Factors related to noncompliance with screening mammogram appointments among low-income African-American women

Despite current mammography recommendations, screening rates among African-American women are suboptimal. The purpose of this case-control study was to identify the psychological, demographic, and health care system barriers to screening mammography use among low-income African-American women. A total of 574 women with screening mammogram appointments at an urban hospital were interviewed to determine the predictors of mammogram appointment noncompliance. Predictor variables included: demographics; breast cancer knowledge, attitudes, beliefs, and screening practices; and type of health care provider making the referral. Age was inversely related to mammogram appointment noncompliance. Relative to women 40 to 49 years old, women 70 years of age and older were the least likely to miss their appointments (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.2, 0.5). Women referred for mammography by a physician's assistant or nurse practitioner were less likely to miss their appointments than women referred by a physician (OR, 0.3; 95% CI, 0.1, 0.8). Embarrassment, lack of breast symptoms, and forgetfulness also contributed to noncompliance. Key demographic, attitudinal, and health care system factors hinder low-income African-American women from obtaining screening mammograms. These findings have significant health education and policy implications for health care delivery to women in this population.     

Breast cancer racial differences before age 40--implications for screening

BACKGROUND: Most authorities advocate mammogram screening for breast cancer beginning at age 40 based on the age-specific distribution and incidence of breast cancer in the general population. This policy has been bolstered by studies that demonstrate that, for the general population, mammography in the 40-49 age bracket reduces mortality. However, it also has been reported that African-American breast cancer patients are diagnosed more often than white patients below the age of 40. Young African-American women are also more likely to have advanced disease at the time of diagnosis with predictably higher mortality. The purpose of this investigation is to explore the question, whether a subset of African-American women, age 30-39, by virtue of increased vulnerability, would benefit from early mammogram screening. STUDY DESIGN: The age-specific distribution (age 30-84) of African-American and white breast cancer patients in five State cancer registries were compared. Prognostic indicators (tumor size and nodal status) in two of the five registries in African-American and white breast cancer cases below the age of 40 were compared. Age-specific incidence in the 30-39 age group and the relative populations of black and white women in the United States were noted in the Surveillance Epidemiology and End Report (SEER) (1994-1998) and The U.S. Census 2000. RESULTS: The differences of age-specific distribution and age-specific incidence of African-American and white breast cancer patients were found to be significant. More than 10% of African-American women with breast cancer were diagnosed before age 40 compared to 5% of white patients. The incidence of breast cancer (SEER Report 1994-1998) in the 30-39-age bracket for African-American and white women was 48.9 and 40.2 at the 95% confidence level, while the proportion of African-American and white women reported by the Census Bureau was not too dissimilar, 15.8% and 14.6% respectively. Prognostic indicators (tumor size and nodal status) support the notion that young African-American women are more likely to have advanced disease at diagnosis. CONCLUSIONS: African-American women in the 30-39 age group have twice the age-specific distribution, have a higher incidence compared to their white counterparts, and exhibit more ominous prognostic signs. This study provides evidence that African-American women in the 30-39 age category represent a high-risk group that may benefit from efforts at earlier detection. Although mammography remains the preferred screening modality, investigators have pointed out difficulties encountered when using mammography in young women, including low sensitivity, high breast density, cost/benefit concerns, and low positive predictive value. Nevertheless, the increasing mortality and persistent racial incidence gap in young African-American women, age 30-39, argue for considering early screening mammography in spite of recognized concerns.     

Self-report and primary care medical record documentation of mammography and Pap smear utilization among low-income women

PURPOSE: To determine whether self-report of mammography and Pap smear utilization was accurate and to determine whether racial/ethnic differences existed. METHODS: Face-to-face surveys were administered to 314 consecutively selected women over 40 attending two low-income inner-city family practice sites. Medical records were reviewed for documentation of mammography and Pap smear utilization. Level of agreement between self-report and chart review was reported. Sensitivity, specificity, positive predictive value and negative predictive value were calculated. MAIN FINDINGS: Puerto Rican women had lower income levels and were less educated than African-American and non-Latina white women. Self-report of mammograms and Pap smears were higher than medical record documentation. Level of agreement was higher for more recent tests. Negative predictive values for mammography were high (75-95.5%). Lower sensitivity, specificity, positive predictive value and negative predictive value for mammography were seen among Puerto Rican women compared to African-American and non-Latina white women. CONCLUSIONS: High negative predictive values suggest that asking women about mammography use may be an inexpensive, easy intervention in the primary care setting to increase screening among women currently not being screened by increasing conversations between patients and providers to address personal barriers to screening.     

