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Objective Decision-making at menopause remains a challenge for women and their health care providers as the paradigm for hormone therapy continues to evolve. The role of decision-support for this process remains to be defined. Methods A randomized controlled trial of a computer-based hormone therapy (HT) decision-aid versus a control intervention consisting of a printed pamphlet among 177 post-menopausal women receiving care in a Veterans Affairs Medical Center. Results Participants found the computer-based decision-aid easy to use and retained risk information incorporated from emerging scientific data. There was no difference between groups with respect to the primary outcomes of knowledge, satisfaction with decision, decisional conflict or HT use. A trend was reported towards decreased decisional conflict in the evidence in decision-making ( p =0.07) and factors of uncertainty ( p =0.06) domains among the subset of participants who were on HT at baseline and used the computer-based decision-aid. Conclusion The computer-based decision-aid was able to effectively incorporate emerging scientific information but was no more effective than a printed pamphlet control with regard to improving decision-process outcomes. Practice implications The incremental benefit of a complex versus simpler decision-aid for post-menopausal women remains to be established prior to widespread dissemination of interactive computer-based HT decision-aids.

Objectives. We examined the association between number of breast cancer operations performed in a hospital (hospital volume) and all-cause and breast cancer–specific mortality using a national database and statistical methods appropriate for clustering and reducing confounding. Methods. In a retrospective cohort study, we linked Surveillance, Epidemiology, and End Results tumor registry data with Medicare claims data. The cohort included 11225 Medicare patients who had undergone surgery for early-stage breast cancer from 1994 to 1996 in 457 different hospitals. Primary outcomes were all-cause and breast cancer–specific survival rates at a mean follow-up time of 62.5 months. Results. In comparison with treatment in a low-volume hospital, treatment in a high-volume hospital was associated with hazard ratios of 0.83 (95% confidence interval [CI]=0.75, 0.92) for all-cause mortality and 0.80 (CI=0.66, 0.97) for breast cancer–specific mortality. Conclusions. An association between the volume of breast cancer operations performed in a hospital and 5-year survival rates was observed for both all-cause and breast cancer–specific mortality. Further work investigating the aspects of hospital volume that contribute to increased survival is warranted.

A multi-attribute utility (MAU) decision model for menopausal hormone replacement therapy (HRT) was developed using structured interviews (n=40) to identify decision factors, and a telephone survey (n=97) to ascertain utility scores. Utility scores for individual factors and composite scores reflecting the HRT decision were compared according to HRT use. Composite utility scores (range of -1.0 to 1.0, with higher values supporting HRT use) were 0.55, -0.27, and -0.19 for the 48 HRT users, 23 former users, and 26 never users, respectively (P

The large-scale Women's Health Initiative has confirmed that, in postmenopausal women, combined estrogen/ progestin therapy entails an increased risk of invasive breast cancer. The investigators have now explored this relationship in detail, characterizing the cancers that developed and seeking to learn whether hormonal effects on the mammogram can influence diagnosis. A total of 16,608 postmenopausal women 50 to 79 years of age, all with an intact uterus, were randomly assigned to receive active treatment (0.625 mg conjugated equine estrogens plus 2.5 mg medroxyprogesterone acetate daily in a single tablet) or placebo. The participants, seen at 40 clinical centers, were to be followed from 1993 to 1998 by annual clinical breast examinations and mammograms, but the trial was ended after a mean interval of 5.2 years. Intent-to-treat analyses demonstrated a hazard ratio of 1.24 for both total cancers and invasive cancers in women given hormone therapy compared with the placebo group. There was some suggestion of an increased risk for in situ breast cancer in hormone-treated women. An increased risk of breast cancer in treated women emerged after 3 years in those not receiving hormones previously and after 2 years in previously treated women. The findings were similar when women in specific risk categories were analyzed, and race and ethnicity were not significant factors. Invasive cancers associated with combined hormone therapy were larger than those in placebo recipients, more likely to be node-positive, and diagnosed when more advanced. There was, however, no difference in tumor grade or in the distribution of histologic types of breast cancer. After the first year, hormone-treated women more often had abnormal or highly suspicious mammograms than did those given placebo. In this prospective, randomized trial, combined estrogen/progestin treatment of postmenopausal women increased both breast cancer risk and the frequency of abnormal mammograms requiring medical assessment. In addition, cancers in treated women were more advanced when diagnosed than was the case for placebo recipients.

