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1.  Screening for Breast Cancer 
Context
Breast cancer screening in community practices may be different from that in randomized controlled trials. New screening modalities are becoming available.
Objectives
To review breast cancer screening, especially in the community and to examine evidence about new screening modalities.
Data Sources and Study Selection
English-language articles of randomized controlled trials assessing effectiveness of breast cancer screening were reviewed, as well as meta-analyses, systematic reviews, studies of breast cancer screening in the community, and guidelines. Also, studies of newer screening modalities were assessed.
Data Synthesis
All major US medical organizations recommend screening mammography for women aged 40 years and older. Screening mammography reduces breast cancer mortality by about 20% to 35% in women aged 50 to 69 years and slightly less in women aged 40 to 49 years at 14 years of follow-up. Approximately 95% of women with abnormalities on screening mammograms do not have breast cancer with variability based on such factors as age of the woman and assessment category assigned by the radiologist. Studies comparing full-field digital mammography to screen film have not shown statistically significant differences in cancer detection while the impact on recall rates (percentage of screening mammograms considered to have positive results) was unclear. One study suggested that computer-aided detection increases cancer detection rates and recall rates while a second larger study did not find any significant differences. Screening clinical breast examination detects some cancers missed by mammography, but the sensitivity reported in the community is lower (28% to 36%) than in randomized trials (about 54%). Breast self-examination has not been shown to be effective in reducing breast cancer mortality, but it does increase the number of breast biopsies performed because of false-positives. Magnetic resonance imaging and ultrasound are being studied for screening women at high risk for breast cancer but are not recommended for screening the general population. Sensitivity of magnetic resonance imaging in high-risk women has been found to be much higher than that of mammography but specificity is generally lower. Effect of the magnetic resonance imaging on breast cancer mortality is not known. A balanced discussion of possible benefits and harms of screening should be undertaken with each woman.
Conclusions
In the community, mammography remains the main screening tool while the effectiveness of clinical breast examination and self-examination are less. New screening modalities are unlikely to replace mammography in the near future for screening the general population.
doi:10.1001/jama.293.10.1245
PMCID: PMC3149836  PMID: 15755947
2.  Communication Between Patients and Providers and Informed Decision Making 
Women with ductal carcinoma in situ (DCIS) need to comprehend the meaning of the diagnosis and the potential benefits and harms of treatment options. Full and understandable information is a requirement, not an option. However, with DCIS, as with many areas of medicine, a high level of uncertainty about the disease remains. In this article, we define informed medical decision making, review challenges to its implementation, and provide suggestions on how to improve communication with women about the diagnosis and treatment of DCIS.
doi:10.1093/jncimonographs/lgq038
PMCID: PMC3140849  PMID: 20956831
3.  Attitudes Toward Participation in Breast Cancer Randomized Clinical Trials in the African American Community 
Cancer nursing  2007;30(4):261-269.
Participation of African Americans in research trials is low. Understanding the perspectives of African American patients toward participation in clinical trials is essential to understanding the disparities in participation rates compared with whites. A qualitative study was conducted to discover attitudes of the African American community regarding willingness to participate in breast cancer screening and randomized clinical trials. Six focus groups consisting of 8 to 11 African American women (N = 58), aged 30 to 65, were recruited from local churches. Focus group sessions involved a 2-hour audiotaped discussion facilitated by 2 moderators. A breast cancer randomized clinical trial involving an experimental breast cancer treatment was discussed to identify the issues related to willingness to participate in such research studies. Six themes surrounding willingness to participate in randomized clinical trials were identified: (1) Significance of the research topic to the individual and/or community; (2) level of trust in the system; (3) understanding of the elements of the trial; (4) preference for “natural treatments” or “religious intervention” over medical care; (5) cost-benefit analysis of incentives and barriers; and (6) openness to risk versus a preference for proven treatments. The majority (80%) expressed willingness or open-mindedness to the idea of participating in the hypothetical trial. Lessons learned from this study support the selection of a culturally diverse research staff and can guide the development of research protocols, recruitment efforts, and clinical procedures that are culturally sensitive and relevant.
doi:10.1097/01.NCC.0000281732.02738.31
PMCID: PMC3908682  PMID: 17666974
African American; Breast cancer; Clinical trials; Focus group study
4.  Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead 
Annals of internal medicine  2012;157(7):461-470.
Background
Little information exists about what primary care physicians (PCPs) and patients experience if patients are invited to read their doctors’ office notes.
Objective
To evaluate the effect on doctors and patients of facilitating patient access to visit notes over secure Internet portals.
Design
Quasi-experimental trial of PCPs and patient volunteers in a year-long program that provided patients with electronic links to their doctors’ notes.
Setting
Primary care practices at Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Washington.
Participants
105 PCPs and 13 564 of their patients who had at least 1 completed note available during the intervention period.
Measurements
Portal use and electronic messaging by patients and surveys focusing on participants’ perceptions of behaviors, benefits, and negative consequences.
Results
11 797 of 13 564 patients with visit notes available opened at least 1 note (84% at BIDMC, 92% at GHS, and 47% at HMC). Of 5391 patients who opened at least 1 note and completed a postintervention survey, 77% to 87% across the 3 sites reported that open notes helped them feel more in control of their care; 60% to 78% of those taking medications reported increased medication adherence; 26% to 36% had privacy concerns; 1% to 8% reported that the notes caused confusion, worry, or offense; and 20% to 42% reported sharing notes with others. The volume of electronic messages from patients did not change. After the intervention, few doctors reported longer visits (0% to 5%) or more time addressing patients’ questions outside of visits (0% to 8%), with practice size having little effect; 3% to 36% of doctors reported changing documentation content; and 0% to 21% reported taking more time writing notes. Looking ahead, 59% to 62% of patients believed that they should be able to add comments to a doctor’s note. One out of 3 patients believed that they should be able to approve the notes’ contents, but 85% to 96% of doctors did not agree. At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop.
