Mammography Utilization Research Articles

The Relationship Between the Supply of Primary Care Physicians and Measures of Breast Health Service Use.

Background: To investigate whether women are more likely to report receipt of a mammography recommendation from a doctor or mammography use if they reside in primary care service areas (PCSAs) having a greater number of clinically active primary care physicians.Materials and Methods: The analysis used a nationally representative sample of women, aged 40 years and above (n = 10,706 unweighted respondents), extracted from the 2005 National Health Interview Survey. The restricted geocoded addresses of the respondents were linked to PCSA data on physician density at a secure research data center. Multivariable logistic regression was used to determine whether, after adjustment, specific measures of primary care providers (e.g., the number of obstetricians and gynecologists [Ob-GyNs] per 10,000 population) were associated with either recommendation receipt or mammography use.Results: After adjusting for other factors, a one-unit increase in the PCSA number of Ob-GyNs per 10,000 population increased the odds of mammography recommendation receipt by 9% and the odds of mammography use by 9%. The ratio of international medical graduate Ob-GyNs to US-trained Ob-GyNs in a PCSA was negatively associated with mammography use.Conclusion: The results from this nationwide study underscore the importance of using physician density measures estimated from within bounded medical markets, where women reside and actually seek preventive breast health services. Results support the hypothesis that PCSA physician supply is independently associated with both mammography recommendation receipt and mammography utilization.

Breast Cancer Screening in Patients With Newly Diagnosed Lung and Colorectal Cancer: A Population-Based Study of Utilization

PurposeTo assess breast cancer screening utilization in Medicare beneficiaries with colorectal and lung cancer versus cancer-free controls. MethodsFemale fee-for-service Medicare beneficiaries who were ≥67 years old and diagnosed with lung or colorectal cancer between 2000 and 2011 and who reported to a Surveillance, Epidemiology, and End Results (SEER) registry (case group) were followed for 2 years after their diagnoses, unless death, a diagnosis of breast cancer, or the end of 2013 came first. A similar number of cancer-free controls were individually matched to cases by age, race, registry region, and follow-up time. Screening utilization was defined as the percentage of women with ≥1 screening mammogram during follow-up. ResultsOverall, 104,164 cases (48% colorectal, 52% lung; 30% advanced cancer) and 104,164 controls were included. Among women with lung or colorectal cancer, 22% underwent ≥1 screening mammogram versus 26% of controls (odds ratio [OR] 0.80; 95% confidence interval [CI] 0.78-0.82). Stratified by cancer type, 28% of colorectal cancer cases versus 29% of controls (OR 0.98; 95% CI 0.95-1.01) and 17% of lung cancer cases versus 23% of controls (OR 0.63; 95% CI 0.60-0.65) received ≥1 mammogram. When stratified by stage, 8% with advanced cancer versus 18% of controls (OR 0.33; 95% CI 0.31-0.35) and 30% with early-stage cancer versus 30% of controls (OR 1; 95% CI 0.97-1.02) underwent ≥1 mammogram. ConclusionScreening mammography utilization rates are similar between Medicare beneficiaries with early-stage cancer versus controls. Although the majority of patients with advanced-stage cancer appropriately do not pursue screening mammography, a small number (8%) continue with screening.

Use of patient decision aids increased younger women's reluctance to begin screening mammography: a systematic review and meta-analysis.

As breast cancer screening guidelines have changed recently, additional investigation is needed to understand changes in women's behavior after using breast cancer screening patient decision aids (BCS-PtDAs) and the potential effect on mammography utilization. This systematic review and meta-analysis sought to evaluate the effect of BCS-PtDAs on changes in women's intentions to undergo screening mammography and whether women deciding to begin or discontinue screening mammography displayed similar changes in screening intentions after using a BCS-PtDA. We searched Medline, Scopus, PsycINFO, CENTRAL, Health and Psychosocial Instruments, Health Technology Assessment Database, PsycARTICLES, and cited references in eligible papers for randomized controlled trials (RCTs) and observational studies, published through August 24, 2016. The proportions of women who did and not intend to undergo screening and who were uncertain about undergoing screening mammography were pooled, using risk ratios (RR) and random effects. According to the protocol, RCTs or observational studies and any language were considered eligible for systematic review if they included data about women for which shared decision making is recommended. We ultimately included six studies with screening intention data for 2040 women. Compared to usual care, the use of BCS-PtDAs in three RCTs resulted in significantly more women deciding not to undergo screening mammography (RR 1.48 [95% CI 1.04-2.13]; P = 0.03), particularly for younger (38-50 years) women (1.77 [1.34-2.34]; P < 0.001). The use of BCS-PtDAs had a non-significant effect on the intentions of older women (69-89 years) to discontinue screening. The use of BCS-PtDAs increased younger women's reluctance to undergo screening for breast cancer. The implementation of such BCS-PtDAs in clinical practice would be expected to result in a 77% increase in the number of younger women (aged 38-50) who do not intend to be screened, and as a consequence, may reduce utilization of screening mammography. The protocol of this review is registered in the PROSPERO database, #CRD42016036695.

