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PubMed2002

Screening mammography in older women: a pilot study of residents' decisions.

BACKGROUND: Screening mammography is a commonly employed preventive modality. The employment of mammography in older women is not supported by evidence from clinical trials, largely because elderly women were excluded from such trials. Most guidelines do not recommend routine screening in older women. How residents reason in this gray zone has been subject to little empirical study. PURPOSES: This study sought to answer two questions: How variable are residents' decision responses to mammography screening scenarios in older women where there is no clear evidence? What reasons do residents give to justify these decisions? METHODS: Residents were asked to respond to four scenarios and give their screening recommendations and the reasons justifying their decisions. RESULTS: There was considerable variability in resident responses to the four scenarios. Only in one scenario was there near unanimity on the preferred screening decision. Resident perceptions of quality of life, longevity and understanding of the guidelines were cited as justification for their decisions. CONCLUSION: Clinical preceptors should be aware of how the variability of resident perceptions of such factors as quality of life and prognosis may influence decision-making.

Aged↗
PubMed2004

Reattendance in the Swiss mammography screening pilot programme.

OBJECTIVES: To explore the patterns and determinants of reattendance among initial attendees at an organised breast cancer screening programme. SETTING: Swiss mammography screening pilot programme, based on first-round enrollment in 1993-1995. METHODS: Data on socio-demographic features, health preventive behaviour and history, prior screening round and referring physicians' attributes were collected at initial attendance. First-round attendees (n=4162) were followed prospectively through next screening round. Determinants of reattendance were identified by multivariate logistic regression. RESULTS: Reattendance rate was high (80%). Women most likely to reattend were urban, Swiss residents with a true-negative first-round screening result. The more intensive the initial recruitment efforts, the lesser were the odds of reattendance. Mammography screening prior to screening enrolment increased reattendance. Having a gynaecologist, a female and a younger doctor as a referring physician was positively associated with reattendance. CONCLUSION: Mammography screening attendance is not only influenced by women-related factors but also by structural factors, and thus requires a global approach. For strategies aimed at improving performances of organised cancer screening programmes, understanding and quantification of determinants of (re)attendance are key elements to consider.

Aged↗
PubMed2006

Service screening mammography reduces breast cancer mortality among elderly women in Turku.

OBJECTIVES: The aim of this study was to assess the effects of service screening mammography on breast carcinoma incidence and refined mortality among women aged 55-69 at entry in three cities employing different screening policies. METHODS: Since 1987, the city of Turku, Finland, has provided service screening mammography for women aged 55-69 at entry (in 1987), and Tampere provided screening for women aged 55-59 at entry, whereas Helsinki did not screen any of these age groups. The incidence of breast carcinoma during the screening period 1987-97 in women born in 1918-32 (1918-22, 1923-27, 1928-32) was compared with incidence during the pre-screening period 1976-86 in women born in 1907-21 (1907-11, 1912-16, 1917-21) in each city. The follow-up for mortality was four years longer. RESULTS: Breast carcinoma incidence was 31-38% higher in the screening period in all three cities irrespective of screening. In breast carcinoma mortality, no significant changes were seen in Helsinki or Tampere. In Turku, a 36% mortality reduction (relative risk [RR] 0.64; 95% confidence interval [CI] 0.47-0.88; P=0.007) in the whole study population and a 47% reduction in women aged 65-69 at entry (RR 0.53; 95% CI 0.28-0.99; P=0.047) were seen. CONCLUSIONS: The incidence of breast carcinoma increased in all study cities irrespective of screening. The comprehensive screening programme in Turku including women aged 55-69 at entry was associated with a significant reduction in breast carcinoma mortality. The pronounced decrease in mortality in the oldest age group (65-69 years at entry) also indicated that women of this age group greatly benefit from mammography screening.

Age Factors↗
PubMed1989

Enhanced risk from low-energy screen--film mammography X rays.

