Program Brief
This program brief summarizes findings from Agency for Healthcare Research and Quality (AHRQ)-supported research projects focused on cancer in women published January 2006 through December 2009.
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Contents
Introduction
AHRQ-Sponsored Research
Breast Cancer
Cervical Cancer
Breast and Cervical/Ovarian Cancer
Other Cancers
Cancer Screening and Diagnosis
More Information
Introduction
Breast cancer continues to be the most commonly diagnosed cancer among women in the United States. In 2008, an estimated 182,400 U.S. women were newly diagnosed with breast cancer, and more than 40,000 women died from the disease.
The good news is that breast cancer deaths have declined in recent years among white women in this country; the bad news is that over the same period, survival has decreased among black women. Although between 12 and 29 percent more white women than black women are stricken with breast cancer, black women are 28 percent more likely to die from the
disease. The 5-year breast cancer survival rate is 69 percent for black women, compared with 85 percent for white women.
In 2008, there were an estimated 11,000 newly diagnosed cases of invasive cervical cancer in U.S. women, and about 3,900 women died from the disease. Cervical cancer occurs most often among minority women, particularly Asian-American (Vietnamese and Korean), Alaska Native, and Hispanic women. Although deaths from cervical cancer have declined substantially over the past 30 years, the cervical cancer death rate for black women continues to be more than twice that of white women. The chance of dying of cervical cancer increases as women get older. Worldwide, cervical cancer is the second or third most common cancer among women, and in some developing countries, it is the most common cancer.
Women who have never had a Pap test or who have not had one for several years have a higher than average risk of developing cervical cancer. Many women still do not have regular Pap tests, particularly older women, uninsured women, minorities, poor women, and women living in rural areas. About half of the women with newly diagnosed invasive cervical cancer have not had a Pap test in the previous 5 years.
AHRQ-Sponsored Research
The Agency for Healthcare Research and Quality (AHRQ) supports a vigorous women's health research program, including research focused on breast cancer, cervical cancer, and other cancers in women. AHRQ-supported projects are addressing women's access to quality health care services, accurate diagnoses, appropriate referrals for procedures, and optimal use of proven therapies.
Following are examples of findings from AHRQ-supported research projects focused on cancer in women published January 2006 through December 2009. Select for more detailed information on AHRQ's research programs and funding opportunities.
Breast Cancer
Nonsurgical method for diagnosing breast cancer found to be safe and effective.
Description: This recent AHRQ report compares the safety and effectiveness of traditional surgical biopsies with various types of "core needle biopsy" for diagnosing breast cancer. Based on a review of scientific evidence, it shows that certain core needle biopsies could distinguish between malignant and benign lesions
approximately as accurately as open surgical biopsy, commonly considered to be the gold standard for evaluating suspicious lesions. The report provides important information to help physicians and patients work together to make the best possible diagnostic choice for each patient.
Source: Comparative Effectiveness of Core Needle and Open Surgical Biopsy for the Diagnosis of Breast Lesions, Comparative Effectiveness Review No. 19, Executive Summary (AHRQ Publication No. 10-EHC007-1)* (Contract 290-02-0019).
Less than 15 percent of radiologists say they definitely would tell a patient about an error in mammogram interpretation.
Description: A survey of 243 radiologists at seven
geographically dispersed breast cancer
surveillance sites found that 9 percent
of those surveyed definitely would not
disclose an error in mammogram
interpretation; 51 percent would
disclose the error only if specifically
asked by the patient; 26 percent said
they probably would disclose the error;
and just 14 percent said they definitely
would disclose the error. Neither
concern about the effects that
malpractice is having on the practice of
radiology nor having been sued
previously was associated with
willingness to disclose or disclosure
content.
Source: Gallagher, Cook, Brenner, et
al., Radiology 253(2):443-452, 2009
(AHRQ grant HS10591).
Automated telephone reminders lead to
increased use of mammography
Description: Researchers tested the effectiveness of
automated telephone reminders
(ATRs), enhanced reminder letters, and
standard letters on the likelihood of
repeat mammograms in 3,547 women
who were randomly assigned to one of
the three groups. The ATRs were found
to be the least costly but most effective
(76 percent) intervention for
prompting repeat mammograms,
compared with the enhanced (72
percent) and standard (74 percent)
reminder letters. Overall, 74 percent of
women had a repeat mammogram
within 10-14 months, compared with
57 percent before the reminders.
