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Women's Health Issues

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Radiologists sometimes vary widely in their interpretation of the same mammograms

U.S. radiologists looking at the same mammogram are likely to interpret it quite differently, according to a study supported in part by the Agency for Health Care Policy and Research (HS07845). Inaccuracy in mammogram interpretation may mean that breast cancer goes undetected or is detected at a later stage when it is more difficult to treat successfully. If mammography is to realize its potential to reduce breast cancer deaths, accreditation programs that certify the technical quality of radiographic equipment and images should also certify the accuracy of mammogram interpretation, concludes Craig A. Beam, Ph.D., of the Medical College of Wisconsin.

Dr. Beam and his colleagues compared interpretation of the same set of 79 screening mammograms by a 1992 random sample of 108 radiologists from American College of Radiology-accredited mammography centers across the United States. The actual breast disease status of the 79 women whose mammograms were interpreted had previously been established either by biopsy or 2-year followup. There was a 53 percent range of variability between the minimum and maximum sensitivity among radiologists in the sample. While some radiologists referred 100 percent of women with cancer for biopsy, others referred only 47 percent.

Fifty percent of the radiologists demonstrated at least 80 percent sensitivity (the proportion of women with cancer who were referred for biopsy) in interpreting the mammograms meaning that half of the radiologists missed detecting 20 percent or fewer of possible cancers on the mammograms. One-fourth of the radiologists had a sensitivity exceeding 88 percent, but the other 25 percent had a sensitivity of less than 67 percent. The researchers estimated at least a 45 percent range of variability in radiologists' specificity, that is, in the rate of recommendation for routine or short-term followup given to women without cancer. The overall specificity for women with normal mammograms was 90 percent.

More details are in "Variability in the interpretation of screening mammograms by U.S. radiologists," by Dr. Beam, Peter M. Layde, M.D., M.Sc., and Daniel C. Sullivan, M.D., which appears in the January 22, 1996 Archives of Internal Medicine 156, pp. 209-213.

Choice of treatment for early-stage breast cancer often depends on hospital characteristics

A woman's chance of having breast-conserving surgery, that is, lumpectomy plus radiation instead of mastectomy (breast removal) for early-stage breast cancer depends on the hospital where she is treated. Although the outcomes of both treatments are similar, not all hospitals have adopted the breast-conserving approach. Urban hospitals and teaching hospitals are more apt to adopt this approach than other hospitals, according to a study by Agency for Health Care Policy and Research investigators and former AHCPR administrator, J. Jarrett Clinton, M.D.

They used hospital data on women discharged with early-stage breast cancer from 1981 to 1987 from more than 500 hospitals included in the Healthcare Cost and Utilization Project (HCUP) to model the influence of hospital characteristics on the use of breast-conserving surgery, while controlling for patient and hospital characteristics. Analysis showed that the overall rate of radical mastectomies (removal of breast tissue, some chest muscles, and axillary lymph nodes) decreased by nearly 21 percent per year. The rate of modified radical mastectomies (large muscles of the chest that move the arms are preserved) and simple mastectomies (only breast tissue is removed) remained relatively constant. In contrast, the rate of breast-conserving surgeries increased by 9 percent per year.

Women treated at nonteaching hospitals were 27 percent less likely to have breast-conserving surgery than those treated at academic medical centers. Also, women treated at urban hospitals were 43 percent more likely to have breast-conserving surgery than those treated at rural hospitals. This difference is commonly attributed to a slower diffusion of new technologies and innovations in rural areas. The authors point out, however, that the choice of mastectomy may be reasonable in light of the limited access in rural areas to radiation therapy.

For more information, see "Treating early-stage breast cancer: Hospital characteristics associated with breast-conserving surgery," by Mary E. Johantgen, Ph.D., R.N., Rosanna M. Coffey, Ph.D., D. Robert Harris, Ph.D., and others, in the October 1995 American Journal of Public Health 85(10), pp. 1432-1434.

Treatment intensity varies by age in elderly women with breast cancer even after controlling for other medical problems

Elderly women account for 44 percent of all newly diagnosed cases of breast cancer, and 93 percent of them are diagnosed before the disease has metastasized. According to a study supported by the Agency for Health Care Policy and Research (HS06589), elderly women are treated less aggressively the older they become, and this trend is not attributable to the increased presence of other medical problems with advancing age. It shows that older women are less likely to undergo surgery, more likely to receive breast-conserving surgery as opposed to mastectomy, and less likely to receive radiotherapy following breast-conserving surgery.

A research team led by Sheldon M. Retchin, M.D., M.S.P.H., of the Medical College of Virginia, examined the influence of patient age and coexisting medical conditions (comorbidity) on initial treatment for breast cancer using Virginia Cancer Registry records for 2,252 women ages 66 years or older. The women were diagnosed as having nonmetastatic, invasive breast cancer between 1984 and 1989. Women with breast cancer who were 85 years of age and older had about one-third the odds of women 66 to 74 years of age to be treated initially by surgery, about half the odds of undergoing radical mastectomy (removal of breast and chest tissue and axillary lymph nodes) instead of breast-conserving surgery, and were much less likely than the younger elderly women to receive radiation therapy within 4 months after surgery.

Women ages 75 through 84 years did not have significantly different odds of undergoing any surgery or receiving breast-conserving surgery than women ages 66 through 74 years. It has been suggested that more coexisting medical conditions in the very elderly may contraindicate more aggressive treatment options. In this study, however, even after adjustment for comorbidity which tends to increase with age, age remained a strong and significant predictor of treatment, according to the researchers.

For more details, see "The effect of age and comorbidity in the treatment of elderly women with nonmetastatic breast cancer," by Craig J. Newschaffer, M.S., Lynne Penberthy, M.D., M.P.H., Christopher E. Desch, M.D., and others, in the January 8, 1996 Archives of Internal Medicine 156, pp. 85-90.

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