Limitations
Only 3 geographic areas were represented, and most participants were experienced in using portals. Doctors volunteering to participate and patients using portals and completing surveys may tend to offer favorable feedback, and the response rate of the patient surveys (41%) may further limit generalizability.
Conclusion
Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue. With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption.
Primary Funding Source
The Robert Wood Johnson Foundation, the Drane Family Fund, the Richard and Florence Koplow Charitable Foundation, and the National Cancer Institute.
doi:10.7326/0003-4819-157-7-201210020-00002
PMCID: PMC3908866  PMID: 23027317
5.  Acute traumatic subdural hematoma: Current mortality and functional outcomes in adult patients at a Level I trauma center 
Background
Existing data on outcomes following subdural hematoma have provided limited information on medical complications and functional outcomes. Mortality rates previously reported range from 22% to 66%.
Methods
This is a retrospective cohort study of prospectively collected data from a trauma registry in Washington State from 2005 through 2008. Patients were categorized by surgical evacuation status with the hypothesis that those undergoing evacuation represented a more severe injury.
Results
The 1,427 patients included in the study had a mean age of 58 years, and most of them were male (63%). Glasgow Coma Scale (GCS) score on presentation was greater than 12 in 58%; the average Injury Severity Score (ISS) was 27.5. Mean length of stay was 9.6 days (range, 1–110), with 40% spending 2 or more days in the intensive care unit. Twenty-eight percent experienced medical complications. At discharge, 94% had GCS score of 13 or greater. Independence with expression, feeding, and locomotion at discharge was noted for 92%, 81%, and 43%, respectively. Inpatient mortality was 16% and did not differ significantly between the evacuated group (15%) and the nonevacuated group (17%).
Conclusion
This large cohort of patients with acute traumatic subdural hematoma demonstrated a lower mortality rate than those of previous reports, including among patients requiring surgical evacuation (J Trauma Acute Care Surg. 2012;73:1348–1352).
Level of Evidence
Epidemiologic study, level III.
doi:10.1097/TA.0b013e31826fcb30
PMCID: PMC3908893  PMID: 23117390
Acute subdural hematoma; traumatic brain injury; subdural hematoma; mortality
6.  Gender Differences in Chronic Medical, Psychiatric, and Substance-Dependence Disorders Among Jail Inmates 
American journal of public health  2009;100(3):476-482.
Objectives
We investigated whether there were gender differences in chronic medical, psychiatric, and substance-dependence disorders among jail inmates and whether substance dependence mediated any gender differences found.
Methods
We analyzed data from a nationally representative survey of 6982 US jail inmates. Weighted estimates of disease prevalence were calculated by gender for chronic medical disorders (cancer, hypertension, diabetes, arthritis, asthma, hepatitis, and cirrhosis), psychiatric disorders (depressive, bipolar, psychotic, posttraumatic stress, anxiety, and personality), and substance-dependence disorders. We conducted logistic regression to examine the relationship between gender and these disorders.
Results
Compared with men, women had a significantly higher prevalence of all medical and psychiatric conditions (P≤.01 for each) and drug dependence (P<.001), but women had a lower prevalence of alcohol dependence (P<.001). Gender differences persisted after adjustment for sociodemographic factors and substance dependence.
Conclusions
Women in jail had a higher burden of chronic medical disorders, psychiatric disorders, and drug dependence than men, including conditions found more commonly in men in the general population. Thus, there is a need for targeted attention to the chronic medical, psychiatric, and drug-treatment needs of women at risk for incarceration, both in jail and after release.
doi:10.2105/AJPH.2008.149591
PMCID: PMC2820077  PMID: 19696388
8.  Inviting Patients to Read Their Doctors' Notes: Patients and Doctors Look Ahead 
Annals of internal medicine  2011;155(12):811-819.
Background
Little is known about what primary care physicians (PCPs) and patients would expect if patients were invited to read their doctors' office notes.
Objective
To explore attitudes toward potential benefits or harms if PCPs offered patients ready access to visit notes.
Design
The PCPs and patients completed surveys before joining a voluntary program that provided electronic links to doctors' notes.
Setting
Primary care practices in 3 U.S. states.
Participants
Participating and nonparticipating PCPs and adult patients at primary care practices in Massachusetts, Pennsylvania, and Washington.
Measurements
Doctors' and patients' attitudes toward and expectations of open visit notes, their ideas about the potential benefits and risks, and demographic characteristics.
Results
110 of 114 participating PCPs (96%), 63 of 140 nonparticipating PCPs (45%), and 37 856 of 90 826 patients (42%) completed surveys. Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea, compared with 16% to 33% of nonparticipating PCPs. Similarly, participating PCPs and patients generally agreed with statements about potential benefits of open visit notes, whereas nonparticipating PCPs were less likely to agree. Among participating PCPs, 74% to 92% anticipated improved communication and patient education, in contrast to 45% to 67% of nonparticipating PCPs. More than one half of participating PCPs (50% to 58%) and most nonparticipating PCPs (88% to 92%) expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%). Thirty-six percent to 50% of participating PCPs and 83% to 84% of nonparticipating PCPs anticipated more patient questions between visits. Few PCPs (0% to 33%) anticipated increased risk for lawsuits. Patient enthusiasm extended across age, education, and health status, and 22% anticipated sharing visit notes with others, including other doctors.
