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Agency for Healthcare Research Quality

Cancer Screening and Treatment in Women

Program Brief

Although breast cancer deaths have declined in recent years among white women in this country, survival among black women has decreased. Similarly, cervical cancer deaths have declined substantially over the past 30 years, but the cervical cancer death rate for black women continues to be more than twice that of white women.

This program brief summarizes findings from research projects focused on cancer in women sponsored by the Agency for Healthcare Research and Quality (AHRQ).

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AHRQ-Sponsored Research
Breast Cancer
Cervical Cancer
Cancer Screening
More Information


Breast cancer continues to be the most commonly diagnosed cancer among women in the United States. In 2002, an estimated 203,500 U.S. women were newly diagnosed with breast cancer, and nearly 39,000 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 2002, there were an estimated 13,000 newly diagnosed cases of invasive cervical cancer in U.S. women, and about 4,100 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

AHRQ supports a vigorous women's health research program, including research focused on breast and cervical cancer, as well as ovarian and colon cancer. 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. This program brief focuses specifically on findings from AHRQ-supported research projects related to cancer in women.

Breast Cancer

Clinicians should discuss use of tamoxifen to prevent breast cancer with women who are likely to benefit from it.
Description: These researchers surveyed 605 women aged 40 to 69 seen in 10 general internal medicine practices in North Carolina in 2001. The found that 9 percent of white women and 3 percent of black women in their 40s were at high risk of breast cancer, compared with 24 percent of white women and 7 percent of black women in their 50s and 53 percent of white women and 13 percent of black women in their 60s. Tamoxifen has been shown to reduce the incidence of breast cancer, but it is associated with a higher risk of endometrial cancer, blood clots, and stroke. When these risks were considered, 10 percent or fewer of white women in all age groups were potentially eligible to take the drug.
Source: Lewis, Kinsinger, Harris, et al. Arch Intern Med 2004;164:1897-1903 (AHRQ contract 290-97-0011).

Study underscores the importance of involving women in breast cancer treatment decisions.
Description: According to this study, women who receive the breast cancer treatment they prefer have a better body image 2 years after treatment than women who do not.
Source: Figueiredo, Cullen, Hwang, et al. J Clin Oncol 2004;22(19):4002-9 (AHRQ grant HS08395).

Most women who are diagnosed with early-stage breast cancer can choose either lumpectomy or mastectomy.
Description: Treatment for early-stage breast cancer usually includes either breast-conserving surgery (lumpectomy) together with radiation or mastectomy (complete removal of the affected breast). This booklet can help women weigh the pros and cons of both options and take a more active role in their breast cancer treatment. The booklet was developed by AHRQ and the National Cancer Institute, along with other government and non-government partners.
Source: Copies of Surgery Choices for Early-Stage Breast Cancer (AHRQ Publication Nos. PHS 04-M053, English; and 05-0031, Spanish) are available from AHRQ.*

Researchers assess quality measures for breast cancer care.
Description: Researchers at AHRQ's University of Ottawa Evidence-based Practice Center analyzed the scientific literature on quality measures/indicators used to assess the quality of breast cancer care in women. They found few evidence-based formal quality measures for breast cancer care and concluded that it was not possible to derive a meaningful overview of gaps in breast cancer care.
Source: Evidence Report/Technology Assessment No. 105, Measuring the Quality of Breast Cancer Care in Women (AHRQ Publication Nos. 04-E030-1, summary; and 04-E030-2, full report) is available from AHRQ.*

Women who have certain breast tumors should not increase their use of soy products to minimize menopausal symptoms.
Description: Chemotherapy for breast cancer, including tamoxifen, may induce or accelerate ovarian failure, resulting in severe menopausal symptoms. This review of the evidence demonstrates that soy products may stimulate breast cancer growth and interfere with tamoxifen's anti-tumor activity.
Source: Duffy, Cyr. J Women's Health 2003;12(7):617-31 (AHRQ grant T32 HS00011).

