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Women's Health Highlights: Recent Findings

Program Brief

This program brief summarizes findings from a cross-section of AHRQ-supported research projects focusing on women's health topics published January 2008 through December 2011.

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Introduction
Cardiovascular Disease
Cancer Screening and Treatment
Reproductive Health
Chronic Illness and Care
Health Impact of Violence Against Women
Health Care Costs and Access to Care
Health Care Quality and Safety
Women and Medications
Data Sources for Gender Research

Introduction

At the beginning of the 20th century, U.S. women were most likely to die from infectious diseases and complications of pregnancy and childbirth. In 2007, the chronic conditions of heart disease, cancer, and stroke accounted for the majority percent of American women's deaths, and they continue to be the leading causes of death for both women and men.

Women have a longer life expectancy than men, but they do not necessarily live those extra years in good physical and mental health. On average, women experience 3.1 years of reduced physical functioning at the end of life, and in 2010, 13.5 percent of women aged 18 and older who were surveyed said they were in fair or poor health.

The Agency for Healthcare Research and Quality (AHRQ) supports research on all aspects of health care provided to women, including:

Enhancing the response of the health system to women's needs.
Understanding differences between the health care needs of women and men.
Understanding and eliminating disparities in health care.
Empowering women to make wellinformed health care decisions.

This summary presents findings from a cross-section of AHRQ-supported research projects on women's health published January 2008 through December 2011. An asterisk (*) at the end of a summary indicates that reprints of an intramural study or copies of other publications are available from the AHRQ Clearinghouse.

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Cardiovascular Disease

Women are more likely than men to experience a meaningful delay in ED care for cardiac symptoms.
Researchers examined time-to-treatment for 5,887 individuals with suspected cardiac symptoms who made a call to 911 in 2004. They found that women were 52 percent more likely than men to be delayed 15 minutes or more in reaching the hospital after calling 911. A delay of 15 minutes or more in heart attack treatment has been shown to result in measurably increased damage to the heart muscle and poorer clinical outcomes. Factors increasing the likelihood of delay included distance, evening rush hour travel, bypassing a local hospital, and transport from a more densely populated neighborhood. Concannon, Griffith, Kent, et al., Circ Cardiovasc Qual Outcomes 2:9-15, 2009 (AHRQ grants HS10282, T32 HS00060).
Association found between cardiac illness and prior use of a certain type of breast cancer drug.
According to this 16-year study of nearly 20,000 women with breast cancer, those who received chemotherapy that included anthracycline had a higher incidence of congestive heart failure, cardiomyopathy, and dysrhythmia than women who received other kinds of chemotherapy or no chemotherapy. For example, the probability of experiencing congestive heart failure in year 10 was 32 percent for women who received anthracycline, compared with 26 percent for women who received other types of chemotherapy and 27 percent for those who received no chemotherapy. Du, Siz, Liu, et al., Cancer 115(22):5296-5308, 2009 (AHRQ grant HS16743).
Postmenopausal women with metabolic syndrome are at increased risk for a cardiovascular event.
Researchers used data on 372 postmenopausal women to investigate the effects of using two competing clinical definitions of metabolic syndrome on their usefulness in identifying women at high risk of future heart attacks or stroke. Metabolic syndrome—a combination of high blood pressure, elevated blood glucose, abnormal lipid levels, and increased waist size—is known to be associated with elevated risk for heart attack and stroke. Overall, women who met at least one of the definitions for metabolic syndrome were significantly more likely to experience a cardiovascular event than those who did not, and there was no difference between the two definitions in their predictive ability. Brown, Vaidya, Rogers, et al., J Womens Health 17(5):841-847, 2008 (AHRQ grant HS13852).
Aspirin therapy to prevent heart attack may have different benefits and harms in men and women.
The U.S. Preventive Services Task Force reviewed new evidence from the National Institutes of Health's (NIH's) Women's Health Study and other recent research and found good evidence that aspirin decreases first heart attacks in men and first strokes in women. The Task Force recommends that women aged 55 to 70 should use aspirin to reduce their risk for ischemic stroke when the benefits outweigh the harms for potential gastrointestinal bleeding. The recommendation and other materials are available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm. U.S. Preventive Services Task Force, Ann Intern Med 150(6):396-404, 2009 (AHRQ supports the Task Force).
Female and black stroke patients are less likely than others to receive preventive care for subsequent strokes.
According to this study of 501 patients hospitalized for stroke, 66 percent of women and 77 percent of blacks received incomplete inpatient evaluations, compared with 54 percent of men and 54 percent of whites. Also, women were more likely than men to receive incomplete discharge regimens (anticoagulants and other stroke prevention medications and outpatient followup). Tuhrim, Cooperman, Rojas, et al., J Stroke Cerebrovasc Dis 17(4):226-234, 2008 (AHRQ grant HS10859).

