Breast cancer screening of the medically underserved: results and implications

Socioeconomic status is the most significant factor influencing the decreased survival associated with breast cancer in minority groups in the United States. Barriers to the use of early detection programs by low-income women often result in the detection of breast cancer at stages too advanced to assure optimum outcomes. In an effort to increase accessibility of breast cancer screening among such individuals, the Early Detection Program (EDP) was initiated in 1987. The program provided breast cancer screening to women 40 years of age and older who attended eight primary healthcare centers located in low-income neighborhoods throughout Dade County, Florida. From its inception in October 1987 through December 1993, 23,866 medically underserved women had mammography examinations, with more than 17,000 of these women undergoing baseline mammograms. Since the program's inception, 126 cancers were diagnosed in 123 women. A dramatic shift from later to earlier stage breast cancers was observed. These results warrant a greater inclusion of medically underserved and lower socioeconomic status women in screening programs for the early detection of breast cancer.     

Student and faculty collaboration in a clinic for the medically underserved

BACKGROUND AND OBJECTIVES: Growing numbers of uninsured and underinsured individuals in the United States have resulted in increased needs for health care for medically underserved populations. Educational strategies are needed that provide opportunities for students to develop the attitudes, knowledge, and skills necessary for providing quality health care for underserved patients. METHODS: Medical students, residents, and faculty of the University of Wisconsin-Madison Medical School worked together to establish extracurricular opportunities for first- and second-year students to participate in medical clinics serving the poor and homeless. The process for the development and operation of a volunteer clinic is described. RESULTS: In the last 2 years, 163 medical students, 27 residents, and 21 faculty have provided care to more than 1,000 patients. Patients, students, residents, and faculty reported high satisfaction with the experience. CONCLUSIONS: Medical students, residents, and faculty working in collaboration can provide increased access to care for the medically underserved. Engaging in community-oriented primary health care early in their medical education provided positive learning opportunities for medical students, especially those interested in generalist careers.     

Breast cancer screening and related attitudes among Filipino-American women

This study assessed mammography screening rates and related attitudes and intervention preferences in Filipino-American women, a group that has been neglected in cancer control research. Face-to-face interviews were conducted in English and Tagalog with a convenience sample of 218 Filipino women 50 years and older residing in Los Angeles. Sixty-six % had ever had a screening mammogram, 42% had had one in the past 12 months, and 54% in the past 2 years. These rates are about 20% lower than those found among African-American and white women in the 1994 California Behavioral Risk Factor Survey. Women who had received a doctor's recommendation to obtain a mammogram, women stating that they were very likely to obtain a mammogram if a physician recommended it, and women who felt very comfortable requesting a mammogram from a physician were more likely to have been screened. Women who had friends and relatives who had obtained mammograms those stating that their friends and relatives would be very supportive of their getting a mammogram, and those who felt that it was very worthwhile to obtain a mammogram were also more likely to have been screened. The following variables were negatively related to the outcome: concern over cost, the attitude that mammograms are only needed in the presence of symptoms, perceived inconvenience of taking the time and difficulties getting to the mammography facility, and embarrassment. Implications for interventions to increase breast cancer screening are discussed.     

Adherence to breast cancer screening guidelines among African-American women of differing employment status

The purpose of this study was to identify and compare the adherence to breast cancer screening guidelines [monthly breast self-examination (BSE), age-related mammography, yearly professional breast examination (PBE)] among African-American women (AAW) of differing employment status. The Breast Cancer Screening Model served as the organizing framework for this study. One hundred fifty-four subjects were quota sampled according to age and employment group status. Findings showed that 63% of all subjects practiced monthly BSE and 76% had undergone a yearly PBE. Only 20% of all subjects had undergone a mammogram according to the age-related guidelines. Overall, breast cancer screening rates were lower than recommended across all employment groups. Variables that uniquely explained 74% of the variance in monthly BSE included level of education, marital status, social influence, knowledge of BSE, and intention to do BSE in the future. Age group, previous instruction on mammography, income, and perceived barriers related to mammography explained 15% of the variance in age-related mammography. Finally, marital status, previous information on PBE, and intrinsic motivation explained 42% of the variance in yearly PBE. Together, these findings highlight the need for (a) the development of strategies that will promote long-term adherence to all three screening guidelines, and (b) the design of qualitative studies using a representative sample of AAW of differing socioeconomic backgrounds.     

A cognitive approach to child mistreatment prevention among medically at-risk infants.