Limitations
Access to electronic patient portals is not widespread, and participation was limited to patients using such portals. Response rates were higher among participating PCPs than nonparticipating PCPs; many participating PCPs had small patient panels.
Conclusion
Among PCPs, opinions about open visit notes varied widely in terms of predicting the effect on their practices and benefits for patients. In contrast, patients expressed considerable enthusiasm and few fears, anticipating both improved understanding and more involvement in care. Sharing visit notes has broad implications for quality of care, privacy, and shared accountability.
doi:10.7326/0003-4819-155-12-201112200-00003
PMCID: PMC3772715  PMID: 22184688
9.  Short-Term Outcomes of Screening Mammography Using Computer-Aided Detection 
Annals of internal medicine  2013;158(8):580-587.
Background
Computer-aided detection (CAD) has rapidly diffused into screening mammography practice despite limited and conflicting data on its clinical effect.
Objective
To determine associations between CAD use during screening mammography and the incidence of ductal carcinoma in situ (DCIS) and invasive breast cancer, invasive cancer stage, and diagnostic testing.
Design
Retrospective cohort study.
Setting
Medicare program.
Participants
Women aged 67 to 89 years having screening mammography between 2001 and 2006 in U.S. SEER (Surveillance, Epidemiology and End Results) regions (409 459 mammograms from 163 099 women).
Measurements
Incident DCIS and invasive breast cancer within 1 year after mammography, invasive cancer stage, and diagnostic testing within 90 days after screening among women without breast cancer.
Results
From 2001 to 2006, CAD prevalence increased from 3.6% to 60.5%. Use of CAD was associated with greater DCIS incidence (adjusted odds ratio [OR], 1.17 [95% CI, 1.11 to 1.23]) but no difference in invasive breast cancer incidence (adjusted OR, 1.00 [CI, 0.97 to 1.03]). Among women with invasive cancer, CAD was associated with greater likelihood of stage I to II versus III to IV cancer (adjusted OR, 1.27 [CI, 1.14 to 1.41]). In women without breast cancer, CAD was associated with increased odds of diagnostic mammography (adjusted OR, 1.28 [CI, 1.27 to 1.29]), breast ultrasonography (adjusted OR, 1.07 [CI, 1.06 to 1.09]), and breast biopsy (adjusted OR, 1.10 [CI, 1.08 to 1.12]).
Limitation
Short follow-up for cancer stage, potential unmeasured confounding, and uncertain generalizability to younger women.
Conclusion
Use of CAD during screening mammography among Medicare enrollees is associated with increased DCIS incidence, the diagnosis of invasive breast cancer at earlier stages, and increased diagnostic testing among women without breast cancer.
Primary Funding Source
Center for Healthcare Policy and Research, University of California, Davis.
doi:10.7326/0003-4819-158-8-201304160-00002
PMCID: PMC3772716  PMID: 23588746
10.  Impact of an Educational Intervention Designed to Reduce Unnecessary Recall During Screening Mammography 
Academic radiology  2012;19(9):1114-1120.
Purpose
To describe the impact of a tailored web based educational program designed to reduce excessive screening mammography recall.
Methods
Radiologists enrolled in one of four mammography registries in the U.S. were invited to take part and were randomly assigned to receive the intervention or to serve as controls. The controls were offered the intervention at the end of the study, and data collection included an assessment of their clinical practice as well. The intervention provided each radiologist with individual audit data for their sensitivity, specificity, recall rate, PPV and cancer detection rates compared to national benchmarks and peer-comparisons for the same measures; profiled breast cancer risk in each radiologist’s respective patient populations to illustrate how low breast cancer risk is in population based settings, and evaluated the possible impact of medical malpractice concerns on recall rates. Participants’ recall rates from actual practice were evaluated for three time periods: the nine months before the intervention was delivered to the Intervention Group (baseline period), the nine months between the Intervention and Control Groups (T1) and nine months after Completion of the intervention by the Controls (T2). Logistic regression models examining the probability a mammogram was recalled included indication of intervention versus control and the time periods (baseline, T1, T2). Interactions between the groups and time period were also included to determine if the association between time period and the probability of a positive result differed across groups.
Results
Thirty-one radiologists who completed the CME were included in the adjusted model comparing radiologists in the Intervention Group (n=22) to radiologists who completed the intervention in the Control Group (n=9). At T1 the Intervention Group had 12% higher odds of a positive mammogram compared to the Controls, after controlling for baseline (OR=1.12, 95% CI=1.00-1.27, p=0.0569). At T2 a similar association was found; however, it was not statistically significant (OR=1.10, 95% CI=0.96-1.25). No associations were found among radiologists in the Controls when comparing those who completed the CME (n=9) to those who did not (n=10). In addition, we found no associations between time-period and recall rate among radiologists who set realistic goals.
Conclusions
In conclusion, our study resulted in a null effect, which may indicate a single one-hour intervention is not adequate to change excessive recall among radiologists who undertook the intervention we were testing.
doi:10.1016/j.acra.2012.05.003
PMCID: PMC3638784  PMID: 22727623
11.  Radiologists’ ability to accurately estimate and compare their own interpretative mammography performance to their peers 
Objective
To determine if U.S. radiologists accurately estimate their own interpretive performance of screening mammography and how they compare their performance to their peers’.