Understanding the role of reactions to race-based treatment in breast and cervical cancer screening

Racial and ethnic disparities in breast and cervical cancer mortality persist despite effective screening methods. We examined associations between race/ethnicity and Pap testing within three years or mammography within two years, controlling for a composite reactions-to-race-based-treatment variable created using data from the 2002 and 2004 Behavioral Risk Factor Surveillance System Reactions to Race module, which assessed respondents experiences based on one's race. We calculated prevalence of Pap testing (for women aged > or = 18) and mammography (for women aged > or = 40) by race, and fit logistic regression models to estimate the strength of association of reactions to race-based treatment with screening and race--before and after controlling for demographics, socioeconomic status, health status, smoking and healthcare access. In the reduced model, black women were more likely (2.03: 95% CI: 1.55-2.65) to be screened for cervical cancer than whites. Reactions to race-based treatment did not impact the odds of black women receiving Pap tests or mammograms. Given current racial and ethnic disparities in breast and cervical cancer mortality, we suggest that more attention needs to be focused on follow-up of abnormal results and state-of-the art treatment for black and Hispanic women.     

Racial differences in ovarian cancer risk

We examined whether the previously observed lower risk of ovarian cancer among African-American women might be the result of differences in known risk factors. In a population-based, case-control study, sociodemographic, reproductive, and physical risk factors among white (669) and African-American (84) women aged 20 through 69 years with a recent diagnosis of epithelial ovarian cancer (study subjects) were compared with white (1110) and African-American (204) community control subjects. African-American women were more likely to have five or more pregnancies and to have a hysterectomy, whereas white women were more likely to have a family history of ovarian cancer. Yet, the risk and protective factors for ovarian cancer were similar among white and African-American women. As compared with white women, the odds of ovarian cancer among African-American women was significantly lower (odds ratio 0.7, 95% confidence interval [CI] 0.5 to 0.9) and remained somewhat lower after adjusting for known, important risk factors (odds ratio 0.8, 95% CI 0.6 to 1.0). Differences in the obstetric and gynecologic experiences of African-American and white women may explain some of the observed racial variability in ovarian cancer risk, but ovarian cancer risk remained lower among African-American women even after adjustment for these factors.     

Oral contraceptives and breast cancer among African-american women and white women

The higher incidence of breast cancer among African-American women younger than 50 as compared to white women points to the need to examine exposures that are common among younger women, including exposure to oral contraceptives (OC). We examined patterns of OC use and their associations with breast cancer in a population-based, case-control study conducted in North Carolina between 1993 and 1996. The study population was comprised of 858 cases and 789 controls, of whom 40% were African-American women. There was little evidence that breast cancer was associated with OC use among older women (age >50) of either race, most of whom discontinued use in the distant past. Among younger women, there was a modest, but nonsignificant, increase in risk associated with ever use of OCs for both African-American and white women. There was a trend of increasing risks with more recent use among African-American women, whereas no such trend was apparent for white women. Overall, we found more substantial age differences than race differences in patterns of OC use and the risk of breast cancer associated with their use. The similarity of the associations between African-American and white women suggest that racial differences in breast cancer incidence are not likely to be attributable to OC use.     

National patterns in human papillomavirus vaccination: an analysis of the National Survey of Family Growth

Human papillomavirus (HPV) vaccine has shown effectiveness for girls and young women. Despite this, there are population disparities in vaccine utilization rates. The purpose of this study was to evaluate maternal correlates of HPV vaccination among their adolescent daughters using a nationally-representative population-based sample, emphasizing race/ethnicity-specific disparities and barriers. Mothers of 9-18 y-old girls having heard of HPV vaccine and completing the HPV vaccine survey module from the 2006-2008 National Survey of Family Growth (NSFG) (n = 444) were analyzed for maternally-reported adolescent HPV vaccination and maternal intent to vaccinate her adolescent daughter if no dose had been received. Correlates of uptake and intent were examined using multivariate logistic regression. 27% of mothers (n = 98) reported that their daughters were vaccinated against HPV. Independent correlates of vaccination included African-American race (adjusted odds ratio (AOR),0.29; 95% confidence interval (CI),0.11-0.77), and living below the poverty level (AOR,4.43; 95%CI, 1.53-12.82). 46% (n = 152) of mothers of non-vaccinated daughters intended to vaccinate them. Correlates of maternal intention included maternal pelvic exam history (AOR,0.06; 95%CI, 0.007-0.51), multiple male lifetime sexual partners (AOR,3.22 ; 95% CI, 1.34-7.76), religiosity (AOR,0.37; 95% CI,0.16-0.87) and acceptability of premarital sex among 18 y-olds (AOR,2.45; 95% CI, 1.16-5.20). In conclusion, HPV vaccination initiation among adolescent daughters of mothers participating in the NSFG continues to lag among African-American participants. However, no racial/ethnic differences in maternal intent-to-vaccinate her daughter were detected. Future interventions need to address specific maternal barriers to vaccine uptake and how these may differ from vaccine intention.     

