Area-level Socioeconomic Inequalities in the Use of Mammography Screening: A Multilevel Analysis of the Health of Houston Survey

Disparity in cognitive factors related to cancer screening uptake based on the theory of planned behavior

INTRODUCTION

Early detection of cancer is a highly effective way to decrease cancer-related deaths. The purpose of this study was to determine the disparity in cognitive factors related to cancer screening uptake based on the theory of planned behavior (TPB).

METHODS

In this cross-sectional study, conducted in Kermanshah County, the west of Iran, during 2019, a total of 1760 people aged 30 to 75 years old, were randomly selected to participate voluntarily in the study. Participants filled out a questionnaire including the socio demographic variables, socioeconomic status (SES), TPB variables, and cancer screening uptake behaviors.

RESULTS

The mean age of respondents was 45.28. 44.96% of the participants had undergone cancer screening at least once. Socioeconomic status (SES) and gender had the most significant impact on the disparity in cancer screening uptake, with contributions of 74.64% and 22.25% respectively. Women were 8.63 times more likely to be screened than men. Participants with a family history of cancer had a 2.84 times higher chance of being screened. Single individuals were significantly less likely to be screened compared to married individuals. The concentration index for attitude, subjective norms (SN), perceived behavior control (PBC), behavior intention, and cancer screening uptake was 0.0735, 0.113, 0.333, 0.067, and 0.132 respectively. Intention (Beta = 0.225 and P: < 0.001) is a significant predictor of cancer screening behaviors.

CONCLUSION

The findings of this study are highly valuable for health policymakers in Iran. They emphasize the significance of creating, executing, and assessing campaigns that promote intention, PBC and SN, particularly among disadvantaged individuals. By doing so, we can effectively decrease the disparity in cancer screening rates. It is crucial to prioritize men, single individuals, and disadvantaged groups in cancer screening promotion programs. This knowledge can be utilized to develop an intervention that is guided by theory and supported by evidence, with the aim of increasing cancer screening rates and minimizing disparities.

Contextual and individual inequalities in breast cancer screening participation and outcomes in Turin (North-West Italy)

Breast cancer incidence and screening participation exhibit an unequal distribution in the population. This study aims to investigate the impact of socioeconomic position (SEP) on three breast screening indicators (participation, recall, and cancer detection rates) among women aged 50-69 in the city of Turin between 2010 and 2019. The study also aims to determine whether contextual factors (deprivation index) or individual factors (educational level) have a greater influence. The data used in this study are sourced from the Turin Breast Screening Program (TBSP) and the Turin Longitudinal Study (TLS). To test the hypothesis and account for the hierarchical structure of the data, multilevel models were used. Both contextual and individual SEP were found to be associated with screening participation. Participation increased with higher levels of deprivation (odds ratio for most deprived: 1.13; 95% CI 1.11-1.16) and decreased with higher educational levels (OR for low educated: 1.37; 95% CI 1.34-1.40). Contextual SEP did not show any association with recall or cancer detection rates, but individual SEP had an impact. Women with lower educational levels had a statistically significant 19% lower odds of being recalled and a statistically significant 20% lower odds of being diagnosed with cancer. Additionally, immigrant women were less likely to participate in screening, be recalled, or receive a cancer diagnosis. Educational level consistently influenced the analyzed screening indicators, while contextual deprivation appeared to have less importance. It is likely that women living in less deprived areas and with higher education have greater access to opportunistic screening.

Social determinants of health and health inequities in breast cancer screening: a scoping review

Introduction

This scoping review aims to highlight key social determinants of health associated with breast cancer screening behavior in United States women aged ≥40  years old, identify public and private databases with SDOH data at city, state, and national levels, and share lessons learned from United States based observational studies in addressing SDOH in underserved women influencing breast cancer screening behaviors.

Methods

The Arksey and O'Malley York methodology was used as guidance for this review: (1) identifying research questions; (2) searching for relevant studies; (3) selecting studies relevant to the research questions; (4) charting the data; and (5) collating, summarizing, and reporting results.

Results

The 72 included studies were published between 2013 and 2023. Among the various SDOH identified, those related to socioeconomic status (n = 96) exhibited the highest frequency. The Health Care Access and Quality category was reported in the highest number of studies (n = 44; 61%), showing its statistical significance in relation to access to mammography. Insurance status was the most reported sub-categorical factor of Health Care Access and Quality.

Discussion

Results may inform future evidence-based interventions aiming to address the underlying factors contributing to low screening rates for breast cancer in the United States.

Effect of neighborhood and individual-level socioeconomic factors on breast cancer screening adherence in a multi-ethnic study

BACKGROUND

Although mammography can significantly reduce breast cancer mortality, many women do not receive their annual breast cancer screening. Differences in screening adherence exist by race/ethnicity, socioeconomic status (SES), and insurance status. However, more detailed investigations into the impact of neighborhood disadvantage and access to resources on screening adherence are lacking.

