Are breast cancer screening practices associated with sociodemographic status and healthcare access? Analysis of a French cross-sectional study

Socioeconomic Deprivation and Invasive Breast Cancer Incidence by Stage at Diagnosis: A Possible Explanation to the Breast Cancer Social Paradox

In this study, we assessed the influence of area-based socioeconomic deprivation on the incidence of invasive breast cancer (BC) in France, according to stage at diagnosis. All women from six mainland French departments, aged 15+ years, and diagnosed with a primary invasive breast carcinoma between 2008 and 2015 were included (n = 33,298). Area-based socioeconomic deprivation was determined using the French version of the European Deprivation Index. Age-standardized incidence rates (ASIR) by socioeconomic deprivation and stage at diagnosis were compared estimating incidence rate ratios (IRRs) adjusted for age at diagnosis and rurality of residence. Compared to the most affluent areas, significantly lower IRRs were found in the most deprived areas for all-stages (0.85, 95% CI 0.81-0.89), stage I (0.77, 95% CI 0.72-0.82), and stage II (0.84, 95% CI 0.78-0.90). On the contrary, for stages III-IV, significantly higher IRRs (1.18, 95% CI 1.08-1.29) were found in the most deprived areas. These findings provide a possible explanation to similar or higher mortality rates, despite overall lower incidence rates, observed in women living in more deprived areas when compared to their affluent counterparts. Socioeconomic inequalities in access to healthcare services, including screening, could be plausible explanations for this phenomenon, underlying the need for further research.

Social Determinants of Health Framework to Identify and Reduce Barriers to Imaging in Marginalized Communities

Social determinants of health (SDOH) are conditions influencing individuals' health based on their environment of birth, living, working, and aging. Addressing SDOH is crucial for promoting health equity and reducing health outcome disparities. For conditions such as stroke and cancer screening where imaging is central to diagnosis and management, access to high-quality medical imaging is necessary. This article applies a previously described structural framework characterizing the impact of SDOH on patients who require imaging for their clinical indications. SDOH factors can be broadly categorized into five sectors: economic stability, education access and quality, neighborhood and built environment, social and community context, and health care access and quality. As patients navigate the health care system, they experience barriers at each step, which are significantly influenced by SDOH factors. Marginalized communities are prone to disparities due to the inability to complete the required diagnostic or screening imaging work-up. This article highlights SDOH that disproportionately affect marginalized communities, using stroke and cancer as examples of disease processes where imaging is needed for care. Potential strategies to mitigate these disparities include dedicating resources for clinical care coordinators, transportation, language assistance, and financial hardship subsidies. Last, various national and international health initiatives are tackling SDOH and fostering health equity.

Health literacy and breast cancer screening adherence: results from the population of Tuscany, Italy

Mammographic screening can reduce breast cancer (BC) mortality in women. In Italy, although attendance rates increased recently, they are still far from the recommended levels internationally. Inadequate health literacy (HL) may be a reason for poor awareness and/or knowledge about the importance of completing cancer screening. This study examined the relationship between HL, other sociodemographic determinants, and their influence on participation in both opportunistic and organized BC screenings among women aged 50-69 in Tuscany. The study analyzed 2017-2019 data from the Tuscan population subsample in the Italian Behavioral Risk Factor Surveillance System PASSI (Progressi delle Aziende Sanitarie per la Salute in Italia). HL was assessed using the Italian version of the six-item European Health Literacy Survey Questionnaire (HLS-EU-Q6). Among the 2250 interviewees, 75.3% underwent the organized BC screening and 9.4% on voluntary basis. Although to a different extent, HL was significantly associated to compliance rates with both opportunistic and organized screenings. Among sociodemographic factors, only occupational status was associated with opportunistic screening attendance rates. As expected, being invited by letter resulted to be strongly associated with participation to organized screening programs and the medical advice predicts for participating to both opportunistic and organized screening. This study highlights the relevant role that HL plays in BC, opportunistic and organized, screening adherence in a universal healthcare system. To increase BC screening participation rates, healthcare systems would benefit by implementing interventions for improved HL at population level or within healthcare organizations.

Revealed versus potential spatial accessibility of healthcare and changing patterns during the COVID-19 pandemic

BACKGROUND

Timely access to healthcare is essential but measuring access is challenging. Prior research focused on analyzing potential travel times to healthcare under optimal mobility scenarios that do not incorporate direct observations of human mobility, potentially underestimating the barriers to receiving care for many populations.

METHODS

We introduce an approach for measuring accessibility by utilizing travel times to healthcare facilities from aggregated and anonymized smartphone Location History data. We measure these revealed travel times to healthcare facilities in over 100 countries and juxtapose our findings with potential (optimal) travel times estimated using Google Maps directions. We then quantify changes in revealed accessibility associated with the COVID-19 pandemic.

RESULTS

We find that revealed travel time differs substantially from potential travel time; in all but 4 countries this difference exceeds 30 minutes, and in 49 countries it exceeds 60 minutes. Substantial variation in revealed healthcare accessibility is observed and correlates with life expectancy (⍴=-0.70) and infant mortality (⍴=0.59), with this association remaining significant after adjusting for potential accessibility and wealth. The COVID-19 pandemic altered the patterns of healthcare access, especially for populations dependent on public transportation.

