Mammography rates 3 years after the 2009 US Preventive Services Task Force Guidelines changes

Long-term Mammography Screening Trends and Predictors of Return to Screening after the COVID-19 Pandemic: Results from a Statewide Registry

Purpose To evaluate long-term trends in mammography screening rates and identify sociodemographic and breast cancer risk characteristics associated with return to screening after the COVID-19 pandemic. Materials and Methods In this retrospective study, statewide screening mammography data of 222 384 female individuals aged 40 years or older (mean age, 58.8 years ± 11.7 [SD]) from the Vermont Breast Cancer Surveillance System were evaluated to generate descriptive statistics and Joinpoint models to characterize screening patterns during 2000-2022. Log-binomial regression models estimated associations of sociodemographic and risk characteristics with post-COVID-19 pandemic return to screening. Results The proportion of female individuals in Vermont aged 50-74 years with a screening mammogram obtained in the previous 2 years declined from a prepandemic level of 61.3% (95% CI: 61.1%, 61.6%) in 2019 to 56.0% (95% CI: 55.7%, 56.3%) in 2021 before rebounding to 60.7% (95% CI: 60.4%, 61.0%) in 2022. Screening adherence in 2022 remained substantially lower than that observed during the 2007-2010 apex of screening adherence (66.1%-67.0%). Joinpoint models estimated an annual percent change of -1.1% (95% CI: -1.5%, -0.8%) during 2010-2022. Among the cohort of 95 644 individuals screened during January 2018-March 2020, the probability of returning to screening during 2020-2022 varied by age (eg, risk ratio [RR] = 0.94 [95% CI: 0.93, 0.95] for age 40-44 vs age 60-64 years), race and ethnicity (RR = 0.84 [95% CI: 0.78, 0.90] for Black vs White individuals), education (RR = 0.84 [95% CI: 0.81, 0.86] for less than high school degree vs college degree), and by 5-year breast cancer risk (RR = 1.06 [95% CI: 1.04, 1.08] for very high vs average risk). Conclusion Despite a rebound to near prepandemic levels, Vermont mammography screening rates have steadily declined since 2010, with certain sociodemographic groups less likely to return to screening after the pandemic. Keywords: Mammography, Breast, Health Policy and Practice, Neoplasms-Primary, Epidemiology, Screening Supplemental material is available for this article. © RSNA, 2024.

Screening Mammography Utilization in the United States

Breast cancer is the second leading cause of cancer mortality in adult women in the United States. Screening mammography reduces breast cancer mortality between 22% and 48%; however, screening mammography remains underutilized. Screening mammography utilization data are available from insurance claims, electronic medical records, and patient self-report via surveys, and each data source has unique benefits and challenges. Numerous barriers exist that adversely affect the use of screening mammography in the United States. This article will review screening mammography utilization in the United States, explore factors that impact utilization, and briefly discuss strategies to improve utilization.

Factors Associated with Mammography Screening Choices by Women Aged 40-49 at Average Risk

Background: The U.S. Preventive Services Task Force (USPSTF) does not recommend routine mammogram screening for women aged 40-49 years at average risk for breast cancer. We aimed to assess the extent to which women were following guideline recommendations and to examine whether guideline awareness and other individual-level factors were associated with adherence. Materials and Methods: We surveyed a nationally representative panel of 383 U.S. women aged 40-49 years at low risk for hereditary breast cancer in October 2019. Results: Only 29% of women reported not having initiated screening mammography. Most women (80%) were unaware of the USPSTF screening guideline related to age of initiation and frequency of mammography. Being aware of the recommendation to initiate screening at age 50 increased the odds of not initiating screening (odds ratio [OR] = 6.70, p < 0.001), whereas being older than 45 years (OR = 0.22, p < 0.001) and having a primary care doctor decreased the odds of not initiating screening (OR = 0.25, p < 0.001). Conclusions: Mammogram screening in excess of USPSTF recommendations is prevalent among U.S. women aged 40-49 years. Efforts are needed to increase women's awareness of the rationale for guidelines and the opportunities to discuss with providers whether delaying mammograms is appropriate.

Health Economics Research in Cancer Screening: Research Opportunities, Challenges, and Future Directions

Cancer screening has long been considered a worthy public health investment. Health economics offers the theoretical foundation and research methodology to understand the demand- and supply-side factors associated with screening and evaluate screening-related policies and interventions. This article provides an overview of health economic theories and methods related to cancer screening and discusses opportunities for future research. We review 2 academic disciplines most relevant to health economics research in cancer screening: applied microeconomics and decision science. We consider 3 emerging topics: cancer screening policies in national as well as local contexts, "choosing wisely" screening practices, and targeted screening efforts for vulnerable subpopulations. We also discuss the strengths and weaknesses of available data sources and opportunities for methodological research and training. Recommendations to strengthen research infrastructure include developing novel data linkage strategies, increasing access to electronic health records, establishing curriculum and training programs, promoting multidisciplinary collaborations, and enhancing research funding opportunities.

Trends in Annual Surveillance Mammography Participation Among Breast Cancer Survivors From 2004 to 2016

BACKGROUND

Annual mammography is recommended for breast cancer survivors; however, population-level temporal trends in surveillance mammography participation have not been described. Our objective was to characterize trends in annual surveillance mammography participation among women with a personal history of breast cancer over a 13-year period.

METHODS

We examined annual surveillance mammography participation from 2004 to 2016 in a nationwide sample of commercially insured women with prior breast cancer. Rates were stratified by age group (40-49 vs 50-64 years), visit with a surgical/oncology specialist or primary care provider within the prior year, and sociodemographic characteristics. Joinpoint models were used to estimate annual percentage changes (APCs) in participation during the study period.

RESULTS

Among 141,672 women, mammography rates declined from 74.1% in 2004 to 67.1% in 2016. Rates were stable from 2004 to 2009 (APC, 0.1%; 95% CI, -0.5% to 0.8%) but declined 1.5% annually from 2009 to 2016 (95% CI, -1.9% to -1.1%). For women aged 40 to 49 years, rates declined 2.8% annually (95% CI, -3.4% to -2.1%) after 2009 versus 1.4% annually in women aged 50 to 64 years (95% CI, -1.9% to -1.0%). Similar trends were observed in women who had seen a surgeon/oncologist (APC, -1.7%; 95% CI, -2.1% to -1.4%) or a primary care provider (APC, -1.6%; 95% CI, -2.1% to -1.2%) in the prior year.

CONCLUSIONS

Surveillance mammography participation among breast cancer survivors declined from 2009 to 2016, most notably among women aged 40 to 49 years. These findings highlight a need for focused efforts to improve adherence to surveillance and prevent delays in detection of breast cancer recurrence and second cancers.

Change in individual physicians' screening mammography completion rates following the updated USPSTF guideline supporting shared decision making: An observational cohort study

OBJECTIVE

To understand changes in physician screening practices in response to the 2009 U.S. Preventive Services Task Force recommendation supporting shared decision making (SDM) for mammography in women aged 40-49 years.

