Breast self-examination in women in two primary care settings: an evaluation of the impact of insurance status

Breast cancer is one of the most common cancers diagnosed among women in the United States. Screening tools available for breast cancer detection include breast self-examination (BSE), clinical breast examination, and mammography. Various studies have indicated that women may inconsistently perform BSE. This investigation evaluated the potential impact of insurance status on BSE. Women with health insurance receiving primary healthcare at a health maintenance organization (HMO) and women without health insurance receiving primary healthcare at a free clinic completed anonymous questionnaires that obtained information about the frequency of BSE performance, whether instruction was given about performing BSE, age at learning BSE, and confidence in performing BSE. One hundred fifty-five (82%) of 200 questionnaires at the HMO and 92 (92%) of 100 questionnaires at the free clinic were completed. Thirty-five percent of women (32% at the HMO, 39% at the free clinic) reported performing BSE. There were no significant differences in the rate of monthly BSE, receiving instruction about performing BSE, age at learning BSE, or confidence in performing BSE in women at the HMO and free clinic. Insurance status did not affect BSE. However, further study is needed to evaluate factors that potentially influence performance of BSE and could encourage compliance with BSE recommendations.     

Three-Year Prospective Adherence to Three Breast Cancer Screening Modalities

Background.This study prospectively examined rates of adherence to mammography, clinical breast examination (CBE), and breast self-examination (BSE) in a cohort of women over 3 years to determine whether participation in BSE influenced participation in the other two screening modalities.Methods.Women ages 51 and older (n= 450) who attended a small group educational session to learn BSE and to hear about CBE and mammography guidelines were assessed annually by telephone for 3 consecutive years to determine their subsequent breast cancer screening behavior.Results.Annual CBE and mammography screening are highly positively associated. Regular performance of BSE has a modest positive association with both CBE and mammography adherence over time.Conclusions.Women who perform BSE regularly over time may be more likely to adhere to the other breast cancer screening guidelines.     

Content and context in health education: persuading women to perform breast self-examination

Content in a breast self-examination (BSE) education program was tested according to three motivational approaches with 923 women in Vermont women's clubs. The program was a slide-tape presentation using one of the three approaches and a BSE demonstration followed by a group discussion led by a nurse. A post-test of 374 women 6 months later showed a significant increase in monthly BSE performance from 40 to 71% regardless of motivational approach and an increase in breast cancer knowledge that was somewhat varied by approach, but was significant across all three approaches. Women who did not adopt monthly BSE after the program had an increase in knowledge similar to those who had adopted it. After the program, older women had somewhat less knowledge but performed BSE as often as younger women. Women with a family history of breast cancer were somewhat less likely to perform monthly BSE than other women, and women admitting to inhibitions about BSE were significantly less likely to adopt the practice than other women, yet their monthly BSE also increased as a result of the program. The significant positive change in BSE and knowledge across all groups appeared to be more a result of the supportive women's club context than of variations in program content. Thus, to achieve desired changes in prevention-oriented health behavior, it is suggested that health educators emphasize structuring a favorable context for the presentation of recommended actions such as BSE.     

A profile of Australian women practicing breast self-examination.

Breast self-examination (BSE) and medical breast examination practices were studied in a group of 1,103 women without diagnosed breast cancer, randomly sampled to conform in age and social status with breast cancer cases from the population of Brisbane, Australia between 1981 and 1985. Relationships between these practices and sociodemographic factors, breast cancer risk indicators, health related behaviors and source of knowledge about BSE were analyzed. Overall, 63% of women reported performing BSE. BSE was practiced frequently (monthly or more). BSE frequency was only weakly associated with breast cancer risk indicators. It was more strongly linked with age, the 20-44 year group being more likely to examine their breasts occasionally and the women 65 years and over being less likely to examine their breasts. Married women were the most likely to practice BSE frequently and widowed or single women most likely never to practice. Women who underwent cervical smear testing were more likely to perform BSE than those who did not have smear tests. Women who learned BSE from their doctors as opposed to other sources practiced BSE more frequently and were more likely to practice BSE exactly as taught.     

The importance of physician encouragement in breast cancer screening of older women.

METHODS. The relationship between physician encouragement and breast cancer screening is examined with a population-based survey of 630 women between the ages of 45 and 75. Although the women interviewed were selected on the basis of their noncompliance with mammography guidelines, nearly half had previously had at least one mammogram. RESULTS. Women reported having received more physician encouragement of breast self-examination than of mammography. Older women reported less encouragement of both screening modalities than younger women. Multivariate analyses revealed physician encouragement to be more strongly associated with screening mammography than with health status, health care utilization, attitudes, and sociodemographic characteristics: those who reported having received physician encouragement were nearly four times more likely to have ever had screening mammography. CONCLUSIONS. These and related findings are used to highlight the critical importance of physician behavior in the secondary prevention of breast cancer in older women and to identify types of patients whose needs for screening are most likely to be overlooked by physicians.     