Racial differences in breast cancer screening,knowledge and compliance

BACKGROUND: Breast cancer is the second leading cause of cancer death among women in the United States. Although the incidence of breast cancer is 13% higher in white women, mortality in black women is 28% higher, due to histological and socioeconomic factors. Existing research regarding racial differences in compliance with breast cancer screening recommendations has found conflicting results. METHODS: Data on more than 4,500 women were taken from the 1992 National Health Interview Survey, a nationally representative, population-based sample survey. Logistic regression was used to estimate the relative odds of knowledge of breast self-exam (BSE) and mammograms, and compliance with BSE, clinical breast exams (CBE), and mammograms. RESULTS: Black women were less likely than white women to be aware of and use breast cancer screening tests. However, among women who were aware of screening tests, compliance was higher among black women. Women with low educational attainment, low cancer knowledge, and no usual source of care were less likely to be CBE or mammogram compliant. Socioeconomic differences were larger for the two clinical tests than for BSE. CONCLUSIONS: Programs should inform women about cancer screening tests and remove barriers that hinder women from receiving clinical screening exams.     

Health behaviors and cancer screening among Californians with a family history of cancer

PurposeThe purpose of this study was to compare health behaviors and cancer screening among Californians with and without a family history of cancer.MethodsWe analyzed data from the 2005 California Health Interview Survey to ascertain cancer screening test use and to estimate the prevalence of health behaviors that may reduce the risk of cancer. We used logistic regression to control for demographic factors and health-care access.ResultsWomen with a family history of breast or ovarian cancer were more likely to be up to date with mammography as compared with women with no family history of cancer (odds ratio = 1.69, 95% confidence interval (1.39, 2.04)); their health behaviors were similar to other women. Men and women with a family history of colorectal cancer were more likely to be up to date with colorectal cancer screening as compared with individuals with no family history of cancer (odds ratio = 2.77, 95% confidence interval (2.20, 3.49)) but were less likely to have a body mass index <25 kg/m² (odds ratio = 0.80, 95% confidence interval (0.67, 0.94)).ConclusionInnovative methods are needed to encourage those with a moderate-to-strong familial risk for breast cancer and colorectal cancer to increase their physical activity levels, strive to maintain a healthy weight, quit smoking, and reduce alcohol use.Genet Med 2013:15(3):212–221     

Routine screening mammography in women older than 74 years: a review of the available data

OBJECTIVE: The efficacy of population screening mammography for the age group of 50-74 years has been demonstrated. However, only limited data are available regarding women aged 75 and over, and recommendations for breast cancer screening in this age group vary in different countries. The aim of the current study is to review the evidence of the efficacy of breast cancer screening in women over the age of 74 years. METHODS: Studies published in English were retrieved by systematically searching MEDLINE (for papers published until August 2006), and by manually examining the references of the original articles and reviews retrieved. All studies that dealt with screening mammography over age 74 years were included. The studies were reviewed according to their outcomes and study design, focusing on breast cancer mortality and stage of breast cancer at diagnosis. RESULTS: Three studies focused on the relationship between breast cancer screening and mortality; in the 75-84 years age group, the risk of disease-specific mortality was approximately two-fold higher among women who did not perform screening mammography compared to women who did. Another four studies showed that women who underwent screening mammography had significantly smaller tumors and earlier disease stage at diagnosis. CONCLUSIONS: Regular mammography screening in older women may be associated with an earlier-stage disease and lower breast cancer mortality. These data support the use of screening mammography above age 75 years based on individual evaluations, rather than setting an upper age limit for breast cancer screening.     