Health numeracy is associated with increased understanding of cancer risk reduction information and improved control of chronic disease. A cross-sectional survey was conducted among a primary care population to evaluate the effect of health numeracy on breast, cervical, and colorectal cancer screening. No association was found between health numeracy and cancer screening. However, at a baseline screening rate of 85%, increased knowledge (RR 1.06, 95% CI 1.02–1.08) and decreased perceived barriers (RR 0.93, 95% CI 0.92–0.95) were associated with increased screening rates. In conclusion, health numeracy was not predictive of cancer screening among a primary care population.

Our objective of this study is to develop a conceptual framework for the construct of health numeracy based on patient perceptions, using a cross-sectional, qualitative design. Interested participants (n=59) meeting eligibility criteria (age 40-74, English speaking) were assigned to one of six focus groups stratified by gender and educational level (low, medium, high). Fifty-three percent were male, and 47% were female. Sixty-one percent were white non-Hispanic, and 39% were of minority race or ethnicity. Participants were randomly selected from three primary care sites associated with an academic medical center. Focus group discussions were held in May 2004 and focused on how numbers are used in the health care setting. Data were presented from clinical trials to further explore how quantitative information is used in health communication and decision making. Focus groups were audio and videotaped; verbatim transcripts were prepared and analyzed. A framework of health numeracy was developed to reflect the themes that emerged. Three broad conceptual domains for health numeracy were identified: primary numeric skills, applied health numeracy, and interpretive health numeracy. Across domains, results suggested that numeracy contains an emotional component, with both positive and negative affect reflected in patient numeracy statements. We conclude that health numeracy is a multifaceted construct that includes applied and interpretive components and is influenced by patient affect.

The effect of combined hormone therapy on breast cancer detection is not established.We examined the effect of combined hormone therapy on breast cancer detection in the Women's Health Initiative trial, which randomized 16,608 postmenopausal women to receive conjugated equine estrogens (0.625 mg/d) plus medroxyprogesterone acetate (2.5 mg/d) or placebo. Mammography and breast examinations were performed at baseline and annually per protocol, with breast biopsies based on clinical findings. The effects of conjugated equine estrogens plus medroxyprogesterone acetate on breast cancer detection was determined throughout 5.6 years of intervention using receiver operating characteristic analyses to evaluate mammography results.Conjugated equine estrogens plus medroxyprogesterone acetate increased the cumulative frequency of mammograms with abnormalities vs placebo (35.0% vs 23.0%; P.001), which had less sensitivity for cancer detection and increased cumulative breast biopsy frequency (10.0% vs 6.1%; P.001). Although breast cancers were significantly increased and were diagnosed at higher stages in the combined hormone group, biopsies in that group less frequently diagnosed cancer (14.8% vs 19.6%; P = .006). After discontinuation of combined hormone therapy, its adverse effect on mammograms modulated but remained significantly different from that of placebo for at least 12 months (P.001).Use of conjugated equine estrogens plus medroxyprogesterone acetate for approximately 5 years resulted in more than 1 in 10 and 1 in 25 women having otherwise avoidable mammogram abnormalities and breast biopsies, respectively, and compromised the diagnostic performance of both. This adverse effect on breast cancer detection should be incorporated into risk-benefit discussions with women considering even short-term combined hormone therapy.clinicaltrials.gov Identifier: NCT00000611.

Background:Arelationshipbetweenhighersurgeonvolume and lower mortality has been described for breast cancer, but selection bias has not been rigorously evaluated. We studied potential bias in the surgeon volume– outcome relationship by comparing the relationship of surgeon volume to breast cancer mortality and to mortality from other causes of death. Methods:We conducted an observational cohort study from tumor registry and Medicare claims data on 12216 women, 66 years or older, with stage I or II breast cancer,whowereoperatedonby1856surgeons.Breastcancer mortality and other-cause mortality were determinedfromdeathcertificatesourcesandsurgeonvolume from Medicare claims. Results: Treatment by a high-volume surgeon was associated with younger patient age, white race, less comorbidity, and residence in a more affluent zip code. Patients treated by low-, medium-, and high-volume surgeons had small differences in breast cancer mortality (17.4, 15.7, and 13.0 deaths per 1000 person-years, respectively; P=.03) but larger differences in non– breast cancer mortality (46.0, 36.8, and 31.7 deaths per 1000 person-years, respectively; P.001). After adjustment for multiple patient and disease factors, women treated by high-volume surgeons, compared with those treated by low-volume surgeons, were not less likely to die of breast cancer (relative risk, 0.94; 95% confidence interval, 0.76-1.16) but were significantly less likely to die of other causes (relative risk, 0.86; 95% confidence interval, 0.75-0.98). Conclusions: The surgeon volume–outcome relationship for these patients with breast cancer was attributablenottomortalityfrombreastcancerbuttoothercauses of death. The lack of specificity of this relationship raises the possibility of selection bias as an explanatory factor.

