Program Brief
The Agency for Healthcare Research and Quality (AHRQ) supports a vigorous extramural and intramural research program focusing principally on health care quality, patient safety, and the outcomes of health care services. This program brief summarizes recent findings from AHRQ supported research related to cancer screening and treatment in women.
This program brief summarizes findings from research projects focused on cancer in women sponsored by the Agency for Healthcare Research and Quality (AHRQ).
Select to download print version PDF File (365 KB). PDF help.
Contents
Background
AHRQ-Sponsored Research
Breast Cancer
Cervical Cancer
Breast and Cervical/Ovarian Cancer
Other Cancers
Cancer Screening and Diagnosis
More Information
Background
Breast cancer continues to be the most commonly diagnosed cancer among women in the United States. 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 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 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. 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
The Agency for Healthcare Research and Quality (AHRQ) supports a vigorous women's health research program, including research focused on breast cancer, cervical cancer, and other cancers in women. 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.
Following are examples of findings from AHRQ-supported research projects focused on cancer in women published January 2005 through December 2008. An asterisk (*) indicates that reprints of an intramural study or copies of other publications are available from AHRQ. Refer to the end of this fact sheet to find out how you can get more detailed information on AHRQ's research programs and funding opportunities.
Breast Cancer
Several factors affect the accuracy of mammogram interpretation.
Description: 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.
Source: Taplin, Abraham, Barlow, et al., J Natl Cancer Inst 100(12):876-887, 2008 (AHRQ grant HS10591). Also go to Miglioretti, Smith-Bindman, Abraham, et al., J Natl Cancer Inst 99(24):1854-1863, 2007 (AHRQ grant HS10591).
Lesions overlooked on mammograms represent missed opportunities for early diagnosis.
Description: From 10 to 20 percent of women diagnosed with breast cancer had lesions that were visible but overlooked on their most recent mammograms, and another 10 to 20 percent had lesions that were misinterpreted. 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.
Source: Elmore and Brenner, J Natl Cancer Inst 99(15):1141-1143, 2007 (AHRQ grant HS10591).
Breast desmoid tumors are rare and often mistaken for cancer.
Description: 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.
Source: Neuman, Brogi, Ebrahim, et al., Ann Surg Oncol 15(1):274-280, 2008 (AHRQ grant T32 HS00066).
More attention is needed to quality of life for breast cancer survivors.
Description: Researchers examined quality of life among women with (114 women) and 2 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.
Source: Trentham-Dietz, Sprague, Klein, et al., Breast Cancer Res 109:379-387, 2008 (AHRQ grant HS06941).
Study underway to develop computer-based tools to improve use of genetic breast cancer tests.
Description: 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 treated 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.
Source: 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.
Description: 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.
Source: Impact of Gene Expression Profiling Tests on Breast Cancer Outcomes, Evidence Report/Technology Assessment No. 160 (AHRQ Publication No. 08-E002)* (AHRQ contract 290-02-0018) and online at http://www.ahrq.gov/clinic/tp/brcgenetp.htm.
Radiation therapy for a primary cancer that develops in a second breast may offer a survival benefit.
Description: 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.
Source: Schootman, Jeffe, Gillanders, et al., Breast Cancer Res Treat 103:77-83, 2007 (AHRQ grant HS14095). Go also to Du, Fan, and Meyer, Am J Clin Oncol 31(2):125-132, 2008 (AHRQ grant HS16743); and Schootman, Fuortes, and Aft, Breast Cancer Res Treat 99:91-95, 2006 (AHRQ grant HS14095).
Some women do not receive recommended adjuvant therapy for breast cancer.
Description: 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.
Source: Bickell, LePar, Wang, and Leventhal, J Clin Oncol 25(18):2516-2521, 2007 (AHRQ grant HS10859). Go also to Anderson and Carlson, J Natl Compr Canc Netw 5(3):349-356, 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.
Description: Women newly diagnosed with early-stage breast cancer usually can choose between breast-conserving surgery (lumpectomy) followed by radiation and mastectomy. 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.
Source: Surgery Choices for Early-Stage Breast Cancer (AHRQ Publication No. PHS 04-M053, English; 05-0031, Spanish)* (Intramural).
Race, age, and other factors affect degree of pain among women with breast cancer.
Description: 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.
Source: Castel, Saville, DePuy, et al., Cancer 112(1):162-170, 2008 (AHRQ grant T32 HS00032).
Death and complications following breast cancer surgery are rare.
Description: 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.
Source: El-Tamer, Ward, Schifftner, et al., Ann Surg 245(5):665-671, 2007 (AHRQ grant HS11913).
Immediate reading of mammograms and followup on false-positive results reduce anxiety among women.
Description: 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.
Source: Stewart, Neumann, Fletcher, and Barton, Health Serv Res 42(4):1464-1482, 2007 (AHRQ Publication No. 07-R067)* (Intramural).
Depression hinders recovery of older breast cancer patients.
