A randomized clinical trial to assess the benefit of offering on-site mobile mammography in addition to health education for older women.

Identifying factors that increase mammography use among Latinas is an important public health priority. Latinas are more likely to report mammography intentions and use, if a family member or friend recommends that they get a mammogram. Little is known about the mechanisms underlying the relationship between social interactions and mammography intentions. Theory suggests that family/friend recommendations increase perceived mammography norms (others believe a woman should obtain a mammogram) and support (others will help her obtain a mammogram), which in turn increase mammography intentions and use. We tested these hypotheses with data from the ¡Fortaleza Latina! study, a randomized controlled trial including 539 Latinas in Washington State. Women whose family/friend recommended they get a mammogram within the last year were more likely to report mammography intentions, norms and support. Perceived mammography norms mediated the relationship between family/friend recommendations and intentions, Mediated Effect = 0.38, 95%CI [0.20, 0.61], but not support, Mediated Effect = 0.002, 95%CI [-0.07, 0.07]. Our findings suggest perceived mammography norms are a potential mechanism underlying the effect of family/friend recommendations on mammography use among Latinas. Our findings make an important contribution to theory about the associations of social interactions, perceptions and health behaviors.

The Mammography Optimum Referral Effort (MORE) is a physician office-based intervention program initiated by the Connecticut Peer Review Organization (CPRO) to increase mammography use among older women in Connecticut. Three locales in the state were targeted for the MORE intervention based on identified low mammography rates in women aged 65 years and older. Thirty-seven physicians participated from March 1, 1996, to August 31, 1996. Annual mammography rates were derived by merging Medicare Part B mammography claims with a database from the Connecticut Tumor Registry. This strategy allowed us to exclude women with a prior history of breast cancer from the analysis, in order to estimate screening rates. The MORE intervention was associated with an absolute increase of 5.9%, which represents a relative increase of 15.4%, in annual mammography use. Our findings suggest that a multifaceted physician intervention is capable of increasing mammography use among older women.

Identifying communities with lower rates of mammography screening is a critical step to providing targeted screening programs; however, population-based data necessary for identifying these geographic areas are limited. This study presents methods to identify geographic disparities in the early detection of breast cancer. Data for all women residing in Dane County, Wisconsin, at the time of their breast cancer diagnosis from 1981 through 2000 (N = 4769) were obtained from the Wisconsin Cancer Reporting System (Wisconsin's tumor registry) by ZIP code of residence. Hierarchical logistic regression models for disease mapping were used to identify geographic differences in the early detection of breast cancer. The percentage of breast cancer cases diagnosed in situ (excluding lobular carcinoma in situ) increased from 1.3% in 1981 to 11.9% in 2000. This increase, reflecting increasing mammography use, occurred sooner in Dane County than in Wisconsin as a whole. From 1981 through 1985, the proportion of breast cancer diagnosed in situ in Dane county was universally low (2%-3%). From 1986 through 1990, urban and suburban ZIP codes had significantly higher rates (10%) compared with rural ZIP codes (5%). From 1991 through 1995, mammography screening had increased in rural ZIP codes (7% of breast cancer diagnosed in situ). From 1996 through 2000, mammography use was fairly homogeneous across the entire county (13%-14% of breast cancer diagnosed in situ). The percentage of breast cancer cases diagnosed in situ increased in the state and in all areas of Dane County from 1981 through 2000. Visual display of the geographic differences in the early detection of breast cancer demonstrates the diffusion of mammography use across the county over the 20-year period.

BackgroundMammography use is affected by multiple factors that may change as public health interventions are implemented. We examined two nationally representative, population‐based surveys to seek consensus and identify inconsistencies in factors associated with mammography use in the entirety of the US population, and by black and white subgroups.MethodsSelf‐reported mammography use in the past year was extracted for 12 639 and 169 116 women aged 40‐74 years from the 2016 National Health Interview Survey (NHIS) and the 2016 Behavioral Risk Factor Surveillance System (BRFSS), respectively. We applied a random forest algorithm to identify the risk factors of mammography use and used a subset of them in multivariable survey logistic regressions to examine their associations with mammography use, reporting predictive margins and effect sizes.ResultsThe weighted prevalence of past year mammography use was comparable across surveys: 54.31% overall, 54.50% in white, and 61.57% in black in NHIS and 53.24% overall, 56.97% in white, and 62.11% in black in BRFSS. Overall, mammography use was positively associated with black race, older age, higher income, and having health insurance, while negatively associated with having three or more children at home and residing in the Western region of the US. Overweight and moderate obesity were significantly associated with increased mammography use among black women (NHIS), while severe obesity was significantly associated with decreased mammography use among white women (BRFSS).ConclusionWe found higher mammography use among black women than white women, a change in the historical trend. We also identified high parity as a risk factor for mammography use, which suggests a potential subpopulation to target with interventions aimed at increasing mammography use.