Source: DeFrank, Rimer, Gierisch, et al., Am J
Prevent Med 36(6):459-467, 2009
(AHRQ grant T32 HS00079).
In St. Louis, black women are more
likely than white women to receive
mammograms.
Description: St. Louis, MO, is known to have high
rates of breast cancer diagnosed at a
late-stage, and researchers have been
looking at ways to increase
mammography use in late-stage
diagnosis areas. From March 2004 to
June 2006, researchers conducted a
survey of women (429 black, 556
white) older than age 40 living in the
St. Louis area. Unexpectedly, more
black women (75 percent) than white
women (68 percent) reported that they
had received mammograms. The
researchers note that such geographic
clustering of late-stage breast cancer
diagnoses can be useful in targeting
interventions to increase
mammography use.
Source: Lian, Jeffe, and
Schootman, J Urban Health 85(5):677-692, 2008 (AHRQ grant HS14095).
Radiologists' perception of malpractice
risk appears to be higher than the
actual number of lawsuits.
Description: Researchers mailed a survey in 2002
and again in 2006 to radiologists in
three States—Washington, Colorado,
and New Hampshire—to determine
their perceived risk of facing a lawsuit
related to mammogram interpretation.
They found that the radiologist's
perceived risk of being sued was
significantly higher than the actual
number of reported malpractice cases
involving breast imaging. Radiologists
who spent more time on breast imaging
or interpreting a higher volume of
mammograms did not have a
significantly higher perceived risk of a
lawsuit. Those who felt more at risk
were more likely to have had a
malpractice claim in the past or know
of other radiologists who had been
sued.
Source: Dick, Gallagher, Brenner, et al.,
Am J Roentgenol 192(2):327-333, 2009
(AHRQ grant HS10591).
Study finds no correlation between
abnormal mammogram interpretation
and radiologists' job satisfaction.
Description: In this study, 131 radiologists were
surveyed about their clinical practices
and attitudes related to screening
mammography. Performance data were
used to determine the odds of an
abnormal mammogram interpretation.
More than half of the radiologists said
they enjoyed interpreting screening
mammograms; most in this group were
female, older, and working part time;
affiliated with academic medical
centers; and/or on an annual salary.
Those who did not enjoy the work
reported it as being tedious. There were
no significant differences in
mammogram interpretation and cancer
detection between those who did and
did not enjoy their work.
Source: Geller,
Bowles, Sohng, et al., Am J Roentgenol
192(2):361-369, 2009 (AHRQ grant
HS10591).
Lack of knowledge and mistrust may
partly explain women's underuse of
adjuvant therapy for breast cancer.
Description: Adjuvant therapies (chemotherapy,
hormone therapy, and radiotherapy)
following breast cancer surgery have
been proven effective in women with
early-stage breast cancer, yet 32 of 258
women in this study who should have
received adjuvant therapy did not get it.
According to practice guidelines, 64 of
the women should have received
chemotherapy, 150 should have
received hormone therapy, and 174
should have received radiotherapy. The
principal factors associated with lack of
adjuvant treatment were age older than
70, coexisting illnesses, and mistrust in
the medical delivery system. The
researchers call for better education of
women regarding the benefits and risks
of treatment, as well as straightforward
discussion about issues of trust.
Source: Bickell,
Weidmann, Fei, et al., J Clin Oncol 27(31):5160-5167, 2009. See also
Bickell, LePar, Wang, and Leventhal, J
Clin Oncol 25(18):2516-2521, 2007
(AHRQ grant HS10859; Anderson and
Carlson, J Natl Compr Canc Netw
5(3):349-356, 2007 (AHRQ grant
HS15756); and Fryback, Stout,
Rosenberg, et al., J Natl Cancer Inst
Monographs 36:37-47, 2006 (AHRQ
grant T32 HS00083).
Tracking system helps to ensure women
with breast cancer see oncologists and
receive followup care.
