Cancer is the second leading cause of death among the world and it has an increasing share among all causes of death. Economical burden of cancer is increasing especially in high and middle-income countries. Leaving cancer in competitive markets would lead to inefficiencies / hence governments should intervene in the market and make public decisions in struggling cancer. Among all cancer types breast cancer has the highest incidence and mortality rates in females. Causes of breast cancer still remains indeterminate and only way to cope with breast cancer are by early diagnoses. Early diagnoses can best be achieved by regular mammography screenings. This study analyzes the possible outcomes of implementing regular breast cancer mammography screening program in Turkey. A simulation model is constructed and run for 10 years, to obtain the costs and benefits of such a screening program. Costs of such a program include the screening costs and costs due to abnormal mammograms. Benefits, on the other hand are reduced treatment costs due to early diagnosis, reduced mortality and morbidity. Simulation model is run for 11 different screening strategies for determining the optimal screening strategy in terms of screening interval and minimum age to screen. The necessary data is obtained from hospital records, Cancer Early Diagnosis and Treatment Center records, IMF, WHO and TUIK databases and literature. Results of the simulation suggest that women over 40 in Turkey should be screened biennially for economical efficiency.

Despite multiple campaigns by the American Cancer Society, reports indicate that Latinas living in the United States who contract breast cancer are more likely than Anglos to die. These findings correlate with low participation in breast cancer screenings among Latinas. The objective of this study was to identify key obstacles that influence Latinas' low participation in breast cancer screenings, based on their health beliefs, knowledge of screenings, acculturation, and socio-economic factors.The study was a face-to-face informal interview, combined with a survey questionnaire conducted at churches, social clubs and/or at the participants' homes in a southwest Florida urban community. The sample consisted of a total of 50 women: all of the participants were Latinas 40 years of age and over; they had to be fluent in Spanish or English or both. A Spanish-English bilingual individual conducted a personal interview in the preferred language of each participant. The first part of the interview was to identify barriers that affect screenings. The second part used a survey to weigh the identified factors in order to determine their importance to the participants' health decisions. This study used a health belief model scale to evaluate women's beliefs about breast cancer, and the benefits of screenings.The research results revealed that Latinas who participated in this study were acculturated to the United States culture; the largest group of participants reported being from Colombia, followed by Cuba and Puerto Rico; only two of the participants were Mexican. Seventy-eight percent of the participants self- reported having yearly mammograms, and 74% performed monthly breast self examination BSE; 60% were bilingual; 68% had some kind of health insurance. These results differ from earlier studies from the western United States where the majority of Latinas were of Mexican or Central American origin. This suggested that Latinas from Southwest Florida are different from Latinas in other areas of the United States. A weak but significant correlation was found between acculturation and perceived barriers to breast cancer screenings, (r = 0.45, p = .01); Latinas who are more acculturated perceived more barriers than those who are less acculturated. There was not significant difference between participants who had health insurance and those who did not (t = 0.96, p = .35). The results of this study are significant for nurses and especially for advanced practice nurses, who can assess patients' knowledge about cancer in general, and breast cancer in particular when caring for Latinas; of particular concern should be the evaluation of patients' levels of acculturation, health beliefs, and understanding of the English language. Still the fundamental barrier to Latinas not bilingual in Spanish and English may be the lack of resources and information in Spanish.

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Colorectal cancer (CRC) is the third most common cancer in the United States (U.S.) and is the second leading cause of cancer deaths. Although the incidence of CRC has been decreasing with CRC screenings, disparities of CRC and screening prevalence exist for racial and ethnic groups. The CRC incidence rates have dramatically increased in Korean Americans, however, there is little known about their CRC screening behaviors and the factors that may predict screening behaviors have not been fully investigated. The purposes of this study were to describe CRC screening behaviors and identify the predictors and barriers influencing CRC screening behaviors among Korean Americans. A sample of 254 Korean Americans participated in this study. Correlation, Multiple logistic regression, and Chi-square were used to analyze data. In this study, Korean American had lower rates of CRC screenings compared to the general U.S. population. Only 20% of the sample had ever had a fecal occult blood Test (FOBT), 49% had ever had a colonoscopy, and 19% responded they had ever had a sigmoidoscopy in their lifetime. Korean Americans had low rates of perception of cancer screening (annual physical exam and periodic cancer screening), moderate CRC knowledge, low cancer fatalism, limited CRC literacy, lack of health care access, and a low rate of receiving the physician's recommendation of CRC screenings. The greatest predictors influencing CRC screening were perception of cancer screening for a FOBT, and the physician's recommendation for a colonoscopy and a sigmoidoscopy. There were no significant differences by gender in CRC screening behaviors. However, significant differences were found between the two groups divided by length of U.S. residence. Compared to those who have lived in the U.S.>10 years, new immigrants had lower rates of all three CRC screening, lower perception of cancer screening, higher uninsured, less receiving physician's recommendation, and higher perceived barriers to CRC screening. The findings of this study suggest that improved efforts are needed to increase CRC screenings among Korean Americans. Further research is needed to increase a physician's recommendation for CRC screenings and awareness for the importance of annual checkups and periodic cancer screening among Korean Americans.