METHODS

We assessed screening completion rates for physicians in the Cleveland Clinic Health System pre-2009 (2006-2008) and post-2009 (2010-2015), and rates for physicians new to the system post-2009. We used mixed effects logistic regression to estimate the odds of a woman receiving screening post-2009. If physicians practiced SDM, we hypothesized their screening rates would change after 2009. To test this, we included each physician's pre-2009 screening rate as a predictor in the model.

RESULTS

Among 125 physicians, the screening rate increased from 40% to 45% from pre-2009 to post-2009. For physicians new to the health system post-2009 the rate was 32%. In the mixed effects model (N = 17,007), the strongest predictor of mammography receipt among patients post-2009 was their physician's pre-2009 screening rate (aOR:3.57 per 10% increase in pre-2009 rate; 95%CI:1.69-7.50).

CONCLUSIONS

Whether a woman received a mammogram post-2009 was highly associated with her physicians' pre-2009 screening rate, suggesting physicians are not individualizing screening decisions via SDM.

PRACTICE IMPLICATIONS

Physicians may need support to effectively practice SDM.

The U.S. Preventive Services Task Force Abdominal Aortic Aneurysm Screening Guidelines Negligibly Impacted Repair Rates in Male Never-Smokers and Female Smokers

OBJECTIVE

In 2014, in addition to male smokers aged 65-75, the U.S. Preventive Services Task Force (USPSTF) recommended abdominal aortic aneurysm (AAA) screening for male never-smokers aged 65-75 with cardiovascular risk factors (Grade C). The USPSTF evolved from a negative to neutral position on screening for female smokers aged 65-75 (Grade I). We sought to determine whether 2014 guidelines resulted in more AAA repairs in these populations.

METHODS

We queried the Vascular Quality Initiative national database (2013-2018) for elective endovascular aortic repairs and open aortic repairs. We implemented difference-in-differences (DID) analysis, a causal inference technique that adjusts for secular time trends, to isolate changes in repair numbers due to the 2014 USPSTF guidelines. Our DID models compared changes in repair numbers in patient groups targeted by the USPSTF updates (intervention group) to those in unaffected, older patient groups (control), before and after 2014. The first model compared changes in repair numbers between male never-smokers aged 65-75 (intervention group) and 76-85 (control). The second model compared repair numbers between female smokers aged 65-75 (intervention group) and 76-85 (control).

RESULTS

There was no significant change in male never-smokers (n=1,295) aged 65-75 (42%) vs. 76-85 (58%) undergoing AAA repairs after guideline updates, averaged over 4.5 years (+2.4 percentage points; 95% Confidence Interval [CI] -.56-5.26). However, when their primary insurer was Medicare, male never-smokers aged 65-75 compared with 76-85 underwent significantly more repairs over 4.5 years (+3.69 percentage points; 95% CI.16-7.22; representing a 10.4% relative increase from baseline in the proportion of male never-smokers on Medicare undergoing AAA repair). Comparing female smokers (n=2,312) aged 65-75 (54%) vs. 76-85 (46%), there was no significant change in repairs over 4.5 years (-.66 percentage points; 95% CI -4.57-3.26).

CONCLUSIONS

The USPSTF 2014 AAA guidelines were associated with modestly increased repairs in male never-smokers aged 65-75 only on Medicare. There was no impact among female smokers. Higher-grade recommendations and improved guideline adherence may be requisites for change.

The Impact of Mammography Screening Guideline Changes in a Universally Insured Population

Background: The U.S. Preventive Services Task Force (USPSTF) modified breast cancer screening guidelines in November 2009. The impact has been studied among privately and Medicare insured populations, but not among universally insured women. Materials and Methods: This study compared the proportion of TRICARE beneficiaries aged 40-64 receiving mammograms from fiscal years 2006 to 2015 using an interrupted time series analysis to determine the impact of the 2009 USPSTF guideline changes. Stratified analyses evaluated differences by age (ages 40-49, 50-64), race, care setting, beneficiary type, and military status. Results: The proportion of women receiving mammograms increased from October 2005 through September 2009. A small, but significant decrease of 65-66 fewer women screened per 10,000 occurred in the first quarter of 2010 (October 1 to December 31) following the screening guideline update publication. The proportion screened then remained unchanged through 2015. Comparative analysis revealed no differences in impact between age groups, blacks and whites, or military dependents and active-duty/retirees. Conclusions: This study determined that the USPSTF guideline updates had a small, but immediate and lasting impact that was not different across age groups, beneficiary type, or race. No racial disparities in the proportion screened or in the impact of the guideline change were noted in our universally insured population.

Changes in mammography screening in Ontario and Alberta following national guideline dissemination: an interrupted time series analysis

Background: In November 2011, the Canadian Task Force on Preventive Health Care released guidelines for screening women at average breast cancer risk. Weak recommendations (framed using GRADE methodology) were made for screening women aged 50 to 74 years every two to three years, and for not screening women aged 40 to 49 years. Methods: We conducted an interrupted time series analysis using administrative data to examine bilateral mammography use before and after a national guideline dissemination strategy targeting primary care physicians. Women aged 40 to 74 years living in Ontario or Alberta from 30 th November 2008 to 30 th November 2014 were included. Strata included age, region of residence, neighbourhood income quintile, immigration status, and education level. Results: In both provinces, mammography use rates were lower in the post-intervention period (527 vs. 556 and 428 vs. 465/1000 participant-months - the monthly screening rate/1000 - in Ontario and Alberta, respectively). In Ontario, mammography trends decreased following guideline release to align with recommendations for women aged 40 to 74 (decrease of 2.21/1000 women, SE 0.26/1000, p<0.0001). In Alberta, mammography trends decreased for women aged 40 to 49 years (3/1000 women, SE 0.32, p<0.001) and 50 to 69 (2.9/1000 women, SE 0.79, p<0.001), but did not change for women aged 70 to 74 (0.7/1000 women, SE 1.23, p=0.553). In both provinces, trends in mammography use rates were sustained for up to three years after guideline release. Conclusions: The guideline dissemination strategy appeared to increase uptake of guideline-concordant screening practice in women aged 40 to 49 years in Ontario and Alberta and for women aged 50 to 74 years in Ontario. Further work is required to understand these findings and whether shared decision making about mammography between women and providers increased among women considering mammography.

