Cancer Screening and Treatment in Women: Recent Findings
Breast cancer continues to be the most commonly diagnosed cancer among women in the United States. In 2008, an estimated 182,400 U.S. women were newly diagnosed with breast cancer, and more than 40,000 women died from the disease.
The good news is that breast cancer deaths have declined in recent years among white women in this country; the bad news is that over the same period, survival has decreased among black women. Although between 12 and 29 percent more white women than black women are stricken with breast cancer, black women are 28 percent more likely to die from the disease. The 5-year breast cancer survival rate is 69 percent for black women, compared with 85 percent for white women.
In 2008, there were an estimated 11,000 newly diagnosed cases of invasive cervical cancer in U.S. women, and about 3,900 women died from the disease. Cervical cancer occurs most often among minority women, particularly Asian-American (Vietnamese and Korean), Alaska Native, and Hispanic women. Although deaths from cervical cancer have declined substantially over the past 30 years, the cervical cancer death rate for black women continues to be more than twice that of white women. The chance of dying of cervical cancer increases as women get older. Worldwide, cervical cancer is the second or third most common cancer among women, and in some developing countries, it is the most common cancer.
Women who have never had a Pap test or who have not had one for several years have a higher than average risk of developing cervical cancer. Many women still do not have regular Pap tests, particularly older women, uninsured women, minorities, poor women, and women living in rural areas. About half of the women with newly diagnosed invasive cervical cancer have not had a Pap test in the previous 5 years.
The Agency for Healthcare Research and Quality (AHRQ) supports a vigorous women's health research program, including research focused on breast cancer, cervical cancer, and other cancers in women. AHRQ-supported projects are addressing women's access to quality health care services, accurate diagnoses, appropriate referrals for procedures, and optimal use of proven therapies.
Nonsurgical method for diagnosing breast cancer found to be safe and effective.
Description: This recent AHRQ report compares the safety and effectiveness of traditional surgical biopsies with various types of "core needle biopsy" for diagnosing breast cancer. Based on a review of scientific evidence, it shows that certain core needle biopsies could distinguish between malignant and benign lesions approximately as accurately as open surgical biopsy, commonly considered to be the gold standard for evaluating suspicious lesions. The report provides important information to help physicians and patients work together to make the best possible diagnostic choice for each patient.
Source: Comparative Effectiveness of Core Needle and Open Surgical Biopsy for the Diagnosis of Breast Lesions, Comparative Effectiveness Review No. 19, Executive Summary (AHRQ Publication No. 10-EHC007-1)* (Contract 290-02-0019).
Less than 15 percent of radiologists say they definitely would tell a patient about an error in mammogram interpretation.
Description: A survey of 243 radiologists at seven geographically dispersed breast cancer surveillance sites found that 9 percent of those surveyed definitely would not disclose an error in mammogram interpretation; 51 percent would disclose the error only if specifically asked by the patient; 26 percent said they probably would disclose the error; and just 14 percent said they definitely would disclose the error. Neither concern about the effects that malpractice is having on the practice of radiology nor having been sued previously was associated with willingness to disclose or disclosure content.
Source: Gallagher, Cook, Brenner, et al., Radiology 253(2):443-452, 2009 (AHRQ grant HS10591).
Automated telephone reminders lead to increased use of mammography
Description: Researchers tested the effectiveness of automated telephone reminders (ATRs), enhanced reminder letters, and standard letters on the likelihood of repeat mammograms in 3,547 women who were randomly assigned to one of the three groups. The ATRs were found to be the least costly but most effective (76 percent) intervention for prompting repeat mammograms, compared with the enhanced (72 percent) and standard (74 percent) reminder letters. Overall, 74 percent of women had a repeat mammogram within 10-14 months, compared with 57 percent before the reminders.
Source: DeFrank, Rimer, Gierisch, et al., Am J Prevent Med 36(6):459-467, 2009 (AHRQ grant T32 HS00079).