Description: Some women diagnosed with breast
cancer, especially blacks and Latinos, do
not follow through with their referrals
to an oncologist. To address this
problem, researchers developed a
tracking system to facilitate followup
with breast cancer patients. They
compared the treatment of 639 women
with early stage breast cancer who were
seen at six New York City hospitals
between January 1999 and December
2000 with 300 women who were seen
between September 2004 and March
2006, after the tracking system began.
Rates of oncology consultations,
chemotherapy, and hormone therapy
were higher for all women once the
system was in place, and the racial
disparities in use of care that had
existed were eliminated.
Source: Bickell, Shastri,
Fei, et al., J Natl Cancer Inst
100(23):1717-1723, 2008 (AHRQ
grant HS10859).
Study finds that three drugs effectively
reduce the risk of breast cancer but
may cause other problems.
Description: Three drugs—tamoxifen, raloxifene,
and tibolone—significantly reduce
invasive breast cancer in middle-aged
and older women who are at risk but
have not previously had breast cancer.
However, each of the three drugs has its
own side effects and risks, and these must be balanced against the benefits
for an individual patient. For example,
tamoxifen carries an increased risk for
endometrial cancer and blood clots and
has side effects such as flushing, night
sweats, and vaginal dryness. Raloxifene
also carries a risk for blood clots and
has side effects such as flushing and leg
cramps. Tibolone carries an increased
risk of stroke and has side effects that
include vaginal bleeding.
Source: Comparative
Effectiveness of Medications to Reduce Risk
of Primary Breast Cancer in Women,
Executive Summary No. 17 (AHRQ
Publication No. 09-EHC028-1)* (AHRQ contract 290-2007-10057-1).
Poverty may explain racial disparities
in receipt of chemotherapy for breast
cancer in older women.
Description: According to this study of nearly
14,500 older women with stage II or
IIIA breast cancer with positive lymph
nodes, black women were less likely
than white women to receive
chemotherapy within 6 months of
diagnosis (56 percent vs. 66 percent,
respectively). When the results were
adjusted to include socioeconomic
status for women aged 65 to 69,
poverty appeared to be at the root of
the disparity. Despite Medicare
coverage, out-of-pocket costs—including copayments, transportation,
and so on—may be overwhelming for
women in the lowest income groups.
Source: Bhargava and Du, Cancer
115(13):2999-3008, 2009 (AHRQ
grant HS16743).
Online support groups seem to benefit
women with metastatic breast cancer.
Description: A group of 20 women (all were white)
with metastatic breast cancer were
assigned to one of three online support
groups. The women received a monthly
E-mail questionnaire and after at least 4
months in the support group, each woman was interviewed for 30 to 90
minutes. Six helpful factors identified
in an earlier study were found to be
present in these groups: group
cohesiveness, universality, information
exchange, instillation of hope, catharsis,
and altruism.
Source: Vilhauer, Women Health
49:381-404, 2009 (AHRQ grant
HS10565).
Behavioral health carve-outs limit
access to mental health services for
women with breast cancer.
Description: Up to 40 percent of women with breast
cancer suffer significant psychological
distress, but only about 30 percent of
them receive treatment for it, according
to this study. Researchers analyzed
insurance claims, enrollment data, and
insurance benefit design data from
1998-2002 on women 63 years of age
or younger with newly diagnosed breast
cancer. They found that women
enrolled in insurance plans with
behavioral health carve-outs were 32
percent less likely to receive mental
health services compared with women
in plans that had integrated behavioral
health services.
Source: Azzone, Frank, Pakes, et
al., J Clin Oncol 27(5):706-712, 2009
(AHRQ grant HS10803)
Journal Supplement focuses on
guidelines for international
implementation of breast health and
breast cancer control initiatives.
Description: This journal supplement presents a
series of 15 articles authored by a group
of breast cancer experts and advocates
and presented at the Global Summit on
International Breast Health
Implementation held in Budapest,
Hungary, in October 2007. The articles
focus on guideline implementation for
early detection, diagnosis, and
treatment; breast cancer prevention;
chemotherapy; and other breast health
topics.
Source: Cancer 113, Supplement 8,
2008 (AHRQ grant HS17218).
Several factors affect the accuracy of
mammogram interpretation.
