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1.  Understanding the patient-provider communication needs and experiences of Latina and non-Latina White women following an abnormal mammogram 
Latinas are more likely to delay recommended follow-up care than non-Latina White (NLW) women after an abnormal mammogram result. Ethnic differences in communication needs and experiences with healthcare staff and providers may contribute to these delays as well as satisfaction with care. Nonetheless, little research has explored the aspects of communication that may contribute to patient comprehension, adherence to follow-up care, and satisfaction across ethnicity. The purpose of this exploratory, qualitative study was to identify patients' communication needs and experiences with follow-up care among Latina and NLW women who received an abnormal mammogram. We conducted 41 semi-structured interviews with 19 Latina and 22 NLW women between the ages of 40 and 74 who had received an abnormal mammogram. Communication themes indicated that women's needs and experiences concerning abnormal mammograms and follow-up care varied across ethnicity. Latinas and NLW women appeared to differ in their comprehension of abnormal results and follow-up care as a result of language barriers and health literacy. Both groups of women identified clear, empathic communication as being important in patient-provider communication; however, Latinas underscored the need for warm communicative styles and NLW women emphasized the importance of providing more information. Women with high levels of satisfaction with patient-provider interactions appeared to have positive perspectives of subsequent screening and cancer treatment. To improve patient satisfaction and adherence to follow-up care among Latinas, educational programs are necessary to counsel healthcare professionals with regard to language, health literacy, and empathic communication needs in healthcare service delivery.
doi:10.1007/s13187-014-0654-6
PMCID: PMC4206667  PMID: 24748097
abnormal mammogram; disparities; Latina; communication; breast cancer screening; follow-up; qualitative; patient interactions
2.  Screening Mammography for Women Aged 40 to 49 Years at Average Risk for Breast Cancer 
Executive Summary
Objective
The aim of this review was to determine the effectiveness of screening mammography in women aged 40 to 49 years at average risk for breast cancer.
Clinical Need
The effectiveness of screening mammography in women aged over 50 years has been established, yet the issue of screening in women aged 40 to 49 years is still unsettled. The Canadian Task Force of Preventive Services, which sets guidelines for screening mammography for all provinces, supports neither the inclusion nor the exclusion of this screening procedure for 40- to 49-year-old women from the periodic health examination. In addition to this, 2 separate reviews, one conducted in Quebec in 2005 and the other in Alberta in 2000, each concluded that there is an absence of convincing evidence on the effectiveness of screening mammography for women in this age group who are at average risk for breast cancer.
In the United States, there is disagreement among organizations on whether population-based mammography should begin at the age of 40 or 50 years. The National Institutes of Health, the American Association for Cancer Research, and the American Academy of Family Physicians recommend against screening women in their 40s, whereas the United States Preventive Services Task Force, the National Cancer Institute, the American Cancer Society, the American College of Radiology, and the American College of Obstetricians and Gynecologists recommend screening mammograms for women aged 40 to 49 years. Furthermore, in comparing screening guidelines between Canada and the United States, it is also important to recognize that “standard care” within a socialized medical system such as Canada’s differs from that of the United States. The National Breast Screening Study (NBSS-1), a randomized screening trial conducted in multiple centres across Canada, has shown there is no benefit in mortality from breast cancer from annual mammograms in women randomized between the ages of 40 and 49, relative to standard care (i.e. physical exam and teaching of breast-self examination on entry to the study, with usual community care thereafter).
At present, organized screening programs in Canada systematically screen women starting at 50 years of age, although with a physician’s referral, a screening mammogram is an insured service in Ontario for women under 50 years of age.
International estimates of the epidemiology of breast cancer show that the incidence of breast cancer is increasing for all ages combined, whereas mortality is decreasing, though at a slower rate. These decreasing mortality rates may be attributed to screening and advances in breast cancer therapy over time. Decreases in mortality attributable to screening may be a result of the earlier detection and treatment of invasive cancers, in addition to the increased detection of ductal carcinoma in situ (DCIS), of which certain subpathologies are less lethal. Evidence from the SEER cancer registry in the United States indicates that the age-adjusted incidence of DCIS has increased almost 10-fold over a 20-year period (from 2.7 to 25 per 100,000).
The incidence of breast cancer is lower in women aged 40 to 49 years than in women aged 50 to 69 years (about 140 per 100,000 versus 500 per 100,000 women, respectively), as is the sensitivity (about 75% versus 85% for women aged under and over 50, respectively) and specificity of mammography (about 80% versus 90% for women aged under and over 50, respectively). The increased density of breast tissue in younger women is mainly responsible for the lower accuracy of this procedure in this age group. In addition, as the proportion of breast cancers that occur before the age of 50 are more likely to be associated with genetic predisposition as compared with those diagnosed in women after the age of 50, mammography may not be an optimal screening method for younger women.
Treatment options vary with the stage of disease (based on tumor size, involvement of surrounding tissue, and number of affected axillary lymph nodes) and its pathology, and may include a combination of surgery, chemotherapy, and/or radiotherapy.
Surgery is the first-line intervention for biopsy confirmed tumours. The subsequent use of radiation, chemotherapy, or hormonal treatments is dependent on the histopathologic characteristics of the tumor and the type of surgery. There is controversy regarding the optimal treatment of DCIS, which is noninvasive.
With such controversy as to the effectiveness of mammography and the potential risk associated with women being overtreated or actual cancers being missed, and the increased risk of breast cancer associated with exposure to annual mammograms over a 10-year period, the Ontario Health Technology Advisory Committee requested this review of screening mammography in women aged 40 to 49 years at average risk for breast cancer. This review is the first of 2 parts and concentrates on the effectiveness of screening mammography (i.e., film mammography, FM) for women at average risk aged 40 to 49 years. The second part will be an evaluation of screening by either magnetic resonance imaging or digital mammography, with the objective of determining the optimal screening modality in these younger women.
Review Strategy
The following questions were asked:
Does screening mammography for women aged 40 to 49 years who are at average risk for breast cancer reduce breast cancer mortality?
What is the sensitivity and specificity of mammography for this age group?
What are the risks associated with annual screening from ages 40 to 49?
What are the risks associated with false positive and false negative mammography results?
What are the economic considerations if evidence for effectiveness is established?
The Medical Advisory Secretariat followed its standard procedures and searched these electronic databases: Ovid MEDLINE, EMBASE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and the International Network of Agencies for Health Technology Assessment.
Keywords used in the search were breast cancer, breast neoplasms, mass screening, and mammography.
In total, the search yielded 6,359 articles specific to breast cancer screening and mammography. This did not include reports on diagnostic mammograms. The search was further restricted to English-language randomized controlled trials (RCTs), systematic reviews, and meta-analyses published between 1995 and 2005. Excluded were case reports, comments, editorials, and letters, which narrowed the results to 516 articles and previous health technology policy assessments.
These were examined against the criteria outlined below. This resulted in the inclusion of 5 health technology assessments, the Canadian Preventive Services Task Force report, the United States Preventive Services Task Force report, 1 Cochrane review, and 8 RCTs.
Inclusion Criteria
English-language articles, and English and French-language health technology policy assessments, conducted by other organizations, from 1995 to 2005
Articles specific to RCTs of screening mammography of women at average risk for breast cancer that included results for women randomized to studies between the ages of 40 and 49 years
Studies in which women were randomized to screening with or without mammography, although women may have had clinical breast examinations and/or may have been conducting breast self-examination.