In St. Louis, black women are more likely than white women to receive mammograms.
Description: St. Louis, MO, is known to have high rates of breast cancer diagnosed at a late-stage, and researchers have been looking at ways to increase mammography use in late-stage diagnosis areas. From March 2004 to June 2006, researchers conducted a survey of women (429 black, 556 white) older than age 40 living in the St. Louis area. Unexpectedly, more black women (75 percent) than white women (68 percent) reported that they had received mammograms. The researchers note that such geographic clustering of late-stage breast cancer diagnoses can be useful in targeting interventions to increase mammography use.
Source: Lian, Jeffe, and Schootman, J Urban Health 85(5):677-692, 2008 (AHRQ grant HS14095).
Radiologists' perception of malpractice risk appears to be higher than the actual number of lawsuits.
Description: Researchers mailed a survey in 2002 and again in 2006 to radiologists in three States—Washington, Colorado, and New Hampshire—to determine their perceived risk of facing a lawsuit related to mammogram interpretation. They found that the radiologist's perceived risk of being sued was significantly higher than the actual number of reported malpractice cases involving breast imaging. Radiologists who spent more time on breast imaging or interpreting a higher volume of mammograms did not have a significantly higher perceived risk of a lawsuit. Those who felt more at risk were more likely to have had a malpractice claim in the past or know of other radiologists who had been sued.
Source: Dick, Gallagher, Brenner, et al., Am J Roentgenol 192(2):327-333, 2009 (AHRQ grant HS10591).
Study finds no correlation between abnormal mammogram interpretation and radiologists' job satisfaction.
Description: In this study, 131 radiologists were surveyed about their clinical practices and attitudes related to screening mammography. Performance data were used to determine the odds of an abnormal mammogram interpretation. More than half of the radiologists said they enjoyed interpreting screening mammograms; most in this group were female, older, and working part time; affiliated with academic medical centers; and/or on an annual salary. Those who did not enjoy the work reported it as being tedious. There were no significant differences in mammogram interpretation and cancer detection between those who did and did not enjoy their work.
Source: Geller, Bowles, Sohng, et al., Am J Roentgenol 192(2):361-369, 2009 (AHRQ grant HS10591).
Lack of knowledge and mistrust may partly explain women's underuse of adjuvant therapy for breast cancer.
Description: Adjuvant therapies (chemotherapy, hormone therapy, and radiotherapy) following breast cancer surgery have been proven effective in women with early-stage breast cancer, yet 32 of 258 women in this study who should have received adjuvant therapy did not get it. According to practice guidelines, 64 of the women should have received chemotherapy, 150 should have received hormone therapy, and 174 should have received radiotherapy. The principal factors associated with lack of adjuvant treatment were age older than 70, coexisting illnesses, and mistrust in the medical delivery system. The researchers call for better education of women regarding the benefits and risks of treatment, as well as straightforward discussion about issues of trust.
Source: Bickell, Weidmann, Fei, et al., J Clin Oncol 27(31):5160-5167, 2009. See also Bickell, LePar, Wang, and Leventhal, J Clin Oncol 25(18):2516-2521, 2007 (AHRQ grant HS10859; Anderson and Carlson, J Natl Compr Canc Netw 5(3):349-356, 2007 (AHRQ grant HS15756); and Fryback, Stout, Rosenberg, et al., J Natl Cancer Inst Monographs 36:37-47, 2006 (AHRQ grant T32 HS00083).
Tracking system helps to ensure women with breast cancer see oncologists and receive followup care.
Description: Some women diagnosed with breast cancer, especially blacks and Latinos, do not follow through with their referrals to an oncologist. To address this problem, researchers developed a tracking system to facilitate followup with breast cancer patients. They compared the treatment of 639 women with early stage breast cancer who were seen at six New York City hospitals between January 1999 and December 2000 with 300 women who were seen between September 2004 and March 2006, after the tracking system began. Rates of oncology consultations, chemotherapy, and hormone therapy were higher for all women once the system was in place, and the racial disparities in use of care that had existed were eliminated.