CONCLUSIONS

Our metrics based on empirical data indicate that revealed travel times exceed potential travel times in many regions. During COVID-19, inequitable accessibility was exacerbated. In conjunction with other relevant data, these findings provide a resource to help public health policymakers identify underserved populations and promote health equity by formulating policies and directing resources towards areas and populations most in need.

Participation in breast cancer screening and its influence on other cancer screening invitations: study in women aged 56 years old in four French departments

BACKGROUND

Today, women 50 years of age are offered three types of cancer screening in France. However, participation is not optimal. The aim was to describe (1) participation in organised breast cancer screening (OS) of women aged 56 years old, and the influence of this participation on colorectal and cervical cancer screening, (2) the reasons for non-participation in breast cancer OS, and (3) the reasons for screening before age 50.

METHODS

A questionnaire was sent to 56-year-old women in four French departments to identify their participation behaviour in three breast cancer OS invitations and their reasons for non-participation. Three groups were determined according to the number of participations in breast cancer OS (3, 1-2 and 0). We described the quantitative responses and grouped the qualitative responses thematically.

RESULTS

A total of 4634 women responded to the questionnaire. Seventy-six percent had undergone all three breast cancer OS, 16% irregular and 7% non-participant. Among women who irregularly perform breast cancer OS, 50.5% also irregularly perform colorectal cancer OS. Women who participated in all three invitations for the breast cancer OS performed more smear tests than women in the other groups. Many of the irregular participants or non-participants underwent opportunistic screening, often initiated before the age of 50. The reasons for non-participation in breast cancer OS were mainly medical or participation in opportunistic screening.

CONCLUSION

There is no fundamental opposition to participation in breast cancer screening. However, it remains of the utmost importance that women should be better informed about OS and its benefits.

Role of mammography accessibility, deprivation and spatial effect in breast cancer screening participation in France: an observational ecological study

BACKGROUND

The detection of cancer in its early latent stages can improve patients' chances of recovery and thereby reduce the overall burden of the disease. Our objectives were to investigate factors (geographic accessibility and deprivation level) affecting mammography screening participation variation and to determine how much geographic variation in participation rates can be explained by spillover effects between adjacent areas, while controlling for covariates.

METHODS

Mammography screening participation rates between 2015 and 2016 were calculated by census blocks (CB), for women aged 50-74 years, residing in Lyon metropolitan area. Global spatial autocorrelation tests were applied to identify the geographic variation of participation. Spatial regression models were used to incorporate spatial structure to estimate associations between mammography participation rate and the combined effect (geographic accessibility and deprivation level) adjusting for modes of travel and social cohesion.

RESULTS

The mammography participation rate was found to have a statistically significant and positive spatial correlation. The participation rate of one CB was significantly and positively associated with the participation rates of neighbouring CB. The participation was 53.2% in residential and rural areas and 46.6% in urban areas, p < 0.001. Using Spatial Lag models, whereas the population living in most deprived CBs have statistically significantly lower mammography participation rates than lower deprived ones, significant interaction demonstrates that the relation differs according to the degree of urbanization.

CONCLUSIONS

This study makes an important methodological contribution in measuring geographical access and understanding better the combined effect of deprivation and the degree of urbanization on mammography participation and other contextual factors that affect the decision of using mammography screening services -which is a critical component of healthcare planning and equity.

Socioeconomic status index is an independent determinant of breast cancer screening practices: Evidence from Eastern China

BACKGROUND

Breast cancer is the most prevalent malignancy affecting Chinese women, and early routine screening is incredibly important for its prevention and control. This study aimed to investigate the role of socioeconomic status (SES) in female breast cancer screening practices using the composite SES index.

METHODS

This cross-sectional study involved 1816 women in Eastern China. Data were collected using an online self-administered questionnaire from January 2020 to May 2021. We used principal component analysis to construct the composite SES index using educational level, annual household income, and occupation. Logistic regression was used to analyze the association between the SES index and breast cancer screening utilization.

RESULTS

Of the participants, 19.27% reported having performed breast self-examination, 12.89% reported having undergone clinical breast examination, and 3.52% reported having received mammography. The SES has a significant influence on the patronage of female breast cancer screening in Eastern China. The composite SES index was found to have a positive and significant association with breast cancer screening practices. An interaction was found between the SES index and patient characteristics, such as health awareness, marital status, and location of residence. In addition, the SES index had a positive effect on breast cancer-related knowledge.

CONCLUSIONS

Socioeconomic inequalities existed in Eastern China and were related to breast cancer screening patronage. The composite SES index was identified as a significant determinant of breast cancer screening practices. Our results highlighted the negative impacts of socioeconomic inequities on female breast cancer screening utilization. This suggests that reducing socioeconomic inequalities in breast cancer screening requires more focused interventions and concerted outreach activities for groups with lower education levels, lower income, or lower occupational classes.

