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Fahim C, Wiebe N, Nisenbaum R, Hamid JS, Ewusie JE, Tonelli M, Brauer P, Shaw E, Bell N, Stacey D, Holmes NM, Straus SE. Changes in mammography screening in Ontario and Alberta following national guideline dissemination: an interrupted time series analysis. F1000Res 2022; 10:1044. [PMID: 36544564 PMCID: PMC9745205 DOI: 10.12688/f1000research.55004.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Background: In November 2011, the Canadian Task Force on Preventive Health Care released guidelines for screening women at average breast cancer risk. Weak recommendations (framed using GRADE methodology) were made for screening women aged 50 to 74 years every two to three years, and for not screening women aged 40 to 49 years. Methods: We conducted an interrupted time series analysis using administrative data to examine bilateral mammography use before and after a release of a national breast screening guideline. Women aged 40 to 74 years living in Ontario or Alberta from 30th November 2008 to 30th November 2014 were included. Strata included age, region of residence, neighbourhood income quintile, immigration status, and education level. Results: In both provinces, mammography use rates were lower in the post-intervention period (527 vs. 556 and 428 vs. 465/1000 women in Ontario and Alberta, respectively). In Ontario, mammography trends decreased following guideline release to align with recommendations for women aged 40 to 74 (decrease of 2.21/1000 women, SE 0.26/1000, p<0.0001). In Alberta, mammography trends decreased for women aged 40 to 49 years (3/1000 women, SE 0.32, p<0.001) and 50 to 69 (2.9/1000 women, SE 0.79, p<0.001), but did not change for women aged 70 to 74 (0.7/1000 women, SE 1.23, p=0.553). In both provinces, trends in mammography use rates were sustained for up to three years after guideline release. Conclusions: We observed a decrease in screening for women aged 40-49. Additional research to explore whether shared decision making was used to optimize guideline-concordant screening for women aged 50-74 is needed.
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Affiliation(s)
- Christine Fahim
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, M5B 1T8, Canada,
| | - Natasha Wiebe
- Department of Medicine, University of Alberta, Edmonton, Alberta, T6G 2G3, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Toronto, Ontario, M5B 1T8, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, M5T 3M7, Canada
| | - Jemila S. Hamid
- Department of Mathematics and Statistics, University of Ottawa, Ottawa, Ontario, K1N 6N5, Canada
| | - Joycelyne E. Ewusie
- Biostatistics Unit, Father Sean O’Sullivan Research Centre, Hamilton, Ontario, L8N 4A6, Canada
| | - Marcello Tonelli
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 1N4, Canada
| | - Paula Brauer
- Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, Ontario, N1G 2W1, Canada
| | - Elizabeth Shaw
- Department of Family Medicine, McMaster University, Hamilton, Ontario, L8S 4K1, Canada
| | - Neil Bell
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, T6G 2R3, Canada
| | - Dawn Stacey
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, K1N 6N5, Canada,Ottawa Hospital Research Institute, Ottawa, Ontario, K1H 8L6, Canada
| | | | - Sharon E. Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, M5B 1T8, Canada,Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada
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A first look at breast cancer screening in over 1000 community health centers in the United States. Prev Med 2022; 161:107115. [PMID: 35724699 DOI: 10.1016/j.ypmed.2022.107115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/03/2022] [Accepted: 06/12/2022] [Indexed: 11/24/2022]
Abstract
Community Health Centers (CHCs) primarily serve low-income and vulnerable patients. Breast cancer screening recently became a quality-of-care metric in the annual Uniform Data System (UDS) report, and this study examines the first year of breast cancer screening data among 1375 CHCs in the United States. Clinics with available screening data (n = 1070) were categorized based on US region, state expansion of Medicaid to low-income adults under the Affordable Care Act, ranked terciles of race/ethnic composition (non-Hispanic Black, non-Hispanic Asian, and Hispanic/Latino patients), and proportion uninsured. Less than half of women eligible for breast cancer screening, 43.6% (95% CI:42.6%, 44.6%), were up-to-date. CHCs with medium or high proportions of Black (PR: 0.91, 0.86) and uninsured (PR: 0.90, 0.86) patients had between 9%-14% lower breast cancer screening rates than CHCs with low proportions of these populations. CHCs in Medicaid expansion states and in Northeastern states had significantly higher screening rates than non-expansion states and the Midwest, South, and Western states. In conclusion, our findings show that only half of women eligible who received care within CHCs were screened for breast cancer. Disparities in breast cancer screening rates are seen for clinics with high proportions of Black and uninsured patients, along with clinics outside the northeast and clinics in non-Medicaid expansion states. Targeted solutions centered around reducing cost, improving quality, and reducing structural disparities are needed to address low rates of breast cancer screening in low-income women who visited CHCs and already experience healthcare inequities.
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Durham DD, Robinson WR, Lee SS, Wheeler SB, Reeder-Hayes KE, Bowling JM, Olshan AF, Henderson LM. Insurance-Based Differences in Time to Diagnostic Follow-up after Positive Screening Mammography. Cancer Epidemiol Biomarkers Prev 2017; 25:1474-1482. [PMID: 27803069 DOI: 10.1158/1055-9965.epi-16-0148] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 08/10/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Insurance may lengthen or inhibit time to follow-up after positive screening mammography. We assessed the association between insurance status and time to initial diagnostic follow-up after a positive screening mammogram. METHODS Using 1995-2010 data from a North Carolina population-based registry of breast imaging and cancer outcomes, we identified women with a positive screening mammogram. We compared receipt of follow-up within 60 days of screening using logistic regression and evaluated time to follow-up initiation using Cox proportional hazards regression. RESULTS Among 43,026 women included in the study, 73% were <65 years and 27% were 65+ years. Median time until initial diagnostic follow-up was similar by age group and insurance status. In the adjusted model for women <65, uninsured women experienced a longer time to initiation of diagnostic follow-up [HR, 0.47; 95% confidence interval (CI), 0.25-0.89] versus women with private insurance. There were increased odds of these uninsured women not meeting the Centers for Disease Control and Prevention guideline for follow-up within 60 days (OR, 1.59; 95% CI, 1.31-1.94). Among women ages 65+, women with private insurance experienced a faster time to follow-up (adjusted HR, 2.09; 95% CI, 1.27-3.44) than women with Medicare and private insurance. Approximately 10% of women had no follow-up by 365 days. CONCLUSIONS We found differences in time to initial diagnostic follow-up after a positive screening mammogram by insurance status and age group. Uninsured women younger than 65 years at a positive screening event had delayed follow-up. IMPACT Replication of these findings and examination of their clinical significance warrant additional investigation. Cancer Epidemiol Biomarkers Prev; 25(11); 1474-82. ©2016 AACR.