Impact of the elimination of cost sharing for mammographic breast cancer screening among rural US women: A natural experiment

Rural US women experience disparities in breast cancer screening and outcomes. In 2006, a national rural health insurance provider, the National Rural Electric Cooperative Association (NRECA), eliminated out-of-pocket costs for screening mammography. This study evaluated the elimination of cost sharing as a natural experiment: it compared trends in screening before and after the policy change. NRECA insurance claims data were used to identify all women aged 40 to 64 years who were eligible for breast cancer screening, and mammography utilization from 1998 through 2011 was evaluated. Repeated measures regression models were used to evaluate changes in utilization over time and the association between screening and sociodemographic factors. The analysis was based on 45,738 women enrolled in the NRECA membership database for an average of 6.1 years and included 279,940 person-years of enrollment. Between 1998 and 2011, the annual screening rate increased from 35% to a peak of 50% among women aged 40 to 49 years and from 49% to 58% among women aged 50 to 64 years. The biennial screening rate increased from 56% to 66% for women aged 40 to 49 years and from 68% to 73% for women aged 50 to 64 years. Screening rates increased significantly (P < .0001) after the elimination of cost sharing and then declined slightly after changes to government screening guidelines in 2009. Younger women experienced greater increases in both annual screening (6.2%) and biennial screening (5.6%) after the elimination of cost sharing in comparison with older women (3.0% and 2.6%, respectively). In a multivariate analysis, rural residence, lower population income, and lower population education were associated with modestly lower screening. In a national sample of predominantly rural working-age women, the elimination of cost sharing correlated with increased breast cancer screening. Cancer 2017;123:2506-15. © 2017 American Cancer Society.

Racial Disparities in Screening Mammography in the United States: A Systematic Review and Meta-analysis

PurposeMany studies have suggested that disparities exist in the use of medical screening tests. The purpose of this study was to assess racial disparities in screening mammography in the United States via a systematic review and meta-analysis. MethodsWe searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus for comparative studies published between 1946 and 2015 comparing utilization of mammography among various racial groups. Two independent reviewers extracted data and appraised study. Meta-analysis was conducted when appropriate using the random-effects model. ResultsA total of 5,818,380 patients were included across 39 relevant studies; 43.1% of patients were white, 33.3% were black, 17.4% were Hispanic, and 6.2% were Asian/Pacific Islander. Black and Hispanic populations had lower odds of utilizing screening mammography when compared with the white population (odds ratio [OR] = 0.81; 95% confidence interval [CI], 0.72-0.91; I2 = 89.4% and OR = 0.83; 95% CI, 0.74-0.93, respectively). For African Americans, these disparities were present in both the 40 to 65 age group and the >65 age group; for Hispanics, these differences were present only in the 40 to 65 age group. There was no difference in mammography utilization between Asians/Pacific Islanders and whites (OR = 1.82; 95% CI, 0.09-38.41). ConclusionsRacial disparities in utilization of screening mammography are evident in black and Hispanic populations in the United States. Further studies are needed to understand reasons for disparities, trends over time, and the effectiveness of interventions targeting these disparities.

Determining the spatial heterogeneity underlying racial and ethnic differences in timely mammography screening.