Changes in mammography screening in Ontario and Alberta following national guideline dissemination: an interrupted time series analysis

Background: In November 2011, the Canadian Task Force on Preventive Health Care released guidelines for screening women at average breast cancer risk. Weak recommendations (framed using GRADE methodology) were made for screening women aged 50 to 74 years every two to three years, and for not screening women aged 40 to 49 years. Methods: We conducted an interrupted time series analysis using administrative data to examine bilateral mammography use before and after a release of a national breast screening guideline. Women aged 40 to 74 years living in Ontario or Alberta from 30th November 2008 to 30th November 2014 were included. Strata included age, region of residence, neighbourhood income quintile, immigration status, and education level. Results: In both provinces, mammography use rates were lower in the post-intervention period (527 vs. 556 and 428 vs. 465/1000 women in Ontario and Alberta, respectively). In Ontario, mammography trends decreased following guideline release to align with recommendations for women aged 40 to 74 (decrease of 2.21/1000 women, SE 0.26/1000, p<0.0001). In Alberta, mammography trends decreased for women aged 40 to 49 years (3/1000 women, SE 0.32, p<0.001) and 50 to 69 (2.9/1000 women, SE 0.79, p<0.001), but did not change for women aged 70 to 74 (0.7/1000 women, SE 1.23, p=0.553). In both provinces, trends in mammography use rates were sustained for up to three years after guideline release. Conclusions: We observed a decrease in screening for women aged 40-49. Additional research to explore whether shared decision making was used to optimize guideline-concordant screening for women aged 50-74 is needed.

The Impact of Mammography Screening Guideline Changes Among Women Serving in the U.S. Military

INTRODUCTION

The U.S. Preventive Services Task Force (USPSTF) modified their screening guidelines for breast cancer in November 2009. Previous studies evaluated the impact of these guideline changes among privately and Medicare insured populations. Women in the military form a unique population exposed to many social, environmental, and occupational hazards that may increase breast cancer incidence. By evaluating mammography screening rates among women in the military before and after the USPSTF guideline changes, this study evaluated the impact of the USPSTF breast cancer guideline change on screening mammography use within the military population and determined whether current guidelines were followed for this high-risk population with universal health care access.

MATERIALS AND METHODS

This study evaluated the impact of the 2009 guideline changes among the population of universally insured military servicewomen, comparing the proportion of active duty women aged 40 to 64 receiving mammograms from fiscal years 2006 to 2015 using an interrupted time series analysis. Stratified analyses evaluated differences by age (aged 40-49, 50-64), race, military branch, and rank. This research is considered exempt by the Uniformed Services University Institutional Review Board.

RESULTS

The proportion of insured military servicewomen receiving mammograms increased from October 2005 through September 2009. A significant decrease occurred in the first quarter of 2010 following the publication of the screening guideline update. From this new baseline, the proportion of women screened increased again through September 2015. Comparative analyses showed more pronounced effects both immediately and over time among the women aged 50 to 64 compared to those aged 40 to 49 years and among older enlisted women compared with their officer counterparts. The patterns were near identical in all subgroups; however, no changes in rate were evident among Air Force and black servicewomen aged 50 to 64 and Army and Navy/Marine Corps servicewomen aged 40 to 49 years. No racial disparities in screening or impact were noted.

CONCLUSIONS

The USPSTF guidelines had differential impacts among some subpopulations. While older women, aged 50 to 64 years, had a greater temporary reduction immediately after the guideline change, younger women aged 40 to 49 years had a longer-term reduction in screening following the guideline changes. No racial disparities in the proportion screened or in the impact of the guideline change were noted in this population with universal health coverage. The lack of Department of Defense standard breast cancer screening guidelines was evident from the different patterns of mammography utilization observed among military branches. To completely understand the impact of the updated screening guidelines, future studies must incorporate research focusing on changes in breast cancer morbidity and mortality as well as updated cost-benefit analyses.

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.

False-positive mammography and mammography screening intentions among black women: the influence of emotions and coping strategies

Introduction: Abnormal mammograms confirmed as benign are known as false-positive mammography (FPM) results. Research indicates that a history of FPM results may be linked to diagnostic delays in Black women, yet much of the research on FPM has focused on White women.Objectives: The purpose of this study was to examine: 1) The influence of FPM on breast cancer (BrCa) screening beliefs and intentions among Black women and 2) Whether emotional states, personality traits or coping behaviors altered the previously described relationships.Design: BrCa-free, Black women, aged 40 and older who completed screening mammograms in 2016 were recruited for a case-control study from 2016 to 2017. Women with FPM results were cases, and women with normal results served as matched controls. Print surveys assessing demographics, personality traits, emotions, BrCa screening history, BrCa beliefs, and africentric coping behaviors were mailed to participants. The final sample consisted of 118 respondents (55 cases, 63 controls). Ordinary least squares (OLS) models were constructed. Personality traits and emotions were tested as mediators and coping behaviors as moderators of the relationship between FPM results and BrCa beliefs.Results: FPM status was associated with a higher perception of barriers to mammography, and an elevated perception of barriers was associated with lower intentions to complete mammography. Collective coping behaviors functioned as a moderator and were associated with a decreased perception of mammography barriers in women with FPM results.Conclusions: FPM status had a detrimental impact on mammography intention indirectly through the perception of mammography barriers, but the use of africentric coping behaviors moderated the relationship between FPM status and perceived barriers to mammography. Culturally specific research focused on Black women is needed to explore influences on BrCa screening beliefs and mammography completion in this population.

Effects of Media Exposure to Conflicting Information About Mammography: Results From a Population-based Survey Experiment

BACKGROUND

Although there is growing theoretical and empirical support for the proposition that media exposure to conflicting health information negatively influences public understanding and behavior, few studies have causally linked exposure to conflict with undesirable outcomes. Such outcomes might be particularly likely in the context of mammography, given widespread media attention to conflicting recommendations about the age at and frequency with which average-risk women should be screened for breast cancer.

PURPOSE

The current study tests whether exposure to conflicting information about mammography negatively influences women's affective and cognitive responses and examines whether effects vary by socioeconomic position.

METHODS

We conducted an online survey experiment in 2016 with a population-based sample of U.S. women aged 35-55 (N = 1,474). Participants were randomly assigned to one of four conditions that differed in the level of conflict about mammography presented in a news story (no, low, medium, or high conflict), stratifying by poverty level.

RESULTS

Greater exposure to conflict increased women's negative emotional responses to the story they read, their confusion about and backlash toward cancer prevention recommendations and research, and their ambivalence about mammography and other types of cancer screening, though ambivalence leveled off at high levels of exposure. There was little evidence that effects varied across socioeconomic position.

CONCLUSIONS

Findings add to the growing evidence base documenting undesirable outcomes of exposure to conflicting health information. Future research should examine whether the negative affective and cognitive responses observed translate into behavior, which could have implications for both health campaigns and patient-provider communication.