Factors influencing participation in breast cancer screening in an urban setting. A study of organized and individual opportunistic screening among potentially active and retired women in the city of Nice

Participation in breast cancer screening in urban settings is poor. Identifying factors accounting for participation and non-participation is essential to target priority areas, tackle health inequalities and suggest innovative approaches. We studied organized and individual opportunistic participation in breast cancer screening within the 144 aggregated units for statistical information (Ilôts regroupés pour l'information statistique: IRIS) of the city of Nice from 2019 to 2021. In each IRIS was assessed a local human development index, among potentially active women aged 50 to 59 years and retired women aged 60 to 74 years. Modelling participation and non-participation in screening according to the IRIS units' socio-economical characteristics was performed using the SURE method (Seemingly Unrelated Regression Equations). Over a 2-year period, 24,396 breast screening tests were conducted (11,173 as organised screening, 13,223 as individual opportunistic screening). The local human development index was positively correlated with the two types of screening, respectively. Access to public transport facilitated participation. Managerial status was negatively correlated with organised screening. Single working women had a higher risk of non-participation. With regard to their socio-economic characteristics, screening rates were lower than expected in 16 IRIS units in the city of Nice. Local human development index, access to public transport, family and professional context appear to be associated with breast cancer screening in an urban setting. An innovative approach targeting these factors is called for to reduce health inequalities.

Geographical and socioeconomic inequalities in female breast cancer incidence and mortality in Iran: A Bayesian spatial analysis of registry data

BACKGROUND

In Iran, trends in breast cancer incidence and mortality have generally been monitored at national level. The purpose of this study is to examine province-level disparities in age-standardised breast cancer incidence versus mortality from 2000 to 2010 and their association with socioeconomic status.

METHODS

In this study, data from Iran's national cancer and death registry systems, and covariates from census and household expenditure surveys were used. We estimated the age-standardised incidence and mortality rates in women aged more than 30 years for all 31 provinces in the consecutive time intervals 2000-2003, 2004-2007 and 2008-2010 using a Bayesian spatial model.

RESULTS

Mean age-standardised breast cancer incidence across provinces increased over time from 15.0 per 100,000 people (95% credible interval 12.0,18.3) in 2000-2003 to 39.6 (34.5,45.1) in 2008-2010. The mean breast cancer mortality rate declined from 10.9 (8.3,13.8) to 9.9 (7.5,12.5) deaths per 100,000 people in the same period. When grouped by wealth index quintiles, provinces in the highest quintile had higher levels of incidence and mortality. In the wealthiest quintile, reductions in mortality over time were larger than those observed among provinces in the poorest quintile. Relative breast cancer mortality decreased by 16.7% in the highest quintile compared to 10.8% in the lowest quintile.

CONCLUSIONS

Breast cancer incidence has increased over time, with lower incidence in the poorest provinces likely driven by underdiagnoses or late-stage diagnosis. Although the reported mortality rate is still higher in wealthier provinces, the larger decline over time in these provinces indicates a possible future reversal, with the most deprived provinces having higher mortality rates. Ongoing analysis of incidence and mortality at sub-national level is crucial in addressing inequalities in healthcare systems and public health both in Iran and elsewhere.

Self-selection for mammography screening according to use of hormone replacement therapy: A systematic literature review

Mammography screening participation may be influenced by the awareness of an increase in breast cancer risk due to hormone replacement therapy (HRT), which received particular attention upon publication of the Women's Health Initiative (WHI) trial results in 2002. Our aim was to synthesize evidence on a potential self-selection for mammography screening according to HRT use. We systematically searched the literature (MEDLINE, EMBASE, CINAHL) for studies reporting on the association between HRT use and mammography screening participation. Data were extracted independently by two reviewers. Overall, 2018 studies were identified. Of these, 32 studies from nine countries, predominantly from North America (50%) and Europe (28%), were included. In studies from all countries and 94% of all studies, higher mammography screening uptake among HRT users compared to non-users was reported. In all 21 studies reporting an odds ratio, the association was positive, and in about 70% of these studies, this association was ≥2. This also held true for studies exclusively using data collected before publication of the WHI findings in 2002 (63% of all studies). The association was not restricted to certain types of screening (organized vs. opportunistic) or certain types of HRT (combined vs. estrogen-only). We found a consistent and relevant association between mammography screening uptake and HRT use. This is of considerable relevance for the design and interpretation of studies investigating risk factors or evaluating preventive measures for breast cancer.

Wealth stratified inequalities in service utilisation of breast cancer screening across the geographical regions: a pooled decomposition analysis

Background

Breast cancer is the most commonly occurring cancer among women in low-resourced countries. Reduction of its impacts is achievable with regular screening and early detection. The main aim of the study was to examine the role of wealth stratified inequality in the utilisation breast cancer screening (BCS) services and identified potential factors contribute to the observed inequalities.

Methods

A population-based cross-sectional multi-country analysis was used to study the utilisation of BCS services. Regression-based decomposition analyses were applied to examine the magnitude of the impact of inequalities on the utilisation of BCS services and to identify potential factors contributing to these outcomes. Observations from 140,974 women aged greater than or equal to 40 years were used in the analysis from 14 low-resource countries from the latest available national-level Demographic and Health Surveys (2008-09 to 2016).

Results

The population-weighted mean utilisation of BCS services was low at 15.41% (95% CI: 15.22, 15.60), varying from 80.82% in European countries to 25.26% in South American countries, 16.95% in North American countries, 15.06% in Asia and 13.84% in African countries. Women with higher socioeconomic status (SES) had higher utilisation of BCS services (15%) than those with lower SES (9%). A high degree of inequality in accessing and the use of BCS services existed in all study countries across geographical areas. Older women, access to limited mass media communication, being insured, rurality and low wealth score were found to be significantly associated with lower utilisation of BCS services. Together they explained approximately 60% in the total inequality in utilisation of BCS services.