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Affiliation(s)
- Danielle D Durham
- Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina
| | - Whitney R Robinson
- Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina
| | - Sheila S Lee
- Department of Radiology, UNC School of Medicine, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina.,Department of Health Policy and Management, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina.,Division of Hematology/Oncology, UNC School of Medicine, Chapel Hill, North Carolina
| | - J Michael Bowling
- Department of Health Behavior, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Andrew F Olshan
- Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina
| | - Louise M Henderson
- Department of Epidemiology, UNC Gillings School of Public Health, The University of North Carolina at Chapel Hill, North Carolina. .,Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, North Carolina.,Department of Radiology, UNC School of Medicine, Chapel Hill, North Carolina
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Inrig SJ, Higashi RT, Tiro JA, Argenbright KE, Lee SJC. Assessing local capacity to expand rural breast cancer screening and patient navigation: An iterative mixed-method tool. EVALUATION AND PROGRAM PLANNING 2017; 61:113-124. [PMID: 28011433 PMCID: PMC5323072 DOI: 10.1016/j.evalprogplan.2016.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 11/08/2016] [Accepted: 11/15/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Despite federal funding for breast cancer screening, fragmented infrastructure and limited organizational capacity hinder access to the full continuum of breast cancer screening and clinical follow-up procedures among rural-residing women. We proposed a regional hub-and-spoke model, partnering with local providers to expand access across North Texas. We describe development and application of an iterative, mixed-method tool to assess county capacity to conduct community outreach and/or patient navigation in a partnership model. METHODS Our tool combined publicly-available quantitative data with qualitative assessments during site visits and semi-structured interviews. RESULTS Application of our tool resulted in shifts in capacity designation in 10 of 17 county partners: 8 implemented local outreach with hub navigation; 9 relied on the hub for both outreach and navigation. Key factors influencing capacity: (1) formal linkages between partner organizations; (2) inter-organizational relationships; (3) existing clinical service protocols; (4) underserved populations. Qualitative data elucidate how our tool captured these capacity changes. CONCLUSIONS Our capacity assessment tool enabled the hub to establish partnerships with county organizations by tailoring support to local capacity and needs. Absent a vertically integrated provider network for preventive services in these rural counties, our tool facilitated a virtually integrated regional network to extend access to breast cancer screening to underserved women.
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Affiliation(s)
- Stephen J Inrig
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX75390-9066, USA.
| | - Robin T Higashi
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX75390-9066, USA.
| | - Jasmin A Tiro
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX75390-9066, USA; Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Road, Dallas, TX 75390, USA.
| | - Keith E Argenbright
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX75390-9066, USA; Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Road, Dallas, TX 75390, USA; Moncrief Cancer Institute, 400 W. Magnolia Ave, Fort Worth, TX 76104, USA.
| | - Simon J Craddock Lee
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX75390-9066, USA; Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Road, Dallas, TX 75390, USA.
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Davis TC, Arnold CL, Wolf MS, Bennett CL, Liu D, Rademaker A. Joint breast and colorectal cancer screenings in medically underserved women. JOURNAL OF COMMUNITY AND SUPPORTIVE ONCOLOGY 2016; 13:47-54. [PMID: 26918252 DOI: 10.12788/jcso.0108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Breast and colon cancer screening in rural community clinics is underused. OBJECTIVE To evaluate the effectiveness and cost-effectiveness of alternative interventions designed to promote simultaneous screening for breast and colon cancer in community clinics. METHODS A 3-arm, quasi-experimental evaluation was conducted during May 2008-August 2011 in 8 federally qualified health clinics in predominately rural Louisiana. Baseline screening rates reported by the clinics was <10% for breast cancer (using mammography) and 1%-2% for colon cancer (using the fecal occult blood test [FOBT]). 744 women aged 50 years or older who were eligible for routine mammography and an FOBT were recruited. The combined screening efforts included: enhanced care; health literacy-informed education (education alone), or health literacy-informed education with nurse support (nurse support). RESULTS Postintervention screening rates for completing both tests were 28.1% with enhanced care, 23.7% with education alone, and 38.7% with nurse support. After adjusting for age, race, and literacy, patients who received nurse support were 2.21 times more likely to complete both screenings than were those who received the education alone (95% confidence interval [CI], 1.12-4.38; P = .023). The incremental cost per additional woman completing both screenings was $3,987 for education with nurse support over education alone, and $5,987 over enhanced care. LIMITATIONS There were differences between the 3 arms in sociodemographic characteristics, literacy, and previous screening history. Not all variables that were significantly different between arms were adjusted for, therefore adjustments for key variables (age, race, literacy) were made in statistical analyses. Other limitations related generalizability of results. CONCLUSIONS Although joint breast and colon cancer screening rates were increased substantially over existing baseline rates in all 3 arms, the completion rate for both tests was modest. Nurse support and telephone follow-up were most effective. However, it is not likely to be cost effective or affordable in clinics with limited resources.
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Affiliation(s)
- Terry C Davis
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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Variation in Screening Abnormality Rates and Follow-Up of Breast, Cervical and Colorectal Cancer Screening within the PROSPR Consortium. J Gen Intern Med 2016; 31:372-9. [PMID: 26658934 PMCID: PMC4803707 DOI: 10.1007/s11606-015-3552-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Primary care providers and health systems have prominent roles in guiding effective cancer screening. OBJECTIVE To characterize variation in screening abnormality rates and timely initial follow-up for common cancer screening tests. DESIGN Population-based cohort undergoing screening in 2011, 2012, or 2013 at seven research centers comprising the National Cancer Institute-sponsored Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. PARTICIPANTS Adults undergoing mammography with or without digital breast tomosynthesis (n = 97,683 ages 40-75 years), fecal occult blood or fecal immunochemical tests (n = 759,553 ages 50-75 years), or Papanicolaou with or without human papillomavirus tests (n = 167,330 ages 21-65 years). INTERVENTION Breast, colorectal, or cervical cancer screening. MAIN MEASURES Abnormality rates per 1000 screens; percentage with timely initial follow-up (within 90 days, except 9-month window for BI-RADS 3). Primary care clinic-level variation in percentage with screening abnormality and percentage with timely initial follow-up. KEY RESULTS There were 10,248/97,683 (104.9 per 1000) abnormal breast cancer screens, 35,847/759,553 (47.2 per 1000) FOBT/FIT-positive colorectal cancer screens, and 13,266/167,330 (79.3 per 1000) abnormal cervical cancer screens. The percentage with timely follow-up was 93.2 to 96.7 % for breast centers, 46.8 to 68.7 % for colorectal centers, and 46.6 % for the cervical cancer screening center (low-grade squamous intraepithelial lesions or higher). The primary care clinic variation (25th to 75th percentile) was smaller for the percentage with an abnormal screen (breast, 8.5-10.3 %; colorectal, 3.0-4.8 %; cervical, 6.3-9.9 %) than for the percentage with follow-up within 90 days (breast, 90.2-95.8 %; colorectal, 43.4-52.0 %; cervical, 29.6-61.4 %). CONCLUSIONS Variation in both the rate of screening abnormalities and their initial follow-up was evident across organ sites and primary care clinics. This highlights an opportunity for improving the delivery of cancer screening through focused study of patient, provider, clinic, and health system characteristics associated with timely follow-up of screening abnormalities.
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van Ravesteyn NT, van Lier L, Schechter CB, Ekwueme DU, Royalty J, Miller JW, Near AM, Cronin KA, Heijnsdijk EAM, Mandelblatt JS, de Koning HJ. Transition from film to digital mammography: impact for breast cancer screening through the national breast and cervical cancer early detection program. Am J Prev Med 2015; 48:535-42. [PMID: 25891052 PMCID: PMC4405659 DOI: 10.1016/j.amepre.2014.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 10/28/2014] [Accepted: 11/17/2014] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides mammograms and diagnostic services for low-income, uninsured women aged 40-64 years. Mammography facilities within the NBCCEDP gradually shifted from plain-film to digital mammography. The purpose of this study is to assess the impact of replacing film with digital mammography on health effects (deaths averted, life-years gained [LYG]); costs (for screening and diagnostics); and number of women reached. METHODS NBCCEDP 2010 data and data representative of the program's target population were used in two established microsimulation models. Models simulated observed screening behavior including different screening intervals (annual, biennial, irregular) and starting ages (40, 50 years) for white, black, and Hispanic women. Model runs were performed in 2012. RESULTS The models predicted 8.0-8.3 LYG per 1,000 film screens for black women, 5.9-7.5 for white women, and 4.0-4.5 for Hispanic women. For all race/ethnicity groups, digital mammography had more LYG than film mammography (2%-4%), but had higher costs (34%-35%). Assuming a fixed budget, 25%-26% fewer women could be served, resulting in 22%-24% fewer LYG if all mammograms were converted to digital. The loss in LYG could be reversed to an 8%-13% increase by only including biennial screening. CONCLUSIONS Digital could result in slightly more LYG than film mammography. However, with a fixed budget, fewer women may be served with fewer LYG. Changes in the program, such as only including biennial screening, will increase LYG/screen and could offset the potential decrease in LYG when shifting to digital mammography.