UK Age Trial results published in December 2006.
Exclusion Criteria
Observational studies, including those nested within RCTs
RCTs that do not include results on women between the ages of 40 and 49 at randomization
Studies in which mammography was compared with other radiologic screening modalities, for example, digital mammography, magnetic resonance imaging or ultrasound.
Studies in which women randomized had a personal history of breast cancer.
Intervention
Film mammography
Comparators
Within RCTs, the comparison group would have been women randomized to not undergo screening mammography, although they may have had clinical breast examinations and/or have been conducting breast self-examination.
Outcomes of Interest
Breast cancer mortality
Summary of Findings
There is Level 1 Canadian evidence that screening women between the ages of 40 and 49 years who are at average risk for breast cancer is not effective, and that the absence of a benefit is sustained over a maximum follow-up period of 16 years.
All remaining studies that reported on women aged under 50 years were based on subset analyses. They provide additional evidence that, when all these RCTs are taken into account, there is no significant reduction in breast cancer mortality associated with screening mammography in women aged 40 to 49 years.
Conclusions
There is Level 1 evidence that screening mammography in women aged 40 to 49 years at average risk for breast cancer is not effective in reducing mortality.
Moreover, risks associated with exposure to mammographic radiation, the increased risk of missed cancers due to lower mammographic sensitivity, and the psychological impact of false positives, are not inconsequential.
The UK Age Trial results published in December 2006 did not change these conclusions.
PMCID: PMC3377515  PMID: 23074501
3.  Health Care Access and Breast Cancer Screening Among Latinas Along the California–Mexican Border 
Latinas are more likely to exhibit late stage breast cancers at the time of diagnosis and have lower survival rates compared to white women. A contributing factor may be that Latinas have lower rates of mammography screening. This study was guided by the Behavioral Model of Health Services Use to examine factors associated with mammography screening utilization among middle-aged Latinas. An academic–community health center partnership collected data from community-based sample of 208 Latinas 40 years and older in the San Diego County who completed measures assessing psychosocial factors, health care access, and recent mammography screening. Results showed that 84.6 % had ever had a mammogram and 76.2 % of women had received a mammogram in the past 2 years. Characteristics associated with mammography screening adherence included a lower acculturation (OR 3.663) a recent physician visit in the past year (OR 6.304), and a greater confidence in filling out medical forms (OR 1.743), adjusting for covariates. Results demonstrate that an annual physical examination was the strongest predictor of recent breast cancer screening. Findings suggest that in this community, improving access to care among English-speaking Latinas and addressing health literacy issues are essential for promoting breast cancer screening utilization.
doi:10.1007/s10903-013-9938-x
PMCID: PMC4076386  PMID: 24150421
Community–academic partnership research; Health services utilization; Mammography screening; Latinas; Breast cancer
4.  HIV testing practices among Latina women at risk of getting infected: A five-year follow-up of a community sample in South Florida 
AIDS care  2015;28(2):137-146.
Latinos are more likely to delay HIV testing, present to care with an AIDS defining illness, and die within one year of learning their HIV-positive status than non-Latino blacks and whites. For this paper, we explore the role of partner-relationship characteristics and health behaviors, in predicting HIV testing among Latina adult women who engaged in risky sexual behaviors (i.e., unprotected vaginal and/or anal sex). Data from a convenience sample of 168 Latina adult women who engaged in risky sexual behavior in the year prior to assessment were analyzed for this paper. Rates and predictors of HIV testing among this sample were assessed after a five year follow-up. Descriptive and analytical estimates include incidence rates and adjusted odds ratios (AOR) from multilevel models. At five-year follow-up, 63.7% (n=107) women reported having been tested for HIV, of whom 12.2% (n=13) were women who never tested before. Main reasons for not having been tested at follow-up included: low risk perception (62.1%) and trusting their partner(s)/being in a monogamous relationship/knowing their partner’s HIV status (17.2%). Predictors of HIV testing included: age (AOR: 0.96; 95%C.I.=0.92–0.99), provider endorsement of HIV testing (AOR: 4.59; 95%C.I.=1.77–11.95), poor quality of their romantic relationships (AOR: 1.12; 95%C.I.=1.03–1.26) and knowing the HIV sero-status of sexual partner (AOR: 4.35; 95%C.I.=1.79–10.54). This study characterizes a group of Latina women at high risk for HIV infection and their HIV testing behaviors. Our findings underscore the need of increasing access to quality health care services and HIV behavioral interventions, and to strengthen the adherence to HIV/STD testing recommendations and guidelines among local health care providers serving the Latino community in South Florida.
doi:10.1080/09540121.2015.1071769
PMCID: PMC4724281  PMID: 26291133
Hispanic/Latina women; HIV testing; sexual risk behavior; sexual transmitted infections
5.  Family/friend recommendations and mammography intentions: the roles of perceived mammography norms and support 
Health Education Research  2015;30(5):797-809.
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.
doi:10.1093/her/cyv040
PMCID: PMC4654755  PMID: 26324395
6.  An Examination of Factors Associated with Healthcare Discrimination in Latina Immigrants: The Role of Healthcare Relationships and Language 
Background
Understanding factors that are associated with perceived discrimination in Latina immigrants may provide opportunities to improve care for this growing population.
Objective
To examine the prevalence of discrimination experiences in urban Latina immigrants and identify socio-cultural and healthcare factors that predict discrimination experiences.
Design
Cross-sectional survey of 166 Latina immigrants.
Measurements
Socio-cultural: region of origin, primary language, and education. Healthcare factors: insurance, place of care, patient-provider communication, trust in provider, and satisfaction with care. Multivariable logistic regression was used to examine factors that predicted discrimination.
Results
42% had at least one discrimination experience. Communication with providers was the factor most strongly associated with reporting having a discrimination experience while controlling for other variables (p<. 01). Women with good communication with their provider were 71% less likely to report discrimination.
Conclusion
Better communication with providers may reduce Latinas’ perceptions of discrimination and thereby improve healthcare access and use of services.
doi:10.1016/S0027-9684(15)30066-3
PMCID: PMC4838486  PMID: 26744111
Latina immigrants; discrimination; healthcare; communication
7.  Are risk factors for breast cancer associated with follow-up procedures in diverse women with abnormal mammography? 
Cancer causes & control : CCC  2005;16(3):245-253.
Objective
We evaluated the association of risk factors for breast cancer with reported follow-up procedures after abnormal mammography among diverse women.
Methods
Women ages 40–80 years were recruited from four clinical sites after receiving a screening mammography result that was classified as abnormal but probably benign, suspicious or highly suspicious, or indeterminate using standard criteria. A telephone-administered survey asked about breast cancer risk factors (family history, estrogen use, physical inactivity, age of menarche, age at birth of first child, parity, alcohol use), and self-reported use of diagnostic tests (follow-up mammogram, breast ultrasound, or biopsy).