Materials and Methods
174 radiologists from six Breast Cancer Surveillance Consortium (BCSC) registries completed a mailed survey between 2005 and 2006. Radiologists’ estimated and actual recall, false positive, and cancer detection rates and positive predictive value of biopsy recommendation (PPV2) for screening mammography were compared. Radiologists’ ratings of their performance as lower, similar, or higher than their peers were compared to their actual performance. Associations with radiologist characteristics were estimated using weighted generalized linear models. The study was approved by the institutional review boards of the participating sites, informed consent was obtained from radiologists, and procedures were HIPAA compliant.
Results
While most radiologists accurately estimated their cancer detection and recall rates (74% and 78% of radiologists), fewer accurately estimated their false positive rate and PPV2 (19% and 26%). Radiologists reported having similar (43%) or lower (31%) recall rates and similar (52%) or lower (33%) false positive rates compared to their peers, and similar (72%) or higher (23%) cancer detection rates and similar (72%) or higher (38%) PPV2. Estimation accuracy did not differ by radiologists’ characteristics except radiologists who interpret ≤1,000 mammograms annually were less accurate at estimating their recall rates.
Conclusion
Radiologists perceive their performance to be better than it actually is and at least as good as their peers. Radiologists have particular difficulty estimating their false positive rates and PPV2.
doi:10.2214/AJR.11.7402
PMCID: PMC3691059  PMID: 22915414
12.  Are radiologists’ goals for mammography accuracy consistent with published recommendations? 
Academic Radiology  2011;19(3):289-295.
Rationale and Objectives
Mammography quality assurance programs have been in place for over a decade. We studied radiologists’ self-reported performance goals for accuracy in screening mammography and compared them to published recommendations.
Materials and Methods
A mailed survey of radiologists at mammography registries in seven states within the Breast Cancer Surveillance Consortium (BCSC) assessed radiologists’ performance goals for interpreting screening mammograms. Self-reported goals were compared to published American College of Radiology (ACR) recommended desirable ranges for recall rate and false positive rate, positive predictive value of biopsy recommendation (PPV2), and cancer detection rate. Radiologists’ goals for interpretive accuracy within desirable range were evaluated for associations with their demographic characteristics, clinical experience and receipt of audit reports.
Results
The survey response rate was 71% (257 of 364 radiologists). The percentage of radiologists reporting goals within desirable ranges was 79% for recall rate, 22% for false positive rate, 39% for PPV2, and 61% for cancer detection rate. The range of reported goals was 0 to 100% for false-positive rate and PPV2. Primary academic affiliation, receiving more hours of breast imaging continuing medical education (CME), and receiving audit reports at least annually were associated with desirable PPV2 goals. Radiologists reporting desirable cancer detection rate goals were more likely to have interpreted mammograms for 10 or more years, and > 1,000 mammograms per year.
Conclusion
Many radiologists report goals for their accuracy when interpreting screening mammograms that fall outside of published desirable benchmarks, particularly for false positive rate and PPV2, indicating an opportunity for education.
doi:10.1016/j.acra.2011.10.013
PMCID: PMC3274618  PMID: 22130089
screening mammography; accuracy; goals; false positive rate
13.  USE OF CLINICAL HISTORY AFFECTS ACCURACY OF INTERPRETIVE PERFORMANCE OF SCREENING MAMMOGRAPHY 
Journal of Clinical Epidemiology  2011;65(2):219-230.
Objective
To examine how use of clinical history affects radiologist's interpretation of screening mammography.
Study Design and Setting
Using a self-administered survey and actual interpretive performance, we examined associations between use of clinical history and sensitivity, false-positive rate, recall rate, positive predictive value, after adjusting for relevant covariates using conditional logistic regression.
Results
The majority of radiologists the 216 radiologists surveyed (63.4%) reported usually or always using clinical history when interpreting screening mammography. Compared to radiologists who rarely use clinical history, radiologists who usually/always use it had a higher false-positive rate with younger women (10.7 vs. 9.7), denser breast tissue (10.1 for heterogeneously dense to 10.9 for extremely dense versus 8.9 for fatty tissue), or longer screening intervals (> prior 5 years) (12.5 vs. 10.5). Effect of current hormone therapy (HT) use on false-positive rate was weaker among radiologists who use clinical history compared to those who did not (p=0.01), resulting in fewer false-positive exams and a non-significant lower sensitivity (79.2 vs. 85.2) among HT users
Conclusions
Interpretive performance appears to be influenced by patient age, breast density, screening interval and hormone therapy use. This influence does not always result in improved interpretive performance.
doi:10.1016/j.jclinepi.2011.06.010
PMCID: PMC3253253  PMID: 22000816
Mammography screening; interpretive acumen; breast cancer detection; breast cancer risk
14.  Delivery of Cancer Screening 
Archives of internal medicine  2007;167(6):580-585.
Background
Patients and physicians strongly endorse the importance of preventive or periodic health examinations (PHEs). However, the extent to which PHEs contribute to the delivery of cancer screening is uncertain.
Methods
In a retrospective cohort study, we determined the association between receipt of a PHE and cancer testing in a population-based sample of enrollees in a Washington State health plan who were aged 52 to 78 years and eligible for colorectal, breast, or prostate cancer screening in 2002–2003 (N = 64 288). Outcomes included completion of any colorectal cancer testing (fecal occult blood testing, sigmoidoscopy, colonoscopy, or barium enema), screening mammography, and prostate-specific antigen testing.
