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Women's Health Highlights: Recent Findings

Program Brief

The vigorous intramural and extramural research program of the Agency for Healthcare Research and Quality (AHRQ) focuses principally on health care quality and the outcomes of health care services. Examples of AHRQ's current and completed research projects concerning conditions especially important to women are described below.

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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. Today, the chronic conditions of heart disease, cancer, and stroke account for 63 percent of American women's deaths and are 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 disability at the end of life.

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 better health care decisions.

This summary presents findings from a cross-section of AHRQ-supported research projects on women's health published January 2005 through December 2008. An asterisk (*) at the end of a summary indicates that reprints of an intramural study or copies of other publications are available from AHRQ.

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Cardiovascular Disease

Heart disease is the number one killer of women in the United States. More than one-fourth of all deaths among U.S. women are due to heart disease, which usually occurs about 10 years later in life in women than in men. Heart disease mortality differs substantially among women of different races.

Process-of-care variables may explain some of the male-female differences in cardiovascular disease outcomes.
Researchers analyzed seven cardiovascular disease (CVD) quality of care indicators in a national sample of managed care plans and found inadequate lipid control in both men and women, with a lower rate of control in women. Also, women with diabetes were 19 percent less likely than men to have their LDL cholesterol controlled; women with a history of CVD were 28 percent less likely than men to have their LDL cholesterol controlled. More women than men had their blood pressure controlled, although the difference was small (2 percent). Chou, Scholle, Weisman, et al., Women's Health Issues 17:120-30, 2007 (AHRQ contract 290040018).
Commercial health plans show disparities between women and men in cardiovascular care.
Researchers evaluated plan-level performance of seven quality of care measures for CVD and found that over half of the plans showed a disparity of 5 percent or more in favor of men for cholesterol control measures among people with diabetes, a recent CVD procedure, or heart attack. The greatest disparity (9.3 percent in favor of men) was among those with recent acute cardiac events; none of the plans showed disparities in favor of women. Disparities between women and men were even greater among Medicare managed care plans. Chou, Wong,Weisman, et al., Women's Health Issues 17:139-49, 2007 (AHRQ contract 290-04-0018). See also Bird, Fremont, Bierman, et al., Women's Health Issues 17:131-38, 2007 (AHRQ contract 290-00-0012).
Among heart disease patients, women are less likely than men to use low-dose aspirin therapy.
Use of a low-dose aspirin regimen reduces the risk of heart attack, stroke, and other vascular events and reduces heart disease deaths. Although daily aspirin is recommended for all patients with cardiovascular disease unless contraindicated, women with heart disease are less likely than men with heart disease to use aspirin regularly, according to this study. Researchers examined data on 1,869 men and women aged 40 or older who reported heart disease prior to a heart attack. After adjusting for demographic, socioeconomic, and clinical characteristics, 62 percent of women reported regular aspirin use, compared with 76 percent of men. Opotowsky, McWilliams, and Cannon, J Gen Intern Med 22:55-61, 2007 (AHRQ grant T32 HS00020).
Women continue to fare worse than men in treatment for heart attack and congestive heart failure.
According to this study of gender disparities among adults age 65 and older, women with acute myocardial infarction (AMI) or congestive heart failure (CHF) do not receive the same care as men. Also, women or men who have other medical conditions associated with AMI or CHF—such as diabetes, hypertension, or end-stage renal disease—do not receive better quality of cardiovascular care than those who have only the heart conditions. Correa-de-Araujo, Stevens, Moy, et al., Women's Health Issues 16(2):44-55, 2006 (AHRQ Publication No. 06-R042)* (Intramural).
Immunosuppression related to transfusion may explain women's increased risk of dying after CABG surgery.
A study of more than 9,000 Michigan Medicare patients found that women undergoing coronary artery bypass graft (CABG) surgery were 3.4 times as likely as men to have received blood transfusions and generally received more units of blood, after accounting for age, coexisting conditions, and other factors. Patients who received a transfusion were more than three times as likely to develop an infection as those who did not, and they were 5.6 times as likely to die within 100 days after surgery. The presence of foreign leukocytes in donor blood may suppress the immune system of the recipient and thus increase the risk of postoperative infection, note the researchers. Rogers, Blumberg, Saint, et al., Am Heart J 152:1028-34, 2006 (AHRQ grant HS11540).
Women with atherosclerosis and high cholesterol receive less intense cholesterol management than men.
The researchers examined cholesterol management of 243 primary care patients from one academic medical center. The patients had coronary heart disease, cerebrovascular disease, or peripheral vascular disease and high (over 130 mg/dl) low-density (bad) cholesterol. Cholesterol management by either medication adjustments or LDL monitoring occurred at 31.2 percent of women's visits and 38.5 percent of men's visits. Women were 23 percent less likely than men to have their cholesterol managed. Persell, Maviglia, Bates, and Ayanian, J Gen Intern Med 20:123-30, 2005 (AHRQ grant T32 HS00020)

