A Nationally Representative US Health and Retirement Study on Mammography Screening Use and Its Predictors Among Older Adult Women Ages 60 to 85

We wanted to determine the frequency of self-reported receipt of screening mammography and Papanicolaou (Pap) tests in older women and investigate important predictors of utilization, based on 2 national longitudinal surveys. This cohort study includes participants from 4 waves (1994-2000) of the Health and Retirement Study (HRS)--5,942 women aged 50 to 61 years, and 4 waves (1993-2000) of the Asset and Health Dynamics Among the Oldest Old (AHEAD) survey--4,543 women aged 70 years and older. The self-reported receipt of screening mammograms and Pap smears in the most recent 2 years were reported in 1996 and 2000 for HRS, with predictors of receipt measured in 1994 and 1998. In AHEAD, the self-reported receipt of screening mammograms and Pap smears in the most recent 2 years were reported in 1995 and 2000, with predictors of receipt measured in 1993 and 1998. Receipt of mammography is stable at 70% to 80% among women aged 50 to 64 years, then declines to around 40% among those aged 85 to 90 years. For Pap tests there is a decline from 75% among women aged 50 to 54 years to 25% in those aged 85 to 90 years. For both mammography and Pap tests, the rates increased in all groups from 1995/1996 to 2000. Higher education, being married, higher income, not smoking, and vigorous exercise were consistently associated with higher rates of receipt. Although the use of mammography and Pap tests for screening declines into old age, use has been increasing recently. The large and increasing number of tests performed might not be justified given the lack of evidence of effect in older age-groups.

Background: In late 2009 significant controversy arose when some screening recommendations were changed to advocate screening mammography starting at age 50 rather than the long standing recommendation of starting at age 40 years. Few would argue, by contrast, that patient compliance with screening mammography, starting at either 40 years or 50 years, is at optimal levels. National data indicate that many more lives would be saved by improving compliance with screening recommendations in individuals ≥50 than would be saved with screening individuals age 40–50 years. The current study was performed to determine if health literacy was associated with use of screening mammography in an underinsured population. Methods: Maricopa Medical Center is the county safety net hospital in Phoenix, Arizona. 944 patients were seen at the Breast Clinic from January 2010 to January 2011. 638 were at least 40 years old and therefore candidates for screening mammography. Sociodemographic variables were collected. Use of mammography was asked of patients and checked by medical records. Health literacy was assessed using the Newest Vital Sign (NVS) validated screening instrument, which categorizes health literacy on 6-point scale as low health literacy likely (0-1 point), low health literacy possible (2-3 points), or health literacy adequate (4-6 points). Differences in patient characteristics were evaluated based on a Fisher's exact test for categorical variables and one-way ANOVA for continuous variables. Multivariate analysis was then performed to determine which patient factors were associated with use of screening mammography. Results: Among women 40 years or older, only 35% used routine screening mammography. For women 50 years or older, 38% underwent screening mammography. Among women 40 years or older and those 50 years or older, significantly more with health literacy adequate (NVS 4–6) obtained screening mammography than did women in the two lower literacy (NVS 0–1 and 2–3) groups (40+: 65% vs. 30% and 30%, p = 0.001. 50+: 65% vs. 33% and 37%, p = 0.001). Multivariate analyses adjusted for insurance status, employment, white race, Hispanic ethnicity, marital status, language, use of alcohol, family history, NVS and education level demonstrated that patients with adequate health literacy were more likely to use screening mammography (OR 3.66; 95% CI 2.14 — 6.27; p < 0.01) than patients in the two lower literacy groups. Similarly, uninsured patients were significantly less likely to undergo screening mammography (OR 0.57; 95% CI 0.38 — 0.86; p = 0.01) than those with insurance. Patients with adequate health literacy and insurance were (OR 8.61) more likely to use screening mammography than patients who were uninsured and were in the two low literacy groups. Patient race, ethnicity, language, employment, income, education level, and family history of breast cancer were not associated with use of screening mammography in this underinsured, undereducated population. Conclusions: Use of screening mammography was poor in this underinsured population. Limited health literacy and lack of insurance are risk factors for failure to obtain mammography. Interventions to increase use of screening mammography among uninsured patients with limited health literacy are needed. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-09-03.

