Impact of an educational intervention on provider knowledge, attitudes, and comfort level regarding counseling women ages 40-49 about breast cancer screening

Abstract

Background: Mammography screening for women under the age of 50 is controversial. Groups such as the US Preventive Services Task Force recommend counseling women 40-49 years of age about mammography risks and benefits in order to incorporate the individual patient's values in decisions regarding screening. We assessed the impact of a brief educational intervention on the knowledge and attitudes of clinicians regarding breast cancer screening.

Methods: The educational intervention included a review of the risks and benefits of screening, individual risk assessment, and counseling methods. Sessions were led by a physician expert in breast cancer screening. Participants were physicians and nurses in 13 US Department of Veterans Affairs primary care clinics in Alabama. Outcomes were as follows: 1) knowledge assessment of mammogram screening recommendations; 2) counseling practices on the risks and benefits of screening; and 3) comfort level with counseling about screening. Outcomes were assessed by survey before and after the intervention.

Results: After the intervention, significant changes in attitudes about breast cancer screening were seen. There was a decrease in the percentage of participants who reported that they would screen all women ages 40-49 years (82% before the intervention, 9% afterward). There was an increase in the percentage of participants who reported that they would wait until the patient was 50 years old before beginning to screen (12% before the intervention, 38% afterward). More participants (5% before, 53% after; P<0.001) said that they would discuss the patient's preferences. Attitudes favoring discussion of screening benefits increased, though not significantly, from 94% to 99% (P=0.076). Attitudes favoring discussion of screening risks increased from 34% to 90% (P<0.001). The comfort level with discussing benefits increased from a mean of 3.8 to a mean of 4.5 (P<0.001); the comfort level with discussing screening risks increased from 2.7 to 4.3 (P<0.001); and the comfort level with discussing cancer risks and screening preferences with patients increased from 3.2 to 4.3 (P<0.001). (The comfort levels measurements were assessed by using a Likert scale, for which 1= not comfortable and 5= very comfortable.).

Conclusion: Most clinicians in the US Department of Veterans Affairs ambulatory practices in Alabama reported that they routinely discuss mammography benefits but not potential harms with patients. An educational intervention detailing recommendations and counseling methods affected the knowledge and attitudes about breast cancer screening. Participants expressed greater likelihood of discussing screening options in the future.

Keywords: breast cancer screening; counseling; education; mammography; primary care.

Figure 1

Outcomes. Comfort level with counseling on benefits, counseling on risks/harms, and discussing patient preference. Notes: The label “Before” indicates before the intervention, and the label “After” indicates after the intervention. In the boxplots, the 25th and the 75th percentiles are represented at the bottom of and at the top of the box (respectively); the band inside the box represents median (50th percentile). The ends of whiskers represent the 1.5 interquartile range for the lower quartile (bottom) and for the upper quartile (top). Comfort was assessed by using the Likert scale, for which 1= not comfortable and 5= very comfortable.