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Affiliation(s)
| | - Lisanne van Lier
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam; Department of General Practice and Elderly Care Medicine, VU University Medical Center, Amsterdam, the Netherlands
| | - Clyde B Schechter
- Departments of Family & Social Medicine and Epidemiology & Population Health, Albert Einstein School of Medicine, Bronx, New York
| | | | | | | | - Aimee M Near
- Department of Oncology, Georgetown University, Lombardi Comprehensive Cancer Center, Washington, District of Columbia
| | - Kathleen A Cronin
- Statistical Research and Application Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, NIH, Bethesda, Maryland
| | | | - Jeanne S Mandelblatt
- Department of Oncology, Georgetown University, Lombardi Comprehensive Cancer Center, Washington, District of Columbia
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam
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White A, Miller J, Royalty J, Ryerson AB, Benard V, Helsel W, Kammerer W. Clinical outcomes of mammography in the National Breast and Cervical Cancer Early Detection Program, 2009-2012. Cancer Causes Control 2015; 26:723-32. [PMID: 25809209 DOI: 10.1007/s10552-015-0567-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 03/18/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) enrolls asymptomatic women for cancer screening and symptomatic women for diagnostic services. This study describes the results of mammograms provided by the NBCCEDP, by examination indication (screening or diagnostic), and by age group. METHODS For the first NBCCEDP-funded mammogram received during 2009-2012, we calculated age-specific percentages of abnormal findings, rates of follow-up testing, and invasive and in situ breast cancer diagnoses per 1,000 mammograms. Logistic regression was used to estimate the odds for each of these outcomes by examination indication. RESULTS The NBCCEDP provided 941,649 screening, 175,310 diagnostic, and 30,434 unknown indication mammograms to 1,147,393 women. The percentage with abnormal mammograms was higher for diagnostic mammograms (40.1 %) than for screening mammograms (15.5 %). Compared with women aged 40-49 years, fewer women aged 50-64 years had abnormal results for screening (13.7 vs. 19.7 %) and diagnostic mammograms (37.7 vs. 42.7 %). Follow-up rates per 1,000 mammograms were lower among women aged 50-64 compared to those aged 40-49 (screening: 143.9 vs. 207.5; diagnostic: 645.3 vs. 760.9); biopsy rates exhibited a similar pattern (screening: 24.1 vs. 32.9; diagnostic: 167.7 vs. 169.7). For screening mammograms, older women had more cancers detected than younger women (invasive: 3.6 vs. 2.2; in situ: 2.3 vs. 2.0). Similarly, for diagnostic mammograms, cancer detection was higher for older women (invasive: 67.8 vs. 36.6; in situ: 17.4 vs. 11.1). CONCLUSIONS Abnormal mammograms and diagnostic follow-up procedures were less frequent in women aged 50-64 years compared to women aged 40-49 years, while breast cancer detection was higher, regardless of indication for the mammogram. Some of these differences between age groups were greater for screening mammograms than for diagnostic mammograms. Cancer detection rates were higher for diagnostic mammograms compared with screening mammograms. These findings support the NBCCEDP's priority of serving women aged 50-64 years and providing both screening and diagnostic mammograms.
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Affiliation(s)
- Arica White
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway Northeast, Mailstop F76, Atlanta, GA, 30341-3717, USA,
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Eheman CR, Leadbetter S, Benard VB, Blythe Ryerson A, Royalty JE, Blackman D, Pollack LA, Adams PW, Babcock F. National Breast and Cervical Cancer Early Detection Program data validation project. Cancer 2014; 120 Suppl 16:2597-603. [PMID: 25099903 DOI: 10.1002/cncr.28825] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 04/15/2014] [Accepted: 04/16/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND The objectives of this study were to evaluate the quality of national data generated by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP); to assess variables collected through the program that are appropriate to use for program management, evaluation, and data analysis; and to identify potential data-quality issues. METHODS Information was abstracted randomly from 5603 medical records selected from 6 NBCCEDP-funded state programs, and 76 categorical variables and 11 text-based breast and cervical cancer screening and diagnostic variables were collected. Concordance was estimated between abstracted data and the data collected by the NBCCEDP. Overall and outcome-specific concordance was calculated for each of the key variables. Four screening performance measures also were estimated by comparing the program data with the abstracted data. RESULTS Basic measures of program outcomes, such as the percentage of women with cancer or with abnormal screening tests, had a high concordance rate. Variables with poor or inconsistent concordance included reported breast symptoms, receipt of fine-needle aspiration, and receipt of colposcopy with biopsy. CONCLUSIONS The overall conclusion from this comprehensive validation project of the NBCCEDP is that, with few exceptions, the data collected from individual program sites and reported to the CDC are valid and consistent with sociodemographic and clinical data within medical records.
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Affiliation(s)
- Christie R Eheman
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Rajan SS, Begley CE, Kim B. Breast cancer stage at diagnosis among medically underserved women screened through the Texas Breast and Cervical Cancer Services. Popul Health Manag 2014; 17:202-10. [PMID: 24921895 DOI: 10.1089/pop.2013.0079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The Texas Breast and Cervical Cancer Services (BCCS) program was established to address the socioeconomic disparities in stage at diagnosis and outcomes among breast cancer patients. This study examines the impact of Texas BCCS on stage at diagnosis among low socioeconomic status (SES) breast cancer patients. This is a retrospective analysis of women aged 40-64 years who were screened and diagnosed with breast cancer through the Texas BCCS program (participants) as compared with similar women living in low-SES census tracts and diagnosed outside the program (comparison group) during 1995-2008. Incident cases among the participants were compared with the comparison group as well. Stage at diagnosis was also analyzed separately for the years 1995-2002 and 2003-2008 in order to estimate the effect of BCCS-related Medicaid expansion in 2002. Over the study period of 1995-2008, BCCS participants had a 1.23 (P value<0.0001) times higher odds, and BCCS incident cases had 40% (P value<0.0001) lower odds of advanced stage at diagnosis as compared with the comparison group. A statistically significant difference in stage at diagnosis between the participants and the comparison group only existed for the 2003-2008 (post-Medicaid) period (odds ratio: 1.39, P value<0.0001). Texas BCCS program acts as a source of diagnosis and treatment access to many suspected cancer cases, especially since the 2002 Medicaid expansion, leading to more advanced stage at diagnosis among the BCCS cases as compared with other low-SES cases. Significant expansion of the program to serve a higher proportion of the eligible population is needed to achieve its goals as a screening program.