Description: Researchers examined how differences
among mammography facilities affect
the results of mammogram
interpretation. They found that the
most accurate facilities offered screening
but not diagnostic mammograms, had a
breast imaging specialist on staff, and
conducted audits of radiologists'
performance two or more times per
year. Their findings are based on a
review of 5 years of mammogram data
and results of surveys received from 43
facilities and their 128 radiologists in
the Pacific Northwest, New Hampshire,
and Colorado.
Source: Taplin, Abraham,
Barlow, et al., J Natl Cancer Inst
100(12):876-887, 2008 (AHRQ grant
HS10591). See also Miglioretti, Smith-Bindman, Abraham, et al., J Natl
Cancer Inst 99(24):1854-1863, 2007
(AHRQ grant HS10591).
Lesions overlooked on mammograms
represent missed opportunities for early
diagnosis.
Description: From 10 to 20 percent of women
diagnosed with breast cancer had
lesions that were visible but overlooked
on their most recent mammograms,
and another 10 to 20 percent had
lesions that were misinterpreted. In
both cases, the opportunities for early
diagnosis and intervention were missed.
These authors discuss the pros and cons
of double or even quadruple reading of
mammograms and computer-aided
detection as a second digital "reader" of
mammograms.
Source: Elmore and Brenner, J
Natl Cancer Inst 99(15):1141-1143,
2007 (AHRQ grant HS10591).
Breast desmoid tumors are rare and
often mistaken for cancer.
Description: A review over 25 years (1982-2006) at
one institution identified 32 patients
with pathologically confirmed breast
desmoids. Their median age was 45;
eight patients had a prior history of
breast cancer, and 14 had undergone
breast surgery, with desmoids diagnosed
an average of 24 months
postoperatively. All patients presented
with physical findings; MRI was more
accurate in visualizing the mass than
mammography or ultrasound. All
patients had their tumors surgically
removed, and eight patients had
recurring tumors at a median of 15
months. The researchers recommend
that clinical judgment be used before
extensive and potentially deforming
breast resections are performed.
Source: Neuman, Brogi, Ebrahim, et al., Ann
Surg Oncol 15(1):274-280, 2008
(AHRQ grant T32 HS00066).
More attention is needed to quality of
life for breast cancer survivors.
Description: Researchers examined quality of life
among women with (114 women) and
without (2,527 women) breast cancer.
Women with breast cancer reported
lower scores on physical function,
general health, vitality, and social
function compared with women who
did not have breast cancer. There was
no difference in mental health scores
between the two groups of women.
Source: Trentham-Dietz, Sprague, Klein, et al.,
Breast Cancer Res 109:379-387, 2008
(AHRQ grant HS06941).
Study underway to develop computer-based
tools to improve use of genetic
breast cancer tests.
Description: AHRQ has funded a new project to
develop, implement, and evaluate four
computer-based decision-support tools
that will help clinicians and patients
better use genetic tests to identify,
evaluate, and treated breast cancer. The
first pair of tools will assess whether a
woman with a family history of cancer
should be tested for BRCA1 and
BRCA2 gene mutations. The second
pair of tools, for women already
diagnosed with breast cancer, will help
determine which patients are suitable
for a gene expression profiling test that
can evaluate the risk of cancer
recurrence and whether they should
have chemotherapy.
Source: More information
is available online at
http://effectivehealthcare.ahrq.gov
(AHRQ contract 290-200-50036I).
Report discusses impact of several gene
expression profiling tests for breast
cancer patients.
Description: Breast cancer treatment today often
involves a multi-modality approach,
including surgery, radiation therapy,
endocrine therapy, and/or
chemotherapy. Gene expression
profiling has been proposed as an
approach to assess women's risk of
distant disease recurrence. This report
discusses the available evidence on three
breast cancer gene expression assays: the
Oncotype DX™ Breast Cancer Assay,
the MammaPrint® Test, and the Breast
Cancer Profiling Test. Tests that
improve such estimates of risk
potentially can affect clinical outcome
in breast cancer patients by either
avoiding unnecessary chemotherapy or
employing it where it otherwise might
not have been used.
Source: Impact of Gene
Expression Profiling Tests on Breast
Cancer Outcomes, Evidence
Report/Technology Assessment No.
160 (AHRQ Publication No. 08-E002)* (AHRQ contract 290-02-0018).
Radiation therapy for a primary cancer
that develops in a second breast may
offer a survival benefit.