Source: Bickell, Shastri, Fei, et al., J Natl Cancer Inst 100(23):1717-1723, 2008 (AHRQ grant HS10859).
Study finds that three drugs effectively reduce the risk of breast cancer but may cause other problems.
Description: Three drugs—tamoxifen, raloxifene, and tibolone—significantly reduce invasive breast cancer in middle-aged and older women who are at risk but have not previously had breast cancer. However, each of the three drugs has its own side effects and risks, and these must be balanced against the benefits for an individual patient. For example, tamoxifen carries an increased risk for endometrial cancer and blood clots and has side effects such as flushing, night sweats, and vaginal dryness. Raloxifene also carries a risk for blood clots and has side effects such as flushing and leg cramps. Tibolone carries an increased risk of stroke and has side effects that include vaginal bleeding.
Source: Comparative Effectiveness of Medications to Reduce Risk of Primary Breast Cancer in Women, Executive Summary No. 17 (AHRQ Publication No. 09-EHC028-1)* (AHRQ contract 290-2007-10057-1).
Poverty may explain racial disparities in receipt of chemotherapy for breast cancer in older women.
Description: According to this study of nearly 14,500 older women with stage II or IIIA breast cancer with positive lymph nodes, black women were less likely than white women to receive chemotherapy within 6 months of diagnosis (56 percent vs. 66 percent, respectively). When the results were adjusted to include socioeconomic status for women aged 65 to 69, poverty appeared to be at the root of the disparity. Despite Medicare coverage, out-of-pocket costs—including copayments, transportation, and so on—may be overwhelming for women in the lowest income groups.
Source: Bhargava and Du, Cancer 115(13):2999-3008, 2009 (AHRQ grant HS16743).
Online support groups seem to benefit women with metastatic breast cancer.
Description: A group of 20 women (all were white) with metastatic breast cancer were assigned to one of three online support groups. The women received a monthly E-mail questionnaire and after at least 4 months in the support group, each woman was interviewed for 30 to 90 minutes. Six helpful factors identified in an earlier study were found to be present in these groups: group cohesiveness, universality, information exchange, instillation of hope, catharsis, and altruism.
Source: Vilhauer, Women Health 49:381-404, 2009 (AHRQ grant HS10565).
Behavioral health carve-outs limit access to mental health services for women with breast cancer.
Description: Up to 40 percent of women with breast cancer suffer significant psychological distress, but only about 30 percent of them receive treatment for it, according to this study. Researchers analyzed insurance claims, enrollment data, and insurance benefit design data from 1998-2002 on women 63 years of age or younger with newly diagnosed breast cancer. They found that women enrolled in insurance plans with behavioral health carve-outs were 32 percent less likely to receive mental health services compared with women in plans that had integrated behavioral health services.
Source: Azzone, Frank, Pakes, et al., J Clin Oncol 27(5):706-712, 2009 (AHRQ grant HS10803)
Journal Supplement focuses on guidelines for international implementation of breast health and breast cancer control initiatives.
Description: This journal supplement presents a series of 15 articles authored by a group of breast cancer experts and advocates and presented at the Global Summit on International Breast Health Implementation held in Budapest, Hungary, in October 2007. The articles focus on guideline implementation for early detection, diagnosis, and treatment; breast cancer prevention; chemotherapy; and other breast health topics.
Source: Cancer 113, Supplement 8, 2008 (AHRQ grant HS17218).
Several factors affect the accuracy of mammogram interpretation.
Description: Researchers examined how differences among mammography facilities affect the results of mammogram interpretation. They found that the most accurate facilities offered screening but not diagnostic mammograms, had a breast imaging specialist on staff, and conducted audits of radiologists' performance two or more times per year. Their findings are based on a review of 5 years of mammogram data and results of surveys received from 43 facilities and their 128 radiologists in the Pacific Northwest, New Hampshire, and Colorado.
