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Volume 15, Issue 4
Fall 2003

• Feature Articles
  CHS 20th Anniversary
  Profile: S. Taplin, MD, MPH
• Center News
• Recent Publications
• Research Newsletter Page

Feature Article

Profile: Stephen Taplin, MD, MPH 

Breast cancer screening pioneer takes Group Health lessons to NCI

By Katie Saunders

As Stephen Taplin, MD, MPH, begins his new job as a senior scientist at the National Cancer Institute (NCI) this fall, he’ll be building on his 20 years of successful breast cancer research at Group Health’s Center for Health Studies (CHS). "I want to take what I’ve learned in the microcosm of Group Health Cooperative and see how it applies in the outside world," Taplin says of his new job, which focuses on improving breast cancer screening nationwide.

He’ll be drawing from experience accumulated at Group Health as a researcher, family practitioner, and clinician advisor to Group Health’s Breast Cancer Screening Program (BCSP), a nationally recognized model for screening programs.

When Taplin came to Group Health in 1984 as a Robert Wood Johnson Fellow through the University of Washington (UW), the BCSP was in its infancy. The brainchild of CHS senior investigator Robert S. "Tom" Thompson, MD, and Ann Carter, MD, the BCSP was envisioned as a population-based program to enhance the early detection of breast cancer, and thus, reduce mortality from this disease, which will affect one in every nine American women in her lifetime.

As Taplin explains, "outreach" is the key to the program. By proactively contacting all Group Health female enrollees when they turn age 40, the program doesn’t wait for women to engage with the health care system—the BCSP comes to them.

Initially, women are asked to complete a one-time survey, which gathers information pertaining to risk factors for breast cancer, such as having a family history of the disease. The program enrolls women upon return of the survey, sending automated reminder letters when a mammogram is due. The BCSP recommends mammogram reminders every one or two years for: 1) all women aged 50 years and older; and 2) women aged 40 to 49 who have risk factors for breast cancer. In the case of an abnormal mammogram, the BCSP nurses staffing one of the six regional centers make sure that the patient receives appropriate follow-up care, such as additional imaging or biopsies. This coordination of care is facilitated by automated systems. The BCSP was the first program of its kind in the U.S.

It was the philosophy underlying this program—the value of delivering clinical prevention services on a population-level—that originally drew Taplin to Group Health. While a resident at the UW, Taplin was struck by the gap—today called a "chasm"—that exists between what is known about ideal medical care and what is actually done in practice. "Why aren’t we doing what we’re supposed to do?" he wondered. At the time, under what Taplin calls Tom Thompson’s "pioneering leadership," Group Health was one of the few places, if not the only place, that was attempting to institute system-wide prevention programs founded on the scientific evidence—in other words, "translating research into practice."

The BCSP was probably the best example of this phenomenon. Chuckling as he recalls his introduction to the program, Taplin says, "[Then CHS Director] Ed Wagner asked me to spend two months fine-tuning aspects of the program—here I am 20 years later."

During this tenure, Taplin brought his clinical and research expertise to the ever-evolving BCSP as the program’s clinical advisor. Describing the development of the BCSP as an "iterative" process, Taplin was in on many changes that have affected all aspects of the program, including the target population, reminder systems, and screening intervals. "The BCSP is an alive program, constantly making changes," he says.

Group Health family practitioner and CHS Affiliate Investigator Bev Green, MD, MPH has taken the role of clinical advisor since Taplin’s departure and is working with staff led by Susan Carol Bradford. "The program will continue, and it will continue to change," Taplin says.

The dynamic nature of the BCSP reflects the ongoing controversies that characterize the breast cancer field. Green and Taplin recently wrote an article for The Journal of the American Board of Family Practice summarizing disputes that, according to Taplin, arise because of the constantly evolving, and sometimes ambiguous, state of the knowledge—as well as the cachet associated with breast cancer screening. Some controversial issues relate to the effectiveness of: 1) mammography screening in women aged 40–49; 2) clinical breast exams; and 3) breast self-exams. Of the sometime vituperative debates, Taplin says, "The data are evolving—people are constantly getting a little more information to fuel their perspective or to contradict someone else’s."