Description: 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.
Source: Caban, Freeman, Zhang, et al., Clin Rehabil 20:513-522, 2006 (AHRQ grant HS11618).
Poor communication of mammogram results may explain disparities in breast cancer diagnosis and outcomes.
Description: 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.
Source: Jones, Reams, Calvocoressi, et al., Am J Public Health 97(3):531-538, 2007 (AHRQ grant HS11603). Go also to Dailey, Kasl, Holford, and Jones, Am J Epidemiol 165(11):1287-1295, 2007 (AHRQ grant HS15686).
Physician communication style may depend on characteristics of breast cancer patients.
Description: 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.
Source: Siminoff, Graham, and Gordon, Patient Educ Counsel 62:355-360, 2006 (AHRQ grant HS08516).
Return to Contents
Cervical Cancer
Instituting new processes can reduce diagnostic errors in Pap smear interpretation.
Description: Lean methods are used to weigh the expenditure of resources against value received. For this study, researchers compared the diagnostic accuracy of Pap tests procured by five clinicians before (5,384 controls) and after (5,442 cases) implementing a process redesign using Lean methods. Following process redesign, there was a significant improvement in Pap smear quality, and the case group showed a 114 percent increase in newly detected cervical intraepithelial cancer following a previous benign Pap test.
Source: Raab, Andrew-Jaja, Grzybicki, et al, J Low Genit Tract Dis 12(2):103-110, 2008 (AHRQ grant HS13321).
Despite new guidelines, most ob-gyns continue to over-screen low-risk women for cervical cancer.
Description: The American Cancer Society suggests that cervical cancer screening with Pap tests begin within 3 years after a woman becomes sexually active or by age 21, whichever comes first. The ACS no longer recommends annual screening in women over age 30 who have had three or more previous normal Pap tests. The American College of Obstetricians and Gynecologists has made similar recommendations. Yet, 185 randomly selected ob-gyns said that they would begin screening girls who were not yet sexually active at age 18. Also, 60 percent of respondents said that they would continue annual screening in a 35-year-old woman with three or more normal tests.
Source: Saint, Gildengorin, and Sawaya, Am J Obstet Gynecol 192:414-421, 2005 (AHRQ grant HS07373).
Return to Contents
Breast and Cervical/Ovarian Cancer
Less access to effective treatment may explain poorer survival of elderly black women with ovarian cancer.
Description: Researchers studied 5,131 elderly women diagnosed with ovarian cancer between 1992 and 1999 with up to 11 years of followup. Overall, 72 percent of white women and 70 percent of black women were diagnosed with stage III or IV (advanced) disease. Among those with stage IV disease, those who underwent ovarian surgery and received adjuvant chemotherapy were 50 percent less likely to die during the followup period compared with those who did not, regardless of race. However, fewer blacks received chemotherapy than whites (50 vs. 65 percent, respectively).
Source: Du, Sun, Milam, et al., Int J Gynecol Cancer 18:660-669, 2008 (AHRQ grant HS16743).
Evidence does not support use of genomic tests to detect ovarian cancer.
Description: According to this scientific review, there is no evidence relevant to the impact of genomic tests for ovarian cancer on health outcomes in asymptomatic women. The researchers used model simulations to predict the usefulness and efficacy of genomic tests for ovarian cancer. The model simulations suggest that annual screening, even with a highly sensitive test, will not reduce ovarian cancer mortality, and that frequent screening has a very low positive predictive value.
Source: Genomic Tests for Ovarian Cancer Detection and Management, Evidence Report/Technology Assessment No. 145 (AHRQ Publication No. 07-E001)* (AHRQ Contract 290-02-0025) and online at http://www.ahrq.gov/clinic/tp/genovctp.htm.
Breast and gynecologic cancers account for one-fourth of all cancer hospitalizations among women.
Description: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.
Source: Hospital and Ambulatory Surgery Care for Women's Cancers, HCUP Highlights No. 2 (AHRQ Publication No. 06-0038)* and online at http://www.ahrq.gov/data/hcup/highlight2/high2.htm.
Despite new guidelines, most ob-gyns continue to overscreen low-risk women for cervical cancer.
Description: The American Cancer Society suggests that cervical cancer screening with Pap tests begin within 3 years after a woman becomes sexually active or by age 21, whichever comes first. The ACS no longer recommends annual screening in women over 30 who have had three or more previous normal Pap tests. The American College of Obstetricians and Gynecologists has made similar recommendations. Yet 185 randomly selected ob-gyns said that they would begin screening girls who were not yet sexually active at age 18. Also, 60 percent of respondents said that they would continue annual screening in a 35-year-old woman with three or more normal tests.
Source: Saint, Gildengorin, and Sawaya, Am J Obstet Gynecol 192:414-421, 2005 (AHRQ grant HS07373)
Return to Contents
Proceed to Next Section
540 Gaither Road Rockville, MD 20850