Source: Taplin, Abraham, Barlow, et al., J Natl Cancer Inst 100(12):876-887, 2008 (AHRQ grant HS10591). See also Miglioretti, Smith-Bindman, Abraham, et al., J Natl Cancer Inst 99(24):1854-1863, 2007 (AHRQ grant HS10591).
Lesions overlooked on mammograms represent missed opportunities for early diagnosis.
Description: From 10 to 20 percent of women diagnosed with breast cancer had lesions that were visible but overlooked on their most recent mammograms, and another 10 to 20 percent had lesions that were misinterpreted. In both cases, the opportunities for early diagnosis and intervention were missed. These authors discuss the pros and cons of double or even quadruple reading of mammograms and computer-aided detection as a second digital "reader" of mammograms.
Source: Elmore and Brenner, J Natl Cancer Inst 99(15):1141-1143, 2007 (AHRQ grant HS10591).
Breast desmoid tumors are rare and often mistaken for cancer.
Description: A review over 25 years (1982-2006) at one institution identified 32 patients with pathologically confirmed breast desmoids. Their median age was 45; eight patients had a prior history of breast cancer, and 14 had undergone breast surgery, with desmoids diagnosed an average of 24 months postoperatively. All patients presented with physical findings; MRI was more accurate in visualizing the mass than mammography or ultrasound. All patients had their tumors surgically removed, and eight patients had recurring tumors at a median of 15 months. The researchers recommend that clinical judgment be used before extensive and potentially deforming breast resections are performed.
Source: Neuman, Brogi, Ebrahim, et al., Ann Surg Oncol 15(1):274-280, 2008 (AHRQ grant T32 HS00066).
More attention is needed to quality of life for breast cancer survivors.
Description: Researchers examined quality of life among women with (114 women) and without (2,527 women) breast cancer. Women with breast cancer reported lower scores on physical function, general health, vitality, and social function compared with women who did not have breast cancer. There was no difference in mental health scores between the two groups of women.
Source: Trentham-Dietz, Sprague, Klein, et al., Breast Cancer Res 109:379-387, 2008 (AHRQ grant HS06941).
Study underway to develop computer-based tools to improve use of genetic breast cancer tests.
Description: AHRQ has funded a new project to develop, implement, and evaluate four computer-based decision-support tools that will help clinicians and patients better use genetic tests to identify, evaluate, and treated breast cancer. The first pair of tools will assess whether a woman with a family history of cancer should be tested for BRCA1 and BRCA2 gene mutations. The second pair of tools, for women already diagnosed with breast cancer, will help determine which patients are suitable for a gene expression profiling test that can evaluate the risk of cancer recurrence and whether they should have chemotherapy.
Source: More information is available online at http://effectivehealthcare.ahrq.gov (AHRQ contract 290-200-50036I).
Report discusses impact of several gene expression profiling tests for breast cancer patients.
Description: Breast cancer treatment today often involves a multi-modality approach, including surgery, radiation therapy, endocrine therapy, and/or chemotherapy. Gene expression profiling has been proposed as an approach to assess women's risk of distant disease recurrence. This report discusses the available evidence on three breast cancer gene expression assays: the Oncotype DX™ Breast Cancer Assay, the MammaPrint® Test, and the Breast Cancer Profiling Test. Tests that improve such estimates of risk potentially can affect clinical outcome in breast cancer patients by either avoiding unnecessary chemotherapy or employing it where it otherwise might not have been used.
Source: Impact of Gene Expression Profiling Tests on Breast Cancer Outcomes, Evidence Report/Technology Assessment No. 160 (AHRQ Publication No. 08-E002)* (AHRQ contract 290-02-0018).
Radiation therapy for a primary cancer that develops in a second breast may offer a survival benefit.