Examining Breast Cancer Screening Behavior Among Southern Black Women After the 2009 US Preventive Services Task Force Mammography Guideline Revisions

Updated United States Preventive Services Task Force (USPSTF) and American Cancer Society mammography screening recommendations push for increased age of initiation and lengthened breast cancer screening intervals. These changes have implications for the reduction of breast cancer mortality in Black women. The purpose of this study was to examine breast cancer screening behavior in a cohort of Southern Black women after the release of the 2009 USPSTF recommendations. Surveys assessing cancer screening information were collected from members of Black churches between 2006 and 2013. The sample was restricted to women aged 40 to 74 years, who did not report a breast cancer diagnosis, or a recent diagnostic mammogram (n = 789). Percentages of women ever completing a mammogram (age 40-49) and annual mammography (age 50-74) in 2006-2009 and 2010-2013 were compared using chi-square statistics. Logistic regression models were fit to determine the predictors of adherence to pre-2010 screening guidelines. No significant changes in mammography rates were found for women in the 40-49 age group (X² = 0.42, p = 0.52) nor for those in the 50-74 age group (X² = 0.67, p = 0.41). Completing an annual clinical breast exam was a significant predictor of adherence to pre-2010 screening guidelines for both age groups (OR 19.86 and OR 33.27 respectively) and participation in education sessions (OR 4.26). Stability in mammography behavior may be a result of PCP's advice, or community activities grounded pre-2010 screening recommendations. More research is needed to understand how clinical interactions and community-based efforts shape Black women's screening knowledge and practices.

The Impact of Breast Density Notification Laws on Supplemental Breast Imaging and Breast Biopsy

BACKGROUND

Dense breast tissue increases breast cancer risk and lowers mammography sensitivity, but the value of supplemental imaging for dense breasts remains uncertain. Since 2009, 37 states and Washington DC have passed legislation requiring patient notification about breast density.

OBJECTIVE

Examine the effects of state breast density notification laws on use of supplemental breast imaging and breast biopsies.

DESIGN

Difference-in-differences analysis of supplemental imaging and biopsies before and after notification laws in 12 states enacting breast density notification laws from 2009 to 2014 and 12 matched control states. Supplemental imaging/biopsy within 6 months following an index mammogram were evaluated during four time periods related to legislation: (1) 6 months before, (2) 0-6 months after, (3) 6-12 months after, and (4) 12-18 months after.

PARTICIPANTS

Women ages 40-64 years receiving an initial mammogram in a state that passed a breast density notification law or a control state.

INTERVENTION

Mandatory breast density notification following an index mammogram.

MAIN MEASURES

Use of breast biopsies and supplemental breast imaging (breast ultrasound, tomosynthesis, magnetic resonance imaging, scintimammography, and thermography), overall and by specific test.

KEY RESULTS

Supplemental breast imaging and biopsy increased modestly in states with notification laws and changed minimally in control states. Adjusted rates of supplemental imaging and biopsy within 6 months of mammography before legislation were 8.5% and 3.1%, respectively. Compared with pre-legislation in intervention and control states, legislation was associated with adjusted difference-in-differences estimates of + 1.3% (p < 0.0001) and + 0.4% (p < 0.0001) for supplemental imaging and biopsies, respectively, in the 6-12 months after the law and difference-in-differences estimates of + 3.3% (p < 0.0001) and + 0.8% (p < 0.0001) for supplemental imaging and biopsies, respectively, 12-18 months after the law.

CONCLUSIONS

As breast density notification laws are considered, policymakers and clinicians should expect increases in breast imaging/biopsies. Additional research is needed on these laws' effects on cost and patient outcomes.

U.S. women's perceived importance of the harms and benefits of mammograms and associations with screening ambivalence: Results from a national survey

The American Cancer Society and the U.S. Preventive Task Force recently recommended that women initiate routine breast cancer screening at older ages (45 and 50, respectively) than previously recommended, and both organizations emphasize the importance of weighing the harms of mammograms against the benefits in making informed decisions. However, little is known from national samples about how women perceive the harms and benefits of mammograms, and how these perceptions relate to their attitudes about getting mammograms. To fill this gap, we surveyed a nationally representative sample of 557 U.S. women aged 30-59 about their perceptions of harms and benefits and their attitudinal ambivalence toward mammograms. We found that respondents overall perceived the benefits as more important than harms, but those who were aware of recent recommendations perceived mammogram harms as more important than those who were unaware. Women who had a mammogram within one year perceived the harms as less important and the benefits as more important, compared to those who had not had a mammogram in the past year. Those who perceived the harms as important were more ambivalent about screening than those who perceived harms as less important. We conclude that if the public health goal is to prevent the population harms from overuse of mammograms (e.g., overdiagnosis, false positives), simply providing women with information about harms and benefits may not lead to this outcome, since women are likely to perceive the benefits as more important than harms, and thus make an informed choice to obtain screening.

Monitoring and Developing a Volunteer Patient Navigation Intervention to Improve Mammography Compliance in a Safety Net Hospital

PURPOSE:

Although mammography screening is crucial for cancer detection, screening rates have been declining, particularly in patients of low socioeconomic status and minorities. We sought to evaluate and improve the compliance rates at our safety net hospital through a prospective randomized controlled trial of a volunteer-run patient navigation intervention.

METHODS:

Baseline 90-day institutional mammography compliance rates were evaluated for patients who received a physician order for screening mammograms over a 1-month period. This analysis aided in the creation of a prospective randomized controlled trial of a volunteer-run patient navigation intervention to improve compliance, with 49 total participants. The primary outcome was 14-day mammography compliance rates. Secondary analysis examined the efficacy of the intervention with respect to patient demographics, prior mammography compliance, family history of cancer, beliefs on mammography, and past medical history.

RESULTS:

Analysis of baseline institutional compliance revealed a 47.87% compliance rate, with the majority of compliance occurring within 14 days of order placement. The patient navigation intervention significantly improved compliance by 34% (42% in the control group, 76% in the intervention group). Additional findings included significantly improved compliance in patients who believed they had a low susceptibility to cancer, those who understood the benefits of mammography and early diagnosis, those who had a prior mammogram, those who were employed, and those with a family history of cancer.

CONCLUSION:

A system to monitor compliance and intervene using patient navigation significantly improved mammography compliance of patients in a safety net hospital. The relatively straightforward design of this volunteer-based intervention makes it affordable, easily replicable, and perhaps beneficial at other institutions.

Screening Mammography Among Older Women: A Review of United States Guidelines and Potential Harms

In the United States, older women (aged ≥65 years) continue to receive routine screening mammography surveillance, despite limited evidence supporting the benefits to this subpopulation. This article reviews screening mammography guidelines and the potential harms of such screening for older women in the United States. Published guidelines and recommendations on screening mammography for older women from professional medical societies and organizations in the United States were reviewed from the mid-20th century to present. Observational data were then synthesized to present the documented harms from screening mammography among older women. In 1976, the American Cancer Society recommended to screen all women aged ≥40 years with no upper age limit. With time, other major U.S. medical societies adopted their own screening guidelines without a consensus on age of screening cessation. A population-wide screening effort has largely continued without an upper age limit and with it, a growing body of literature on the harms of screening older women. Reported harms from screening mammography procedures have included physical pain, psychological distress, excessive use of health services from overdiagnoses/false positives, and undue financial expenses. These costs are particularly pronounced among special populations with limited life expectancies such as those of very advanced age ≥80 years, long-term nursing home residents, and the cognitively impaired. When potential harms, remaining life years, and the viability of available treatments are considered, the burdens of screening mammography often outweigh the benefits for older women. For some cases, an individualized approach to recommendations would be appropriate. National guidelines should be updated to provide clear guidance for screening women of advanced age, especially those in special populations with limited life expectancies.