BackgroundThe leading cause of cancer death for women worldwide continues to be breast cancer. Early detection through timely mammography has been recognized to increase the probability of survival. While mammography rates have risen for many women in recent years, disparities in screening along racial/ethnic lines persist across nations. In this paper, we argue that the role of local context, as identified through spatial heterogeneity, is an unexplored dynamic which explains some of the gaps in mammography utilization by race/ethnicity.MethodsWe apply geographically weighted regression methods to responses from the 2008 Public Health Corporations’ Southeastern Household Health Survey, to examine the spatial heterogeneity in mammograms in the Philadelphia metropolitan area.ResultsWe find first aspatially that minority identity, in fact, increases the odds of a timely mammogram: 74% for non-Hispanic Blacks and 80% for Hispanic/Latinas. However, the geographically weighted regression confirms the relation of race/ethnicity to mammograms varies by space. Notably, the coefficients for Hispanic/Latinas are only significant in portions of the region. In other words, the increased odds of a timely mammography we found are not constant spatially. Other key variables that are known to influence timely screening, such as the source of healthcare and social capital, measured as community connection, also vary by space.ConclusionsThese results have ramifications globally, demonstrating that the influence of individual characteristics which motivate, or inhibit, cancer screening may not be constant across space. This inconsistency calls for healthcare practitioners and outreach services to be mindful of the local context in their planning and resource allocation efforts.

The Effect of the Controversial US Preventive Services Task Force Recommendations on the Use of Screening Mammography

PurposeThe 2009 release of updated US Preventive Services Task Force (USPSTF) recommendations on screening mammography differed sharply from those of the American Cancer Society, the ACR, and the American College of Obstetricians and Gynecologists. The aim of this study was to ascertain the effect of these recommendations on the utilization of screening mammography in the Medicare population. MethodsThe Medicare Part B Physician/Supplier Procedure Summary Master Files from 2005 through 2010 were used to determine the annual utilization rate of screening mammography from 2005 to 2010. A utilization trend line was plotted for those years. ResultsThe utilization rate of screening mammography per 1,000 women in the Medicare population was 311.6 in 2005 and increased gradually each year to 322.9 in 2009 (a compound annual growth rate of 0.9%). However, after the USPSTF recommendations were issued in late 2009, this rate decreased abruptly to 309.1 (−4.3%) in 2010. ConclusionsThe abrupt decrease in the utilization of screening mammography in 2010 was in sharp contrast to the previous slow annual increases in its utilization from 2005 to 2009. Because there are no other factors to explain a decrease of this magnitude, it would seem that the USPSTF recommendations and the ensuing publicity resulted in a decrease in the utilization of screening mammography in the Medicare population in the first year after issuance of the new recommendations.

Utilization of screening mammography in older women according to comorbidity and age: protocol for a systematic review.

BackgroundApproximately half of new invasive breast cancer cases diagnosed each year in the United States occur among women aged 65 years and older. The increasing life expectancy coupled with the attendant rise in breast cancer incidence and elimination of out-of-pocket expenses for screening mammography as a result of the Affordable Care Act could lead to higher utilization rates of screening mammography. Although research indicates that life expectancy should be a strong consideration when making screening decisions among older women, the extent to which screening mammography utilization is tailored to comorbidity and life expectancy is not well established.Methods/designTo identify relevant studies, a systematic search of the literature will be conducted using PubMed and EMBASE between January 1, 1991, and March 1, 2016. Additional studies will be found through citation review or by contacting experts in the field. The inclusion criteria will be any study design comprised of women aged 65 and older, assessing women’s comorbidity, functional impairments, and/or health status, and reporting outcome measures that addressed mammography utilization within the last 1–5 years. For each study, two authors will independently abstract data regarding study eligibility and outcomes to determine relevance. Quantitative results will be extracted from text and tables, choosing preferably those adjusted for important confounders.DiscussionThe review will provide evidence on the impact of comorbidity, functional limitations, and health status on screening mammography utilization in older women and inform decision aids in this area.Systematic review registrationPROSPERO CRD42016032661 Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0345-y) contains supplementary material, which is available to authorized users.