During the past decade, the reported incidence of breast cancer in the United States, as well as in other westernized countries, has been gradually increasing. In addition, a recent sharp increase in incidence in older women (>60 years) has occurred. However, before one may attribute an increase in reported incidence to a change in risk, other causes of an apparent increase in incidence, such as more accurate registration, earlier diagnosis, and overdiagnosis of breast cancer cases, must be excluded. Relevant to this consideration is the increasing availability of screening mammography. It is a well-known fact that screening asymptomatic women by periodic mammographic examinations detects breast cancer at an earlier stage than when the disease is symptomatic. Screendetected cancers are more frequently non-invasive; and, if invasive, are of smaller size and less commonly metastasized to axillary lymph nodes than those which are diagnosed without screening. Also, there is evidence of a shift towards cancers of a more differentiated and specialized type (e.g., papillary, cribriform) and a redistribution of estrogen receptor concentrations towards higher concentrations (1-3). Examination of the distribution of tumor stage-at-presentation is, therefore, one method of monitoring the efficiency of a screening program. In two recent reports in this Journal (one in today's issue) tumor stage-atpresentation has been used to determine the contribution of mammographic screening to the increased incidence rates (4,5). Both studies confirm that a substantial increase in the detected incidence rate for breast cancer has occurred in older women living on the west coast of the US during the 1980s. However, whereas Glass and Hoover reported that this increase comprised both those with cancer confined to the breast and those with regional spread of disease (e.g., to axillary lymph nodes), White and her colleagues, in their much larger study, found that for women between the ages of 45 and 65 years, the increase was limited to those with localized cancer. They suggest that earlier diagnosis may be responsible for the apparent increase in this age group. In the Glass and Hoover study, only 9% of the 178 invasive cancers diagnosed during 1985 were first detected by screening mammography. Similar information is not available in today's report, but the proportion of normal women living in the locality who used mammography was assessed by a telephone survey. This survey indicated that of those aged 45-74 years, 30% of the respondents had undergone a screening mammogram during 1987 and 15% a first mammogram. The predicted yield of new cases, calculated from the ratio of the incidence rate in screenees compared with that in controls and the proportion of women screened for the first time in a given year, was then compared with the observed increase in incidence rate. This comparison led to the conclusion that all of the increased incidence observed in women aged 45-64 years could be accounted for by the increased use of screening mammography. But the increased use of mammography alone did not explain the increased incidence rates for younger or for older women. Although this method for determining use of mammography was not free from selection bias, these findings support the value of screening mammography in detecting cases at an earlier stage. There is now unequivocal evidence that mammography screening reduces breast cancer mortality (6-5). But screening can be effective in reducing total mortality from breast cancer within a nation only if it is applied to a greater number of women than a self-selected 30% of the population who are likely to be healthaware, educated, motivated, and economically stable. Mammographic screening on a population basis can be achieved only when an organized effort is made to reach out to all women in a target group, and when it is accepted that their need overrides that of preserving traditional, and at times vested, professional interests. The fact that mammography screening can be offered universally has been demonstrated in several European countries, including the United Kingdom, which have freely available health care. Sadly, despite the remarkably far-seeing initiative taken by Shapiro and Strax in launching the first-ever trial of population screening for breast cancer in New York in 1963, a similar service is not presently available in this country (6).