Modern screen-film mammography with molybdenum-anode X rays results in tissue doses being delivered primarily by photons with an energy of less than 20 keV. Such photons interact with tissue predominantly through the photoelectric effect, producing low-energy electrons that have different patterns of energy deposition at the cellular level compared with those from higher-energy X rays. These differences result in low doses of typical molybdenum-based mammography X rays having an estimated radiobiological effectiveness of approximately 1.3 compared with 80 kVp or 250 kVp X rays, and approximately 2 compared with higher-energy gamma rays. Thus the risk from mammography could be higher, by such factors, than previously estimated. This would result in the optimal age for beginning mammographic screening, derived from risk-benefit ratios, being increased by at least 1-2 years and possibly by as many as 10 years.

Age Factors↗
PubMed1993

Calibration of ion chambers for use in mammography.

There is at present no UK calibration service for ion chambers for mammography, where X-ray beams are produced from tubes having molybdenum targets and filters. This paper reports calibrations against a radiotherapy secondary standard (calibrated for beams from tungsten targets with aluminium filters) using beams from both types of target and filter. Two examples of the Radcal mammography dosimeter were found to have calibration factors which varied by less than 1% in molybdenum target beams from 30 to 40 kV. Differences between calibrations using the two types of X-ray beam did not exceed about 2%. All calibration factors were within about +/- 2% of 1.0. Errors are thought to be within +/- 3%. The results of an independent calibration of one of these dosimeters against a similar chamber calibrated by CEC are also reported. Calibrations of this kind can only be temporary expedients until adequate calibration facilities for mammography beams become available, but are nevertheless useful.

Calibration↗
PubMed1995

Mammography in the follow-up after breast-conserving treatment in cancer of the breast: suitability for mammographic interpretation, validity and interobserver variation.

The aims of this study were to determine the suitability for radiographic interpretation, interobserver variability and validity of mammography after breast-conserving treatment. Initial and post-treatment mammograms of 100 consecutive patients treated between 1982 and 1987, with a minimal follow-up of 5 years, were independently selected for review by two radiologists. Mammograms were classified according to suitability for interpretation and radiological diagnosis based on the presence of characteristics of malignancy. The interobserver variability was expressed in kappa values, the validity in a receiver operating characteristic (ROC) plot. 534 post-treatment and 86 initial mammograms of 92 patients were obtained. Suitability for interpretation was not different from pre-treatment mammograms and was significantly associated with age, being better in the age group over 50 years. No association was observed between suitability for interpretation and treatment-related factors, even if irradiation was combined with concurrent chemotherapy. Reliability of conclusions regarding sensitivity and specificity in this study are limited due to the small number of events. Interobserver agreement concerning classification was moderate (weighted kappa = 0.49). ROC analysis showed an optimal decision threshold between the "uncertain" and "suspect" categories of malignancy, resulting in a sensitivity of 86% and a specificity of 98%. The appearance of new pathological microcalcifications with or without tumour mass seemed to be the most important characteristics of malignancy predicting local relapse. No clear alteration in suitability for interpretation was observed in the mammograms after breast-conserving treatment, even if irradiation was combined with concurrent chemotherapy. Mammography after breast conserving-treatment may be slightly less sensitive but is equally specific compared with mammography in the screening situation.

Age Factors↗
PubMed1997

Quality control programme in mammography: second level quality controls.

Mammography is the most reliable method by which to detect lesions in the breast. Since contrast between normal and pathological areas in the breast is extremely low, mammographic image quality should reach high standards without exceeding acceptable exposure levels for the breast. A quality control programme in mammography has been implemented. This programme is subdivided into two levels. The first consists of simple daily checks of image quality and film processing, while the second deals with more complex checks of mammographic unit, screen-film system, darkroom, illuminators, viewing conditions and reference dose determination. The values of all the parameters undergoing measurement are compared with the limiting values given by National and International Protocols. This paper describes the second level controls carried out every 6 months by the medical physicist. The parameters described are only those which have been studied and analysed in detail since the quality control programme in mammography was implemented. Such parameters (kilovoltage, focal spot dimension, half value layer, tube output, automatic exposure control system, screen-film characteristic curve and mean glandular dose) were measured during the period 1991-1995 and the results summarised. The values obtained prove the constant correct functioning of the equipment.