METHODS

We comprehensively examined the effect of individual social, economic, and demographic factors (n = 34 variables), as well as neighborhood level SES (nSES) indicators (n = 10 variables) on breast cancer screening adherence across a multi-ethnic population (n = 472). In this cross-sectional study, participants were surveyed from 2017 to 2018. The data was analyzed using univariate regression and LASSO for variable reduction. Significant predictors were carried forward into final multivariable mixed-effect logistic regression models where odds ratios (OR), 95% confidence intervals and p-values were reported.

RESULTS

Nineteen percent of participants were non-adherent to breast screening guidelines. Race/ethnicity was not associated with adherence; however, increasing age (OR = 0.97, 95%CI = 0.95-0.99, p = 0.01), renting a home (OR = 0.53, 95%CI = 0.30-0.94, p = 0.04), food insecurity (OR 0.46, 95%CI = 0.22-0.94, p = 0.01), and overcrowding (OR = 0.58, 95% CI = 0.32-0.94, p = 0.01) were significantly associated with lower breast cancer screening adherence.

CONCLUSION

Socioeconomic indicators at the individual and neighborhood levels impact low breast cancer screening adherence and may help to inform future screening interventions.

Experience of a single healthcare system with screening mammography before and after COVID-19 shutdown

PURPOSE

To evaluate COVID-19's longitudinal impact on screening mammography volume trends.

METHODS

HIPAA-compliant, IRB-approved, single institution, retrospective study of screening mammogram volumes before (10/21/2016-3/16/2020) and greater than two years after (6/17/2020-11/30/2022) a state-mandated COVID-19 shutdown (3/17/2020-6/16/2020) were reviewed. A segmented quasi-poisson linear regression model adjusting for seasonality and network and regional population growth compared volume trends before and after the shutdown of each variable: age, race, language, financial source, risk factor for severe COVID-19, and examination location.

RESULTS

Adjusted model demonstrated an overall increase of 65 screening mammograms per month before versus a persistent decrease of 5 mammograms per month for >2 years after the shutdown (p < 0.0001). In subgroup analysis, downward volume trends were noted in all age groups <70 years (age < 50: +9/month before vs. -7/month after shutdown; age 50-60: +17 vs. -7; and age 60-70: +21 vs. -2; all p < 0.001), those identifying as White (+55 vs. -8, p < 0.0001) and Black (+4 vs. +1, p = 0.009), all financial sources (Medicare: +22 vs. -3, p < 0.0001; Medicaid: +5 vs. +2, p = 0.006; private insurance/self-pay: +38 vs. -4, p < 0.0001), women with at least one risk factor for severe COVID-19 (+30 vs. -48, p < 0.0001), and screening mammograms performed at a hospital-based location (+48 vs. -14, p = 0.0001).

CONCLUSION

The screening mammogram volume trend more than two years after the COVID-19 shutdown has continued to decline for most patient populations. Findings highlight the need to identify additional areas for education and outreach.

Comorbidities and neighborhood factors associated with prescription of sodium-glucose cotransporter protein-2 inhibitors and glucagon-like peptide-1 receptor agonists among medically underserved populations