Breast Cancer Incidence by Stage Before and After Change in Screening Guidelines

INTRODUCTION

The U.S. Preventive Services Task Force changed breast cancer screening guidelines in November 2009 for mammograms in women aged 40-49 and 50-74 years. The aim of this study was to assess the impact of the 2009 guideline changes on breast cancer incidence by stage among women aged 40-49 and 50-74 years in the U.S.

METHODS

This was a cross-sectional trend analysis of the impact of 2009 guideline change on breast cancer incidence by stage, using data from the National Program for Cancer Registries and Surveillance, Epidemiology, and End Results Incidence-U.S. Cancer Statistics 2001-2014 database among women aged 40-74 years. Incidence was age adjusted to the U.S. standard population. Data were collected in 2001-2014, released in 2017, and analyzed in 2018.

RESULTS

Among women aged 40-49 years, the 4-year average annual incidence of breast cancer increased slightly in 2011-2014 for in situ, localized, and distant cancer, but decreased for regional cancer compared with the incidence in 2006-2009. Among women aged 50-74 years, the 4-year average annual incidence of breast cancer increased in 2011-2014 for localized and distant cancer, but decreased for in situ and regional cancer. Joinpoint analyses revealed that annual percentage changes decreased after 2009 for distant cancer among both women aged 40-49 and 50-74 years. The composition of breast cancer by stage was similar between 2006-2009 and 2011-2014 among both women aged 40-49 and 50-74 years.

CONCLUSIONS

Changes in breast cancer screening by the 2009 U.S. Preventive Services Task Force guidelines had little immediate adverse effects on the stage distribution of breast cancer diagnoses in the U.S. Monitoring the incidence by cancer stages over time is needed.

The Evolution of Mammography Controversy in the News Media: A Content Analysis of Four Publicized Screening Recommendations, 2009 to 2016

BACKGROUND

There is longstanding expert disagreement about the age at and frequency with which women should be screened for breast cancer. These debates are reflected in the conflicting recommendations about mammography issued by major professional organizations, such as the U.S. Preventive Services Task Force and the American Cancer Society. Previous research has shown that these recommendations garner substantial media attention-and therefore might affect women's screening perceptions and behaviors-but to date analyses of such media coverage have focused on single publicized announcements.

METHODS

To assess whether media coverage of mammography screening recommendations has evolved, we conducted a content analysis of televised news from four discrete media events from 2009 to 2016, all of which focused on publicized screening recommendations from the U.S. Preventive Services Task Force and American Cancer Society (N = 364 stories).

RESULTS

Media coverage of mammography screening recommendations has featured persistent messages of conflict and/or controversy over time. The evolution of controversy was also reflected in shifts in the relative attention given to mammography screening's risks and benefits, with consistent and, in some cases, heightened attention to screening's risks during more recent media events. Overall, the accuracy of media coverage improved over time.

CONCLUSIONS

Results underscore the continued prevalence of conflicting and/or controversial information about mammography screening in the public information environment. Cumulative exposure to such messages could influence women's decision making around screening and trust in cancer prevention recommendations. Strategies are needed to better equip all women (and particularly underserved women) to negotiate mammography controversy and weigh the benefits and risks of screening.

Screening mammography among nursing home residents in the United States: Current guidelines and practice

OBJECTIVE

United States (US) guidelines regarding when to stop routine breast cancer screening remain unclear. No national studies to-date have evaluated the use of screening mammography among US long-stay nursing home residents. This cross-sectional study was designed to identify prevalence, predictors, and geographic variation of screening mammography among that population in the context of current US guidelines.

MATERIALS AND METHODS

Screening mammography prevalence, identified with Physician/Supplier Part B claims and stratified by guideline age classification (65-74, ≥75 years), was estimated for all women aged ≥65 years residing in US Medicare- and Medicaid- certified nursing homes (≥1 year) with an annual Minimum Data Set (MDS) 3.0 assessment, continuous Medicare Part B enrollment, and no clinical indication for screening mammography as of 2011 (n = 389,821). The associations between resident- and regional- level factors, and screening mammography, were estimated by crude and adjusted prevalence ratios from robust Poisson regressions clustered by facility.

RESULTS

Women on average were 85.4 (standard deviation ±8.1) years old, 77.9% were disabled, and 76.3% cognitively impaired. Screening mammography prevalence was 7.1% among those aged 65-74 years (95% Confidence Interval (CI): 6.8%-7.3%) and 1.7% among those ≥75 years (95% CI, 1.7%-1.8%), with geographic variation observed. Predictors of screening in both age groups included race, cognitive impairment, frailty, hospice, and some comorbidities.

CONCLUSIONS

These results shed light on the current screening mammography practices in US nursing homes. Thoughtful consideration about individual screening recommendations and the implementation of more clear guidelines for this special population are warranted to prevent overscreening.

Effect of High-Deductible Insurance on High-Acuity Outcomes in Diabetes: A Natural Experiment for Translation in Diabetes (NEXT-D) Study

OBJECTIVE

High-deductible health plans (HDHPs) are now the predominant commercial health insurance benefit in the U.S. We sought to determine the effects of HDHPs on emergency department and hospital care, adverse outcomes, and total health care expenditures among patients with diabetes.

RESEARCH DESIGN AND METHODS

We applied a controlled interrupted time-series design to study 23,493 HDHP members with diabetes, aged 12-64, insured through a large national health insurer from 2003 to 2012. HDHP members were enrolled for 1 year in a low-deductible (≤$500) plan, followed by 1 year in an HDHP (≥$1,000 deductible) after an employer-mandated switch. Patients transitioning to HDHPs were matched to 192,842 contemporaneous patients whose employers offered only low-deductible coverage. HDHP members from low-income neighborhoods (n = 8,453) were a subgroup of interest. Utilization measures included emergency department visits, hospitalizations, and total (health plan plus member out-of-pocket) health care expenditures. Proxy health outcome measures comprised high-severity emergency department visit expenditures and high-severity hospitalization days.

RESULTS

After the HDHP transition, emergency department visits declined by 4.0% (95% CI -7.8, -0.1), hospitalizations fell by 5.6% (-10.8, -0.5), direct (nonemergency department-based) hospitalizations declined by 11.1% (-16.6, -5.6), and total health care expenditures dropped by 3.8% (-4.3, -3.4). Adverse outcomes did not change in the overall HDHP cohort, but members from low-income neighborhoods experienced 23.5% higher (18.3, 28.7) high-severity emergency department visit expenditures and 27.4% higher (15.5, 39.2) high-severity hospitalization days.

