Stochastic Decision Modeling to Improve Breast Cancer Preventive Care

Breast cancer is a leading cause of premature mortality among women in the United States. Breast cancer screening tests can help with detecting breast cancer in early stages and thereby reducing the breast cancer mortality risk. However, due to the imperfect nature of screening tests, there is always some associated overdiagnosis, false positives, and false negatives risks. Therefore, to improve breast cancer preventive care, we defined the focus of this dissertation on modeling breast cancer screening decisions.Breast cancer overdiagnosis is the first issue that is addressed in this dissertation. Although overdiagnosis is known to be the major risk inherent in mammography screening; currently there is no way to distinguish between overdiagnosed cancers and the ones that would cause problems over a patient’s lifetime. Overdiagnosis risk significantly depends on a patient’s compliance with screening recommendations. In Chapter 2, we use a stochastic framework to perform a harm-benefit analysis to compare the overdiagnosis risk with the benefits that breast cancer screening provides. In addition, we estimate the lifetime mortality risk of breast cancer while considering the overdiagnosis risk and the uncertainty in a patient’s adherence behavior. Our results show that, although overdiagnosis rate is relatively high in breast cancer screening, the benefits of breast cancer mammography screening outweigh the overdiagnosis risk.The second issue that is addressed in this dissertation is false negative results caused by density of breast tissue. Breast density is known to increase breast cancer risk and decrease mammography screening sensitivity. Breast density notification laws, require physicians to inform women with high breast density of these potential risks. The laws usually require healthcare providers to notify patients of the possibility of using more sensitive supplemental screening tests (e.g., ultrasound). Since the enactment of the laws, there have been controversial debates over i) their implementations due to the potential radiologists bias in breast density classification of mammogram images and ii) the necessity of supplemental screenings for all patients with high breast density. Breast density is a dynamic risk factor. Therefore, in the third chapter, we apply a hidden Markov model (HMM) on a sparse unbalanced longitudinal data to quantify the yearly progression of breast density based on Breast Imaging Reporting and Data System (BI-RADs) classifications.In Chapter 4, we use the results from previous chapter to investigate the effectiveness of supplemental screening and the impact of radiologists’ bias on patients’ outcomes under the breast density notification law. We consider the conditional probability of eventually detecting breast cancer in early states given that the patient develops breast cancer in her lifetime and the expected number of supplemental tests as patient’s outcome. Our results indicate that referring patients to a supplemental test solely based on their breast density may not necessarily improve their health outcomes and other risk factors need to be considered when making such referrals. Additionally, average-skilled radiologists’ performances are shown to be comparable with the performance of a perfect radiologist

A Simulation Approach to Evaluate the Impact of Breast Cancer Overdiagnosis on Patient Outcomes

Breast cancer overdiagnosis risk is difficult to estimate and varies significantly across current research. This research establishes a simulation approach to examine the relationship between breast cancer overdiagnosis and patient outcome and understand the impact that the range of breast cancer overdiagnosis rate estimates in the current literature has on patient outcomes. Overdiagnosis is represented in this study by a set of disease regression probabilities. Using microsimulation, we evaluate patient outcome, measured by number of mammograms and lifetime breast cancer mortality risk, as a function of treatment policy and regression probability. We use numerical experiments to evaluate treatment policies and disease regression probabilities, and we conclude through sensitivity analysis that treatment policy is a statistically significant factor for patient outcome and regression probability, or overdiagnosis rate, is only partially statistically significant for patient outcome