BACKGROUND: Evidence from clinical trials shows that newer second-line diabetes medications-glucagon-like peptide 1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is)-have cardio-renal protective effects in addition to their glucose-lowering properties. Despite strong evidence of benefits, there is limited evidence regarding prescribing patterns for these medications, especially among populations at high risk for disparities. OBJECTIVE: To examine the associations of cardio-renal and obesity comorbidities and neighborhood factors with the prescribing of GLP-1RAs or SGLT2is in comparison with dipeptidyl peptidase 4 inhibitors (DPP-4is) or sulfonylureas (SFUs) and for each of the newer second-line diabetes medications (GLP-1RA vs DPP-4i, SGLT2i vs DPP-4i, GLP-1RA vs SFU, and SGLT2i vs SFU) in medically underserved populations. METHODS: A retrospective cohort study was conducted using electronic medical records from a health care delivery system that serves medically underserved populations in the Mid-South region of the United States. Metformin-treated adult patients with type 2 diabetes, and at least 1 prescription for GLP-1RA, SGLT2i, DPP-4i, or SFU class medications, were identified between April 2016 and August 2021. Neighborhood factors were assessed at the census tract level by geocoding and linking patient addresses to neighborhood-level risk factors. Using multilevel logistic regression models, we examined the associations of comorbidities and neighborhood factors with the prescription of newer second-line diabetes medications. RESULTS: 7,723 patients received newer second-line diabetes medications, with 16% prescribed GLP-1RAs, 11% prescribed SGLT2is, 28% prescribed DPP-4is, and 45% prescribed SFUs. Patients with cerebrovascular disease were significantly less likely to receive newer second-line diabetes medications (odds ratio [OR] = 0.65, 95% CI = 0.52-0.80). Patients with obesity were more likely to receive newer second-line diabetes medications (OR = 1.68, 95% CI = 1.48-1.90). Living in neighborhoods with higher proportions of college graduates was associated with a higher likelihood of receiving newer second-line diabetes medications (quartile 3 vs 1: OR = 1.30, 95% CI = 1.06-1.59; and quartile 4 vs 1: OR = 1.46, 95% CI = 1.13-1.88). CONCLUSIONS: Our findings demonstrate substantial underprescribing and significant clinical and neighborhood variations in the use of newer second-line diabetes medications. We found lower use of newer second-line diabetes medications among patients with cerebrovascular disease and higher use in those with obesity. Our findings also suggest that newer second-line diabetes medications are first adopted by those in higher socioeconomic groups, thus increasing disparities in care. DISCLOSURES: Dr Surbhi reports grants or contracts from the Tennessee Department of Health, Agency for Healthcare Research and Quality, and PhRMA Foundation. Dr Bailey reports honoraria from the SouthEast Texas Chapter of the American College of Healthcare Executives, leadership or fiduciary role in the Coalition for Better Health and The Healthy City, Inc., and stock or stock options in Proctor and Gamble, Walmart, and Apple. Dr Kovesdy reports personal fees from Bayer, Abbott, AstraZeneca, Takeda, Tricida, Akebia, Cara Therapeutics, Vifor, Rockwell, CSL Behring, Boehringer Ingelheim, and GSK, outside the submitted work. The other authors report no conflicts of interest.

Factors Associated With Breast Cancer Screening Behaviors Among Women With Dense Breasts

OBJECTIVE

We sought to identify patient factors associated with patient-reported screening behaviors in women with dense breasts.

METHODS

An IRB-approved survey study of women with dense breasts presenting for annual screening mammography at an outpatient imaging center was previously conducted from March 2017 to February 2018. The survey included questions regarding mammographic screening frequency and recent participation in supplemental screening. These survey data were combined post hoc with clinical and demographic data and socioeconomic data imputed from census data. Logistic regression was used to identify patient factors associated with reported screening behaviors.

RESULTS

Surveys were completed by 508 women (median age, 59.0 years; range, 31.0-86.0 years) with dense breasts. Multivariable analysis demonstrated an independent association of undergoing mammographic screening annually with a history of discussing breast density with a doctor (adjusted odds ratio [AOR], 2.60; P = 0.019). Undergoing supplemental screening in the previous three years was independently associated with younger age (AOR, 1.59; P = 0.004), strong family history of breast cancer (AOR, 3.84; P = 0.027), higher perceived personal risk for breast cancer (AOR, 3.47; P = 0.004), and increased concern about radiation associated with screening examinations (AOR, 3.31; P = 0.006).

CONCLUSION

Women with dense breasts who had discussed breast density with a doctor were more likely to report undergoing annual screening mammography, while younger women and women with a strong family history of breast cancer, higher perceived personal risk for breast cancer, or greater concern about radiation were more likely to report recently undergoing supplemental screening.

Health inequities in mammography: A scoping review

OBJECTIVE

The objective of this scoping review is to chart the existing evidence on health inequities related to mammography and identify existing knowledge gaps to guide future research.

METHODS

This scoping review followed guidelines from the Joanna Briggs Institute and the PRISMA extension for scoping reviews. In July 2022, we searched PubMed and Ovid Embase for published articles on mammography screening, published between 2011 and 2021, written in English, and examining at least one health inequity as defined by the NIH. Screening and charting were both performed in a masked, duplicate manner. Frequencies of each health inequity examined were analyzed and main findings from each included study were summarized.

RESULTS

Following screening, our sample consisted of 128 studies. Our findings indicate that mammography screening was less likely in historically marginalized groups, patients who live in rural areas, and in women with low income status and education level. Significant research gaps were observed regarding the LGBTQ + community and sex and gender. No trends between inequities investigated over time were identified.

DISCUSSION

This scoping review highlights the gaps in inequities research regarding mammography, as well as the limited consensus across findings. To bridge existing research gaps, we recommend research into the following: 1) assessments of physician knowledge on the LGBTQ + community guidelines, 2) tools for health literacy, and 3) culturally competent screening models.

Inequality in mammography uptake: results from recruitment phase of first cohort study among Iranian Kurdish population

Background

Breast cancer is the most common malignant disease in women and is the leading cause of cancer deaths among women. Mammography is the best and the most available diagnostic method for breast cancer early detection. The aim of this study was to investigate the prevalence and inequality in the mammography uptake among Kurdish women in the west of Iran.