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Affiliation(s)
- Suja S Rajan
- 1 Division of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center at Houston , Houston, Texas
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11
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Davis TC, Rademaker A, Bennett CL, Wolf MS, Carias E, Reynolds C, Liu D, Arnold CL. Improving mammography screening among the medically underserved. J Gen Intern Med 2014; 29:628-35. [PMID: 24366401 PMCID: PMC3965756 DOI: 10.1007/s11606-013-2743-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 07/27/2013] [Accepted: 12/02/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND We evaluated the effectiveness and cost-effectiveness of alternative interventions designed to promote mammography in safety-net settings. METHODS A three-arm, quasi-experimental evaluation was conducted among eight federally qualified health clinics in predominately rural Louisiana. Mammography screening efforts included: 1) enhanced care, 2) health literacy-informed education of patients, and 3) education plus nurse support. Outcomes included mammography screening completion within 6 months and incremental cost-effectiveness. RESULTS Overall, 1,181 female patients ages 40 and over who were eligible for routine mammography were recruited. Baseline screening rates were < 10%. Post intervention screening rates were 55.7% with enhanced care, 51.8% with health literacy-informed education and 65.8% with education and nurse support. After adjusting for race, marital status, self-efficacy and literacy, patients receiving health-literacy informed education were not more likely to complete mammographic screening than those receiving enhanced care; those additionally receiving nurse support were 1.37-fold more likely to complete mammographic screening than those receiving the brief education (95% Confidence Interval 1.08-1.74, p = 0.01). The incremental cost per additional women screened was $2,457 for literacy-informed education with nurse support over literacy-informed education alone. CONCLUSIONS Mammography rates were increased substantially over existing baseline rates in all three arms with the educational initiative, with nurse support and follow-up being the most effective option. However, it is not likely to be cost-effective or affordable in resource-limited clinics.
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Affiliation(s)
- Terry C Davis
- Department of Medicine and Pediatrics, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71130, USA,
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12
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Highfield L. Spatial patterns of breast cancer incidence and uninsured women of mammography screening age. Breast J 2013; 19:293-301. [PMID: 23521583 DOI: 10.1111/tbj.12100] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Breast cancer is the most common cancer and second leading cause of cancer mortality in women in the United States. Women who lack insurance have mammography screening rates that are suboptimal. Our objective was to spatially correlate incidence rates of breast cancer and uninsured women aged 40-64 years and identify outliers-areas where women may be underscreened due to poor access. The eight-county consolidated metropolitan statistical area centered on Harris County, Texas was selected as the study region. Breast cancer incidence data from 1995 to 2004 were acquired from the State of Texas Cancer Registry as individual case data geocoded at the census tract level. A bivariate local indicator of spatial autocorrelation was used to evaluate the spatial pattern of breast cancer incidence and uninsured. Statistically significant negative spatial autocorrelation was observed between breast cancer incidence and uninsured status in women aged 40-64 (Moran's I -0.2065, p < 0.001), indicating that as breast cancer incidence increased, uninsured rates decreased globally. Statistically significant local clusters of low breast cancer incidence and high incidence of uninsured were found. Future research is needed to assess mammography screening behaviors and barriers to screening at the local level.
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Davis TC, Arnold CL, Rademaker A, Bailey SC, Platt DJ, Reynolds C, Esparza J, Liu D, Wolf MS. Differences in barriers to mammography between rural and urban women. J Womens Health (Larchmt) 2012; 21:748-55. [PMID: 22519704 DOI: 10.1089/jwh.2011.3397] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Few studies have examined differences between rural and urban women in mammography barriers, knowledge, and experiences. Exploring differences can help inform tailored interventions. METHODS Women, aged ≥40, who had not been screened in the past 2 years were recruited from eight federally qualified health centers across Louisiana. They were given a structured interview assessing mammography knowledge, beliefs, barriers, experiences, and literacy. RESULTS Of the 1189 patients who participated, 65.0% were African American, 61.6% were rural, and 44.0% had low literacy. Contrary to guidelines, most believed mammography should be done annually (74.3%) before age 40 (70.5%). Compared to urban women, rural participants were more likely to believe mammography will find small breast lumps early (34.4% vs. 6.5%, p<0.0001) and strongly disagree that mammography is embarrassing (14.6% vs. 8.4%, p=0.0002) or that they are afraid of finding something wrong (21.2% vs.12.3%, p=0.007). Rural women were more likely to report a physician recommendation for mammography (84.3% vs. 76.5%, p=0.006), but they were less likely to have received education (57.2% vs. 63.6%, p=0.06) or to have ever had a mammogram (74.8% vs. 78.1%, p=0.007). In multivariate analyses controlling for race, literacy, and age, all rural/urban differences remained significant, except for receipt of a mammogram. CONCLUSIONS Most participants were unclear about when they should begin mammography. Rural participants reported stronger positive beliefs, higher self-efficacy, fewer barriers, and having a physician recommendation for mammography but were less likely to receive education or screening.
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Affiliation(s)
- Terry C Davis
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA.
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Roubidoux MA. Breast cancer and screening in American Indian and Alaska Native women. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2012; 27:S66-S72. [PMID: 22351427 DOI: 10.1007/s13187-012-0323-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Data relative to breast cancer among American Indian and Alaska native (AI/AN) women are limited and vary by regions. Despite national decreases in breast cancer incidence and mortality rates, declines in these measures have not yet appeared among AI/AN women. Health disparities in breast cancer persist, manifest by higher stage at diagnosis, and lower screening rates compared to other racial and ethnic groups. Disproportionately more AI/AN are younger at diagnosis. Screening beginning at age 40, improving access, annual rescreening, community education and outreach, and mobile mammography for rural areas are ways to improve these disparities in breast cancer.
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Affiliation(s)
- Marilyn A Roubidoux
- Department of Radiology, University of Michigan Health Systems, Box 5326, TC 2910, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5326, USA.
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Abstract
BACKGROUND Breast cancer is frequently diagnosed after an abnormal mammography result. Language barriers can complicate communication of those results. OBJECTIVES We evaluated the association of non-English language with delay in follow-up. METHODS Retrospective cohort study of women at 3 mammography facilities participating in the San Francisco Mammography Registry with an abnormal mammogram result from 1997 to 2008. We measured median time from report of abnormal result to first follow-up test. RESULTS Of 13,014 women with 16,109 abnormal mammograms, 4027 (31%) had a non-English patient language. Clinical facilities differed in proportion of non-English speakers and in time to first follow-up test: facility A (38%; 25 d), facility B (18%; 14 d), and facility C (51%; 41 d). Most mammography examinations (67%) had breast imaging and reporting data system 0 (incomplete) assessment, requiring radiographic follow-up. At 30 days of follow-up, 67% of all English speakers with incomplete assessments had a follow-up examination compared with 50% of all non-English speakers (P<0.0001). The facility with the least delay and the lowest proportion of non-English speakers, had the biggest difference by language; compared with English speakers and adjusting for education, non-English speakers had twice the odds ratio of >30-day delay in follow-up (odds ratio=2.3; 95% confidence interval, 1.4-3.9). CONCLUSIONS There are considerable differences among facilities in delays in diagnostic follow-up of abnormal mammography results. More attention must be paid to understanding mammography facility factors, such as wait time to schedule diagnostic mammography and radiology workload, to improve rates of timely follow-up, particularly for those facilities disproportionately serving vulnerable non-English speaking patients.
