). RESULTS: Mean weight gain in the LT patients was 1.0 kg versus 2.1 kg in the CT group (P =.02). No significant differences between groups in trend over time were observed for REE and energy intake; however, a significant difference was noted for physical activity (P =.01). Several differences between groups in 1-year change scores were detected. The mean change (+/- SE) in LT versus CT groups and P values for uncontrolled/controlled (age, race, radiation therapy, baseline body mass index, and end point under consideration) analysis are as follows: percentage of body fat (-0.1 +/- 0.4 v +2.2 +/- 0.6%; P =.001/0.04); fat mass (+0.1 +/- 0.3 v +2.3 +/- 0.7 kg; P =.002/0.04); lean body mass (+0.8 +/- 0.2 v -0.4 +/- 0.3 kg; P =.02/0.30); and leg lean mass (+0.5 +/- 0.1 v -0.2 +/- 0.1 kg; P =.01/0.11). CONCLUSION: These data do not support overeating as a cause of weight gain among breast cancer patients who receive CT. The data suggest, however, that CT-induced weight gain is distinctive and indicative of sarcopenic obesity (weight gain in the presence of lean tissue loss or absence of lean tissue gain). The development of sarcopenic obesity with evidence of reduced physical activity supports the need for interventions focused on exercise, especially resistance training in the lower body, to prevent weight gain.

Women's interest in chemoprevention for breast cancer.

BACKGROUND: Chemoprevention is the use of pharmacologic or natural agents to inhibit the development of cancer. Tamoxifen citrate is the only approved chemopreventive agent for breast cancer. We sought to determine whether women are interested in taking a drug to prevent breast cancer and to assess the relationship between objective and subjective breast cancer risk and interest in chemoprevention. METHODS: We conducted telephone interviews (November 3, 1997, to May 6, 1998) among a community sample of women aged 40 to 45 and 50 to 55 years enrolled in a randomized controlled trial to evaluate the efficacy of a tailored mammography decision aid. Objective breast cancer risk was measured using the 5-year Gail score. Subjective breast cancer risk was measured using perceptions of absolute risk, perceptions of comparative risk, and worry about getting breast cancer. At 12-month follow-up (November 2, 1998, to July 20, 1999), we measured interest in taking a drug to prevent breast cancer. RESULTS: Among the 1273 women surveyed, 23% were interested in taking a drug to prevent breast cancer; 8% were potentially eligible for tamoxifen therapy (5-year Gail score > or = 1.66%). Eligibility for chemoprevention, based on the 5-year Gail score, was not associated with interest in taking a drug to prevent breast cancer. Women who were worried about breast cancer were 3 times more likely to be interested in taking a drug to prevent breast cancer than those who were not worried. CONCLUSION: Women's interest in chemoprevention might arise more from worries about getting breast cancer than from their objective risk factors.

Is there a use for tailored print communications in cancer risk communication?

The manner of presentation of cancer risk information is critical to its understanding and acceptance by the individual recipient. Optimal communication of cancer risk information must effectively translate the technical meaning and subtleties of risk and its associated factors to a conceptual level understandable by the recipient. Tailored print communications (TPCs) may be an appropriate medium for cancer risk communication (CRC). TPCs are more refined than targeted communication materials. They are print materials created especially for an individual on the basis of knowledge about that person. The goal is to provide individually relevant and appropriate information. This review examines the nature of TPCs, assesses the use and potential of TPCs for the purpose of CRC, and highlights new directions in CRC. Articles dealing with TPCs were located by searching the MEDLINE(R) and PsychInfo(R) databases and seeking in-press articles. TPCs were identified for several areas of CRC, including dietary change, smoking cessation, mammography use, hormone replacement therapy, health risk appraisal, and genetic susceptibility to cancer. Although TPCs have been used in a number of different behavioral areas, they have not yet achieved their potential for CRC. The use of TPCs in the communication of cancer risk shows great promise, however, particularly as knowledge evolves regarding both the nature of risk and the most effective tailoring of health communication messages.

The psychosocial consequences of mammography.