Methods

This cohort study was conducted using data extracted from the Ravansar Non-communicable Cohort Study among Kurdish women in the west of Iran from 2014 to 2018. The sample included 5289 women aged 35–65 years. The relative and generalized (absolute) concentration index (RC and GC, respectively) was used to quantify and decompose socioeconomic inequalities in mammography uptake.

Results

Overall concentration index for mammography was 0.2107, indicating that the mammography uptake concentration was greater in women with a higher socioeconomic status (SES). The predictor variables accounted for 44.6% of the inequality in the mammography uptake. Higher SES, living in urban areas, and age group of 51–55 years old increased the chance of having a mammogram. Available evidence supports the inequality of mammography uptake in favor of women with higher SES.

Conclusions

Cost-free screening services for low SES women, and the development of breast cancer prevention campaigns focusing on disadvantaged women could have an important role in mammography uptake and in the reduction of inequalities.

Screening Mammogram Adherence in Medically Underserved Women: Does Language Preference Matter?

This study examines the relationship between language preference and screening mammogram adherence in medically underserved women in New York City. A survey was conducted with 518 women age 40 and over attending breast health education programs in English, Spanish, Chinese (Mandarin/Cantonese), and French. Women who preferred Chinese were 53% less likely to have had a mammogram within the past year compared to women who preferred English (p < .01). Women age 75 and older (p < .0001) and those without insurance (p < .05) were also found to be significantly less likely to have had a screening mammogram compared to women ages 55-74 and those with private insurance, respectively. This research indicates medically underserved women who prefer a non-English language may benefit from linguistically appropriate interventions to improve screening mammogram adherence. Future research should examine appropriateness of breast cancer screening for women age 75 and older and explore ways to improve screening mammogram use in the uninsured population.

Patient Characteristics Associated With Patient-Reported Deterrents to Adjunct Breast Cancer Screening of Patients With Dense Breasts

BACKGROUND. The success of adjunct breast cancer screening of women with dense breasts can be enhanced by identifying and addressing patient concerns regarding adjunct screening modalities. OBJECTIVE. The purpose of this study was to identify patient characteristics associated with patient-reported concerns about adjunct breast cancer screening to facilitate the development of a more effective screening model for women with dense breasts. METHODS. Patients with dense breasts completed surveys between March 2017 and February 2018 regarding factors that might deter them from adjunct screening and about which of three hypothetical screening examinations they might prefer. Additional patient data were extracted from medical records, and socioeconomic data were imputed from federal census data. Logistic regression analyses were conducted to identify associations between patient characteristics and patient attitudes toward adjunct screening. RESULTS. Surveys were completed by 508 women (median age, 59.0 years) with dense breasts. Lower confidence in the sensitivity of mammography of dense breasts was independently associated with lesser concern about adjunct screening examination time (1 divided by adjusted odds ratio [1/AOR], 0.55 [95% CI, 0.34-0.89]), additional imaging that could result (1/AOR, 0.51 [95% CI, 0.31-0.85]), and greater preference for a more sensitive hypothetical screening examination (1/AOR, 1.85 [95% CI, 1.20-2.86]). Concern about examination cost, the most commonly cited deterrent to adjunct screening (66.9%), was independently associated with younger age (1/AOR, 1.45 [95% CI, 1.01-2.08]) but not with imputed socioeconomic variables or other tested variables. Younger age was also associated with lesser concern about pain (1/AOR, 0.69 [95% CI, 0.48-0.99]), additional imaging that could result (1/AOR, 0.48 [95% CI, 0.31-0.76]), and IV contrast administration (1/AOR, 0.56 [95% CI, 0.37-0.83]). CONCLUSION. Younger age and lower confidence in the sensitivity of mammography among women with dense breasts are independently associated with lesser patient concern about common deterrents to adjunct breast cancer screening. Younger age is independently associated with greater concern about the cost of undergoing adjunct breast cancer screening. CLINICAL IMPACT. Concerns about adjunct screening may be reduced by educating patients about the lower sensitivity of mammography of dense breasts and by finding ways to address or mitigate the financial and daily-life impact of adjunct screening, especially for younger patients.

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.

Impact of the COVID-19 pandemic on breast cancer screening volumes and patient screening behaviors

Purpose

In order to facilitate targeted outreach, we sought to identify patient populations with a lower likelihood of returning for breast cancer screening after COVID-19-related imaging center closures.

