Seven statistical models showed that both screening mammography and treatment have helped reduce the rate of death from breast cancer in the United States.

First implemented in 1990, patient navigation interventions are emerging today as an approach to reduce cancer disparities. However, there is lack of consensus about how patient navigation is defined, what patient navigators do, and what their qualifications should be. Little is known about the efficacy and cost-effectiveness of patient navigation. For this review, the authors conducted a qualitative synthesis of published literature on cancer patient navigation. By using the keywords 'navigator' or 'navigation' and 'cancer,' 45 articles were identified in the PubMed database and from reference searches that were published or in press through October 2007. Sixteen studies provided data on the efficacy of navigation in improving timeliness and receipt of cancer screening, diagnostic follow-up care, and treatment. Patient navigation services were defined and differentiated from other outreach services. Overall, there was evidence of some degree of efficacy for patient navigation in increasing participation in cancer screening and adherence to diagnostic follow-up care after the detection of an abnormality. The reported increases in screening ranged from 10.8% to 17.1%, and increases in adherence to diagnostic follow-up care ranged from 21% to 29.2% compared with control patients. There was less evidence regarding the efficacy of patient navigation in reducing either late-stage cancer diagnosis or delays in the initiation of cancer treatment or improving outcomes during cancer survivorship. There were methodological limitations in most studies, such as a lack of control groups, small sample sizes, and contamination with other interventions. Although cancer-related patient navigation interventions are being adopted increasingly across

Background Despite trials of mammography and widespread use, optimal screening policy is controversial. Design and Objective Six models use common data elements to evaluate US screening strategies. Data Sources The models use national data on age-specific incidence, competing mortality, mammography characteristics and treatment effects. Target Population and Time Horizon A contemporary population cohort followed over their lifetimes. Perspective We use a societal perspective for analysis. Interventions We evaluate 20 screening strategies with varying initiation and cessation ages applied annually or biennially. Outcome Measures Number of mammograms, breast cancer mortality reduction or life years gained [LYG] (vs. no screening), false positives, unnecessary biopsies and over-diagnosis. Results of Base Case The 6 models produce consistent rankings of screening strategies. Screening biennially maintains an average of 81% (range across strategies and models 67–99%) of the benefit of annual screening with almost half the number of false positives. Screening biennially from ages 50 to 69 achieves a median 16.5% (range 15%–23%) breast cancer mortality reduction vs. no screening. Initiating biennial screening at age 40 (vs. 50) reduces mortality by an additional 3% (range 1%–6%), consumes more resources and yields more false positives. Biennial screening after age 69 yields some additional mortality reduction in all models but over-diagnosis increases most substantially at older ages. Sensitivity Analysis Results Varying test sensitivity or treatment patterns do not change conclusions. Limitations Results do not include morbidity from false positives, knowledge of earlier diagnosis or under-going unnecessary treatment. Conclusion Biennial screening achieves most of the benefit of annual screening with less harm. Decisions about the best strategy depend on program and individual objectives and the weight placed on benefits, harms and resource considerations.

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A B S T R A C T PurposeAlthough guidelines recommend in-person counseling before BRCA1/BRCA2 gene testing, genetic counseling is increasingly offered by telephone. As genomic testing becomes more common, evaluating alternative delivery approaches becomes increasingly salient. We tested whether telephone delivery of BRCA1/2 genetic counseling was noninferior to in-person delivery. Patients and MethodsParticipants (women age 21 to 85 years who did not have newly diagnosed or metastatic cancer and lived within a study site catchment area) were randomly assigned to usual care (UC; n ϭ 334) or telephone counseling (TC; n ϭ 335). UC participants received in-person pre-and post-test counseling; TC participants completed all counseling by telephone. Primary outcomes were knowledge, satisfaction, decision conflict, distress, and quality of life; secondary outcomes were equivalence of BRCA1/2 test uptake and costs of delivering TC versus UC. ResultsTC was noninferior to UC on all primary outcomes. At 2 weeks after pretest counseling, knowledge (d ϭ 0.03; lower bound of 97.5% CI, Ϫ0.61), perceived stress (d ϭ Ϫ0.12; upper bound of 97.5% CI, 0.21), and satisfaction (d ϭ Ϫ0.16; lower bound of 97.5% CI, Ϫ0.70) had group differences and confidence intervals that did not cross their 1-point noninferiority limits. Decision conflict (d ϭ 1.1; upper bound of 97.5% CI, 3.3) and cancer distress (d ϭ Ϫ1.6; upper bound of 97.5% CI, 0.27) did not cross their 4-point noninferiority limit. Results were comparable at 3 months. TC was not equivalent to UC on BRCA1/2 test uptake (UC, 90.1%; TC, 84.2%). TC yielded cost savings of $114 per patient. ConclusionGenetic counseling can be effectively and efficiently delivered via telephone to increase access and decrease costs. J Clin

Screening with HPV plus Pap tests every 2 years appears to save additional years of life at reasonable costs compared with Pap testing alone. Applying age limits to screening is a viable option to maintain benefits while reducing costs.