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Hoerger TJ, Ekwueme DU, Miller JW, Uzunangelov V, Hall IJ, Segel J, Royalty J, Gardner JG, Smith JL, Li C. Estimated effects of the National Breast and Cervical Cancer Early Detection Program on breast cancer mortality. Am J Prev Med 2011; 40:397-404. [PMID: 21406272 PMCID: PMC5844559 DOI: 10.1016/j.amepre.2010.12.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 10/01/2010] [Accepted: 12/07/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast cancer screening to medically underserved, low-income women aged 40-64 years. No study has evaluated NBCCEDP's effect on breast cancer mortality. PURPOSE This study estimates life-years saved by NBCCEDP breast cancer screening compared with screening in the absence of NBCCEDP and with no screening. METHODS A breast cancer simulation model based on existing Cancer Intervention and Surveillance Modeling Network models was constructed. The screening module from these models was modified to reflect screening frequency for NBCCEDP participants. Screening data for uninsured women represented what would have happened without the program. Separate simulations were performed for women who received NBCCEDP (Program) screening, women who potentially received screening without the program (No Program), and women who received no screening (No Screening). The impact of NBCCEDP was estimated as the difference in life-years between the Program and No Program, and the Program and No Screening scenarios. The analysis was performed in 2008-2009. RESULTS Among 1.8 million women who were screened between 1991 and 2006, the Program saved 100,800 life-years compared with No Program and 369,000 life-years compared with No Screening. Per woman screened, the Program saved 0.056 life-years (95% CI=0.031, 0.081) compared with No Program and 0.206 life-years (95% CI=0.177, 0.234) compared with No Screening. Per woman with invasive breast cancer and screen-detected invasive cancer, the Program saved 0.41 and 0.71 life-years, respectively, compared with No Program. CONCLUSIONS These estimates suggest that NBCCEDP breast cancer screening has reduced mortality among medically uninsured and underinsured low-income women.
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Affiliation(s)
- Thomas J Hoerger
- Research Triangle Institute International, Research Triangle Park, North Carolina, USA
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Maxwell AE, Jo AM, Crespi CM, Sudan M, Bastani R. Peer navigation improves diagnostic follow-up after breast cancer screening among Korean American women: results of a randomized trial. Cancer Causes Control 2010; 21:1931-40. [PMID: 20676928 PMCID: PMC2959157 DOI: 10.1007/s10552-010-9621-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 07/19/2010] [Indexed: 12/05/2022]
Abstract
Objective To test an intervention to increase adherence to diagnostic follow-up tests among Asian American women. Methods Korean American women who were referred for a diagnostic follow-up test (mainly diagnostic mammograms) and who had missed their follow-up appointment were eligible to participate in the study. Women from two clinics (n = 176) were randomly allocated to a usual care control arm or a peer navigator intervention arm. A 20-min telephone survey was administered to women in both study arms six months after they were identified to assess demographic and socio-economic characteristics and the primary outcome, self-reported completion of the recommended follow-up exam. Results Among women who completed the survey at six-month follow-up, self-reported completion of follow-up procedures was 97% in the intervention arm and 67% in the control arm (p < 0.001). Based on an intent-to-treat analysis of all women who were randomized and an assumption of no completion of follow-up exam for women with missing outcome data, self-reported completion of follow-up was 61% in the intervention arm and 46% in the usual care control arm (p < 0.069). Conclusions Our results suggest that a peer navigator intervention to assist Korean American women to obtain follow-up diagnostic tests after an abnormal breast cancer screening test is efficacious.
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Affiliation(s)
- Annette E Maxwell
- School of Public Health, University of California, Los Angeles and Jonsson Comprehensive Cancer Center, University of California, 650 Charles Young Drive South, A2-125 CHS, Box 956900, Los Angeles, CA 90095-6900, USA.
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Thind A, Diamant A, Hoq L, Maly R. Method of detection of breast cancer in low-income women. J Womens Health (Larchmt) 2010; 18:1807-11. [PMID: 19951215 DOI: 10.1089/jwh.2008.1224] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Breast cancer is the most common malignancy among women, and its timely diagnosis and treatment are of paramount importance, especially for vulnerable groups, such as low-income and uninsured women. Recent literature confirms that the method of breast cancer detection may be an important prognostic factor, but there are no studies that examine the method of breast cancer detection in low-income populations. We sought to analyze the determinants of method of detection (medical vs. self) in a cohort of low-income women with breast cancer receiving care through California's Breast and Cervical Cancer Treatment Program. METHODS This is a cross-sectional survey analysis of 921 low-income women interviewed within 6 months of definitive surgical treatment. The outcome analyzed was self vs. medical detection of breast cancer. RESULTS The mean age of the women was 53 years, with nearly 88% reporting an income of <$30,000 per year; 64% of women self-detected their breast cancer. Logistic regression analyses revealed that older women, Latinas, and women having any health insurance before diagnosis had lower odds of self-detecting their lesions. CONCLUSIONS Patient age, ethnicity, and regular source of care were associated with method of breast cancer detection in a low-income underserved population. The rate of self-detection in our population correlates with the literature, but we need to improve efforts to increase mammography screening to ensure early detection of disease in this vulnerable group.
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Affiliation(s)
- Amardeep Thind
- Department of Family Medicine, Department of Epidemiology and Biostatistics, Schulich School of Medicine, University of Western Ontario, Canada.
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Kapp JM, Walker R, Haneuse S, Buist DSM, Yankaskas BC. Are there racial/ethnic disparities among women younger than 40 undergoing mammography? Breast Cancer Res Treat 2010; 124:213-22. [PMID: 20204501 DOI: 10.1007/s10549-010-0812-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 02/16/2010] [Indexed: 10/19/2022]
Abstract
While the probability of a woman developing invasive breast cancer at age <40 is low (<1%), mammography use reported among younger women (age <40) is substantial, and varies by race/ethnicity. Little detail is known about mammography use among women aged <40, particularly by race/ethnicity. We describe racial/ethnic differences in: (1) mammography indication after considering underlying risk factors (breast symptoms and family history); (2) follow-up recommendations, and (3) mammography outcomes for first mammograms in women aged <40. These 1996-2005 Breast Cancer Surveillance Consortium data are prospectively pooled from seven U.S. mammography registries. Our community-based sample included 99,615 women aged 18-39 who self-reported race/ethnicity and presented for a first mammogram (screening or diagnostic) with no history of breast cancer. Multivariable analyses controlled for registry site, age, family history of breast cancer, symptoms, and exam year. Overall, 73.6% of the women in our sample were seen for a screening mammogram. Following screening mammography, African American (AA) women were more likely than white women to be recommended for additional workup [relative risk (RR): 1.15 (95% CI: 1.07-1.23)]. Following diagnostic mammography, AA [RR: 1.30 (95% CI: 1.17-1.44)] and Asian [RR: 1.44 (95% CI: 1.26-1.64)] women were more likely to be recommended for biopsy, fine-needle aspiration, or surgical consultation. Depending on race/ethnicity, and considering the rate of true positive to total first screening mammograms of younger women, a women has a likelihood of a true positive of 1 in 363-1,122; she has a likelihood of a false positive of 1 in 7-10. This study of community-based practice found racial/ethnic variability in mammography indication, recommendations, and outcomes among women undergoing first mammography before 40. These findings highlight important areas for future research to understand the motivating factors for these practice patterns and the implications of early mammography use.
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Affiliation(s)
- Julie M Kapp
- Department of Family and Community Medicine, University of Missouri, MA306 Medical Sciences Bldg, 1 Hospital Drive, Columbia, MO 65212, USA.