Increasing numbers of mammograms being performed in the United States will be accompanied inevitably by an increasing number of false positives. According to reliable estimates from a survey of radiology facilities, U.S. women in their forties experience close to one million false positive mammograms every year. To determine the impact of false positive mammograms and the broader psychological impact of mammography, we conducted literature searches of Medline, CancerLit, and PsycInfo. We identified nine studies examining the impact of false positive mammograms. Most found short-term increases in such psychological measures as anxiety, distress, and intrusive thoughts. One study found substantial effects on these measures three months after an abnormal mammogram. Another study found an 18-month impact on anxiety. Few studies have used behavioral outcomes, but one reported overpractice of breast self-exam among women who had received false positive results. Another found no reduction in adherence to mammography among women who have had an abnormal test. The more general mammography literature suggests that many women are anxious about mammography before the exam; women with lower levels of education, African Americans, and women with a family history of breast cancer may be more vulnerable to distress. Unfortunately, this literature suffers major limitations, such as small sample sizes, inconsistent and sometimes inappropriate measures, variations in the time frames for measurement, few studies with women aged 40-49, and a paucity of U.S. research. More research is needed to characterize at-risk women and to test interventions designed to reduce the negative impact of abnormal mammograms. Improved communication is also needed throughout the entire mammography process.

Results of an antismoking media campaign utilizing the Cancer Information Service.

In this paper, results are presented on the response to an antismoking media campaign designed to encourage women cigarette smokers with young children to call for information on quitting. The intervention campaign used a mix of professionally produced broadcast and print materials that encouraged smokers to call the National Cancer Institute's Cancer Information Service (CIS) for information on quitting. The campaign was implemented in seven media markets in New York state, Pennsylvania, and Delaware; each of these markets was paired with a control market in one of the three states. Response to the campaign was gauged by monitoring calls to the New York and Pennsylvania area CIS offices from smokers residing in intervention and control media markets. Results from the 46-week campaign show that the number of calls for smoking-cessation information was five times greater from intervention markets than from control markets. The campaign also was successful in reaching the target audience of mothers of young children. Twenty-nine percent of calls received from intervention markets were from the target audience compared with 10% from the control markets. Forty-four percent of all calls received from intervention markets came during a 5-week period when time was purchased to air television spots.

Older callers to the Cancer Information Service.

Cancer incidence and mortality are disproportionately high in older adults, yet most public service campaigns have not been directed explicitly at this population. We analyzed Cancer Information Service (CIS) call data from the years 1983-1990 to characterize callers age 60 years and over. Of 1,091,809 calls from which the age of the caller was ascertained, 206,104 (19%) were from this age group. Most older callers learned of the CIS from the telephone book, television, and brochures or pamphlets. In addition, we examined calls specifically from 1990 to ascertain recent trends in CIS utilization. Comparisons also were made between callers 60 and older and those 40-59. Additional targeting could increase calls from older adults.

Reduced rates of metabolism and decreased physical activity in breast cancer patients receiving adjuvant chemotherapy.

Weight gain, a common side effect among breast cancer patients receiving adjuvant chemotherapy, may decrease quality of life and impair survival. Weight gain during treatment is a well-known problem and has been studied by many investigators. However, few controlled studies have been conducted to determine reasons to explain this apparent energy imbalance. An exploratory study was undertaken to quantitate potential changes in energy intake and specific components of energy expenditure in breast cancer patients receiving adjuvant chemotherapy. The research hypothesis was that a reduction in resting metabolic rate (RMR) would be observed during the period in which women received adjuvant chemotherapy. Twenty premenopausal patients with stage I or II breast cancer and receiving cyclophosphamide+doxorubicin+5-fluorouracil; cyclophosphamide +methotrexate+5-fluorouracil+/-doxorubicin; doxorubicin +cyclophosphamide+/-leucovorin; or methotrexate+5-fluorouracil +leucovorin chemotherapy were recruited. RMR, diet-induced thermogenesis, energy intake, physical activity, and body composition were assessed before the initiation and throughout the course of therapy. Complete data on 18 subjects suggest that RMR decreased significantly from baseline to midtreatment (P = 0.02) and rebounded to levels similar to those at baseline on completion of chemotherapy. Overall, levels of physical activity and energy intake also decreased significantly during treatment compared with baseline levels (P = 0.04 and P = 0.03, respectively). These findings suggest that chemotherapy provokes many significant changes in body composition and metabolic requirements. Additional research in this area will provide valuable insight into creating optimal interventions to curb weight gain in women with breast cancer.

Relationships among objective and subjective risk for breast cancer and mammography stages of change.

This study examined the relationships among objective and subjective risk for breast cancer and mammography stages of change as defined by the Transtheoretical Model. Women who had higher objective risk of breast cancer, as defined by the Gail et al. algorithm (M. H. Gail et al., J. Natl. Cancer Inst., 81: 1879-1886, 1989), were more likely to perceive themselves at greater subjective risk for breast cancer. Among the components of objective risk, family history of breast cancer was the only significant predictor of subjective risk. Both objective and subjective risk individually predicted stages of change, such that higher objective and subjective risk were associated with an increased probability of being in a later stage of adopting mammography. However, when objective and subjective risk were included in a multivariate model, only subjective risk predicted stages of change. In additional multivariate analyses, subjective risk continued to predict mammography stages of change when "con" and "decisional balance" scores were included in separate models. These results suggest that future research may benefit from the explicit integration of personal risk perceptions with elements of the Transtheoretical Model to provide more powerful accounts of behavioral change processes.

