Reducing Barriers to Use of Breast Cancer Screening
Stony Brook University, NY
Dr. Dorothy Lane, of Stony Brook University, investigated whether a telephone counseling intervention aimed at women who are known to underuse breast cancer screening can with, or without, an accompanying educational intervention for their physicians, increase use of breast cancer screening.
She found that women who had a previous mammogram at the start of the study and who subsequently received telephone counseling were more likely to become regular mammography users than women who did not receive counseling. In addition, the findings suggested that the educational intervention for physicians is associated with initiation of mammography use among women who have never had a mammography. More research with larger samples is needed to confirm this finding.
The study found that women who had a previous mammogram at the start of the study and who received telephone counseling were 40 percent more likely than women who did not receive counseling to become regular mammography users by the end of the study. Greater reductions in perceived barriers to mammography were associated with receiving telephone counseling. Telephone counseling did not appear to be effective among women who never had a mammogram. However, data suggested that physicians continuing medical education (CME) intervention has potential for initiating mammography use among women who never had a previous mammogram (described later). Further study with larger samples is needed to confirm this finding.
In a first step of the study, Dr. Lane and colleagues surveyed more than 8,900 Long Island women, ages 50-80, by telephone about their use of breast cancer screening, and over 540 doctors by questionnaire. The researchers identified over 3,400 women who had not received mammograms in the past two years and the past two years prior to that. Forty-five percent of women in the 65 years-of-age and older age group were found to underuse mammography, and 34 percent of women in the 50 to 64 years-of-age group to underuse it.
The chief reasons given for not getting mammograms were procrastination and not believing a mammography was needed the latter reason given more frequently by women in the older age group. The researchers found that over 80 percent of the women who were underusers of mammography had less than a college degree, the majority (58 percent) had family incomes of under $35,000, and most were homemakers or retired.
During the intervention phase of the study, the effectiveness of telephone counseling and physician education were tested. An annual mailing alerted women that they would be called by the Early Detection Guidelines Education (EDGE) Project and encouraged them to go for mammography. Three annual mailings were conducted during this intervention period and included educational materials and incentives to promote screening.
A three-month period elapsed following each educational mailing before initiating telephone counseling of women who did not return the response sheet, in order to allow them time to obtain a mammogram if they were prompted by the mailings. In the intervention group, 1,165 underuser women reported that 597 mammograms were obtained during the first year of the intervention, and 615 mammograms were obtained during the second year of intervention, for a total of 1,195 mammograms.
A quality control evaluation was also conducted of a sample of 117 counseling calls for the telephone counseling intervention. Seventy-one percent of women who were contacted reported that the calls were "entirely reassuring," and 71 percent of the women said the calls were "entirely helpful." In addition, 65 percent of the women said that they felt "entirely encouraged" by the EDGE counselor to have mammogram in the future. Among women who mentioned a barrier to mammography, 64 percent reported that after discussing it with the EDGE telephone counselor, the barrier would not keep them from getting a mammogram in the future.
Ninety-three physicians obtained the in-office continuing medical education (CME) intervention which included three modules: (1) office systems, (2) behavioral counseling, and (3) revisiting physical examination of the breast. The in-office intervention also included an optional follow-up visit with the office staff and a subsequent visit by a standardized patient.
As an adjunct to the educator office visit, the researchers developed a workbook that can also be used as a freestanding self-instructional continuing medical education (CME) activity. The workbook was mailed to those physicians in the intervention group who did not receive an in-office visit. Physicians' anonymous evaluations of the in-office intervention were very positive.
The researchers found that self-reported overall breast cancer screening educational need scores improved for a greater proportion of physicians in the intervention group, especially among those who received the in-office CME intervention, compared to physicians who did not receive the intervention. Educational need with regard to clinical breast examinations also declined while use of provider reminder systems, preparedness to counsel women about clinical breast exams, and recognition of age as an important risk factor for breast cancer improved in more intervention physicians than control physicians. Findings from the study were reported in1999 to 2002.