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.     

Ethanol blocks the central action of IGF-1 to induce luteinizing hormone secretion in the prepubertal female rat

OBJECTIVE: To test the simultaneous effect of various established predictors of breast and cervical cancer screening (breast self-examination, clinical breast examination by a physician, Papanicolaou [Pap] smear, and pelvic examination) in a low-income, Mexican-American sample. MATERIAL AND METHODS: A total of 188 Mexican-American women participated in a face-to-face structured interview in their preferred language. We tested a model with four established predictors of breast and cervical cancer screening--communication skills, knowledge of cancer, access to health care (finances and availability of care), and anxiety about cancer. Simultaneous structural equations analysis was used to form latent variables and to control for the effect of all predictors concurrently. RESULTS: Screening behavior was inversely associated with anxiety about cancer when all other predictors were statistically controlled. In addition, anxiety substantially affected the relationship between communication skills and screening behavior. Unexpectedly, knowledge of cancer was positively, rather than negatively, associated with anxiety about cancer. Predictors in the model demonstrated an excellent fit of the proposed model to the data. CONCLUSION: Successful cancer screening programs for Mexican-American women must address not only access barriers but also communication skills, knowledge, and, perhaps most importantly, anxiety.     

Potential contribution of screening to cancer mortality reduction

The objective of screening for cancer is to reduce mortality or to improve quality of life. Screening is practiced for several anatomical sites and by several tests. Only cervical cancer screening based on cytological smears has been shown to be effective as a public health policy. Screening for breast cancer based on mammography was shown to reduce mortality in several randomized trials and nonexperimental studies. However, no data are available on its effectiveness at population levels in terms of a public health policy. There are several other valid tests. Application of these tests has failed to demonstrate a reduction in mortality or such an application was never tried and tested. This emphasizes that the prerequisite for effective screening is that the total program is valid and not only the test. At present, knowledge on screening is not fully applied in most European countries. Regular screening for cervical cancer will result in a 90% reduction in the risk of invasive disease. It is likely that the protective effect for breast cancer is about 30%. At the population level, smaller protections are to be expected, and well-organized screening programs are likely to reduce the total cancer death rate by 6 to 10% among females.     

Improving utilization of breast and cervical cancer screening in your office practice

It has been well documented that early detection and early intervention for breast and cervical cancer saves lives. However, the challenge is to ensure that physicians' practices are effective in implementing the standard guidelines for screening and that all women are screened and undergo appropriate follow-up. Early detection and intervention are imperative since African-American women are twice as likely as European-American women to die from breast cancer even though the incidence of breast cancer is lower. African-American women have fewer mammograms and are being diagnosed later after metastases have occurred. Studies also show that women are more likely to have mammograms if their physicians so advise. However, the most common reason women give for not obtaining mammograms is, "My doctor never recommended it." By using a simple critical path analysis tool to systematically evaluate an office practice and by implementing practical, simple principles, a physician can increase utilization of breast and cervical cancer screening.     

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.     

Breast cancer screening programmes in 22 countries: current policies, administration and guidelines. International Breast Cancer Screening Network (IBSN) and the European Network of Pilot Projects for Breast Cancer Screening

BACKGROUND: Currently there are at least 22 countries worldwide where national, regional or pilot population-based breast cancer screening programmes have been established. A collaborative effort has been undertaken by the International Breast Cancer Screening Network (IBSN), an international voluntary collaborative effort administered from the National Cancer Institute in the US for the purposes of producing international data on the policies, funding and administration, and results of population-based breast cancer screening. METHODS: Two surveys conducted by the IBSN in 1990 and 1995 describe the status of population-based breast cancer screening in countries which had or planned to establish breast cancer screening programmes in their countries. The 1990 survey was sent to ten countries in the IBSN and was completed by nine countries. The 1995 survey was sent to and completed by the 13 countries in the organization at that time and an additional nine countries in the European Network. RESULTS: The programmes vary in how they have been organized and have changed from 1990 to 1995. The most notable change is the increase in the number of countries that have established or plan to establish organized breast cancer screening programmes. A second major change is in guidelines for the lower age limit for mammography screening and the use of the clinical breast examination and breast self-examination as additional detection methods. CONCLUSION: As high quality population-based breast cancer screening programmes are implemented in more countries, they will offer an unprecedented opportunity to assess the level of coverage of the population for initial and repeat screening, evaluation of performance, and, in the longer term, outcome of screening in terms of reduction in the incidence of late-stage disease and in mortality.     

