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“The totality of the worldwide epidemiological evidence indicates that pregnancies ending as either spontaneous or induced abortions do not have adverse effects on women’s subsequent risk of developing breast cancer”: This is the conclusion of an analysis of data from 53 studies of women with invasive breast cancer that included information on abortion history. (1) The studies took place in 16 countries with liberal abortion laws and included a total of about 83,000 women. In analyses pooling data from the 12 studies in which information about spontaneous abortion was recorded before women’s breast cancer was diagnosed (and which presumably suffer from less underreporting of abortion than those in which this information was collected retrospectively), the risk of breast cancer was statistically indistinguishable between women who had ever had a spontaneous abortion and those who had not. Thirteen studies reporting prospective data on induced abortion showed a small but statistically significant reduction in risk for women who had terminated a pregnancy. Results were similar regardless of women’s age, whether they had given birth, the number of abortions they had had or the timing of their abortions.

A 34-year-old, previously healthy nurse whose mother and maternal aunt had breast cancer presented in January 2003 complaining of itching of her left areola and the area just lateral to it at the 3 o’clock position. The itching had begun 6 months ago, stopped, and recurred. She reported no other symptoms.

Examination yielded normal findings without skin changes, palpable masses, or lymphadenopathy. She was treated with hydrocortisone 1% cream and was asked to return in 2 to 3 weeks to discuss further evaluation if the itching had not resolved. At the time, she was working overseas as a humanitarian aid worker and unable to get a mammogram or other evaluation without leaving the country. She did not return for a follow-up visit, though the itching continued intermittently.

About 2 months later, the patient discovered on self-examination a mass in the left breast lateral to the areola at the 9 o’clock position. She was due to go home to the United States in 2 months and deferred evaluation. In the meantime the breast mass doubled in size. Upon returning home, she had a mammogram (negative finding) followed by ultrasound and a needle biopsy. Pathology examination revealed a 1.8-cm mass positive for ductal carcinoma with local micrometastasis. Results of node biopsies were negative. There was no evidence of Paget’s disease.

Since her diagnosis, both her mother and sister have tested positive for the BRCA gene. The patient herself declined testing. Initially, the patient underwent lumpectomy followed by chemotherapy. After her lumpectomy, the itching resolved. After counseling concerning the BRCA gene and cancer risk, she elected to undergo bilateral mastectomies in October.

Could itching be a warning sign of possible cancer, especially in a patient at high risk? Pruritis has been well described as a presenting symptom of Paget’s disease of the breast, malignant nevi, and of other cancers. (1-3) Itching may be localized to the area of cancer or more generalized. (2,3) Both itching and pain involve activation of a peripheral group of C nerve fibers, and itching can originate anywhere along the afferent neural path. I hypothesize that this patient’s itching was caused by nerve fibers in the breast being affected by the growth of the breast mass.

Could itching be the presenting symptom of other types of breast cancer as well? Have you observed this phenomenon? If there is indeed a connection between such itching and breast cancer, would a more aggressive evaluation of unexplained itching lead to earlier diagnoses and decreased morbidity and mortality from cancer?

When a woman presents with a breast complaint, initial management nearly always includes a clinical breast examination and an imaging study. Frequently, risk factors for breast cancer are assessed. Individualized risk predictions employing more formalized tools, such as the Gail model (1) or the Claus model, (2) are being used increasingly in screening populations. However, an important question remains: in symptomatic women, are risk factors for breast cancer still clinically important? Unfortunately, the answer is unclear.

The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer (3) states that when a woman presents with a breast lump or a suspicious change in breast texture, her risk factors for breast cancer should be noted, but the presence or absence of risk factors should not influence decisions about further workup. Similarly, recommendations for evaluation and follow-up of mammographic abnormalities generally are made without regard to individual breast cancer risk. However, improved use of breast cancer risk factors has the potential to reduce the number of biopsies performed in women who do not have cancer and to increase the percentage of positive biopsies.