Improving Mammography Adherence in the Primary Care Setting

Despite exhaustive efforts over the past several decades aimed at prevention, early detection, and improved treatment regimens, breast cancer remains the most commonly diagnosed cancer among American women and is nearly the deadliest; it is second only to lung cancer in mortality (American Cancer Society [ACS], 2019; Centers for Disease Control and Prevention, 2018a; National Cancer Institute [NCI}, 2018). Women of average risk carry a 12% or 1 in 8 chance of developing breast cancer in their lifetime. Most recent estimates reveal 270,000 new breast cancer cases and over 42,000 breast cancer related deaths will occur in 2019 (ACS, 2019). Screening mammography remains the gold standard for early detection of breast cancer; detection before signs and symptoms appear is shown to decrease mortality and improve survival related to breast cancer (NCI, 2016, 2018). Multiple barriers and disparities were discussed in the literature in relation to mammography adherence and screening rates remain suboptimal despite known benefits of this important preventive tool. This Doctor of Nursing Practice scholarly project further explored the background and influencing factors related to mammography adherence, integrated a comprehensive review of the literature, and provided an evidence-based quality improvement initiative tailored toward improving mammography adherence in the primary care setting. This quality improvement project was designed in collaboration with a local primary care clinic and breast diagnostic center. The project aimed to identify women in the community who were past due for a screening mammogram, identify past and current efforts to improve mammogram rates within the chosen clinical setting, and develop a multimodal outreach initiative to improve women’s adherence to timely mammogram screenings. A scripted, evidence-based telephone outreach initiative was developed and built upon in-person and reminder letter initiatives completed by the clinic prior to this project. Fifty women from the clinic who were of average lifetime risk, were at least 12 months past due for a screening mammogram, and had received both previous forms of outreach were included in the sample population. The post-intervention sample population consisted of 44 women; the project was successful in influencing 20% of participants to schedule a mammogram while 16% followed through in obtaining a mammogram. The results of this scholarly project are beneficial in providing the clinic and diagnostic center stakeholders with additional knowledge and methodology regarding breast cancer screening outreach in addition to reaffirming a theme revealed in the literature surrounding mammography adherence: improving mammogram rates for women who are past due for screening is best accomplished through multimodal outreach that progressively increases in intensity over time

Determinants of Mammography Usage across Rural and Urban Regions of Canada

Breast cancer is a leading source of mortality among Canadian women; however early detection via mammography considerably improves survival rates. Accordingly, national guidelines advocate biennial screening for asymptomatic women aged 50 to 69 years. Unfortunately many women do not abide by such recommendations, and there is some evidence that compliance rates are lower in rural areas. This report explores the extent of regional variation within and between Canadian provinces using a new and more detailed set of rural indicators based on economic zones of influence. We find the incidence of ever having a mammogram and screening within the last two years are significantly lower for women most removed from large urban centers. This result is obtained after controlling for demographic and socio-economic characteristics, concentration of physicians and specialists in the local area and whether the woman has a regular family doctor. An important reason for the observed differences across rural and urban areas is found to be awareness of the need for regular screening. We also observe that differences in mammography usage between rural and urban areas vary significantly across Canadian provinces.mammography, cancer screening, rural health, women's health

Women's perception, attitudes, and intended behavior towards predictive epigenetic risk testing for female cancers in 5 European countries: A cross-sectional online survey

BACKGROUND: Epigenetic markers might be used for risk-stratifying cancer screening and prevention programs in the future. Although the clinical utility of consequent epigenetic tests for risk stratification is yet to be proven, successful adoption into clinical practice also requires the public's acceptance of such tests. This cross-sectional online survey study sought to learn for the first time about European women's perceptions, attitudes, and intended behavior regarding a predictive epigenetic test for female cancer (breast, ovarian, cervical, and endometrial) risks. METHODS: 1675 women (40-75 years) from five European countries (Czech Republic, Germany, United Kingdom, Italy, Sweden), drawn from online panels by the survey sampling company Harris Interactive (Germany), participated in an online survey where they first received online leaflet information on a predictive epigenetic test for female cancer risks and were subsequently queried by an online questionnaire on their desire to know their female cancer risks, their perception of the benefit-to-harm ratio of an epigenetic test predicting female cancer risks, reasons in favor and disfavor of taking such a test, and their intention to take a predictive epigenetic test for female cancer risks. RESULTS: Most women desired information on each of their female cancer risks, 56.6% (95% CI: 54.2-59.0) thought the potential benefits outweighed potential harms, and 75% (72.0-77.8) intended to take a predictive epigenetic test for female cancer risks if freely available. Results varied considerably by country with women from Germany and the Czech Republic being more reserved about this new form of testing than women from the other three European countries. The main reason cited in favor of a predictive epigenetic test for female cancer risks was its potential to guide healthcare strategies and lifestyle changes in the future, and in its disfavor was that it may increase cancer worry and coerce unintended lifestyle changes and healthcare interventions. CONCLUSIONS: A successful introduction of predictive epigenetic tests for cancer risks will require a balanced and transparent communication of the benefit-to-harm ratio of healthcare pathways resulting from such tests in order to curb unjustified expectations and at the same time to prevent unjustified concerns