Description: Radiation therapy following breast-conserving surgery (BCS) for a primary breast cancer reduces the risk of recurrence, but it has only a small overall survival benefit. However, omission of radiation therapy following BCS for a primary cancer that later develops in a second breast appears to double the risk of dying, according to this study. Researchers compared mortality rates of women aged 40 to 69 who did not receive radiation therapy following BCS for the second breast (43 percent of women) with those who did. Women who did not receive radiation had slightly more than twice the risk of dying from breast cancer and 1.7 times the risk of dying from all causes as women who received radiation.
Source: Schootman, Jeffe, Gillanders, et al., Breast Cancer Res Treat 103:77-83, 2007 (AHRQ grant HS14095). See also Du, Fan, and Meyer, Am J Clin Oncol 31(2):125-132, 2008 (AHRQ grant HS16743); and Schootman, Fuortes, and Aft, Breast Cancer Res Treat 99:91-95, 2006 (AHRQ grant HS14095).
Some women do not receive recommended adjuvant therapy for breast cancer.
Description: A survey of surgeons at six New York hospitals who treated 119 breast cancer patients who did not receive adjuvant therapy found that the surgeons did not recommend adjuvant treatment in one-third of the cases, most often because they believed the risks outweighed the benefits. Among the two-thirds of women for whom surgeons did recommend adjuvant therapy, 31 percent declined the treatment, and 34 percent did not receive it for unknown reasons. Adjuvant therapy recommended for breast cancer patients includes radiotherapy after breast conserving surgery, chemotherapy for estrogen receptor-negative tumors, and hormonal therapies for estrogen receptor-positive tumors larger than 1 cm.
Source: Bickell, LePar, Wang, and Leventhal, J Clin Oncol 25(18):2516-2521, 2007 (AHRQ grant HS10859). Go to also Anderson and Carlson, J Natl Compr Canc Netw 5(3):349-356, 2007 (AHRQ grant HS15756); and Fryback, Stout, Rosenberg, et al., J Natl Cancer Inst Monographs 36:37-47, 2006 (AHRQ grant T32 HS00083).
Booklet helps women assess their treatment options for early-stage breast cancer.
Description: Women newly diagnosed with early-stage breast cancer usually can choose between breast-conserving surgery (lumpectomy) followed by radiation and mastectomy. Research has shown that long-term outcomes are similar for both treatments. This booklet provides information to help women work with their providers to choose which type of surgery they will have and, if they choose mastectomy, whether they want to have reconstructive surgery. The booklet was developed collaboratively by the National Cancer Institute and AHRQ.
Source: Surgery Choices for Women with Early-Stage Breast Cancer (AHRQ Publication No. PHS 04-M053, English; AHRQ 05-0031, Spanish)* (Intramural).
Race, age, and other factors affect degree of pain among women with breast cancer.
Description: Researchers studied 1,124 women with stage IV breast cancer over the course of a year and found that minority women who had advanced breast cancer suffered more pain than white women. In addition, women who were inactive and younger women also reported more severe pain.
Source: Castel, Saville, DePuy, et al., Cancer 112(1):162-170, 2008 (AHRQ grant T32 HS00032).
Death and complications following breast cancer surgery are rare.
Description: The most common complication of breast cancer surgery is wound infection, which is twice as common after mastectomy as lumpectomy and lymph node dissection, according to this study. Factors that may contribute to the higher rate of wound infection following mastectomy include extensive tissue dissection, drain placement, formation of pockets of fluid, and longer operation time, as well as a woman's overall health status. Researchers analyzed data on 1,660 women (mean age 56) who underwent mastectomy and 1,447 women who underwent breast conserving surgery at 14 university and 4 community medical centers. There were few cardiac or pulmonary complications in the mastectomy group and none in the lumpectomy group; central nervous system problems were rare in both groups.
Source: El-Tamer, Ward, Schifftner, et al., Ann Surg 245(5):665-671, 2007 (AHRQ grant HS11913).
Immediate reading of mammograms and followup on false-positive results reduce anxiety among women.