Abstract 2583: Mammography decision-making: Trends, predictors and effects of provider communication in the Health Information National Trends Survey 2011-2015

Abstract Introduction: In 2009 the US Preventive Services Task Force (USPSTF) recommended against routine annual mammograms among women aged 40-49. However, mammography utilization appears unchanged since that time. We examined whether women, particularly those ages 40-49, are having discussions about mammography with their healthcare providers and how this affects screening behavior. Methods: Data were drawn from the 2011-2014 Health Information National Trends Survey (HINTS). We included female respondents age 40 or older with no personal history of breast cancer who reported a medical visit in the previous two years, and responded to the following question: ‘Has a doctor or other health professional ever told you that you could choose whether or not to have a mammogram?’ (N = 5085). We examined trends in the proportion of women reporting provider communication on mammogram choice according to 10-year age group. We used logistic regression to generate odds ratios (OR) and 95% confidence intervals (CI) for predictors of provider communication and also assessed whether provider communication was associated with mammography screening in the previous two years. Results: Less than half of the women reported provider communication on mammogram choice in each year (2011:44.3%; 2012: 37.5%; 2013: 37.0%; 2014: 43.6%). In every year except 2014, women age 40-49 were most likely to report provider communication, though this difference was only significant in 2013 (45% vs. 30.2-36.6%; p = 0.02). In multivariable-adjusted models, women age 40-49 were 27% more likely to report provider communication on mammogram choice (OR: 1.27, 95% CI: 1.02-1.59) compared to women age 50-59. Non-Hispanic black women were 33% less likely to report such communication (OR: 0.67, 95% CI: 0.52-0.88) compared to non-Hispanic Whites. The youngest (40-49 years) and oldest (≥70 years) women were most likely to report no mammogram in the previous two years. Women who reported provider communication on mammogram choice were 17% more likely to report no mammogram in the past two years (OR: 1.17, 95% CI: 0.93-1.46), though this was not statistically significant. When stratified by 10-year age group, provider communication was only associated with higher risk of no mammogram among women age 70 and older (OR: 1.93, 95% CI: 1.29-2.89). Conclusions: Between 2011-2014 women age 40-49 were the most likely to receive healthcare provider communication on mammogram choice. Still, the majority of women in that age group did not receive such communication despite the 2009 USPSTF recommendation that the decision to start screening mammography prior to age 50 should be an individualized one that takes into account patient values regarding specific benefits and harms. Provider communication on mammogram choice can influence screening behavior, particularly for older women. Citation Format: Laura Spring, Megan R. Marshall, Erica T. Warner. Mammography decision-making: Trends, predictors and effects of provider communication in the Health Information National Trends Survey 2011-2015. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2583.

Response costs of mammography adherence: Iranian women's perceptions.

Background: Mammography as the most common secondary prevention method has known to be helpful in detecting breast cancer at the early stages. Low level of participation among women toward mammography uptake due to cultural beliefs is a great concern. This study aimed at exploring the perceptions of women about response costs of mammography adherence (MA) in Yazd, Iran. Methods: A qualitative study using semi-structured interviews was performed. Fourteen women,one oncology nurse, and a breast cancer survivor were purposefully interviewed. Interviews were transcribed verbatim and analyzed by directed content analysis method based on protection motivation theory (PMT). Results: One main theme was emerged from the analysis namely called "response costs".Two main categories were also emerged from the data; (1) psychological barriers with six subcategories including "embarrassment," "worry about being diagnosed with cancer," "preoccupation with underlying disease," "misconception about mammography," "need for an accompanying person," and "internalizing the experiences of the others," and (2) maladaptive coping modes which encompassed three subcategories: "religious faith," "fatalism," and"avoidance and denial." Conclusion: Useful information was provided about the response costs of mammography utilization based on the perceptions of women. Cognitive barriers may be decreased by conducting modifications in women’s awareness and attitude toward MA as well as changing the national health system infrastructures. Incorporating religious and cultural belief systems into MA educational programs through motivational messages is recommended.

Bayesian spatiotemporal modelling for identifying unusual and unstable trends in mammography utilisation

ObjectivesTo compare two Bayesian models capable of identifying unusual and unstable temporal patterns in spatiotemporal data.SettingAnnual counts of mammography screening users from each statistical local area (SLA) in Brisbane, Australia,...

Abstract C28: Racial and ethnic disparities in mammography utilization among women with intellectual disabilities: An exploratory mixed methods approach