Characteristics of men reporting for prostate cancer screening

A survey to determine demographics, prostate cancer screening practices, and prostate cancer-related knowledge and beliefs was administered to over 1,700 participants at five sites during Prostate Cancer Awareness Week (1991) screening events. Findings are presented by site since significant differences in demographics existed. Results suggest that screenings conducted at the major medical centers attract primarily white males, a number of whom already practice adequate secondary prevention. Thus, if optimal benefit is sought through mass prostate cancer screening, innovative strategies to reach populations that are currently underserved and at risk are necessary.     

Socioeconomic status and cancer screening

The only widely applied cancer screening programmes are those for cancers of the cervix and female breast. Participation in breast cancer screening has been shown to depend on income and education, health insurance and type of health service. Women in low social classes tend to have lower screening participation rates than those in higher classes. Socioeconomic differences in screening practices tend to decrease when participation is promoted, cultural and economic barriers are removed, and social support is offered. In both developed and developing countries, women of low socioeconomic status have a higher than average risk of cervical cancer, and a lower than average participation in Pap smear screening.     

The North Carolina Breast Cancer Screening Program: foundations and design of a model for reaching older, minority, rural women

Breast cancer screening programs do not reach all women at the same rate. Screening mammography use varies according to sociodemographic characteristics; mammography utilization is highest among women in their fifties but then decreases with age. In North Carolina, breast cancer is a particular burden for Black and lower-income women. Black women are more likely to be diagnosed with late stage disease, and their rate of breast cancer mortality is higher than it is for White women even though the incidence in White women is greater. Older, Black, and low-income women are less likely to obtain screening by mammography and clinical breast examination. The Black-White gap is even more pronounced among rural women, in part because they are more likely to be poor. The North Carolina Breast Cancer Screening Program (NC-BCSP) was established to increase the rate of regular mammography screening by an absolute 20% in 3 years among older Black women ages 50 and older in five rural counties in the eastern part of the state. In this paper, we describe the genesis of this comprehensive community intervention model, highlighting the behavioral science constructs, health education principles, and theories of behavioral and organizational change that form its conceptual foundation. NC-BCSP's theoretical foundations include the social ecological perspective, the PRECEDE model of health promotion, the Health Belief Model of individual change, and the "stages of change" transtheoretical model. We also review the experiences and lessons learned from two previous outreach initiatives in North Carolina that provided valuable "lessons" in the development of the NC-BCSP intervention model. In the second half of the paper, we describe the actual NC-BCSP interventions, activities, and evaluation tools, citing specific examples of how the underlying theories are implemented. NC-BCSP's goal goes beyond individual behavior change to raise low mammography screening rates among Black women in rural North Carolina. Its ultimate objective is to create linkages across agencies, and between agencies and communities, that will endure after the research project ends.     

Narratives of breast symptom discovery and cancer diagnosis: psychologic risk for advanced cancer at diagnosis

In spite of cancer screening programs, women continue to present with advanced breast cancer. How do women decide whether and when to seek an evaluation for self-discovered symptoms? This study examined 104 narratives told by 80 Anglo-, Latina-, and African-American women who participated in 1 of 16 community-based focus groups. The women's narratives contained powerful thematic messages about breast cancer and their expected behavior in the event of a self-discovered breast symptom. Narrative explanations that predicted an increased likelihood of advanced disease at diagnosis included these factors: incorrect symptom attributions and risk estimations; reluctance to consider the threat posed by the symptom; failure to tell another person about the symptom; and expectations of abandonment by male partners, deportation, prejudice, and refusal of treatment due to poverty. Stories of advanced breast cancer also told of reliance on alternative healing, concerns about overwhelming family resources, and extreme modesty that inhibited obtaining a physical examination. Interventions aimed at earlier detection of breast cancer must connect with the beliefs and assumptions embedded in these narratives, provide pragmatic solutions for perceived constraints on seeking evaluations of self-discovered symptoms, and explore the use of community narratives to confirm the value of early detection of breast cancer.     