Description: A group of women aged 40 and older participated in this study at seven sites in the Boston area between February 1999 and January 2001. Radiologists read the mammograms of 564 women immediately, while the films of 576 women were read in batches at a later time. Although there were more false-positives in the immediate-reading group, that strategy provided quick resolution of false-positives and led to significantly lower anxiety among those women. Immediate reading of mammograms increased costs to health plans by 10 percent because of reduced efficiency and the need for extra films. However, 12-month costs did not differ significantly between the two groups.
Source: Stewart, Neumann, Fletcher, and Barton, Health Serv Res 42(4):1464-1482, 2007 (AHRQ Publication No. 07-R067)* (Intramural).
Depression hinders recovery of older breast cancer patients.
Description: Researchers examined data on 187 women aged 60 years and older, including the presence of depressive symptoms 2 months after breast cancer diagnosis. They also examined sociodemographic factors, type of breast cancer treatment, and shoulder range of motion at 12 months after diagnosis. Results showed that each unit increase in depressive symptoms was associated with an 8 percent decreased odds of having full range of shoulder motion a year after diagnosis.
Source: Caban, Freeman, Zhang, et al., Clin Rehabil 20:513-522, 2006 (AHRQ grant HS11618).
Poor communication of mammogram results may explain disparities in breast cancer diagnosis and outcomes.
Description: Researchers surveyed 411 black and 734 white women who had screening mammograms at five hospital-based facilities in Connecticut between 1996 and 1998 and found no difference between the two groups of women in the proportion of abnormal screening mammograms. However, communication of mammogram results was problematic for 14.5 percent of the women; 12.5 percent had not received their results, and 2 percent had received their results but their self-report differed from the radiology record. Inadequate communication of mammogram results was nearly twice as common among black women as among white women.
Source: Jones, Reams, Calvocoressi, et al., Am J Public Health 97(3):531-538, 2007 (AHRQ grant HS11603). See also Dailey, Kasl, Holford, and Jones, Am J Epidemiol 165(11):1287-1295, 2007 (AHRQ grant HS15686).
Physician communication style may depend on characteristics of breast cancer patients.
Description: According to this study, oncologists tend to communicate differently with women newly diagnosed with breast cancer, depending on their age, race, education, and income. A series of videotaped visits between 58 oncologists with 405 women revealed that the physicians spent more time engaged in building relationships with white women than with women of other races; the same was true of visits with more educated and affluent patients compared with less advantaged patients. The women who asked more questions tended to be younger, white, better educated (beyond high school), and more affluent than other patients.
Source: Siminoff, Graham, and Gordon, Patient Educ Counsel 62:355-360, 2006 (AHRQ grant HS08516).
Many young women have not received the HPV vaccine.
Description: This survey found that more than 60 percent of 1,011 young women aged 13 to 26 years knew about Gardasil®, the vaccine against human papilloma virus (HPV) that causes cervical cancer. However, only 30 percent of those aged 13 to 17 and 9 percent of those aged 18-26 had received the vaccine. Because the vaccine is most beneficial when given before young women become sexually active, the authors urge practitioners and parents to step up efforts to educate young women about the importance of receiving the vaccine early.
Source: Caskey, Lindau, and Alexander, J Adolesc Health 45(5):453-462, 2009 (AHRQ grant HS15699).
Instituting new processes can reduce diagnostic errors in Pap smear interpretation.
Description: Lean methods are used to weigh the expenditure of resources against value received. For this study, researchers compared the diagnostic accuracy of Pap tests procured by five clinicians before (5,384 controls) and after (5,442 cases) implementing a process redesign using Lean methods. Following process redesign, there was a significant improvement in Pap smear quality, and the case group showed a 114 percent increase in newly detected cervical intraepithelial cancer following a previous benign Pap test.
Source: Raab, Andrew-Jaja, Grzybicki, et al, J Low Genit Tract Dis 12(2):103-110, 2008 (AHRQ grant HS13321).