Little is known about the receipt of cancer screening for new primary cancers among Canadian cancer survivors. The objectives of this thesis are to i) synthesize evidence comparing receipt cancer screening between cancer survivors and non-cancer controls; and ii) analyze breast and cervical cancer screening receipt among Nova Scotian colorectal cancer (CRC) survivors. This thesis consists of a systematic review and meta-analysis, and a population-based cohort study of Nova Scotian CRC survivors. We found that while cancer survivors were more likely to receive cancer screening than the general population, a significant proportion of cancer survivors were not screened. We observed significant heterogeneity between studies, most of which remained unexplained after subgroup and sensitivity analyses. 30.1% and 47.9% of Nova Scotian CRC survivors never received a breast and cervical cancer screen after their CRC diagnosis. Receipt of pre-CRC diagnosis screening was strongly predictive of receiving screening post-diagnosis.

In medical settings, a teachable moment (TM) has been described as an event which may lead to psychological changes prompting individuals to engage in health promoting behaviors. A cancer screening (CS) has been suggested as a potential TM because several types of positive health behavior change (HBC), ranging from dietary changes to smoking cessation, have been linked to CS. However, most research has examined the TM in CS settings using cross-sectional and prospective methodologies and has lacked a theory-driven model. Moreover, few intervention studies have attempted to capitalize on the potential TM in CS settings. In light of this, the primary purpose of this study was to examine the potential for routine ovarian CS to serve as a TM to enhance the potential for HBC using a theory-driven conceptual model of a TM. A prospective, longitudinal design was used to track changes in positive affect, self-efficacy (SE), HBC intentions and HBC following participation in routine ovarian CS. The impact of a brief, written intervention intended to enhance SE to engage in HBC was also examined. There were three total study assessments: the baseline (T1), 24-hour follow-up (T2), and one month follow-up (T3) assessment. Results indicated positive affect and positive consequences of screening increased over time (p’s<.01) and increases in positive affect were positively associated with greater healthy diet HBC. Additionally, greater positive consequences of screening at T2 predicted greater exercise HBC. No significant changes were observed in exercise or healthy diet intentions over time; there were no differential effects based upon the intervention for positive affect, SE, HBC, or HBC intentions (p’s>.05). Healthy diet SE and exercise SE remained stable (p>.05) but were found to be a robust predictor for both exercise and healthy diet HBC intentions. While several of our hypotheses were supported, the brief health information intervention did not appear to impact SE, HBC intentions, or actual HBC. To better equip health providers in CS settings, studies should continue examining both the potential for CS settings to serve as a TM to enhance HBC and how receipt of a normal test result impacts this potential.

Benign breast biopsy (BBB) can be a stressful experience for many women. Few studies have examined the specific aspects of the BBB more and less distressing. However, no research studies have examined demographic and clinical variables as they relate to distress associated with specific aspects of the BBB or the informational interests of women following a BBB. This study evaluated the magnitude of distress associated with each aspect of the BBB (additional mammography, waiting for the results of the mammography, being informed of needing a biopsy, etc.) as well as the clinical (family history of BC in first degree relative, history of BBB, and type of biopsy) and demographic (age and education) variables as correlates of distress associated with each aspect of a BBB. Additionally, we examined health information interests in women following a BBB and the manner in which women preferred to have this health information communicated.