Results
Nine hundred and seventy women completed the interview, mean age was 56, 42% were White, 19% Latina, 25% African American, and 15% Asian. White women were more likely to have a positive family history (20%), use estrogen (32%), be nulliparous (17%) and drink alcohol (62%). Latinas were more likely to be physically inactive (93%), African Americans to have early onset of menarche (53%) and Asians first child after age 30 (21%). White women were more likely to have suspicious mammograms (40%) and to undergo biopsy (45%). In multivariate models, Latinas were more likely to report breast ultrasound, physical inactive women reported fewer follow-up mammograms, and care outside the academic health center was associated with fewer biopsies. Indeterminate and suspicious mammography interpretations were significantly associated with more biopsy procedures (OR = 8.4; 95% CI = 3.8–18.5 and OR = 59; 95% CI = 35–100, respectively).
Conclusions
Demographic profile and breast cancer risk factors have little effect on self-reported use of diagnostic procedures following an abnormal mammography examination. Level of mammography abnormality determines diagnostic evaluation but variance by site of care was observed.
doi:10.1007/s10552-004-4028-y
PMCID: PMC2936818  PMID: 15947876
ethnicity; abnormal mammography; follow-up procedures; breast cancer
8.  Access to mammography screening in a large urban population: a multi-level analysis 
Cancer Causes & Control   2009;20(8):1469-1482.
Objective
To understand area-based sociodemographics, physician and medical practice characteristics, and community indicators associated with mammography use in Los Angeles County. An earlier multi-level analysis by Gumpertz et al. found that distance to the nearest mammography facility helped explain the higher proportion of Latinas diagnosed with late stage breast cancer compared with non-Latina Whites in Los Angeles County. Our study examined whether Latinas also have lower rates of mammography use.
Methods
We used a multi-level spatial modeling approach to examine individual and community level associations with mammography use among a diverse group of women aged 40–84 years in Los Angeles County. To build our multi-level spatial data set, we integrated five data sources: (1) 2001 California Health Interview Survey (CHIS) data, (2) 2001 Food and Drug Administration (FDA) certified mammography facility data, (3) 2003 LA Transit Authority data, (4) 2000 US Decennial Census data, and (5) 2001 Community Tracking Study (CTS) Physician’s Survey data.
Results
Our study confirmed for Los Angeles County many associations for mammography use found in other locations. An unexpected finding was that women with limited English proficiency (predominantly Latina) were significantly more likely to have had a recent mammogram than English-proficient women. We also found that, after controlling for other factors, mammography use was higher in neighborhoods with a greater density of mammography facilities.
Conclusion
Women with limited English proficiency were especially likely to report recent mammography in Los Angeles. This unexpected finding suggests that the intensive Spanish-language outreach program conducted by the Every Woman Counts (EWC) Program in low-income Latina communities in Los Angeles has been effective. Our study highlights the success of this targeted community-based outreach conducted between 1999 and 2001. These are the same populations that Gumpertz et al. identified as needing intervention. It would be useful to conduct another study of late-stage diagnosis in Los Angeles County to ascertain whether increased rates of mammography have also led to less late-stage diagnosis among Latinas in the neighborhoods where they are concentrated in Los Angeles.
doi:10.1007/s10552-009-9373-4
PMCID: PMC2746895  PMID: 19543987
Breast neoplasms; Mammography; Healthcare disparities; Inequalities; GIS; Logistic models; Socioeconomic factors; Multi-level spatial models
9.  Determinants of mammography screening behavior in Iranian women: A population-based study 
Background:
Breast cancer remains a substantial health concern in Iran due to delay and late stage at diagnosis and treatment. Despite the potential benefits of mammography screening for early detection of breast cancer, the performance of this screening among Iranian women is low. For planning appropriate intervention, this study was carried out to identify mammography rates and explore determinants of mammography screening behavior in females of Isfahan, Iran.
Materials and Methods:
In this population-based study, 384 women of 40 years and older were interviewed by telephone. The Farsi version of Champion's Health Belief Model scale (CHBMS) was used to examine factors associated with mammography screening. The obtained data were analyzed by SPSS (version 16.0) using statistical Chi-square, Fisher Exact test, t-test and multiple logistic regression model to identify the importance rate of socio-demographic and Health Belief Model (HBM) variables to predict mammography screening behavior. In all of tests, the level of significant was considered a = 0.05.
Results:
Mean age ± SD of women was 52.24 ± 8.2 years. Of the 384 participants, 44.3% reported at least one mammogram in their lifetime. Logistic regression analysis indicated that women were more likely to have mammography if they heard/read about breast cancer (OR = 4.17, 95% CI 2.09, 8.34), menopause in lower age (OR = 0.2, 95% CI 0.87, 0.99) and history of breast problem (OR = 0.9, 95% CI 0.12, 0.32). Also, women who perceived more benefits of mammography (OR = 1.84, 95% CI 1.63, 2.09), fewer barriers of mammography (OR = 0.91, 95% CI 0.86, 0.96) and had more motivation for health (OR = 0.94, 95% CI 0.89, 1) were more likely to have mammography.
Conclusion:
The findings indicated that the rate of mammography screening among women in Isfahan province is low and highlights the need for developing a comprehensive national breast cancer control program, which should be considered as the first priority for healthcare providers. Also, identification of these factors can help to design an appropriate educational intervention that focuses on benefits of mammography screening, decreasing changeable barriers, improving access to mammography, increasing health motivation, promoting perceived self-efficacy and mammography adherence.
PMCID: PMC3687882  PMID: 23798942
Breast cancer; health belief model; mammography screening; women
10.  Validating self-reported mammography use in vulnerable communities: findings and recommendations 
Background
Most health surveys ask women whether they have had a recent mammogram, all of which report mammography use (past two years) at about 70–80% regardless of race or residence. We examined the potential extent of over-reporting of mammography use in low income African-American and Latina women, and whether self-report inaccuracies might bias estimated associations between patient characteristics and mammography use.
Methods
Using venue based sampling in two poor communities on the west side of Chicago, we asked eligible women living in two west side communities of Chicago to complete a survey about breast health (n=2,200) and to provide consent to view their medical record. Of the n=1,909 women who screened eligible for medical record review, n=1,566 consented (82%). We obtained medical records of all women who provided both permission and a valid local mammography facility (n=1,221). We compared the self-reported responses from the survey to the imaging reports found in the medical record (documented). To account for missing data we conducted multiple imputations for key demographic variables and report standard measures of accuracy.
Results
Although 73% of women self-reported a mammogram in the last 2 years, only 45% of self-reports were documented. Over-reporting of mammography use was observed for all three ethnic groups.
Conclusions
These results suggest considerable over-estimation of prevalence of use in these vulnerable populations.
Impact
Relying on known faulty self-reported mammography data as a measure of mammography use provides an overly optimistic picture of utilization, a problem that may be exacerbated in vulnerable minority communities.
doi:10.1158/1055-9965.EPI-13-1253
PMCID: PMC4135480  PMID: 24859870
breast cancer disparities; mammography use disparities; validation of survey responses; vulnerable communities; breast cancer
11.  Quality of life among Latina breast cancer patients: a systematic review of the literature 
Journal of Cancer Survivorship  2011;5(2):191-207.
Introduction
The Latino population is the most rapidly growing ethnic minority in the United States and Latinas have higher rates of advanced breast cancer and more rigorous treatments than White women. However, the literature lacks reviews on quality of life among this population of breast cancer patients.