Description: Radiation therapy following breast-conserving
surgery (BCS) for a primary
breast cancer reduces the risk of
recurrence, but it has only a small
overall survival benefit. However, omission of radiation therapy following
BCS for a primary cancer that later
develops in a second breast appears to
double the risk of dying, according to
this study. Researchers compared
mortality rates of women aged 40 to 69
who did not receive radiation therapy
following BCS for the second breast
(43 percent of women) with those who
did. Women who did not receive
radiation had slightly more than twice
the risk of dying from breast cancer and
1.7 times the risk of dying from all
causes as women who received
radiation.
Source: Schootman, Jeffe, Gillanders,
et al., Breast Cancer Res Treat 103:77-83,
2007 (AHRQ grant HS14095). See
also Du, Fan, and Meyer, Am J Clin
Oncol 31(2):125-132, 2008 (AHRQ
grant HS16743); and Schootman,
Fuortes, and Aft, Breast Cancer Res Treat
99:91-95, 2006 (AHRQ grant
HS14095).
Some women do not receive
recommended adjuvant therapy for
breast cancer.
Description: A survey of surgeons at six New York
hospitals who treated 119 breast cancer
patients who did not receive adjuvant
therapy found that the surgeons did not
recommend adjuvant treatment in one-third
of the cases, most often because
they believed the risks outweighed the
benefits. Among the two-thirds of
women for whom surgeons did
recommend adjuvant therapy, 31
percent declined the treatment, and 34
percent did not receive it for unknown
reasons. Adjuvant therapy
recommended for breast cancer patients
includes radiotherapy after breast
conserving surgery, chemotherapy for
estrogen receptor-negative tumors, and
hormonal therapies for estrogen
receptor-positive tumors larger than 1
cm.
Source: Bickell, LePar, Wang, and
Leventhal, J Clin Oncol 25(18):2516-2521, 2007 (AHRQ grant HS10859).
Go to also Anderson and Carlson, J Natl
Compr Canc Netw 5(3):349-356, 2007
(AHRQ grant HS15756); and Fryback,
Stout, Rosenberg, et al., J Natl Cancer
Inst Monographs 36:37-47, 2006
(AHRQ grant T32 HS00083).
Booklet helps women assess their
treatment options for early-stage breast
cancer.
Description: Women newly diagnosed with early-stage
breast cancer usually can choose
between breast-conserving surgery
(lumpectomy) followed by radiation
and mastectomy. Research has shown
that long-term outcomes are similar for
both treatments. This booklet provides
information to help women work with
their providers to choose which type of
surgery they will have and, if they
choose mastectomy, whether they want
to have reconstructive surgery. The
booklet was developed collaboratively
by the National Cancer Institute and
AHRQ.
Source: Surgery Choices for Women with
Early-Stage Breast Cancer (AHRQ
Publication No. PHS 04-M053,
English; AHRQ 05-0031, Spanish)* (Intramural).
Race, age, and other factors affect
degree of pain among women with
breast cancer.
Description: Researchers studied 1,124 women with
stage IV breast cancer over the course of
a year and found that minority women
who had advanced breast cancer
suffered more pain than white women.
In addition, women who were inactive
and younger women also reported more
severe pain.
Source: Castel, Saville, DePuy, et
al., Cancer 112(1):162-170, 2008
(AHRQ grant T32 HS00032).
Death and complications following
breast cancer surgery are rare.
Description: The most common complication of
breast cancer surgery is wound
infection, which is twice as common
after mastectomy as lumpectomy and lymph node dissection, according to
this study. Factors that may contribute
to the higher rate of wound infection
following mastectomy include extensive
tissue dissection, drain placement,
formation of pockets of fluid, and
longer operation time, as well as a
woman's overall health status.
Researchers analyzed data on 1,660
women (mean age 56) who underwent
mastectomy and 1,447 women who
underwent breast conserving surgery at
14 university and 4 community medical
centers. There were few cardiac or
pulmonary complications in the
mastectomy group and none in the
lumpectomy group; central nervous
system problems were rare in both
groups.
Source: El-Tamer, Ward, Schifftner, et
al., Ann Surg 245(5):665-671, 2007
(AHRQ grant HS11913).
Immediate reading of mammograms
and followup on false-positive results
reduce anxiety among women.