Cancer preventive screening behavior among elderly women

Screening procedures and recommendations for early detection of cervical and breast cancer are reviewed with special reference to suggested guidelines for screening among the elderly. Data on preventive practices related to cancer detection were obtained from 675 women in Maryland by telephone interviews. The elderly (65 years of age and older) reported fewer detection tests of any type; specifically, 23% report never having had a Pap test and an additional 28% have not had one within 5 years, compared with women under the age of 65, where 98% report having had a Pap test and 79% have had one within the past two years. Elderly women were also less likely than younger women to report receiving routine breast examinations by their physicians, to perform BSE, or to have been taught BSE by a health professional. Type of provider utilized, having a personal physician, and going to a gynecologist account for a significant proportion of the variance in screening practices.     

Knowledge and beliefs of breast cancer among elderly women in Puerto Rico

This is the first national study of breast-cancer knowledge, beliefs, and early detection practices among elderly women (65+) in Puerto Rico. Cancer breast examination (CBE) was the most common early detection practice, followed by the mammogram, with breast self exam (BSE) a distant third. The primary reasons most often cited for never having a mammogram related to both personal and external factors: not having symptoms, negligence or forgetfulness, and not having a physician's referral. No statistically significant difference (p < 0.05) was found between knowledge and early detection practices. Conversely, beliefs had an impact on preventive behavior. Those who had less misconceptions were most likely to have had a CBE or a mammogram. Bivariate analysis demonstrated that age was associated with performing a BSE once or twice monthly, ever having a mammogram, and having a mammogram in the past two years. A higher socioeconomic status was associated to performing BSE and ever having had a mammogram. Education correlated positively to ever having a mammogram or having a mammogram in the two years prior to the interview. Factors that explained compliance with a mammogram in the last two years included referral from a physician, owning a car, and receiving information after menopause on breast cancer from a health care provider. A gynecological visit increased the probability of having had a mammogram during the last two years. Logistic regression determined that a referral from a physician was the most important factor for mammogram compliance when a combination of variables were considered.     

JAPANESE AMERICAN WOMEN: BEHAVIORS AND ATTITUDES TOWARD BREAST CANCER EDUCATION AND SCREENING

Moores University of California, San Diego, Cancer Center's Asian Grocery Store-Based Cancer Education Program trained bilingual, bicultural student health educators to provide breast cancer information to Japanese American women. A subset consented to help evaluate the program by completing baseline and follow-up surveys. Study participants reported high adherence to mammography screening guidelines, but lower than optimal adherence to clinical breast examination (CBE) and monthly breast self-examination (BSE) guidelines. While less than half of the women felt they had enough knowledge about breast cancer, nearly all indicated that they would be willing to share any knowledge they gained with loved ones and that their loved ones would be receptive to their information. A limitation of the study is its small sample.     

Breast Self-Examination and Mammography Among University Staff and Faculty

Women faculty and staff (N = 201) answered a series of questions about breast self-examination (BSE) and mammography. Although all subjects indicated familiarity with BSE, and two-thirds of them knew it should be practiced monthly, only 31% actually did so. Women who learned BSE from physicians or other health professionals reported more frequent BSE than those who learned from other sources. About one-third of respondents indicated that they would like to learn more about BSE; women health professionals were the most preferred learning source. Respondents indicated that they fail to do BSE because they do not remember to do it and reported that reminders would increase their likelihood of compliance. Of subjects age 40 and older, about four-fifths had had a mammogram. Those who had not had one reported that the cost of mammography was a significant barrier for them. These results are discussed and recommendations for practice and for future research are made.     

Breast self-examination and mammography among university staff and faculty

Women faculty and staff (N = 201) answered a series of questions about breast self-examination (BSE) and mammography. Although all subjects indicated familiarity with BSE, and two-thirds of them knew it should be practiced monthly, only 31% actually did so. Women who learned BSE from physicians or other health professionals reported more frequent BSE than those who learned from other sources. About one-third of respondents indicated that they would like to learn more about BSE; women health professionals were the most preferred learning source. Respondents indicated that they fail to do BSE because they do not remember to do it and reported that reminders would increase their likelihood of compliance. Of subjects age 40 and older, about four-fifths had had a mammogram. Those who had not had one reported that the cost of mammography was a significant barrier for them. These results are discussed and recommendations for practice and for future research are made.     

