Health literacy and pap testing in insured women.

Several studies have found a link between health literacy and participation in cancer screening. Most, however, have relied on self-report to determine screening status. Further, until now, health literacy measures have assessed print literacy only. The purpose of this study was to examine the relationship between participation in cervical cancer screening (Papanicolaou [Pap] testing) and two forms of health literacy-reading and listening. A demographically diverse sample was recruited from a pool of insured women in Georgia, Massachusetts, Hawaii, and Colorado between June 2009 and April 2010. Health literacy was assessed using the Cancer Message Literacy Test-Listening and the Cancer Message Literacy Test-Reading. Adherence to cervical cancer screening was ascertained through electronic administrative data on Pap test utilization. The relationship between health literacy and adherence to evidence-based recommendations for Pap testing was examined using multivariate logistic regression models. Data from 527 women aged 40 to 65 were analyzed and are reported here. Of these 527 women, 397 (75 %) were up to date with Pap testing. Higher health literacy scores for listening but not reading predicted being up to date. The fact that health literacy listening was associated with screening behavior even in this insured population suggests that it has independent effects beyond those of access to care. Patients who have difficulty understanding spoken recommendations about cancer screening may be at risk for underutilizing screening as a result.

Underutilizers of mammography screening today: characteristics of women planning, undecided about, and not planning a mammogram.

Using concepts from the Precaution Adoption Process Model, we identified behavioral factors, sociodemographic and psychosocial variables, and beliefs about breast cancer that discriminated among women at different stages with regard to their intention to obtain mammography screening. An independent survey company conducted telephone interviews with 2,507 women aged 50 to 80 who were identified as underutilizers of mammography screening. Each underutilizer was assigned to one of three stages with regard to intention to get a mammogram: (a) definitely planning, (b) thinking about, and (c) not planning. Estimated actual risk of breast cancer, perceived risk to breast cancer, worry about breast cancer, and fear of learning from a mammogram that one has breast cancer were variables found to be significantly associated with intention to obtain a mammogram for several subgroups of underutilizing women. There are significant behavioral and psychosocial variables, beliefs and feelings about breast cancer, and demographic characteristics that distinguish underutilizing women at various stages with regard to intention to obtain mammography screening. Our findings provide new information that could help the health care professional motivate women who are not planning to utilize this preventive health measure to become regular utilizers.

Promoting mammography: results of a randomized trial of telephone counseling and a medical practice intervention.

BACKGROUND: Despite widespread promotion of mammography screening, a distinct minority of women have remained underusers of this effective preventive measure. We sought to measure the effects of barrier-specific telephone counseling (BSTC) and a physician-based educational intervention (MD-ED) on mammography utilization among underusers of mammography screening. DESIGN: This was a randomized controlled trial. Women meeting criteria for mammography underuse at baseline (grouped by practice affiliation) were randomized to a reminder control condition (RC group received annual mailed reminders), BSTC or MD-ED interventions and followed for 3 years. Underuse was defined by failure to get two annual or biannual mammograms over a 2- to 4-year period prior to a baseline survey. PARTICIPANTS AND SETTING: The study included 1655 female underusers of mammography aged 50-80 years who were members of two health maintenance organizations (HMO) in central Massachusetts. INTERVENTIONS: BSTC consisted of periodic brief, scripted calls from trained counselors to women who had not had a mammogram in the preceding 15 months. Women could receive up to three annual calls during the study. MD-ED consisted of physician and office staff trainings aimed at improving counseling skills and office reminder systems. MAIN OUTCOME MEASURE: Self-report of mammography use during the study period was the main outcome measure. Regular use was defined as > or =1 mammogram every 24 months. RESULTS: Forty-four percent in each intervention group became regular users compared to 42% in the RC group. Among subjects who had prior but not recent mammograms at baseline, BSTC was effective (OR=1.48; 95% CI=1.04; 2. 10), and MD-ED marginally effective (OR=1.28; 95% CI=0.88, 1.85). Most recent users at baseline and few never users became regular users (61% and 17%, respectively) regardless of intervention status. CONCLUSIONS: Among mammography underusers BSTC modestly increases utilization for former users at a reasonable cost ($726 per additional regular user).