Results
More than half (52.4%) of the enrollees received a PHE during the study period. After adjusting for demographics, comorbidity, number of outpatient visits, and historical preventive service use before January 1, 2002, receipt of a PHE was significantly associated with completion of colorectal cancer testing (incidence difference, 40.4% [95% confidence interval (CI), 39.4%–41.3%]; relative incidence, 3.47 [95% CI, 3.34–3.59]), screening mammography [incidence difference, 14.2% [95% CI, 12.7%–15.7%]; relative incidence, 1.23 [95% CI, 1.20–1.25]), and prostate-specific antigen testing (incidence difference, 39.4% [95% CI, 38.3%–40.5%]; relative incidence, 3.06 [95% CI, 2.95–3.18]).
Conclusions
Among managed care enrollees eligible for cancer screening, PHE receipt is associated with completion of colorectal, breast, and prostate cancer testing. In similar populations, the PHE may serve as a clinically important forum for the promotion of evidence-based colorectal cancer and breast cancer screening and of screening with relatively less empirical support, such as prostate cancer screening.
doi:10.1001/archinte.167.6.580
PMCID: PMC3443471  PMID: 17389289
15.  Examining accuracy of screening mammography using an event order model 
Statistics in medicine  2006;25(2):267-283.
SUMMARY
Screening mammography is a widely used method for breast cancer detection. For each mammogram we propose a performance model based on order of outcomes. That is, we envision an initial assessment, a follow up assessment if the initial one is positive and, eventually, a determination of whether cancer was present or not. A model can be built at each stage reflecting effects due to patient characteristics, to the facility where mammogram was performed and to the radiologist reading the mammogram. Since assessment is not perfectly associated with outcome, familiar rates of agreement and disagreement are of interest. These rates can be investigated at various levels of risk factors of interest. The approach is illustrated with screening mammography data from the Group Health Cooperative in Seattle, WA. A Bayesian framework is adopted for inference and an analysis of the data set is presented.
doi:10.1002/sim.2220
PMCID: PMC3422573  PMID: 16381074
breast cancer; false positive/negative; logistic regression; model selection; sensitivity; specificity
16.  Effectiveness of Computer-Aided Detection in Community Mammography Practice 
Background
Computer-aided detection (CAD) is applied during screening mammography for millions of US women annually, although it is uncertain whether CAD improves breast cancer detection when used by community radiologists.
Methods
We investigated the association between CAD use during film-screen screening mammography and specificity, sensitivity, positive predictive value, cancer detection rates, and prognostic characteristics of breast cancers (stage, size, and node involvement). Records from 684 956 women who received more than 1.6 million film-screen mammograms at Breast Cancer Surveillance Consortium facilities in seven states in the United States from 1998 to 2006 were analyzed. We used random-effects logistic regression to estimate associations between CAD and specificity (true-negative examinations among women without breast cancer), sensitivity (true-positive examinations among women with breast cancer diagnosed within 1 year of mammography), and positive predictive value (breast cancer diagnosed after positive mammograms) while adjusting for mammography registry, patient age, time since previous mammography, breast density, use of hormone replacement therapy, and year of examination (1998–2002 vs 2003–2006). All statistical tests were two-sided.
Results
Of 90 total facilities, 25 (27.8%) adopted CAD and used it for an average of 27.5 study months. In adjusted analyses, CAD use was associated with statistically significantly lower specificity (OR = 0.87, 95% confidence interval [CI] = 0.85 to 0.89, P < .001) and positive predictive value (OR = 0.89, 95% CI = 0.80 to 0.99, P = .03). A non-statistically significant increase in overall sensitivity with CAD (OR = 1.06, 95% CI = 0.84 to 1.33, P = .62) was attributed to increased sensitivity for ductal carcinoma in situ (OR = 1.55, 95% CI = 0.83 to 2.91; P = .17), although sensitivity for invasive cancer was similar with or without CAD (OR = 0.96, 95% CI = 0.75 to 1.24; P = .77). CAD was not associated with higher breast cancer detection rates or more favorable stage, size, or lymph node status of invasive breast cancer.
Conclusion
CAD use during film-screen screening mammography in the United States is associated with decreased specificity but not with improvement in the detection rate or prognostic characteristics of invasive breast cancer.
doi:10.1093/jnci/djr206
PMCID: PMC3149041  PMID: 21795668
17.  Self-Detection Remains a Key Method of Breast Cancer Detection for U.S. Women 
Journal of Women's Health  2011;20(8):1135-1139.
Abstract
Purpose
The method by which breast cancer is detected becomes a factor for long-term survival and should be considered in treatment plans. This report describes patient characteristics and time trends for various methods of breast cancer detection in the United States.
Methods
The 2003 National Health Interview Survey (NHIS), a nationally representative self-report health survey, included 361 women survivors diagnosed with breast cancer between 1980 and 2003. Responses to the question, How was your breast cancer found? were categorized as accident, self-examination, physician during routine breast examination, mammogram, and other. We examined responses by income, race, age, and year of diagnosis.
Results
Most women survivors (57%) reported a detection method other than mammographic examination. Women often detected breast cancers themselves, either by self-examination (25%) or by accident (18%).
Conclusions
Despite increased use of screening mammography, a large percentage of breast cancers are detected by the patients themselves. Patient-noted breast abnormalities should be carefully evaluated.
doi:10.1089/jwh.2010.2493
PMCID: PMC3153870  PMID: 21675875
18.  Is Confidence of Mammographic Assessment a Good Predictor of Accuracy? 
Ajr. American Journal of Roentgenology  2012;199(1):W134-W141.
