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1.  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
2.  Development of a diagnostic test set to assess agreement in breast pathology: practical application of the Guidelines for Reporting Reliability and Agreement Studies (GRRAS) 
BMC Women's Health  2013;13:3.
Background
Diagnostic test sets are a valuable research tool that contributes importantly to the validity and reliability of studies that assess agreement in breast pathology. In order to fully understand the strengths and weaknesses of any agreement and reliability study, however, the methods should be fully reported. In this paper we provide a step-by-step description of the methods used to create four complex test sets for a study of diagnostic agreement among pathologists interpreting breast biopsy specimens. We use the newly developed Guidelines for Reporting Reliability and Agreement Studies (GRRAS) as a basis to report these methods.
Methods
Breast tissue biopsies were selected from the National Cancer Institute-funded Breast Cancer Surveillance Consortium sites. We used a random sampling stratified according to woman’s age (40–49 vs. ≥50), parenchymal breast density (low vs. high) and interpretation of the original pathologist. A 3-member panel of expert breast pathologists first independently interpreted each case using five primary diagnostic categories (non-proliferative changes, proliferative changes without atypia, atypical ductal hyperplasia, ductal carcinoma in situ, and invasive carcinoma). When the experts did not unanimously agree on a case diagnosis a modified Delphi method was used to determine the reference standard consensus diagnosis. The final test cases were stratified and randomly assigned into one of four unique test sets.
Conclusions
We found GRRAS recommendations to be very useful in reporting diagnostic test set development and recommend inclusion of two additional criteria: 1) characterizing the study population and 2) describing the methods for reference diagnosis, when applicable.
doi:10.1186/1472-6874-13-3
PMCID: PMC3610240  PMID: 23379630
Reporting guidelines; Reliability of results; Agreement studies; Breast; Pathology; Diagnostic techniques
3.  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
4.  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
5.  Screening Mammograms by Community Radiologists: Variability in False-Positive Rates 
Background
Previous studies have shown that the agreement among radiologists interpreting a test set of mammograms is relatively low. However, data available from real-world settings are sparse. We studied mammographic examination interpretations by radiologists practicing in a community setting and evaluated whether the variability in false-positive rates could be explained by patient, radiologist, and/or testing characteristics.
Methods
We used medical records on randomly selected women aged 40–69 years who had had at least one screening mammographic examination in a community setting between January 1, 1985, and June 30, 1993. Twenty-four radiologists interpreted 8734 screening mammograms from 2169 women. Hierarchical logistic regression models were used to examine the impact of patient, radiologist, and testing characteristics. All statistical tests were two-sided.
Results
Radiologists varied widely in mammographic examination interpretations, with a mass noted in 0%–7.9%, calcification in 0%–21.3%, and fibrocystic changes in 1.6%–27.8% of mammograms read. False-positive rates ranged from 2.6% to 15.9%. Younger and more recently trained radiologists had higher false-positive rates. Adjustment for patient, radiologist, and testing characteristics narrowed the range of false-positive rates to 3.5%–7.9%. If a woman went to two randomly selected radiologists, her odds, after adjustment, of having a false-positive reading would be 1.5 times greater for the radiologist at higher risk of a false-positive reading, compared with the radiologist at lowest risk (95% highest posterior density interval [similar to a confidence interval] = 1.17 to 2.08).
Conclusion
Community radiologists varied widely in their false-positive rates in screening mammograms; this variability range was reduced by half, but not eliminated, after statistical adjustment for patient, radiologist, and testing characteristics. These characteristics need to be considered when evaluating false-positive rates in community mammographic examination screening.
PMCID: PMC3142994  PMID: 12237283
6.  Predictors of Radiologists' Perceived Risk of Malpractice Lawsuits in Breast Imaging 
OBJECTIVE
The shortage of radiologists in breast imaging may be related to heightened malpractice lawsuit concerns. Our objective was to examine radiologists' reported experiences and perceptions of future lawsuit risk and explore personal and professional factors that may be associated with elevated perceptions of risk.
MATERIALS AND METHODS
Radiologists who routinely interpret mammography examinations in diverse regions of the United States (Washington, Colorado, and New Hampshire) completed a mailed survey in 2002 and 2006, including questions on demographics, practice characteristics, and medicolegal experience and perceptions as well as a validated scale measuring reactions to uncertainty in clinical situations. A survey assessing the radiologists' work facilities was also completed in 2002.
RESULTS
Participation by eligible radiologists was 77% (139 of 181) in 2002 and 71% (84 of 118) in 2006. The percentage of radiologists reporting malpractice claims related to mammography in the previous 5 years was 8% on the 2002 survey and 10% on the 2006 survey. Radiologists' mean estimate of the probability of being sued for malpractice in the next 5 years (41% in 2002 and 35% in 2006) was markedly higher than the actual reported risk. Radiologists' age, sex, clinical experience, and workload were not associated with a higher perceived risk of being sued. Radiologists who reported higher perceived risk of lawsuits were more likely to have experienced a prior malpractice claim, to report knowing colleagues with prior lawsuits, and to score higher on a scale measuring anxiety caused by uncertainty in clinical situations. Radiologists working at facilities that did not use double reading reported higher perceived risk, but the difference was not statistically significant.
