Screening mammography: a cross-sectional study to compare characteristics of women aged 40 and older from the deep South who are current, overdue, and never screeners

Contextual factors associated with cancer screening uptake: A systematic review of observational studies

We conducted a systematic review of a wide range of contextual factors related to cancer screening uptake that have been studied so far. Studies were identified through PubMed and Web of Science databases. An operational definition of context was proposed, considering as contextual factors: social relations directly aimed at cancer screening, health care provider and facility characteristics, geographical/accessibility measures and aggregated measures at supra-individual level. We included 70 publications on breast, cervical and/or colorectal cancer screening from 42 countries, covering a data period of 24 years. A wide diversity of factors has been investigated in the literature so far. While several of them, as well as many interactions, were robustly associated with screening uptake (family, friends or provider recommendation, provider sex and experience, area-based socio-economic status…), others showed less consistency (ethnicity, urbanicity, travel time, healthcare density …). Screening inequities were not fully explained through adjustment for individual and contextual factors. Context, in its diversity, influences individual screening uptake and lots of contextual inequities in screening are commonly shared worldwide. However, there is a lack of frameworks, standards and definitions that are needed to better understand what context is, how it could modify individual behaviour and the ways of measuring and modifying it.

Assessing health disparities in breast cancer incidence burden in Tennessee: geospatial analysis

Background

Tennessee women experience the 12th highest breast cancer mortality in the United States. We examined the geographic differences in breast cancer incidence in Tennessee between Appalachian and non-Appalachian counties from 2005 to 2015.

Methods

We used ArcGIS 10.7 geospatial analysis and logistic regression on the Tennessee Cancer Registry incidence data for adult women aged ≥ 18 years (N = 59,287) who were diagnosed with breast cancer from 2005 to 2015 to evaluate distribution patterns by Appalachian county designation. The Tennessee Cancer Registry is a population-based, central cancer registry serving the citizens of Tennessee and was established by Tennessee law to collect and monitor cancer incidence. The main outcome was breast cancer stage at diagnosis. Independent variables were age, race, marital status, type of health insurance, and county of residence.

Results

Majority of the sample were White (85.5%), married (58.6%), aged ≥ 70 (31.3%) and diagnosed with an early stage breast cancer (69.6%). More than half of the women had public health insurance (54.2%), followed by private health insurance coverage (44.4%). Over half of the women resided in non-Appalachian counties, whereas 47.6% were in the Appalachian counties. We observed a significant association among breast cancer patients with respect to marital status and type of health insurance coverage (p =  < 0.0001). While the logistic regression did not show a significant result between county of residence and breast cancer incidence, the spatial analysis revealed geographic differences between Appalachian and non-Appalachian counties. The highest incidence rates of 997.49–1164.59/100,000 were reported in 6 Appalachian counties (Anderson, Blount, Knox, Rhea, Roane, and Van Buren) compared to 3 non-Appalachian counties (Fayette, Marshall, and Williamson).

Conclusions

There is a need to expand resources in Appalachian Tennessee to enhance breast cancer screening and early detection. Using geospatial techniques can further elucidate disparities that may be overlooked in conventional linear analyses to improve women’s cancer health and associated outcomes.

Older Women’s Perspectives Driving Mammography Screening Use and Overuse: a Narrative Review of Mixed-Methods Studies

Purpose of Review

Examining what older women know and perceive about mammography screening is critical for understanding patterns of under- and overuse, and concordance with screening mammography guidelines in the USA. This narrative review synthesizes qualitative and quantitative evidence around older women’s perspectives toward mammography screening.

Recent Findings

The majority of 43 identified studies focused on promoting mammography screening in women of different ages, with only four studies focusing on the overuse of mammography in women ≥ 70 years old. Older women hold positive attitudes around screening, perceive breast cancer as serious, believe the benefits outweigh the barriers, and are worried about undergoing treatment if diagnosed. Older women have limited knowledge of screening guidelines and potential harms of screening.

Summary

Efforts to address inequities in mammography access and underuse need to be supplemented by epidemiologic and interventional studies using mixed-methods approaches to improve awareness of benefits and harms of mammography screening in older racially and ethnically diverse women. As uncertainty around how best to approach mammography screening in older women remains, understanding women’s perspectives along with healthcare provider and system-level factors is critical for ensuring appropriate and equitable mammography screening use in older women.

