Breast cancer screening is risky business.

Breast cancer is the second leading cause of cancer mortality in women.1 Although risk factors are well known, and models for predicting breast cancer risk (such as the Gail model) are readily available, physicians and patients may not accurately perceive an individual's breast cancer risk, the benefits of screening mammography or the likelihood of survival when a woman is diagnosed with breast cancer. Risk is defined as “possibility of loss or injury.”2 Every woman is at some risk of developing breast cancer and much effort has been put into quantitatively ascertaining women's individual risk or likelihood of developing the disease. Actual breast cancer risk can be measured in several ways. Age is the major determinant of breast cancer risk and risk of breast cancer increases with increasing age. A 40-year-old woman has a 0.6% chance of developing breast cancer in the next 5 years, whereas a 70-year-old woman has a 2.2% chance of developing breast cancer in the next 5 years.3 The modified Gail model4,5 uses age, age at menarche, age at first birth, number of benign breast biopsies, and number of first-degree relatives with breast cancer to estimate a woman's risk of developing breast cancer in 5 years. Perceived risk may or may not be related to actual risk. Perceived risk is a woman's estimate of her own risk of developing disease, and it is often reported as either higher or lower than other women of similar age. Perceived risk is important, especially since one's perceived risk may contribute to the decision of whether or not to pursue screening. In this issue of the Journal, 2 studies address the issue of breast cancer risk. Both studies address the question of how well risk is identified—one study focuses on patients and the other focuses on physicians. The first study by Sabatino et al.6 addresses breast cancer risk and how it might influence physician behavior. The second study by Haggstrom et al.7 addresses differences in women's risk perception with respect to mammography benefit and breast cancer survival. Sabatino et al. addressed the question of whether breast cancer risk influences provider recommendation for screening mammography in unscreened women. Breast cancer risk was assessed among eligible, unscreened women using the modified Gail model. Among unscreened women, less than a third reported a provider recommendation for screening in the past year. Furthermore, only 25% of unscreened high-risk women reported a provider recommendation. Although mammography should be offered to all women aged 50 to 69 regardless of risk, we would anticipate that screening would be offered more frequently to high-risk women. It is concerning that even when a woman has seen a physician, mammography is not ordered; however, we do not know anything about the context of the physician visit. It is less likely that preventive services will be offered during an acute visit for a medical problem than during a preventive or “well-woman” visit. Recently, the American Cancer Society, the American Heart Association, and the American Diabetes Association issued a joint set of preventive guidelines with the goal of reducing cancer, heart disease, and diabetes. One of the important components of these guidelines was the recommendation for a periodic health examination focusing primarily on opportunistic preventive care including cancer screening and lifestyle changes as opposed to an “annual physical examination.” These periodic health maintenance visits with primary care providers should be age and gender appropriate, and should be adequately reimbursed to ensure that these goals are reached.8 Implementation of this recommendation could increase the number of women reporting provider recommendation for screening. Haggstrom and Schapira addressed the question of whether black and white women have differing estimates of the benefits of screening mammography and breast cancer survival. Although prior studies have addressed differences in breast cancer risk perception, few have addressed racial differences. Among black and white women attending general medicine clinics, the majority of women overestimated the risk of dying from breast cancer and overestimated the benefit of screening mammography. Black women had a more accurate estimate of breast cancer survival as well as screening mammography benefits. Because more white women overestimated the benefits of screening mammography, black women's estimates of mammography benefit were described as more pessimistic than those of white women. Why might black women be more pessimistic? The results of this study raise this interesting question about the impact of beliefs on perceived risk. One explanation for the observed findings is the presence of fatalistic thinking and cancer fatalism, a complex construct identified years ago as a possible barrier to participation in cancer screening. The presence of cancer fatalism, the belief that death is inevitable when cancer is present, has been well documented in blacks.9–11 Early work by Powe explored the impact of cancer fatalism on participation in fecal occult blood testing (FOBT) in blacks. The Powe Fatalism Model (PFM) depicts the proposed influence of cancer fatalism on the decision to participate in health seeking behaviors.9 Through the use of the PFM, Powe observed a significant relationship between race and cancer fatalism, with blacks being significantly more fatalistic than whites.10,11 Those who were more fatalistic were also less like to participate in screening.10 The impact of fatalism on breast cancer screening in black women has also been explored.12–15 Phillips et al.15 found that fear was a primary reason not to engage in breast cancer screening among low- and middle-income black women. Mayo et al. assessed the impact of fatalistic beliefs on the participation in breast cancer screening in rural black women and found that fatalism was associated with noncompliance with mammography screening. However, after adjusting for possible confounders, fatalism was not significantly associated with noncompliance with screening.14 Fatalistic thinking has been described in other ethnic minority groups. Perez-Stable et al.16 identified the presence of misconceptions and fatalistic attitudes toward cancer among Latinos. The impact of fatalism on cancer screening in Latina women has also been explored and while some studies suggest that such thinking negatively influences cancer-screening behavior17 others suggest a lack of impact.18 One explanation for conflicting results is the lack of a standardized scale to measure the construct of fatalism may be one reason for differences in study results. Although the Powe Fatalism Inventory has been used to measure fatalism in blacks, it is not used consistently in other ethnic groups where other scales have been used. These scales vary in length and content and this variability must be considered when exploring the impact of fatalism on screening behavior. For example, while some scales explore religiosity and cancer fatalism; others focus on loss of control. In the study by Haggstrom and Schapira, pessimistic thinking was not measured directly but was implied based on perceptions. Women who believed that there was a 0% to 50% chance of living 5 years or longer were considered to be more pessimistic. Similarly, women who believed that regular mammograms decrease the risk of dying from breast cancer 0% to 50% were considered more pessimistic. Although pessimism and fatalism may be essentially the same, inclusion of a fatalism scale would have helped clarify the impact of this attitude on risk perception. Although we have tools that can accurately predict breast cancer risk, women and their physicians are not accurately predicting risk. Furthermore, black women appear to have more pessimistic perceived risk, which may be because of fatalistic thinking. The impact of fatalistic thinking on perceived risk must be explored further, especially in other ethnic minorities. However, in order to proceed, work should focus on developing a standardized fatalism scale or validating existing ones among different ethnic minority groups. The differences in pessimistic thinking between black and white women also highlight the importance of providing culturally sensitive care. As the demographic profile of the U.S. continues to change, providers need a heightened awareness of cultural values and beliefs that impact patient care. Individual beliefs such as pessimistic thinking and fatalism should be explored during the physician-patient interaction as it is possible that addressing these beliefs may influence cancer-screening behaviors, though there is little data that explores the impact of addressing these beliefs on screening. In the big picture, how important is accurate risk perception and how will it affect screening behavior? Given that the U.S. Preventive Services Task Force currently recommends screening mammography for all women aged 40 to 74 regardless of risk, will improving accuracy of risk perception impact screening behavior? If black women and women from other ethnic minority groups are indeed more pessimistic or fatalistic, how does this affect screening behavior? Will increased provider awareness of patient attitudes influence screening recommendation? It is unclear to what extent addressing such attitudes will impact screening behaviors; yet the results of these studies highlight the need for continued exploration. Encouraging communication between patients and physicians that accurately conveys risk is an important goal, however, the most important overall goal is to ensure that all eligible women undergo mammography as this is what will decrease overall breast cancer mortality.