With his research expertise, Taplin played a key role in establishing and justifying the BCSP’s position in regard to several controversial issues. For example, along with the concept of "outreach," Group Health’s BCSP is known for its risk-based approach to screening. That is, in contrast to some other organizations that use a fixed one-year screening interval for all women 50 years and older, Group Health considers risk factors in addition to age—e.g., having a family history of breast cancer, not having given birth before age 30—and recommends screening every year for women with additional risks factors and every two years for women without added risk. Thus, more intensive resources are focused on women at higher risk. Taplin and colleagues recently conducted analyses showing that the two-year screening interval that is applied to a subset of women aged 50 years and older did not adversely affect rates of late stage breast cancer. "By using a risk-based program, we have been able to use resources in the areas in which they’re going to do the most good. Group Health was founded on this slogan—‘the greatest good for the greatest number,’" he explains.

And what’s the bottom-line for the BCSP? As of 2002, over 200,000 women had been mailed risk factor surveys, with a response rate of 87 percent; more than 300,000 mammograms had been performed through the program. Most significantly, analyses by Taplin and colleagues showed that in 1998, the rate of late-stage breast cancers was lower at Group Health than that of the surrounding community, and that the risk of late-stage disease was lower among BCSP participants at Group Health compared to those who did not enroll in the program. (It is still too early to assess the program’s effect on mortality).

While this is good news, there’s still room for improvement. In his role as researcher, Taplin questioned why late-stage disease still exists in health plans where all women have access to cancer screening. Is it because women don’t get screened, they get screened but the cancer is not detected, or the cancer is detected but not appropriately evaluated or followed-up?

Using large databases maintained through the Cancer Research Network, a group of 11 HMOs seeking to improve cancer care nationwide, Taplin and colleagues discovered that the majority of late stage breast cancers were found in women who were not screened. The second largest number of late-stage cancers was found in women with negative mammograms at the time of screening, while only 8 percent of late-stage disease was due to inadequate follow-up. Taplin summarizes the implications of these findings: " We physicians spend a lot of time making sure we don’t get sued—if we have a positive mammogram we make sure we evaluate it. Of course, that’s important, but lack of follow-up only accounts for 8 percent of late-stage cancers. If we really want to have an additional impact on late-stage disease, we need to be ready to spend the time and energy to understand and recruit those women who have never been screened."

Boosting participation in cancer screening has been a major focus of Taplin’s research over the years. While 87 percent of women complete the risk factor survey, only 65 percent follow through on an invitation for a mammogram within one year. In the late 1980s, Taplin and colleagues described the characteristics of women who responded to an invitation for a mammogram. The observational study showed that having a family history of breast cancer was a predictor of participation and that older women (60–79) were more likely to follow-up on an invitation for a mammogram than were younger women (50–59). Taplin says the latter was a particularly important finding because the common wisdom at the time was that older women tended not to participate in breast cancer screening. "We showed that, if they were invited, they would participate," says Taplin, an important point given the aging of American society.

After this observational study, Taplin and colleagues conducted several randomized trials that tested ways to increase participation in screening. Most recently, the researchers compared three methods: 1) a 10-minute motivational phone call addressing women’s barriers to mammography; 2) a three-minute phone call reminding women to schedule an appointment and actually scheduling the appointment, if possible; and 3) a postcard reminder. The study found that the brief phone call was as effective as the longer motivational call in increasing mammography participation rates (and both were superior to the reminder postcard).

Once a woman participates in a breast cancer screening program, the underlying assumption is that cancer, if present, will be detected. This is not always the case. Examining the reasons for missed cancers is one of the goals of Breast Cancer Surveillance, a multi-HMO project that links automated data on mammography and cancer outcomes to evaluate screening-related issues. In 1994, Group Health, under Taplin’s leadership, became one of the first two sites in the NCI’s Breast Cancer Surveillance Consortium (there are now eight). The Seattle Surveillance investigator team—Taplin, Emily White and Peggy Porter of the Fred Hutchinson Cancer Research Center, and Margaret Mandelson and Diana Buist of CHS—has published 30 to 40 peer-reviewed articles in the last decade. While Taplin is proud of this entire body of work, when pressed, he singles out a few studies that were particularly gratifying.

