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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Contents
Background
AHRQ-Sponsored Research
Breast Cancer
Cervical Cancer
Cancer Screening
More Information
Background
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 http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm.
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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