Conclusions

The level of wealth relates to the inequality in accessing BCS amongst reproductive women in these 14 low-resource countries. The findings may assist policymakers to develop risk-pooling financial mechanisms and design strategies to increase community awareness of BCS services. These strategies may contribute to reducing inequalities associated with achieving higher rates of the utilisation of BCS services.

Socioeconomic Inequalities in Uptake of Breast Cancer Screening among Saudi Women: A Cross-Sectional Analysis of a National Survey

Timely and adequate screening for breast cancer could improve health outcomes and reduce health costs. However, the utilization of free breast cancer screening services among Saudi women is very low. This study aims to investigate socioeconomic inequalities in breast cancer screening among Saudi women. The data of this study were extracted from the nationally representative Saudi Health Interview Survey, conducted in 2013; the study included 2786 Saudi women. Multivariate logistic regression, the concentration curve, and the concentration index were used to examine, illustrate, and quantify income- and education-related inequalities in three outcomes: Knowledge about self-breast examination (SBE), clinical breast examination (CBE) received in the last year, and mammography, that has ever been previously carried out. Results showed a marked socioeconomic gradient in breast cancer screening services. The concentration index by income was 0.229 (SBE), 0.171 (CBE), and 0.163 (mammography). The concentration index by education was 0.292 (SBE), 0.149 (CBE), and 0.138 (mammography). Therefore, knowledge about breast cancer screening, and the utilization of screening services, were more concentrated among richer and better-educated women. Poorer and less educated women had less knowledge about self-breast examination, and had considerably less adherence to clinical breast examination and mammography. The findings are helpful for policy makers to devise and implement strategies to promote equity in breast cancer screening among Saudi women.

Predictors and Trend in Attendance for Breast Cancer Screening in Lithuania, 2006-2014

In Lithuania, a Nationwide Breast Cancer (BC) Screening Program was launched in 2005, offering mammography for women aged 50 to 69 years, every other year. This study aimed to determine the trend in the attendance for mammography screening during 2006–2014 and to identify the factors that are predictive for participation in it. The study sample consisted of 1941 women aged 50–64 years, who participated in five cross-sectional biennial postal surveys of Lithuanian Health Behavior Monitoring, carried out in independent national random samples. The attendance for screening was identified if women reported having had a mammogram within the last two years. The proportion of women attending the screening was continuously increasing from 20.0% in 2006 up to 65.8% in 2014. The attendance for BC screening was associated with the participation in cervical cancer screening. A higher level of education, living in a city, frequent contact with a doctor, and healthy behaviors (fresh-vegetable consumption, physical activity, and absence of alcohol abuse) were associated with higher participation rates in BC screening. To increase BC screening uptake and to reduce inequalities in attendance, new strategies of organized BC screening program using systematic personal invitations are required in Lithuania.

Mapping Variation in Breast Cancer Screening: Where to Intervene?

Small geographic areas with lower mammography screening participation rates may reflect gaps in screening efforts. Our objective was to use spatial analyses to understand disparities in mammography screening use and to identify factors to increase its uptake in areas that need it in Lyon metropolitan area, France. Data for screened women between the ages of 50 and 74 were analyzed. Census blocks of screened and non screened women were extracted from the mammography screening programme 2015-2016 dataset. We used spatial regression models, within a generalized additive framework to determine clusters of census blocks with significantly higher prevalence of non-participation of mammography screening. Smoothed risk maps were crude and adjusted on the following covariates: deprivation index and opportunistic screening. Among 178,002 women aged 50 to 74, 49.9% received mammography screening. As hypothesized, women living in highly deprived census blocks had lower participation rates compared to less deprived blocks, 45.2% vs. 51.4% p < 0.001. Spatial analyses identified four clusters, one located in an urban area and three in suburban areas. Moreover, depending on the location of the cluster, the influence came from different variables. Knowing the impact of site-specific risk factors seems to be important for implementing an appropriate prevention intervention.

Breast cancer screening programme participation and socioeconomic deprivation in France

The objective was to quantify the relationship between deprivation and national breast cancer screening programme (NBCSP) participation at an ecological level in mainland France. Data from 4,805,390 women-living in 36,209 municipalities within 95 departments-participating in the 2013-2014 NBCSP were analysed using the French Deprivation Index (FDep). FDep population quintiles by municipality were computed to describe NBCSP participation according to deprivation. To better examine the relationship between continuous value of deprivation index and participation rates at the municipality level, we built a generalized linear mixed model. Geographical variations in participation rates were marked. The national standardized participation rate was higher in the intermediate quintiles (55%), 45% for the least deprived one and 52% for the most deprived one. Using our model, we also obtained an inverted U-curve for the relationship between NBCSP participation and municipality deprivation: participation was lower for both the least and most deprived municipalities. This relationship was also observed for each of the two subpopulations-urban municipalities and rural ones-considered separately. Introducing the FDep in the model reduced slightly the unexplained variations in participation rates between departments and between municipalities (with a proportional change in variance of 14% and 12% respectively). We highlight major disparities in departmental participation rates and FDep/participation profiles. However, deprivation appears to have only little influence on geographical variation in participation rates. There is a need to further understand the factors affecting geographical variation in participation rates, in particular the use of opportunistic screening.