Background Identifying risk factors for breast cancer specific to women in their forties could inform screening decisions. Purpose To determine what factors increase risk for breast cancer in women age 40–49 years and the magnitudes of risk for each factor. Data Sources MEDLINE (January 1996 to November 2011), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (fourth Quarter 2011), Scopus, and reference lists for published studies; and data from the Breast Cancer Surveillance Consortium (BCSC). Study Selection English-language studies and systematic reviews of risk factors for breast cancer in women age 40–49 years. Additional inclusion criteria were applied for each risk factor. Data Extraction Data on participants, study design, analysis, follow-up, and outcomes were abstracted. Study quality was rated using established criteria and only studies rated good or fair were included. Results were summarized using meta-analysis when sufficient studies were available, or from the best evidence based on study quality, size, and applicability when meta-analysis was not possible. BCSC data were analyzed with proportional hazards models using partly conditional Cox regression. Reference groups for comparisons were set at U.S. population means. Data Synthesis 65 studies provided data for estimates. Extremely dense breasts on mammography or first-degree relatives with breast cancer were associated with ≥2-fold increase in breast cancer. Prior breast biopsy, second degree relatives with breast cancer, or heterogeneously dense breasts were associated with 1.5–2.0 increased risk; current oral contraceptive use, nulliparity, and age ≥30 at first birth were associated with 1.0–1.5 increased risk. Limitations Studies varied by measures, reference groups, and adjustment for confounders; effects of multiple risk factors were not considered. Conclusions Extremely dense breasts and first degree relatives with breast cancer were each associated with ≥2-fold increased breast cancer risk in women age 40–49. Identification of these risk factors may be useful for personalized mammography screening. Primary Funding Source National Cancer Institute Activities to Promote Research Collaboration supplement (U01CA086076-10S1). Data collection was supported by the National Cancer Institute funded Breast Cancer Surveillance Consortium (BCSC) cooperative agreement (U01CA63740, U01CA86076, U01CA86082, U01CA63736, U01CA70013, U01CA69976, U01CA63731, U01CA70040).

Background Controversy persists about optimal mammography screening strategies. Objective To evaluate mammography strategies considering screening and treatment advances. Design Collaboration of six simulation models. Data Sources National data on incidence, risk, breast density, digital mammography performance, treatment effects, and other-cause mortality. Target Population An average-risk cohort. Time Horizon Lifetime. Perspective Societal. Interventions Mammograms from age 40, 45 or 50 to 74 at annual or biennial intervals, or annually from 40 or 45 to 49 then biennially to 74, assuming 100% screening and treatment adherence. Outcome Measures Screening benefits (vs. no screening) include percent breast cancer mortality reduction, deaths averted, and life-years gained. Harms include number of mammograms, false-positives, benign biopsies, and overdiagnosis. Results for Average-Risk Women Biennial strategies maintain 79.8%-81.3% (range across strategies and models: 68.3–98.9%) of annual screening benefits with almost half the false-positives and fewer overdiagnoses. Screening biennially from ages 50–74 achieves a median 25.8% (range: 24.1%-31.8%) breast cancer mortality reduction; annual screening from ages 40–74 years reduces mortality an additional 12.0% (range: 5.7%-17.2%) vs. no screening, but yields 1988 more false-positives and 7 more overdiagnoses per 1000 women screened. Annual screening from ages 50–74 had similar benefits as other strategies but more harms, so would not be recommended. Sub-population Results Annual screening starting at age 40 for women who have a two- to four-fold increase in risk has a similar balance of harms and benefits as biennial screening of average-risk women from 50–74. Limitations We do not consider other imaging technologies, polygenic risk, or non-adherence. Conclusion These results suggest that biennial screening is efficient for average-risk groups, but decisions on strategies depend on the weight given to the balance of harms and benefits. Primary Funding Source National Institutes of Health