Preventive Maintenance Decision Modeling in Health and Service Systems

This dissertation focuses on the preventive maintenance decision modeling in healthcare and service systems. In the first part of this dissertation, some issues in preventive health decisions for breast cancer are addressed, and in the second part, the required characteristics for preventive maintenance of an unreliable queuing system are derived. Adherence to cancer screening is the first issue that is addressed in this dissertation. Women’s adherence or compliance with mammography screening remained low in the recent years. In this dissertation, we first develop a design-based logistic regression model to quantify the probability of adherence to screening schedules based on women’s characteristics. In Chapter 3, we develop a randomized finite-horizon partially observable Markov chain to evaluate and compare different mammography screening strategies for women with different adherence behaviors in terms of quality adjusted life years (QALYs) and lifetime breast cancer mortality risk. The results imply that for the general population, the American Cancer Society (ACS) policy is an efficient frontier policy. In Chapter 4, the problem of overdiagnosis in cancer screening is addressed. Overdiagnosis is a side effect of screening and is defined as the diagnosis of a disease that will never cause symptoms or death during a patient\u27s lifetime. We develop a mathematical framework to quantify the lifetime overdiagnosis and mortality risk for different screening policies, and derive the (near) optimal policies with minimum overdiagnosis risk. In the second part, we consider an unreliable queuing system with servers stored in a shared stack. In such a system, servers have heterogeneous transient usage since servers on the top of the stack are more likely to be used. We develop a continuous-time Markov chain model to derive the utilization and usage time of servers in the system. These quantities are critical for the decision maker for deriving a maintenance policy

Public actions for control of breast cancer in Brazil: integrative review

Objective: to analyze the scientific production on "breast cancer" in the period from 2002 to 2013 and determine the public policies for screening and early diagnosis of breast cancer. Method: this is an integrative literature review conducted in the databases MEDLINE, LILACS, SciELO and Google Scholar. Inclusion criteria: year and period of publicationavailability of the full articlepublication in Braziland the cross-check of the keywords Breast Cancer, Primary Health Care, Screening Programs, and Early Detection of Cancer. Results: after analysis, four thematic categories were obtained: breast self-examination, clinical examination of breast, mammography, and factors that hinder the adherence to the screening. Conclusion: health professionals have deficits of knowledge on the area, indicating the need for other studies on the subject addressed and greater investment in continuing education of professionals.Objetivo: analisar a produção científica sobre "câncer de mama" no período de 2002 a 2013 e identificar quais são as políticas públicas de rastreamento e diagnóstico precoce para o câncer de mama. Método: trata-se de uma revisão integrativa da literatura realizada nas bases de dados MEDLINE, LILACS, SciELO e Google Acadêmico. Utilizou-se como critérios de inclusão: ano e período de publicação; disponibilidade do artigo na íntegra; publicação no Brasil; e o cruzamento entre os descritores Câncer de Mama, Atenção Primária à Saúde, Programas de Rastreamento e Detecção Precoce de Câncer. Resultados: após análise, obtiveram-se quatro (4) categorias temáticas: autoexame das mamas, exame clínico das mamas, mamografia e fatores que dificultam a adesão ao rastreamento. Conclusão: há déficits de conhecimento dos profissionais de saúde sobre a área, indicando a necessidade de realização de outros estudos sobre a temática abordada e maior investimento na educação continuada dos profissionais.Univ Fed Sao Paulo, Hlth Multiprofess Residency Program, Sao Paulo, BrazilUniv Fed Sao Paulo, Sao Paulo Sch Nursing, Clin & Surg Nursing Dept, Sao Paulo, BrazilUniv Fed Triangulo Mineiro, Hosp Care Nursing Dept, Belo Horizonte, MG, BrazilUniv Fed Sao Paulo, Sao Paulo Sch Nursing, Womens Hlth Nursing Dept, Sao Paulo, BrazilUniv Fed Sao Paulo, Hlth Multiprofess Residency Program, Sao Paulo, BrazilUniv Fed Sao Paulo, Sao Paulo Sch Nursing, Clin & Surg Nursing Dept, Sao Paulo, BrazilUniv Fed Sao Paulo, Sao Paulo Sch Nursing, Womens Hlth Nursing Dept, Sao Paulo, BrazilWeb of Scienc

Shared Decision-making in breast cancer screening programmes: Contributions to its implementations