The authors assessed the effectiveness of a home visitation program in enhancing the early parenting history of infants born at medical risk--a population that is at risk for mistreatment. A randomized clinical trial design was used to compare the effects of a cognitively based extension of the Healthy Start home visitation program (HV+) with a visitation condition that did not include this component (HV). In the HV+ condition, they observed (a) a lower use of corporal punishment, (b) greater safety maintenance in the home, and (c) fewer reported child injuries. The sample (N = 102) was primarily Latino; however, the effects of the intervention were not qualified by ethnicity, maternal education, or immigration status. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

WWW-based access to object-oriented clinical databases: the KHOSPAD project

KHOSPAD is a project aiming at improving the quality of the process of patient care concerning general practitioner-patient-hospital relationships, using current information and networking technologies. The studied application field is a cardiology division, with hemodynamic laboratory and the population of PTCA patients. Data related to PTCA patients are managed by ARCADIA, an object-oriented database management system developed for the considered clinical setting. We defined a remotely accessible view of ARCADIA medical record, suitable for general practitioners (GPs) caring patients after PTCA, during the follow-up period. Using a PC, a modem and Internet, an authorized GP can consult remotely the medical records of his PTCA patients. Main features of the application are related to the management and display of complex data, specifically characterized by multimedia and temporal features, based on an object-oriented temporal data model.     

Acculturation and breast cancer screening among Hispanic women in New York City

Surfactant protein D (SP-D), which has structural homology to C-type lectin binding regions, may play a role in host defense and has no known surfactant function. Because other surfactant proteins have been shown to be increased after prolonged periods of hyperoxia, we sought to evaluate the early effects of hyperoxia (95% O2) on expression of SP-D in the adult male rat lung. Animals were exposed to air or to 12, 36, or 60 h of 95% O2. Northern blot analysis of total lung RNA revealed marked SP-D mRNA increases at 12 h 95% O2 compared with air-exposed controls, with decreasing expression to near that of air-exposed animals by 60 h. Semiquantitative in situ RNA hybridization demonstrated parallel results, with increased numbers of labeled alveolar epithelial (AE) and bronchiolar epithelial (BE) cells at 12 h and increased intensity of labeled alveolar cells, compared with air-exposed controls. After 60 h of exposure to 95% O2, mRNA label intensity in AE and BE was decreased to levels near those seen in air-exposed animals. In contrast, Western blotting showed a decline in total lung SP-D with 95% O2 exposure, beginning at 12 h and continuing at 36 and 60 h, respectively. Semiquantitative immunohistochemistry demonstrated a decline in AE labeling parallel to the total lung Western blot results, but labeled total BE cell numbers increased (P = 0.10). Hyperoxia had differential effects on SP-D abundance in AE and BE cells, and therefore may influence the availability of SP-D to bind microbial pathogens in the airways depending on cell type and location.     

Comorbid survival among elderly male participants of the Canada health survey: relevance to prostate cancer screening and treatment

This study assessed the survival of a nationally representative sample of older Canadian men, taking into account common comorbid conditions. Mortality follow-up between 1978 and 1989 was conducted for male participants of the Canada Health Survey who were at least 60 years of age at baseline. The proportional hazards model and life table methods were used to examine survival by comorbidity status. Comorbid conditions examined included history of stroke and/or heart disease, high blood pressure, chronic bronchitis or emphysema, diabetes and smoking status, but excluded cancer because of small numbers. For those subjects aged 80 and older, comorbidity was not a significant predictor of survival. A large portion of men between the ages of 60 and 79, even those with pre-existing comorbid conditions, survived at least 10 years after interview. In a clinical setting, more detailed information on comorbid conditions can be obtained to better estimate long-term survival. Notwithstanding, our findings may have implications for the administration of population-based health interventions (e.g. the use of prostate-specific antigen [PSA] blood tests for the early detection of prostate cancer). In particular, our results suggest that there may be little benefit in restricting access to PSA screening based on survival probability in men under age 80.     

Cervical cancer screening: knowledge of own screening status among women aged 20-29 years

BACKGROUND: Studies have shown that accuracy of self-reported screening for cervical cancer is not optimal. In order to improve women's knowledge of their screening status and in broader terms improve communication between patient and doctor the risk groups who require special attention with regard to information have to be identified. The purpose of this study was to identify lifestyle and socio-demographic determinants for denying screening when in fact it had been performed. METHODS: A case-control study among 7,763 women aged 20-29 years from Copenhagen. Data were obtained by means of a personal interview using a standardized questionnaire and from a computerized pathology registry. Determinants for not knowing own screening status were identified using multiple logistic regression analysis. RESULTS: In all, 13% of the women could not state correctly that they had been screened for cervical cancer. The major determinant was younger age (adjusted odds ratio: 5.8, for women aged 20-22 years compared with women aged 26-29 years). Other determinants included few Pap smears, increasing years since last Pap smear, no previous abnormal Pap smear, lower education, never having used oral contraceptives, and current smoking. CONCLUSIONS: Knowledge about own screening status is not optimal in Denmark. Our study shows that doctors have to be extra careful with information to the youngest women and to certain other groups.     