Methods

Weekly total screening mammograms performed throughout 2019 (baseline year) and 2020 (COVID-19-impacted year) were compared. Demographic and clinical characteristics, including age, race, ethnicity, breast density, breast cancer history, insurance status, imaging facility type used, and need for interpreter, were compared between patients imaged from March 16 to October 31 in 2019 (baseline cohort) and 2020 (COVID-19-impacted cohort). Census data and an online map service were used to impute socioeconomic variables and calculate travel times for each patient. Logistic regression was used to identify patient characteristics associated with a lower likelihood of returning for screening after COVID-19-related closures.

Results

The year-over-year cumulative difference in screening mammogram volumes peaked in week 21, with 2962 fewer exams in the COVID-19-impacted year. By week 47, this deficit had reduced by 49.4% to 1498. A lower likelihood of returning for screening after COVID-19-related closures was independently associated with younger age (odds ratio (OR) 0.78, p < 0.001), residence in a higher poverty area (OR 0.991, p = 0.014), lack of health insurance (OR 0.65, p = 0.007), need for an interpreter (OR 0.68, p = 0.029), longer travel time (OR 0.998, p < 0.001), and utilization of mobile mammography services (OR 0.27, p < 0.001).

Conclusion

Several patient factors are associated with a lower likelihood of returning for screening mammography after COVID-19-related closures. Knowledge of these factors can guide targeted outreach to vulnerable patients to facilitate breast cancer screening.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06252-1.

Are There Disparities in Surgical Treatment for Breast Cancer Patients with Prior Physical Disability A Path Analysis

Introduction

Cancer care for patients with prior physical disability has hardly been researched in clinical research, health services research, or special education. This article aims to compare the severity of disease and the surgical treatment of diagnosed breast cancer patients with and without prior physical disability.

Methods

A total of 4,194 patients with primary breast cancer who underwent surgery in a breast cancer center in North Rhine-Westphalia, Germany, participated in an annual postoperative postal survey, which was complemented by clinical data. Latent class analysis and logit path models were applied to study (1) differences in terms of UICC staging and local cancer treatment between patients with and without prior physical disability and (2) respective differences by disability severity.

Results

Patients with physical disability (n = 780; 18.7%) had a higher chance of receiving mastectomy compared to breast-conserving therapy, even after controlling for socioeconomic status and UICC staging. Disability severity is directly and indirectly associated with receiving a mastectomy.

Conclusion

In light of the research gap on disability and cancer, this work indicates disparities in care for breast cancer patients with prior physical disability. Inequalities might be attributable to (1) unequal access to care, (2) individual preferences and difficulties, or (3) medical difficulties.

Determinants of women's decision to undergo early mammography: A survey study

For young women, mammography has limited effectiveness and entails exposure to radiation, discomfort, and additional expense. This study identifies factors associated with women's willingness to undergo mammography despite official guidelines to the contrary. Using the Health Belief Model, we surveyed Israeli women aged 40-51 who are not at high risk of breast cancer and who had or had never undergone mammography. The results show that sociodemographic characteristics, private insurance coverage, out-of-pocket payments to physicians, and three Health Belief Model categories - lower perceived barriers to mammography, higher expectations of benefits, and stronger health motivation - are associated with the decision to undergo mammography. In addition, higher levels of perceived susceptibility to illness and experience with mammography are significant predictors of intentions to undergo early mammography. Understanding the determinants of women's tendency to undergo mammography contrary to recommendations may help nurses and healthcare policymakers to create health promotion programs targeting this group of women. Preventing unnecessary mammograms may reduce costs to households and health maintenance organizations, mitigate ineffective use of medical facilities, and alleviate the burden on the healthcare system.

Social determinants of mammography screening among women aged 50 to 59, Peru 2015

Breast cancer (BC) screening could reduce its mortality; however, its access is influenced by societal forces. Our objective is to identify the social determinants associated with mammography screening (MS) in women aged 50 to 59 in Peru. In this cross-sectional analysis of the Peruvian Demographic Health Survey, 2015, MS within the past two years was evaluated through self-report. Prevalence for MS was 21.9% [95% CI: 18.9 to 25.1]. The average age was 54 years (s.d.: 2.5). The higher the socioeconomic status, the higher the prevalence of screening (3.2% vs 41.4% in extreme quintiles, p < .001). In the adjusted models, higher socioeconomic status (PR: 5.81, 95% CI: 2.28 to 14.79), higher education level (PR: 2.03, 95% CI: 1.30 a 3,15) and having health insurance from the Ministry of Health (PR: 2.21, 95% CI: 1.28 to 3.82) and EsSalud (PR: 4.37, 95% CI: 2.67 to 7.15), were positively associated with MS. Social inequalities in screening access exist and might translate into inequalities in cancer morbidity and mortality. The Peruvian government urgently needs to improve screening rates in these vulnerable populations.