A mesura que els pacients prenen consciència de ser usuaris del Sistema Nacional de Salut, demanen una prestació no relacionada només en resoldre el seu problema de salut de manera oportuna, sinó que també inclogui un bon acompanyament per part dels professionals, de manera que aconsegueixin un millor benestar. És a dir, sentir-se escoltat, rebre informació comprensible, ser tractat amb empatia i poder-se involucrar en les decisions que afecten la seva salut, sembla que són elements importants a considerar. Així ho han entès els diferents sistemes de salut, que han declarat com a centre del model els pacients, encara que de vegades sigui un desafiament portar-lo a la pràctica diària. La Presa de Decisions Compartides (TDC) pot ser una alternativa per concretar una atenció més participativa i centrada en el pacient, i models com "The Three-talk" faciliten la seva aplicació en situacions específiques de salut o malaltia. En aquest context, en el cribratge de càncer de mama, les dones tenen una baixa implicació a l'hora de decidir la seva participació, ja que no tenen ni un espai ni un temps específic on poder expressar els seus temors, dubtes o preferències a un professional de la salut, i moltes vegades manca informació sobre els beneficis i efectes adversos de participar en el cribratge. Més encara, elles no visualitzen aquestes mancances com una necessitat, perquè està molt interioritzat el benefici d'una detecció precoç com l'únic resultat possible i desconeixen o minimitzen els efectes adversos que coexisteixen amb el cribratge: falsos positius, falsos negatius o sobrediagnòstic. Aquesta tesi té per finalitat contribuir al desenvolupament d'una salut més participativa en l'àmbit del cribratge de càncer de mama, en un context de Sistema Nacional de Salut, utilitzant el model de TDC. Així, els resultats de tres estudis han permès: 1) conèixer les barreres i facilitadors per a l'aplicació de la TDC des de la perspectiva dels professionals de la salut, 2) crear dos documents –manual i guia– que ofereixen suport empíric als professionals de la salut per involucrar les dones en la presa de decisions del cribratge; 3) entendre les preferències de les dones comparant la significació dels atributs que defineixen el model de salut convencional i un amb incorporació d'una TDC.A medida que los pacientes toman conciencia como usuarios del Sistema Nacional de Salud, demandan prestaciones relacionadas no sólo con la resolución óptima de su problema de salud, sino una atención que también incluya un buen acompañamiento por parte de los profesionales, de forma que consigan un mejor bienestar. Es decir, sentirse escuchado, recibir información comprensible, ser tratado con empatía y poder involucrarse en las decisiones que afectan a su salud parecen ser elementos importantes que considerar. Así lo han entendido los diferentes sistemas de salud, que han declarado, como centro del modelo, a los pacientes, aunque en ocasiones sea un desafío llevarlo a la práctica diaria. La Toma de Decisiones Compartidas (TDC) puede ser una alternativa para concretar una atención más participativa y centrada en el paciente, y modelos como “The Three-talk model” facilitan su aplicación en situaciones específicas de salud o enfermedad. En este contexto, en el cribado de cáncer de mama, las mujeres tienen una baja implicación a la hora de decidir su participación, puesto que no tienen ni un espacio ni un tiempo específico donde poder expresar sus temores, dudas o preferencias a un profesional sanitario, y muchas veces carece de información sobre los beneficios y efectos adversos de participar en el cribado. Más aún, ellas no visualizan estas carencias como una necesidad, porque está muy interiorizado el beneficio de una detección precoz como el único resultado posible y desconocen o minimizan los efectos adversos que coexisten con el cribado: falsos positivos, falsos negativos o sobrediagnóstico. Esta tesis tiene por finalidad contribuir al desarrollo de una salud más participativa en el ámbito del cribado de cáncer de mama, en un contexto de Sistema Nacional de Salud, utilizando el modelo de TDC. Se realizaron tres estudios que han permitido: 1) conocer las barreras y facilitadores para la aplicación de la TDC desde la perspectiva de los profesionales de la salud, 2) crear dos documentos –manual y guía– que ofrecen soporte empírico a los profesionales sanitarios para involucrar a las mujeres en la toma de decisiones del cribado; 3) entender las preferencias de las mujeres comparando la significación de los atributos que definen el modelo de salud convencional y uno con incorporación de una TDC.As the awareness of patients as users of the national health system increases, they demand more well-being, which is not only related to solving their problem, but also a good accompaniment by health professionals. That is, feeling heard, receiving understandable information, being treated with empathy, and getting involved in decisions that affect your health seem to be important elements to consider. This has been understood by the different health systems, which have declared patients as the center of the model, although it is sometimes a challenge to put it into routine practice. Shared Decision-making (SDM) could be an alternative for more participatory and patient-centered care, as well as “The Three-talk” model would simplify its application in specific health or disease situations. In this context, women in breast cancer screening have a low involvement in the decision to participate, since they do not have a space in which to express their fears, doubts, or preferences to a health professional, and do not have sufficient information on the benefits and adverse effects of participating in screening. Even worse, they do not see these deficiencies as a necessity, since the benefit of early detection is very much internalized as the only possible result and they do not know or minimize the adverse effects they may suffer due to screening: false positives, false negatives or overdiagnosis. This thesis aims to contribute to the development of a more participatory health in the context of breast cancer screening in a context of the National Health System, using the SDM model. Three studies were carried out: 1) to know the barriers and facilitators for the application of the SDM from the perspective of health professionals, 2) create two documents, manual and guide, to give practical support to health professionals to involve women in the screening decision, 3) to know the preferences of women by comparing the attributes of the conventional health model and one with the incorporation of an SDM