The breast self-examination practices of high risk women: implications for patient education

The breast self-examination (BSE) behavior of 142 women referred to a large cancer center with malignant or benign breast disease was investigated. The women were interviewed about their BSE practices and variables that may have influenced their BSE behavior. Those reporting prior BSE practice were asked to demonstrate their breast examination to a trained nurse, who rated their performance against a set of standard criteria. Although it might be assumed that these women have had more opportunity to become educated about BSE, results showed the ratings of the women's performances were uniformly poor. Less than half reported having formal instruction by a medical professional. This is of particular consequence considering that those women taught by a doctor or nurse performed significantly more BSE steps than did those taught in other ways. Women who were encouraged to do BSE by friends or relatives also performed significantly more steps. Based on the study findings, specific recommendations are made, which can be applied to the improvement of BSE educational programs.     

Japanese American women: behaviors and attitudes toward breast cancer education and screening

Moores University of California, San Diego, Cancer Center's Asian Grocery Store-Based Cancer Education Program trained bilingual, bicultural student health educators to provide breast cancer information to Japanese American women. A subset consented to help evaluate the program by completing baseline and follow-up surveys. Study participants reported high adherence to mammography screening guidelines, but lower than optimal adherence to clinical breast examination (CBE) and monthly breast self-examination (BSE) guidelines. While less than half of the women felt they had enough knowledge about breast cancer, nearly all indicated that they would be willing to share any knowledge they gained with loved ones and that their loved ones would be receptive to their information. A limitation of the study is its small sample.     

Beliefs, recommendations and intentions are important explanatory factors of mammography screening behavior among Muslim Arab women in Israel

The rates of mammography screening by Muslim Arab women in Israel are lower compared with the general population. The current study aimed to examine factors related to screening mammography behavior among Arab women by employing components from the Health Belief Model and the Theory of Reasoned Action. Sociodemographic factors, knowledge, beliefs about breast cancer and mammography, self-efficacy, cues to action, norms and intention to perform mammography were examined as explanatory variables for mammography use. Face-to-face interviews with a random sample of 510 Muslim Arab women, aged 50-69 years, were conducted. The women had limited knowledge about breast cancer and mammography, and the rate of mammography screening behavior (at the recommended interval) was only 20%. The women who were significantly more likely to undergo mammography were those who received a recommendation from a health professional or from family/friends, perceived themselves as vulnerable to getting breast cancer, believed in the efficacy of the test, perceived it as not painful, were younger, were more educated and were only of borderline significance among those who expressed an intention to undergo mammography. The findings indicate that professional recommendation and beliefs sets are essential factors for developing effective mammography screening interventions in this unique population.     

Breast self‐exams: Are health professionals doing their part?

Although breast cancer cannot be prevented at this time, early detection is the single most important factor in recovery. Early detection is largely dependent on discovery of the breast cancer by women through self breast examinations. This study indicates that health professionals either neglect to teach breast self‐exam (BSE) or fail to document teaching it in the patient's record. One hundred eight records of hospitalized clients who had identified risk for breast cancer were reviewed for documentation of teaching of BSE by the health professional. Even though all clients had multiple risk factors, no documentation of teaching BSE was present. These findings indicate a need for some structure in the health care system to assure that health professionals are fulfilling their obligations to teach BSE and to document it in the patient's records. Including it as part of nursing history, a standard nursing care plan, or as a part of audit criteria would assure more consistency in the teaching of BSE.     

Interventions to enhance breast self-examination practice: a review

Breast self-examination (BSE) is an important component of any program for the early detection of breast cancer. Compared to clinical breast examination and mammography, BSE is relatively safe, low cost, offers monthly assessment, and does not require overcoming barriers associated with access to the medical care system (unless an abnormality is discovered). Over the past decade, considerable research has been directed at encouraging women to perform BSE. This paper reviews 33 intervention studies that vary in the type and intensity of strategies employed, and in the BSE behaviors assessed. In general, more-intensive interventions result in better outcomes. With regard to BSE frequency, the provision of information seems sufficient to obtain BSE initiation but not necessarily adequate to maintain practice or to establish proficiency. The addition of skills training and corrective feedback leads to significantly improved BSE proficiency. Prompts and reminder aids seem also to contribute to long-term frequency. The search should continue for motivational mechanisms regarding BSE frequency, and for creative approaches to teaching and maintaining proficiency.     

DIFFERENCES IN MEXICAN-BORN AND U.S.-BORN WOMEN OF MEXICAN DESCENT REGARDING FACTORS RELATED TO BREAST CANCER SCREENING BEHAVIORS

A survey on factors related to breast cancer screening was completed by 179 U.S.-resident women of Mexican descent who were either Mexican born (n = 76) or U.S. born (n = 103). The U.S.born women had significantly higher levels of income, education, and acculturation and were significantly more likely to be covered by health insurance and to receive health professional interventions such as breast self-exam (BSE) instruction. Accordingly, these U.S.-born women engaged in BSE more frequently and were more motivated to engage in other health behaviors. In comparison, the Mexican-born women reported significantly greater beliefs that breast cancer is a serious illness and that they were relatively more susceptible to this illness. For the Mexican-born women health locus of control was significantly more geared toward powerful others and chance factors. Factor differences suggest that Mexican-born women face more breast cancer screening barriers than the U.S.born women of Mexican descent.     

