Receipt Of Screening Mammography Research Articles

Abstract P019: Continued depression of breast and lung cancer screening among Medicare enrollees during the COVID-19 pandemic

Abstract Background: Several studies reported sharp decreases in screening mammography for breast cancer and low-dose computerized tomographic screening for lung cancer in the early months of the COVID-19 pandemic, followed by a return to normal or near-normal levels in the summer of 2020. Objective: To determine the observed vs. expected mammography and low dose computed tomography rates from the beginning of the pandemic through April 2022. Methods: Retrospective cohort study assessing mammography and low dose computed tomography rates from January 2017 through April 2022. Data for January 2016 to February 2020 were used to generate expected rates for the period March 2020 to April 2022.Setting: United States Medicare population. Participants: A 20% national sample of Medicare fee-for-service enrollees among women aged 50-74 for mammography, and men and women aged 55-79 for low dose computerized tomography. Main outcome: Receipt of screening mammography or low dose computed tomography. Results: From January 2017 through February 2020, monthly mammography rates were flat, while there was a monotonic increase in low dose computed tomography rates, from approximately 500 per million per month in early 2017 to 1100 per million per month by January 2020. Over the period from March 2020 to April 2022, there were episodic drops in both mammography and low dose computed tomography rates, coincident with increases in national COVID-19 infection rates. For the periods from March 2020 to February 2020 and March 2021 to February 2022, the observed low dose computed tomography rates were 24% (95% Confidence Interval: 23%, 24%) and 14% (95% Confidence Interval: 13%, 15%) below expected rates, while mammography rates were 17% (95% Confidence Interval: 17%, 18%) and 4% (95% Confidence Interval: 4%, 3%) below expected. Conclusions and Relevance: The negative impact of the COVID-19 pandemic on lung cancer screening and breast cancer screening did not resolve after the initial pandemic surges. Successful interventions to improve screening rates should address pandemic-specific reasons for low screening participation. Citation Format: Christopher Huy D. Doan, Shuang Li, James Goodwin. Continued depression of breast and lung cancer screening among Medicare enrollees during the COVID-19 pandemic. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P019.

Receipt of Screening Mammography by Insured Women Diagnosed With Breast Cancer and Impact on Outcomes.

The purpose of this study was to determine factors associated with receipt of screening mammography by insured women before breast cancer diagnosis, and subsequent outcomes. Using claims data from commercial and federal payers linked to a regional SEER registry, we identified women diagnosed with breast cancer from 2007 to 2017 and determined receipt of screening mammography within 1 year before diagnosis. We obtained patient and tumor characteristics from the SEER registry and assigned each woman a socioeconomic deprivation score based on residential address. Multivariable logistic regression models were used to evaluate associations of patient and tumor characteristics with late-stage disease and nonreceipt of mammography. We used multivariable Cox proportional hazards models to identify predictors of subsequent mortality. Among 7,047 women, 69% (n=4,853) received screening mammography before breast cancer diagnosis. Compared with women who received mammography, those with no mammography had a higher proportion of late-stage disease (34% vs 10%) and higher 5-year mortality (18% vs 6%). In multivariable modeling, late-stage disease was most associated with nonreceipt of mammography (odds ratio [OR], 4.35; 95% CI, 3.80-4.98). The Cox model indicated that nonreceipt of mammography predicted increased risk of mortality (hazard ratio [HR], 2.00; 95% CI, 1.64-2.43), independent of late-stage disease at diagnosis (HR, 5.00; 95% CI, 4.10-6.10), Charlson comorbidity index score ≥1 (HR, 2.75; 95% CI, 2.26-3.34), and negative estrogen receptor/progesterone receptor status (HR, 2.09; 95% CI, 1.67-2.61). Nonreceipt of mammography was associated with younger age (40-49 vs 50-59 years; OR, 1.69; 95% CI, 1.45-1.96) and increased socioeconomic deprivation (OR, 1.05 per decile increase; 95% CI, 1.03-1.07). In a cohort of insured women diagnosed with breast cancer, nonreceipt of screening mammography was significantly associated with late-stage disease and mortality, suggesting that interventions to further increase uptake of screening mammography may improve breast cancer outcomes.