Development, Implementation and Evaluation of a Screening Mammography Program

Breast cancer is a major public health concern in the United States and remains a priority for national women’s health centers, primary care practices and cancer control organizations such as the American Cancer Society (ACS). The cancer care continuum includes the spectrum of prevention/risk reduction, early detection, treatment, and living with the diagnosis. Currently there are no proven primary prevention options for women at average risk of developing breast cancer; therefore, secondary prevention interventions such as screening mammography and clinical breast examination (CBE) are required to reduce morbidity and mortality. This manuscript describes a Doctor of Nursing Practice (DNP) led quality improvement project aimed at increasing mammography screening completion rates in one community health center within a reputable safety-net community health network with access to a mobile mammography van. The intent of this project was to discover the barriers that patients view in complying with their breast cancer screening recommendation, the workflow of the health centers with the best practice, and the creation of a mammography toolkit to provide consistency in processes amongst multiple sites. Although there were challenges in reaching a significant amount of patients to unveil all the possible barriers, overall implementation of this quality improvement project resulted in a well appreciated mammography toolkit, which will be available to all primary care health centers and included in the orientation of medical evaluation workers and health workers as it relates to patients obtaining proper breast health. Keywords: screening mammography, telephone reminder calls, toolkit, DN

Engaging diverse underserved communities to bridge the mammography divide

<p>Abstract</p> <p>Background</p> <p>Breast cancer screening continues to be underutilized by the population in general, but is particularly underutilized by traditionally underserved minority populations. Two of the most at risk female minority groups are American Indians/Alaska Natives (AI/AN) and Latinas. American Indian women have the poorest recorded 5-year cancer survival rates of any ethnic group while breast cancer is the number one cause of cancer mortality among Latina women. Breast cancer screening rates for both minority groups are near or at the lowest among all racial/ethnic groups. As with other health screening behaviors, women may intend to get a mammogram but their intentions may not result in initiation or follow through of the examination process. An accumulating body of research, however, demonstrates the efficacy of developing 'implementation intentions' that define when, where, and how a specific behavior will be performed. The formulation of intended steps in addition to addressing potential barriers to test completion can increase a person's self-efficacy, operationalize and strengthen their intention to act, and close gaps between behavioral intention and completion. To date, an evaluation of the formulation of implementation intentions for breast cancer screening has not been conducted with minority populations.</p> <p>Methods/Design</p> <p>In the proposed program, community health workers will meet with rural-dwelling Latina and American Indian women one-on-one to educate them about breast cancer and screening and guide them through a computerized and culturally tailored "implementation intentions" program, called <it>Healthy Living Kansas - Breast Health</it>, to promote breast cancer screening utilization. We will target Latina and AI/AN women from two distinct rural Kansas communities. Women attending community events will be invited by CHWs to participate and be randomized to either a mammography "implementation intentions" (<b>MI</b>^<b>2</b>) intervention or a comparison general breast cancer prevention informational intervention (<b>C</b>). CHWs will be armed with notebook computers loaded with our Healthy Living Kansas - Breast Health program and guide their peers through the program. Women in the <b>MI</b>^{<b>2 </b>}condition will receive assistance with operationalizing their screening intentions and identifying and addressing their stated screening barriers with the goal of guiding them toward accessing screening services near their community. Outcomes will be evaluated at 120-days post randomization via self-report and will include mammography utilization status, barriers, and movement along a behavioral stages of readiness to screen model.</p> <p>Discussion</p> <p>This highly innovative project will be guided and initiated by AI/AN and Latina community members and will test the practical application of emerging behavioral theory among minority persons living in rural communities.</p> <p>Trial Registration</p> <p>ClinicalTrials (NCT): <a href="http://www.clinicaltrials.gov/ct2/show/NCT01267110">NCT01267110</a></p