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Alexandraki I, Mooradian AD. Barriers Related to Mammography Use for Breast Cancer Screening Among Minority Women. J Natl Med Assoc 2010; 102:206-18. [DOI: 10.1016/s0027-9684(15)30527-7] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Pruitt SL, Shim MJ, Mullen PD, Vernon SW, Amick BC. Association of area socioeconomic status and breast, cervical, and colorectal cancer screening: a systematic review. Cancer Epidemiol Biomarkers Prev 2010; 18:2579-99. [PMID: 19815634 DOI: 10.1158/1055-9965.epi-09-0135] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Although numerous studies have examined the association of area socioeconomic status (SES) and cancer screening after controlling for individual SES, findings have been inconsistent. A systematic review of existing studies is timely to identify conceptual and methodologic limitations and to provide a basis for future research directions and policy. OBJECTIVE The objectives were to (a) describe the study designs, constructs, methods, and measures; (b) describe the independent association of area SES and cancer screening; and (c) identify neglected areas of research. METHODS We searched six electronic databases and manually searched cited and citing articles. Eligible studies were published before 2008 in peer-reviewed journals in English, represented primary data on individuals ages > or = 18 years from developed countries, and measured the association of area and individual SES with breast, cervical, or colorectal cancer screening. RESULTS Of 19 eligible studies, most measured breast cancer screening. Studies varied widely in research design, definitions, and measures of SES, cancer screening behaviors, and covariates. Eight employed multilevel logistic regression, whereas the remainder analyzed data with standard single-level logistic regression. The majority measured one or two indicators of area and individual SES; common indicators at both levels were poverty, income, and education. There was no consistent pattern in the association between area SES and cancer screening. DISCUSSION The gaps and conceptual and methodologic heterogeneity in the literature to date limit definitive conclusions about an underlying association between area SES and cancer screening. We identify five areas of research deserving greater attention in the literature.
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Affiliation(s)
- Sandi L Pruitt
- Division of Health Behavior Research, Washington University School of Medicine, Campus Box 8504, 4444 Forest Park Avenue, Suite 6700, St. Louis, MO 63108, USA.
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Wujcik D, Shyr Y, Li M, Clayton MF, Ellington L, Menon U, Mooney K. Delay in diagnostic testing after abnormal mammography in low-income women. Oncol Nurs Forum 2010; 36:709-15. [PMID: 19887359 DOI: 10.1188/09.onf.709-715] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE/OBJECTIVES To identify factors associated with diagnostic delay after an incomplete or abnormal mammogram among women participating in a state mammography screening program. RESEARCH APPROACH Retrospective case-control design using bivariate and multivariate logistic regression analyses to explore the associations between age, race, ethnicity, marital status, breast cancer history, and self-reported breast symptoms and delay. SETTING A statewide program of free screening mammography for women who are under- or uninsured. PARTICIPANTS 11,460 women enrolled in a free, statewide screening program from 2002-2006. METHODOLOGIC APPROACH Using the Tennessee Breast and Cervical Cancer Screening Program database, further analyses were conducted. MAIN RESEARCH VARIABLES The outcome measure was delay in completion of all diagnostic tests and was defined as women who did not complete testing within 60 days. FINDINGS Thirty-seven percent of women required follow-up, and of a subset used in the analysis, 30% experienced delay of more than 60 days. Controlling for marital status, age, and breast cancer history, women who experienced delay were more likely to be African American versus Caucasian (odds ratio [OR] = 1.45, 95% confidence interval [CI] = 1.13, 1.85) or Hispanic (OR = 0.72, 95% CI = 0.55, 0.93) and to have self-reported breast symptoms (OR = 1.50, 95% CI = 1.27, 1.77). CONCLUSIONS In a sample of women with low income needing mammography follow-up, delay was associated with three intrapersonal variables, potentially reducing the effectiveness of mammography screening for women who were African American, or Hispanic, or had self-reported breast symptoms. INTERPRETATION Nurses providing cancer screening examinations are uniquely positioned to assess the knowledge, beliefs, and resources of women using the program and to navigate women through barriers to completion. Knowledge of factors associated with delay is valuable for planning interventions and allocating program resources.
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Affiliation(s)
- Debra Wujcik
- Vanderbilt-Ingram Cancer Center, School of Nursing, Vanderbilt University, Nashville, TN, USA.
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Zapka J, Taplin SH, Price RA, Cranos C, Yabroff R. Factors in quality care--the case of follow-up to abnormal cancer screening tests--problems in the steps and interfaces of care. J Natl Cancer Inst Monogr 2010; 2010:58-71. [PMID: 20386054 PMCID: PMC3731434 DOI: 10.1093/jncimonographs/lgq009] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
To achieve the benefit of cancer screening, appropriate follow-up of abnormal screening test results must occur. Such follow-up requires traversing the transition between screening detection and diagnosis, including several steps and interfaces in care. This article reviews factors and interventions associated with follow-up of abnormal tests for cervical, breast and colorectal cancers. We synthesized 12 reviews of descriptive and intervention studies published between 1980 and 2008. There was wide variability in definition of follow-up, setting, study population, and reported prevalence rates. Correlates of follow-up included patient characteristics (eg, knowledge and age), social support, provider characteristics, practice (eg, having reminders systems), community and professional norms (eg, quality measures), and policy (eg, federal programs). Effective interventions included patient education and support; delivery systems design changes, such as navigation; and information system changes, most notably patient tracking and physician reminders. Few studies focused explicitly on interfaces and steps of care, such as communication between primary care and specialists, or simultaneously targeted the multilevel factors that affect care. Future practice and research priorities should include development of clear operational definitions of the steps and interfaces related to patients, providers, and organizations; reflect evolving guidelines and new technologies; determine priorities for intervention testing; and improve measures and apply appropriate study designs.
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Affiliation(s)
- Jane Zapka
- Department of Medicine, Division of Biostatistics and Epidemiology, Medical University of South Carolina, 135 Cannon St, Charleston, SC 29425, USA.
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Richardson LC, Royalty J, Howe W, Helsel W, Kammerer W, Benard VB. Timeliness of breast cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program, 1996-2005. Am J Public Health 2009; 100:1769-76. [PMID: 20019308 DOI: 10.2105/ajph.2009.160184] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To determine the effects of program policy changes, we examined service delivery benchmarks for breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS We analyzed NBCCEDP data for women with abnormal mammogram or clinical breast examination (n=382 416) from which 23 701 cancers were diagnosed. We examined time to diagnosis and treatment for 2 time periods: 1996 to 2000 and 2001 to 2005. We compared median time for diagnostic, treatment initiation, and total intervals with the Kruskal-Wallis test. We calculated adjusted proportions (predicted marginals) with logistic regression to examine diagnosis and treatment within program benchmarks (<or=60 days) and time from screening to treatment (<or=120 days). RESULTS Median diagnostic intervals decreased by 2 days (25 vs 23; P<.001). Median treatment initiation intervals increased by 2 days (12 vs 14; P<.001). Total intervals decreased by 3 days (43 vs 40; P<.001). Women meeting the 60-day benchmark for diagnosis improved the most for women with normal mammograms and abnormal clinical breast examinations from 77% to 82%. CONCLUSIONS Women screened by the NBCCEDP received diagnostic follow-up and initiated treatment within preestablished program guidelines.
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Affiliation(s)
- Lisa C Richardson
- National Center for Chronic Disease Prevention and Health Promotion, 4770 Buford Highway, NE, Mailstop K-55, Atlanta, GA 30341, USA.