Breast↗
PubMed1998

Objective assessment of phantom image quality in mammography: a feasibility study.

The need for test objects in mammography quality control programmes to provide an objective measure of image quality pertinent to clinical problems is well documented. However, interobserver variations may be greater than the fluctuations in image quality that the quality control programme is seeking to detect. We have developed a computer algorithm to score a number of features in the Leeds TOR(MAX) mammography phantom. Threshold scoring techniques have been applied in the first instance; scoring schemes which utilize measures such as signal-to-noise ratio and modulation have also been formulated. This fully automatic algorithm has been applied to a set of 10 films which have been digitized at 25 microns resolution using a Joyce-Loebl scanning microdensitometer. The films were chosen retrospectively from quality control test films to demonstrate: (a) a range of optimized imaging systems, and (b) variation from the optimum. The performance of the algorithm has been compared with that of five experienced observers, and has been shown to be as consistent as individual observers, but more consistent than a pool of observers. Problems have been encountered with the detection of small details, indicating that a more sophisticated localization technique is desirable. The computer performs more successfully with the scoring scheme which utilizes the full imaging information available, rather than with the threshold-determined one. However, both the observers and the computer algorithm failed to identify the non-optimum films, suggesting that the sensitivity of the TOR(MAX) test object may not be adequate for modern mammography imaging systems.

Algorithms↗
PubMed2000

A comparison of fixed and variable kVp technique protocols for film-screen mammography.

Mammographic image quality, contrast and dose for a variable tube potential (kVp) technique protocol for film-screen mammography have been investigated. In this protocol, the tube potential is increased for larger breast thicknesses. Comparisons were made with fixed kVp protocols, in which the tube potential is kept constant and the breast thickness compensated for by prolonging the exposure ("fixed kVp" protocol). All measurements were performed on a mammography unit with a molybdenum target and filter. Image quality was quantified by image contrast, image detail detection and the minimum detectable dimension of low contrast objects. It was demonstrated that for a compressed breast thickness of less than about 40 mm, varying the tube potential had a negligible effect upon dose but a significant effect upon image quality. For a compressed breast thickness greater than about 60 mm, the effect of the tube potential upon image quality was much reduced; however, the effect upon dose was significantly greater. The variable kVp protocol takes advantage of this feature to yield a significantly lower dose for thicker breasts with a small reduction in image quality, often only within experimental uncertainty. For an exposure under automatic exposure control, increasing the tube potential from 26 kVp to 30 kVp for a breast of a reference tissue composition (50% adipose and 50% glandular) with a compressed thickness of 60 mm reduced the mean glandular dose from 6 mGy to 3.9 mGy (-35%), but increased the minimum detectable dimension of a low contrast mass from 0.8 (+/- 0.1) mm to 1.1 (+/- 0.1) mm. Adopting a variable kVp protocol led to a median patient mean glandular dose per film of 2.7 mGy, nearly independent of compressed breast thickness. In our survey, the mean age of women presenting for mammography is younger and the mean compressed breast thickness is less than reported from screening centres. This suggests that there will be a higher proportion of denser, glandular tissue in the breasts incorporated within this survey than for surveys from screening centres. The clinical use of the variable kVp protocol allows the extraction from patient data of separate changes in breast composition which are due to patient age and breast thickness. It is concluded that the reference breast tissue composition is not an accurate representation of the women presenting at this centre.

Adolescent↗
PubMed2006

The reliability of measuring physical characteristics of spiculated masses on mammography.