Description: A group of women aged 40 and older
participated in this study at seven sites
in the Boston area between February
1999 and January 2001. Radiologists
read the mammograms of 564 women
immediately, while the films of 576
women were read in batches at a later
time. Although there were more false-positives
in the immediate-reading
group, that strategy provided quick
resolution of false-positives and led to
significantly lower anxiety among those
women. Immediate reading of
mammograms increased costs to health
plans by 10 percent because of reduced
efficiency and the need for extra films.
However, 12-month costs did not differ
significantly between the two groups.
Source: Stewart, Neumann, Fletcher, and
Barton, Health Serv Res 42(4):1464-1482, 2007 (AHRQ Publication No.
07-R067)* (Intramural).
Depression hinders recovery of older
breast cancer patients.
Description: Researchers examined data on 187
women aged 60 years and older,
including the presence of depressive
symptoms 2 months after breast cancer
diagnosis. They also examined
sociodemographic factors, type of breast
cancer treatment, and shoulder range of
motion at 12 months after diagnosis.
Results showed that each unit increase
in depressive symptoms was associated
with an 8 percent decreased odds of
having full range of shoulder motion a
year after diagnosis.
Source: Caban, Freeman,
Zhang, et al., Clin Rehabil 20:513-522,
2006 (AHRQ grant HS11618).
Poor communication of mammogram
results may explain disparities in breast
cancer diagnosis and outcomes.
Description: Researchers surveyed 411 black and
734 white women who had screening
mammograms at five hospital-based
facilities in Connecticut between 1996
and 1998 and found no difference
between the two groups of women in
the proportion of abnormal screening
mammograms. However,
communication of mammogram results
was problematic for 14.5 percent of the
women; 12.5 percent had not received
their results, and 2 percent had received
their results but their self-report differed
from the radiology record. Inadequate
communication of mammogram results
was nearly twice as common among
black women as among white women.
Source: Jones, Reams, Calvocoressi, et al., Am J
Public Health 97(3):531-538, 2007
(AHRQ grant HS11603). See also
Dailey, Kasl, Holford, and Jones, Am J
Epidemiol 165(11):1287-1295, 2007
(AHRQ grant HS15686).
Physician communication style may
depend on characteristics of breast
cancer patients.
Description: According to this study, oncologists
tend to communicate differently with
women newly diagnosed with breast
cancer, depending on their age, race,
education, and income. A series of
videotaped visits between 58
oncologists with 405 women revealed
that the physicians spent more time
engaged in building relationships with
white women than with women of
other races; the same was true of visits
with more educated and affluent
patients compared with less advantaged
patients. The women who asked more
questions tended to be younger, white,
better educated (beyond high school),
and more affluent than other patients.
Source: Siminoff, Graham, and Gordon, Patient
Educ Counsel 62:355-360, 2006
(AHRQ grant HS08516).
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Cervical Cancer
Many young women have not received
the HPV vaccine.
Description: This survey found that more than 60
percent of 1,011 young women aged
13 to 26 years knew about Gardasil®,
the vaccine against human papilloma
virus (HPV) that causes cervical cancer.
However, only 30 percent of those aged
13 to 17 and 9 percent of those aged
18-26 had received the vaccine. Because
the vaccine is most beneficial when
given before young women become
sexually active, the authors urge
practitioners and parents to step up
efforts to educate young women about
the importance of receiving the vaccine
early.
Source: Caskey, Lindau, and Alexander, J
Adolesc Health 45(5):453-462, 2009
(AHRQ grant HS15699).
Instituting new processes can reduce
diagnostic errors in Pap smear
interpretation.
Description: Lean methods are used to weigh the
expenditure of resources against value
received. For this study, researchers
compared the diagnostic accuracy of
Pap tests procured by five clinicians
before (5,384 controls) and after (5,442
cases) implementing a process redesign
using Lean methods. Following process
redesign, there was a significant
improvement in Pap smear quality, and
the case group showed a 114 percent
increase in newly detected cervical
intraepithelial cancer following a
previous benign Pap test.
Source: Raab,
Andrew-Jaja, Grzybicki, et al, J Low
Genit Tract Dis 12(2):103-110, 2008
(AHRQ grant HS13321).
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