Does mammogram attendance influence participation in cervical and colorectal cancer screening? A prospective study among 1856 French women

BACKGROUND

We aimed to determine participation rates and factors associated with participation in colorectal (fecal occul blood test) and cervical cancer (Pap-smear) screening among a population of women participating in breast cancer screening.

METHODS

From August to October 2015, a self-administered questionnaire was sent by post to 2 900 women aged 50-65, living in Côte-d'Or, France, and who were up to date with mammogram screening. Polytomic logistic regression was used to identify correlates of participation in both cervical and colorectal cancer screenings. Participation in all 3 screenings was chosen as the reference.

RESULTS

Study participation rate was 66.3% (n = 1856). Besides being compliant with mammogram, respectively 78.3% and 56.6% of respondents were up to date for cervical and colorectal cancer screenings, while 46.2% were compliant with the 3 screenings. Consultation with a gynecologist in the past year was associated with higher chance of undergoing the 3 screenings or female cancer screenings (p<10-4), when consultation with a GP was associated with higher chance of undergoing the 3 screenings or organized cancer screenings (p<0.05). Unemployment, obesity, age>59 and yearly flu vaccine were associated with a lower involvement in cervical cancer screening. Women from high socio-economic classes were more likely to attend only female cancer screenings (p = 0.009). Finally, a low level of physical activity and tobacco use were associated with higher risk of no additional screening participation (p<10-3 and p = 0.027).

CONCLUSIONS

Among women participating in breast screening, colorectal and cervical cancer screening rates could be improved. Including communication about these 2 cancer screenings in the mammogram invitation could be worth to explore.

Patterns and determinants of mammography screening in Lebanese women

The associations of ever using and/or repeating a mammography test with psychosocial and socio-demographic factors were surveyed in 2014 among Lebanese women ≥ 40. A sample of 2400 women was selected across Lebanon. Variables with significant bivariate associations with various types of behaviors were entered in multivariate analysis. Of the total, 105 women (4·4%) had never heard of mammography as a tool for early breast cancer detection. Among the remaining 2295, 45% had ever used it, of whom 10% had obtained it for the first time within the 12 months preceding the survey. Repeaters were 67% of 926 women who had the time opportunity to do so (median lifetime frequency: 2). Older age, higher socio-economic status (SES) and living within the Greater Beirut (GB) area were significantly associated with ever-use. Within GB, psychosocial factors such as perceived susceptibility and benefits were most strongly associated with ever-use. Outside GB, socio-economic advantage seemed to mostly affect ever-use. Only 4% reported opposition from husbands to their mammography, and husband's support was significant for adherence to mammography guidelines mostly outside GB. Higher education emerged also as a significant socio-demographic determinant for ever-repeating in all regions. Perceived comfort of the previous test strongly affected the likelihood of repeating it. Providing mammography free-of-charge may alleviate some obstacles among women with socio-economic disadvantage. Stressing that good results one year do not make the cancer less likely or repeating the test less important, as well as improving the comfort of mammography testing could ensure test repeating.

[Reluctances in organized breast cancer screenig in Yvelines]

OBJECTIVES

Women's participation in organized screening of breast cancer was 52% in France and 40% in the Île de France in 2010. We wanted to investigate the reasons for non-participation in the screening program and the reluctance of women to it at the level of a department in Île de France.

MATERIALS AND METHODS

An anonymous questionnaire was sent to non-respondents in organized screening for breast cancer in the Yvelines department in September 2011 on the occasion of the event "Octobre Rose", month of national mobilization for mass screening for breast cancer. The analysis of these questionnaires was used to determine the causes of non-adherence to organized screening and reluctance to it. We compared the questionnaire responses in the characteristics of patients attending an individual screening with those of patients without any screening.

RESULTS

Two thousand nine hundred and ninety-two questionnaires were sent and 3026 responses received (10%). Two thousand six hundred and fifteen women (86%) reported regular screening and make mammograms every two years while 411 (14%) reported occasional or no screening. About the reluctance to conduct the review, the lack of time, the bad memories of a previous mammogram and the fear of pain were the predominant brakes. Nearly 50% of women do not participate in screening because they did not consider themselves at risk for various reasons (lack of symptoms, healthy lifestyle and no family history) and 22% of women surveyed had an attitude of denial cope with the disease. The typical profile of women performing individual or organized screening of breast cancer was that young, single, working, of low socio-professional category and rarely attending their general practitioner or gynaecologist. Health-care professionals seem most likely to cause adherence to screening for breast cancer.

DISCUSSION AND CONCLUSION

Focusing on the poor communication and promote organized screening instead of individual screening by health-care professionals themselves could increase adherence to organized screening in the Yvelines.

Women's participation in breast cancer screening in France--an ethical approach

Background

Breast cancer is a major public health challenge. Organized mammography screening (OS) is considered one way to reduce breast cancer mortality. EU recommendations prone mass deployment of OS, and back in 2004, France introduced a national OS programme for women aged 50–74 years. However, in 2012, participation rate was still just 52.7%, well short of the targeted 70% objective. In an effort to re-address the (in) efficiency of the programme, the French National Cancer Institute has drafted an expert-group review of the ethical issues surrounding breast cancer mammography screening.