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Developing and testing a cost-assessment tool for cancer screening programs. Am J Prev Med 2009; 37:242-7. [PMID: 19666160 DOI: 10.1016/j.amepre.2009.06.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Revised: 05/29/2009] [Accepted: 06/11/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cancer screening programs require substantial resources, and economic assessments have become increasingly important in identifying the most cost-effective means of conducting these programs. Such economic assessments require detailed program cost data, but there is no standardized instrument for obtaining these data. PURPOSE This study was designed to develop a standardized instrument to collect cost data from cancer screening programs. METHODS A cost-assessment tool (CAT) was developed to collect annual cost data based on the findings from case studies at four sites funded by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The data elements collected in the CAT were specifically tailored to collect cost and resource-use information from cancer screening programs. The tool was pilot-tested at nine NBCCEDP sites, and activity-based costs were generated by assigning all cost and resource-use data to specific program activities. Data were collected from November 2004 to February 2005, and the analysis was performed from March to July 2005. RESULTS Overall, a majority of the sites (eight of nine) met the acceptable threshold of <5% of total cost remaining unallocated. On average, the largest cost components of the nine programs were screening and diagnostic services (44.4%); recruitment (11.4%); database management (10.9%); and patient support/case management (9.3%). CONCLUSIONS Findings from the CAT pilot-testing showed that NBCCEDP cancer screening programs were able to report detailed activity-based cost data. The comparability of these cost data across programs should facilitate pooled analyses that, in turn, may lead to a better understanding of the impact and cost effectiveness of the screening program.
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Bhaskara A, Altamirano M, Trisal V, Paz IB, Lai LL. Effectiveness of Decentralized Community-Based Screening, Detection, and Treatment of Breast Cancer in Low-Income, Uninsured Women. Am Surg 2008. [DOI: 10.1177/000313480807401029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Different systems exist currently in the provision of breast care to low-income, uninsured women. We assessed the efficacy of screening, diagnosis, and treatment of breast cancer in this patient population through a decentralized network of providers. We retrospectively reviewed charts of all patients referred for evaluation and treatment under the Cancer Detection Program: Every Woman Counts (CDP:EWC), the California equivalent of the National Breast and Cervical Cancer Detection and Prevention Program, in a suburban area of Los Angeles County. A total of 972 CDP:EWC screening mammograms was performed in the Antelope Valley during a 7-year study period (2000 to 2007). Sixty-two screened women aged 40 to 64 years were referred for further evaluation. Breast cancer detection rate per screening mammogram was 0.8 per cent; 80 per cent were early-stage breast cancer. The majority of the women (nine of 15) underwent breast conservation surgery. The axilla was staged using sentinel lymph node dissection and/or axillary lymph node dissection. Adjuvant chemotherapy and radiation were administered to all eligible patients. Compliance with published practice guidelines was high. This suggests that a decentralized community-based network of providers may be an effective model to deliver breast care to a low-income, uninsured patient population.
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Affiliation(s)
- Achala Bhaskara
- Department of General and Oncologic Surgery, City of Hope, Duarte, California; and the
| | | | - Vijay Trisal
- Department of General and Oncologic Surgery, City of Hope, Duarte, California; and the
| | - I. Benjamin Paz
- Department of General and Oncologic Surgery, City of Hope, Duarte, California; and the
| | - Lily L. Lai
- Department of General and Oncologic Surgery, City of Hope, Duarte, California; and the
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Keen JD, Keen JE. How does age affect baseline screening mammography performance measures? A decision model. BMC Med Inform Decis Mak 2008; 8:40. [PMID: 18803871 PMCID: PMC2563001 DOI: 10.1186/1472-6947-8-40] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Accepted: 09/21/2008] [Indexed: 11/10/2022] Open
Abstract
Background In order to promote consumer-oriented informed medical decision-making regarding screening mammography, we created a decision model to predict the age dependence of the cancer detection rate, the recall rate and the secondary performance measures (positive predictive values, total intervention rate, and positive biopsy fraction) for a baseline mammogram. Methods We constructed a decision tree to model the possible outcomes of a baseline screening mammogram in women ages 35 to 65. We compared the single baseline screening mammogram decision with the no screening alternative. We used the Surveillance Epidemiology and End Results national cancer database as the primary input to estimate cancer prevalence. For other probabilities, the model used population-based estimates for screening mammography accuracy and diagnostic mammography outcomes specific to baseline exams. We varied radiologist performance for screening accuracy. Results The cancer detection rate increases from 1.9/1000 at age 40 to 7.2/1000 at age 50 to 15.1/1000 at age 60. The recall rate remains relatively stable at 142–157/1000, which varies from 73–236/1000 at age 50 depending on radiologist performance. The positive predictive value of a screening mammogram increases from 1.3% at age 40 to 9.8% at age 60, while the positive predictive value of a diagnostic mammogram varies from 2.9% at age 40 to 19.2% at age 60. The model predicts the total intervention rate = 0.013*AGE2 - 0.67*AGE + 40, or 34/1000 at age 40 to 47/1000 at age 60. Therefore, the positive biopsy (intervention) fraction varies from 6% at age 40 to 32% at age 60. Conclusion Breast cancer prevalence, the cancer detection rate, and all secondary screening mammography performance measures increase substantially with age.
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Affiliation(s)
- John D Keen
- Department of Radiology, John H. Stroger Jr. Hospital of Cook County, 1901 West Harrison Street, Chicago, IL 60612-9985, USA.
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Ekwueme DU, Hall IJ, Richardson LC, Gardner JG, Royalty J, Thompson TD. Estimating personal costs incurred by a woman participating in mammography screening in the National Breast and Cervical Cancer Early Detection Program. Cancer 2008; 113:592-601. [DOI: 10.1002/cncr.23613] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Subramanian S, Ekwueme DU, Gardner JG, Bapat B, Kramer C. Identifying and controlling for program-level differences in comparative cost analysis: lessons from the economic evaluation of the National Breast and Cervical Cancer Early Detection Program. EVALUATION AND PROGRAM PLANNING 2008; 31:136-144. [PMID: 18359084 DOI: 10.1016/j.evalprogplan.2008.02.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Revised: 11/07/2007] [Accepted: 02/01/2008] [Indexed: 05/26/2023]
Abstract
Performing economic evaluations of established health care programs is essential to identify and control for underlying program-level variations and to make valid comparisons. At a time when the need for such evaluations is growing, health care professionals have limited information on the methodological challenges of performing these evaluations. In this study, we used the National Breast and Cervical Cancer Early Detection Program to illustrate these potential underlying variations. We performed site visits to four grantees and collected activity-based cost data from nine additional representative programs. We identified five specific types of cost factors that should be considered when evaluating and comparing health care programs: clinical services, service mix, in-kind contributions, indirect costs, and year-to-year expenditures of specific activities. A key lesson is that case studies and pilot testing should be performed before initiating cost analysis to identify underlying variation and to test appropriate methods to adequately control for these differences.
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Affiliation(s)
- Sujha Subramanian
- RTI International 1440 Main Street-Suite 310 Waltham, MA 02451-1623, USA.