Knowledge, beliefs, attitudes, and cancer screening among inner-city African-American women

Three hundred twenty-one inner-city African-American women were interviewed to determine their knowledge, attitudes, and beliefs regarding cancer and cancer screening, and their cancer screening histories. The women were recruited from a variety of sources in Atlanta and were interviewed in their homes by trained lay health workers. Half of the subjects had an annual household income of < $15,000. About half had received a Pap smear and clinical breast examination within the year preceding the interviews. For women > 35 years old, 35% had received a mammogram within the recommended interval. Younger women and women with higher incomes were more likely than older women and those with lower incomes to have received a Pap test and clinical breast examination within the preceding year, but income was not significantly associated with mammography histories. In general, women who were more knowledgeable about cancer and its prevention were more likely to have been appropriately screened. However, various attitudes and beliefs regarding cancer generally were not associated with screening histories. We conclude that cancer screening programs for inner-city minority women should focus on improving knowledge levels among older women rather than attempting to alter attitudes and beliefs.     

Laboratory tests and clinical practice: from diagnosis of an inflammatory syndrome to colon cancer screening]

The general practitioner is continually faced to the greater complexity, number, variety, and costs of available laboratory tests. The challenge is to decide in each topic what is the most important within these vast data. In a deluge of correct but relatively unimportant results, answers to questions might be hidden. This article is meant to guide clinicians to select and interpret useful laboratory tests for the diagnosis of an inflammatory process and the screening of colon cancer.     

Relations between in-treatment and follow-up abstinence among cocaine-dependent homeless persons in three clinical trials.

Clinical trials with cocaine-dependent outpatients have found a strong relation between in-treatment and follow-up abstinence, and the strength of this relation is constant across treatment conditions with variable efficacy in generating abstinence. The authors conducted secondary analyses of data from 3 clinical trials to determine whether this relation generalizes to cocaine-dependent homeless persons. The 3 trials (total N = 543) were conducted in a community health care facility for homeless people. The 7 treatment arms across the 3 trials were combinations of day treatment, abstinence-contingent housing, and vocational training. Drug use was measured with urine toxicology testing. Consecutive weeks of abstinence during treatment were strongly related to abstinence at the 12-month follow-up, whether or not missing 12-month data were included in the analysis. The treatment arms differed in their efficacy in generating abstinence, but the relation between in-treatment and follow-up abstinence did not differ across treatment arms. These results replicate earlier reports of these relations and extend them to a population of homeless people. The lack of differences between treatment arms in the in-treatment–follow-up abstinence relation implies that that relation is independent of the treatment-specific intervention components that generate group differences in abstinence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family, work, and access to health insurance among mature women

We use a life course approach to address much ignored variation in access to health insurance. Using data from the National Longitudinal Survey of Mature Women, we reinterpret the role of both family and employment characteristics in shaping coverage. Mature women are more likely to be insured as wives than as workers, but that safety net is only available to married women. As a result, unmarried women are two to three times as likely to be uninsured or to rely on public programs such as Medicaid. And because they are significantly less likely to be married to a covered worker, Black women are two to three times more likely to be uninsured or to rely on public programs. Given rising instability in employment and marital status across the life course, stable health insurance coverage can only be attained by universal rather than employment-based or family-based schemes.     

Breast cancer screening among women in their forties: an overview of the issues

This article summarizes the issues prompting a recent NIH Consensus Conference on mammography screening for women in their forties. To date, eight randomized controlled trials of breast cancer screening have been conducted, and a reduction in breast cancer mortality has emerged after 10 to 15 years of follow-up among women offered screening in their forties. No effect appears for at least eight years, and the reason for the delay, compared to that seen in women aged 50-69, is not clear. Two possibilities include cancer-stage shift due to screening in younger women and the aging of women into their fifties during the course of screening. Possible adverse effects of screening include radiation risk, although this is low, false-negative and false-positive screening tests, and overdiagnosis due to detection of ductal carcinoma in situ (DCIS). In order to make appropriate decisions regarding mammography, women need age-related information about both the benefits and potential risks of screening.     

