Mammography and Beyond Developing Technologies for the Early Detection of Breast Cancer (2001) / Chapter Skim
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6 Dissemination: Increasing the Use and Availability of New Technologies
6 Dissemination: Increasing the Use and Availability of New Technologies
Pages 199-220
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From page 199... ...
Medical technologies must also be readily available in their own communities if women are to take advantage of them. Even in the case of a highly accurate breast cancer screening tool, it would be truly effective only if it was widely available and acceptable to women and used routinely by them.
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From page 200... ...
As the results of the first randomized controlled trial for the assessment of mammography as a screening tool were published over a number of years, the real potential of mammography to reduce breast cancer mortality seemed to have been realized (about 30 percent fewer deaths among screened women than among unscreened controls for women over age 50~. The screening technology then began to diffuse more widely, in large part because of a demonstration project (a noncontrolled study)
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From page 201... ...
convened an expert panel for a consensus conference in 1977. The panel agreed that annual screening mammography of women over age 50 was appropriate but recommended that women ages 40 to 49 receive a screening mammogram only if they had previously had breast cancer or had a strong family history of breast cancer.
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From page 202... ...
for women ages mamma 50 and older NOTE: Abbreviations: ACS, American Cancer Society; ACR, American College of Radiol ogy; AMA, American Medical Association; NCI, National Cancer Institute; AAFP, Ameri
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From page 203... ...
.~. raphy Monthly BSE, Mammography Monthly BSE, Mammography -2 years annual CBE, and with or without annual CBE, every 2 years ten ages mammography CBE every 1-2 and for women ages elder years.
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From page 204... ...
Many reasons have been cited for the lack of breast cancer screening at recommended intervals, including limited access to health
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From page 205... ...
care and health insurance, lack of education and physician referral, pain or discomfort from the procedure, fear of what could be found, beliefs that mammograms are necessary only when symptoms arise, and inconvenience because of the location of the test facility (Baines et al., 1990; Rimer et al., 1989; Vernon et al., 1990~. Some women with disabilities have also found mammography facilities to be inaccessible to them (Haran, 2000)
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From page 206... ...
report, Ensuring Quality Cancer Care (Institute of Medicine, 1999~. The authors of that report concluded that the underuse of screening mammography to detect breast cancer early, in conjunction with lack of adherence to diagnostic standards and treatment regimens, leads to reduced survival rates and, in some cases, compromised quality of life.
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From page 207... ...
. Data are based on the National Vital Statistics System, National Center for Health Statistics.
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From page 208... ...
Very few studies have directly examined the breast cancer screening behaviors of immigrant women, but the available data suggest that the rates of screening among first-generation immigrants are significantly lower than the rates among women in other groups of the population (Wismar, 1999~. Language and cultural barriers can make it difficult for immigrant women to obtain information about screening tests, and immigrants often have limited access to health care and insurance, a major reason why women are not screened.
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From page 209... ...
Inconsistent and Conflicting Guidelines Practice guidelines for screening mammography have been developed by many different scientific and professional organizations (U.S. Preventive Services Task Force, 1996~.
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From page 210... ...
For women with adequate health insurance, screening mammography may still be unavailable if facilities are not readily accessible where they live (Katz and Hofer, 1994; Mandelblatt et al., 1995~. Women living in both rural and inner-city settings are less likely to undergo cancer screening than those living in other urban locations, which often have more mammogram facilities.
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From page 211... ...
In all areas of its work, the program seeks to collaborate with a variety of public and private organizations. The breast cancer screening and diagnostic services available through the program include clinical breast examinations, screening and diagnostic mammograms, breast ultrasound, fine-needle aspiration, and breast biopsy.
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From page 212... ...
To date, there have been few documented cases of breast screening facilities closing because of financial difficulties, but some anecdotal cases of breast screening facility closings have recently been reported (Brice, 2000~. Even if facilities are not closing, preliminary results from a recent survey of the Society of Breast Imaging (SBI)
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From page 213... ...
The SBI Residency Training Curriculum contains extensive and detailed lists of key concepts in 14 subject areas and recommends that residents be familiar with several texts. The SBI Curriculum Committee concluded that the program should require 3 full-time-equivalent months in breast imaging, interpretation of a minimum of 1,000 mammograms, and performance of breast ultrasound and needle localization.
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From page 215... ...
Second, jury verdicts in medical malpractice claims and insurance settlements based on predictions of jury decisions may reflect a change in public expectations. The negligence basis (Box 6-3)
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From page 216... ...
Furthermore, juries often idealistically believe that medical technologies should be used whenever a patient might possibly benefit, even if the probability is quite low (Havighurst, 1998~. Most medical malpractice claims for breast cancer are due to missed diagnoses.
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From page 217... ...
POTENTIAL FOR RISK-BASED SCREENING Since the time of the first randomized clinical trial conducted to evaluate screening mammography, questions have been raised about whether risk stratification could be used to identify populations for which screening would be most beneficial. The goal of risk profiling is to identify groups with a significantly higher or a significantly lower risk for breast cancer than that for the general population and to develop different screening strategies based on that risk.
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From page 218... ...
Much of the effort has focused on women with dense breast tissue, a characteristic associated with an increased risk for breast cancer (Byng et al., 1998) , as well as the reduced accuracy of screening mammography (Mandelson et al., 1995~.
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From page 219... ...
will have on patient demand and dissemination is as yet unknown, but it is likely to be significant. SUMMARY Use of screening mammography has increased greatly in the last decade, but it has not been universally adopted and accepted by women.
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From page 220... ...
Although data are unavailable to confirm or refute such concerns, some suggest that the potential threats to future screening services may include the financial difficulties of some screening facilities, high rates of medical malpractice claims for missed breast cancer diagnosis, and anecdotal reports of a downward trend in the numbers of individuals enrolled in training programs in breast imaging. Lessons learned from the adoption and dissemination of mammography may be informative as new technologies become available.
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