Methods
A systematic review of the breast cancer quality of life (QOL) literature was conducted among studies that provided a comparison of mental, physical, social, or sexual QOL between Latinas and other racial/ethnic groups. Of the 375 studies reviewed, 20 quantitative studies and two qualitative studies met criteria for inclusion.
Results
Latinas were more likely to report poor mental, physical, and social QOL, relative to non-Latinas. Only four studies assessed sexual QOL, making it difficult to draw any conclusions. Of these four QOL domains, the largest disparity was found in the area of mental health in which Latinas reported poorer QOL compared to non-Latina Whites and Blacks.
Discussion/conclusions
Most quantitative studies revealed either that Latinas consistently evidenced significantly lower QOL than non-Latinas on all measures (6 studies) or reported mixed findings in which Latinas generally demonstrated significantly worse QOL on most, but not all, measures (12 studies) included in the study. Explanatory mechanisms including socio-demographic, treatment-related, and culturally-relevant factors are discussed. Implications for research design, measurement, and clinical work are also included.
Implications for cancer survivors
Although not entirely consistent, data suggest that Latina breast cancer survivors on average experience worse QOL than non-Latina Whites.
Understanding ethnic differences in QOL among breast cancer survivors can inform interventions targeted at improving health status for Latinas.
doi:10.1007/s11764-011-0171-0
PMCID: PMC3096762  PMID: 21274649
Latina; Literature review; Quality of life; Breast cancer; Cancer survivorship
12.  The Effect of Access and Satisfaction on Regular Mammogram and Papanicolaou Test Screening in a Multiethnic Population 
Medical care  2004;42(9):914-926.
Background
Access and satisfaction are determinants of preventive service use, but few studies have evaluated their role in breast and cervical cancer screening in multiethnic populations.
Objectives
We sought to investigate the relationship between race/ethnicity, access, satisfaction, and regular mammogram and Papanicolaou test receipt in 5 racial/ethnic groups.
Research Design
We conducted a telephone survey in 4 languages.
Subjects
Our subjects were black, Chinese, Filipino, Latino, or white women aged 40 to 74 residing in Alameda County, California.
Measures
Outcome: regular mammograms (last test within 15 months and another within 2 years prior) and Papanicolaou tests (36 months and 3 years, respectively). Independent: race/ethnicity, sociodemographic variables, access (health insurance, usual site of care, regular doctor, check-up within 12 months, knowing where to go, copayment for tests), and satisfaction (overall satisfaction scale, waiting times, test-related pain and embarrassment, test satisfaction).
Results
Among women who had ever had a mammogram or Papanicolaou test, 54% and 77%, respectively, received regular screening. In multivariate analyses, regular mammography was positively associated with increased age (odds ratio [OR] 1.05 per year), private insurance (OR 1.7), check-up in the past year (OR 2.3), knowing where to go for mammography (OR 3.0), and greater satisfaction with processes of care (OR 1.04 per unit), and negatively with not knowing copayment amount (OR 0.4), too many forms to fill out (OR 0.5), embarrassment at the last mammogram (OR 0.6), and Filipino race/ethnicity. Similar results were found for regular Papanicolaou tests.
Conclusions
Access and satisfaction are important predictors of screening but do little to explain racial/ethnic variation. Tailored interventions to improve regular mammography and Papanicolaou test screening in multiethnic populations are needed.
PMCID: PMC1618783  PMID: 15319618
access to care; mammography; race and ethnicity; cancer screening; patient satisfaction
13.  Ductal carcinoma in situ (DCIS): posttreatment follow-up care among Latina and non-Latina White women 
Background
There is a lack of information about posttreatment care among patients with ductal carcinoma in situ (DCIS). This study compares posttreatment care by ethnicity–language and physician specialty among Latina and White women with DCIS.
Methods
Latina and White women diagnosed with DCIS between 2002 and 2005 identified through the California Cancer Registry completed a telephone survey in 2006. Main outcomes were breast surveillance, lifestyle counseling, and follow-up physician specialty.
Key results
Of 742 women (396 White, 349 Latinas), most (90 %) had at least one clinical breast exam (CBE). Among women treated with breast-conserving surgery (BCS; N= 503), 76 % had received at least two mammograms. While 92 % of all women had follow-up with a breast specialist, Spanish-speaking Latinas had the lowest specialist follow-up rates (84 %) of all groups. Lifestyle counseling was low with only 53 % discussing exercise, 43 % weight, and 31 % alcohol in relation to their DCIS. In multivariable analysis, Spanish-speaking Latinas with BCS had lower odds of receiving the recommended mammography screening in the year following treatment compared to Whites (OR 0.5; 95 % CI, 0.2–0.9). Regardless of ethnicity–language, seeing both a specialist and primary care physician increased the odds of mammography screening and CBE (OR 1.6; 95 % CI, 1.2–2.3 and OR 1.9; 95 % CI, 1.3–2.8), as well as having discussions about exercise, weight, and alcohol use, compared to seeing a specialist only.
Conclusions
Most women reported appropriate surveillance after DCIS treatment. However, our results suggest less adequate follow-up for Spanish-speaking Latinas, possibly due to language barriers or insurance access.
Implications for Cancer Survivors
Follow-up with a primary care provider in addition to a breast specialist increases receipt of appropriate follow-up for all women.
doi:10.1007/s11764-012-0262-6
PMCID: PMC3627346  PMID: 23408106
DCIS; Posttreatment care; Survivorship; Latina; Language barriers; Health disparities
14.  Factors Associated with Annual-Interval Mammography for Women in Their 40s 
Cancer Epidemiology  2009;33(1):72-78.
Background
Evidence is mounting that annual mammography for women in their 40s may be the optimal schedule to reduce morbidity and mortality from breast cancer. Few studies have assessed predictors of repeat mammography on an annual interval among these women.
Methods
We assessed mammography screening status among 596 insured Black and Non-Hispanic white women ages 43 to 49. Adherence was defined as having a second mammogram 10 to 14 months after a previous mammogram. We examined socio-demographic, medical and healthcare-related variables on receipt of annual-interval repeat mammograms. We also assessed barriers associated with screening.
Results
44.8% of the sample were adherent to annual-interval mammography. A history of self-reported abnormal mammograms, family history of breast cancer and never having smoked were associated with adherence. Saying they had not received mammography reminders and reporting barriers to mammography were associated with non-adherence. Four barrier categories were associated with women's non-adherence: lack of knowledge/not thinking mammograms are needed, cost, being too busy, and forgetting to make/keep appointments.
Conclusions
Barriers we identified are similar to those found in other studies. Health professionals may need to take extra care in discussing mammography screening risk and benefits due to ambiguity about screening guidelines for women in their 40s, especially for women without family histories of breast cancer or histories of abnormal mammograms. Reminders are important in promoting mammography and should be coupled with other strategies to help women maintain adherence to regular mammography.
doi:10.1016/j.cdp.2009.03.001
PMCID: PMC2727566  PMID: 19481879
breast neoplasms; guideline adherence; health behavior; middle aged; attitude to health; patient compliance; mass screening; female; risk factor; health knowledge
15.  Role of Physician Involvement on Latinas’ Mammography Screening Adherence 
Background
Disparities in breast cancer (BC) screening continue to affect Latinas significantly but the factors that explain these disparities remain unclear.