Use of tamoxifen to prevent breast cancer should depend on a woman's potential benefits and risks.
Description: This meta-analysis of 32 clinical trials of women (average age 55) on tamoxifen for 4.3 years showed that tamoxifen was associated with a significantly increased risk of endometrial and gastrointestinal cancers, stroke, and pulmonary emboli. Conversely, tamoxifen use significantly decreased heart attack deaths and was associated with an insignificant decrease in heart attack incidence.
Source: Braithwaite, Chlebowski, Lau, et al. J Gen Intern Med 2003;19:937-47 (AHRQ grant HS09796).

Benefits of adding radiation therapy to tamoxifen after lumpectomy diminish with increasing age.
Description: This study found that a woman aged 50 who is postmenopausal and has localized breast cancer is 54 percent less likely to die if she receives radiation therapy and tamoxifen after a lumpectomy, compared with receipt of tamoxifen alone. The reduced risk for an 80-year-old woman is 42 percent.
Source: Punglia, Kuntz, Lee, et al. J Clin Oncol 2003;21(12):2260-7 (AHRQ grant T32 HS00020).

Study finds significant differences in survival for three breast cancer treatment alternatives.
Description: Using Medicare claims data, the researchers found highly significant differences in survival for older women with early-stage breast cancer who underwent one of three treatments: mastectomy, lumpectomy with radiation, and lumpectomy only. These results, which are based on observational data, differ from results of randomized clinical trials.
Source: Hadley, Polsky, Mandelblatt, et al. Health Econ 2003;12:171-86 (AHRQ grant HS08395).

Two treatments for early-stage breast cancer are equally cost effective.
Description: Two studies by researchers at Georgetown University examined the cost-effectiveness of surgical treatments for early-stage breast cancer and patients' quality of life after surgery. The first study found that giving older breast cancer patients a choice of either lumpectomy followed by radiation or mastectomy is cost effective. The second study showed that how older women are treated during their care, not the therapy itself, is the most important determinant of long-term quality of life.
Sources: Polsky, Mandelblatt, Weeks, et al. J Clin Oncol 2003;21(5):1139-46; and Mandelblatt, Edge, Meropol, et al. J Clin Oncol 2003;21(5):855-63 (AHRQ grant HS08395).

Among low-income black women, those most at risk for breast cancer know the least.
Description: Elderly women are more likely than younger women to die from breast cancer, and black women die of breast cancer more often than white women due to late diagnosis. In this study, low-income black women 65 and older underestimated their risk of getting breast cancer, and those 85 and older were the least likely to have had a mammogram or breast exam in the preceding 2 years.
Source: Jones, Thompson, Oster, et al. J Natl Med Assoc 2003;95(9):791-805 (AHRQ grant HS10875).

Breast cancer survival is increased in women who perceive high levels of emotional support.
Description: This study involved 145 black and 177 white women diagnosed with breast cancer in Connecticut between January, 1987 and March, 1989. Higher levels of perceived emotional support had a significant association with increased survival among the women, who were followed for 10 years.
Source: Soler-Vila, Kasl, and Jones. Cancer 2003;98:1299-1308 (AHRQ grant HS06910).

Racial disparities found in timely and thorough followup of suspected breast cancer.
Description: More than one-fourth of black women who have abnormal results from mammography or clinical breast exam have not resolved the diagnosis with followup tests 6 months later. In this study, black women with prior breast abnormalities or higher levels of cancer anxiety were about half as likely as other women to follow up on the abnormal results within 3 to 6 months. Delays of 3 to 6 months have been associated with lower survival rates compared with more timely followup.
Source: Kerner, Yedida, Padgett, et al. Prev Med 2003;37:92-101 (AHRQ grant HS08395).