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Ekwueme DU, Gardner JG, Subramanian S, Tangka FK, Bapat B, Richardson LC. Cost analysis of the National Breast and Cervical Cancer Early Detection Program: selected states, 2003 to 2004. Cancer 2008; 112:626-35. [PMID: 18157831 DOI: 10.1002/cncr.23207] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) was established by the U.S. Congress in 1990. In recent years, there has been an emphasis on ascertaining the NBCCEDP's costs of delivering screening and diagnostic services to medically underserved, low-income women. The objective of this report was to address 3 economic questions: What is the cost per woman served in the program, what is the cost per woman served by program component, and what is the cost per cancer detected through the program? METHODS The authors developed a questionnaire to systematically collect activity-based costs on screening for breast and cervical cancer from 9 participating programs. The questionnaire was developed based on well established methods of collecting cost data for program evaluation. Data were collected from July 2003 through June 2004. RESULTS With in-kind contributions, the cost of screening services to women in 9 programs was estimated at $555 per woman served. Without in-kind contributions, this cost was $519. Among the program components, screening and coalitions/partnerships accounted for the highest and lowest cost per woman served, respectively. The median cost of screening a woman for breast cancer was $94, and the cost per breast cancer detected was $10,566. For cervical cancer, these costs were $56 and $13,340, respectively. CONCLUSIONS Costs per woman served, screened, and cancers detected are needed for programs to accurately determine the resources required to reach and screen eligible women. With limited program resources, these cost estimates can provide useful information to assist programs in planning and implementing cost-effective activities that could maximize the allocation of program resources.
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Affiliation(s)
- Donatus U Ekwueme
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia 30341, USA.
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Schootman M, Walker MS, Jeffe DB, Rohrer JE, Baker EA. Breast cancer screening and incidence in communities with a high proportion of uninsured. Am J Prev Med 2007; 33:379-386. [PMID: 17950403 PMCID: PMC2100034 DOI: 10.1016/j.amepre.2007.07.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 07/05/2007] [Accepted: 07/11/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND Research has not established (1) if breast cancer screening varies by county-level proportion of uninsured or (2) whether county-level-proportion of uninsured correlates with county-level early-stage and late-stage breast cancer incidence. METHODS A multilevel study was conducted to determine if individual-level self-reported breast cancer screening data from the 2000 Behavioral Risk Factor Surveillance System (BRFSS) was associated with county-level-proportion-uninsured data from the 1999-2001 BRFSS. An ecologic study was conducted to determine if county-level proportion of uninsured correlated with incidence of early-stage and late-stage breast cancer using the 1999-2001 BRFSS data from the overlapping counties in the Surveillance, Epidemiology, and End Results (SEER) program. Data were analyzed in 2005. RESULTS Women were less likely to be screened (prevalence odds ratio: 0.95; 95% confidence interval=0.93-0.97) with every 5% increasing county-level proportion of uninsured. African-American and Hispanic women who resided in counties with a proportion of uninsured of 9%-19% had higher screening utilization than white non-Hispanic women. The county-level-proportion of uninsured had little effect on screening use among women with household incomes less than $25,000 or greater than $75,000. Screening prevalence decreased with increasing county-level proportion of uninsured among women with intermediate income. The rate of T1 (<2 cm diameter) tumors decreased with increasing county-level proportion of uninsured while controlling for poverty rate; Spearman correlation -0.294. CONCLUSIONS High county-level proportions of uninsured may lead to lower early-stage breast-cancer incidence through lower screening use among women living in these less-well-insured counties.
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Affiliation(s)
- Mario Schootman
- Departments of Medicine and Pediatrics, Division of Health Behavior Research, Washington University, 4444 Forest Park Road, Saint Louis, MO 63108, USA.
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Du XL, Sun CC, Milam MR, Bodurka DC, Fang S. Ethnic differences in socioeconomic status, diagnosis, treatment, and survival among older women with epithelial ovarian cancer. Int J Gynecol Cancer 2007; 18:660-9. [PMID: 17892451 DOI: 10.1111/j.1525-1438.2007.01081.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The purpose of the study was to determine the ethnic disparities in socioeconomic status (SES) and in receiving definitive surgical treatment and adjuvant chemotherapy and to examine if these differences contribute to ethnic disparities in survival. We studied a population-based cohort of 5131 women diagnosed with epithelial ovarian cancer at age >or=65 between 1992 and 1999, identified from the Surveillance, Epidemiology and End Results-Medicare linked databases with up to 11 years of follow-up. The percentage of women diagnosed with epithelial ovarian cancer at advanced stage (stage III or IV) was 71.6% in Caucasians and 69.7% in African-Americans. Of these 4264 with stage IC-IV disease who are recommended for chemotherapy, fewer African-Americans received chemotherapy compared to Caucasians (50.2% versus 64.7%, P < 0.001). The risk of all-cause mortality in African-Americans was not significantly different from Caucasians (hazard ratio [HR] = 1.00, 95% CI = 0.88-1.13) after controlling for patient demographics, tumor characteristics, and comorbidity. The HR remained not significant in African-Americans compared to Caucasians after additionally adjusting for treatments (0.93, 0.82-1.06) or SES (0.94, 0.82-1.08) or both (0.88, 0.77-1.01). Women who underwent cancer-directed surgery and received adjuvant chemotherapy were 50% less likely to die than those who did not. The survival benefits from these therapies were similar in Caucasian and African-American women with ovarian cancer. There was no significant difference in survival between African-American and Caucasian women with ovarian cancer after adjusting for tumor characteristics, treatment, and sociodemographic factors. Although adjuvant chemotherapy was effective in prolonging survival, substantial numbers of women with ovarian cancer still did not receive chemotherapy.
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Affiliation(s)
- X L Du
- School of Public Health, The University of Texas Health Science Center, Houston, Texas 77030, USA.
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Tangka FKL, Dalaker J, Chattopadhyay SK, Gardner JG, Royalty J, Hall IJE, DeGroff A, Blackman DK, Coates RJ. Meeting the mammography screening needs of underserved women: the performance of the National Breast and Cervical Cancer Early Detection Program in 2002-2003 (United States). Cancer Causes Control 2007; 17:1145-54. [PMID: 17006720 PMCID: PMC1764594 DOI: 10.1007/s10552-006-0058-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Accepted: 06/26/2006] [Indexed: 11/30/2022]
Abstract
Objective To examine the extent to which the National Breast and Cervical Cancer Early Detection Program (Program) has helped to meet the mammography screening needs of underserved women. Methods Low-income, uninsured women aged 40–64 are eligible for free mammography screening through the Program. We used data from the U.S. Census Bureau to estimate the number of women eligible for services. We obtained the number of women receiving Program-funded mammograms from the Program. We then calculated the percentage of eligible women who received mammograms through the Program. Results In 2002–2003, of all U.S. women aged 40–64, approximately 4 million (8.5%) had no health insurance and had a family income below 250% of the federal poverty level, meeting Program eligibility criteria. Of these women, 528,622 (13.2%) received a Program-funded mammogram. Rates varied substantially by race and ethnicity. The percentage of eligible women screened in each state ranged from about 2% to approximately 79%. Conclusions Although the Program provided screening services to over a half-million low-income, uninsured women for mammography, it served a small percentage of those eligible. Given that in 2003 more than 2.3 million uninsured, low-income, women aged 40–64 did not receive recommended mammograms from either the Program or other sources, there remains a substantial need for services for this historically underserved population.
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Affiliation(s)
- Florence K. L. Tangka
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
- Centers for Disease Control and Prevention, DCPC, 4770 Buford Highway, NE, Mailstop K-55, Atlanta, GA 30341-3717 USA
| | - Joseph Dalaker
- Housing and Household Economic Statistics Division, U.S. Census Bureau, Washington, DC USA
| | - Sajal K. Chattopadhyay
- Office of Strategy and Innovation, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - James G. Gardner
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Janet Royalty
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Ingrid J. E. Hall
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Amy DeGroff
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Donald K. Blackman
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Ralph J. Coates
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
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