To assess the extent to which self-reported patient involvement in decision-making for initiation of mammography differs with age. Data from the 1992 National Health Interview Survey (NHIS) Cancer Control Supplement were evaluated. Prevalences were weighted and variances were adjusted using SUDAAN software to account for the complex, multistage sampling probability design of the NHIS. Logistic regression was used to evaluate the relative likelihood of self-reported involvement in the decision to have a mammogram within the preceding year as a function of age and other covariates. Mammography use was assessed among 3,863 NHIS female respondents 40 years of age or older. The analysis of decision-making was restricted to the subgroup of 1,064 women who reported a screening mammogram within the preceding year and who provided information on the other relevant variables. The probability of reported mammography use within the preceding year declines among older groups of interviewees. Among women with a mammogram in the preceding year, the weighted percentage of women reporting active involvement in the decision (patient decision or decided jointly with a physician) declines from 51% among women 40 to 45 years of age to 19% among those aged 75 years or older. The adjusted odds ratio comparing the likelihood of participating in the decision to have a mammogram for the oldest women, compared with the youngest, was 0.31 (95% confidence interval 0.15 to 0.61). Older women are substantially less likely than younger women to report active involvement in the mammography decision-making process. Increased use of screening mammography among older women will require greater promotion by physicians. Other interventions, such as directed educational efforts, may also be needed to increase mammography demand among older women.

The use of life expectancy in cancer screening guidelines

Decision aids for breast cancer screening are increasingly being used by physicians, but the association between physician practice decision-aid use and mammography rates remains uncertain. Using national data, this study examines the association between practice-level decision-aid use and mammography use among older women. Physician practice responses to the 2017/2018 National Survey of Healthcare Organizations and Systems (n=1,236) were linked to 2016 and 2017 Medicare fee-for-service beneficiary data from eligible beneficiaries (n=439,684) aged 65-74 years. In 2021, multivariable generalized linear models estimated the association of practice decision-aid use for breast cancer screening and advanced health information technology functions with mammography use, controlling for practice and beneficiary characteristics. Overall, 60.1% of eligible beneficiaries had a screening mammogram, and 37.3% of physician practices routinely used decision aids for breast cancer screening. In adjusted analyses, advanced health information technology functions (OR=1.19, p=0.04) were associated with mammography use, but practice use of decision aids was not (OR=0.95, p=0.21). Beneficiary clinical and socioeconomic characteristics, including race, comorbidities, Medicare and Medicaid eligibility, and median household income were more strongly associated with mammography use than practice-level decision-aid use or advanced health information technology functions. Health information technology‒enabled automation of mammography reminders and other advanced health information technology functions may support mammography, whereas breast cancer decision aids may reduce patients' propensities to be screened through the alignment of their preferences and screening decision. More resources may be needed for decision aids to be routinely implemented to improve solicitation of patient preferences and targeting of mammography services.

Compared to normal weight women, women with obesity have higher mortality from breast cancer but are less often screened. To examine the relation between mammography use and weight category and to examine the influence of race, illness burden, and other factors on this relationship. The 1998 National Health Interview Survey, a U.S. civilian population-based survey. Five thousand, two hundred, and seventy-seven women ages 50 to 75 years who responded to the Sample Adult and Prevention questionnaires. Mammogram use in the preceding 2 years. Among 5277 eligible women, 72% reported mammography use. The rate was 74% among white women and 70% among black women. Among white women, mammogram use was lowest in women with a body mass index (BMI) greater than 35 kg/m(2) (64% to 67%). After adjusting for sociodemographic factors, health care access, medical conditions, hospitalizations, and mobility status, higher BMI was associated with lower screening among white women, P =.02 for trend; the relative risk (RR) for screening in moderately obese white women (BMI, 35 to 40 kg/m(2)) was 0.83 (95% confidence interval [CI], 0.68 to 0.96) compared to normal weight white women. Compared to normal weight black women, mammography use was similar or higher in overweight (BMI, 25 to 30 kg/m(2); RR, 1.19; 95% CI, 1.01 to 1.32), mildly obese (BMI, 30 to 35 kg/m(2); RR, 1.22; 95% CI, 0.98 to 1.39), and moderately obese black women (RR, 1.37; 95% CI, 1.37 to 1.50) after adjustment. The P value for the race-BMI interaction was.001. Results for white and black women were unchanged after additional adjustment for psychological functioning and health habits. Among white women, those with higher BMI were less likely to undergo breast cancer screening than normal weight women. This relationship was not seen in black women. Our findings were not explained by differences in sociodemographic factors, health care access, illness burden, or health habits. More research is needed to determine the reasons for these disparities so that appropriate efforts can be made to improve screening.