Language discordance between patient and physician is associated with worse patient self-reported healthcare quality. As Hispanic patients have low rates of cardiovascular and cancer screening, we sought to determine whether patient-physician language concordance was associated with differences in rates of screening. We performed a retrospective medical record review of 101 Spanish-speaking patients cared for by 6 Spanish-speaking PCPs (language-concordant group) and 205 Spanish-speaking patients cared for by 44 non-Spanish-speaking PCPs (language-discordant group). Patients were included in the study if they were of age 35 to 75 years and had used interpreter services 2001 to 2006 in 2 Boston-based primary care clinics. Our outcomes included screening for hyperlipidemia, diabetes, cervical cancer, breast cancer, and colorectal cancer with age-appropriate and sex-appropriate subgroups. Our main predictor of interest was patient-physician language concordance. In multivariable modeling, we adjusted for age, sex, insurance status, number of primary care visits, and comorbidities. We adjusted for clustering of patients within individual physicians and clinic sites using generalized estimating equations. Patients in the language-discordant group tended to be female compared with patients in the language-concordant group. There were no significant differences in age, insurance status, number of primary care visits, or Charlson comorbidity index between the 2 groups. Rates of screening for hyperlipidemia, diabetes, cervical cancer, and breast cancer were similar for both language-concordant and language-discordant groups. However, patients in the language-concordant group were less likely to be screened for colorectal cancer compared with the language-discordant group risk ratio 0.78 (95% confidence interval, 0.61-0.99) after multivariable adjustment. This study finds that Spanish-speaking patients cared for by language-concordant PCPs were not more likely to receive recommended screening for cardiovascular risk factors and cancer. Furthermore, language concordance was associated with lower likelihood colorectal cancer screening. Further research is needed to examine which conditions are optimal to improve cardiovascular and cancer screening for Spanish-speaking patients, particularly for colorectal cancer, which has a low rate of screening.

To examine racial differences in mammography use and its determinants in the City of St. Louis, MO, USA, we recruited women age 40 or older using random-digit dialing to (1) examine the difference in mammography use between white women and African American women and (2) identify individual- and census-tract-level risk factors of nonadherence to mammography. During telephone interviews, we inquired about mammography use and several demographic, psychosocial, and health behavior variables. We determined the residential census tracts of study subjects using a geographic information system. The rate of mammography use was 68.0% among white women and 74.7% among African American women (P = 0.022). African American women were more likely to have mammograms than white woman (adjusted odds ratio [OR] = 1.71; 95% confidence interval [CI] = 1.09-2.69). System-level barriers to mammography and heavy smoking were associated with lower mammography use among both white and African American women. Personal-experience barriers to mammography and no physician recommendation also were independently associated with mammography use among white women. White women residing within a historic geographic cluster area of late-stage breast cancer were less likely to have mammograms (adjusted OR = 0.42, 95% CI = 0.22-0.80), while African American women residing within a historic geographic cluster area of late-stage breast cancer were equally likely to have mammograms (adjusted OR = 0.79, 95% CI = 0.28-2.24). Neither individual- nor census-tract-level socioeconomic status was associated with mammography screening. These findings suggest that there may be a greater need for increasing mammography use among white women, especially in the historic cluster area of late-stage breast cancer in St. Louis.