The effectiveness of using standardized patients to improve community physician skills in mammography counseling and clinical breast exam.

BACKGROUND: Traditional didactic continuing education is relatively ineffective in improving physicians' clinical skills. We hypothesized that a centralized course including small group workshops utilizing standardized patients could improve clinical skills for a reasonable cost. METHODS: We designed a 5-h course aimed at improving physicians' counseling skills (re: screening mammography) and clinical breast exam (CBE) skills. The course included lectures, demonstrations, and small group skills sessions utilizing standardized patients and was offered to 156 typical community-based primary care physicians. Pre- and postcourse evaluation included in-office assessments of physician CBE and counseling performance by standardized patients and a written test of knowledge and attitudes. RESULTS: A total of 54.5% of eligible physicians participated. They improved modestly in only one of three areas of counseling skills measured (providing counseling appropriate to the patient's readiness to accept mammography, P = 0.01). The overall CBE score increased substantially from 24.8 to 34.7 (P < 0.0001). Knowledge in all areas measured and confidence in counseling patients also increased. The basic course cost $202 per physician trained. CONCLUSIONS: Most community-based primary care physicians may find small group training and in-office evaluation involving standardized patients acceptable. Such training may be more effective in improving physical exam skills than complex communication skills.

Safety and efficacy of using a single agent or a phase II agent before instituting standard combination chemotherapy in previously untreated metastatic breast cancer patients: report of a randomized study--Cancer and Leukemia Group B 8642.

PURPOSE: We undertook a prospective, randomized phase III trial to evaluate the safety and efficacy of using a phase II agent before initiating therapy with standard combination chemotherapy in metastatic breast cancer patients. PATIENTS AND METHODS: A total of 365 women with measurable metastatic breast cancer, previously untreated with chemotherapy for their metastatic disease, were randomized to receive either immediate chemotherapy with cyclophosphamide, doxorubicin, and fluorouracil (CAF) or up to four cycles of one of five sequential cohorts of single-agent drugs: trimetrexate, melphalan, amonafide, carboplatin, or elsamitrucin, followed by CAF. RESULTS: The toxicity of each single agent followed by CAF was comparable to that of CAF alone. The cumulative response rates for the single agent followed by CAF were not statistically different from those of CAF alone (44% v 52%; P = .24). However, in the multivariate analysis, patients with visceral disease had a trend toward lower response rates on the phase II agent plus CAF arm (P = .078). Although survival and response duration also were not statistically significantly different between the two study arms (P = .074 and P = .069, respectively), there was a suggestion of benefit for the CAF-only arm. CONCLUSION: The brief use of a phase II agent, regardless of its efficacy, followed by CAF resulted in response rates, toxicities, durations of response, and survival statistically equivalent to those seen with the use of CAF alone. These findings support the use of a new paradigm for the evaluation of phase II agents in the treatment of patients with metastatic breast cancer.

Confirmatory analysis of opinions regarding the pros and cons of mammography.

This investigation extends prior research to apply decision-making constructs from the transtheoretical model (TTM) of behavior change to mammography screening. Study subjects were 8,914 women ages 50-80, recruited from 40 primarily rural communities in Washington State. Structural equation modeling showed that favorable and unfavorable opinions about mammography (i.e., pros and cons) fit the observed data. Analysis of variance supported the associations between readiness to obtain screening (i.e., stage of adoption) and opinions about mammography (i.e., decisional balance) previously found in research using smaller samples from another geographic region. This report extends these earlier studies by using structural equation modeling, opinion scales based both on principal component analyses and on a priori definitions, a developmental sample and a confirmatory sample, and by sampling from a different geographic region. It is recommended that future research examine whether opinions regarding the cons of mammography are more individually specific than the pros.

Breast cancer screening: early recognition.