Communicating breast cancer risks to women using different formats.

Using a pre-post test design with a baseline, laboratory, and a 6-month follow-up, we communicated women's objective breast cancer risks, based on the Gail Model, using two formats: (a) range of risks (e.g., risk of breast cancer can be as low as 1% and as high as 5%); and (b) as a point estimate (e.g., your risk of breast cancer is 3%). We examined how these presentations individually and jointly affected women's perceived lifetime breast cancer risks. Overall, providing risk estimates either as a range of risks or as a point estimate lowered women's perceived lifetime risks compared with women who did not get information presented this way shortly after receipt of this information relative to baseline. At the 6-month follow-up, perceptions of lifetime risks generally returned to their baseline values. Overall, women viewed their risk feedback, whether presented as a point estimate or as a range of risks, as equally credible, trustworthy, accurate, and personally relevant. These results suggest that women evaluate risk feedback containing either point estimates or range of risks as equally acceptable. Both formats lead to short-term reductions in perceived risk (i.e., greater accuracy).

Effectiveness and cost-effectiveness of multiple outcalls to promote mammography among low-income women.

A multiple outcall approach based on the Transtheoretical Model was used to encourage mammography behavior in low-income women in the state of Colorado. Women (n = 983) were recruited in person at grocery and discount stores and were then called over the telephone to receive the multiple outcall intervention. These women were compared with 3,080 women who were recruited by telephone and randomly assigned to three study groups: health survey only (control); single outcall; or advance card + single outcall. Subsequent mammography behavior was assessed through a telephone interview conducted 6 months after initiation of the protocol. After controlling for baseline differences between groups in age, education, income, health status, and previous mammography behavior, the multiple outcall intervention was significantly related to mammography behavior among women nonadherent at baseline (odds ratio, 2.58; 95% confidence interval, 1.45-4.60). Furthermore, women who received the multiple outcall intervention had higher "stage of change" at follow-up and more positive attitudes toward mammography. Cost-effectiveness analysis indicated that although the multiple outcall intervention was more costly to deliver ($14.84 per subject compared with about $7.00 for the single outcall interventions), it cost considerably less per subject converted from nonadherent to adherent. Despite study design limitations, the multiple outcall intervention appears to be an effective method of promoting mammography among previously nonadherent women. The results suggest that a combined approach, in which nonadherent women receive multiple calls promoting screening behavior, followed by single calls at the appropriate intervals to promote repeat screening, may be a useful strategy in defined populations.

Impact of an HMO-based intervention to increase mammography utilization.

A health maintenance organization (HMO)-based program designed to increase breast cancer screening was evaluated, focusing on changes in mammography utilization. The program consisted of a multistage intervention aimed at women members and primary care physicians of the HMO. This report examines the effect of the intervention on mammography utilization. The program was evaluated using a quasiexperimental design in which a random sample of women aged 50-74 from the HMO (intervention) was compared to a similarly aged geographic control group selected through random digit dialing. From 1988 to 1990, 450 intervention women and 450 control women were sampled (without replacement) each year and surveyed about breast cancer screening practices and related knowledge. A clear increase in self-reported mammography utilization was associated with the intervention. The percentage of women who reported a mammogram in the 12 months prior to the survey increased from 41% in 1988 (baseline) to 68% in 1990 among HMO women, compared to a change from 39% to 49% among control women. Comparing postintervention rates of mammography in HMO versus control women yielded a rate ratio (RR) of 1.4. However, this effect was strongly modified by income and race. Women with annual incomes of $31,000 or more showed little (whites, RR = 1.2) or no (blacks, RR = 1.0) effect of the intervention. Among women with incomes less than $31,000, the effect among whites (RR = 1.9) was much stronger than among blacks (RR = 1.2).

Relationships among breast cancer perceived absolute risk, comparative risk, and worries.