CONCLUSIONS

After an HDHP switch, direct hospitalizations declined by 11.1% among patients with diabetes, likely driving 3.8% lower total health care expenditures. Proxy adverse outcomes were unchanged in the overall HDHP population with diabetes, but members from low-income neighborhoods experienced large, concerning increases in high-severity emergency department visit expenditures and hospitalization days.

Factors Influencing Overuse of Breast Cancer Screening: A Systematic Review

BACKGROUND

Excessive breast cancer screening with mammography or other modalities often burdens patients with false-positive results and costs. Yet, screening patients beyond the age at which they will benefit or at too frequent intervals persists. This review summarizes the factors associated with overuse of breast cancer screening.

METHODS

We searched Medline and Embase from January 1998 to March 2017 for articles addressing the overuse of breast cancer screening and hand-searched the reference lists of included articles. Studies were included if they were written in English, pertained to a U.S. population, and identified a factor associated specifically with overuse of breast imaging. Paired reviewers independently screened abstracts, extracted data, and assessed quality.

RESULTS

We included 15 studies: 3 cohort, 5 cross-sectional, 6 surveys, and 1 in-depth interview. White women (non-Hispanic) were less vulnerable than other racial groups to overuse in 3 of 5 studies. Physician specialty was consistently associated with screening overuse in three of three studies. Abundant access to primary care and a patient desire for screening were associated with breast cancer screening overuse. Lower self-confidence, lower risk taking tendencies, higher perception of conflict in expert recommendations, and a belief in screening effectiveness were clinician traits associated with overuse of screening in the surveys.

CONCLUSIONS

The literature supports that liberal access to care and clinicians' recommendations to screen, possibly influenced by conflicting guidelines, increase excessive breast cancer screening. Overuse might conceivably be reduced with more concordance across guidelines, physician education, patient involvement in decision-making, thoughtful insurance restrictions, and limitations on the supply of services; however, these will need careful testing regarding their impact.

Lack of Impact of the 2009 USPSTF Guidelines on Rates of Mammography Screening

BACKGROUND

In November 2009, the United States Preventive Services Task Force (USPSTF) changed their mammography screening guidelines from recommending a screen every 1-2 years for women older than 40 years. The revised guideline recommends against regular screening for women aged 40-49 and recommends biennial screening for women aged 50-74.

RESEARCH DESIGN

We used autoregressive integrated moving-average (ARIMA) time series modeling to estimate the effect of the USPSTF 2009 guidelines on trends in screening rates. Enrollment and encounter files from the PharMetrics LifeLink+ commercial insurance claims database, years 2006-2014, were linked to determine monthly screening rates. The main outcome measure was mammography screening rates per 1,000 commercially insured women aged 40-49 or aged 50-64.

RESULTS

The study sample included 493,347 women aged 40-49 years with at least 1 month of eligibility and 658,052 women aged 50-64 years with at least 1 month of eligibility. There were 1,305,375 total screening mammograms from 2007 to 2014. Average monthly mammography screening rates from 2007 to 2014 were 40.4 per 1,000 women aged 40-49 and 54.8 per 1,000 women aged 50-64. There was a temporary decline in monthly screening rates of 11.8% and 11.2% for the 40-49 and 50-64 age groups, respectively, in the 2-month period after the guideline change (January and February 2010), but the rates quickly returned to pre-USPSTF trend levels afterward.

CONCLUSION

Implementation of the USPSTF 2009 guidelines was not associated with a persistent long-term change in mammography screening rates over the next 5 years, despite a temporary decline of 2 months immediately following the guidelines.

Linking physician attitudes to their breast cancer screening practices: A survey of US primary care providers and gynecologists

Despite changes to breast cancer screening guidelines intended to decrease screening in younger and older women, mammography rates remain high. We investigated physician attitudes towards screening younger and older women. Surveys were mailed to US primary care providers and gynecologists between May and September 2016 (871/1665, 52.3% adjusted response rate). We assessed physician (1) attitudes towards screening younger (45-49years) and older (75+ years) women and (2) recommendations for routine mammography. We used exploratory factor analysis to identify underlying themes among physician attitudes and created measures standardized to a 5-point scale. Using multivariable logistic regression models, we examined associations between physician attitudes and screening recommendations. Attitudes identified with factor analysis included: potential regret, expectations, and discordant guidelines (referred to as potential regret), patient-related hazards due to screening, physician limitations and uncertainty, and concerns about rationing care. Gynecologists had higher levels of potential regret compared to internists. In adjusted analyses, physicians with increasing potential regret (1-point increment on 5-point scale) had higher odds of recommending mammography to younger (OR 8.68; 95% CI 5.25-14.36) and older women (OR 4.62; 95% CI 3.50-6.11). Increasing concern for patient-related hazards was associated with decreased odds of recommending screening to older women (OR 0.68; 95% CI 0.56-0.83). Physicians were more motivated by potential regret in recommending screening for younger and older women than by concerns for patient-related hazards in screening. Addressing physicians' most salient concerns, such as fear of missing cancer diagnoses and malpractice, may present an important opportunity to improving delivery of guideline-concordant cancer screening.

When Guidelines Conflict: A Case Study of Mammography Screening Initiation in the 1990s

BACKGROUND

Cancer screening guidelines communicate important information to patients and physicians regarding the costs and benefits of screening. Currently, guideline recommendations from major organizations conflict regarding the age of mammography screening initiation. To understand current and future U.S. mammography screening patterns we study age-mammography patterns from the 1990s, another period of conflicting guideline recommendations.

METHODS

We examine mammography use rates by single year of age to understand compliance with guideline-recommended initiation ages in the 1990s. Mammography test use data was taken primarily from the 1991 to 2001 Behavioral Risk Factor Surveillance System. The analytic sample included all women 35 to 54 years of age.

RESULTS

We found a discrete 8.7-percentage point increase in mammography use precisely at age 40 and a much smaller 1.6-percentage point increase in mammography use at age 50. These findings varied by insurance status, with the insured experiencing a large, discrete increase primarily at age 40 and the uninsured experiencing notable discrete increases at ages 40 and 50.

CONCLUSION

Physicians and patients converged primarily on the age 40 mammography screening threshold during the 1990s. Prices, along with guidelines, were key determinants of the age of screening initiation, with the insured responding to age 40 coverage and cost-sharing reductions and the uninsured affected by guidelines and public funding tied to the age 50 threshold. The policy factors underlying these results, recent ACA coverage increases, and ACA cost-sharing requirements imply that a substantial number of women will continue to receive mammography screening in their 40s.