Objective
The objective of this study was to investigate whether physician’s instruction on breast examination and mammography recommendations predicted Latinas’ adherence to mammography screening above and beyond other influential variables.
Methods
A cross-sectional, descriptive design was utilized. Convenience and snowball sampling techniques were followed to recruit 344 Latinas age 41 years and older from predominantly Latino neighborhoods in Denver, Colorado.
Main Outcome Measures
Latinas’ adherence to mammography screening recommendations by the American Cancer Society (Smith et al., 2003).
Results
Characteristics that were significantly associated with mammography adherence were age, Pap smear adherence, physician’s breast examination instructions and physician’s mammography recommendations.
Conclusion
The study provides evidence that the BC screening disparities that significantly affect Latinas can be addressed by increasing physician’s involvement through BC screening instruction and referral.
doi:10.1016/j.whi.2010.09.001
PMCID: PMC3074189  PMID: 21232975
cancer control; health disparities; social determinants; Hispanic
16.  Time to definitive diagnosis of breast cancer in Latina and non-Hispanic white women: the six cities study 
SpringerPlus  2013;2:84.
Time delay after an abnormal screening mammogram may have a critical impact on tumor size, stage at diagnosis, treatment, prognosis, and survival of subsequent breast cancer. This study was undertaken to evaluate disparities between Latina and non-Hispanic white (NHW) women in time to definitive diagnosis of breast cancer after an abnormal screening mammogram, as well as factors contributing to such disparities.
As part of the activities of the National Cancer Institute (NCI)-funded Redes En Acción research network, clinical records of 186 Latinas and 74 NHWs who received abnormal screening mammogram results were reviewed to determine the time to obtain a definitive diagnosis. Data was obtained from participating clinics in six U.S. cities and included demographics, clinical history, and mammogram characteristics. Kaplan-Meier estimates and Cox proportional hazards models were used to test differences in median time to definitive diagnosis by ethnicity after adjusting for clinic site, demographics, and clinical characteristics.
Time-to-event analysis showed that Latinas took 2.2 times longer to reach 50% definitively diagnosed with breast cancer relative to NHWs, and three times longer to reach 80% diagnosed (p=0.001). Latinas’ median time to definitive diagnosis was 60 days compared to 27 for NHWs, a 59% gap in diagnosis rates (adjusted Hazard Ratio [aHR] = 1.59, 95% CI = 1.09, 2.31; p=0.015). BI-RADS-4/5 women’s diagnosis rate was more than twice that of BI-RADS-3 (aHR = 2.11, 95% CI = 1.18, 3.78; p=0.011).
Disparities in time between receipt of abnormal screening result and definitive diagnosis adversely affect Latinas compared to NHWs, and remain significant after adjusting for demographic and clinical variables. With cancer now the leading cause of mortality among Latinos, a greater need exists for ethnically and culturally appropriate interventions like patient navigation to facilitate Latinas’ successful entry into, and progression through, the cancer care system.
doi:10.1186/2193-1801-2-84
PMCID: PMC3601250  PMID: 23519779
Health disparities; Breast cancer screening; Definitive diagnosis; Latinas; Six cities study
17.  Cancer Screening with Digital Mammography for Women at Average Risk for Breast Cancer, Magnetic Resonance Imaging (MRI) for Women at High Risk 
Executive Summary
Objective
The purpose of this review is to determine the effectiveness of 2 separate modalities, digital mammography (DM) and magnetic resonance imaging (MRI), relative to film mammography (FM), in the screening of women asymptomatic for breast cancer. A third analysis assesses the effectiveness and safety of the combination of MRI plus mammography (MRI plus FM) in screening of women at high risk. An economic analysis was also conducted.
Research Questions
How does the sensitivity and specificity of DM compare to FM?
How does the sensitivity and specificity of MRI compare to FM?
How do the recall rates compare among these screening modalities, and what effect might this have on radiation exposure? What are the risks associated with radiation exposure?
How does the sensitivity and specificity of the combination of MRI plus FM compare to either MRI or FM alone?
What are the economic considerations?
Clinical Need
The effectiveness of FM with respect to breast cancer mortality in the screening of asymptomatic average- risk women over the age of 50 has been established. However, based on a Medical Advisory Secretariat review completed in March 2006, screening is not recommended for women between the ages of 40 and 49 years. Guidelines published by the Canadian Task Force on Preventive Care recommend mammography screening every 1 to 2 years for women aged 50 years and over, hence, the inclusion of such women in organized breast cancer screening programs. In addition to the uncertainty of the effectiveness of mammography screening from the age of 40 years, there is concern over the risks associated with mammographic screening for the 10 years between the ages of 40 and 49 years.
The lack of effectiveness of mammography screening starting at the age of 40 years (with respect to breast cancer mortality) is based on the assumption that the ability to detect cancer decreases with increased breast tissue density. As breast density is highest in the premenopausal years (approximately 23% of postmenopausal and 53% of premenopausal women having at least 50% of the breast occupied by high density), mammography screening is not promoted in Canada nor in many other countries for women under the age of 50 at average risk for breast cancer. It is important to note, however, that screening of premenopausal women (i.e., younger than 50 years of age) at high risk for breast cancer by virtue of a family history of cancer or a known genetic predisposition (e.g., having tested positive for the breast cancer genes BRCA1 and/or BRCA2) is appropriate. Thus, this review will assess the effectiveness of breast cancer screening with modalities other than film mammography, specifically DM and MRI, for both pre/perimenopausal and postmenopausal age groups.
International estimates of the epidemiology of breast cancer show that the incidence of breast cancer is increasing for all ages combined whereas mortality is decreasing, though at a slower rate. The observed decreases in mortality rates may be attributable to screening, in addition to advances in breast cancer therapy over time. Decreases in mortality attributable to screening may be a result of the earlier detection and treatment of invasive cancers, in addition to the increased detection of ductal carcinoma in situ (DCIS), of which certain subpathologies are less lethal. Evidence from the Surveillance, Epidemiology and End Results (better known as SEER) cancer registry in the United States, indicates that the age-adjusted incidence of DCIS has increased almost 10-fold over a 20 year period, from 2.7 to 25 per 100,000.
There is a 4-fold lower incidence of breast cancer in the 40 to 49 year age group than in the 50 to 69 year age group (approximately 140 per 100,000 versus 500 per 100,000 women, respectively). The sensitivity of FM is also lower among younger women (approximately 75%) than for women aged over 50 years (approximately 85%). Specificity is approximately 80% for younger women versus 90% for women over 50 years. The increased density of breast tissue in younger women is likely responsible for the decreased accuracy of FM.
Treatment options for breast cancer vary with the stage of disease (based on tumor size, involvement of surrounding tissue, and number of affected axillary lymph nodes) and its pathology, and may include a combination of surgery, chemotherapy and/or radiotherapy. Surgery is the first-line intervention for biopsy-confirmed tumors. The subsequent use of radiation, chemotherapy or hormonal treatments is dependent on the histopathologic characteristics of the tumor and the type of surgery. There is controversy regarding the optimal treatment of DCIS, which is considered a noninvasive tumour.