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Cancer Screening and Treatment

Breast cancer continues to be the most commonly diagnosed cancer among women in the United Sates. 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 recently among white women in this country; the bad news is that over the same period, survival has decreased among black women. 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.

Breast Cancer

Several factors affect the accuracy of mammogram interpretation.
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. Taplin, Abraham, Barlow, et al., J Natl Cancer Inst 100(12):876-87, 2008 (AHRQ grant HS10591). See also Miglioretti, Smith-Bindman, Abraham, et al., J Natl Cancer Inst 99(24):1854-63, 2007 (AHRQ grant HS10591).
Lesions overlooked on mammograms represent missed opportunities for early diagnosis.
Among women with breast cancers that are diagnosed between routine screening mammograms, 10 to 20 percent have lesions that were visible but overlooked at their previous exam, and a similar percentage have lesions that were misinterpreted at the previous exam. 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. Elmore and Brenner, J Natl Cancer Inst 99(15):1141-43, 2007 (AHRQ grant HS10591).
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. Although every demographic group was affected, black women and women with lower incomes and educations levels often were covered by plans that required cost-sharing. Trivedi, Rakowski, and Ayanian, N Engl J Med 358(4):375-83, 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. The researchers recommend that clinical judgment be used before extensive and potentially deforming breast resections are performed. Neuman, Brogi, Ebrahim, et al., Ann Surg Oncol 15(1):274-80, 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 109:379-87, 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).
Report discusses impact of several gene expression profiling tests for breast cancer patients.
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. Impact of Gene Expression Profiling Tests on Breast Cancer Outcomes, Evidence Report/Technology Assessment No. 160 (AHRQ Publication No. 08E002)* (AHRQ contract 290-02-0018). Available online at http://www.ahrq.gov/clinic/tp/brcgenetp.htm.
Noninvasive tests may miss breast cancer.
This report indicates that four common noninvasive tests for breast cancer are not accurate enough to replace biopsies for women who receive abnormal findings from mammography or a clinical breast exam. Researchers found that each of the four tests—magnetic resonance imaging (MRI), ultrasonography (ultrasound), positron emission tomography scanning (PET scan), and scintimammography (nuclear medicine scan)—would miss a significant number of cases of cancer, compared with immediate biopsy, in women at high enough risk to warrant evaluation for breast cancer. Effectiveness of Noninvasive Diagnostic Tests for Breast Abnormalities, Executive Summary No. 2 (AHRQ Publication No. 06-EHC005-1)* and online at http://effectivehealthcare.ahrq.gov.
Radiation therapy for a primary cancer that develops in a second breast may offer a survival benefit.
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. 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):125-32, 2008 (AHRQ grant HS16743); and Schootman, Fuortes, and Aft, Breast Cancer Res Treat 99:91-5, 2006 (AHRQ grant HS14095).
Some women do not receive recommended adjuvant therapy for breast cancer.
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. Bickell, LePar, Wang, and Leventhal, J Clin Oncol 25(18):2516-21, 2007 (AHRQ grant HS10859). See also Anderson and Carlson, J Natl Compr Canc Netw 5(3):349-56, 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.
Women newly diagnosed with early-stage breast cancer usually can choose between mastectomy and breast-conserving surgery (lumpectomy) followed by radiation. 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. Surgery Choices for Women with Early-Stage Breast Cancer (AHRQ Publication No. PHS 04-M053, English; AHRQ 05-0031, Spanish)* (Intramural). Available online at http://www.ahrq.gov/consumer/brcanchoice.htm.
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):162-70, 2008 (AHRQ grant T32 HS00032).
Death and complications following breast cancer surgery are rare.
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. El-Tamer, Ward, Schifftner, et al., Ann Surg 245(5):665-71, 2007 (AHRQ grant HS11913).
Breast screening is less common in counties that have many uninsured women.