Implementation and Utilization of a "Pink Card" Walk-In Screening Mammography Program Integrated With Physician Visits

PURPOSE

The aim of this study was to evaluate the implementation and utilization of the Pink Card program, which links a physician-delivered reminder that a woman is due for screening mammography (SM) during an office visit with the opportunity to undergo walk-in screening.

METHODS

In 2016, the authors' community-based breast imaging center provided physicians from three primary care and obstetrics and gynecology practices located in the same outpatient facility business card-sized Pink Cards to offer women due for SM during office visits. The card includes a reminder that screening is due and can be used to obtain SM on a walk-in basis. The primary outcome measure was the proportion of women who used Pink Cards among all screened women over 2 years. Independent predictors of Pink Card utilization were evaluated using multivariate logistic regression analyses.

RESULTS

Among 3,688 women who underwent SM, Pink Cards were used by 19.9% (733 of 3,688). Compared with women with prescheduled screening visits, Pink Card users were more likely to be Asian (odds ratio [OR], 1.37; P =.032), Black (OR, 2.05; P = .002), and Medicaid insured (OR, 1.71; P = .013) and less likely to use English as their primary language (OR, 2.75; P = .003). Additionally, Pink Card users were less likely to be up to date for biennial SM compared with women with prescheduled visits (31.9% [234 of 733] versus 66.6% [1,968 of 2,955], P < .001).

CONCLUSIONS

The Pink Card walk-in SM program can improve screening access, particularly for racial/ethnic minorities and Medicaid-insured patients. Expansion of this program may help reduce disparities and increase engagement in breast cancer screening.

Breast Screening Utilization and Cost Sharing Among Employed Insured Women After the Affordable Care Act

OBJECTIVE

To assess changes in screening mammography cost sharing and utilization before and after the Affordable Care Act (ACA) and the revised US Preventive Services Task Force (USPSTF) guidelines. To compare mammography cost sharing between women aged 40 to 49 and those 50 to 74.

METHODS

We used patient-level analytic files between 2004 and 2014 from Clinformatics Data Mart (OptumInsight, Eden Prairie, Minnesota). We included women 40 to 74 years without a history of breast cancer or mastectomy. We conducted an interrupted time series analyses assessing cost sharing and utilization trends before and after the ACA implementation and USPSTF revised guidelines.

RESULTS

We identified 1,763,959 commercially insured women aged 40 to 74 years. Between 2004 and 2014, the proportion of women with zero cost share for screening mammography increased from 81.9% in 2004 to 98.2% in 2014, reaching 93.1% with the 2010 ACA implementation. The adjusted median cost share remained $0 over time. Initially at 36.0% in 2004, screening utilization peaked at 42.2% in 2009 with the USPSTF guidelines change, dropping to 40.0% in 2014. Comparing women aged 40 to 49, 50 to 64, and 65 to 74, the proportion exposed to cost sharing declined over time in all groups.

CONCLUSIONS

A substantial majority of commercially insured women had first-dollar coverage for mammography before the ACA. After ACA, nearly all women had access to zero cost-share mammography. The lack of an increase in mammography use post-ACA can be partially attributed to a USPSTF guideline change, the high proportion of women without cost sharing before the ACA, and the relatively low levels of cost sharing before the policy implementation.

Change in Breast Cancer Screening Knowledge is Associated With Change in Mammogram Intention in Mexican-Origin Women After an Educational Intervention

Purpose:

To determine the relationship between breast cancer screening knowledge and intent to receive a mammogram within 6 months in a sample of Mexican-origin women living in El Paso, Texas.

Methods:

A total of 489 uninsured Mexican-origin women were assigned to treatment or control and completed surveys at pre- and postintervention. Pre-post associations between breast cancer screening knowledge and intent were tested.

Results:

Participants were on average were 56.7 years of age and spoke primarily Spanish (92.6%). Most of the samples had not had a mammogram in 3 or more years (51.6%) and 14.6% had never had a mammogram. At baseline, the majority intended to be screened for breast cancer within the next 6 months (93.4%). At postintervention, half of the intervention group changed their 6-month intent to be screened for breast cancer from likely to unlikely. Change in intent was associated with a change in knowledge of risk of having a first child by the age of 30 and breast cancer being rare after the age of 70.

Discussion:

Intent to be screened for breast cancer in Mexican-origin women may be influenced by the type of knowledge.

Conclusions:

Change in screening knowledge may influence perceived risk that influences intention to be screened.