The epidemic of breast cancer and the availability of tools to increase early detection and decrease mortality require care and diligence on the part of every physician directly caring for patients. With the widespread implementation of managed care, primary care physicians are in the best position to recommend breast cancer screening. Educational programs to emphasize the primary care physician's role in breast cancer prevention and detection, to improve physical examination skills, and to implement office systems to facilitate screening should be available to primary care physicians, and may have a major impact on breast cancer mortality in the future.

Amonafide: An active agent in the treatment of previously untreated advanced breast cancer--a cancer and leukemia group B study (CALGB 8642).

Amonafide is a new imide derivative of naphthalic acid. The drug had demonstrated significant activity in preclinical studies and some activity in Phase I trials. The drug is extensively metabolized and detected in plasma and urine. Its toxicity has previously been correlated to the formation of an active metabolite, N-acetyl-amonafide. Amonafide was chosen for inclusion in the Cancer and Leukemia Group B (CALGB) master metastatic breast cancer protocol. CALGB 8642 randomizes previously untreated metastatic breast cancer patients either to one of several Phase II agents given for up to four cycles and then followed by standard cyclophosphamide-doxorubicin-5-fluorouracil, or to immediate treatment with standard cyclophosphamide-doxorubicin-5-fluorouracil. The end point of CALGB 8642 is to assess the difference in survival, toxicity, and overall response when limited exposure to Phase II agents precedes standard chemotherapy. This report deals only with amonafide as a Phase II agent. Comparisons with the cyclophosphamide-doxorubicin-5-fluorouracil arm will not be addressed. Patients had to have histologically documented measurable breast cancer and a performance status of 0-1. Patients could not have had prior chemotherapy for metastatic disease. Prior adjuvant chemotherapy was permitted. Patients could not have visceral crisis. Amonafide was given at 300 mg/m2/day i.v. for 5 days, and repeated at 21-day intervals for a maximum of four cycles. Escalation and reduction in dose was mandated dependent on hematotoxicity or lack thereof. Toxicity was primarily hematological and bimodal: 32% had grade 3 or 4 leukopenia and 24% had grade 3 or 4 thrombocytopenia; 22% had no leukopenia and 44% had no thrombocytopenia. The response rate was 18%, including one complete response. When response was analyzed by hematological toxicity, there was a 35.7% response if patients had leukopenia grade 3/4 (versus 8.3%, P = 0.08). There was a 50% response if patients had thrombocytopenia grade 3/4 (versus 7.1%, P = <0.01). We conclude that amonafide is somewhat active in previously untreated breast cancer patients. There may be a steep dose-response curve, based on the significant correlation between myelosuppression and response. Rates of responses in patients adequately dosed (i.e., with significant hematotoxicity) with amonafide ranged from 35 to 50%. Further studies will incorporate individualized dosing based on pretreatment acetylator phenotyping.

Can practicing physicians improve their counseling and physical examination skills in breast cancer screening? A feasibility study.

OBJECTIVE: To improve breast cancer screening skills, practicing non-academic primary care physicians were offered an opportunity to participate in a one-hour private skills-assessment session with a patient instructor. Research questions included: would physicians in non-academic practice be interested in a skills course; would the course improve their skills in breast examination and/or in counseling for mammography; and if they did improve, would the effect endure? DESIGN: Pilot study with cohort follow-up. INTERVENTIONS: Physicians were offered an opportunity to have their counseling and physical examination skills evaluated in a one-on-one interaction with standardized patients. The protocol included patient instructors who were trained to use a uniform breast health history that emphasized their increased risk of breast cancer, scant knowledge of breast-cancer screening, and fear of medical tests and cancer. The standardized patients were trained using a 77-point checklist. They demonstrated a high degree of consistency and reproducibility. A critical part of the learning experience was immediate feedback to the physicians regarding their performances. Physicians who took the course were given an opportunity to repeat it approximately 18 months later. MEASUREMENTS AND MAIN RESULTS: Of the 82 primary care physicians in the community, 49 (60%) were eligible to have their skills evaluated. Of these, 38 (77.6%) participated in the intervention. Baseline skills had mean scores (correct responses) better than 50% in most aspects of the physical examination but less than 35% in several critical counseling areas: reviewing mechanics of getting mammography, actually recommending mammography, and directing the patient regarding scheduling. Of the 38 physicians, 15 repeated the course. There was a significant improvement in their overall performance: 49% vs 67% (p = 0.002). CONCLUSIONS: Primary care physicians in a non-academic practice are interested in reviewing and improving their counseling skills. They are capable of improving their skills after receiving background information, instruction, and brief feedback. They maintain these improvements over time.