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Cancer Screening and Treatment

Breast Cancer

No link found between use of chemotherapy for breast cancer in older women and later cognitive impairment.
Researchers examined data on more than 62,500 women aged 65 and older with breast cancer. They compared data on a subset of 9,752 of the women who received chemotherapy with data on an equal number of women who did not receive chemotherapy. They found no significant increase in risk of cognitive impairment associated with chemotherapy use up to 16 years after treatment. Du, Xia, and Hardy, Am J Clin Oncol 33(6):533-543, 2010 (AHRQ HS16743).
Researchers examine ways to increase breast cancer screening among Latinas.
Many immigrant Hispanic women do not get yearly mammograms or perform breast self-exams. This study evaluated two interventions to address the problem: (1) use of focus groups to assess the women's knowledge about breast cancer and identify barriers to screening and (2) participation in discussion groups, including an animated video on breast self-exam plus training in the technique using latex models. Both interventions were cost effective and successful in increasing the women's knowledge and screening behaviors. Calderon, Bazargan, and Sangasubana, J Health Care Poor Underserved 21:76-90, 2010 (AHRQ grant HS14022).
Physicians often rely on untrained individuals to help them discuss breast cancer treatment options with limited English-proficient women.
Researchers surveyed 348 physicians about their use and availability of trained interpreters when counseling limited English-proficient women with breast cancer. Almost all of the physicians had treated patients with limited English proficiency in the preceding 12 months, and fewer than half reported good availability of trained medical interpreters or telephone language interpretation services. Instead, they used bilingual staff not specifically trained in medical interpretation and patients' family members or friends. This was more likely to be the case for physicians in solo practice or single-specialty medical groups than those working in large HMOs. Rose, Tisnado, Malin, et al., Health Serv Res 45(1):172-194, 2010 (Interagency agreement AHRQ/National Cancer Institute [NCI]).
Online support groups for women with metastatic breast cancer appear promising.
This study reports on the development and implementation of pilot peer-to-peer online support groups for women with metastatic breast cancer (MBC). Thirty women with MBC were assigned to either an immediate online support group or a wait-listed control group and were assessed monthly over a 6-month period. Retention rates, assessment completion rates, and support group participation were high; reported satisfaction was also high. Vilhauer, McClintock, and Matthews, Psychosoc Oncol 28:560-586, 2010 (AHRQ grant HS10565).
More than half of women do not get regular mammograms.
This study found that women in their 40s were more likely than women in their 50s to forgo regular mammograms, and those who rated their health as fair or poor also were more likely to skip screening, compared with women who rated their health as good or excellent. Also, dissatisfaction with a previous mammography experience reduced the likelihood of regular screening. Most of the women participating in the study were college educated, in a higher income bracket, and insured; all of the women in the study received regular reminders about scheduling their mammograms. Gierisch, Earp, Brewer, and Rimer, Cancer Epidemiol Biomark Prevent 19(4):1103-1111, 2010 (AHRQ grant T32 HS00032). See also Meissner, Klabunde, Han, et al., Cancer 117:3101-3111, 2011 (AHRQ interagency agreement with NIH).
Radiologists' characteristics and clinical factors influence interpretation of mammograms.
This study involving 638,947 screening mammograms performed by 134 radiologists in 101 facilities found that women with clinical risk factors for breast cancer were more likely than women without risk factors to be asked to return for additional mammograms and biopsies. Increased recall rates for women with risk factors did not lead to a higher probability of detecting cancer. Recall rates were also higher when the radiologist was younger, had interpreted more mammograms per year, and was affiliated with a teaching institution. Cook, Elmore, Miglioretti, et al., J Clin Epidemiol 63(4):441-451, 2010 (AHRQ grant HS10591).
Booklet provides helpful information about breast biopsy.
This guide for women with breast cancer discusses the different kinds of breast biopsies, including their accuracy and side effects. It can help women who need biopsies talk with their doctors and nurses about the procedure and what to expect. Having a Breast Biopsy: A Guide for Women and Their Families (AHRQ Publication No. 10-EHC007-A).* See also Core-Needle Biopsy for Breast Abnormalities: Clinician Guide (AHRQ Publication No. 10-EHC-007-3)* and 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)* (AHRQ contract 290-02-0019).
Guide for women discusses two drugs used to lower the risk of breast cancer.