The primary goals were to examine mammography use rates among older women in Connecticut and to determine if there was significant variation among different areas and racial groups in the state. The secondary goal was to examine what impact the initiation of Medicare reimbursement for mammography screening has had on mammography use. Statewide use rates were determined by retrospective Medicare Part B mammography claims analysis. Small area analysis methodology (SAA) was used to identify mammography rates for 23 hospital service areas (HSAs), representing all of the catchment areas for Connecticut's acute care hospitals. Female Medicare beneficiaries 65 years and older with Part B coverage residing in Connecticut during the study period. The main outcome (the use of at least one mammogram) was calculated for the calendar years 1991, 1992, and 1993. Mean annual use rates in 1993 were generated for the 23 HSAs and the different racial groups in Connecticut. To examine the effect that Medicare reimbursement for screening mammograms has had on mammography use, rates were calculated for women who met Medicare reimbursement criteria in 1991 through 1993. The rates in 1992 and 1993 were then compared with those in 1991, when the reimbursement program was first initiated. The mean statewide annual rates among women aged 65 years and older were 23.4% (1991), 24.5% (1992), and 24.9% (1993). The mammography use rates among black women 65 years and older were significantly lower than their white peers in 1991 (18.8% black vs 23.8% white, P < .001), 1992 (20.6% vs 24.7%, P < .001), and 1993 (22.0% vs 25.1%, P < .001). Significant variation was identified among hospital service areas (HSAs) within the state for each time interval studied. The use rates among women aged 65 years and older who were eligible for Medicare screening mammography reimbursement increased significantly from 14.6% in 1991, when Medicare reimbursement for screening mammograms was first initiated, to 18.9% in 1992 (P < .001). The rates in 1993 (17.4%) also increased from the baseline year 1991 (P < .001). However, the observed increases since 1991 have been limited in magnitude. Low mammography use persists among older women in Connecticut and, in particular, among older black women. The initiation of Medicare reimbursement for screening mammograms in 1991 has had some impact on mammography use although its effects are still limited. Through the use of small area analysis methodology, significant underutilization of mammography in localized areas of the state was identified. These findings have facilitated local outreach interventions. Additional research is needed to understand if health service barriers are contributing to the local variation in rates observed in this study.

To identify differences in the prevalence of ever having had a mammogram and having had a recent mammogram between older black and white women and to compare factors associated with mammography use in older black and white women. Data analysis and comparative study using nationally representative multistage sampling survey. Data were obtained from the 1998 National Health Interview Survey. Four hundred forty-nine black and 3,328 white older women were examined. The outcome variables included never having had a mammogram (yes/no) and not having had a mammogram in the past 3 years (yes/no). The results of chi-square tests showed that older blacks were less likely to have ever had a mammogram than older whites, but there was no difference in having had a recent mammogram between older blacks and whites. After adjusting for other related factors, race was not related to mammography use in older blacks and whites. Health insurance was related to mammography use in older whites but not in older blacks. Family income was associated with never having had a mammogram in older whites but not in older blacks. Older blacks with less than 12 years of education were less likely to have had a mammogram (recently or ever) than older whites with less than 12 years of education. Even though race, per se, was not associated with mammography use in older black and white women, many barriers to mammography use between older black and white women were different or did not have similar effects. To promote mammography use in older black and white women, barriers need to be specifically targeted for each group to enhance the effectiveness of breast cancer screening programs.