In response to a topic nomination by Kaiser Permanente Northern California, the Agency for Healthcare Research and Quality (AHRQ) funded a systematic review of the literature. (4) The objective was to assess published evidence on the relationship between risk factors, breast abnormalities (clinical symptoms or mammographic findings), and breast cancer, and to provide practical recommendations for applying this information.

The systematic review (4) found that although many studies reported breast cancer incidence in association with risk factors (menstrual status, hormone therapy, pregnancy history, family history, age) or abnormal breast findings, relatively few studies reported the incidence in association with both. In addition, the literature suffers from a lack of standardization of terms for reporting information about breast disease. Hence, reported results vary, depending on whether breast cancer incidence is derived from the number of lesions or the number of affected patients.

The literature on mammography also is problematic. Although mammographic results almost always are given, variations in reporting formats make it impossible to combine data in a useful way. The Breast Imaging Reporting and Data System (BI-RADS) terminology was developed for the purpose of standardizing mammogram reports. (5,6) Widespread use of the BI-RADS nomenclature (e.g., in studies that relate cancer incidence by age to BI-RADS scores) could make data integration possible. (7-11)

Thus, although risk factors for breast cancer are well established and commonly used to direct evaluation in other clinical scenarios, current evidence does not permit assessment of the impact of individual risk factors on the likelihood that a breast abnormality represents cancer. Family history, (12-19) pregnancy and menstrual history, (13,14) and hormone therapy (20) lacked a consistent evidence base for inferring any conclusions about the risk of cancer when these factors were associated with a clinical or mammographic abnormality. The only exception is patient age. In this instance, studies show that age over 50 years greatly increases the risk of breast cancer in women with a clinical or mammographic abnormality.

At this time, no published evidence supports modifying the work-up of breast symptoms or mammographic abnormalities based on risk factors other than age.

We thank the extended MetaWorks team members, the members of the Technical Expert Panel, peer reviewers, representatives from Kaiser Permanente Northern California, and the AHRQ for their contributions to this project.

References

(1.) Gail MH, Brinton LA, Byar DP, Corle KD, Green SB, Schairer C, et al. Projecting individualized probabilities of developing breast cancer for white females who are being examined annually. J Natl Cancer Inst 1989;81:1879-86.

(2.) Claus EB, Risch N, Thompson WD. Autosomal dominant inheritance of early-onset breast cancer. Implications for risk prediction. Cancer 1994;73:643-51.

(3.) The palpable breast lump: information and recommendations to assist decision-making when a breast lump is detected. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Canadian Association of Radiation Oncologists. CMAJ 1998;158(suppl 3):S3-8.

(4.) Diagnosis and management of specific breast abnormalities. Rockville, Md.: Agency for Healthcare Research and Quality, Dept. of Health and Human Services, 2001; evidence report/technology assessment, 1530-4396, no. 33; AHRQ publication no. 01-E 046.

(5.) Barton MB, Elmore JG, Fletcher SW. Breast symptoms among women enrolled in a health maintenance organization: frequency, evaluation and outcome. Ann Intern Med 1999;130:651-7.

(6.) Liberman L, Abramson AF, Squires FB, Glassman JR, Morris EA, Dershaw DD. The Breast Imaging Reporting and Data System: positive predictive value of mammographic features and final assessment categories. AJR Am J Roentgenol 1998;171:35-40.

“Functional foods,” “nutraceuticals,” “designer foods” and “medicinal foods” are terms that describe foods, and key ingredients isolated from foods, that have non-nutritive or tertiary functional properties. Researchers, healthcare practitioners, laypersons, and the popular media use these words interchangeably. The purpose of this article is to detail valid scientific and pertinent clinical information on the effects of toxic exposure on breast cancer risk and whole foods recognized for their ability to detoxify chemicals from the body.