Trends in Mortality Due to Cancer in the United States by Age and County-Level Income, 1999-2015

Disparities in cancer mortality by county-level income have increased. It is unclear whether these widening disparities have affected older and younger adults equally. National death certificate data were utilized to ascertain cancer deaths during 1999-2015. Average annual percent changes in mortality rates and mortality rate ratios (RRs) were estimated by county-level income quintile and age (25-64 vs ≥65 years). Among 25- to 64-year-olds, cancer mortality rates were 30% higher (RR = 1.30, 95% confidence interval [CI] = 1.29 to 1.31) in the lowest-vs the highest-income counties in 1999-2001 and 56% higher (RR = 1.56, 95% CI = 1.55 to 1.57) in 2013-2015; the disparities among those 65 years and older were smaller but also widened over time (RR1999-2001 = 1.04, 95% CI = 1.03 to 1.05; RR2013-2015 = 1.14, 95% CI = 1.13 to 1.14). Widening disparities occurred across cancer sites. If all counties had the mortality rates of the highest-income counties, 21.5% of cancer deaths among 25- to 64-year-olds and 7.3% of cancer deaths in those 65 years and older would have been avoided in 2015. These results highlight an ongoing need for equity-focused interventions, particularly among younger adults.

Psychological and neighborhood factors associated with urban women's preventive care use

Women are more likely than men to forego care-including preventive care. Understanding which factors influence women's preventive care use has the potential to improve health. This study focuses on the largely understudied areas of psychological barriers (depression) and neighborhood factors (support and stressors) that may be associated with women's preventive care use through secondary analysis of the Chicago Community Adult Health Study. Across models, 30-40% of the variance in preventive care adherence was explained by the neighborhood. Depressive symptoms were not associated with preventive care use when neighborhood factors were included. However, stratified models showed that associations varied by race/ethnicity. Previous research has tended to focus on individual determinants of care, but this study suggests that barriers to care are far more complex. Efforts aimed at improving care utilization need to be multipronged and interventions need to take an individual's demographics, mental health, and context into account.

Effects of different reminder strategies on first-time mammography screening among women in Taiwan

Background

The study’s purpose was to examine the effectiveness of different reminder strategies on first-time free mammography screening among middle-aged women in Taiwan.

Methods

A quasi-experimental design with random assignment was adopted to divide the participants into three Reminder Strategies groups (mail reminder, telephone reminder, and combined mail and telephone reminders) and one control group. This study recruited 240 eligible middle-aged women, and 205 of them completed the study. Upon the completion of data collection, mail reminders were provided to women of the first group; telephone reminders were provided to the second group; mail followed by telephone reminders were provided to the third group, and the usual postcards were provided to the control group 1 month after the interventions. Two follow-up assessments were conducted 1 and 3 months after the intervention to collect mammography-screening behaviors from all groups.

Results

The findings showed that, compared to the control group, more participants in the intervention groups underwent mammography screening after receiving reminder interventions. Telephone contact as reminder was found to have the most significant influence among the interventions (OR = 5.0556; 95% CI = 2.0422–13.5722).

Conclusions

Government and healthcare providers are recommended to consider adopting the telephone reminder strategy to encourage women to undergo their first-time mammography screening.

Social Determinants and Disparities in Active Aging Among Older Taiwanese

This study assesses equity in active aging across social determinants among older Taiwanese. The data were collected from face-to-face interviews with adults aged 55 years or more in Taiwan in 2017 (n = 738). A total of 30 individual-level Taiwan active aging indicators were chosen, and the relationship between social determinants and active aging indicators were analyzed by logistic regression models. Women were more likely to participate in volunteering and other social groups and in lifelong learning activities, whereas men were more likely to be employed, to engage in physical activity, to feel safe from violence, and to use preventive care. Higher education was related to higher employment, social participation, independent living, lifelong learning, and a lower likelihood of poverty and severe cognitive impairment. Those living in rural areas were more likely to be employed, perform physical activity, feel physically safe, have better mental well-being, and have higher social respect and social integration ratings, whereas living in urban areas was related to greater access to medical care, owning assets, less severe cognitive impairment, greater likelihood of using information and communications technology, higher level of education, and higher access to convenient transportation. The significant disparities that exist in active aging may suggest inequality.

Long-Term Impact of a Culturally Tailored Patient Navigation Program on Disparities in Breast Cancer Screening in Refugee Women After the Program's End

Purpose: To examine the long-term effects of a patient navigation (PN) program for mammography screening tailored to refugee women and to assess screening utilization among these women after PN ended.

Methods: We assessed the proportion of patients completing mammography screening during the prior 2 years during 2012–2016 for refugee women who had previously received PN compared with that of English-speaking women cared for at the same health center during the same period, both overall and stratifying by age. We used logistic regression to compare screening completion between refugees and English speakers, adjusting for age, race, insurance status, number of clinic visits, and clustering by primary care physician and to test trends in screening over time.