Abstract Background: Racial and ethnic disparities in mammography utilization among the general population persist to this day. Women with intellectual disabilities have much lower rates of mammography receipt compared to women without ID and are diagnosed with breast cancer at more advanced stages. Among women with ID, the diverse perceptions and experiences among different racial and ethnic groups surrounding mammography utilization are unknown. The purpose of this study is to conduct a mixed methods study to explore racial and ethnic differences in mammography utilization and experience among women with ID who are Black/African American, Hispanic, and non-Hispanic White. Specific Aims: 1. Collect mammography medical records and demographic information from Black/African American, Hispanic, and non-Hispanic White women with ID to determine general trends in mammography utilization from 2010-2013. 2. Determine the barriers and facilitators contributing to mammography utilization among different racial and ethnic groups of this population via in-depth interviews. 3. Explore how culture may affect the social interactions that in turn may affect mammography utilization among this population. This approach is innovative as it combines quantitative and qualitative methodologies to data collection among a priority population. The proposed research is significant because it will increase awareness on the different racial and ethnic perspectives regarding mammography utilization among women with ID. In the long-term, the results from this research may improve the delivery of appropriate healthcare to this population to achieve a reduction in mammography disparities. In addition, expected results from this research can be considered when planning breast cancer prevention interventions within this population and may be used to enhance the quality of healthcare for women with ID. This research is funded by AHRQ GRANT11714050. Preliminary findings are expected for November 2015. Citation Format: Evelyn Arana. Racial and ethnic disparities in mammography utilization among women with intellectual disabilities: An exploratory mixed methods approach. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C28.

Abstract B86: Disparities in mammogram screening among women with access to care: The role of socioeconomic status and education

Abstract Purpose: Differences in mammogram screening (MS) rates are well documented. While multiple barriers limit screening, lack of health insurance has been identified as a main reason. However, even among women with health insurance, only 71 percent had a mammogram within the past two years. Understanding factors affecting screening beyond access to care are therefore imperative to reduce the gap. This study's objectives are three-fold: 1) To explore barriers to mammogram screening (MS), 2) To examine disparities in MS among women with insurance coverage and a usual source of care (USC) and 3) To study the association between provider characteristics with the receipt of timely MS. Methods: An unweighted analytic sample of 24475 women, 50 years and older was identified using the 2007-2012 pooled cross-sections of the Medical Expenditure Panel Survey (MEPS). Mammogram screening was measured by the respondent's answer to the survey question “how long since the last mammogram”. Based on the 2009 U.S Preventive Services Task Force's breast cancer screening recommendations, responses were coded as “timely” if it was indicated that a mammogram was received at least within the past two years. Logistic regressions were used to examine the factors associated with the probability of MS. Results: The mean age of the cohort was 64years (+/-0.15) with a majority (77%) of non-Hispanic whites (NHW), 10% non-Hispanic blacks (NHB), 8% Hispanics while the remaining 6% indicated other races. Overall, the study population had at least a high school education but about 30% reported an income below 200% of the federal poverty level. While women in this cohort primarily had private insurance (66%), 27% were on public insurance, 10% reported not having a USC and most women had a good health status (81%). 24% women reported not receiving a timely MS. Regression results demonstrated that being a NHW, lower socio-economic status (SES), living in the rural areas, having less than 12 years of education, being uninsured, reporting poor physical health status and not having a USC lowered the probability of receiving timely screening. Disparities in MS persisted even among those women with insurance coverage and a USC. Interestingly, in this cohort, NHB and Hispanic women continued to have higher odds of MS (OR: 1.63; 95% CI: 1.42-1.88 and OR:1.61; 95% CI:1.35-1.91 respectively) compared to NHW. However, the most notable and significant differences were found based on SES and the education level even after adjusting for other variables. For example, women in low SES and those without any education had approximately 43% lower odds of receiving MS compared to those in higher SES and those with at least a high school education. To further explore disparities in MS, regression analysis will incorporate system-level factors such as characteristics of the usual source of care and provider's communication skills to examine the association of racial/sex concordance, provider's specialty and patient satisfaction with the quality of care with the receipt of a timely mammogram. Conclusions: Improving access to mammography is an important health policy concern. The crucial role of insurance coverage and access to primary care cannot be undermined. However, social determinants such as education and socio-economic level are also vital as lack of awareness and poor knowledge regarding breast cancer screening, language and financial barriers continue to persist among the vulnerable population. Particularly in women with a usual source of care, provider recommendations and improving patient's satisfaction with care can prove vital to boost timely screening by building trust in the healthcare system. Thus, recognizing predictors of mammogram even after providing access to care may improve utilization of screening mammography among the underserved women. Citation Format: Anushree Vichare. Disparities in mammogram screening among women with access to care: The role of socioeconomic status and education. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B86.