OBJECTIVE
Interpretive accuracy varies among radiologists, especially in mammography. This study examines the relationship between radiologists’ confidence in their assessments and their accuracy in interpreting mammograms.
MATERIALS AND METHODS
In this study, 119 community radiologists interpreted 109 expert-defined screening mammography examinations in test sets and rated their confidence in their assessment for each case. They also provided a global assessment of their ability to interpret mammograms. Positive predictive value (PPV) and negative predictive value (NPV) were modeled as functions of self-rated confidence on each examination using log-linear regression estimated with generalized estimating equations. Reference measures were cancer status and expert-defined need for recall. Effect modification by weekly mammography volume was examined.
RESULTS
Radiologists who self-reported higher global interpretive ability tended to interpret more mammograms per week (p = 0.08), were more likely to specialize (p = 0.02) and to have completed a fellowship in breast or women’s imaging (p = 0.05), and had a higher PPV for cancer detection (p = 0.01). Examinations for which low-volume radiologists were “very confident” had a PPV of 2.93 times (95% CI, 2.01–4.27) higher than examinations they rated with neutral confidence. Trends of increasing NPVs with increasing confidence were significant for low-volume radiologists relative to noncancers (p = 0.01) and expert nonrecalls (p < 0.001). A trend of significantly increasing NPVs existed for high-volume radiologists relative to expert nonrecall (p = 0.02) but not relative to noncancer status (p = 0.32).
CONCLUSION
Confidence in mammography assessments was associated with better accuracy, especially for low-volume readers. Asking for a second opinion when confidence in an assessment is low may increase accuracy.
doi:10.2214/AJR.11.7701
PMCID: PMC3391746  PMID: 22733922
accuracy; confidence; mammography; radiologist performance; screening
19.  Evaluating the impact of patients' online access to doctors' visit notes: designing and executing the OpenNotes project 
Background
Providers and policymakers are pursuing strategies to increase patient engagement in health care. Increasingly, online sections of medical records are viewable by patients though seldom are clinicians' visit notes included. We designed a one-year multi-site trial of online patient accessible office visit notes, OpenNotes. We hypothesized that patients and primary care physicians (PCPs) would want it to continue and that OpenNotes would not lead to significant disruptions to doctors' practices.
Methods/Design
Using a mixed methods approach, we designed a quasi-experimental study in 3 diverse healthcare systems in Boston, Pennsylvania, and Seattle. Two sites had existing patient internet portals; the third used an experimental portal. We targeted 3 key areas where we hypothesized the greatest impacts: beliefs and attitudes about OpenNotes, use of the patient internet portals, and patient-doctor communication. PCPs in the 3 sites were invited to participate in the intervention. Patients who were registered portal users of participating PCPs were given access to their PCPs' visit notes for one year. PCPs who declined participation in the intervention and their patients served as the comparison groups for the study. We applied the RE-AIM framework to our design in order to capture as comprehensive a picture as possible of the impact of OpenNotes. We developed pre- and post-intervention surveys for online administration addressing attitudes and experiences based on interviews and focus groups with patients and doctors. In addition, we tracked use of the internet portals before and during the intervention.
Results
PCP participation varied from 19% to 87% across the 3 sites; a total of 114 PCPs enrolled in the intervention with their 22,000 patients who were registered portal users. Approximately 40% of intervention and non-intervention patients at the 3 sites responded to the online survey, yielding a total of approximately 38,000 patient surveys.
Discussion
Many primary care physicians were willing to participate in this "real world" experiment testing the impact of OpenNotes on their patients and their practices. Results from this trial will inform providers, policy makers, and patients who contemplate such changes at a time of exploding interest in transparency, patient safety, and improving the quality of care.
doi:10.1186/1472-6947-12-32
PMCID: PMC3351950  PMID: 22500560
Patient access to records; Electronic health records; Primary care physicians; Internet; Medical records; Medical informatics; Patient participation
20.  Using a Tailored Web-based Intervention to Set Goals to Reduce Unnecessary Recall 
Academic radiology  2011;18(4):495-503.
Purpose
To examine whether an intervention strategy consisting of a tailored web-based intervention, which provides individualized audit data with peer comparisons and other data that can affect recall can assist radiologists in setting goals for reducing unnecessary recall.
Methods
In a multi-site randomized controlled study, we used a tailored web-based intervention to assess radiologists' ability to set goals to improve interpretive performance. The intervention provided peer-comparison audit data, profiled breast cancer risk in each radiologist's respective patient populations, and evaluated the possible impact of medical malpractice concerns. We calculated the percentage of radiologists who would consider changing their recall rates, and examined the specific goals they set to reduce recall rates. We describe characteristics of radiologists who developed realistic goals to reduce their recall rates, and their reactions to the importance of patient risk factors and medical malpractice concerns.
Results
Forty-one of 46 radiologists (89.1%) who started the intervention completed it. Thirty-one (72.1%) indicated they would like to change their recall rates and 30 (69.8%) entered a text response about changing their rates. Sixteen of the 30 (53.3%) radiologists who included a text response set realistic goals that would likely result in reducing unnecessary recall. The actual recall rates of those who set realistic goals were not statistically different from those who did not (13.8% vs. 15.1% respectively). The majority of selected goals involved re-reviewing cases initially interpreted as BI-RADS category 0. Over half of radiologists who commented on the influence of patient risk (56.3%) indicated that radiologists planned to pay more attention to risk factors, and 100% of participants commented on concerns radiologists have about malpractice with the primary concern (37.5%) being fear of lawsuits.