Discussion

Prompted by emerging debate over the efficiency of the screening scheme and its allied public information provision, we keynote the experts’ report based on analysis of epidemiological data and participation rate from the public health authorities. The low coverage of the OS scheme may be partly explained by the fact that a significant number of women undergo mammography outside OS and thus outside OS criteria. These findings call for further thinking on (i) the ethical principles of beneficence and non-malfeasance underpinning this public health initiative, (ii) the reasons behind women’s and professionals’ behavior, and (iii) the need to analyze how information provision to women and the doctor-patient relationship need to evolve in response to scientific controversy over the risks and benefits of conducting mammographic screening.

Summary

This work calls for a reappraisal of the provision of screening programme information. We advocate a move to integrate the points sparking debate over the efficiency of the screening scheme to guarantee full transparency. The perspective is to strengthen the respect for autonomy allowing women to make an informed choice in their decision on whether or not to participate.

To what extent is women's economic situation associated with cancer screening uptake when nationwide screening exists? A study of breast and cervical cancer screening in France in 2010

PURPOSE

In France, larger social inequalities are reported for cervical cancer screening, based on individual practice, than for breast cancer screening for which organized screening exists. Our aim was to investigate the association between women's economic situation and breast and cervical cancer screening.

METHODS

We used data from a large French national health survey conducted in 2010. The economic situation was assessed using the number of adverse economic conditions respondents were facing, based on three variables (low income, lacking food, and perceived financial difficulties). Logistic regressions were adjusted for socioeconomic and sociodemographic characteristics, healthcare use and insurance, and health behaviors.

RESULTS

Mammography was less frequent among women experiencing two or more adverse economic conditions, whereas Pap smear was less frequent among women experiencing at least one adverse economic condition. For both screenings, higher rates were observed among women who lived in the Paris region. Sociodemographic indicators and health behaviors were associated with Pap smear, whereas healthcare use and insurance characteristics were associated with mammography.

CONCLUSIONS

The women's economic situation is an important determinant of breast and cervical cancer screening in France in 2010. Alleviating economic barriers to female cancers screening should be a priority in future programs implementation.

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.

Diverging trends in educational inequalities in cancer mortality between men and women in the 2000s in France

BACKGROUND

Socioeconomic inequalities in cancer mortality have been observed in different European countries and the US until the end of the 1990s, with changes over time in the magnitude of these inequalities and contrasted situations between countries. The aim of this study is to estimate relative and absolute educational differences in cancer mortality in France between 1999 and 2007, and to compare these inequalities with those reported during the 1990s.

METHODS

Data from a representative sample including 1% of the French population were analysed. Educational differences among people aged 30-74 were quantified with hazard ratios and relative indices of inequality (RII) computed using Cox regression models as well as mortality rate difference and population attributable fraction.

RESULTS

In the period 1999-2007, large relative inequalities were found among men for total cancer and smoking and/or alcohol related cancers mortality (lung, head and neck, oesophagus). Among women, educational differences were reported for total cancer, head and neck and uterus cancer mortality. No association was found between education and breast cancer mortality. Slight educational differences in colorectal cancer mortality were observed in men and women. For most frequent cancers, no change was observed in the magnitude of relative inequalities in mortality between the 1990s and the 2000s, although the RII for lung cancer increased both in men and women. Among women, a large increase in absolute inequalities in mortality was observed for all cancers combined, lung, head and neck and colorectal cancer. In contrast, among men, absolute inequalities in mortality decreased for all smoking and/or alcohol related cancers.

CONCLUSION

Although social inequalities in cancer mortality are still high among men, an encouraging trend is observed. Among women though, the situation regarding social inequalities is less favourable, mainly due to a health improvement limited to higher educated women. These inequalities may be expected to further increase in future years.

Understanding barriers to organized breast cancer screening in France: women's perceptions, attitudes, and knowledge

BACKGROUND

The participation rate in organized breast cancer screening in France is lower than recommended. Non-participants either use opportunistic screening or do not use either screening modality.

OBJECTIVE

To assess any differences in perceptions, attitudes and knowledge related to breast cancer screening between users of opportunistic screening and non-users of any screening mammograms and to identify potential barriers to participation in organized screening.

METHODS

Six focus groups were conducted in May 2010 with 34 French non-participants in organized screening, 15 who used opportunistic screening (OpS group) and 19 who used no screening (NoS group). The guide used for both groups explored perceptions and attitudes related to health, cancer and screening; perceptions of femininity; and knowledge about breast cancer screening. Thematic content analysis was performed.

RESULTS

Perceptions, attitudes and knowledge differed between the two groups. Women in the OpS group perceived a high susceptibility to breast cancer, visited their gynaecologist regularly, were unfamiliar with organized screening modalities and had doubts about its quality. NoS women had very high- or low-perceived susceptibility to breast cancer, knew about screening modalities, had doubts about its usefulness and expressed negative opinions of mammograms.

CONCLUSIONS

Differences in perceptions and attitudes related to breast cancer screening partially explain why some women choose opportunistic screening or no screening. General practitioners and gynaecologists are in a unique position to provide individually tailored preventative messages to improve participation in organized screening.

Mammography use for breast cancer screening in Portugal: results from the 2005/2006 National Health Survey

BACKGROUND

Understanding the patterns of mammography use is essential to promote the participation in breast cancer screening.

OBJECTIVES

To describe the patterns of screening mammography use in Portugal.