OBJECTIVES The study tested a behavioral and structural barriers model of breast cancer screening, while seeking to determine age effects of behavioral barriers, in order to identify the factors that inhibit screening among older, minority women. 405 older African-American women eligible for a federally funded cancer screening program were enrolled in the study. Participants were administered an intake questionnaire and followed for 3 months to determine mammography use. Three months after enrollment in the program, 79% had not received breast cancer screening. The oldest cohort had significantly lower rates of mammography (just 16% of screened women were > or = 60, p<0.05). Behavioral barriers (knowledge/information deficits, cancer risk perception, cancer fears) inhibited mammography in the oldest group; their breast cancer information deficits included less knowledge of breast cancer risk, treatment, and survivability (all p<0.001). Older women, with greater breast cancer risk than younger cohorts, should be targeted as a high need population for cancer screening. Even when financial and insurance barriers are removed mammography rates are 1/3 those of women <50. Since failure to be screened is related to knowledge and information barriers, health care providers have the potential to educate their older patients and subsequently increase the likelihood they will have regular cancer screening.

Screening Mammography Use in Medicare Beneficiaries Reflects 4-Year Mortality Risk

Cognitive decline and impairment among older adults have become an important public health issue. Previous research shows older women have a greater prevalence of Alzheimer's disease than Men. Among women, breast cancer is one of the most common types of cancer. Over half of breast cancer deaths occur in women aged 65 and older. Therefore, early detection of breast cancer through mammogram screening is important among older women. This study aimed to examine the influence of cognitive function on adherence to mammogram breast cancer screening among older American women aged 65 and older. Data from the Health and Retirement Study (2012-2016) was obtained and analyzed. The independent variable of the study was cognitive function (normal, not normal). Adherence to mammogram (low, moderate, high) was the dependent variable. Multinomial regression was performed to examine the association between cognitive function and adherence to mammogram after controlling for demographic covariates. In the study, 33.3% of respondents had impaired cognitive function and 21.7% showed low adherence to mammogram screening. Regression results found that older women with impaired cognitive function were more likely to be in low adherence group (OR=1.30, p=0.01) or moderate adherence group (OR=1.47, p<0.001) relatively to be in high adherence group compared to older women with normal cognitive function. The development and implementation of interventions are needed for reducing barriers to accessing cancer screening services in high-risk vulnerable populations. This submission is considered late-breaking research because study findings were obtained from a recently completed student's master's project.

Cognitive decline and impairment among older adults have become an important public health issue. Previous research shows older women have a greater prevalence of Alzheimer's disease than Men. Among women, breast cancer is one of the most common types of cancer. Over half of breast cancer deaths occur in women aged 65 and older. Therefore, early detection of breast cancer through mammogram screening is important among older women. This study aimed to examine the influence of cognitive function on adherence to mammogram breast cancer screening among older American women aged 65 and older. Data from the Health and Retirement Study (2012-2016) was obtained and analyzed. The independent variable of the study was cognitive function (normal, not normal). Adherence to mammogram (low, moderate, high) was the dependent variable. Multinomial regression was performed to examine the association between cognitive function and adherence to mammogram after controlling for demographic covariates. In the study, 33.3% of respondents had impaired cognitive function and 21.7% showed low adherence to mammogram screening. Regression results found that older women with impaired cognitive function were more likely to be in low adherence group (OR=1.30, p=0.01) or moderate adherence group (OR=1.47, p<0.001) relatively to be in high adherence group compared to older women with normal cognitive function. The development and implementation of interventions are needed for reducing barriers to accessing cancer screening services in high-risk vulnerable populations. This submission is considered late-breaking research because study findings were obtained from a recently completed student's master's project.