A summary of cancer screening guidelines

Guidelines and programs for the early detection of cancer or cancer screening are based on the premise that outcomes are improved if the cancer is diagnosed and treated at the early stages of disease. However, there are also disadvantages to the early detection of cancer that must be considered when evaluating and establishing guidelines and programs. The Cancer Bureau of the Laboratory Centre for Disease Control at Health Canada has compiled a summary of existing guidelines for the early detection of various cancers. Recommendations have been provided by governmental organizations, non-governmental organizations, health agencies and professional associations. Many organizations base their guidelines on current evidence and periodically update them as new evidence becomes available. Therefore, it is our intention to revise this compilation in the future to reflect any updates. Guidelines for the early detection of cancer are listed in the tables that follow for 12 different cancer sites: breast, cervical, prostate, colorectal, ovarian, skin, testicular, gastric, lung, pancreatic, bladder and oral cancers.     

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

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

Pre-treatment with misoprostol increases the efficacy of omeprazole plus amoxycillin to cure Helicobacter pylori infection. A pilot study

The members of the European Group for Breast Cancer Screening have considered the use of ultrasound in breast diagnosis and breast cancer screening. After wide consultation and a detailed literature review, the consensus of the Group on the role of ultrasound is as follows: current evidence indicates that ultrasound of the breast is an important adjunct to mammography and clinical examination in the further assessment of both palpable and impalpable breast abnormalities. However, the use of ultrasound in population screening of asymptomatic women is associated with unacceptably high rates of both false positive and false negative outcomes. At present there is little evidence to support the use of ultrasound in population breast cancer screening at any age.     

Workshop on screening for cancer of the uterine cervix in Central America

This article describes the objectives and content of a workshop held in Managua, Nicaragua, during November 1995, on screening for cervical cancer. The aims were to discuss cost-effective models of screening in countries with a high incidence of cervical cancer and to reach a consensus on principles for screening that is balanced with a country's resources. The workshop aimed to develop a planning framework and to identify program strengths and weaknesses by country. In 1990 there were 25,000 deaths due to cervical cancer in Central America; even so, most countries attach a low priority to cervical cancer screening. Workshop plenary sessions were devoted to discussions about the natural history of cancer of the cervix and the implications for screening, the high costs of human papillomavirus (HPV) tests, approaches to national registries of cervical cancer, screening issues in Central America, downstaging, laboratory quality control issues, treatment of abnormalities, recruitment of women, and IEC. This report includes individual country program reports for Nicaragua, Panama, Haiti, the Dominican Republic, Guatemala, Honduras, and St. Vincent and the Grenadines. Participants concluded that priority should be placed on education about cancer and cancer of the cervix and education of primary health care professionals. It was agreed that all participating countries should begin pilot programs adapted to resource availability, with the idea of a later nationwide expansion. Health care professionals who treat women during the prime reproductive years should use the opportunity to identify women at high risk of invasive cancer. There is overcoverage of women aged under 35 years and insufficient coverage of women aged 35-64 years. Health programs need to enlist the help of women's groups in creating a need and demand in communities. Cytology laboratories need to provide quality services.     

A prototype multidisciplinary cancer screening clinic for the military medical facility

Optimal treatment of cancer depends upon early diagnosis. With an aging retiree and dependent population, cancer diagnosis and management must be addressed by military medical treatment facilities (MTFs) in a coherent and cost-effective fashion. A prototype multidisciplinary cancer screening clinic is described which interdigitated MTF and local American Cancer Society resources. Sites screened included breast, prostate, skin, cervix, and oral cavity, with mammograms, prostate-specific antigens, PAP smears, and physical exams, as appropriate. Of 194 patient contacts over a 4-hour period, eight cancers were found and subsequently treated (five skin, three prostate). Patient selection criteria, screening results by site, lessons learned, and recommendations for future clinics are discussed. The multidisciplinary screening clinic is readily applicable to the MTF setting, cost-effective, and provides an invaluable service to eligible patients.     

Efforts in cancer diagnosis: national task forces--large bowel cancer

Current information from the National Large Bowel Cancer Project and other sources is given concerning new leads and avenues of research that may be used in early diagnosis or possibly in monitoring therapy. The search for biological markers has developed in two general directions: (1) to identify by genetic studies patients with a high probability of developing cancer who will provide insight into biochemical changes as premalignant lesions develop into frankly developed cancer, and (2) to fine differences between tissue and body fluid constituents in normal subjects and patients with cancer. Screening for colon cancer is discussed with a selective diagnostic approach and with emphasis on this approach in early diagnosis of asymptomatic high risk patients.     