Cervical cancer is the second most common cancer, with about 500 000 new cases per year among women worldwide. With a well-organized screening programme the number of cases can be reduced by more than 50%. In spite of having such a screening programme there are still around 450 new cases yearly in Sweden. The majority of these cases occur in non-attendees. There is thus a need to improve the Swedish cervical cancer screening programme in order to further reduce the number of cases of cervical cancer. Cervical cancer and high-grade cervical dysplasia are caused by sexually transferred high-risk human papillomaviruses (HR-HPVs). In cases of persistent HR-HPV infection there is a risk of development of dysplasia and in some cases subsequent progress to cervical cancer. HR-HPV testing shows high sensitivity as regards the detection of cervical dysplasia. Self-sampling of vaginal fluid for the analysis of HR-HPV has many advantages, since a woman can perform the sampling herself in a private setting, whenever suitable, without the need to travel to a clinic. Our studies have shown that sensitivity in the detection of precancerous lesions is about twice as great with the HR-HPV self-test compared with cytology-based tests.  If a woman was HR-HPV-positive in two consecutive tests, the specificity of the HR-HPV test increased to about 98%. Among women with short-term persistent HR-HPV infection, the prevalence of CIN 2+ was over 40%. There was good concordance in sensitivity as regards the detection of CIN 2+ between self-obtained and physician-obtained samples, although self-sampling was associated with slightly lower specificity. The prevalence of HR-HPV from day to day in premenopausal women was not influenced by hormonal changes during the menstrual cycle. Neither were there significant day-to-day changes in postmenopausal women. A single self-test thus provides reliable information on whether or not a woman has an HR-HPV infection. In conclusion, self-sampling combined with the analysis of HR-HPV appears to be a powerful alternative as a primary screening method for the prevention of cervical cancer. Self-sampling for HR-HPV testing is a suitable, safe and accepted strategy for cervical cancer prevention among women.

This thesis focuses on the modelling and prediction of factors affecting attendance to screening invitations of the NHS Breast Screening Programme. The analysis is based on data collected by the Warwickshire, Solihull and Coventry Breast Screening Unit from 1989 up to 2001 with respect to invitation to screening for the prevention of breast cancer in non-symptomatic women. Using a novel approach to the analysis of the data, from the perspective of the screening episode of each woman, rather than the usual analysis from the perspective of the screening round of the units, a statistical analysis is carried out on the whole registered population for the first time. Amendments to the current formulae for coverage calculations, the introduction of a new parameter (invitation rate) and the proposal for a reduction of the invitation period (period of time between two consecutive invitations) follows from the analysis. A preliminary analysis of predictive methodologies, including traditional statistical methods and artificial intelligent methods, gives the foundation to the formulation of two new algorithms; the first, for the prediction of attendance of women to screening invitations, and the second for the prediction of occurrence of screening variation (change of appointment dates) of women to invitations. Both algorithms are based on neural network generated models able to learn from the previous screening behaviour history of the woman, a technique not previously explored for the prediction of attendance. The accuracy of the new proposed algorithm for the prediction of attendance to invitation is tested on a blind study using data not previously seen by the predictive system, and for which results were unknown at the time when the predictions were made. From the obtained results, it is concluded to recommend the implementation by the NHS Breast Screening Unit of the two algorithms proposed for the prediction of the women’s attendance and screening variation to their invitation for screening. With these predictions, women likely not to attend, or change appointment date, can be identified and appropriately targeted with the aim of increasing their attendance in the short term, and in the long term, reducing breast cancer mortality.

Background: This thesis is composed of three studies testing the effect of the Colon Cancer Check (CCC) program, the organized screening program for colorectal cancer in Ontario, on screening participation. In the first paper, we described the trends of participation to Fecal Occult Blood Test (FOBT) and endoscopy, and the trend of ‘up-to-date’ consistent with guidelines, overall and stratified by demographic characteristics between 2005 and 2011. In the second paper, we tested the effect of physician’s recommendation on FOBT participation and disparities in participation. In the third paper, we measured the effect of the CCC program on FOBT participation using an interrupted time series. Methods: We identified six annual cohorts of individuals eligible for CRC screening in Ontario between 2005 and 2011 by linking the Registered Persons Database to Ontario Health Insurance Plan and 2006 Census from Statistics Canada. We used descriptive statistics to describe the trends of participation. The effect of physician’s recommendation on screening participation was tested using multiple logistic regression analysis. The effect of the CCC program on FOBT participation was tested using segmented regression analysis. Results: An increasing trend in FOBT participation and ‘up-to-date’ status was observed across all demographic characteristics. The disparity gaps persisted over time by gender, income, recent registrant and age. The rural/urban gap was removed. Physician’s recommendation tripled the likelihood of FOBT participation (prevalence rate ratio=3.23, CI= 3.22-3.24) and mitigated disparities. The CCC led to a temporary increase in level (8.2‰ person-month) in FOBT participation followed by a decline in trend and then a plateau. The increase in level was significant across all population sub-groups. Conclusions: We found that CRC screening has increased in Ontario across all subgroups of the population but remained suboptimal. Disparities in screening participation were identified. Proposed strategies to improve performance include interventions to increase the rate of physician’s recommendation at the practice level, tailored interventions to motivate under-users and public media campaigns.