Neighborhood area-level social determinants and receipt of mammography screening in an area with high deprivation: A retrospective cohort study.

e18550 Background: Early detection through screening mammography has been shown to decrease breast cancer mortality. Screening mammography rates remains low among racial/ethnic minorities and patients with socioeconomic deprivation (SED). Most studies evaluating the role of area-level social determinants of health and breast cancer screening have included only a small number of variables; in this study, a comprehensive and granular measure of socioeconomic deprivation (SED) which included 17 variables was used to determine an association with screening mammogram completion. Methods: A retrospective cohort study was conducted at an academic hospital system between 2014-2020 to identify asymptomatic female patients who received screening mammogram referrals in their primary care clinic after they were deemed eligible per screening guidelines. Patients were assessed for mammogram completion at their annual visits. SED was evaluated using the area deprivation index (ADI), a measure of 17 variables including education, housing, and income at the census block group level. Other covariates analyzed were insurance status, age, and race. Chi-square test, Kruskal-Wallis test and a multivariate logistic regression model were used for statistical analysis. Results: 856 women were referred for screening mammography. 324 (38%) underwent mammogram. Patients with high, moderate, and low SED comprised 69 (8%), 287 (34%) and 500 (58%) of the cohort, respectively. In multivariable analysis, SED and race were not associated with higher screening rates. Uninsured and self-pay patients had the lowest odds of screening mammography completion (AOR 0.22; 95% 0.08, 0.60) and Medicare patients had decreased odds of mammogram completion relative to privately insured patients (AOR 0.64; 95% CI 0.43, 0.97). Older age was associated with a slightly higher odds of mammography completion (AOR 1.02; 95% CI 1.00, 1.04). Conclusions: The receipt of screening mammography was low among all patients relative to previously published rates. Uninsured/self-pay status was the strongest indicator for completion of mammography. Additional research is needed to understand the barriers that may influence mammography completion in this population with high socioeconomic deprivation. Multivariate Logistic Regression Estimates for Associations Between Mammogram Completion and SED category.[Table: see text]

Abstract P6-02-01: Perceived life expectancy, multimorbidity, and breast cancer screening in older women

Abstract Objective: Screening mammography (SM) benefits are maximal in women who have a several years' life expectancy. Perceived life expectancy (PLE), however, can be compromised by older age, and/or poor health. Prior studies have shown low rates of SM in younger and/or healthier women, while women who are older and/or those presenting with multimorbidity (MM) continue to undergo screening. The resulting under/overuse of SM causes an imbalance in the use of finite resources that should be rectified as we prepare for population aging. In this study, we investigate the use of SM in women 50 years of age or older in the context of age, PLE, MM, and other social determinants of health. Methods: This is a cross-sectional study using the nationally-representative 2012 U.S. Health and Retirement Study (n= 8934 women). In addition to demographics, we examined a broad range of variables on social determinants of health; as well as conditions constituting MM, including self-reported chronic conditions (e.g., heart disease), functional limitations (e.g., strength, and mobility limitations), and geriatric syndromes (e.g., low cognitive performance). We defined MM0-MM3 as gradients of MM, based on the occurrence/co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. PLE was calculated based on respondent's age-specific assessment of the chance they would live another 10-15 years. The outcome variable was self-reported mammography in the past 2 years. We conducted logistic regression analysis to evaluate the independent and interactive association between each of PLE and MM relative to SM, adjusting for potential confounders. Results: The median age was 65.7 years; 10.5% were Non-Hispanic Black (NHB), 7.8% were Hispanic, and 3.2% were Other Race. The percent of women with SM was 71.5% in the total population. The median assessment of PLE was a 50% chance of living another 10-15 years. 71.9% of women presented with chronic conditions, 36.8% with functional limitations, and 58.2 with geriatric syndromes. Adjusting for confounders, receipt of mammogram was positively associated with greater certainty of PLE (AOR for an increase of 10% –1.03 (1.01, 1.05)). Compared to those with no conditions (MM0), the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes was also positively associated with SM (AOR MM1– 1.48 (1.19, 1.84); AOR MM2– 1.35 (1.09, 1.69); and AOR MM3– 1.29 (1.02, 1.62)). In addition, PLE further strengthened the association between MM and SM. Although age was negatively associated with SM, this interacted with PLE such that the likelihood of having a mammogram was unrelated to age among women 100% certain they would live another 10-15 years. Conclusion: Both multimorbidity (MM) and perceived life expectancy (PLE) are independently and interactively associated with increased screening mammography (SM), suggesting overuse. Indeed, even among women 75 years of age or older, when SM may be least beneficial, receipt of SM in the past two years was 59.6% in the presence of highest MM gradient, and 68.1% when they were at least 75% certain they will live 10-15 years. A more detailed examination of the basis for PLE is warranted to understand the context in which screening recommendation is made. Citation Format: Koroukian SM, Warner DF, Schiltz NK, Cooper GS, Owusu C, Stange KC, Berger NA. Perceived life expectancy, multimorbidity, and breast cancer screening in older women [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-02-01.