Mammography volume is only one factor affecting radiologists' accuracy.
Description: Radiologists who examine more than 5,000 mammograms a year are more likely to accurately interpret them than radiologists who read a low volume of mammograms. Other factors affecting radiologists' accuracy in reading mammograms include their fear of medical malpractice, characteristics of individual women in the population being screened (e.g., number of women in the screened population who are taking hormone replacement therapy, variation in the timing of mammography during the women's menstrual cycles), and whether or not women are returning to the same facility each year for their mammograms so that films from prior years are available for comparison.
Source: Elmore, Miglioretti, Carney. J Natl Cancer Inst 2003;95(4):250-2 (AHRQ grant HS10591).

Patients' choice of breast cancer treatment affects health.
Description: A sample of 683 older women with localized breast cancer was surveyed (at 5 months, 1 year, and 2 years) following surgery for breast cancer at 1 of 29 hospitals in Massachusetts, Texas, New York, and Washington, DC. The investigators found that women aged 67 years and older who participate with their doctor in choosing which treatment they receive recover faster and have a more positive short-term outlook than women who are not given a choice.
Source: Polsky, Keating, Weeks, et al. Med Care 2002;40(11):1068-79 (AHRQ grant HS08395).

Study finds that interpretations of mammograms vary.
Description: In this study, investigators examined results from 24 community radiologists' interpretations of 8,734 screening mammograms from 2,169 women over an 8-1/2-year period. The investigators found wide variation in how frequently different radiologists noted masses, calcifications, and other suspicious lesions. The rate of false-positive readings among the radiologists ranged from 2.6 to 15.9 percent. After adjustment for differences in patient, radiologist, and testing characteristics, the rate of false-positive readings ranged from 3.5 to 7.9 percent.
Source: Elmore, Miglioretti, Reisch, et al. J Natl Cancer Inst 2003;94(18):1373-80 (AHRQ grant HS10591).

Older black women may not receive preferred breast cancer treatment.
Description: Data from 984 black and 849 white Medicare-insured women aged 67 years or older who were diagnosed with localized breast cancer were analyzed along with data from a subset of 732 surviving women who were interviewed 3 to 4 years after treatment. Elderly black women were 36 percent more likely than elderly white women to receive mastectomy versus breast-conserving surgery (BCS) and radiation, say researchers. Furthermore, when black women received BCS, they were 48 percent more likely than white women to not have radiotherapy.
Source: Mandelblatt, Kerner, Hadley, et al. Cancer 2002;95:1401-14 (AHRQ grant HS08395).

Patient age and provider specialty affect the use of axillary dissection.
Description: Using medical records for 464 elderly women with stage 1-2 breast cancer who underwent breast-conserving surgery (BCS) and 158 surgeon surveys, investigators examined patient, clinical, and surgeon characteristics associated with the non-use of axillary lymph node biopsy. Increasing age was strongly associated with decreasing odds of undergoing node biopsy. Women who were cared for by surgeons with subspecialty training in surgical oncology were 60 percent less likely to undergo node dissection than women who were cared for by other surgeons.
Source: Edge, Gold, Gerg, et al. Cancer 2002;94:2534-41 (AHRQ grant HS08395).

Communication of treatment options enhances quality of care.
Description: Researchers analyzed data from 613 surgeons and their patients who had been diagnosed with localized breast cancer. According to the study results, older women who are told about treatment options by their surgeons are more likely to get breast-conserving surgery with radiation than other types of treatment. These women are also more likely to have a sense of treatment choice and be more satisfied with the care received.
Source: Liang, Burnett, Rowland, et al. J Clin Oncol 2002;20(4):1008-16 (AHRQ grant HS08395).