METHODS

As part of the fourth National Health Survey (2005/2006), 3045 women were evaluated in face-to-face interviews. The previous use of mammography for screening was classified as never or ever, and the latter was further grouped according to the time elapsed since the latest mammography. Having undergone the latest mammography >2 years before was considered underuse. We assessed the determinants of never having been screened by mammography and, among those who had been tested, the determinants of mammography underuse, through age- and education-adjusted odds ratios (ORs), with 95% confidence intervals (95% CIs).

RESULTS

Among women aged 45-49 and 50-69 years, 86.3% and 88.0%, respectively, underwent a screening mammography before, and most of them were tested in the previous 2 years. The lowest risk of never having been screened was in Norte (OR = 0.41, 95% CI: 0.21-0.80) and the highest in Açores (OR = 4.04, 95% CI: 2.37-6.92), in comparison with Centro (the region with organized screening for a longer time). Participants with <4 years of formal education were more likely to have never been screened than the more educated (OR = 4.27, 95% CI: 1.67-10.89). Women with private health insurance (OR = 0.16, 95% CI: 0.04-0.65), as well as those who had undergone cervical cytology screening before (OR = 0.50, 95% CI: 0.30-0.85), had a lower risk of underuse.

CONCLUSIONS

This study provides useful information to improve the allocation of resources to breast cancer screening.

Socioeconomic disparities in the uptake of breast and cervical cancer screening in Italy: a cross sectional study

BACKGROUND

Breast and cervical cancer screening are widely recognized as effective preventive procedures in reducing cancer mortality. The aim of this study was to evaluate the impact of socioeconomic disparities in the uptake of female screening in Italy, with a specific focus on different types of screening programs.

METHODS

A cross-sectional study was conducted using data from the 2004-2005 national health interview survey. A sample of 15, 486 women aged 50-69 years for mammography and one of 35, 349 women aged 25-64 years for Pap smear were analysed. Logistic regression models were used to estimate the association between socioeconomic factors and female screening utilization.

RESULTS

Education and occupation were positively associated with attendance to both screening. Women with higher levels of education were more likely to have a mammogram than those with a lower level (OR = 1.28; 95% CI = 1.10-1.49). Women of intermediate and high occupational classes were more likely to use breast cancer screening (OR = 1.77; 95% CI = 1.55-2.03, OR = 1.63; 95% CI = 1.40-1.91) compared to unemployed women. Women in the highest occupational class had a higher likelihood of cervical cancer screening compared to those in the lowest class (OR = 1.81; 95% CI = 1.63-2.01). Among women who attended screening, those with lower levels of education and lower occupational classes were more likely than more advantaged women to attend organized screening programs rather than being screened on the basis of their own initiative.

CONCLUSIONS

Inequalities in the uptake of female screening widely exist in Italy. Organized screening programs may have an important role in increasing screening attendance and tackling inequalities.

The impact of family history of breast cancer on knowledge, attitudes, and early detection practices of Mexican women along the Mexico-US border

Rates of breast cancer (BC) have increased in Mexico, with the highest incidence and mortality rates observed in the northern Mexican states. This study aimed to describe the BC knowledge, attitudes and screening practices among Mexican women with and without a family history of BC residing along the Mexico-US border, and identify factors associated with screening behaviors. One hundred and twenty eight Mexican women aged 40 and older completed an interviewer-administered questionnaire on sociodemographic characteristics, knowledge, family history, and screening practices. There were no significant differences between Mexican women with and without a family history. Over 60% of women in both groups had never had a mammogram/breast ultrasound, and more than 50% had never obtained a clinical breast exam. Age, marital status, insurance, and breast cancer knowledge significantly influenced BC screening behaviors among Mexican women. Further research is needed to examine other key factors associated with screening utilization, in effort of improving BC rates.

The contribution of risk factors to the higher incidence of invasive and in situ breast cancers in women with higher levels of education in the European prospective investigation into cancer and nutrition

The authors investigated the role of known risk factors in educational differences in breast cancer incidence. Analyses were based on the European Prospective Investigation Into Cancer and Nutrition and included 242,095 women, 433 cases of in situ breast cancer, and 4,469 cases of invasive breast cancer. Reproductive history (age at first full-term pregnancy and parity), exposure to endogenous and exogenous hormones, height, and health behaviors were accounted for in the analyses. Relative indices of inequality (RII) for education were estimated using Cox regression models. A higher risk of invasive breast cancer was found among women with higher levels of education (RII = 1.22, 95% confidence interval (CI): 1.09, 1.37). This association was not observed among nulliparous women (RII = 1.13, 95% CI: 0.84, 1.52). Inequalities in breast cancer incidence decreased substantially after adjusting for reproductive history (RII = 1.11, 95% CI: 0.98, 1.25), with most of the association being explained by age at first full-term pregnancy. Each other risk factor explained a small additional part of the inequalities in breast cancer incidence. Height accounted for most of the remaining differences in incidence. After adjusting for all known risk factors, the authors found no association between education level and risk of invasive breast cancer. Inequalities in incidence were more pronounced for in situ breast cancer, and those inequalities remained after adjustment for all known risk factors (RII = 1.61, 95% CI: 1.07, 2.41), especially among nulliparous women.