Women at high risk for breast cancer are defined as genetic carriers of the more commonly known breast cancer genes (BRCA1, BRCA2 TP53), first degree relatives of carriers, women with varying degrees of high risk family histories, and/or women with greater than 20% lifetime risk for breast cancer based on existing risk models. Genetic carriers for this disease, primarily women with BRCA1 or BRCA2 mutations, have a lifetime probability of approximately 85% of developing breast cancer. Preventive options for these women include surgical interventions such as prophylactic mastectomy and/or oophorectomy, i.e., removal of the breasts and/or ovaries. Therefore, it is important to evaluate the benefits and risks of different screening modalities, to identify additional options for these women.
This Medical Advisory Secretariat review is the second of 2 parts on breast cancer screening, and concentrates on the evaluation of both DM and MRI relative to FM, the standard of care. Part I of this review (March 2006) addressed the effectiveness of screening mammography in 40 to 49 year old average-risk women. The overall objective of the present review is to determine the optimal screening modality based on the evidence.
Evidence Review Strategy
The Medical Advisory Secretariat followed its standard procedures and searched the following electronic databases: Ovid MEDLINE, EMBASE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and The International Network of Agencies for Health Technology Assessment database. The subject headings and keywords searched included breast cancer, breast neoplasms, mass screening, digital mammography, magnetic resonance imaging. The detailed search strategies can be viewed in Appendix 1.
Included in this review are articles specific to screening and do not include evidence on diagnostic mammography. The search was further restricted to English-language articles published between January 1996 and April 2006. Excluded were case reports, comments, editorials, nonsystematic reviews, and letters.
Digital Mammography: In total, 224 articles specific to DM screening were identified. These were examined against the inclusion/exclusion criteria described below, resulting in the selection and review of 5 health technology assessments (HTAs) (plus 1 update) and 4 articles specific to screening with DM.
Magnetic Resonance Imaging: In total, 193 articles specific to MRI were identified. These were examined against the inclusion/exclusion criteria described below, resulting in the selection and review of 2 HTAs and 7 articles specific to screening with MRI.
The evaluation of the addition of FM to MRI in the screening of women at high risk for breast cancer was also conducted within the context of standard search procedures of the Medical Advisory Secretariat. as outlined above. The subject headings and keywords searched included the concepts of breast cancer, magnetic resonance imaging, mass screening, and high risk/predisposition to breast cancer. The search was further restricted to English-language articles published between September 2007 and January 15, 2010. Case reports, comments, editorials, nonsystematic reviews, and letters were not excluded.
MRI plus mammography: In total, 243 articles specific to MRI plus FM screening were identified. These were examined against the inclusion/exclusion criteria described below, resulting in the selection and review of 2 previous HTAs, and 1 systematic review of 11 paired design studies.
Inclusion Criteria
English-language articles, and English or French-language HTAs published from January 1996 to April 2006, inclusive.
Articles specific to screening of women with no personal history of breast cancer.
Studies in which DM or MRI were compared with FM, and where the specific outcomes of interest were reported.
Randomized controlled trials (RCTs) or paired studies only for assessment of DM.
Prospective, paired studies only for assessment of MRI.
Exclusion Criteria
Studies in which outcomes were not specific to those of interest in this report.
Studies in which women had been previously diagnosed with breast cancer.
Studies in which the intervention (DM or MRI) was not compared with FM.
Studies assessing DM with a sample size of less than 500.
Intervention
Digital mammography.
Magnetic resonance imaging.
Comparator
Screening with film mammography.
Outcomes of Interest
Breast cancer mortality (although no studies were found with such long follow-up).
Sensitivity.
Specificity.
Recall rates.
Summary of Findings
Digital Mammography
There is moderate quality evidence that DM is significantly more sensitive than FM in the screening of asymptomatic women aged less than 50 years, those who are premenopausal or perimenopausal, and those with heterogeneously or extremely dense breast tissue (regardless of age).
It is not known what effect these differences in sensitivity will have on the more important effectiveness outcome measure of breast cancer mortality, as there was no evidence of such an assessment.
Other factors have been set out to promote DM, for example, issues of recall rates and reading and examination times. Our analysis did not show that recall rates were necessarily improved in DM, though examination times were lower than for FM. Other factors including storage and retrieval of screens were not the subject of this analysis.
Magnetic Resonance Imaging
There is moderate quality evidence that the sensitivity of MRI is significantly higher than that of FM in the screening of women at high risk for breast cancer based on genetic or familial factors, regardless of age.
Radiation Risk Review
Cancer Care Ontario conducted a review of the evidence on radiation risk in screening with mammography women at high risk for breast cancer. From this review of recent literature and risk assessment that considered the potential impact of screening mammography in cohorts of women who start screening at an earlier age or who are at increased risk of developing breast cancer due to genetic susceptibility, the following conclusions can be drawn:
For women over 50 years of age, the benefits of mammography greatly outweigh the risk of radiation-induced breast cancer irrespective of the level of a woman’s inherent breast cancer risk.
Annual mammography for women aged 30 – 39 years who carry a breast cancer susceptibility gene or who have a strong family breast cancer history (defined as a first degree relative diagnosed in their thirties) has a favourable benefit:risk ratio. Mammography is estimated to detect 16 to 18 breast cancer cases for every one induced by radiation (Table 1). Initiation of screening at age 35 for this same group would increase the benefit:risk ratio to an even more favourable level of 34-50 cases detected for each one potentially induced.
Mammography for women under 30 years of age has an unfavourable benefit:risk ratio due to the challenges of detecting cancer in younger breasts, the aggressiveness of cancers at this age, the potential for radiation susceptibility at younger ages and a greater cumulative radiation exposure.
Mammography when used in combination with MRI for women who carry a strong breast cancer susceptibility (e.g., BRCA1/2 carriers), which if begun at age 35 and continued for 35 years, may confer greatly improved benefit:risk ratios which were estimated to be about 220 to one.
While there is considerable uncertainty in the risk of radiation-induced breast cancer, the risk expressed in published studies is almost certainly conservative as the radiation dose absorbed by women receiving mammography recently has been substantially reduced by newer technology.
A CCO update of the mammography radiation risk literature for 2008 and 2009 gave rise to one article by Barrington de Gonzales et al. published in 2009 (Barrington de Gonzales et al., 2009, JNCI, vol. 101: 205-209). This article focuses on estimating the risk of radiation-induced breast cancer for mammographic screening of young women at high risk for breast cancer (with BRCA gene mutations). Based on an assumption of a 15% to 25% or less reduction in mortality from mammography in these high risk women, the authors conclude that such a reduction is not substantially greater than the risk of radiation-induced breast cancer mortality when screening before the age of 34 years. That is, there would be no net benefit from annual mammographic screening of BRCA mutation carriers at ages 25-29 years; the net benefit would be zero or small if screening occurs in 30-34 year olds, and there would be some net benefit at age 35 years or older.
The Addition of Mammography to Magnetic Resonance Imaging
The effects of the addition of FM to MRI screening of high risk women was also assessed, with inclusion and exclusion criteria as follows:
Inclusion Criteria
English-language articles and English or French-language HTAs published from September 2007 to January 15, 2010.
Articles specific to screening of women at high risk for breast cancer, regardless of the definition of high risk.
Studies in which accuracy data for the combination of MRI plus FM are available to be compared to that of MRI and FM alone.