Abstract P1-09-06: The effect of Hispanic nativity and ethnicity on mammography use through the Avon breast health outreach program

Abstract Introduction Although Hispanic women have lower rates of breast cancer compared to non-Hispanic whites (NHW), breast cancer remains the leading cause of cancer death among Hispanic women . Some studies suggest that Hispanic women have lower rates of breast cancer screening compared to NHW women, primarily due to lack of health insurance and socioeconomic disadvantages . This study aims to understand the demographic characteristics of Hispanic women in the U.S. who access and utilize the Avon Breast Health Outreach Program (BHOP), and how Hispanic women's mammography history differs by nativity. Avon BHOP supports community-based organizations to conduct education and outreach to over 50,000 low-income and uninsured women each year, linking them to routine breast cancer screening and care. Methods This study analyzed 2014 Client Intake Forms (CIF) for all women aged 40 and older, who were served by BHOP for the first time (∼16,000 women). Descriptive analysis was conducted to summarize their demographic and breast health information, comparing Hispanics with NHW. Multivariate logistic regression was performed to examine the relationship between ethnicity and nativity and having a mammogram in the last two years. Lastly, a sub-analysis among foreign-born (FB) Hispanics only was conducted to assess how the length of time living in the U.S. (number of years) impacts the likelihood of having a mammogram in the last two years. Results Of the first time clients served through BHOP in 2014, 10.4% were US-born Hispanics, 45.2% were FB-Hispanics, and 44.4% were NHW. The majority of FB-Hispanic women were from Mexico (66.2%). FB-Hispanics are less likely to have insurance as compared to US-born Hispanic women (19.7% vs. 39.3%), and less likely to have a high school degree (34.3% vs. 44.8%). After controlling for demographic and socioeconomic variables, FB-Hispanics had significantly greater odds of having a mammogram in the past two years compared to US-born Hispanics (OR=1.6, 95% CI, 1.3-1.9), and NHW women (OR=1.4, 95% CI, 1.2-1.6). FB-Hispanics living in the U.S. for 5+ years had a 1.7 greater odds of having a mammogram in the past 2 years, as compared to recent immigrants living in the U.S. for less than one year (OR=1.7 ;95% CI, 1.1 – 2.7). Discussion In 2014, the percentage of BHOP Hispanic women aged 40+, reporting a mammogram in the last two years (41.1%) was lower than the overall U.S. Hispanic rate (61.4%) , suggesting confirmation that BHOP serves vulnerable and underserved populations, as it aims to do. This study also demonstrates how screening behaviors differ among Hispanic women served through BHOP, with FB-Hispanics having higher mammography utilization rates as compared to their US-born counterparts, with variation seen by the number of years living in the U.S. In conclusion, it is critical to view Hispanics as a heterogeneous group in order to best address their clinical needs. Specifically, the results point to how U.S.-born Hispanic BHOP clients may be at particularly high risk for low breast cancer screening. Citation Format: Gates-Ferris K, Senter L, Aliaga M, Hurlbert M, Ricci C. The effect of Hispanic nativity and ethnicity on mammography use through the Avon breast health outreach program. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-09-06.

Optimal breast cancer screening strategies for older women: current perspectives.

Breast cancer is a major cause of cancer-related deaths among older women, aged 65 years or older. Screening mammography has been shown to be effective in reducing breast cancer mortality in women aged 50–74 years but not among those aged 75 years or older. Given the large heterogeneity in comorbidity status and life expectancy among older women, controversy remains over screening mammography in this population. Diminished life expectancy with aging may decrease the potential screening benefit and increase the risk of harms. In this review, we summarize the evidence on screening mammography utilization, performance, and outcomes and highlight evidence gaps. Optimizing the screening strategy will involve separating older women who will benefit from screening from those who will not benefit by using information on comorbidity status and life expectancy. This review has identified areas related to screening mammography in older women that warrant additional research, including the need to evaluate emerging screening technologies, such as tomosynthesis among older women and precision cancer screening. In the absence of randomized controlled trials, the benefits and harms of continued screening mammography in older women need to be estimated using both population-based cohort data and simulation models.

Breast and cervical cancer screening among Hispanic subgroups in the USA: estimates from the National Health Interview Survey 2008, 2010, and 2013.