There is little consensus about recommending mammography for women 75 years of age and older. These women have mammography less frequently and are more likely to receive a diagnosis of advanced breast cancer. To examine the relationship between use of screening mammography and size and stage of cancer at diagnosis in older women. Retrospective cohort study. Tumor registries in the Surveillance, Epidemiology, and End Results (SEER) program. 12 038 women who were Medicare beneficiaries, were at least 69 years of age, resided in a SEER area, and received a new diagnosis of breast cancer in 1995 through 1996. Screening mammograms obtained in the 2 years before breast cancer diagnosis (none, one, or at least two) and stage and size of tumor at diagnosis. Older women (> or =75 years of age) had larger tumors at diagnosis and were less likely to have undergone screening mammography than younger women (69 to 74 years of age). The association between increased mammography use and smaller tumor size and stage was significantly greater in older women than in younger women (P = 0.010 for stage; P = 0.001 for size). The percentage of regular mammography users who received a diagnosis of high-stage disease (28% vs. 26%; P > 0.2) and the mean size of the tumors (15.0 mm vs. 15.1 mm; P > 0.2) did not significantly differ between younger and older women, respectively. These findings remained constant after controlling for factors that might contribute to biases. Mammography in older women is associated with elimination of age-related disparities in size and stage of breast cancer at diagnosis.

Women with inadequate health insurance have lower mammography rates than the general population. Finding successful strategies to enroll eligible women is an ongoing challenge for the National Breast and Cervical Cancer Early Detection Program. To test the effectiveness of a population-based strategy to increase mammography utilization among low-income underinsured women ages 40 to 64 years, a randomized trial was conducted to assess the effect of two mailed interventions on mammography utilization through Sage, the National Breast and Cervical Cancer Early Detection Program in Minnesota. Women (N = 145,467) ages 40 to 63 years [mean (SD), 49.7 (6.8)] with estimated household incomes below 50,000 US dollars (47.9% were < 35,000 US dollars) from a commercial database were randomized to three groups: Mail, Mail Plus Incentive, or Control. Both the Mail and the Mail Plus Incentive groups received two simple mailings prompting them to call a toll-free number to access free mammography services. The Mail Plus Incentive intervention offered a small monetary incentive for a completed mammogram. After 1 year, both intervention groups had significantly higher Sage mammography rates than the Controls, and the Mail Plus Incentive group had a significantly higher rate than the Mail group. The Mail and Mail Plus Incentive interventions were estimated to produce increases in Sage screening rates of 0.23% and 0.75%, respectively, beyond the composite Control rate of 0.83%. Direct mail is an effective strategy for increasing mammography use through Sage. Coupling direct mail with an incentive significantly enhances the intervention's effectiveness. Direct mail should be considered as a strategy to increase mammography use among low-income, medically underserved women.

Objective: Many past interventions have been based on the assumption that improving attitudes about mammography can increase mammography use. We studied changes in breast cancer and mammography attitudes over time in mediating the effect of intervention exposures on mammography use in the North Carolina Breast Cancer Screening Program. Data came from interviews with a cohort of 331 black women who said they had heard of mammography at baseline interview. Methods: We created scores and score changes for mammography (7 items) and breast cancer (11 items) attitudes at baseline (1993–1994) and follow-up interviews (1996–1997). We modeled intervention exposures, attitude changes, and mammography use in linear risk and logistic regression. Intervention exposures were defined for mammography discussion with a project lay health advisor (“LHA advice”), mammography discussion with anyone besides a doctor or nurse, and project awareness. Results: Positive change in mammography attitudes was associated with intervention exposures and mammography use and appeared to account for a large percentage (34–98%) of the effect of mammography discussion variables on increased mammography use. Greatest effect of attitude improvement was found for women without a recent mammogram at baseline and with the least positive baseline attitude scores. Conclusion: Using cohort data enabled us to examine the role of attitude change over time on mammography use. Breast cancer screening programs should target women with the most negative mammography attitudes and the least mammography use to start with and concentrate their messages on improving attitudes specific to mammography rather than improving attitudes about breast cancer risk.