Results: In 2012, the year when the funding for PN ceased, among 126 refugee women eligible for breast cancer screening, mammography screening rates were significantly higher among refugees (90.5%, 95% confidence interval [CI]: 83.5–94.7%) than among English speakers (81.9%, 95% CI: 76.2–86.5%, p=0.006). By 2016, screening rates decreased among refugee women (76.5%, 95% CI: 61.6–86.9%, p=0.023) but were not statistically significantly different from those among English-speaking women (80.5%, 95% CI: 74.4–85.3%, p=0.460). Screening prevalence for refugee women remained above the pre-PN program screening levels, and considerably so in women <50 years.

Conclusion: The culturally and language-tailored PN program for refugee women appeared to have persistent effects, with refugee women maintaining similar levels of mammography screening to English-speaking patients 5 years after the PN program's end.

Inequities in access to mammographic screening in Brazil

Abstract: Our objectives with this study were to describe the spatial distribution of mammographic screening coverage across small geographical areas (micro-regions) in Brazil, and to analyze whether the observed differences were associated with spatial inequities in socioeconomic conditions, provision of health care, and healthcare services utilization. We performed an area-based ecological study on mammographic screening coverage in the period of 2010-2011 regarding socioeconomic and healthcare variables. The units of analysis were the 438 health micro-regions in Brazil. Spatial regression models were used to study these relationships. There was marked variability in mammographic coverage across micro-regions (median = 21.6%; interquartile range: 8.1%-37.9%). Multivariable analyses identified high household income inequality, low number of radiologists/100,000 inhabitants, low number of mammography machines/10,000 inhabitants, and low number of mammograms performed by each machine as independent correlates of poor mammographic coverage at the micro-region level. There was evidence of strong spatial dependence of these associations, with changes in one micro-region affecting neighboring micro-regions, and also of geographical heterogeneities. There were substantial inequities in access to mammographic screening across micro-regions in Brazil, in 2010-2011, with coverage being higher in those with smaller wealth inequities and better access to health care.

Mobile Mammography Participation Among Medically Underserved Women: A Systematic Review

Introduction

Although breast cancer deaths have declined, the mortality rate among women from medically underserved communities is disproportionally high. Screening mammography is the most effective tool for detecting breast cancer in its early stages, yet many women from medically underserved communities do not have adequate access to screening mammograms. Mobile mammography may be able to bridge this gap by providing screening mammograms at no cost or low cost and delivering services to women in their own neighborhoods, thus eliminating cost and transportation barriers. The objective of this systematic review was to describe the scope and impact of mobile mammography programs in promoting mammographic screening participation among medically underserved women.

Methods

We searched electronic databases for English-language articles published in the United States from January 2010 through March 2018 by using the terms “mobile health unit,” “mammogram,” “mammography,” and “breast cancer screening.” Of the 93 articles initially identified, we screened 55; 16 were eligible to be assessed and 10 qualified for full text review and data extraction. Each study was coded for study purpose, research design, data collection, population targeted, location, sample size, outcomes, predictors, analytical methods, and findings.

Results

Of the 10 studies that qualified for review, 4 compared mobile mammography users with users of fixed units, and the other 6 characterized mobile mammography users only. All the mobile mammography units included reached underserved women. Most of the women screened in mobile units were African American or Latina, low income, and/or uninsured. Mobile mammography users reported low adherence to 1-year (12%–34%) and 2-year (40%–48%) screening guidelines. Some difficulties faced by mobile clinics were patient retention, patient follow-up of abnormal or inconclusive findings, and women inaccurately perceiving their breast cancer risk.

Conclusion

Mobile mammography clinics may be effective at reaching medically underserved women. Adding patient navigation to mobile mammography programs may promote attendance at mobile sites and increase follow-up adherence. Efforts to promote mammographic screening should target women from racial/ethnic minority groups, women from low-income households, and uninsured women. Future research is needed to understand how to best improve visits to mobile mammography clinics.

Spatial distribution of mammography adherence in a Swiss urban population and its association with socioeconomic status

Purpose

Local physical and social environment has a defining influence on individual behavior and health‐related outcomes. However, it remains undetermined if its impact is independent of individual socioeconomic status. In this study, we evaluated the spatial distribution of mammography adherence in the state of Geneva (Switzerland) using individual‐level data and assessed its independence from socioeconomic status (SES).

Methods

Georeferenced individual‐level data from the population‐based cross‐sectional Bus Santé study (n = 5002) were used to calculate local indicators of spatial association (LISA) and investigate the spatial dependence of mammography adherence. Spatial clusters are reported without adjustment; adjusted for neighborhood income and individual educational attainment; and demographic factors (age and Swiss nationality). The association between adjusted clusters and the proximity to the nearest screening center was also evaluated.