Breast cancer is second only to lung cancer as the most common cause of cancer mortality in the US. Further, in the year 2000 alone, 182,000 new cases of breast cancer were diagnosed and there were 40,800 associated female deaths in the US as a result. In fact, breast cancer is the leading cause of death in women between the ages of 35 and 54. (1) A key contributing factor, that is supported by clinical research, to the onset of breast is toxic exposure, in the form of synthetic hormone replacement therapy and chemicals in the food, air and water supply.

he Toxic Effects of Synthetic Hormone Replacement Therapy

A woman’s chance of developing breast cancer significantly increases with age

As a woman ages, she will naturally approach menopause and the cessation of ovarian function, increasing her chances of taking hormone replacement therapy (HRT) to reduce symptoms commonly associated with menopause and to prevent the onset of heart disease and osteoporosis. In fact, surveys by the North American Menopause Society show that about a third of US women ages 45 to 65–some 16 million women–use hormone supplements, either estrogen alone or combined with progestin. Disturbingly, HRT increases a woman’s risk of breast cancer, sometimes by more than 50% and, we now know, it fails to prevent heart disease and in fact increases a woman’s chance of developing a life-threatening blood clot or a stroke. The now famous study (2) published in 2002 in the Journal of the American Medical Association provided definitive evidence that the use of combined HRT (meaning conjugated equine estrogens and medroxyprogesterone acetate (PremPro) significantly increases a woman’s chance of developing breast cancer. This was a randomized, placebo-controlled trial, which was a component of the Women’s Health Initiative, a multi-part study begun by the National Institutes of Health that enrolled more than 160,000 postmenopausal women at 40 US medical centers between 1993 and 1998.

The purpose of the study was to investigate the efficacy and safety of long-term hormone replacement therapy in preventing diseases in postmenopausal women such as heart disease, breast and colorectal cancers, and osteoporosis. Over 16,000 menopausal women with an intact uterus participated in this trial, receiving conjugated estrogens (at .625 mg/day) plus medroxyprogesterone acetate (at 2.5 mg per day) combined in one tablet or placebo. Considered one of the largest studies of women’s health ever taken, it made headlines when the review committee for the study halted the study three years early (final results were due out in 2005). They determined that the number of cases of invasive breast cancer in the combined HRT group crossed the boundary established for the study as a signal of increased risk.

For example, the estrogen/progestin therapy used in this trial resulted in a 26% increase in breast cancer. The combined HRT also resulted in:

* 41% increase in strokes

* 29% increase in heart attacks

* Doubled rates of blood clots in legs and lungs

* 37% fewer incidents of colorectal cancer

* 33% fewer hip fractures

* 24% fewer total fractures

It is interesting to note that other parts of the WHI trial, including a study evaluating the effects of estrogen alone (Premarin), in postmenopausal women without a uterus, continued. This study continued irrespective of the fact that a cohort observational study involving over 44,000 postmenopausal women without a uterus, published in same issue of JAMA (334-341) by Lacey et al. (3) found that estrogen-only HRT resulted in a 300% increase in ovarian cancer. Finally, in March of this year, the NIH discontinued this phase of the trial because estrogen had no

effect on preventing heart disease after 7 years of continuous use, and it was shown to increase the risk of stroke. A separate report points to “probable” dementia and/or mild cognitive impairment associated with estrogen-alone therapy. (4)

Toxic Exposure from the Air, Water, and Food Supply

Beyond the toxic effects of synthetic HRT, which women have been exposed to for decades, environmental chemicals in the air, water and food supply have a well-documented effect on breast cancer risk. For the last 40 years, substantial evidence has surfaced on the hormone-like effects of environmental chemicals such as pesticides and industrial chemicals in humans.