When trying to predict breast cancer screening, it may be important to understand the relationships between perceived breast cancer risks and worries about getting breast cancer. This study examines the extent to which women's worries about breast cancer correlate with perceptions of both absolute (assessment of own) and comparative (self versus other) 10-year and lifetime risks. As part of a larger randomized intervention trial concerning hormone replacement therapy, 581 women participated in a telephone baseline survey to assess their perceptions of breast cancer risks and worries. Worries about getting breast cancer in the next 10 years and in one's lifetime were related positively to both absolute and comparative 10-year and lifetime risks. The magnitude of these relationships did not differ by time frame. Worry about breast cancer is a function of both how a woman views her own risk and how she compares her risk with that of other women. Some practitioners may encourage women to get screened for breast cancer by using emotional appeals, such as heightening women's worries about breast cancer by using risk information. Our data suggest that they should give careful consideration how best to combine, if at all, information about absolute and comparative risks. For example, if the motivation to screen is based on a sequential assessment of risk beginning with comparative and then absolute risk, creating communications that heighten perceived risk on both of these risk dimensions may be needed to evoke sufficient worry to initiate breast cancer screening.

Recruiting high risk women into a breast cancer health promotion trial.

This study sought to identify factors that facilitate or hinder participation in a breast cancer health promotion trial among high-risk women. The subjects were 271 women ages 35 years and older who had a family history of breast cancer in at least one first-degree relative. All subjects were eligible for participation in a randomized trial which compares breast cancer risk counseling with general health counseling. Structured telephone interviews evaluated demographic characteristics, risk factors, risk perceptions, breast cancer concerns, and past screening practices. The results showed that education level was a key determinant of the importance of these factors in participation. Logistic regression modeling indicated that women with a high school education or less were most likely to participate if: (a) their relatives' diagnoses had greatly increased their perceptions of their personal risks [OR (OR) = 4.1], particularly if they perceived that risk to be very high (OR for interaction = 6.4); and (b) if they were ages 40-49 years versus 35-39 or 50 + years (OR = 2.6). By contrast, among women with education beyond high school, participation was predicted by (a) marital status (OR = 2.6), (b) employment (OR = 0.03 for employed), (c) number of affected relatives (OR = 0.07 for 1 versus 2 first-degree relatives), and (d) previous biopsy (OR = 0.42). These findings suggest that recruitment strategies that tailor messages to women's educational levels might be most effective.

Why do women's attitudes toward mammography change over time? Implications for physician-patient communication.

The present study examines women's decision making about mammography over a 1-year period, using "decisional balance," a summary of women's positive and negative perceptions about mammography derived from the Transtheoretical Model (TTM). Data were from a survey of women ages 50-74 years who completed both the baseline and 1-year follow-up telephone surveys (n = 1144) for an intervention study to increase the use of mammography screening. A shift toward less favorable perceptions about mammography was related to being a smoker and not having a recent clinical breast examination and Pap test. Change in women's attitudes toward mammography was also related to four dimensions of a woman's information environment. Women who rated the opinions of a physician as somewhat or not important, those who reported that at least one family member or friend discouraged them from having a mammogram, and women who felt they lacked enough people in their social network with whom they could discuss health concerns were less likely to express favorable attitudes about mammography over 1 year. In contrast, women who consistently communicated the value of mammography to others expressed more favorable views of screening over the study period. Interventions designed to promote breast cancer screening must recognize that a woman not only reacts to mammography information provided by significant others in her social network but may proactively reach out to others as an advocate of breast cancer screening, thus reinforcing or changing others' opinions or behavior as well as her own.

Genetic testing for breast cancer susceptibility: awareness and interest among women in the general population.

Previous research has suggested that demand for genetic testing for breast cancer susceptibility may be quite high, even among those at relatively low risk of carrying a mutation. This study examined the extent to which a group of female HMO enrollees were aware of the discovery of the BRCA1 gene and, without having received detailed information about the test, whether they would be interested in being tested to find out if they have the gene. Factors associated with awareness of and interest in testing were also examined. Four hundred seventy-three women age 50 and over, almost all of whom did not have an increased risk of breast cancer based on family history, were surveyed by telephone. Fifty-one percent of respondents had heard about the discovery of a breast cancer gene. In logistic regression analysis, women who described themselves as comfortable financially, had at least some college education, and were premenopausal were more likely to have heard of the gene discovery than women who were not comfortable financially, had no more than a high school education, and were postmenopausal. Sixty-nine percent of the respondents said that they would be interested in being tested to find out if they had a breast cancer gene. Women who were younger than 60, white, believed their family would benefit if they had a mammogram, and believed that regular mammograms give them a feeling of control over their health, were more likely to be interested in testing than those who were 60 or older, African-American or other, and did not believe that their family would benefit if they had a mammogram or that mammograms give them a feeling of control over their health. These findings have implications for education and counseling. Women who express an interest in being tested must be made fully aware of the limitations and possible consequences of testing. Special efforts may be needed to make information about testing available to women who have low levels of education.