Conclusions
Interventions designed to reduce unnecessary recall can succeed in assisting radiologists to develop goals that may ultimately reduce unnecessary recall.
doi:10.1016/j.acra.2010.11.017
PMCID: PMC3065970  PMID: 21251856
21.  Feasibility and Satisfaction with a Tailored Web-based Audit Intervention for Recalibrating Radiologists’ Thresholds for Conducting Additional Work-up 
Academic radiology  2010;18(3):369-376.
Purpose
To examine the feasibility of and satisfaction with a tailored web-based intervention designed to decrease radiologists' recommendation of inappropriate additional work-up following a screening mammogram.
Methods
We developed a web-based educational intervention designed to reduce inappropriate recall. Radiologists were randomly assigned to participate in an early intervention group or a late (control) intervention group, the latter of which served as a control for a nine-month follow-up period, after which they were invited to participate in the intervention. Intervention content was derived from our prior research and included three modules: 1) an introduction to audit statistics for mammography performance; 2) a review of data showing radiologists' inflated perceptions of medical malpractice risks related to breast imaging, and 3) a review of data on breast cancer risk among women seen in their practices. Embedded within the intervention were individualized audit data for each participating radiologists obtained from the national Breast Cancer Surveillance Consortium.
Results
Seventy-four radiologists (37.8%; 74/196) consented to the intervention, which was completed by 67.5% (27/40) of those randomized to the early intervention group and 41.2% (14/34) of those randomized to the late (control) group. Thus, a total of 41 (55%) completed the intervention. On average, three log-ins were used to complete the program (range 1–14), which took approximately 1 hour. Ninety-five percent found the program moderately to very helpful in understanding how to calculate basic performance measures. Ninety-three percent found viewing their own performance measures moderately to very helpful, and 83% reported it being moderately to very important to learn that the breast cancer risk in their screening population program was lower than perceived. The percentage of radiologists who reported that the risk of medical malpractice influences their recall rates dropped from 36.3% pre-intervention to 17.8% post-intervention with a similar drop in perceived influence of malpractice risk on their recommendations for breast biopsy (36.4 to 17.3%). Over 75% of radiologists answered the post intervention knowledge questions correctly, and the percent of time spent in breast imaging did not appear to influence responses. The majority (>92%) of participants correctly responded that the target recall rate in the U.S. is 9%. The mean self-reported recall rates were 13.0 for radiologists spending<40% time in breast imaging and 14.9% for those spending > 40% time spent in breast imaging, which was highly correlated with their actual recall rates (0.991; p<0.001).
Conclusions
Radiologists who begin an internet-based tailored intervention designed to help reduce unnecessary recall will likely complete it, though only 55% who consented to the study actually undertook the intervention. Participants found the program useful in helping them understand why their recall rates may be elevated.
doi:10.1016/j.acra.2010.10.011
PMCID: PMC3034778  PMID: 21193335
22.  Mouse cursor movement and eye tracking data as an indicator of pathologists’ attention when viewing digital whole slide images 
Context:
Digital pathology has the potential to dramatically alter the way pathologists work, yet little is known about pathologists’ viewing behavior while interpreting digital whole slide images. While tracking pathologist eye movements when viewing digital slides may be the most direct method of capturing pathologists’ viewing strategies, this technique is cumbersome and technically challenging to use in remote settings. Tracking pathologist mouse cursor movements may serve as a practical method of studying digital slide interpretation, and mouse cursor data may illuminate pathologists’ viewing strategies and time expenditures in their interpretive workflow.
Aims:
To evaluate the utility of mouse cursor movement data, in addition to eye-tracking data, in studying pathologists’ attention and viewing behavior.
Settings and Design:
Pathologists (N = 7) viewed 10 digital whole slide images of breast tissue that were selected using a random stratified sampling technique to include a range of breast pathology diagnoses (benign/atypia, carcinoma in situ, and invasive breast cancer). A panel of three expert breast pathologists established a consensus diagnosis for each case using a modified Delphi approach.
Materials and Methods:
Participants’ foveal vision was tracked using SensoMotoric Instruments RED 60 Hz eye-tracking system. Mouse cursor movement was tracked using a custom MATLAB script.
Statistical Analysis Used:
Data on eye-gaze and mouse cursor position were gathered at fixed intervals and analyzed using distance comparisons and regression analyses by slide diagnosis and pathologist expertise. Pathologists’ accuracy (defined as percent agreement with the expert consensus diagnoses) and efficiency (accuracy and speed) were also analyzed.
Results:
Mean viewing time per slide was 75.2 seconds (SD = 38.42). Accuracy (percent agreement with expert consensus) by diagnosis type was: 83% (benign/atypia); 48% (carcinoma in situ); and 93% (invasive). Spatial coupling was close between eye-gaze and mouse cursor positions (highest frequency ∆x was 4.00px (SD = 16.10), and ∆y was 37.50px (SD = 28.08)). Mouse cursor position moderately predicted eye gaze patterns (Rx = 0.33 and Ry = 0.21).
Conclusions:
Data detailing mouse cursor movements may be a useful addition to future studies of pathologists’ accuracy and efficiency when using digital pathology.
doi:10.4103/2153-3539.104905
PMCID: PMC3551530  PMID: 23372984
Digital whole slide images; digital pathology; eye-tracking; interpretive behavior; visual attention
23.  Radiologists’ Perceptions of Computer Aided Detection versus Double Reading for Mammography Interpretation 
Academic radiology  2010;17(10):1217-1226.