Screening Mammography Utilization and Medicare Beneficiaries' Perceptions of Their Primary Care Physicians

RATIONALE AND OBJECTIVES

To assess associations between screening mammography utilization and Medicare beneficiaries' relationships with, and impressions of, their primary care physicians.

MATERIALS AND METHODS

Using the Medicare Current Beneficiary Survey Access to Care Public Use File, we retrospectively studied responses from a national random cross section of Medicare beneficiaries surveyed in 2013 regarding perceptions of their primary care physicians and their screening mammography utilization. Statistical analysis accounted for subject weighting factors to estimate national screening utilization.

RESULTS

Among 7492 female Medicare beneficiaries, 62.0% (95% confidence interval 59.8%-64.2%) underwent screening mammography. Utilization was higher for beneficiaries having (vs. not) a regular medical practice or clinic (63.2% vs. 34.6%) and a usual physician (63.8% vs. 50.3%). Utilization was higher for beneficiaries very satisfied (vs. very dissatisfied) with the overall quality of care they received (66.0% vs. 35.8%), their ease of getting to a doctor (67.7% vs. 43.2%), and their physician's concerns for their health (65.7% vs. 53.4%), as well as for beneficiaries strongly agreeing (vs. strongly disagreeing) that their physician is competent (66.0% vs. 54.1%), understands what is wrong (66.3% vs. 47.1%), answers all questions (67.0% vs. 46.7%), and fosters confidence (66.0% vs. 50.6%). Independent predictors of screening mammography utilization (P < .05) were satisfaction with quality of care, having a regular practice or clinic, and satisfaction with ease of getting to their physician.

CONCLUSIONS

Screening mammography utilization is higher among Medicare beneficiaries with established primary physician relationships, particularly when those relationships are favorable. To optimize screening mammography utilization, breast imagers are encouraged to support initiatives to enhance high-quality primary care relationships.

Patient and physician characteristics affect adherence to screening mammography: A population-based cohort study

BACKGROUND

Screening mammograms are widely recommended biennially for women between the ages of 50 and 74. Despite the benefits of screening mammograms, full adherence to recommendations falls below 75% in most developed countries. Many studies have identified individual (obesity, smoking, socio-economic status, and co-morbid conditions) and primary-care physician parameters (physician age, gender, clinic size and cost) that influence adherence, but little data exists from large population studies regarding the interaction of these individual factors.

METHODS

We performed a historical cohort study of 44,318 Israeli women age 56-74 using data captured from electronic medical records of a large Israeli health maintenance organization. Univariate analysis was used to examine the association between each factor and adherence (none, partial or full) with screening recommendations between 2008-2014. Multivariate analysis was used to examine the significance of these factors in combination, using binary and multinomial logistic regression.

RESULTS

Among 44,318 women, 42%, 43% and 15% were fully, partially and non-adherent to screening recommendations, respectively. Factors associated with inferior adherence identified in our population included: smoking, obesity, low body weight, low socio-economic status, depression, diabetes mellitus and infrequent physician visits, while, women with ischemic heart disease, female physicians, physicians between the ages of 40 and 60, and medium-sized clinics were associated with higher screening rates. Most factors remained significant in the multivariate analysis.

CONCLUSIONS

Both individual and primary-care physician factors contribute to adherence to mammography screening guidelines. Strategies to improve adherence and address disparities in mammography utilization will need to address these factors.

Breast cancer screening disparities among immigrant women by world region of origin: a population-based study in Ontario, Canada

Rates of mammography screening for breast cancer are disproportionately low in certain subgroups including low-income and immigrant women. The purpose of the study was to examine differences in rates of appropriate breast cancer screening (i.e., screening mammography every 2 years) among Ontario immigrant women by world region of origin and explore the association between appropriate breast cancer screening among these women groups and individual and structural factors. A cohort of 183,332 screening-eligible immigrant women living in Ontario between 2010 and 2012 was created from linked databases and classified into eight world regions of origin. Appropriate screening rates were calculated for each region by age group and selected sociodemographic, immigration, and healthcare-related characteristics. The association between appropriate screening across the eight regions of origin and selected sociodemographic, immigration, and health-related characteristics was explored using multivariate Poisson regression. Screening varied by region of origin, with South Asian women (48.5%) having the lowest and Caribbean and Latin American women (63.7%) the highest cancer screening rates. Factors significantly associated with lower screening across the world regions of origin included living in the lowest income neighborhoods, having a refugee status, being a new immigrant, not having a regular physical examination, not being enrolled in a primary care patient enrollment model, having a male physician, and having an internationally trained physician. Multiple interventions entailing cross-sector collaboration, promotion of patient enrollment models, community engagement, comprehensive and intensive outreach to women, and knowledge translation and transfer to physicians should be considered to address screening disparities among immigrant population. Consideration should be given to design and delivery of culturally appropriate and easily accessible cancer screening programs targeted at high- risk immigrant subgroups, such as women of South Asian origin, refugees, and new immigrants.