Cues to action in prostate cancer screening

PURPOSES/OBJECTIVES: To describe factors that cue men of all ages to participate in prostate cancer screening programs and to explore the relationship of age to the rating of the cues. DESIGN: Exploratory survey. SETTING: A large community prostate cancer screening program in the Midwest. SAMPLE: 127 men (mean = 66.3 years of age) who participated in community prostate screening. METHODS: Subjects completed and returned by mail the 13-item Prostate Screening Follow-Up Questionnaire developed, piloted, and refined by the investigator for measuring the rating of the cues to action. MAIN OUTCOME MEASURES: Results of the rating of each cue to action, selected demographic variables, and comparison of the cue ratings by age group. FINDINGS: Appointment scheduling, reminder cards, a friend/family member with cancer, and newspaper promotion were perceived by the sample as most influential in their decision to have prostate cancer screening. No practical significant differences in cue ratings were found between the two age groups: 70 years of age and older and less than 70 years of age. CONCLUSION: Reminder cards, specific appointments, and newspaper promotion should be used when structuring community prostate cancer screening programs. Men who have a friend or family member with cancer may be more likely to participate in screening activities. IMPLICATIONS FOR NURSING PRACTICE: By incorporating influential cues to action into their everyday practice, nurses can be instrumental in reaching the population of men who are at risk for prostate cancer. Strategies for promoting prostate cancer screening should include: educating patients and family members about prostate cancer screening guidelines, using specific influential promotional practices when setting up prostate screening programs, and networking with seniors programs in the community.     

National cancer clinical trials: children have equal access; adolescents do not

PURPOSE: To determine whether adolescents with cancer, who in comparison to younger patients have a higher cancer incidence and lower mortality reduction, have equal access to national cancer clinical trials. METHODS: The ethnic/racial distribution of 29,859 subjects < 20 years of age entered onto National Cancer Institute-sponsored clinical trials between January 1, 1991, and June 30, 1994, was compared with the expected distribution of patients of the same age in the United States. RESULTS: The Children's Cancer Group and Pediatric Oncology Group had 29,134 (97.6%) of the total study entries among < 20-year-old subjects during the 3.5 years of surveillance. The adult cooperative groups accounted for < 3% of the clinical trials entries in the 15-19-year age range. When analyzed nationally by region, the under-representation of the older adolescent subjects was universal. From other analyses, the two pediatric cooperative groups were estimated to have registered > 94% of the children < 15 years of age who were expected to have been diagnosed to have cancer, but only 21% of the cancer patients in the 15-19-year age group. CONCLUSIONS: The national pediatric cancer cooperative groups allow the majority of American children < 15 years of age and their families equal opportunity to access clinical cancer trials, regardless of race or ethnicity. Among patients 15-19 years of age, however, > 75% are not being enrolled by any cooperative group sponsored by the National Cancer Institute. Thus, older adolescents are disadvantaged with respect to access to the national clinical trials, regardless of their race or ethnicity.     

The role of sexuality in cervical cancer screening among Chinese women.

Objective: Chinese women have significantly lower rates of Papanicolaou (Pap) testing than Euro-Canadian women despite efforts to promote testing. Evidence suggests that Chinese women's reluctance to undergo Pap testing may be related to culture-linked discomfort with sexuality. The purpose of this study was to explore the role of sexuality in the interaction between acculturation and Pap testing. Design: Euro-Canadian (n = 213) and Chinese (n = 260) female university students completed a battery of questionnaires. Main Outcome Measures: Questionnaires assessing sexual knowledge, sexual function, acculturation, and Pap testing frequency. Results: Euro-Canadian women had significantly more accurate sexual knowledge, higher levels of sexual functioning, a broader repertoire of sexual activities, and higher Pap testing rates. Chinese women were more likely to cite embarrassment as a barrier to Pap testing. Heritage acculturation, but not mainstream acculturation, predicted Chinese women's Pap testing behavior. Mainstream acculturation was associated with more accurate sexual knowledge and greater sexual desire and satisfaction. Conclusion: The findings provide support for the hypothesis that low Pap testing rates in Chinese women may be associated with heritage acculturation, although the hypothesis that sexual function would predict Pap testing behavior was not supported. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A cost-effectiveness approach to the Norwegian follow-up programme in colorectal cancer

BACKGROUND: Today, continued periodic follow-up of patients treated for colorectal cancer (CRC) seems often to be routine because of tradition, rather than its demonstrated value. Recently, the Norwegian Gastrointestinal Cancer Group (NGICG) has recommended a standard surveillance programme in this malignancy. In this protocol patients are suggested followed for four years with CEA monitoring, ultrasound of the liver, chest radiograph and colonoscopy at regular intervals. MATERIALS AND METHODS: In this study, the cost-effectiveness of this programme was addressed employing Norwegian cost data and data from the Cancer Registry of Norway. Clinical data from the existing English language literature was used in the analysis. RESULTS: The basic cost of the NGICG recommended programme was 1,232 Pounds per patient. Including extended investigation due to suspected relapse in 45% of cases, the figure raised to 1,943 Pounds per patient. The cost per life year saved was indicated to 9,525 Pounds-16,192 Pounds. The corresponding cost per quality adjusted life year (QALY) was indicated to 11,476 Pounds-19,508 Pounds. CONCLUSION: We conclude the NGICG recommended follow-up programme in CRC cost-effective. Excluding CEA monitoring may improve the cost-effectiveness.