Issues in breast cancer screening in older women.

Screening is a way of detecting disease early in an asymptomatic population. For cancer screening to be effective, there not only must be a test that will detect cancer earlier, but there also must be a treatment that will result in an improved outcome. The strongest evidence for screening benefit comes from randomized prospective trials with a decrease in mortality as the outcome. For women older than 69 years of age, there is no direct scientific evidence that screening mammography will decrease their mortality from breast cancer. If there is no direct evidence (positive or negative), what can we say about any potential benefit for older women? The Forum on Breast Cancer Screening in older women (held in Sturbridge, Massachusetts, in 1990 and sponsored by the National Cancer Institute and the National Institute of Aging) systematically reviewed a number of issues that were considered to have an indirect but positive impact on the benefit of screening mammography--incidence (which rises dramatically with age), mortality (greater in women older than 65), mammography detection (enhanced in breasts of older women), and elderly survival rates (the average women older than 65 lives long enough to benefit from screening). Unresolved issues were the proper interval for screening (12 vs. 24 vs. 33 months) and the extent to which clinical breast examination contributes to a decrease in mortality. Clinical research in the form of a national trial is needed, because the recommendations to initiate or continue screening mammography in women older than 65 is based not on scientific evidence but on opinion.

The extent of breast cancer screening in older women.

Women 65 and older present a unique challenge to health professionals, particularly with respect to breast cancer screening. These women are at the highest risk for developing breast cancer; they represent 50% of all newly diagnosed breast cancers. This group represents 60% of the breast cancer deaths, however, demonstrating how serious a disease breast cancer is in the 65-and-older age group. Moreover, the 65-and-older population cohort is growing rapidly. By 2010, it is estimated that greater than 15% of the population will be older than 65, and, as is the case now, the majority of this group will be women. Therefore, preventing breast cancer deaths in older women is a very significant and pressing issue. Ironically, most studies have reported that screening for breast cancer is less widespread in women older than 65 than in those younger than 65. Regional surveys emphasize a number of barriers, some of which seem to be age-specific--a lower level of knowledge about the usefulness and benefit of mammography, particularly in the absence of symptoms; less of a sense of personal vulnerability; fewer screening recommendations from family, friends, or physicians; and more problems with access (cost, transportation). To improve breast cancer screening rates in older women, sound health education interventions are needed to improve knowledge of and belief and attitudes regarding mammography. These should be targeted not only to older women, but also to their physicians and/or primary care givers. In addition, specific attention should be given to those barriers that are particularly burdensome for the elderly: cost, transportation problems, and loss of mobility.

Effect of a community health center intervention on breast cancer screening among Hispanic American women.

OBJECTIVE: A multiple component intervention in a community health center is presented, and its effect on breast cancer screening participation by Hispanic American women between the ages of 45 and 75 years is discussed. DATA SOURCES/STUDY SETTING: In 1990, data were collected through a retrospective audit (at least as far back as 1987) of community health center medical records, as well as from a client referral log. The health center, located in a small Massachusetts city, primarily serves clients of Latino heritage. STUDY DESIGN: The study used a nonexperimental pretest-posttest intervention design to document clients' screening activities. To control for uneven length of enrollment, aging of the population, and sporadic utilization, the unit of analysis chosen for the principle study variables was an "eligible year." DATA COLLECTION: Variables of interest included screening (clinical breast exam and mammography), periodicity of screening, and compliance with referrals. PRINCIPAL FINDINGS: Postintervention, considerably greater screening mammography occurred among all age groups, more women had at least one screening mammogram during the period, more clinical breast exams included a mammogram referral, and the compliance rate improved. The rate of clinical breast exam did not significantly improve, showing a downward trend.