Family/friend recommendations and mammography intentions: the roles of perceived mammography norms and support

Identifying factors that increase mammography use among Latinas is an important public health priority. Latinas are more likely to report mammography intentions and use, if a family member or friend recommends that they get a mammogram. Little is known about the mechanisms underlying the relationship between social interactions and mammography intentions. Theory suggests that family/friend recommendations increase perceived mammography norms (others believe a woman should obtain a mammogram) and support (others will help her obtain a mammogram), which in turn increase mammography intentions and use. We tested these hypotheses with data from the ¡Fortaleza Latina! study, a randomized controlled trial including 539 Latinas in Washington State. Women whose family/friend recommended they get a mammogram within the last year were more likely to report mammography intentions, norms and support. Perceived mammography norms mediated the relationship between family/friend recommendations and intentions, Mediated Effect = 0.38, 95%CI [0.20, 0.61], but not support, Mediated Effect = 0.002, 95%CI [-0.07, 0.07]. Our findings suggest perceived mammography norms are a potential mechanism underlying the effect of family/friend recommendations on mammography use among Latinas. Our findings make an important contribution to theory about the associations of social interactions, perceptions and health behaviors.

Changes in colorectal cancer screening intention among people aged 18-49 in the United States

BACKGROUND

To determine whether exposure to a peer-led intervention focused on colorectal cancer (CRC) screening, physical activity, and multi-vitamin intake can lead to increased intentions to be screened for CRC once age eligible among adults under the age of 50.

METHODS

Participants were residents of low-income housing sites, and CRC screening intentions were assessed at baseline and at follow-up (approximately 2 years later) to determine changes in screening intentions and factors associated with changes in intentions.

RESULTS

Participants (n = 692) were 78.4% female, 42.6% Hispanic and 50.8% black. At follow-up, 51% maintained their intention to be screened and 14.6% newly intended to get screened. Individuals newly intending to get screened were more likely to have participated in the intervention, be older, male, and born in Puerto Rico or the United States compared to those who maintained their intention not to get screened (p < 0.05).

CONCLUSION

Exposure to CRC prevention messages before the age of 50 can increase screening intentions among individuals who did not initially intend to get screened. Peer-led interventions to promote CRC screening should include individual less than 50 years of age, as this may contribute to increased screening at the recommended age threshold.

Mammography utilization among Black and White Medicare beneficiaries in high breast cancer mortality US counties

BACKGROUND

Disparities in US breast cancer mortality between older Black and White women have increased in the last 20 years. Regular mammography use is important for early detection and treatment: its utilization among older Blacks especially in counties with high Black mortality is of interest, but its extent and determinants are unknown.

METHODS

We used Medicare claims for Black and White women 65–74 years old in 203 counties with the highest Black breast cancer mortality. Outcomes over 6 years were as follows: ever mammogram, i.e., C 1 screening mammogram, and regular mammogram, i.e., C 3 mammograms. With logistic regressions, we examined the independent effect of race on screening controlling for individual- and county-level factors.

RESULTS

Of 406,602 beneficiaries, 17 % were Black. Ever and regular mammogram was significantly lower among Blacks (51.6 vs. 56.9 %; 32.9 vs. 43.1 %, respectively). Controlling for covariates, including use of cervical cancer screening, flu shots, or lipids tests, Black women were more likely to have ever mammogram (OR 1.23, CI 1.20–1.25), but not regular mammogram (OR 0.95, CI 0.93–0.97) than White women. County-level managed care penetration was negatively associated with ever and regular mammograms.

CONCLUSIONS

In Medicare enrollees from these counties, breast cancer screening was low. Black women had same or better odds of screening than White women. Some health care factors, e.g., managed care, were negatively associated with screening. Further studies on the determinants of mammography utilization in older women from these counties are warranted.