Benefit Type and Care Source in Relation to Mammography Screening and Breast Cancer Stage at Diagnosis Among DoD Beneficiaries.

Type of insurance and out-of-pocket costs influence the use of medical care. Specifically, type of insurance can impact an individual's likelihood of receiving a screening mammogram. Additionally, variation in tumor stage at diagnosis exists for patients with different types of insurance. It is not clear whether different benefit types and care sources differ in breast cancer care and outcomes among Department of Defense (DoD) beneficiaries. The objective of this study was to examine differences in screening mammography and tumor stage at diagnosis between different benefit types (TRICARE Prime vs. non-Prime) and among different care sources (direct care, purchased care, and both) in the DoD Military Health System. Study subjects were women 40 to 64 years of age, diagnosed with malignant breast cancer between 2003 and 2007. Multivariable logistic regression analyses were conducted to assess differences by benefit type and care source in receipt of screening mammography before diagnosis and tumor stage at diagnosis. A total of 2,668 women were included in this study. Patients with Prime were more likely to receive a screening mammography and have an earlier tumor stage than those with non-Prime. Women with direct care were more likely to have an earlier tumor stage but less likely to receive a screening mammogram than those with purchased care. In an equal access health care system, the use of mammography screening and tumor stage at diagnosis may differ by benefit type and care source among DoD beneficiaries. To our knowledge, this was the first study to assess mammography screening and tumor stage differences by benefit type and care source in the Military Health System. Although underlying reasons for the differences are not clear, they may be related to out-of-pocket costs, distance from medical treatment facilities, and frequency of doctor visits for other medical problems. Further research is needed to assess these differences and related factors among DoD beneficiaries.

Receipt of Cancer Screening Is a Predictor of Life Expectancy.

Obtaining cancer screening on patients with limited life expectancy has been proposed as a measure for low quality care for primary care physicians (PCPs). However, administrative data may underestimate life expectancy in patients who undergo screening. To determine the association between receipt of screening mammography or PSA and overall survival. Retrospective cohort study from 1/1/1999 to 12/31/2012. Receipt of screening was assessed for 2001-2002 and survival from 1/1/2003 to 12/31/2012. Life expectancy was estimated as of 1/1/03 using a validated algorithm, and was compared to actual survival for men and women, stratified by receipt of cancer screening. A 5% sample of Medicare beneficiaries aged 69-90years as of 1/1/2003 (n = 906,723). Receipt of screening mammography in 2001-2002 for women, or a screening PSA test in 2002 for men. Survival from 1/1/2003 through 12/31/2012. Subjects were stratified by life expectancy based on age and comorbidity. Within each stratum, the subjects with prior cancer screening had actual median survivals higher than those who were not screened, with differences ranging from 1.7 to 2.1years for women and 0.9 to 1.1years for men. In a Cox model, non-receipt of screening in women had an impact on survival (HR = 1.52; 95% CI = 1.51, 1.54) similar in magnitude to a diagnosis of complicated diabetes or heart failure, and was comparable to uncomplicated diabetes or liver disease in men (HR = 1.23; 1.22, 1.25). Receipt of cancer screening is a powerful marker of health status that is not captured by comorbidity measures in administrative data. Because life expectancy algorithms using administrative data underestimate the life expectancy of patients who undergo screening, they can overestimate the problem of cancer screening in patients with limited life expectancy.