Breast cancer screening outreach effectiveness: Mammogram-specific reminders vs. comprehensive preventive services birthday letters

We compared the effectiveness of two outreach strategies on timely mammography adherence: a mammogram-specific reminder letter (sent just before a woman was due) to a birthday letter (addresses multiple preventive services and not timed around due dates). We evaluated screening mammography adherence following 79,848 mammogram-specific and 151,626 birthday letters mailed between 2002 and 2012 to women aged 40-74years enrolled in Kaiser Permanente Washington. Screening mammogram adherence was specifically tied to due date and was evaluated separately by age group and up-to-date or overdue status at the time of mailing. We used generalized estimating equations to account for correlation between repeated observations, to model the odds of screening mammography adherence by letter type. Among women up-to-date, adherence following birthday letters was 22-76% lower compared to the mammogram-specific reminders, with the greatest decreases in adherence in women aged 70-74. Birthday letters were more effective at activating screening uptake among some subgroups of overdue women aged 50-69 and most overdue women aged 70-74, but universally low adherence rates were observed in overdue women. Increasing number of recommended services for women aged 50-74 who were up-to-date resulted in 12-17% lower mammography adherence, but had no effect in women aged 40-49 or in overdue women. Birthday letters are less effective than mammogram-specific reminder letters at prompting women to undergo timely breast cancer screening, particularly among women up-to-date with screening. Birthday letters may be effective at increasing overall preventive care; however, supplemental outreach may be needed around the due date to increase timely preventive services receipt.

Mammography rates after the 2009 revision to the United States Preventive Services Task Force breast cancer screening recommendation

BACKGROUND

In 2009, the United States Preventive Services Task Force (USPSTF) recommended against routine mammography screening for women aged 40-49 years. This revised recommendation was widely criticized and has sparked off intense debate. The objectives of this study are to examine the impact of the revised recommendation on the proportion of women receiving mammograms and how the effect varied by age.

METHODS

We identified women who had continuous health insurance coverage and who did not have breast cancer between 2008 and 2011 in the Truven Health MarketScan Commercial Claims Databases using mammogram procedure codes. Using women aged 50-59 years as a control group, we used a differences-in-differences approach to estimate the impact of the revised recommendation on the proportion of women ages 40-49 years who received at least one mammogram. We also compared the age-specific changes in the proportion of women ages 35-59 years who were screened before and after the release of the revised recommendation.

RESULTS

The proportion of women screened among the 40-49 and 50-59 age groups were 58.5 and 62.5%, respectively, between 2008 and 2009, and 56.9 and 62.0%, respectively, between 2010 and 2011. After 2009, the proportion of women screened declined by 1.2 percentage point among women aged 40-49 years (P < 0.01). The proportion of women screened decreased for all ages, and decreases were larger among women closer to the 40-year threshold.

CONCLUSIONS

The 2009 USPSTF breast cancer recommendation was followed by a small reduction in the proportion of insured women aged 40-49 years who were screened. Reductions were larger among women at the younger end of the age range, who presumably had less prior experience with mammography than women nearing 50.

Change in Mammography Use Following the Revised Guidelines from the U.S. Preventive Services Task Force

The U.S. Preventive Services Task Force (USPSTF) recommended screening mammography every 1-2 years for women 40 years and older in 2002, and changed its recommendations in 2009 to no routine screening for women between 40 and 49 years of age; and biennial screening for women between 50 and 74 years of age. This study evaluates the change in mammographic use after the issuance of the revised recommendations. Women who participated in a cross-sectional study of breast cancer risk factors from 2007 to 2013 were asked if they had received a mammogram in the preceding 2 years. All 3442 study participants who enrolled in the study after January 1, 2011 were matched by race, age, and educational level with women enrolled between 2007 and 2010. The proportions of women who stated they had received a mammogram in the past 2 years were compared between the two groups. One fourth of the participants were African American and 39% were 40-49 years of age. Among white women, significant decreases in recent mammogram use from 2007-2010 to 2011-2013 were detected for women 40-49 years of age (-10.3%, p < 0.001) and 50-74 years of age (-8.8%, p < 0.001). Among African-American women, the change in recent mammogram use was not statistically significant for women 40-49 years of age (-2.7%, p = 0.440) or 50-74 years of age (-2.2%, p = 0.398). Following the change in the USPSTF guidelines, mammography use among white women declined; however, no change was observed among African-American women.

The American Cancer Society challenge goal to reduce US cancer mortality by 50% between 1990 and 2015: Results and reflections

In 1996, the Board of Directors of the American Cancer Society (ACS) challenged the United States to reduce what looked to be possible peak cancer mortality in 1990 by 50% by the year 2015. This analysis examines the trends in cancer mortality across this 25-year challenge period from 1990 to 2015. In 2015, cancer death rates were 26% lower than in 1990 (32% lower among men and 22% lower among women). The 50% reduction goal was more fully met for the cancer sites for which there was enactment of effective approaches for prevention, early detection, and/or treatment. Among men, mortality rates dropped for lung cancer by 45%, for colorectal cancer by 47%, and for prostate cancer by 53%. Among women, mortality rates dropped for lung cancer by 8%, for colorectal cancer by 44%, and for breast cancer by 39%. Declines in the death rates of all other cancer sites were substantially smaller (13% among men and 17% among women). The major factors that accounted for these favorable trends were progress in tobacco control and improvements in early detection and treatment. As we embark on new national cancer goals, this recent past experience should teach us that curing the cancer problem will require 2 sets of actions: making new discoveries in cancer therapeutics and more completely applying those discoveries in cancer prevention we have already made. CA Cancer J Clin 2016;66:359-369. © 2016 American Cancer Society.

The Immediate Impact of the 2009 USPSTF Screening Guideline Change on Physician Recommendation of a Screening Mammogram: Findings from a National Ambulatory and Medical Care Survey-Based Study

Regular screening is considered the most effective method to reduce the mortality and morbidity associated with breast cancer. Nevertheless, contradictory evidence about screening mammograms has led to periodic changes and considerable variations among different screening guidelines. This study is the first to examine the immediate impact of the 2009 US Preventive Services Task Force (USPSTF) guideline modification on physician recommendation of mammograms. The study included visits by women aged 40 years and older without prior breast cancer from the National Ambulatory and Medical Care Survey 2008-2010. Bivariate and multiple logistic regressions were used to determine the factors associated with mammography recommendation. Approximately 29,395 visits were included and mammography was recommended during 1350 visits; 50-64-year-old women had 72% higher odds, and 65-74-year-old women had twice the odds of getting a mammogram recommendation compared with 40-49-year-old women in 2009. However, there was no difference in recommendation by age groups in 2008 and 2010. Obstetricians and gynecologists did not modify their recommendation behavior in 2009, unlike all other specialists who reduced their recommendation for 40-49-year-old women in 2009. Other characteristics associated with mammogram recommendations were certain patient comorbidities, physician specialty and primary care physician status, health maintenance organization status of the clinic, and certain visit characteristics. This study demonstrated a temporary effect of the USPSTF screening guideline change on mammogram recommendation. However, in light of conflicting recommendations by different guidelines, the physicians erred toward the more rigorous guidelines and did not permanently reduce their mammogram recommendation for women aged 40-49 years.