Differences in Mexican-born and U.S.-born women of Mexican descent regarding factors related to breast cancer screening behaviors

A survey on factors related to breast cancer screening was completed by 179 U.S.-resident women of Mexican descent who were either Mexican born (n = 76) or U.S. born (n = 103). The U.S.-born women had significantly higher levels of income, education. and acculturation and were significantly more likely to be covered by health insurance and to receive health professional interventions such as breast self-exam (BSE) instruction. Accordingly, these U.S.-born women engaged in BSE more frequently and were more motivated to engage in other health behaviors. In comparison, the Mexican-born women reported significantly greater beliefs that breast cancer is a serious illness and that they were relatively more susceptible to this illness. For the Mexican-born women health locus of control was significantly more geared toward powerful others and chance factors. Factor differences suggest that Mexican-born women face more breast cancer screening barriers than the U.S.-born women of Mexican descent.     

Longitudinal Patterns of Breast Cancer Screening: Mammography,Clinical, and Breast Self-Examinations in a Rural and Urban Setting

BackgroundWe identified breast screening patterns over time and patterns among women residing in rural and urban areas by sociodemographic factors.MethodsThis study employs a longitudinal design over 9 years from 2001 on 11,200 women aged 50 to 55 from the Australian Longitudinal Study on Women's Health. Area of residence was defined in accordance with the accessibility remoteness index of Australia Plus. Breast screening measures included mammography utilization, clinical breast examinations (CBE), and breast self-examinations (BSE).FindingsMost women had a mammogram in the past 2 years in combination with CBE or BSE or both. Despite poorer access to mammography services, women residing in rural areas had similar mammography screening rates to their urban counterparts. Women residing in rural areas were less likely to have CBEs, but more likely to conduct BSEs. The breast screening behaviors were generally consistent over time.ConclusionsThe poorer breast cancer survival among rural women is unlikely to be explained by differences in mammography service use. A substantial proportion of the population may be experiencing overscreening by conducting all three types of breast screening.     

Mammograms and healthcare access among US Hispanic and non-Hispanic women 40 years and older

Compared to non-Hispanic women, Hispanic women have disproportional mortality rates due to breast cancer. Mammographic screening detects breast cancer in its early stages and reduces mortality. We examined data obtained from the 2002 Behavioral Risk Factor Surveillance System questionnare using logistic regression analyses to study the relationships between demographic and healthcare factors and mammography use among Hispanic and non-Hispanic White women 40 years and older. Overall, the odds of ever having had a mammogram were similar among Hispanic and non-Hispanic White women (odds ratio = 1.2; 95% confidence interval = 0.9, 1.6), when adjusted for age, employment status, and other demographic variables. Having a personal physician and the type of healthcare facility typically used were associated with mammography use, regardless of Hispanic ethnicity. Although associations between mammography use and demographic factors were similar between ethnic groups, larger proportions of Hispanics had demographic characteristics that were negatively associated with mammography use. Establishing policies and mechanisms to provide all women with regular access to a personal physician or healthcare professional for their preventive and nonemergency healthcare needs may improve mammography use among both Hispanic and non-Hispanic White women. Similarly, reaching out to women who are uninsured and who use facilities other than physicians' offices for their healthcare needs may increase the use of mammography among both ethnic groups.     

How Old are African American Women When they Receive their First Mammogram? Results from a Church-Based Study

African American women in the U.S. have the highest breast cancer mortality though not the highest breast cancer incidence. This high mortality rate has been attributed in part to discrepancies in screening between African American and White women. Although this gap in mammography utilization is closing, little is known about what has been and is driving the screening practices of African American women, in particular age at first mammogram. This study examined the rates of breast cancer screening in an African American community sample from eight churches in greater Baltimore, Maryland and investigated the association between various factors and age at first mammogram. Participants were 213 women ages 22-89 years. About 77% of women had ever had a mammogram. Over 40% had their first mammogram before age 40. Women who first screened before age 40 had greater odds than women who had never screened of being knowledgeable about screening guidelines, of having received a physician recommendation to screen, and of having three or more female relatives who had been screened. Women who first screened at or after age 40 were more likely to have stronger religious beliefs of health than women who never had screened. These findings suggest the importance of reinforcing factors in screening behavior for African American women and have implications for physician training and public health education about breast cancer screening. A better understanding of African American women's mammography practice including early screening is needed to reduce this population's disproportionate breast cancer mortality risk.