Breast cancer mortality in relation to receipt of screening mammography: a case-control study in Saskatchewan, Canada.

The efficacy of screening mammography in reducing breast cancer mortality continues to be controversial. In addition, few data exist on the efficacy of screening mammography in women 70years of age or older. An organized screening mammogram program has existed in Saskatchewan since the mid-1990s. It offers mammography every 2years to women ≥50years of age. We conducted a population-based case-control study to evaluate the efficacy of screening mammography, as practiced in Saskatchewan, Canada. Cases (n=501) were women who died of breast cancer during 1995-2008 and were at least 52years of age at the time of their diagnosis. Controls (n=5,009) were matched to cases on birth year and duration of healthcare coverage prior to the cases' breast cancer diagnosis date. In cases and controls, receipt of screening mammography during the several years up to and including the date of the case's diagnosis of breast cancer was ascertained from the records of the screening program. Receipt of a screening mammogram in the preceding 2years was more common among controls (53%) than cases (37%), OR 0.51 (95% CI 0.42-0.62). A decreased risk was observed among women in all age groups, including those 70-79years (OR 0.40; 95% CI 0.27-0.60). Our findings suggest that receipt of screening mammography among women in Saskatchewan has been associated with a decreased risk of death from breast cancer.

Impact of the 2009 US Preventive Services Task Force guidelines on screening mammography rates on women in their 40s.

BackgroundThe 2009 US Preventive Services Task Force breast cancer screening update recommended against routine screening mammography for women aged 40–49; confusion and release of conflicting guidelines followed. We examined the impact of the USPSTF update on population-level screening mammography rates in women ages 40–49.Methods and FindingsWe conducted a retrospective, interrupted time-series analysis using a nationally representative, privately-insured population from 1/1/2006-12/31/2011. Women ages 40–64 enrolled for ≥1 month were included. The primary outcome was receipt of screening mammography, identified using administrative claims-based algorithms. Time-series regression models were estimated to determine the effect of the guideline change on screening mammography rates. 5.5 million women ages 40–64 were included. A 1.8 per 1,000 women (p = 0.003) decrease in monthly screening mammography rates for 40–49 year-old women was observed two months following the guideline change; no initial effect was seen for 50–64 year-old women. However, two years following the guideline change, a slight increase in screening mammography rates above expected was observed in both age groups.ConclusionsWe detected a modest initial drop in screening mammography rates in women ages 40–49 immediately after the 2009 USPSTF guideline followed by an increase in screening rates. Unfavorable public reactions and release of conflicting statements may have tempered the initial impact. Renewal of the screening debate may have brought mammography to the forefront of women's minds, contributing to the observed increase in mammography rates two years after the guideline change. This pattern is unlikely to reflect informed choice and underscores the need for improved translation of evidence-based care and guidelines into practice.