QUESTION: The authors, in an article for the JAMA section on the rational clinical examination, consider the evidence on whether and how to use clinical breast examination as a cancer screening technique.BACKGROUND: Breast cancer is a common disease, particularly in older women. The authors note that by age 70 the annual incidence of breast cancer is one in 200 women. Breast cancer survival is strongly influenced by the stage of the disease at the time of diagnosis. As a result, it is important to consider how best to screen for this disease.In recent years there has been considerable attention in the clinical literature and in the popular media paid to the screening strategies of breast self‐examination and of screening mammography, but somewhat less to the potential role of the breast examination by the healthcare provider. In actual clinical practice, the same woman may be the recipient of any, none, or all of these screening modalities. The best way to combine these screening strategies, particularly in the case of the older woman, remains a subject of some uncertainty and controversy.DATA SOURCES: Data were obtained from a MEDLINE search of the English‐language literature for 1966 through 1997 and additional articles as identified by the authors.STUDY SELECTION CRITERIA: In their evaluation of the effectiveness of clinical breast examination, the authors included both controlled trials and case‐controlled studies in which clinical breast examination was used as a component of the screening. Study of breast examination technique considered both clinical studies and studies using silicone breast models.DATA EXTRACTION: The combined data from the trials included information on approximately 200,000 women who received a breast cancer screening intervention (mammography and/or clinical breast examination). However, none of the studies made the direct comparison of a group receiving clinical breast examination as a sole intervention with a control group that did not receive any screening. Data on the utility of clinical breast examination were partially derived from studies where that screening modality was used in combination with mammography.MAIN RESULTS: A number of trials of cancer screening have demonstrated a reduction in mortality from the use of mammography and clinical breast examination as combined screening strategies compared with no screening, with the inference that the reduction in mortality comes from the earlier detection of breast cancer. The percentage of the detected cancers that are detected in the trials by clinical breast examination despite having been missed on mammography varies across the trials from a low of 3% of the detected cancers to a high of 45%. It is speculative whether the marginal contribution of clinical breast examination to the mortality reduction in these screening trials corresponds to the percentage of cancers detected by clinical breast examination alone.In most of the clinical trials, the technique of breast examination reportedly was not well described. It is unclear therefore how much the technique of breast examination used varied within and among the clinical trials. Data from studies using examinations of breast models made of silicone demonstrated that test performance accuracy correlated with a lengthier breast examination, better breast examination technique, and perhaps with examiner experience.The report includes data from six comparator studies and from two demonstration projects. Of the six comparator studies, four compared a screened population with an unscreened population and two compared different intensities of screening strategies. None of the eight clinical trials was directed to a geriatric population and in fact older women were excluded by upper age entry criteria from the six comparator studies. (The upper age limit for study entry in the six comparator studies varied from 49 to 64.)CONCLUSION: The authors drew on the pooled results of these eight studies to conclude that clinical breast examination has a sensitivity of 54% (95% confidence interval, 48.3–59.8) and a specificity of 94% (95% confidence interval, 90.2–96.9). The authors conclude that screening clinical breast examination should be done for women age older than 40.

: Older black women are diagnosed with advanced stage breast cancer more frequently than whites possibly because they receive fewer mammograms. We investigated the extent to which regular mammography use explains black-white differences in stage at diagnosis among older women with breast cancer. We studied black and white women, aged greater than or equal 67, diagnosed with breast cancer from 1987-1993, residing in three SEER Program areas. Women were classified based on their mammography use during the 2 years before diagnosis: non users (no prior mammograms), regular users (at least 2 mammograms at least 10 months apart), or peri-diagnosis users (only mammogram(s) within 3 months before diagnosis). Stage was classified as early (in situ/local) or late (regional/distant). Black women were more likely to be nonusers of mammography (OR=2.19, 95% Cl, 1.65-2.92) and to be diagnosed with late-stage disease (OR=1 .78,95% Cl, 1.34-2.35) than white women. When stratified by prior mammography use, the black-white difference in stage occurred only among nonusers (adjusted OR=1 .54,95% Cl, 1.04-2.28). Among regular users, blacks and whites were diagnosed at similar stages (adjusted OR=1 .01,95% Cl, 0.54-1.88). These results suggest that differences in stage between older blacks and whites are related to prior mammography use. Increased regular mammography use may result in a shift toward earlier stage disease and narrow observed differences in stage between older black and white women.