This study examined patterns in mammography and Pap test use across and within subpopulations of Hispanic women. Based on data from the National Health Interview Survey (2008, 2010, and 2013), we estimated the proportion of Hispanic women reporting testing for breast and cervical cancer for specific subgroups. We examined test use by demographic characteristics using Chi-square tests. Overall, the proportion of women aged 50-74 years who reported a mammogram within the past 2 years did not differ significantly across Hispanic subgroups. Among publically and uninsured women, however, proportions of mammography utilization varied significantly across Hispanic subgroups. The proportion of women aged 21-65 years who received a Pap test within the past 3 years differed significantly across Hispanic subgroups. Among subgroups of Hispanic women, patterns in mammography and Pap test use vary by insurance status, length of US residency, and type of screening. Certain subgroups of Hispanic women may benefit from culturally tailored efforts to promote breast and cervical cancer screening.

Trends in mammography utilization for breast cancer screening in a Middle-Eastern country: Lebanon 2005–2013

IntroductionIn Lebanon, annual national breast awareness campaigns were started in 2002 during the international breast month of October to promote the utilization of mammography for women aged ≥40. The impact of the campaigns has been assessed periodically since 2003. Results of 2003–2005 campaigns have been published previously. ObjectivesTo measure the prevalence of two behavioral outcomes of interest: ever-use of mammography, and repeat mammography in the previous 12 months among ever-users. The prevalence was described by region and age group. The aim was to document the effectiveness of the program towards reaching a nationally defined goal of 80% screening coverage. MethodsThe survey’s sampling frame was developed incrementally, and since 2005 it has included women aged ≥40 from all areas of Lebanon. The sample size has also increased incrementally from 1200 in 2005 to 2400 in 2013. Results have been tabulated biannually and presented as historical trends with regional and demographic variations covering a 9-year period. ResultsIn all six consecutive surveys presented here, the mean age of participating women was about 50 years. Year-by-year increases in utilization indicators were detected, with consistent differences in favor of the more urban areas in and around the capital city Beirut and its suburbs (Greater Beirut or GB). By 2013, ever-utilization had reached 43% (41–45) and recent mammography 20% (18–22) nationwide. Utilization was significantly more important in the age group 50–59 compared with the age group 40–49 or ≥60. While recent rates have increased nationwide, they have reached a plateau of about 25% in GB and are tending to the same level in other areas. Discussion and conclusionsWhile initial progress was slow, it has been accelerating in the last 4–5 years, indicating that the message is being accepted by a larger audience of targeted women at each iteration. However, concern remains that women between 40 and 50 and those >60 are not responding as well as desired to the screening message, for reasons currently under investigation.

Web-Based Study for Improving Mammography Among Korean American Women.

Web-based culture-specific interventions for Korean American (KA) women to improve mammography utilization are not available. An established intervention developed to improve mammography utilizations for Korean American (KA) women was tested via the Web for its efficacy, feasibility, and acceptability. A randomized controlled trial, with a pretest-posttest control group design, was conducted with 136 KA women and their spouses. Intention to have a mammogram within the next 12months increased significantly in the intervention group compare to controls. Among women whose mammograms had not been updated, 22% of women in the intervention and 13% of women in the control group obtained a mammogram at 2-month post-baseline, even though the difference was not statistically significant. The Web-based study educating couples was feasible and could improve KA women's breast cancer screening intention and behaviors. Combining off-line contact for recruitment/data collection with online intervention material could decrease the attrition rate in the future study because the attrition rate in this study was higher than the original study.

Breast cancer screening utilization and understanding of current guidelines among rural U.S. women with private insurance.

Women living in rural areas of the U.S. face disparities in screening mammography and breast cancer outcomes. We sought to evaluate utilization of mammography, awareness of screening guidelines, and attitudes towards screening among rural insured U.S. women. We conducted a cross-sectional self-administered anonymous survey among 2000 women aged 40-64 insured by the National Rural Electric Cooperative Association, a non-profit insurer for electrical utility workers in predominantly rural areas across the U.S. Outcomes included mammographic screening in the past year, screening interval, awareness of guidelines, and perceived barriers to screening. 1588 women responded to the survey (response rate 79.4 %). 74 % of respondents lived in a rural area. Among women aged 40-49, 66.5 % reported mammographic screening in the past year. 46 % received annual screening, 32 % biennial screening, and 22 % rare/no screening. Among women aged 50-64, 77.1 % reported screening in the past year. 63 % received annual screening, 25 % biennial screening, and 12 % rare/no screening. The majority of women (98 %) believed that the mammography can find breast cancer early and save lives. Less than 1 % of younger women, and only 14 % of women over age 50 identified the recommendations of the U.S. Preventative Services Screening Task Force as the current expert recommendations for screening. Screening practices tended to follow perceived guideline recommendations. When rural U.S. women over age 40 have insurance, most receive breast cancer screening. The screening guidelines of cancer advocacy groups and specialty societies appear more influential and widely recognized than those of the U.S. preventative services taskforce.