The goal of this study was to assess the reliability of measurements of the physical characteristics of spiculated masses on mammography. The images used in this study were obtained from the Digital Database for Screening Mammography. Two experienced radiologists measured the properties of 21 images of spiculated masses. The length and width of all spicules and the major axis of the mass were measured. In addition, the observers counted the total number of spicules. Interobserver and intraobserver variability were evaluated using a hypothesis test for equivalence, the intraclass correlation coefficient (ICC) and Bland-Altman statistics. For an equivalence level of 30% of the mean of the senior radiologist's measurement, equivalence was achieved for the measurements of average spicule length (p<0.01), average spicule width (p = 0.03), the length of the major axis (p<0.01) and for the count of the number of spicules (p<0.01). Similarly, with the ICC analysis technique "excellent" inter-rater agreement was observed for the measurements of average spicule length (ICC = 0.770), the length of the major axis (ICC = 0.801) and for the count of the number of spicules (ICC = 0.780). "Fair to good" agreement was observed for the average spicule width (ICC = 0.561). Equivalence was also demonstrated for intraobserver measurements. Physical properties of spiculated masses can be measured reliably on mammography. The interobserver and intraobserver variability for this task is comparable with that reported for other measurements made on medical images.

Breast Neoplasms↗
PubMed1999

Managed care organizations and mammography: opportunities to serve underserved women.

Breast cancer is one of the major causes of mortality and morbidity among women. Breast cancer screening (mammography) has been shown to be an effective preventive service. Significant proportions of women for whom mammography would be an appropriate intervention, especially older, low-income, and minority women, do not receive it. A large proportion of American women (including those in the workforce or who are Medicare and Medicaid beneficiaries) is now enrolled in managed care plans and that trend is likely to continue. Analysts have identified several concerns related to access and use of preventive services by low-income and other vulnerable populations. Research related to these concerns is summarized. Many research-based interventions have been identified that increase the likelihood of women receiving mammography. These are summarized and recommendations are made for managed care organizations to implement them.

Adult↗
PubMed2002

Perceptions of risk factors for breast cancer and attitudes toward mammography among women who are current, ex- and non-smokers.

Understanding risk perceptions for breast cancer among women smokers is important because smokers tend to underutilize breast cancer screening. Perceptions of the relative importance of a variety of factors which may increase breast cancer risk and the benefits/barriers of mammography, were examined among women who were current (n = 185), ex- (n = 632) and never (n = 623) smokers. Participants were a subset of women taking part in a project to increase mammography utilization among women aged 50 and over. Current smokers, but not ex-smokers, were significantly less likely than never smokers to agree that health risk behaviors most frequently seen in smokers (e.g., smoking cigarettes, high-fat diet, low intake of fruits and vegetables, physical inactivity, drinking alcohol) may increase risk for breast cancer. Current smokers, but not ex-smokers, perceived more barriers and fewer benefits of mammography, than never smokers.

Aged↗
PubMed2002

Knowledge, attitudes, and behavior of women ages 65 and older on mammography screening and Medicare: results of a national survey.

BACKGROUND: Compared to younger women, women 65+ will experience the greatest increase in new breast cancer cases. In 1991, Medicare began offering partial reimbursement for screening mammography every 2 years. METHODS: In 1999, the National Cancer Institute (NCI) conducted a telephone survey on breast cancer, mammography, and Medicare reimbursement with a sample of households containing women ages 65+ using random-digit-dialing. Results were weighted to provide nationally representative estimates of U.S. women 65+. NCI compared 1999 results with similar data from a 1992 AARP survey. RESULTS: Of the 814 women surveyed, 88% had had at least one mammogram in their lifetime; within this group, 80% had received their most recent mammogram 2 years ago or less. Only 57%, however, knew about recommendations to have a mammogram every 1-2 years. Approximately one-third indicated that they were not as concerned about getting breast cancer as when they were younger, and/or that women without risk factors could be less vigilant about mammograms. More than 75% were aware of Medicare coverage, but only 58% had used Medicare to help pay for their last mammogram. Minority women were almost twice as likely to be unaware of Medicare coverage. RECOMMENDATIONS: (1) Highlight that breast cancer risk increases with age (and does not decline in the absence of risk factors) and communicate the correct frequency for having mammograms; (2) expand primary care physicians' roles in promoting mammography screening for women 65+; and (3) provide Medicare coverage information to older women, particularly those not taking advantage of this benefit.