Perceived barriers to mammography among underserved women in a Breast Health Center Outreach Program

BACKGROUND

To investigate perceived barriers to mammography among underserved women, we asked participants in the Siteman Cancer Center Mammography Outreach Registry-developed in 2006 to evaluate mobile mammography's effectiveness among the underserved-why they believed women did not get mammograms.

METHODS

The responses of approximately 9,000 registrants were analyzed using multivariable logistic regression. We report adjusted odds ratios (OR) and 95% confidence intervals (CI) significant at 2-tailed P values less than .05.

RESULTS

Fears of cost (40%), mammogram-related pain (13%), and bad news (13%) were the most commonly reported barriers. Having insurance was associated with not perceiving cost as a barrier (OR .44, 95% CI .40 to .49), but with perceiving fear of both mammogram-related pain (OR 1.39, 95% CI 1.21 to 1.60) and receiving bad news (OR 1.38, 95% CI 1.19 to 1.60) as barriers.

CONCLUSION

Despite free services, underserved women continue to report experiential and psychological obstacles to mammography, suggesting the need for more targeted education and outreach in this population.

Improving mammography screening among the medically underserved

BACKGROUND

We evaluated the effectiveness and cost-effectiveness of alternative interventions designed to promote mammography in safety-net settings.

METHODS

A three-arm, quasi-experimental evaluation was conducted among eight federally qualified health clinics in predominately rural Louisiana. Mammography screening efforts included: 1) enhanced care, 2) health literacy-informed education of patients, and 3) education plus nurse support. Outcomes included mammography screening completion within 6 months and incremental cost-effectiveness.

RESULTS

Overall, 1,181 female patients ages 40 and over who were eligible for routine mammography were recruited. Baseline screening rates were < 10%. Post intervention screening rates were 55.7% with enhanced care, 51.8% with health literacy-informed education and 65.8% with education and nurse support. After adjusting for race, marital status, self-efficacy and literacy, patients receiving health-literacy informed education were not more likely to complete mammographic screening than those receiving enhanced care; those additionally receiving nurse support were 1.37-fold more likely to complete mammographic screening than those receiving the brief education (95% Confidence Interval 1.08-1.74, p = 0.01). The incremental cost per additional women screened was $2,457 for literacy-informed education with nurse support over literacy-informed education alone.

CONCLUSIONS

Mammography rates were increased substantially over existing baseline rates in all three arms with the educational initiative, with nurse support and follow-up being the most effective option. However, it is not likely to be cost-effective or affordable in resource-limited clinics.

Are immigrants and nationals born to immigrants at higher risk for delayed or no lifetime breast and cervical cancer screening? The results from a population-based survey in Paris metropolitan area in 2010

OBJECTIVES

This study aims to compare breast cancer screening (BCS) and cervical cancer screening (CCS) practices of French women born to French parents with those of immigrants and nationals born to immigrants, taking their socioeconomic status into account.

METHODS

The study is based on data collected in 2010 in the Paris metropolitan area among a representative sample of 3000 French-speaking adults. For women with no history of breast or cervical cancer, multivariate logistic regressions and structural equation models were used to investigate the factors associated with never having undergone BCS or CCS.

RESULTS

We confirmed the existence of a strong gradient, with respect to migration origin, for delaying or never having undergone BCS or CCS. Thus, being a foreign immigrant or being French of immigrant parentage were risk factors for delayed and no lifetime screening. Interestingly, we found that this gradient persisted (at least partially) after adjusting for the women's socioeconomic characteristics. Only the level of income seemed to play a mediating role, but only partially. We observed differences between BCS and CCS which suggest that organized CCS could be effective in reducing socioeconomic and/or ethnic inequities.

CONCLUSION

Socioeconomic status partially explained the screening nonparticipation on the part of French women of immigrant origin and foreign immigrants. This was more so the case with CCS than with BCS, which suggests that organized prevention programs might reduce social inequalities.

The role of a lack of social integration in never having undergone breast cancer screening: results from a population-based, representative survey in the Paris metropolitan area in 2010

OBJECTIVES

This study aims to investigate the association between social contact and social support and women's breast cancer screening (BCS) practices, taking their socioeconomic status (SES) into account.