Rationale and Objectives
To examine radiologists’ use and perceptions of computer-aided detection (CAD) and double reading for screening mammography interpretation.
Materials and Methods
A mailed survey of 257 community radiologists participating in the national Breast Cancer Surveillance Consortium assessed perceptions and practices related to CAD and double reading. We used latent class analysis to classify radiologists’ overall perceptions of CAD and double reading based on their agreement or disagreement with specific statements about CAD and double reading.
Results
Most radiologists (64%) reported using CAD for more than half the screening mammograms they interpreted, but only <5% reported double reading that much. More radiologists perceived that double reading improved cancer detection rates compared with CAD (74% vs. 55% reported), while fewer radiologists thought that double reading decreased recall rates compared with CAD (50% vs. 65% reported). Radiologists with the most favorable perceptions of CAD were more likely to think that CAD improved cancer detection rate without taking too much time compared with radiologists with the most unfavorable overall perceptions. In latent class analysis an overall favorable perception of CAD was significantly associated with use of CAD (81%), higher percent of workload in screening mammography (80%), academic affiliation (71%), and fellowship training (58%). Perceptions of double reading that were most favorable were associated with academic affiliation (98%).
Conclusion
Radiologists’ perceptions were more favorable toward double reading by a second clinician than by a computer, although fewer used double reading in their own practice. The majority of radiologists perceived both CAD and double reading at least somewhat favorably, although for largely different reasons.
doi:10.1016/j.acra.2010.05.007
PMCID: PMC3149895  PMID: 20832024
Breast imaging; mammography; computer-aided detection (CAD); double reading
24.  Influence of Computer-Aided Detection on Performance of Screening Mammography 
The New England journal of medicine  2007;356(14):1399-1409.
Background
Computer-aided detection identifies suspicious findings on mammograms to assist radiologists. Since the Food and Drug Administration approved the technology in 1998, it has been disseminated into practice, but its effect on the accuracy of interpretation is unclear.
Methods
We determined the association between the use of computer-aided detection at mammography facilities and the performance of screening mammography from 1998 through 2002 at 43 facilities in three states. We had complete data for 222,135 women (a total of 429,345 mammograms), including 2351 women who received a diagnosis of breast cancer within 1 year after screening. We calculated the specificity, sensitivity, and positive predictive value of screening mammography with and without computer-aided detection, as well as the rates of biopsy and breast-cancer detection and the overall accuracy, measured as the area under the receiver-operating-characteristic (ROC) curve.
Results
Seven facilities (16%) implemented computer-aided detection during the study period. Diagnostic specificity decreased from 90.2% before implementation to 87.2% after implementation (P<0.001), the positive predictive value decreased from 4.1% to 3.2% (P = 0.01), and the rate of biopsy increased by 19.7% (P<0.001). The increase in sensitivity from 80.4% before implementation of computer-aided detection to 84.0% after implementation was not significant (P = 0.32). The change in the cancer-detection rate (including invasive breast cancers and ductal carcinomas in situ) was not significant (4.15 cases per 1000 screening mammograms before implementation and 4.20 cases after implementation, P = 0.90). Analyses of data from all 43 facilities showed that the use of computer-aided detection was associated with significantly lower overall accuracy than was nonuse (area under the ROC curve, 0.871 vs. 0.919; P = 0.005).
Conclusions
The use of computer-aided detection is associated with reduced accuracy of interpretation of screening mammograms. The increased rate of biopsy with the use of computer-aided detection is not clearly associated with improved detection of invasive breast cancer.
doi:10.1056/NEJMoa066099
PMCID: PMC3182841  PMID: 17409321
25.  Decision-making processes for breast, colorectal, and prostate cancer screening: results from the DECISIONS study 
Background
Patients should understand the risks and benefits of cancer screening in order to make informed screening decisions.
Objectives
Evaluate the extent of informed decision making in patient-provider discussions for colorectal (CRC), breast (BrCa), and prostate (PCa) cancer screening.
Design
National random-digit dial telephone survey.
Subjects
English-speaking U.S. adults aged 50 and older who had discussed cancer screening with a health care provider within the previous two years.
Measurements
Cancer screening survey modules that asked about sociodemographic characteristics, cancer knowledge, the importance of various sources of information, and self-reported cancer-screening decision-making processes.
Results
Overall, 1,082 participants completed one or more of the three cancer modules. Although participants generally considered themselves well informed about screening tests, half or more could not correctly answer even one open-ended knowledge question for any given module. Participants consistently overestimated risks for being diagnosed with and dying from each cancer and overestimated the positive predictive values of PSA tests and mammography. Providers were the most highly rated information source, usually initiated screening discussions (64–84%), and often recommended screening (73–90%). However, participants reported providers elicited their screening preferences in only 31% (CRC women) to 57% (PCa) of discussions. While over 90% of the discussions addressed the pros of screening, only 19% (BrCa) to 30% (PCa) addressed the cons of screening.
Limitations
Recall bias is possible because screening process reports were not independently validated.
Conclusions
Cancer screening decisions reported by patients who discussed screening with their health care providers consistently failed to meet criteria for being informed. Given the high ratings for provider information and frequent recommendations for screening, providers have important opportunities to ensure that informed decision-making occurs for cancer screening decisions.
doi:10.1177/0272989X10378701
PMCID: PMC3139436  PMID: 20881154
prostatic neoplasms; breast neoplasms; colorectal neoplasms; early detection of cancer; decision making

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