Aged↗
PubMed2005

Identifying barriers and facilitating factors to improve screening mammography rates in women diagnosed with mental illness and substance use disorders.

Little is known about screening mammography rates among women diagnosed with mental illness-even though some studies have suggested that this population might be particularly vulnerable to breast cancer. The purpose of this pilot study was to identify facilitators and barriers to mammography among women diagnosed with mental illness and/or substance use disorders. Four focus groups were conducted, with a total of 26 women, ages 40-65 years, with mental illness and/ or substance use disorders. Analysis was performed using the grounded-theory editing approach. Several major themes emerged from the transcripts: (1) motivators for obtaining mammograms, (2) fears and concerns, (3) shame and embarrassment, (4) the clinical environment, (5) provider-patient communication, and (6) the need for increased patient education. A family history of breast cancer and/or cancer was the most powerful motivator among focus group participants for obtaining a mammogram. Doctor recommendations and referrals were also identified as key facilitating factors. The overall knowledge of mammography and breast cancer among these women suggested educational deficiencies-despite extensive breast cancer screening and awareness campaigns. The findings highlight the importance of patient education as well as the positive effects of physician recommendations to encourage patients to receive breast cancer screening.

Adult↗
PubMed2005

Increasing mammography screening among African American women in rural areas.

The objective of this study was to evaluate the effectiveness of a church-based breast cancer screening education program on mammography attainment by African American women 40 years old and older in rural Alabama. The sample consisted of 192 women who volunteered to participate in the study through 13 African American churches in a rural, economically-depressed Alabama county. The design was quasi-experimental and had some features of community-based participatory research. Churches were randomly assigned to three groups (full program, partial program and control). The full program (group educational session plus an in-home visit from a Home Health Educator) positively affected mammography attainment (38% increase from baseline to Time 2). In addition, barriers to mammography attainment were reduced for women who had not obtained a mammogram by follow-up. Community-based participatory projects in collaboration with churches and cooperative extension programs have the potential to reduce racial disparities in breast cancer in rural areas.

Adult↗
PubMed2002

Women's receptivity to church-based mobile mammography.

Mobile mammography can increase access to preventive screening and might be effective in church-based settings. Among 1,117 women ages 50 to 80 from 45 Los Angeles County churches, 31.7 percent said they would definitely use a mobile van at church, 21.9 percent would probably use one, 28.7 percent would probably not use one, and 17.6 percent would definitely not use one. The odds of saying yes to mobile mammography were six times higher for Spanish-speaking Latinas than for whites, over two times higher for English-speaking nonwhites than for whites, five times higher for the uninsured than for those with public or private health insurance, and three times higher for women who reported no mammogram in the previous 24 months than for women who reported a mammogram. Partnering with churches to provide mobile mammography offers the potential to increase screening adherence for traditionally underscreened women.

Aged↗
PubMed2006

Development of a culturally specific instrument for mammography screening: an example with American Indian women in Vermont.

This article presents the triangulation process for translating qualitative data about mammography screening from a grounded theory study with American Indian women in Vermont, into questionnaire items based on an existing model of behavior change, the Transtheoretical Model (TTM) Stages-of-Change. Qualitative data were used to derive a theory, Moving in Between Mammography, which suggested that traditionality influenced American Indian women's screening decisions. To examine the relationship between mammography and traditionality, new items were developed for each of three key TTM constructs: Pros, Cons, and Processes-of-Change. The process for developing the new TTM-based items, as well as traditionality items specific for American Indian women living off-reservation, are presented. This article provides one example of how an instrument can be developed within a culturally competent nursing framework.

Adult↗
PubMed1979

Awareness, opinion and behavioral intention of urban women regarding mammography.

A representative sample of women living in metropolitan Los Angeles were asked what they heard and what they believed about mammography and whether they would obtain a mammogram if their doctor advised it. Forty percent of these women said they had not heard of mammography even after the procedure was described. Few of those who had heard of mammography had negative feelings about it. Further, 93 percent of the overall sample said they would obtain a mammogram if their physician recommended it.

Attitude to Health↗