Osteoporosis screening is unjustifiably low in older African-American women

BACKGROUND: More than one million Americans suffer osteoporotic fractures yearly, resulting in a marked increase in morbidity and mortality. Despite a decrease in bone mineral density with increasing age in all ethnic groups and both genders, preventative and therapeutics efforts in osteoporosis have been focused on caucasian and Asian women. This study assesses the osteoporosis screening practices and the frequency of low bone density in a primarily African-American population of older women. METHODS: Medical records of 252 women at risk for osteoporosis were reviewed for the diagnosis of osteoporosis, prior osteoporosis screening, prior breast cancer screening, and the use of calcium, vitamin D or estrogen. Subsequently, 128 women were assessed for risk factors for osteoporosis, and their bone mineral density was measured using a peripheral bone densitometer. RESULTS: Osteoporosis screening had been performed in 11.5% of the subjects. Of the women evaluated by peripheral bone densitometry, 44.5% of all women, 40.4% of African-American women, and 53.3% of caucasian women had abnormally low bone density measurements. The frequency of abnormal bone density increased with both increasing age and decreasing body mass index. CONCLUSIONS: Although few women in this population were previously screened for osteoporosis, low bone density occurred in African-American women at substantial rates. Increasing age and low body mass are important risk factors for low bone density in African-American women. Ethnicity should not be used as an exclusion criterion for screening for osteoporosis.     

Perceived risk for breast cancer and its relationship to mammography in Blacks, Hispanics, and Whites

A challenge for health behavior science is to develop theory and best practices that take cultural diversity into account. Using data from Black, Hispanic, and White respondents to the 2003 Health Information National Trends Survey, we examined racial/ethnic differences in: (1) breast cancer risk perceptions/worry; (2) the associations between perceived risk/worry and ever having received a mammogram; and (3) perceived risk/worry and having had at least 2 mammograms over a 4-year period (consecutive mammography). Compared to White race/ethnicity, Black race/ethnicity was associated with lower perceived absolute risk and comparative risk for developing cancer. For the sample as a whole, higher perceived risk (both absolute risk and comparative risk) and worry predicted greater odds of mammography use; however, this was not true for Hispanics. In stratified analyses, perceived risk and worry were not associated with mammography use for either Hispanics or Blacks whereas they were for Whites; however, this interaction effect was significant only for Hispanics vs. Whites. Results support the need for formative research to identify determinants of health behavior prior to cancer prevention message planning for diverse audiences in order to accommodate racial/ethnic differences not only in the level of perceived risk, but also the association between risk perception to behavior change in that community.     

African-American clinicians providing HIV care: the experience of the National HIV/AIDS Clinicians' Consultation Center

This analysis compares patient and provider characteristics of African-American clinicians and non-African-American clinicians who called the National HIV Telephone Consultation Service (Warmline). In 2004, a total of 2,077 consultations were provided for 1,020 clinicians, 70 (6.9%) of whom were African American. Compared to the non-African-American group, a higher percentage of African-American clinicians were nurses (20.0% vs. 8.8%, p=0.002). A significantly lower percentage of African-American physicians were infectious disease specialists (3.5% vs. 25.6%, p=0.007). African-American clinicians were more likely to work in a community clinic (48.5% vs. 34.1%, p=0.015). Both African-American and non-African American clinicians reported caring for a similar number of HIV-infected patients. Patient-provider racial concordance was common among African-American clinicians (76.4%), whereas non-African-American clinicians called about patients of more diverse racial and ethnic backgrounds. African-American clinicians who called Warmline exhibited differences in patient and provider characteristics when compared to all other clinicians. These findings contribute to the growing body of research on HIV providers in the United States.     

The obscuring object of race: Clinical breast exams and coping styles in ethnic subpopulations of women

Objectives. Differences in breast cancer screening rates have been linked to many factors including race, access to healthcare, and breast cancer knowledge and beliefs; less frequently studied has been the role of characteristic styles of coping. In this study, we examined ethnicity and the role of coping with a possible breast cancer diagnosis in the context of whether or not women obtained clinical breast examinations (CBE). Design. To measure coping, a stressor, in the form of a vignette asking participants to imagine they had just received a breast diagnosis upon a doctor's visit, was used. Method. Three hundred and eight women from seven ethnic subpopulations (and from three racial groups) in the USA were interviewed regarding frequency of breast screening, as well as how they would likely cope with a diagnosis of breast cancer. Results. CBE rates were similar across groups and were differentially predicted by the different coping styles. Analysing the results using typical racial categories (rather than distinct ethnic groupings) obscured these results. Furthermore, avoidance predicted CBE and mammogram rates differently, specifically, predicting mammogram rates differentially for each group, with no relation to CBE rates. Conclusion. Recognition of the roles of problem solving, social support, and avoidance in coping with a possible breast cancer diagnosis may guide the development and provision of interventions that are more sensitive to the characteristics of specific groups of women. Examinations of psychological variables in preventive health behaviours must begin to analyse diversity by paying attention to ethnic specificity, rather than race, as well as to the underlying nature of the screening task.     