One of the most productive lines of inquiry relates to the impact of breast density on mammography accuracy. Dense breasts, as compared to fatty breasts, have a larger proportion of connective and epithelial tissue, which appears opaque on a screening mammogram and can thus obscure a tumor. A CHS study by Mandelson, Taplin, and colleagues examined density as a risk factor for interval cancer, defined as cancer that is detected in a certain period—e.g., one or two years—after a negative mammogram. The study found that women with extremely dense breasts were six times more likely to have their breast cancer missed by mammography compared to women with predominantly fatty tissue.

Partly because younger women have greater breast density on average than do older women, mammograms are less effective in the 40- to 49-year (premenopausal) age group. Another Surveillance study by White, Taplin, and others found that among women aged 40 to 49, breasts tend to be less dense during the first two weeks of the menstrual cycle as opposed to the third or fourth week. This finding has important implications for the optimal timing of a screening mammogram among premenopausal women. "Emily White and others have changed the focus from ‘does mammography benefit pre-menopausal women’ to ‘how can we improve effectiveness in this age group?’" says Taplin.

In yet another Surveillance study conducted by CHS’ Carolyn Rutter, Taplin, and others, initiation of hormone replacement therapy (HRT) by post-menopausal women was shown to increase breast density, while terminating use of HRT led to a reduction in density. This finding led to an ongoing study by CHS investigators Diana Buist and Katherine Newton to determine whether screening accuracy improves if a woman stops taking HRT two months before a mammogram. Commenting on the logical progression of this research, Taplin says, "That’s what I find exciting—when the Breast Cancer Surveillance team’s work contributes the foundation for somebody else’s future research—it’s a great feeling."

A first-of-its-kind study by Peggy Porter, Taplin, and others, described the biologic characteristics of tumors that were more likely to be found at the time of a screening mammogram compared to the characteristics of cancers found after a negative screen. "No one had really examined these characteristics before in one inclusive dataset—our group did. I’m proud that there’s a biologic aspect to our research," Taplin says.

Taplin concludes his recitation of research highlights with his recent study showing that the chances of missing a cancer during mammography more than doubles when poor patient positioning occurs. Proper positioning allows for visualization of the muscle behind the breast, the entire breast, and the nipple. Improper positioning is "something we can do something about," says Taplin. Indeed, a commentary published along with Taplin’s article discusses the potential impact of this work: "[The study should] encourage efforts to further ensure proper image quality in (radiology) practices around our nation."

Given space constraints, Taplin could single out only a few highlights from the 70+ peer-reviewed publications that he has authored or co-authored over the last 15 years. There are obviously many more. And, there will be more to come, as he plans to continue his research related to the Surveillance Project as part of his NCI job, which began in September, 2003.

In addition to pursuing his research interests, Taplin will work to further breast cancer screening nationwide. With the weight of the evidence showing that mammography screening among women aged 50 years and older reduces breast cancer-related mortality by up to 40 percent, there’s ample incentive to maximize the process. To that end, Taplin will help evaluate whether the NCI is sponsoring research that is asking the right questions. He will also continue his current involvement with the Cancer Collaborative, a group of 20 health care teams across the U.S. that is working with the Bureau of Primary Health Care, a government organization that funds over 700 low-income primary care clinics throughout the U.S. Commenting on these clinics’ efforts to improve breast cancer screening, Taplin says: "It’s really satisfying because their main concern is not their need for more resources, but rather, how can they do better, given that they have very limited resources."

Discussing Taplin’s contribution, Tom Thompson says, "Steve has grasped, articulated, and pioneered the delivery of population-based, but individually tailored, breast cancer screening services. For practitioners and the research community, his work serves as a model for systematically planned care that makes a major and direct difference to patients."

Explaining his decision to move to the NCI, Taplin says, "I’m looking at this as an opportunity to expand my horizons and see what’s happening in the rest of the world." When asked what he will miss most about Group Health and CHS, he initially deflects the question with a joke about exchanging his view of the Space Needle and the Olympic Mountains for a view of a parking lot. Then Taplin turns serious. "I’ll really miss taking care of people—it’s a privilege to have people open up their lives to you. And, I’ll miss my colleagues, who taught me so much," he says.

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