Learn, share, and live: breast cancer education for older, urban minority women

Among older urban minority women, for whom breast cancer risk is high and the propensity to be screened is low, both social support and breast cancer knowledge have been linked to mammography use. The authors describe a theory-based breast cancer education program implemented via an existing informal network for low-income urban elderly coordinated by a social service agency. The program is both structured and flexible. Core education sessions include delineated content and methods and are led by health professionals. Participants choose from a variety of follow-up activities to promote screening within their community. Pre- and posttests administered among 80 program attendees in two sites indicate significant improvement in knowledge (p < .001). Program attendees in each site also planned and participated in follow-up activities to promote screening among their peers. Learn, Share, and Live seems to be an effective program for promoting breast cancer screening among older, urban, primarily minority women.     

Trends in breast cancer screening in Missouri from 1987 to 1995, and predictions for the years 2000 and 2010

BACKGROUND: Breast cancer is a major cause of morbidity and mortality in the United States (U.S.) and Missouri. In 1992, 3,915 new breast cancer cases were diagnosed and in 1995, 1,006 deaths from breast cancer were reported in Missouri. Although breast cancer incidence has increased in Missouri in the past 20 years, there are indications that early detection has also increased during the same period. Knowledge about which segments of the population have experienced the greatest increase in mammography screening rates helps in planning and implementation of breast cancer control programs at the state level. OBJECTIVES: Examine the prevalence and trends of lifetime mammography and 2-year mammography compliance in Missouri by age, race, and education from 1987 to 1995 and make predictions for the years 2000 and 2010. METHODS: We used data from the Missouri Behavioral Risk Factor Surveillance System (BRFSS), 1987 to 1995, to estimate the prevalence of ever having had a mammogram and compliance with mammography screening guidelines within two years by race, age, and education status among Missouri women over age 18. Using linear models, we regressed breast cancer screening prevalence estimates on time to obtain trends and predictions. RESULTS: Overall, African-American women were more likely to have had a lifetime mammogram than white women. However, we found a steady increase in the prevalence of ever having had a mammogram for all groups of women defined by age and education status, except among African Americans. Increase in the prevalence of ever having had a mammogram was much higher in women age 50 and older and slightly higher among women with a high school education or less. The average prevalence of 2-year mammography screening compliance was about 60% for all groups, a rate which did not significantly change between 1987 and 1995. By the year 2000, white women will have mammography rates equal to or higher than African-American women, and the majority of all women age 50 and older (98.3% to 100%) will have had a lifetime mammogram. CONCLUSION: Missouri target populations are predicted to attain Year 2000 National Health Objectives concerning lifetime mammography. Current efforts should be continued in order to maintain levels of mammography, particularly among African-American women.     

Screening women aged less than 50 years with a family history of breast cancer

Family history is an important breast cancer risk factor and is a common reason for referral to specialist breast clinics for consideration of breast screening. The aims of this study were to determine cancer detection rates and prognostic features of breast cancers identified in women aged less than 50 years at increased risk of breast cancer who attend a Family History Breast Screening Clinic (FHC). Between January 1988 and December 1995, 1371 asymptomatic women aged less than 50 years underwent annual clinical breast examination and biennial mammography due to a family history of breast cancer. A total of 29 cancers (23 invasive and 6 in situ) were detected or presented as interval cancer during a mean follow-up of 22 months (range 0-96 months). This gave a relative risk for invasive breast cancer in this high-risk group of 5 when compared with an age-matched female population in the U.K. The cancer screening detection rates were similar to those of women aged 50 years or over undergoing population screening in the NHS Breast Screening Programme (NHSBSP)--FHC prevalent screen 8 per 1000 screening visits versus NHSBSP 6.5 per 1000, FHC incident screen 3.3 per 1000 screening visits versus NHSBSP 3.8 per 1000. A higher proportion of in situ cancers were detected in the FHC screened group compared with cancers identified in symptomatic patients from an age-matched risk group (21% versus 4%). No differences were demonstrated for invasive tumour size, grade or lymph node stage between symptomatic and screened women. The early results of this study suggests that young women at risk of breast cancer due to a family history may benefit from regular breast screening due to the early detection of in situ lesions.