Loss-framed minimal intervention increases mammography use

Background The influence of church attendance and spirituality on mammography use was studied among Native American, White, and African American women living in a rural county. Methods A randomized trial was conducted to increase mammography use. Women (n = 851) were randomly assigned to receive either an educational program delivered by a lay health advisor or a physician letter and brochure about cervical cancer screening (control group). Church attendance and spirituality were measured at baseline and mammography use was evaluated 12 months after enrollment using medical record review. Results Almost two-thirds of the women reported that they attended church at least once a week, and less than 4% were classified as having low spirituality. Church attendance (P = 0.299) or spirituality (P = 0.401) did not have a significant impact on mammography use. Conclusions Church attendance and spirituality did not impact mammography use.

American cancer society reports on 25-year cancer mortality rate goals.

In November 2009, the United States Preventive Services Task Force (USPSTF) updated their guidelines to recommend against routine screening mammography for women aged 40 to 49 years and recommended biennial instead of annual mammography for women aged 50 to 74 years for women of average risk.1,2 The Task Force also concluded that “current evidence is insufficient to assess the additional benefits and harms of screening mammography in women age 75 years or older (p.716).”1 The guideline update invoked many medical societies to release their own guidelines to support annual mammogram in women age 40 years and older.3 Most private and public insurers continued to cover annual mammography for women age 40 years and older.4-7 Moreover, breast cancer screening is the only preventive procedure that the Patient Protection and Affordable Care Act (ACA) coverage did not match the 2009 USPSTF recommendations and instead, covers annual mammography without co-pay or co-insurance for women starting at age 40 years of average risk.8 The National Breast and Cervical Cancer Early Detection Program continues to pay for annual mammography for underserved women aged 40 to 64 years of average risk.9 We used the Medical Expenditure Panel Survey-National Health Interview Survey (MEPS-NHIS) linked data to identify women aged 41 years and older. We obtained person-level data covering three calendar years (2008-2010). Women aged 41 years or older were asked about mammography use in the past year three times during the study period. We stratified women into three age groups: 41 to 49, 51 to 74, and 76 years and older. We reported trends of the percentage of women who reported a mammogram in the past year by age group. We estimated logistic multivariate regression models with person-specific fixed effects to compare self-reported mammography screening in each of the three years. Variables in the regression analyses include survey year, household income compared to federal poverty line, insurance status, whether the respondent has a usual source of care, and self-rated health status measure. Because we stratify by age, we do not further control for it in the regression models. Insurance status was not controlled in the analyses of the age group 75 years of older because they are by and large Medicare beneficiaries. The model included person-specific fixed effects to account for unobservable characteristics that could bias estimates of mammography utilization. In the 41 to 49 age group, the percentage of women reporting a past-year mammogram rose from 46% in 2008 to 56% in 2010 (p<0.05). We have observed The mammography rates in older women were virtually unchanged (Figure 1). Table 1 confirms the patterns observed. Women aged 41 to 49 years (odds ratio=2.00, 95% CI: 1.26-3.17) were more likely to report a past-year mammogram in 2010 than in 2008. For women aged 51 to 74 and 76 or older, the past-year mammograms were unchanged from 2008 to 2010 in the multivariate analyses. Women aged 51 to 74 years who had a usual source of care were more likely to report mammography in the past year (odds ratio =2.84, 95% CI: 1.60-5.04). Figure 1 Percentage of women reporting a past-year mammogram Table 1 The Odds Ratio (95% CI) By following a cohort of women from 2008 to 2010, we found that mammography screening rates did not decrease in any age group after the 2009 issuance of guideline changes. Contrasting to a downward trend in mammography rates between 2000 and 2008,10 the percentage of women who reported a past-year mammogram was higher in 2010 than in 2008 in women aged 41 to 49 years. Although aging may explain some of the increase in mammography use in this age group, it probably safe to conclude that there was very little response to the new USPSTF guideline recommendations for younger women. Mammography rates were unchanged over time in other age groups. The vigorous debate following the USPTF new guidelines may have raised the awareness of breast cancer screening. Continued analysis of mammography rates with more years of longitudinal data will inform whether there is a long-term impact of the 2009 guidelines on screening rates. The next USPSTF breast cancer screening recommendations are due in the near future. We should be prepared for an ongoing debate about balance of benefit and harms, the age at which screening should begin and end, and issues of over-diagnosis/over-treatment.

A Program to Enhance Completion of Screening Colonoscopy Among Urban Minorities

Colonoscopy Completion in a Large Safety Net Health Care System