Empowering Physicians to Improve Breast Cancer Screening (EPICS)

Although utilization of screening mammography has steadily increased since the early 1980's, some women remain underutilizers of mammography despite widespread promotion. Some have never had a mammogram, and others have lapsed in regular use or after having one or more mammograms.

Empowering Physicians to Improve Breast Cancer Screening (EPICS) main objective is to increase the number and effectiveness of primary care physicians' efforts to encourage women to receive regular mammograms. The program employs a physician-based educational curriculum on mammography and clinical breast examination. EPICS is intended to increase screening mammography utilization among women aged 50 - 80 years among those who have had fewer than two screening mammograms over the previous 4 years.

The course was five hours long and included: (1) a 40-minute introductory lecture on breast cancer epidemiology and risk factors about mammography accuracy, utilization, and common patient barriers to underutilization; (2) a two-hour mammography counseling module, mentioned below; (3) a 50-minute clinical breast examination CBE module; (4) a 30-minute lecture on pitfalls in breast cancer diagnosis; (5) a 30-minute module on office systems support; and (6) two 15-minute pre- and postcourse written tests.

The two-hour mammography counseling protocol was divided into four parts including (1) a 30-minute didactic presentation; (2) a five-minute videotape demonstration of the protocol; (3) a 15-minute live demonstration; and (4) 75 minutes for small group role plays with standardized patients.

A five-hour primary care physician course that includes three hours of skill demonstration in clinic-based breast exam and counseling patients on the importance of regular mammography use is required. An additional 2-hour office staff workshop is necessary.

Primary care physicians receive quarterly reports identifying women in their practice who are overdue by 15 and 24 months for screening. Once identified, annual computer-generated mammogram reminders are printed and sent to the women. In addition to mailed reminders, women in the telephone counseling arm of the study received telephone counseling. Women were called by Master's level telephone counselors trained to use a scripted message to identify and address specific barriers to mammography utilization. The average duration of counseling was 5.5 minutes.

Study participants were women aged 50-80 years who were identified as underutilizers of mammography screening and primary care physicians who:

1. were either solo practitioners or members of a ten physician or fewer practice,
2. had a minimum of 16 women who were HMO enrollees between the ages of 50 and 80 years, and
3. had at least one woman patient over the age of 64 years.

EPICS can be implemented in small group primary care practice settings.

Required resources for physicians include the following: 1) Office Systems Manual, 2) Screening and Diagnosis of Breast Cancer for Primary Care Physicians Manual, 3) Screening and Diagnosis of Breast Cancer for Primary Care Physicians Video, 4) MammaCare Method of Clinical Breast Examination Sheet, and 5) Diagnosis-Treatment Chart.

EPICS costs roughly $26 for women who are regular receivers of mammography screenings, and $72 for women who are underusers (women who have not received a mammogram within a two year period.)

Patients and practice groups were randomly assigned to one of three groups. Women in all three groups were mailed annual reminders to get a screening mammogram and follow-up reminders if they became overdue for a mammogram. Primary care physicians received lists of women in their practices who were overdue for a mammogram by 15 months and 24 months. Women assigned to the Reminder Control group (RC) received the reminder and no other intervention.

Women in the Barrier-Specific Telephone Counseling (BSTC) group were also called by trained counselors who used a barrier-specific telephone script to encourage them to get a mammogram.

Some women were assigned to the Physician Education group (MD-ED). In this group, primary care physicians received a course on breast cancer prevention, prevention counseling skills, workshops and videos on office systems.

Results indicated:

• Among former mammogram underusers, 44% of the women in the MD-ED group and 47% of the women in the BSTC group became regular users by the end of the study, compared with 38% of former underusers in the RC condition.
• At follow-up, 75% of physicians in the MD-ED group reported that they would recommend a mammogram at an acute visit if the patient was overdue for one, compared with 69% at the baseline survey.
• The investigators estimate that the cost-effectiveness of BSTC and MEED for HMOs to cover former users (women who have not had a mammogram in the 24 months prior to the study) who became regular users after the study was $726 and $2,179, respectively, per patient.