Breast and ovarian cancer are the second and fifth leading causes of cancer death, respectively, among women in the United States (1). One in eight women will have breast cancer during their lifetimes, and one in 70 will have ovarian cancer. Mutations in two genes, BRCA1 and BRCA2 (BRCA1/2), are associated with predisposition for inherited breast and ovarian cancer and are identified in 5%-10% of women with breast or ovarian cancer (BOC) (2). Since 1996, genetic testing for these mutations has been available clinically (3); however, population-based screening is not recommended because of the complexity of test interpretation and limited data on clinical validity and utility (1,4-6). Despite the test’s limited applicability in the general population, the U.S. provider of clinical BRCA1/2 testing (Myriad Genetic Laboratories, Inc., Salt Lake City, Utah) conducted a pilot direct-to-consumer (DTC) marketing campaign in two cities (Atlanta, Georgia, and Denver, Colorado) during September 2002-February 2003. Although DTC advertisements have been used to raise consumer awareness about pharmaceuticals (7), this was the first time an established genetic test was marketed to the public. To assess the impact of the campaign on consumer behaviors and health-care provider practices, CDC and the respective state health departments for the pilot cities and two comparison cities (Raleigh-Durham, North Carolina, and Seattle, Washington) surveyed consumers and providers. This report summarizes results of those surveys, which indicated that consumer and provider awareness of BRCA1/2 testing increased in the pilot cities and that providers in these cities perceived an impact on their practice (e.g., more questions asked about testing, more BRCA1/2 tests requested, and more tests ordered). However, in all four cities, providers often lacked knowledge to advise patients about inherited BOC and testing. These findings underscore the need for evidence-based recommendations on appropriate use of genetic tests and education of providers and the public to achieve maximum individual and public health benefit from genetic testing.

Women aged 25-54 years with personal or family histories of BOC and their health-care providers were target audiences of the DTC campaign. The campaign consisted of television, radio, and print advertising to raise awareness about BRCA1/2 testing and to motivate women to ask their providers how genetic testing might help assess BOC risk and guide them to effective medical management options. Providers received precampaign information and patient support materials (8).

During April 21–May 20, 2003, a 51-question consumer telephone survey was conducted by using randomly generated household telephone numbers. Approximately 1,600 women were targeted for participation. Survey questions addressed family history, campaign awareness, interest in BRCA1/2 testing, cancer concerns, and interactions with health-care providers, family members, and friends. On May 1, 2003, providers were mailed a 35-question survey and a monetary incentive. Questions surveyed knowledge of inherited BRCA1/2 mutations, campaign awareness, and perceived changes in practice subsequent to the campaign. Approximately 1,600 physicians were selected randomly from the American Medical Association master list to be proportionally representative of four specialties (i.e., family practice, internal medicine, obstetrics/gynecology, and ontology).

Consumer Survey

A total of 1,635 women completed the survey (participation rate: 45%); the majority (79%) were non-Hispanic white, with a median age of 40 years and more than a high school education (75%). Thirteen percent had a family history of BOC in a first-degree relative (e.g., parent or sibling). In the pilot cities, consumers were substantially more likely than those in the comparison cities to have heard of the test and to have seen a television, radio, or magazine advertisement; however, perceived knowledge about testing did not differ between consumers in the pilot and comparison cities. No differences were observed between pilot and comparison cities in the percentage of women who reported talking to anyone about the test or in the level of concern about their risk for BOC. Among women who had heard of the test, interest in testing did not vary by city. Among women who had heard of and were interested in the test, 20% had a first-degree relative with BOC compared with 17% of women who had heard of the test but were not interested.

Provider Survey

A total of 1,054 providers completed the survey (participation rate: 66%); the majority (66%) were male, had been in practice for > 10 years (62%), and evaluated <100 patients per week (65%). In the pilot cities, providers were more likely than those in comparison cities to report that they and their patients saw or heard an advertisement about genetic testing for BOC (Table 2). When asked to compare the previous 6 months with the same period 1 year before, more providers in the pilot cities than in comparison cities reported an increase in the number of patients who had asked questions about testing, asked for genetic counseling referrals to consider testing, and requested testing. Providers in the pilot cities also reported ordering more tests but not more referrals to genetics or oncology centers

Long recommended as a defense against heart disease, aspirin may soon help lesbians in the fight against another leading killer, breast cancer. In a study published in the Journal of the American Medical Association on May 26, researchers at Columbia University showed that women who used aspirin at least four times a week were almost 30% less likely to develop hormone-fueled breast cancer.They theorize that the drug interferes with the body’s production of estrogen, which promotes cancer growth.