METHODS

The SIRS survey was conducted in 2010 in the Paris metropolitan area among a representative sample of 3000 French-speaking adults. For the 784 women aged 50years or older with no history of breast cancer, multivariate logistic regressions and bootstrap methods were used to analyze the factors associated with never having undergone BCS.

RESULTS

6.5% of these women had never undergone BCS. In multivariate analysis, being older, having a low education level, having poor-quality health insurance, and having one or less than one social contact per 3-day period were significantly associated with never having undergone BCS during their lifetime, but the level of social support was not. The strength of the association with a low frequency of social contact tended to increase with age.

CONCLUSION

This study analyzed the role of social contact in social inequalities in BCS practices in the Paris metropolitan area. Like SES, social integration and social isolation should be taken into consideration by public health professionals and practitioners when planning BCS programs and incentives.

Intermittent attendance at breast cancer screening

BACKGROUND

To determine why women skip rounds and factors influencing return of previous non attenders (PNAs) to breast screening.

DESIGN AND METHODS

Retrospective, quantitative, structured questionnaire posted to 2500 women. First PNAs did not attend their first screening appointment in 2007/2008 but then attended in 2010; First Controls first attended in 2010 without missed previous appointments. Women who attended screening in 2006 or earlier then skipped a round but returned in 2010 were Subsequent PNAs; Subsequent Controls attended all appointments.

RESULTS

More First Controls than First PNAs had family history of cancer (72.7% vs 63.2%; P=0.003); breast cancer (31.3% vs 24.8%; P=0.04). More PNAs lived rurally; more First PNAs had 3rd level education (33.2% vs 23.6%; P=0.002) and fewer had private insurance than First Controls (57.7% vs 64.8%; P=0.04). Excellent/good health was reported in First PNAs and First Controls (82.9% vs 83.2%), but fewer Subsequent PNAs than Subsequent Controls (72.7% vs 84.9%; P=0.000). Common considerations at time of missed appointment were had mammogram elsewhere (33% First PNA) and postponed to next round (16% First PNA, 18.8% Subsequent PNA). Considerations when returning to screening were similar for First PNAs and Subsequent PNAs: I am older (35.4%, 29.6%), I made sure I remembered (29%, 23.6%), could reschedule (17.6%, 20.6%), illness of more concern (16.5%, 19%). More First PNAs stated my family/friends advised (22.3% vs 15.2%) or my GP (12.6% vs 4.6%) advised me to attend, heard good things about BreastCheck (28.8% vs 13.6%).

CONCLUSIONS

Intermittent attenders do not fit socio-demographic patterns of non-attenders; GP recommendation and word of mouth were important in women's return to screening. Fear and anxiety seem to act as a screening facilitator rather than an inhibitor. Significance for public healthAll breast cancer screening programmes strive to achieve and maintain a high level of attendance, as this is essential to reduce breast cancer mortality, together with cancer detection. While non-attendance has been widely studied, little is known about intermittent attenders. It is unclear why a woman chooses not to attend her breast screening appointment but then decides to respond positively to screening invitation two or more years later. The literature identifies many reasons why some women choose not to attend; but this study distinguishes those who then change their mind and return to screening. This study explores a sub-set of non-attenders which have, to date, been largely ignored, or grouped with people who never attend. This study will inform those struggling with non-attendance in their population based health programmes and will help to tackle the problem of non-attendance, which has adverse affects both economically and epidemiologically.

Barriers to screening mammography

Breast cancer (BRCA) is the second most commonly diagnosed cancer among women in the USA, and mammography is an effective means for the early detection of BRCA. Identifying the barriers to screening mammography can inform research, policy and practice aiming to increase mammography adherence. A literature review was conducted to determine common barriers to screening mammography adherence. PsycINFO and PubMed databases were searched to identify studies published between 2000 and 2012 that examined barriers associated with reduced mammography adherence. Three thematic groups of barriers, based on social ecology, were identified from the literature: healthcare system-level, social and individual-level barriers. Researchers must consider screening behaviour in context and, therefore, should simultaneously consider each level of barriers when attempting to understand screening behaviour and create interventions to increase mammography adherence.

Influence of primary care physician availability and socioeconomic deprivation on breast cancer from 1988 to 2008: a spatio-temporal analysis

Background

Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among women in the United States. It is unclear how county-level primary care physician (PCP) availability and socioeconomic deprivation affect the spatial and temporal variation of breast cancer incidence and mortality.