Using cultural beliefs and patterns to improve mammography utilization among African-American women: the Witness Project

Breast cancer and early detection of the disease is a significant issue for all women. Moreover, the sociocultural implications in the differential mortality rates increased interest in possible barriers to screening practices. Recently, a number of studies have investigated African Americans' cultural beliefs associated with breast cancer. This study is based upon qualitative focus group data gathered from 1989 to 1991 and 1996. This article provides focus group data that informed a culturally competent community-based cancer education program for African-American women--the Witness Project. Analysis of the qualitative data along with the quantitative outcome data revealed a direct relationship between cultural beliefs and patterns with mammography utilization. The once perceived cultural barriers can actually be applied as a cultural intervention strategy to improve breast cancer screening initiatives designed specifically for African-American women.     

Measures of racial/ethnic health disparities in cancer mortality rates and the influence of socioeconomic status

OBJECTIVES: In the 1990s, U.S. cancer mortality rates declined due to reductions in tobacco use among men and beneficial cancer interventions, such as mammography and Pap smears. We examined the cancer rates by racial/ethnic group, socioeconomic status and time period to identify disparities underlying the overall mortality trend. METHODS: We examined racial/ethnic disparities by measuring excess cancer burden [rate ratio (RR) and ratio differences (RD)] and trends in their cancer rates for nine cancer sites. The trend (T) is calculated as a ratio of the average annual cancer mortality rate for 1995-2000 relative to the rate for 1990-1994 for three levels of poverty (counties with <10% living below the poverty level, 10% - <20% and > or =20%) for the major racial/ethnic populations. We also compared the trend for each racial/ethnic SES group to the trend for lowest SES white group (TD). RESULTS: Blacks have RR disparities relative to whites for each cancer site examined, except for female lung cancer, while the other minorities had RR disparities for cervical cancer (RR>1). There are increases in RR disparities from 1990-1994 to 1995-2000 (RD>0) for colorectal cancer, prostate cancer and breast cancer for each racial/ethnic minority. Whites and blacks had declining trends for every SES group (T<1) and positive high SES gradients (the highest SES group had the best trend and the lowest SES group had the worst trend) at each cancer site, except female lung cancer (T>1). In contrast, American Indians/Alaska natives, Hispanics and Asians/ Pacific Islanders had increasing trends for some of their cancer sites, and their trends did not have the SES gradients. CONCLUSIONS: Increases in racial/ethnic disparities (RD>0) for colorectal, breast and prostate cancer were largest in the lowest SES groups. At some cancer sites, the highest SES group for minorities had worse trend results than the trends for the lowest SES white group (TD>0).     

Breast and cervical cancer screening among low-income women: impact of a simple centralized HMO intervention.

In 1994, it was estimated that about 44,500 American women would die from breast cancer and 7000 women from cervical cancer. While early detection methods (screening mammography, breast examinations, and pap smears) have proven to be effective means of decreasing these cancers, they are underused by all groups. In particular, low-income women use them least, resulting in their lower survival and higher mortality rates than the rest of the population. This article quantifies the effect of a simple intervention undertaken by a health maintenance organization (HMO) serving the indigent to improve breast and cervical cancer screening rates. The HMO mailed personal letters and newsletter articles to women members > or = 40 years about the need for cancer prevention. Articles also were printed in the monthly HMO newsletters to providers about the benefits of using these early detection methods. A review of provider claims from 574 women showed that baseline utilization rates for screening mammograms and pap smears before the intervention in year 1 (1990) were 14% and 16.4%, respectively. After the intervention, in years 2 and 3, mammograms had increased to 41% and pap smears to 38% for both years, indicating a levelling off effect of the intervention by year 3. These data show that while a significant improvement in screening behaviors was achieved, the intervention impact was limited to only about one third of the sample on the long term. Further, data do not indicate whether behavioral change was initiated as the member or provider level. More research is needed to increase overall screening behavior among the indigent and their physicians. The results reported here provide a baseline against which more intensive interventions can be measured in this setting.