THEY’RE quite a team–the professional basketball player and the six other women whose stories follow. They are African-American breast cancer survivors and women with a game plan for survival.

They have dedicated their lives to preaching the gospel of early detection, regular check-ups and routine mammograms and to encouraging women to be proactive in their health choices.

Breast cancer can be beaten, they say, and they are here to tell how and why.

Sacramento Monarchs guard Edna Campbell rejoined the team last August for their final game of the season against the Seattle Storm. What is so remarkable about that is that the 5-foot-8-inch shooting guard sat out most of the 2002 season battling breast cancer. Campbell was diagnosed in February and is the first active player in the WNBA with this disease.

“I wanted to end the season on a positive note,” says the 33-year-old. “I want to share with my teammates my victory. This is more than a game, and it’s bigger than winning or losing.”

Campbell says she first noticed the lump but thought it was the result of a hit in the chest during a basketball game. “I was actually icing it,” she says, but then her doctor noticed the lump during a routine exam and recommended a mammogram. “Things snowballed from there,” she says.

After her cancer was diagnosed last winter in Italy, she flew to the United States and had a small lump removed during one of two operations doctors performed. After completing chemotherapy and radiation treatments, Campbell dealt with the disease “head-on,” with the support of family and friends, especially her son, David, and her baby sister Jovita. “I urge young women to pay attention to this disease; it’s affecting us younger and younger.”

Every year breast cancer kills 5,600 African-American women, in fact, breast cancer ranks second among causes of cancer death among Black women, according to the American Cancer Society. Although breast cancer cannot be prevented, it can be detected at an early, treatable stage. Five-year survival after treatment for early-stage breast cancer is 96 percent.

A number of organizations have joined together to promote early detection. WNBA star Lisa Leslie makes six appearances annually in support of the Sears/WNBA Breast Health Awareness program including a Public Service Announcement encouraging women to be proactive in their breast health.

The National Alliance of Breast Cancer Organizations recommends that all women have a mammogram every year, beginning at age 40. In addition, women should have a breast exam by a doctor or nurse, starting at age 20 and should perform a monthly breast self-exam.

Reona Berry is living proof that early detection saves lives. It saved hers. In 1990, shortly after Thanksgiving, she noticed a rash underneath her breast. The rash had been there for a while, but recently had grown painful and warm to the touch. “I recalled reading a breast cancer article the previous month and I immediately grabbed my EBONY magazine,” Berry recalls. “And there it was, the article explaining how the cell activity could make the afflicted area hot.” After being diagnosed, she joined a support group but noticed that there were few Sisters in attendance. So she started the African American Breast Cancer Alliance in Minneapolis. “It helps you to talk to other Black survivors because we go through issues that others may not,” she says. “There are economic, family, and other lifestyle issues involved that keep women from going to see a doctor. If you don’t have insurance, the last thing you’re going to do is spend your money to go to a doctor when you have to feed your family and pay your bills.”

As a 12-year survivor, Berry pulls no punches. “Breast cancer is a disease, not a punishment,” she states. “Being assertive is key because cancer doesn’t stop for us. We can’t be afraid. We have to fight.”

Fighting is surviving for Jackie Pugh, director of community outreach, the Contra Costa Breast Cancer Partnership. At the age of 28, she noticed that it was uncomfortable to sleep on one side of her body. Because of her age, and the lack of a family history of breast cancer, the first doctor she visited sent her home, twice. A second doctor diagnosed her cancer. She was shocked but not thrown off track. “There was no time for sadness.” She had a small daughter (and her namesake, Jacque) to raise. “While I was sitting in the hospital, I knew that I was going to be proactive. I’m going to fight this thing and I just decided that whatever I was going to have to do to beat this thing that’s what I was going to do.”