Methods

We used the 1988–2008 public-use county-based data from nine Surveillance, Epidemiology, and End Results (SEER) programs to analyze the temporal and spatial disparity of PCP availability and socioeconomic deprivation on early-stage incidence, advanced-stage incidence and breast cancer mortality. The spatio-temporal analysis was implemented by a novel structural additive modeling approach.

Results

Greater PCP availability was significantly associated with higher early-stage incidence, advanced-stage incidence and mortality during the entire study period while socioeconomic deprivation was significantly negatively associated with early-stage incidence, advanced-stage incidence, and mortality up to 1992. However, the observed influence of PCP availability and socioeconomic deprivation varied by county.

Conclusions

We showed important associations of PCP availability and socioeconomic deprivation with the three breast cancer indicators. However, the effect of these associations varied over time and across counties. The association of PCP availability and socioeconomic deprivation was stronger in selected counties.

Differences in barriers to mammography between rural and urban women

BACKGROUND

Few studies have examined differences between rural and urban women in mammography barriers, knowledge, and experiences. Exploring differences can help inform tailored interventions.

METHODS

Women, aged ≥40, who had not been screened in the past 2 years were recruited from eight federally qualified health centers across Louisiana. They were given a structured interview assessing mammography knowledge, beliefs, barriers, experiences, and literacy.

RESULTS

Of the 1189 patients who participated, 65.0% were African American, 61.6% were rural, and 44.0% had low literacy. Contrary to guidelines, most believed mammography should be done annually (74.3%) before age 40 (70.5%). Compared to urban women, rural participants were more likely to believe mammography will find small breast lumps early (34.4% vs. 6.5%, p<0.0001) and strongly disagree that mammography is embarrassing (14.6% vs. 8.4%, p=0.0002) or that they are afraid of finding something wrong (21.2% vs.12.3%, p=0.007). Rural women were more likely to report a physician recommendation for mammography (84.3% vs. 76.5%, p=0.006), but they were less likely to have received education (57.2% vs. 63.6%, p=0.06) or to have ever had a mammogram (74.8% vs. 78.1%, p=0.007). In multivariate analyses controlling for race, literacy, and age, all rural/urban differences remained significant, except for receipt of a mammogram.

CONCLUSIONS

Most participants were unclear about when they should begin mammography. Rural participants reported stronger positive beliefs, higher self-efficacy, fewer barriers, and having a physician recommendation for mammography but were less likely to receive education or screening.

Clustering very low-income, insured women's mammography screening barriers into potentially functional subgroups

BACKGROUND

Mammography screening is essential for early detection of breast cancer and increased survival rates. Women, particularly those of low socioeconomic status, face barriers that impede their screening adherence. Although many studies have sought to identify these barriers, more research is needed on to address these obstacles in practice. The objective of this study is to divide mammography screening barriers into functional clusters using empirical evidence, which may guide the development of effective mammography screening promotion messages.

METHODS

A sample of 173 low-income White and Black women randomly selected from a managed care organization rated each of 21 potential mammography barriers on a scale ranging from "strongly agree" to "strongly disagree." A maximum clustering similarity method was used to identify relevant clusters of screening barriers.

RESULTS

Five clusters were derived, with a high similarity index (0.881). Each cluster was named to reflect the shared theme of the barriers within it: Perceived Lack of Value in Health Care, Lack of Information, Mistrust/Skepticism, Medical Delay Behavior, and Anxiety/No Control. A dominant barrier within each cluster was identified, and bivariate correlation coefficients were reported.

CONCLUSION

Cluster analysis yielded five distinct subgroups of mammography screening barriers.

Recruitment for the National Breast and Cervical Cancer Early Detection Program

BACKGROUND

To reduce disparities in breast and cervical cancer in the U.S., it is essential that programs such as CDC's National Breast and Cervical Cancer Early Detection Program (NBCCEDP) use evidence-based strategies. Recommendations for interventions to increase breast and cervical cancer screening have been disseminated by national public health organizations. To increase screening, cancer control planners would benefit from use of evidence-based strategies for recruitment of participants in their communities.

PURPOSE

The purpose of the study was to inventory recruitment activities for cancer screening within NBCCEDP programs and assess if activities used to increase cancer screening are evidence-based.

METHODS

Interviews were conducted with 61 recruitment coordinators in 2008 to elicit their recruitment activities, use of evidence-based resources, and barriers to using evidence-based interventions (EBIs). Study data were analyzed in 2009.