Listening to Women: Expectations and Experiences in Breast Imaging.

Those who discuss breast cancer detection and diagnosis with women know that many patients have misconceptions and anxieties about mammography. Some patients may misunderstand screening recommendations of their primary care provider or receive misinformation from friends, family, or other sources. Other women might be confused by changes or updates in official recommendations about the frequency for screening mammography or the age to begin obtaining mammograms. Still others might not be aware of breast cancer mammography screening coverage by the Patient Protection and Affordable Care Act (ACA), requiring that all new private insurance and Medicare plans eliminate cost-sharing by patients. Furthermore, healthcare providers can add to the confusion if they are not informed about the latest guidance. Anxiety about breast cancer screening can occur especially in women who have been called back for additional tests based on an inconclusive mammogram. In a recent database review of 1,723,139 women who received a screening mammogram between January 2011 and June 2013, Alcusky and colleagues found that 15% were recalled,1 while other studies reported recall rates between 10–14%.2,3 Most recalls result in “false positives,” meaning that additional testing ultimately yielded a benign outcome. Additional tests can include diagnostic mammography, breast ultrasound, breast biopsy, or magnetic resonance imaging. The majority of recalls reveal normal tissue, cysts, or other benign processes.4 The denser the breast tissue5–8 and the more annual mammograms a woman has had, the greater the probability of a callback and a false positive finding. False positives have been shown to increase patient anxiety in the short term,9 temporarily reduce quality of life,10 and lead to worries about breast cancer that can last for several years beyond the resolution of a false positive diagnosis.11 Anxiety and fear have been reported to have a major impact on breast cancer screening behaviors.12 As Harvey and colleagues note in a recent report, behaviors and responses to healthcare screenings can vary based on race/ethnicity and socioeconomic factors,13 perhaps helping to explain the greater fear of the healthcare system among African-American women.14 This undoubtedly plays a role in why African-American women present for diagnosis at later stages of breast cancer.15 We do know that almost all women experience increased anxiety when faced with finding a possible breast screening abnormality.16 Breast cancer is the most common cancer in U.S. women.17 The National Cancer Institute (NCI) of the National Institutes of Health projects 231,840 new cases of breast cancer in U.S. women and 40,290 deaths from the disease in 2015.18 NCI further estimates that 12.3% (1 in 8) of U.S. women with average risk will be diagnosed with breast cancer during their lifetime. Mortality from breast cancer has decreased significantly since 1990, probably related to improved mammography technology and detection, increased public awareness of the value of screening, and more effective treatments. Despite these improvements, breast cancer remains a serious health concern and is the second leading cause of cancer death among all women. There is one notable exception, which is for Hispanic women, in whom breast cancer is the number one cause of cancer death.17 Mammography screening is highly effective at detecting existing disease and reducing mortality. It has been associated with a 19% reduction in breast cancer deaths.19 The likelihood that mammography will detect existing breast cancer is 70% to 90% in most women; the exception is women with dense breast tissue where the sensitivity falls to 30 to 48%.20 Newer screening technologies including digital breast tomosynthesis (DBT) may yield even better results. This technology has the ability to both increase invasive cancer detection and decrease false positive results.4,21–24 In 2014, The Society for Women's Health Research conducted a national survey to assess women's knowledge and attitudes regarding mammography. We sought to identify misunderstandings about mammography among women of different racial/ethnic and age groups. We further sought to identify barriers that keep women from seeking screening mammography and motivators that would propel women toward screening. We queried participants about their emotional responses to being recalled for follow-up diagnostic testing and about what might lead them to use one mammography center over another for their breast cancer screening. Our results clearly showed areas where there are successes and areas where there are challenges. Our results demonstrate opportunities and potential ways forward to improve access and utilization of screening mammography. The authors believe that with improved access and utilization paired with new technologies, there may be potential for improved outcomes.