She not only survived, she thrived and for two years in a row, she has spearheaded a project, a 24-month calendar of beautifully posed breast cancer survivors, entitled Celebrate: Reflections Beyond Surviving. Celebrating each day is Pugh’s new mantra. “Surviving cancer is a reason to celebrate,” she says excitedly. “We have gone through something that is very traumatic and we’re still here. We’re celebrating life because we know that God is good.”

By using computers programmed to recognize suspicious mammograms, doctor can find breast cancers that would otherwise escape diagnosis, say radiologists who are among the minority in their profession currently using the technique.

Stamatia Destounis of the University of Rochester in New York and her colleagues employed an X-ray-scanning computer to reanalyze old mammogram results of 318 women. Although doctors hadn’t originally read the mammograms as being abnormal, all the women in the study had been diagnosed with breast cancer at least 1 year after their mammograms were performed. In 52 cases, a pair of physicians who had initially read the results hadn’t noticed developing cancers that, in retrospect, were visible on the breast images.

The computer-assisted analyses correctly pegged 37 of these missed cancers, Destounis and her colleagues report in the August Radiology. However, the computer flagged as suspicious about twice that number of masses that turned out to be harmless. If doctors had acted on all the computer’s suggestions by performing follow-up biopsies, they would have caught more breast cancers, but they would also have performed more unneeded procedures.

Machines can’t replace doctors who read mammograms, but computer-aided detection, or CAD, can guide them, Destounis says.

In a second study, pairs of radiologists on Destounis’ team first performed 18,586 new mammograms and identified more than 400 that were suspicious enough to require biopsies. Of those, 85 proved to be cancer. That biopsy-to-cancer ratio is typical. The radiologists also consulted the computer and, on the basis of its recommendations, performed six additional biopsies. All six identified a cancer that would have been missed.

PURPOSE: The purpose of this study was to determine the dynamic parameter (EC50) of flavonoids apigenin, biochanin A, chrysin, genistein, kaempferol, hesperetin, naringenin, and silymarin for breast cancer resistance protein (BCRP) inhibition when used alone, and to evaluate their potential interactions (additive, synergistic, or antagonistic) with regards to BCRP inhibition when used in rnultiple-flavonoid combinations. METHODS: The effects of flavonoids on BCRP-mediated transport were examined by evaluating their effects on mitoxantrone accumulation and cytotoxicity in MCF-7 MX100 cells overexpressing BCRP. The EC50 values of these flavonoids for increasing mitoxantrone accumulation were estimated using a Hill equation. The potential interactions among multiple flavonoids with regard to BCRP inhibition were assessed by isobologram and Berenbaum’s interaction index methods. RESULTS: The EC50 values of these flavonoids for increasing mitoxantrone accumulation ranged from 0.39+/-0.13 microM to 33.7+/-2.78 microM. Quantitative analysis of the combined effects of multiple flavonoids on mitoxantrone accumulation indicated that these flavonoids act additively in inhibiting BCRP when given as 2-, 3-, 5-, or 8-flavonoid combinations with equimolar concentrations of all constituents. The results of the mitoxantrone cytotoxicity studies were consistent with these findings. CONCLUSIONS: The additive effects of multiple flavonoids for BCRP inhibition suggests that prediction of BCRP-mediated food (herbal product)-drug interactions should also take into consideration the presence of multiple flavonoids and provides a rationale for using “flavonoid cocktails” as a potential approach for multidrug resistance reversal in cancer treatment.

Asians account for an increasing proportion of the U.S. population (1). Koreans are the fifth largest Asian subpopulation, totaling 1.2 million in 2000 (1). In Santa Clara County (2000 population: 1.7 million), California, Koreans constitute 1.3% of the population (2). In 1994 and 2002, two population-based surveys were conducted among Korean women (2000 population: approximately 12,000) in Santa Clara County regarding breast- and cervical-cancer screening. The results were contrasted with two surveys of the general population of California women conducted during the same years. This report summarizes the findings of those surveys, which indicated that Korean women received less frequent breast- and cervical-cancer screening compared with all California women. This report also assesses compliance with the 2010 national health objectives for Papanicolaou (Pap) tests and mammography screening *. Multifaceted community programs that include culturally and linguistically sensitive education of community members and their health-care providers, along with improved health-care access, will be required to achieve the 2010 national health objectives.