CONCLUSION
Radiologists working in breast imaging substantially overestimate their risk of a future malpractice lawsuit. Radiologists with higher risk perceptions show more negative reactions to uncertainty in a clinical setting. Understanding that their actual risk of malpractice lawsuits may be substantially lower than anticipated may help reduce radiologists' fears and alleviate the manpower shortage in mammography. Programs to address the shortage of breast imagers could be targeted toward radiologists with heightened malpractice lawsuit concerns.
doi:10.2214/AJR.07.3346
PMCID: PMC3138733  PMID: 19155390
mammography; medical malpractice risk
7.  Specificity of Clinical Breast Examination in Community Practice 
Background
Millions of women receive clinical breast examination (CBE) each year, as either a breast cancer screening test or a diagnostic test for breast symptoms. While screening CBE had moderately high specificity (∼94%) in clinical trials, community clinicians may be comparatively inexperienced and may conduct relatively brief examinations, resulting in even higher specificity but lower sensitivity.
Objective
To estimate the specificity of screening and diagnostic CBE in clinical practice and identify patient factors associated with specificity.
Design
Retrospective cohort study.
Subjects
Breast-cancer-free female health plan enrollees in 5 states (WA, OR, CA, MA, and MN) who received CBE (N = 1,484).
Measurements
Medical charts were abstracted to ascertain breast cancer risk factors, examination purpose (screening vs diagnostic), and results (true-negative vs false-positive). Women were considered “average-risk” if they had neither a family history of breast cancer nor a prior breast biopsy and “increased-risk” otherwise.
Results
Among average- and increased-risk women, respectively, the specificity (true-negative proportion) of screening CBE was 99.4% [95% confidence interval (CI): 98.8–99.7%] and 97.1% (95% CI: 95.7–98.0%), and the specificity of diagnostic CBE was 68.7% (95% CI: 59.7–76.5%) and 57.1% (95% CI: 51.1–63.0%). The odds of a true-negative screening CBE (specificity) were significantly lower among women at increased risk of breast cancer (adjusted odds ratio 0.21; 95% CI: 0.10–0.46).
Conclusions
Screening CBE likely has higher specificity among community clinicians compared to examiners in clinical trials of breast cancer screening, even among women at increased breast cancer risk. Highly specific examinations, however, may have relatively low sensitivity for breast cancer. Diagnostic CBE, meanwhile, is relatively nonspecific.
doi:10.1007/s11606-006-0062-7
PMCID: PMC1824753  PMID: 17356964
breast cancer; sensitivity and specificity; screening; physical examination
8.  Specificity of Clinical Breast Examination in Community Practice 
Background
Millions of women receive clinical breast examination (CBE) each year, as either a breast cancer screening test or a diagnostic test for breast symptoms. While screening CBE had moderately high specificity (∼94%) in clinical trials, community clinicians may be comparatively inexperienced and may conduct relatively brief examinations, resulting in even higher specificity but lower sensitivity.
Objective
To estimate the specificity of screening and diagnostic CBE in clinical practice and identify patient factors associated with specificity.
Design
Retrospective cohort study.
Subjects
Breast-cancer-free female health plan enrollees in 5 states (WA, OR, CA, MA, and MN) who received CBE (N = 1,484).
Measurements
Medical charts were abstracted to ascertain breast cancer risk factors, examination purpose (screening vs diagnostic), and results (true-negative vs false-positive). Women were considered “average-risk” if they had neither a family history of breast cancer nor a prior breast biopsy and “increased-risk” otherwise.
Results
Among average- and increased-risk women, respectively, the specificity (true-negative proportion) of screening CBE was 99.4% [95% confidence interval (CI): 98.8–99.7%] and 97.1% (95% CI: 95.7–98.0%), and the specificity of diagnostic CBE was 68.7% (95% CI: 59.7–76.5%) and 57.1% (95% CI: 51.1–63.0%). The odds of a true-negative screening CBE (specificity) were significantly lower among women at increased risk of breast cancer (adjusted odds ratio 0.21; 95% CI: 0.10–0.46).
Conclusions
Screening CBE likely has higher specificity among community clinicians compared to examiners in clinical trials of breast cancer screening, even among women at increased breast cancer risk. Highly specific examinations, however, may have relatively low sensitivity for breast cancer. Diagnostic CBE, meanwhile, is relatively nonspecific.
doi:10.1007/s11606-006-0062-7
PMCID: PMC1824753  PMID: 17356964
breast cancer; sensitivity and specificity; screening; physical examination
9.  Breast Cancer Screening Use by African Americans and Whites in an HMO 
OBJECTIVE
To examine racial differences in breast cancer screening in an HMO that provides screening at no cost.
DESIGN
Retrospective cohort study of breast cancer screening among African-American and white women. Breast cancer screening information was extracted from computerized medical records.
SETTING
A large HMO in New England.
PATIENTS/PARTICIPANTS
White and African-American women (N =2,072) enrolled for at least 10 years in the HMO.
MAIN RESULTS
Primary care clinicians documented recommending a screening mammogram significantly more often for African Americans than whites (70% vs 64%; P <.001). During the 10-year period, on average, white women obtained more mammograms (4.49 vs 3.93; P <.0001) and clinical breast examinations (5.35 vs 4.92; P <.01) than African-American women. However, a woman's race was no longer a statistically significant predictor of breast cancer screening after adjustment for differences in age, estimated household income, estrogen use, and body mass index (adjusted number of mammograms, 4.47 vs 4.25, P =.17; and adjusted number of clinical breast examinations, 5.35 vs 5.31, P =.87).
CONCLUSIONS
In this HMO, African-American and white women obtained breast cancer screening at similar rates. Comparisons with national data showed much higher screening rates in this HMO for both white and African-American women.
doi:10.1111/j.1525-1497.2000.01339.x
PMCID: PMC1495437  PMID: 10759997
breast cancer screening; race; ethnicity; socioeconomic status

Results 1-9 (9)