Receipt of mammography recommendations among White and non-White women before and after the 2009 United States Preventive Services Task Force recommendation change

PURPOSE

Receipt of a mammography recommendation from a physician is a strong predictor of obtaining a mammogram. In 2009, the United States Preventive Services Task Force (USPSTF) recommended routine biennial mammography for women aged 50-74 but not for women aged 40-49. We examined changes in reports of clinician recommendations for mammography among White and non-White women after these age-specific recommendations were issued.

METHODS

Data from women aged 40-49 and 50-74 were drawn from the 2008 and 2013 National Health Interview Surveys. We used linear probability models to determine whether the proportions of women reporting a mammography recommendation changed after the USPSTF recommendation was issued and whether any changes observed differed across White and non-White women. All analyses were stratified by age groups and mammography history.

RESULTS

Among women without a recent mammogram, reported clinician recommendations did not change for White women, but they decreased by 13-percentage points (95 % CI -0.22, -0.03) among non-White women aged 40-49 (p = 0.01) and increased by 9-percentage points (95 % CI 0.01, 0.17) among non-White women aged 50-74 (p = 0.04). Among women with a mammogram in the past 2 years, reported mammography recommendation from a clinician did not change for White or non-White women.

CONCLUSIONS

Recommendations to reduce screening may be differentially implemented across racial/ethnic groups. Changes in reports of mammography recommendation from a clinician after the USPSTF breast cancer screening recommendation change were observed only among non-White women without a recent history of mammography. It is unclear whether these differences are due to the clinician, the women, or both.

Mammography Use and Physician Recommendation After the 2009 U.S. Preventive Services Task Force Breast Cancer Screening Recommendations

INTRODUCTION

In 2009, the U.S. Preventive Services Task Force (USPSTF) no longer recommended routine mammography for women aged 40-49 and ≥75 years (younger and older women, respectively). Whether mammography usage and physician recommendation among younger and older women changed in response to these recommendations is unclear.

METHODS

Cross-sectional data from women aged ≥40 years in the 2008 and 2013 National Health Interview Surveys were used (n=4,942 younger and 3,047 older women) and were analyzed in 2015. Changes between 2008 and 2013 in self-reports about having undergone mammography in the past 2 years and physician recommendation for mammography were expressed as adjusted prevalence difference (PD) and 95% CI.

RESULTS

Overall, adjusted prevalence of mammography among younger women was similar in 2008 (62.2%) and 2013 (58.5%) (p=0.05), but significantly declined in high-income (PD=-6.1%, 95% CI=-11.2, -1.0); non-Hispanic white (PD=-5.5%, 95% CI=-10.2, -0.8); and privately insured (PD=-5.7%, 95% CI=-9.8, -1.6) younger women. For older women, there was no change in adjusted mammography prevalence overall (2008, 56.2%; 2013, 54.2%; p=0.473) or by SES. Physician mammography recommendation declined in younger (PD=-5.0%, 95% CI=-8.7, -1.3) and older (PD=-5.8%, 95% CI=-10.5, -1.1) women.

CONCLUSIONS

Four years after publication of USPSTF mammography recommendations, mammography prevalence for younger and older women did not significantly decrease except for higher-SES younger women. The significant decrease in physician recommendation of mammography in younger and older women may reflect a change in practice patterns by some physicians in response to USPSTF recommendations.

Racial and Ethnic Disparities in the Quality of Health Care

The annual National Healthcare Quality and Disparities Reports document widespread and persistent racial and ethnic disparities. These disparities result from complex interactions between patient factors related to social disadvantage, clinicians, and organizational and health care system factors. Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias. Recent data suggest slow progress in many areas but have documented a few notable successes in eliminating these disparities. To eliminate these disparities, continued progress will require a collective national will to ensure health care equity through expanded health insurance coverage, support for primary care, and public accountability based on progress toward defined, time-limited objectives using evidence-based, sufficiently resourced, multilevel quality improvement strategies that engage patients, clinicians, health care organizations, and communities.

Mammography Screening in a Large Health System Following the U.S. Preventive Services Task Force Recommendations and the Affordable Care Act

Background

Practice recommendations for mammography screening were issued by the U.S. Preventive Services Task Force in 2009 and expansion of insurance coverage was provided under the Patient Protection and Affordable Care Act soon thereafter, yet the influence of these changes on screening practices in the United States is not known.

Methods

To determine changes in mammography screening and their associations with new practice recommendations and the Affordable Care Act, we examined patient-level data from 249,803 screening mammograms from January 1, 2008 through December 31, 2012 in a large community-based health system in the northwestern United States. Associations were determined by an intervention analysis of time-series data method.

Results

Among women screened, 64% were age 50-74 years; 84% self-identified as white race; 62% had commercial insurance; and 70% were seen in facilities located in metropolitan areas. Practice recommendations were associated with decreased screening volumes among women age <40 (-37.4 mammograms/month; -39.4% change; P<0.001), 40-49 (-106.0 mammograms/month; -11.2% change; P<0.001), and ≥75 (-54.7 mammograms/month; -10.0% change; P<0.001), but not women age 50-74. Implementation of the Affordable Care Act was associated with increased screening among women age 50-74 (+184.3 mammograms/month; +7.2% change; P=0.001), but not women <40 or ≥75; increases for age 40-49 were of borderline statistical significance (+56.9 mammograms/month; +6% change; P=0.06). Practice recommendations were also associated with decreased screening for women with commercial insurance, while the Affordable Care Act was associated with increased screening for women with Medicare, Medicaid, or other noncommercial sources of payment.

Conclusions

Mammography screening volumes in a large community health system decreased among women age <50 and ≥75 in association with new U.S. Preventive Services Task Force practice recommendations, while insurance coverage changes under the Affordable Care Act were associated with increased screening volumes among women age 50-74.

Regional variation in mammography use among insured women 40-49 years old: impact of a USPSTF guideline change

PURPOSE

The impact of the US Preventive Services Task Force (USPSTF) recommendation that 40-49 year old women should no longer routinely receive screening mammography in November 2009 in different regions of the US is unknown.

METHODS

We conducted a retrospective cohort study using medical claims from administrative health records from privately insured 40-59 year old women enrolled between 2005 and 2012 to evaluate biennial screening trends.

RESULTS

There was a slight decrease in mammography usage among 40-49 year old US women after the 2008-2009 biennial period (p<0.001). There were some regional differences in mammography trends, with the West showing the greatest difference in odds of 40-49 year olds receiving a mammography in 2011-2012 compared to 2008-2009 (OR: 0.93; 95% CI: 0.91-0.94). Although trends for 50-59 year olds mirrored that of 40-49 year olds, the younger age group had a stronger decline in 2009-2010 and 2010-2011.

CONCLUSIONS

These findings show that USPSTF guideline changes made some differences in mammography usage among 40-49 year olds, but adherence was uneven across regions.