Social Class Inequalities in the Utilization of Health Care and Preventive Services in Spain, a Country with a National Health System

In Spain, despite the existence of a National Health System (NHS), the utilization of some curative health services is related to social class. This study assesses (1) whether these inequalities are also observed for preventive health services and (2) the role of additional private health insurance for people of advantaged social classes. Using data from the Spanish National Health Survey of 2006, the authors analyze the relationships between social class and use of health services by means of Poisson regression models with robust variance, controlling for self-assessed health. Similar analyses were performed for waiting times for visits to a general practitioner (GP) and specialist. After controlling for self-perceived health, men and women from social classes IV-V had a higher probability of visiting the GP than other social classes, but a lower probability of visiting a specialist or dentist. No large class differences were observed in frequency of hospitalization or emergency services use, or in breast cancer screening or influenza vaccination; cervical cancer screening frequency was lower among women from social classes IV-V. The inequalities in specialist visits, dentist visits, and cervical cancer screening were larger among people with only NHS insurance than those with double health insurance. Social class differences in waiting times were observed for specialist visits, but not for GP visits. Men and women from social classes IV-V had longer waits for a specialist; this was most marked among people with only NHS insurance. Clearly, within the NHS, social class inequalities are still evident for some curative and preventive services. Further research is needed to identify the factors driving these inequalities and to tackle these factors from within the NHS. Priority areas include specialist services, dental care, and cervical cancer screening.

Socio-economic inequalities in breast and cervical cancer screening practices in Europe: influence of the type of screening program

BACKGROUND

The aim of this study was to describe inequalities in the use of breast and cervical cancer screening services according to educational level in European countries in 2002, and to determine the influence of the type of screening program on the extent of inequality.

METHODS

A cross-sectional study was performed using individual-level data from the WHO World Health Survey (2002) and data regarding the implementation of cancer screening programmes. The study population consisted of women from 22 European countries, aged 25-69 years for cervical cancer screening (n =11 770) and 50-69 years for breast cancer screening (n = 4784). Dependent variables were having had a PAP smear and having had a mammography during the previous 3 years. The main independent variables were socio-economic position (SEP) and the type of screening program in the country. For each country the prevalence of screening was calculated, overall and for each level of education, and indices of relative (RII) and absolute (SII) inequality were computed by educational level. Multilevel logistic regression models were fitted.

RESULTS

SEP inequalities in screening were found in countries with opportunistic screening [comparing highest with lowest educational level: RII = 1.28, 95% confidence interval (CI) 1.12-1.48 for cervical cancer; and RII = 3.11, 95% CI 1.78-5.42 for breast cancer] but not in countries with nationwide population-based programmes. Inequalities were also observed in countries with regional screening programs (RII = 1.35, 95% CI 1.10-1.65 for cervical cancer; and RII = 1.58, 95% CI 1.26-1.98 for breast cancer).

CONCLUSIONS

Inequalities in the use of cancer screening according to SEP are higher in countries without population-based cancer screening programmes. These results highlight the potential benefits of population-based screening programmes.

Comparison of interval breast cancer rates for two-versus single-view screening mammography: a population-based study

OBJECTIVE

To determine whether the implementation of two-view mammography was followed by a reduction in the rates of interval cancers.

MATERIAL AND METHOD

We analyzed the data concerning women aged 50-69 who attended the breast cancer screening program between January 1, 1994 and December 31, 2006 in Isère, France. We performed Poisson regressions to estimate age-adjusted rate ratios of women being recalled, cancer detection, and interval cancer for two-view compared to single-view mammography.

RESULTS

After adjusting for age, two-view mammography was associated with a higher risk of cancer detection (1.37 [95% CI, 1.16-1.62]) and with a decreased risk of 12-month (0.46 [95% CI, 0.23-0.92]) and 24-month (0.64 [95% CI, 0.46-0.88]) interval cancer.

CONCLUSION

Two-view mammography for first and subsequent screens is associated with lower rates of interval breast cancer. This is at the expense of an increased number of women being recalled for further assessment after subsequent screens.

[Which factors influence screening practices for female cancer in France?]

BACKGROUND

The two aims of the study were, first to estimate the declared two-year coverage of breast cancer and cervical cancer screenings, and second to determine the main factors influencing female cancer screening behaviors.

METHODS

Three groups of women from the 2003 French decennial health interview survey were analyzed: 3378 women aged 50-74 years who answered the question on mammography use, 7912 women aged 25-65 years who answered the question on Pap-smear use, and 2528 women aged 50-65 years who answered both questions.

RESULTS

The declared coverage of breast cancer screening was 71.2%, the declared coverage of cervical cancer screening was 76.3%. Almost 18% of women declared having undergone neither a mammography nor a Pap-smear in the last two years. The main factor linked to a more frequent practice of one or both cancer screenings (breast or cervix) was to have undergone recently the other screening. The other factors linked to mammography use were mainly healthcare and practitioner access variables. Those linked to Pap-smear use were mainly socioeconomic and socio-demographic variables, healthcare and practitioner access variables being also linked. The main factors linked to having undergone none of these two screenings were of financial nature, particularly household income and home ownership.

CONCLUSION

The study showed that it is appropriate to communicate on both screenings at the same time since they have a positive effect each other. Finally, practitioners continue to play a central role in collecting information on cancer screenings and encouraging screening in women not regularly screened.