RCTs or prospective, paired studies only.
Studies in which women were previously diagnosed with breast cancer were also included.
Exclusion Criteria
Studies in which outcomes were not specific to those of interest in this report.
Studies in which there was insufficient data on the accuracy of MRI plus FM.
Intervention
Both MRI and FM.
Comparators
Screening with MRI alone and FM alone.
Outcomes of Interest
Sensitivity.
Specificity.
Summary of Findings
Magnetic Resonance Imaging Plus Mammography
Moderate GRADE Level Evidence that the sensitivity of MRI plus mammography is significantly higher than that of MRI or FM alone, although the specificity remains either unchanged or decreases in the screening of women at high risk for breast cancer based on genetic/familial factors, regardless of age.
These studies include women at high risk defined as BRCA1/2 or TP53 carriers, first degree relatives of carriers, women with varying degrees of high risk family histories, and/or >20% lifetime risk based on existing risk models. This definition of high risk accounts for approximately 2% of the female adult population in Ontario.
PMCID: PMC3377503  PMID: 23074406
18.  Patient-Physician Language Concordance and Use of Preventive Care Services Among Limited English Proficient Latinos and Asians 
Public Health Reports  2015;130(2):134-142.
Objectives
Patient-physician language concordance among limited English proficient (LEP) patients is associated with better outcomes for specific clinical conditions. Whether or not language concordance contributes to use of specific preventive care services is unclear.
Methods
We pooled data from the 2007 and 2009 California Health Interview Surveys to examine mammography, colorectal cancer (CRC) screening, and influenza vaccination use among self-identified LEP Latino and Asian (i.e., Chinese, Korean, and Vietnamese) immigrants. We defined language concordance by respondents reporting that their physician spoke their non-English language. Analyses were completed in 2013–2014.
Results
Language concordance did not appear to facilitate mammography use among Latinas (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI] 0.72, 1.45). Among Asian women, we could not definitively exclude a negative association of language concordance with mammography (AOR=0.55, 95% CI 0.27, 1.09). Patient-physician language concordance was associated with lower odds of CRC screening among Asians but not Latinos (Asian AOR=0.50, 95% CI 0.29, 0.86; Latino AOR=0.85, 95% CI 0.56, 1.28). Influenza vaccination did not differ by physician language use among either Latinos or Asians.
Conclusions
Patient-physician language concordance was not associated with higher use of mammography, CRC screening, or influenza vaccination. Language concordance was negatively associated with CRC screening among Asians for reasons that require further research. Future research should isolate the impact of language concordance on the use of preventive care services from health system factors.
PMCID: PMC4315854  PMID: 25729102
19.  Diabetes-Related Behaviors in Latinas and Non-Latinas in California 
Diabetes Care  2013;36(2):355-361.
OBJECTIVE
Certain dietary and physical activity behaviors have been associated with the risk of developing type 2 diabetes, yet little is known about the prevalence of these behaviors among Latinas (Latino women). The purpose of this cross-sectional study was to compare the prevalence of diabetes-related behaviors in Latinas and non-Latinas.
RESEARCH DESIGN AND METHODS
Using data from the 2009 California Health Interview Survey, we compared self-reported diabetes-related behaviors of Latinas (n = 4,321) to non-Latinas (n = 21,112) after excluding women who were pregnant or had diabetes. For six behaviors, we determined the cut point for the least healthy tertile: walking, doing moderate to vigorous physical activity, and consuming fried potatoes, sugar-sweetened beverages (SSBs), desserts, and fast food. We used logistic regression to examine the association between Latina ethnicity and being in the least healthy tertile compared with the other two tertiles for each of these behaviors.
RESULTS
In multivariate models adjusted for age, income, education, marital status, health status, smoking, and acculturation, Latinas had a higher risk (odds ratio [95% CI]) of being in the least healthy tertile for the consumption of fast food (1.94 [1.63–2.31]), SSBs (1.53 [1.29–1.82]), and fried potatoes (1.32 [1.18–1.67]), and lower risk for desserts (0.82 [0.70–0.95]). Latinas and non-Latinas had similar physical activity levels.
CONCLUSIONS
Dietary differences between Latinas and non-Latinas (particularly in the consumption of fast food and SSBs) may be the focus of interventions to prevent diabetes in Latinas. Further research among Latinas is needed to understand and modify these dietary behaviors.
doi:10.2337/dc12-0548
PMCID: PMC3554295  PMID: 22961569
20.  Prospective Study of Factors Predicting Adherence to Surveillance Mammography in Women Treated for Breast Cancer 
Journal of Clinical Oncology  2012;30(8):813-819.
Purpose
This prospective study examined the factors that predicted sustained adherence to surveillance mammography in women treated for breast cancer.
Methods
Breast cancer survivors (N = 204) who were undergoing surveillance mammography completed questionnaires assessing mammography-related anticipatory anxiety, persistent breast pain, mammography pain, and catastrophic thoughts about mammography pain. Adherence to mammography in the following year was assessed.
Results
In the year after study entry, 84.8% of women (n = 173) returned for a subsequent mammogram. Unadjusted associations showed that younger age, shorter period of time since surgery, and having upper extremity lymphedema were associated with lower mammography adherence. Forty percent of women reported moderate to high levels of mammography pain (score of ≥ 5 on a 0 to 10 scale). Although mammography pain was not associated with adherence, higher levels of mammography-related anxiety and pain catastrophizing were associated with not returning for a mammogram (P < .05). The impact of anxiety on mammography use was mediated by pain catastrophizing (indirect effect, P < .05).
Conclusion
Findings suggest that women who are younger, closer to the time of surgery, or have upper extremity lymphedema may be less likely to undergo repeated mammograms. It may be important for health professionals to remind selected patients directly that some women avoid repeat mammography and to re-emphasize the value of mammography for women with a history of breast cancer. Teaching women behavioral techniques (eg, redirecting attention) or providing medication for reducing anxiety could be considered for women with high levels of anxiety or catastrophic thoughts related to mammography.
doi:10.1200/JCO.2010.34.4333
PMCID: PMC3295570  PMID: 22331949
21.  Design and evaluation of a theory-based, culturally relevant outreach model for breast and cervical cancer screening for Latina immigrants 
Ethnicity & disease  2012;22(3):274-280.
Objectives
Breast and cervical cancer are common among Latinas, but screening rates among foreign-born Latinas are relatively low. In this article we describe the design and implementation of a theory-based (PEN-3) outreach program to promote breast and cervical cancer screening to Latina immigrants, and evaluate the program’s effectiveness.
Methods
We used data from self-administered questionnaires completed at six annual outreach events to examine the sociodemographic characteristics of attendees and evaluate whether the program reached the priority population – foreign-born Latina immigrants with limited access to health care and screening services. To evaluate the program’s effectiveness in connecting women to screening, we examined the proportion and characteristics of women who scheduled and attended Pap smear and mammography appointments.
Results
Among the 782 Latinas who attended the outreach program, 60% and 83% had not had a Pap smear or mammogram, respectively, in at least a year. Overall, 80% scheduled a Pap smear and 78% scheduled a mammogram. Women without insurance, who did not know where to get screening and had not been screened in the last year were more likely to schedule appointments (p < 0.05). Among women who scheduled appointments, 65% attended their Pap smear and 79% attended the mammogram. We did not identify significant differences in sociodemographic characteristics associated with appointment attendance.