During August 1994-February 1995 and February-June 2002, the Center for Family and Community Health (CFCH) at the University of California, Berkeley, and Asian Health Services (AHS) conducted two household telephone surveys among Korean women in Santa Clara County. These results were compared with results for all California women from the 1994 and 2002 California Behavioral Risk Factor Survey (BRFS) and with the 2010 national health objectives for Pap tests and mammography screening.

The surveys of Korean women were adapted from the 1993 California BRFS and modified for cultural sensitivity and appropriateness. Questionnaires were developed in English, translated into Korean, back-translated into English, and pre-tested. In 1994 and 2002, 94.2% and 93.0%, respectively, of the interviews were administered in Korean. Approximately 500 Korean surnames were identified, and Korean surname–based telephone lists were purchased from commercial sources.

In 1994, a total of 5,079 listed telephone numbers with Korean surnames were sampled; 501 (9.8%) were eligible, 4,385 (86.3%) were ineligible, and 193 (3.8%) were of unknown eligibility. Most ineligible telephone numbers represented households without a Korean woman (71.5%) or were incorrect, disconnected, or nonworking (20.4%). The estimated survey response rate was 79.5%.

In 2002, a total of 10,785 listed telephone numbers with Korean surnames were sampled; 626 (5.8%) were eligible, 9,180 (85.1%) were ineligible, and 979 (9.1%) were of unknown eligibility. Most ineligible telephone numbers represented households without a Korean woman (68.7%) or were incorrect, disconnected, or nonworking (24.6%). The estimated survey response rate was 66.5%.

Interviewers spoke in Korean and switched to English if the respondent did not reply in Korean. The survey was described as a “study about health and immigration among Koreans.” Respondents were eligible for the study if they self-identified as either Korean, Korean American, or of Korean origin. Both surveys consisted of two phases; in phase 1, one Korean woman aged [greater than or equal to] 18 years was selected randomly within each eligible household and, in phase 2, to ensure an oversample of older women, additional Korean women aged [greater than or equal to] 50 years were selected randomly from eligible households. In 1994, a total of 414 interviews were completed; in 2002, a total of 458 interviews were completed. Results were weighted to account for the probability of selection of the respondent and for the age distribution of Korean women in Santa Clara County in the 1990 Census for the 1994 survey and in the 2000 Census for the 2002 survey. Because of complex survey samples, SUDAAN was used to estimate sampling errors. For each pair of comparable estimates, t-tests were conducted, and estimates were examined to determine statistical significance (p<0.05).

From 1994 to 2002, four statistically significant changes in sociodemographic characteristics were observed: 1) the percentage of women aged 18-29 years decreased from 29.3% to 18.1%, 2) the percentage with some college education increased from 61.7% to 71.7%, 3) the percentage who immigrated during the 5 years preceding the survey increased from 9.9% to 19.3%, and 4) the percentage who spoke little or no English increased from 61.0% to 77.2%. Thus, in 2002 compared with 1994, Korean women were more likely to be middle-aged, college educated, and recent immigrants who spoke little or no English.

In 1994, 79.2% of Korean women in Santa Clara County reported having at least one routine checkup during their lifetimes, and 40.5% had routine checkups during the preceding year (Table). An estimated 65.0% had at least one Pap test during their lifetimes, and 56.6% had Pap tests during the preceding 3 years. Approximately 66.3% of Korean women had performed breast self-examinations at least once during their lifetimes, and 23.6% performed breast self-examinations monthly. Among Korean women aged [greater than or equal to] 50 years, 40.9% had at least one clinical breast examination during their lifetimes, 29.2% had clinical breast examinations during the preceding 2 years, 43.3% had at least one mammogram during their lifetimes, and 28.7% reported having mammograms during the preceding 2 years.