Researchers used data from two large surveillance systems to determine whether screening for breast cancer varied by the proportion of uninsured women in the community. The data showed that as the rate of uninsurance in a community increased by 5 percent, women were 5 percent less likely to receive either clinical breast exams or mammograms. Breast cancer screening declined significantly for women earning $25,000 to $75,000 who lived in counties with high rates of uninsurance. On the other hand, black women and Hispanic women had higher screening rates than white women when they lived in communities with low rates of uninsurance. Schootman, Walker, Jeffe, et al., Am J Prevent Med 33(5):379-86, 2007 (AHRQ grant HS14095).
Women aged 40 to 49 were responsive to changes in mammography recommendations.
According to interviews with 1,451 women who received screening mammograms at one of five hospital-based clinics between October 1996 and January 1998, opinions about mammography have changed among women aged 40 to 49. Prior to the issuance of recommendations by the American Cancer Society and the National Cancer Institute that women aged 40 to 49 should receive screening mammograms every 1 or 2 years, only 49 percent of women in this age group endorsed annual screening. After the new recommendations were issued, 64 percent of women in this age group endorsed annual screening. Calvocoressi, Sun, Kasl, et al., Cancer 120(3):473-80, 2008 (AHRQ grant HS11603).
Immediate reading of mammograms and followup on false-positive results reduce anxiety among women.
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. Stewart, Neumann, Fletcher, and Barton, Health Serv Res 42(4):1464-82, 2007 (AHRQ Publication No. 07-R067)* (Intramural).
Depression hinders recovery of older breast cancer patients.
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. Caban, Freeman, Zhang, et al., Clin Rehabil 20:513-22, 2006 (AHRQ grant HS11618).
Poor communication of mammogram results may explain disparities in breast cancer diagnosis and outcomes.
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. Jones, Reams, Calvocoressi, et al., Am J Public Health 97(3):531-8, 2007 (AHRQ grant HS11603). See also Dailey, Kasl, Holford, and Jones, Am J Epidemiol 165(11):1287-95, 2007 (AHRQ grant HS15686).
Physician communication style may depend on characteristics of breast cancer patients.
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. Siminoff, Graham, and Gordon, Patient Educ Counsel 62:355-60, 2006 (AHRQ grant HS08516).
Breast and gynecologic cancers account for one-fourth of all cancer hospitalizations among women.
This publication summarizes findings on hospital use, outpatient surgery use, hospital charges, and changing practice patterns for the care of breast and gynecologic cancers in U.S. women. The information is based on inpatient hospital discharge data and outpatient ambulatory surgery data from AHRQ's Healthcare Cost and Utilization Project (HCUP) and covers the period 1993-2003. Hospital and Ambulatory Surgery Care for Women's Cancers, HCUP Highlights No. 2 (AHRQ Publication No. 06-0038).*
More radiologists are needed at community mammography facilities.
In a 2000-2001 survey of mammography facilities in three States, nearly half of the 45 facilities reported radiologist staffing shortages. Almost two-thirds (60 percent) of not-for-profit facilities reported shortages, compared with less than one-third (28 percent) of for-profit facilities. Waiting times for diagnostic mammography ranged from less than 1 week to 4 weeks. Forty-seven percent of facilities had a waiting time of 2 or more weeks for screening mammography, and some had waiting times of 1 to 2 months. D'Orsi, Tu, Nakano, et al., Radiology 235:391-395, 2005 (AHRQ grant HS10591).
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.ahrq.gov/clinic/uspstf/uspsbrca.htm (Intramural).
Task Force recommends against routine testing for genetic risk of breast or ovarian cancer.
According to the U.S. Preventive Services Task Force, primary care physicians should only refer certain women for genetic counseling and DNA testing to detect the presence of specific BRCA1 and BRCA2 gene mutations that may be associated with breast and ovarian cancer. Physicians should suggest counseling and DNA testing only for women who have specific family history patterns that put them at risk for these gene mutations. Nelson, Huffman, Fu, and Harris, Ann Intern Med 143(5):362-79, 2005; see also pages 355-61 in the same journal (AHRQ contract 290-97-0011).

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