Results

Mammography adherence was not randomly distributed throughout Geneva with clusters geographically coinciding with known SES distributions. After adjustment for SES indicators, clusters were reduced to 56.2% of their original size (n = 1033). Adjustment for age and nationality further reduced the number of individuals exhibiting spatially dependent behavior (36.5% of the initial size). The identified SES‐independent hot spots and cold spots of mammography adherence were not explained by proximity to the nearest screening center.

Conclusions

SES and demographic factors play an important role in shaping the spatial distribution of mammography adherence. However, the spatial clusters persisted after confounder adjustment indicating that additional neighborhood‐level determinants could influence mammography adherence and be the object of targeted public health interventions.

Investigation of Frequency Distribution of Breast Imaging Reporting and Data System (BIRADS) Classification and Epidemiological Factors Related to Breast Cancer in Iran: A 7-year Study (2010-2016)

Background

The first cause of women mortality due to cancer is breast cancer. Mammography plays a central part in early detection of breast cancers. The screening methods can play a major role to reduce the morbidity and mortality rate due to this malignancy. We sought the basic data in this study on our population because knowing about the baseline data is apt and vital.

Materials and Methods

In this study, data were collected from a questionnaire, contained baseline bio data information, and mammographic imaging of the patients came during 7 years. Breast imaging reporting and data system (BIRADS) score, breast composition, presence of axillary lymph nodes, microcalcifications, and other incidental positive findings were determined by a radiologist and analysis was performed by SPSS package.

Results

The most common indication for mammography was annual screening. The mean age of participants to the study was 55 ± 7.9 years. The majority (80%) of the patients with known breast cancer (BIRADS 6) had the extremely dense breast. The most common incidental findings in mammogram studies were focal asymmetry, architectural distortion, intramammary lymph node and accessory breasts, respectively.

Conclusion

The frequency distribution of BIRADS classification in our society was clarified. It seems that the breast cancer risk is higher in women with dense breasts. Architectural distortion was also correlated to BIRADS score.

Contextual effects and cancer outcomes in the United States: a systematic review of characteristics in multilevel analyses

PURPOSE

There is increasing call for the utilization of multilevel modeling to explore the relationship between place-based contextual effects and cancer outcomes in the United States. To gain a better understanding of how contextual factors are being considered, we performed a systematic review.

METHODS

We reviewed studies published between January 1, 2002 and December 31, 2016 and assessed the following attributes: (1) contextual considerations such as geographic scale and contextual factors used; (2) methods used to quantify contextual factors; and (3) cancer type and outcomes. We searched PubMed, Scopus, and Web of Science and initially identified 1060 studies. One hundred twenty-two studies remained after exclusions.

RESULTS

Most studies utilized a two-level structure; census tracts were the most commonly used geographic scale. Socioeconomic factors, health care access, racial/ethnic factors, and rural-urban status were the most common contextual factors addressed in multilevel models. Breast and colorectal cancers were the most common cancer types, and screening and staging were the most common outcomes assessed in these studies.

CONCLUSIONS

Opportunities for future research include deriving contextual factors using more rigorous approaches, considering cross-classified structures and cross-level interactions, and using multilevel modeling to explore understudied cancers and outcomes.

Exploring neighborhood inequality in female breast cancer incidence in Tehran using Bayesian spatial models and a spatial scan statistic

OBJECTIVES

The aim of this study was to explore the spatial pattern of female breast cancer (BC) incidence at the neighborhood level in Tehran, Iran.

METHODS

The present study included all registered incident cases of female BC from March 2008 to March 2011. The raw standardized incidence ratio (SIR) of BC for each neighborhood was estimated by comparing observed cases relative to expected cases. The estimated raw SIRs were smoothed by a Besag, York, and Mollie spatial model and the spatial empirical Bayesian method. The purely spatial scan statistic was used to identify spatial clusters.

RESULTS

There were 4,175 incident BC cases in the study area from 2008 to 2011, of which 3,080 were successfully geocoded to the neighborhood level. Higher than expected rates of BC were found in neighborhoods located in northern and central Tehran, whereas lower rates appeared in southern areas. The most likely cluster of higher than expected BC incidence involved neighborhoods in districts 3 and 6, with an observed-to-expected ratio of 3.92 (p<0.001), whereas the most likely cluster of lower than expected rates involved neighborhoods in districts 17, 18, and 19, with an observed-to-expected ratio of 0.05 (p<0.001).

CONCLUSIONS

Neighborhood-level inequality in the incidence of BC exists in Tehran. These findings can serve as a basis for resource allocation and preventive strategies in at-risk areas.