Increased use of health care is related to increased screening.
Description: This study examined mammography use among 2,059 HIV-positive and 569 HIV-negative socioeconomically disadvantaged women enrolled in the Women's Interagency HIV Study. Mammography use was also compared with U.S. women using data from the National Health Interview Survey. HIV-positive women were 60 percent more likely than HIV-negative women to be screened for the first time while in the study. More HIV-positive than HIV-negative women reported having health insurance (82 versus 59 percent); a primary care provider (93 versus 67 percent); and a visit to a doctor in the past 2 months (84 versus 54 percent).
Source: Preston-Martin, Kirstein, Pogoda, et al. Prev Med 2002;34:386-92 (sponsored by AHRQ, NIH, CDC).

Mammography improves outcomes of elderly cancer patients.
Description: To determine the impact of mammography screening on elderly breast cancer patients, data were examined on 718 patients newly diagnosed with stage 1 and 2 disease at 29 hospitals. Researchers found that 96 percent of women with cancer diagnosed with a mammogram had stage 1 lesions compared with 81 percent of women diagnosed by other means. Screening was associated with a higher likelihood of receiving breast-conserving surgery with radiation than other local therapies, even after controlling for stage and histology.
Source: Kerner, Mandelblatt, Silliman, et al. Breast Cancer Res Treat 2001;69(1):81-91 (AHRQ grant HS08395).

Illness burden and breast cancer therapy are not correlated.
Description: Investigators assessed the correlations between five measures of illness burden, global health, and physical function and evaluated how each measure correlated with breast cancer treatment patterns in a group of 718 older women with early-stage breast cancer. All of the measures were significantly correlated with each other and with physical function and self-rated health. Although several measures were associated with breast cancer therapy, each measure accounted for only a small amount of variance in treatment patterns.
Source: Mandelblatt, Bierman, Gold, et al. Health Serv Res 2001;36(6):1085-1107 (AHRQ grant HS08395).

Two interventions prevent psychosocial declines.
Description: Women with metastatic breast cancer were randomly assigned to a control or intervention group (expressive-supportive group psychotherapy or an online support group) to examine the impact of these two interventions on psychosocial well-being. Despite differences (in the use of specific therapeutic methods, the presence of a skilled professional, and the physical proximity of group members), both interventions prevented psychosocial declines in social connection, activity, and coping.
Source: Psychosocial Interventions for Metastatic Breast Cancer. Grant final report (NTIS Accession No. PB2002-10140), Ruvanee M. Pietersz, Ph.D., University of Chicago (AHRQ HS10565).**

A previous mammogram may reduce the risk of a false-positive reading.
Description: This project examined the incidence of false-positive mammography using detection controlled estimation on an extensive database from a hospital-based mammography program. Results imply that access to a previous mammogram reduces the incidence of false-positive readings by 50 to 80 percent.
Source: False-Positive Mammograms and Detection-Controlled Estimation. Grant final report (NTIS Accession No. PB2002-101464), Andrew N. Kleit, Ph.D., Pennsylvania State University (AHRQ grant HS10068).**

Hospitals should implement care coordination mechanisms for early-stage breast cancer patients.
Description: Researchers interviewed 67 physicians, nurses, and support staff practicing at six hospitals about hospital- and office-based approaches to coordinating care for breast cancer patients. At high-coordination hospitals, 88 percent of women with breast-conserving surgery received recommended radiotherapy, and 84 percent of those with tumors larger than 1 cm received recommended systemic chemotherapy compared with 76 and 73 percent of women, respectively, at low-coordination hospitals.
Source: Bickell, Young, J Gen Intern Med 2001;16:737-42 (AHRQ grant HS09844).