Mental Illness and Use of Screening Mammography Among Medicaid Beneficiaries

Disparities in receipt of preventive services by people with mental illness have been documented previously. However, whether these disparities extend to screening mammography among individuals experiencing comparable barriers to accessing care has not been examined fully. To determine whether disparities exist in receipt of screening mammography between women with and without mental illness enrolled in Medicaid, a program with documented potential to reduce healthcare disparities. Receipt of screening mammography was examined among women aged 50-64 years enrolled in Ohio's Medicaid program during the years 2002-2008 (n=130,088). Receipt of annual screening mammography was examined among those with at least one screening mammography during the study period. Mental illness was identified through diagnostic, service, and pharmacotherapy codes (n=61,661). Compared to women without mental illness, more women with mental illness received at least one screening mammography during the study period (31.7% vs 38.1%, p<0.001). However, after adjusting for potential confounders, including the presence of comorbid conditions and length of enrollment in Medicaid, women with mental illness were 32% less likely to undergo at least one screening mammography (AOR=0.68, 95% CI=0.66, 0.70). Among those who received at least one screening mammography, fewer women with mental illness received screening mammography on an annual basis (5.9% vs 12.7%, p<0.001; AOR=0.53, 95% CI=0.49, 0.56). For all beneficiaries, each year of enrollment in Medicaid increased the likelihood of screening mammography use by at least 50%. Medicaid beneficiaries with mental illness constitute a particularly vulnerable population for suboptimal breast cancer screening.

Do community health worker interventions improve rates of screening mammography in the United States? A systematic review.

Community health workers (CHW) are lay individuals who are trained to serve as liaisons between members of their communities and health care providers and services. A systematic review was conducted to synthesize evidence from all prospective controlled studies on effectiveness of CHW programs in improving screening mammography rates. Studies reported in English and conducted in the United States were included if they: (i) evaluated a CHW intervention designed to increase screening mammography rates in women 40 years of age or older without a history of breast cancer; (ii) were a randomized controlled trial (RCT), case-controlled study, or quasi-experimental study; and (iii) evaluated a CHW intervention outside of a hospital setting. Participation in a CHW intervention was associated with a statistically significant increase in receipt of screening mammography [risk ratio (RR): 1.06 (favoring intervention); 95% CI: 1.02-1.11, P = 0.003]. The effect remained when pooled data from only RCTs were included in meta-analysis (RR: 1.07; 95% CI: 1.03-1.12, P = 0.0005) but was not present using pooled data from only quasi-experimental studies (RR: 1.03; 95% CI: 0.89-1.18, P = 0.71). In RCTs, participants recruited from medical settings (RR: 1.41; 95% CI: 1.09-1.82, P = 0.008), programs conducted in urban settings (RR: 1.23; 95% CI: 1.09, 1.39, P = 0.001), and programs where CHWs were matched to intervention participants on race or ethnicity (RR: 1.58, 95% CI: 1.29-1.93, P = 0.0001) showed stronger effects on increasing mammography screening rates. CHW interventions are effective for increasing screening mammography in certain settings and populations. CHW interventions are especially associated with improvements in rate of screening mammography in medical settings, urban settings, and in participants who are racially or ethnically concordant with the CHW.

Abstract B41: Effect of community health worker (CHW) interventions on rates of screening mammography: A systematic review and meta-analysis