Two drugs—tamoxifen and raloxifene—have been approved for the prevention of primary (first occurrence) breast cancer in women who have a higher than average risk of breast cancer. This guide provides information about the drugs' benefits, side effects, and cost, and can help women talk with their doctors to decide whether one of these drugs would be right for them. Reducing the Risk of Breast Cancer with Medicine: A Guide for Women (AHRQ Publication No. 09(10)EHC028-A).* See also Medications to Reduce the Risk of Primary Breast Cancer in Women: Clinician Guide (AHRQ Publication No. 09(10)-EHC028-3)* and 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).
Less than 15 percent of radiologists say they definitely would tell a patient about an error in mammogram interpretation.
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. Gallagher, Cook, Brenner, et al., Radiology 253(2):443-452, 2009 (AHRQ grant HS10591).
Automated telephone reminders lead to increased use of mammography.
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. 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.
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. 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.
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. 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. 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.
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. 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.
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. Bickell, Weidmann, Fei, et al., J Clin Oncol 27(31):5160-5167, 2009. (AHRQ grant HS10859).
Tracking system helps to ensure women with breast cancer see oncologists and receive followup care.
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. Bickell, Shastri, Fei, et al., J Natl Cancer Inst 100(23):1717-1723, 2008 (AHRQ grant HS10859).
Poverty may explain racial disparities in receipt of chemotherapy for breast cancer in older women.
In 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. Bhargava and Du, Cancer 115(13):2999-3008, 2009 (AHRQ grant HS16743).
Online support groups seem to benefit women with metastatic breast cancer.
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 groups, each woman was interviewed for 30 to 90 minutes. Six helpful factors identified in an earlier study were found to be present: group cohesiveness, universality, information exchange, instillation of hope, catharsis and altruism. Vilhauer, Women's Health 49:381-404, 2009 (AHRQ grant HS10565).
Behavioral health carve-outs limit access to mental health services for women with breast cancer.
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. 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.
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. Cancer 113, Supplement 8, 2008 (AHRQ grant HS17218).
Requirement for cost-sharing reduces use of mammography among some groups of women.
Researchers examined data on mammography use and cost-sharing from 2002 to 2004 for more than 365,000 women covered by Medicare. Of the 174 Medicare health plans studied, just 3 required copayments of $10 or more or coinsurance of more than 20 percent in 2001; by 2004, 21 plans required cost-sharing of one form or another. The increase in coinsurance requirements correlated with a decrease in screening mammograms. Less than 70 percent of women in cost-sharing plans were screened, compared with nearly 80 percent of fully covered women. Trivedi, Rakowski, and Ayanian, N Engl J Med 358(4):375-383, 2008 (AHRQ grant T32 HS00020).
Breast desmoid tumors are rare and often mistaken for cancer.
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. 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.
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. 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.
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 treat 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. More information is available online at http://effectivehealthcare.ahrq.gov (AHRQ contract 290-200-50036I).
Gene expression profiling tests can inform treatment decisions for breast cancer patients.
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. 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).
Race, age, and other factors affect degree of pain among women with breast cancer.
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. Castel, Saville, DePuy, et al., Cancer 112(1):162-170, 2008 (AHRQ grant T32 HS00032).
Task Force revises recommendations for mammography.
The U.S. Preventive Services Task Force updated its recommendation by calling for screening mammography, with or without clinical breast exam, every 1 to 2 years for women 40 and over. The recommendation acknowledges some risks associated with mammography, which will lessen as women age. The strongest evidence of benefit and reduced mortality from breast cancer is among women ages 50 to 69. The recommendation and materials for clinicians and patients are available at http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrca.htm.

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