RESULTS

Of the 340 activities reported, many were categorized as educational materials, one-on-one education, mass media, group education, and special events. Two thirds of inventoried activities matched an EBI. Coordinators reported that colleagues and the CDC are their primary sources of information about EBIs and few coordinators had used evidence-based resources. Lack of money or funding, questionable applicability to priority populations, limited staffing or staff time, and insufficient evidence-based research were the most important barriers to EBI use.

CONCLUSIONS

Although the majority of NBCCEDP recruitment activities were evidence-based, one third were not. Additional training and technical assistance are recommended to help public health agencies adopt the use of these strategies.

Integrated community education model: breast health awareness to impact late-stage breast cancer

Race and ethnicity play roles in breast cancer mortality, particularly for African American women. As a result, a three-pronged integrated community education model (i.e., faith-based, community, and state agencies) was generated and tested in a medically underserved area with high mortality rates from breast cancer to increase participation in breast health education, provide early screening and detection practices, and provide access to annual mammograms and referral sources. The model provided three women with life-saving early diagnoses, in addition to providing potentially hundreds of women with a network of breast health, self-monitoring, and referral sources for future issues.

Breast and Cervical Cancer Screening and Health Beliefs Among African American Women Attending Educational Programs

This article assessed the relationship between breast and cervical cancer screening rates and health beliefs in African American women participating in Witness Project of Harlem (WPH) education sessions. WPH is a culturally sensitive, faith-based breast and cervical cancer screening education program targeting African American women in medically underserved New York City communities. A questionnaire administered to women participating for the first time in a Witness Project education session collected demographics, adherence to breast and cervical cancer screening, and information about health beliefs related to cancer worry, medical mistrust, and religious faith. Screening adherence guidelines applied were as per the American Cancer Society recommendations. No statistically significant relationship was found between worry about getting breast or cervical cancer and screening adherence, or between screening adherence and agreement with statements about medical mistrust and religious beliefs. The low screening mammography and monthly breast self-exam rates emphasize the utility of programs like WPH that teach the importance of screening mammography and breast self-exam and point to the need for increased access to quality health care and cancer screening in underserved populations.

Updated recommendations for breast cancer screening

PURPOSE OF REVIEW

To describe the rationale behind the new recommendations for breast cancer screening issued by the U.S. Preventive Services Task Force (USPSTF).

RECENT FINDINGS

The USPSTF reviewed new summary evidence provided by the Oregon Evidence-based Practice Center and the Cancer Intervention Surveillance and Modeling Network about benefits and harms including radiation exposure and the likelihood of false-positive testing, unnecessary biopsies and treatments that may not impact overall breast cancer mortality.

SUMMARY

The USPSTF concluded maximal benefit in breast cancer mortality with least harms can be achieved with biennial mammography screening commenced at age 50 and continuing until age 74 years. A small additional benefit could be realized if screening starts at age 40 years. The USPSTF concluded that the decision to start biennial screening before age 50 years should be a personal one and take into account individual patient context, including an individual's values regarding specific benefits and harms. Evidence from large-scale randomized trials led the USPSTF to recommend against the teaching of breast self-examination. The USPSTF found insufficient evidence to recommend for or against performing clinical breast examination.

Antecedents and mediators of community connection in African American women with breast cancer

OBJECTIVE

To describe the theory of community connection defined as close relationships with women and men who are members of a neighborhood, a church, a work group, or an organization. Antecedent and mediator variables related to community connection are identified.

DESIGN/METHODS

A cross-sectional design was used to assess for relationships among theorized antecedents and mediators of community connection in a sample of 144 African American women aged 21 years and older (mean = 54.9) who had been diagnosed with invasive/infiltrating ductal carcinoma. MEASUREMENT AND ANALYSES: Community connection was measured with the relational health indices-community subscale. Mediator analysis was conducted to assess significance of the indirect effects of the mediator variables, which were fear, breast cancer knowledge, and isolation.

RESULTS

Community connection was found to be associated with three of the four antecedents, cancer stigma, stress, and spirituality, but not associated with fatalism. Effects were mediated primarily through fear and isolation with isolation as was more dominant of the two mediators. Surprisingly, breast cancer knowledge showed no significant mediator role.

CONCLUSIONS

The importance of isolation and fear as mediators of community connection is highlighted by this research. The study could serve as a model for other researchers seeking to understand connection in ethnic groups and communities.