Abstract Background: Community health workers (CHWs) are lay individuals who are specially trained to serve as liaisons between members of their communities and healthcare providers and services. Research conducted on the effectiveness of CHW programs in promoting screening mammography has reported conflicting results (i.e., some studies favored the use of CHWs while some do not). The aim of this study was to conduct a synthesis of all prospective studies on the effectiveness of CHW programs in improving screening mammography rates using the techniques of systematic-review and meta-analysis. It was hypothesized that study participants who received a CHW intervention would be more likely to receive a screening mammogram when compared to participants who did not receive a CHW intervention. Methods: Any prospective study conducted in the U.S. assessing the effect of a CHW intervention in a controlled setting and enrolling a minimum of 10 participants was eligible for inclusion. A comprehensive search of CINAHL, MEDLINE, PsycINFO, and Web of Science databases along with the reference lists of published articles was performed to identify potentially relevant studies conducted and published between 1980 and January 31, 2008. All retrieved citations were reviewed by two researchers for inclusion. Data extraction was performed using a standardized data collection form. Dichotomous data (receipt of mammogram) were summarized as risk ratios (RRs) for each study. The summary results from each study were pooled under a random effects model. Heterogeneity was assessed both by visual inspection of forest plots for each outcome, as well as by formal statistical testing for heterogeneity using the chi square and I2 test. Robustness of findings was assessed according to characteristics of CHW interventions, methodological quality of included studies, or study design. Results: Initial search yielded 228 citations of which 24 studies met the pre-determined inclusion criteria. Of the 24 studies, 18 had extractable data. Altogether these 18 studies included a total of 26,660 participants at baseline. In a combined sample of RCTs (n=10) and quasi-experimental studies (n= 8), participation in a CHW intervention was associated with a small, but significant increase in receipt of screening mammography [RR: 1.06 (favoring intervention); 95% Confidence interval (CI: 1.02, 1.11), p = .003]. The effect remained when pooled data from only the RCTs were included in the meta-analysis (RR: 1.07, 95% CI: 1.03, 1.12, p &amp;lt; .001), but was not present using pooled data from only the quasi-experimental studies (RR: 1.03, 95% CI: 0.89, 1.18, p = .71). Sensitivity analyses using data from the RCTs indicated that CHW programs where participants were recruited from medical settings (RR: 1.41, 95% CI: 1.09, 1.82, p = .008), programs conducted in urban settings (RR: 1.23, 95% CI: 1.09, 1.39, p = .001), and programs where CHWs were matched to intervention participants on race or ethnicity (RR: 1.58, 95% CI: 1.29, 1.93, p &amp;lt; .001) demonstrated stronger effects on increasing mammography screening rates. Conclusions: Results from the meta-analysis indicate that CHW interventions are an effective strategy for increasing screening mammography, but intervention effectiveness depends on the research design of studies, as well as characteristics of the CHW intervention. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B41.

Health Disparities in Receipt of Screening Mammography in Latinas: A Critical Review of Recent Literature

Increased use of screening mammography is associated with lower death rates from breast cancer in the United States. Despite recommendations that women over 40 years of age should obtain regular screening mammography at least every 2 years, many women do not adhere to these guidelines. Historically, women from underserved and minority populations have been less likely to receive screening mammography. A critical review of recent research literature was conducted to evaluate whether Latinas are less likely to receive screening mammography, determine whether disparities in screening mammography persist when controlling for other variables, and examine what other variables are associated with screening mammography. The articles were obtained from a search of the PubMed database. Fifteen published articles met the inclusion criteria and were critically reviewed. The unadjusted odds ratios (ORs) of the association between Hispanic ethnicity and screening mammography ranged from 0.40 to 0.93. For the most part, the ORs adjusted for other variables in multiple logistic regression analyses increased (range: 0.3 to 1.67). Age, education, income, health insurance, having a usual source of care, and having a recent visit to a physician were consistently related to screening mammography in multiple logistic regression analysis. Hispanic ethnicity is a risk factor for lack of adherence to screening mammography. However, other demographic, socioeconomic, and health system variables account for some of the disparity related to Hispanic ethnicity.

Associations Between Obesity and Receipt of Screening Mammography, Papanicolaou Tests, and Influenza Vaccination: Results from the Health and Retirement Study (HRS) and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study

Obese Americans, who receive more care for chronic diseases, may receive fewer preventive services. We evaluated the association between body mass index (BMI) and receipt of screening mammography and Papanicolaou tests among middle-aged women and the association between BMI and receipt of influenza vaccination among the elderly. We analyzed 2 datasets: the Health and Retirement Study (4439 women aged 50-61 years) and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study (4045 women and 2154 men aged 70 years or more). When BMI was greater than 18.5 kg/m2, we found an inverse dose-response relationship between BMI and receipt of screening mammography and Pap tests among White, but not Black, middle-aged women. We found a similar association between BMI and influenza vaccination among the elderly. Higher BMI was associated with less frequent receipt of preventive services among middle-aged White women and elderly White women and men. The Healthy People 2010 clinical preventive service goals remain elusive, especially for overweight and obese White persons.