Conclusions
Using a theoretical approach to outreach design and implementation, it is possible to reach a substantial number of Latina immigrants and connect them to cancer screening services.
PMCID: PMC3762980  PMID: 22870569
Cancer screening; community-based participatory research; program evaluation; Latina immigrants
22.  Latina Patient Perspectives about Informed Treatment Decision Making for Breast Cancer 
Patient education and counseling  2008;73(2):363-370.
Objective
To evaluate Latina breast cancer patient perspectives regarding informed decision making related to surgical treatment decision making for breast cancer.
Methods
2030 women with non-metastatic breast cancer diagnosed from 8/05-5/06 and reported to the Los Angeles metropolitan SEER registries were mailed a survey shortly after surgical treatment. Latina and African American women were over-sampled. We conducted regression of four decision outcome to evaluate associations between race/ethnicity, demographic and clinical factors, and mechanistic variables (i.e., health literacy) and decision outcomes.
Results
Our analytic sample was 877 women: 24.5% Latina Spanish speaking (Latina-SP), 20.5% Latina English speaking, 24% African American and 26.6% Caucasian. Approximately 28% of women in each ethnic group reported a surgeon-based, 36% a shared, and 36% a patient-based surgery decision. Spanish-preferent Latina women had the greatest odds of high decision dissatisfaction and regret controlling for other factors (OR 5.5, 95% CI:2.9, 10.5 and OR 4.1, 95% CI: 2.2,8.0, respectively). Low health literacy was independently associated with dissatisfaction and regret (OR 5.6, 95% CI:2.9, 11.1 and OR 3.5, 95% CI 1.8,7.1, respectively) and slightly attenuated associations between Latina-SP ethnicity and decision outcomes,.
Conclusion
Despite similar clinical outcomes, patients report very different experiences with treatment decision making. Latina women, especially those who prefer Spanish, are vulnerable to poor breast cancer treatment decision outcomes.
Practice implications
Providers need to be aware of the role of ethnicity, acculturation and literacy in breast cancer treatment discussions.
doi:10.1016/j.pec.2008.07.036
PMCID: PMC3603851  PMID: 18786799
Latina; breast cancer; surgical treatment; decision making; involvement
23.  Determinants of Breast, Cervical and Colorectal Cancer Screening Adherence in Mexican American Women 
Journal of Community Health  2012;37(2):421-433.
Despite the effectiveness of cancer screening procedures, its utilization among Latinas remains low. Guided, in part, by the Behavioral Model for Vulnerable Populations, this study examined the associations between predisposing, enabling, and need factors with self-reported breast, cervical, and colorectal cancer screening adherence. Participants were 319 Mexican American women, from a range of socioeconomic (SES) backgrounds, living near the United States-Mexico border. Women were adherent with breast cancer (BC) screening (≥42 years) if they had received at least one mammogram within the last two years, with cervical cancer (CC) screening (≥40 years) if they had received at least one Pap exam in the last three years, and with colorectal cancer (CRC) screening (≥52 years) if they had undergone one or more of the following: Fecal Occult Blood Test (FOBT) within the last year, or sigmoidoscopy in the last 5 years, or colonoscopy within the last 10 years. BC and CC screenings were higher in the current sample compared to national and state figures: 82% with mammography and 86% adherent with Pap exam screening. However, only 43% were adherent with CRC screening recommendations. Characteristics associated with mammography adherence included CC adherence and usual source of care. BC adherence was associated to CC adherence. Characteristics associated with CRC adherence included BC adherence, being premenopausal, and insurance coverage. A key correlate of cancer screening adherence was adherence to other preventive services. Results underscore the need for continued efforts to ensure that Latinas of all SES levels obtain regular and timely cancer screenings.
doi:10.1007/s10900-011-9459-2
PMCID: PMC3296890  PMID: 21874364
Breast cancer screening; Cervical cancer screening; Colorectal cancer screening; Cancer disparities; Mexican Americans
24.  The interaction of perceived risk and benefits and its relationship to predicting mammography adherence in African-American women 
Oncology nursing forum  2012;39(1):53-60.
PURPOSE/OBJECTIVES
To test the interaction of perceived risk and benefits on stage of mammography readiness and adherence.
DESIGN
Cross-sectional study
SETTING
Community gathering places and health care clinics across a Midwestern state.
SAMPLE
299 African-American women who had not had a mammogram in ≥ 18 months.
METHODS
In-person interviews were used to collect data on sociodemographics, health belief variables and stage of readiness to undertake mammography screening. Four categories were created to measure the combined magnitude of high/low levels of perceived risk and benefit with health belief variables linked to modifying mammography screening behavior.
MAIN RESEARCH VARIABLES
Perceived risks and benefits, stage of readiness, mammography adherence.
FINDINGS
The lowest rate of mammography adherence was in women with a high perceived risk and low benefit towards mammography adherence (25.6) compared to women with a high perceived benefit and low risk towards mammography adherence (46.0). Differences in mammography adherence were statistically significant between these groups p=(0.009).
CONCLUSIONS
The interaction of high perceived risk and low benefits additively effected readiness to undertake screening mammography.
IMPLICATIONS FOR NURSING
Reducing disparities in breast cancer diagnosis and survival requires timely and efficient mammography adherence. Minority, medically underserved women with perceived high risk and low benefits exhibit immobilization to move forward with mammography adherence when they experience higher perceived risk. Further interventions to increase the perception of benefit of mammography are recommended to reduce breast cancer mortality.
doi:10.1188/12.ONF.53-60
PMCID: PMC3721522  PMID: 22201655
25.  Do Appalachian Women Attending a Mobile Mammography Program Differ from Those Visiting a Stationary Mammography Facility? 
Journal of community health  2013;38(4):698-706.
To compare the characteristics (demographic, access to care, health-related behavioral, self and family medical history, psychosocial) of women aged 40 years and above who utilize a mobile mammography unit with those women aged 40 years and above who obtain mammography screening at a stationary facility. A cross-sectional study design was used with participant cohorts comprised of women age 40 years and above throughout West Virginia (WV) who utilized mobile mammography unit to get mammogram and those who had mammography screening at the stationary facility and completed the Mammography Screening and Preventive Care Survey. A total of 1,161 women who utilized the mobile mammography unit and 1,104 women who utilized stationary facility were included in the analysis. In logistic regression after adjusting for all the variables, women who utilized mobile mammography unit were more likely to be in age group 40–49, with lower income, with no health insurance coverage, not visit doctor or obstetrician/gynecologist (OB/GYN) in the past year, not adherent to clinical breast exam and mammography screening guidelines, with lower perceived five-year risk of developing breast cancer and with high knowledge about mammography screening. Women who utilize mobile unit are not adherent to mammography screening guidelines thereby suggesting that the mobile mammography unit is indeed reaching a rural vulnerable population who may not routinely access preventive health services. Financial and insurance constraints, as well as access to medical care, restricted WV women from receiving mammography screening from the stationary screening facilities.
doi:10.1007/s10900-013-9667-z
PMCID: PMC4893946  PMID: 23504266
Mammography screening; Stationary mammography facility; Mobile mammography unit

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