Task Force issues updated recommendation for mammography.
Description: The U.S. Preventive Services Task Force has updated its recommendation on screening mammography and now calls for screening mammography, with or without clinical breast exam, every 1 to 2 years for women ages 40 and over. The recommendation acknowledges some risks associated with mammography, which will lessen as women age, and that the strongest evidence of benefit and reduced mortality from breast cancer is among women ages 50 to 69.
Source: The breast cancer screening recommendation and materials for clinicians and patients are available at

Outpatient mastectomies have increased over the past decade.
Description: This study revealed that two key factors influence whether a woman gets a complete mastectomy in the hospital or in an outpatient setting: the State where she lives and who is paying for the surgery. The researchers examined hospital inpatient and outpatient discharge records for all women who were treated for cancer with a breast procedure in five States: Colorado, Maryland, New Jersey, New York (1990-1996 data for these States), and Connecticut (1993-1996 data). They found dramatic increases in outpatient complete mastectomies in these States. For example, outpatient complete mastectomies in Colorado jumped from under 1 percent in 1990 to 22 percent in 1996. Nearly all women who were Medicare or Medicaid beneficiaries were kept in the hospital after surgery, as were 89 percent of women enrolled in HMOs.
Source: Case, Johantgen, Steiner. Health Serv Res 2001;36(5):869-84 (Reprints, AHRQ Publication No. 01-R008) (Intramural).*

Physicians' preferences help determine treatment for older women with breast cancer.
Description: Researchers at the Georgetown University School of Medicine queried a random sample of 1,000 surgeons. Respondents were given three scenarios involving older women with localized breast cancer and asked whether they would use breast-conserving surgery (BCS) or mastectomy and whether they would use radiation therapy after BCS. Surgeons' preferences were significantly associated with self-reported practices and treatments and explained some of the variations in breast cancer treatment patterns among older women.
Source: Mandelblatt, Berg, Meropol, et al. Med Care 2001;39(3):228-42 (AHRQ grant HS08395).

Hormone replacement therapy does not appear to increase risk of breast cancer recurrence.
Description: Hormone replacement therapy (HRT) that can relieve symptoms of menopause usually is withheld from women who have had breast cancer because of concern that it might increase the risk of recurrence. These researchers conducted a systematic review of research studies through May 1999. They compared the findings from 11 studies of breast cancer recurrence in women taking and not taking HRT. Over a 30-month followup period, 4.2 percent of HRT users and 5.4 percent of non-users per year had a recurrence of breast cancer.
Source: Col, Hirota, Orr, et al. J Clin Oncol 2001;19:2357-63 (AHRQ grant HS09796).

AHRQ publishes report on management of breast abnormalities.
Description: Researchers conducted an extensive review of the literature and reported findings such as the evidence for performing an excisional biopsy following a stereotactic core needle biopsy, use of tamoxifen therapy, and sentinel lymph node biopsy. They suggest future research should examine breast disease risk factors, breast symptoms, and how these relate to cancer diagnoses.
Source: The full evidence report, Management of Specific Breast Abnormalities, Evidence Report/Technology Assessment No. 33 (AHRQ Publication No. 01-E046), and a summary (AHRQ Publication No. 01-E045) are available from AHRQ (contract 290-97-0016).*

Community programs are an effective way to reach poor and minority women with health messages.
Description: Researchers who examined the cost and cost-effectiveness of the Los Angeles Mammography Program (LAMP) recommend that careful consideration be given to community-based and other approaches outside of the traditional purview of medicine to enhance use of mammography among poor and minority women. Additionally, community- and church-based programs should be compared with a range of alternative programs targeting poor and minority women who have limited access to mammography. LAMP, which involved 45 churches and 2 interventions to improve rates of mammography screening, generated 3.24 additional screenings among 56 women.
Source: Siegel, Clancy. Health Serv Res 2000;35(5):905-9 (Reprints, AHRQ Publication No. 01-R032) (Intramural).*

Attitudes about mammography affect appointment-keeping.
Description: This study found that negative attitudes about mammography may play a role in the disproportionate number of breast cancer deaths among black women compared with white women. Knowledge of screening recommendations and access to free mammograms were not enough to get some low-income black women to keep their mammography appointments. Most of the women who skipped their appointments said they were embarrassed or believed that a mammogram was unnecessary if they did not have symptoms.
Source: Crump, Mayberry, Taylor, et al. J Nat Med Assoc 2000;92:237-46 (AHRQ grant HS07400).

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