Cancer prevention practices and continuing education needs of primary care physicians.

We surveyed 1,500 primary care physicians in Massachusetts regarding their current attitudes and practices, as well as their interests and preferences in regard to a continuing education course, in cancer prevention and screening. Thirty-three percent (n = 488) of physicians returned questionnaires, with equal distribution among internists, family practitioners, and gynecologists. Our findings are based on physicians' self-report: 80%-92% of physicians routinely perform or order breast, cervical, skin, prostate, and colon examinations (with the exception of proctoscopy) for asymptomatic patients 50 years of age and older. Perceived barriers reported were as follows: for mammography, patient age older than 75; for sigmoidoscopy, cost; for counseling, lack of educational materials. Ninety-one percent of physicians rated a comprehensive course on cancer detection and prevention emphasizing practical matters and offering opportunity to upgrade clinical skills in physical exam and in counseling as somewhat to very useful. Specific topic preferences varied by specialty, but first preference for all three primary care groups was a course in improving their office management of cancer prevention and screening activities. Most appealing to practitioners was a one-day course leading to accreditation in screening and prevention and to reduction in malpractice premiums.

Impact of a breast cancer screening community intervention.

BACKGROUND: Efforts to detect breast cancer in its early stages are necessary to reduce breast cancer-associated mortality. This study evaluated the impact of a multicomponent intervention implemented between 1987 and 1990 to increase a community's utilization of breast cancer screening by women over 50 years of age. METHODS: The study used a pretest/post-test two-community design, with one community assigned as the intervention community and the other as the comparison. The intervention consisted of a comprehensive physician involvement component and a community education effort. To assess the overall impact of the interventions, we measured women's participation in screening via random digit dial telephone surveys at three time points, each approximately 18 months apart. RESULTS: Over the course of the study, there were dramatic improvements in breast cancer screening participation in both communities. However, the intervention city showed more improvement in selected variables than did the comparison community in the early phases of the project between baseline and midpoint. These included increased advice by physicians to have mammograms, increased awareness that screening is necessary in the absence of symptoms, increased awareness that many women over 50 have mammograms, decreased perception of barriers to clinical breast exam, and an increase in the proportion of women having a clinical breast exam. In addition, significantly fewer women in the intervention city than in the comparison city reported never having had a mammogram at midpoint. CONCLUSIONS: The findings demonstrate limited impact of a community intervention during a period of increasing adoption of mammography screening, in part, due to this rapidly rising secular trend. Additionally, increased activities in the comparison community were documented. Therefore, as incidence of screening increases, targeted activities aimed at population subgroups are warranted, and evaluation designs need to include multiple comparison groups or broader geographic random samples.

Impact of a physician intervention program to increase breast cancer screening.

In order to improve compliance with the National Cancer Institute's breast cancer screening guidelines, we developed a multifaceted intervention designed to alter physician screening practice. A pre-post test, two-community design was used. Primary care physicians in one community served as the control. Data were collected by two mailed surveys (1987 and 1990). Response rates were 61% and 64%, respectively. The physician intervention program consisted of a hospital-based continuing medical education program and an outreach component which focused on implementing a reminder system. Outcome measures were self-reported attitudinal, knowledge, and screening practices changes. In spite of an impressive change in comparison community physicians' practice, the difference in change over time in the intervention community physicians' ordering of annual mammography compared to the change in the comparison community physicians' ordering was significant (P = 0.04). The adjusted odds ratio is nearly 8. We conclude that our in-service continuing medical education program was successful in improving breast cancer screening practices among primary care physicians.