Hypothesis Adherence to National Institutes of Health consensus statement recommendations for early-stage breast cancer will vary by surgeon characteristics. Design Secondary data analysis using the Surveillance, Epidemiology, and End Results national tumor registry linked with Medicare claims data. Logistic regression was used to analyze data on a cohort of 1045 surgeons who operated on 9449 Medicare patients with early-stage breast cancer. Main Outcome Measure Care adherent to the 1990 National Institutes of Health consensus statement recommendations. Results Surgeon age and specialty were not associated with adherent care overall, nor among breast-conserving surgery or mastectomy subgroups. Patients of higher-volume surgeons were significantly more likely to undergo adherent care overall because of greater use of lymph node dissection among women who received either breast-conserving surgery or mastectomy. Patients of female surgeons and surgeons with a medical school affiliation were less likely to undergo adherent care overall, which was related to greater use of breast-conserving surgery and lesser use of lymph node dissection among patients who underwent breast-conserving surgery. Conclusions Several surgeon characteristics are significantly associated with variations in breast cancer treatment received. These results warrant further investigation into the association between these surgeon characteristics and cancer care outcomes.

BACKGROUND Physician volume of at least 15–30 annual breast cancer operations has been associated with higher 5-year survival rates. The authors sought to determine whether surgical volumes for breast cancer in the United States frequently reach this threshold. METHODS The authors conducted a retrospective cohort study of 987 surgeons who operated on 8105 Medicare patients with breast cancer during 1994–1995 in 6 areas in the Surveillance, Epidemiology and End Results tumor registry. The 2-year physician volume of breast cancer operations was estimated among Medicare patients (approximating the on-average annual volumes for patients of all ages) and its association was examined with physician characteristics and with 3 measures of surgical care. RESULTS The median 2-year Medicare volume for breast cancer surgeons was 6, and 79% of physicians performed ≤ 12 operations. Approximately 50% of patients were cared for by physicians who performed ≤ 12 operations over 2 years, and 10% of patients were cared for by physicians who performed ≥ 30 operations. Surgeon characteristics of age, female gender, general surgery board certification, and academic affiliation were associated with modestly higher volumes of breast cancer surgery. Higher surgeon volumes were associated with higher patient receipt of breast-conserving surgery, testing for hormone receptors, and lymph node dissection during mastectomy. CONCLUSIONS Most physicians who perform breast cancer surgery perform few annual operations in Medicare patients, and lower volumes are associated with differences in surgical processes of care. Because patients in the Medicare age group comprise almost 50% of all incident breast cancer cases, surgical volumes for patients of all ages also are likely to be low. It is likely that only approximately 10% of patients in the United States are treated by surgeons who performing at least 30 annual operations. Cancer 2004. © 2004 American Cancer Society.

There is increasing demand for prediction of individual women's risk for breast cancer from women, clinicians, researchers, and health planners. Risk assessment for breast cancer is the process of identifying characteristics of an individual woman that are relevant to her risk, and combining those characteristics into a quantitative or qualitative risk profile. This article reviews and compares available methods of predicting risk, discusses benefits and drawbacks to the methods, and compares risk estimates for several hypothetical subjects using the different methods. Current and future uses for risk assessment are described. Risk assessment, while a promising tool for research now, and for clinical areas in the future, is still too imprecise for accurate prediction of breast cancer occurrence in individuals.

ContextThe Women's Health Initiative trial of combined estrogen plus progestin was stopped early when overall health risks, including invasive breast cancer, exceeded benefits. Outstanding issues not previously addressed include characteristics of breast cancers observed among women using hormones and whether diagnosis may be influenced by hormone effects on mammography.ObjectiveTo determine the relationship among estrogen plus progestin use, breast cancer characteristics, and mammography recommendations.Design, Setting, and ParticipantsFollowing a comprehensive breast cancer risk assessment, 16 608 postmenopausal women aged 50 to 79 years with an intact uterus were randomly assigned to receive combined conjugated equine estrogens (0.625 mg/d) plus medroxyprogesterone acetate (2.5 mg/d) or placebo from 1993 to 1998 at 40 clinical centers. Screening mammography and clinical breast examinations were performed at baseline and yearly thereafter.Main Outcome MeasuresBreast cancer number and characteristics, and frequency of abnormal mammograms by estrogen plus progestin exposure.ResultsIn intent-to-treat analyses, estrogen plus progestin increased total (245 vs 185 cases; hazard ratio [HR], 1.24; weighted P