Progress in Chronic Disease Prevention Use of Mammography for Breast Cancer Screening -- Rhode Island, 1987

Rhode Island's age-adjusted mortality rates for breast cancer have been consistently higher than national rates since at least 1950 (1). During this period, while age-adjusted mortality rates have remained relatively stable, demographic changes due to an aging population have led to increasing numbers of deaths from breast cancer. In 1986, the number of Rhode Island women who died from this cause was 232--more than the number who died from any other type of cancer.

The Rhode Island Department of Health's Breast Cancer Screening Program is designed to reduce breast cancer mortality by promoting annual breast cancer screening, including mammography, for women greater than or equal to40 years of age. Components of the program include a broad promotional effort, a strong quality assurance program, lowered costs for mammography, and a scheduling and notification system located in the Department of Health. Women with positive, suspicious, or inconclusive findings are followed up by personal contact from health department staff, and their mammograms are also reviewed by a panel of radiologists. If widely instituted, this intervention has the potential for substantially reducing breast cancer mortality (2,3).

A survey of Rhode Island women aged greater than or equal to40 was conducted to establish a baseline for evaluating the program. Women were interviewed concerning their knowledge, attitudes, and practices related to breast cancer screening, including mammography. For this survey, random-digit dialing was used to select a sample of Rhode Island households with telephones. Households that could be contacted were screened for the presence of women aged greater than or equal to40. If more than one possible respondent was identified in a household, one respondent was selected by using a procedure that randomized the selection. Because only 6% of households contacted had more than one eligible respondent, no adjustment has been made in the analysis for the lower probability of selecting women living in households with other eligible respondents. There were 852 completed interviews, for a response rate of 78%. Thirty-seven percent of women aged greater than or equal to40 reported having had a mammogram within the past year, and 70% reported having had a physical breast examination (Table 1). The likelihood of having had a mammogram or a physical breast examination in the past year was found to vary with the woman's age, education, and income. The age group with the lowest proportion (29%) of women who had had a mammogram in the past year was the age group greater than or equal to70. However, 69% of this age group had had a physical breast examination, a proportion similar to that of other age groups. Among all women aged greater than or equal to40, both the proportion of women having had a mammogram and the proportion of women having had a physical breast examination increased with education and income. Nearly half of the women in the highest income group and 44% of college graduates had had a mammogram in the previous year, and 78% of both groups had had a physical breast examination. The lowest utilization rates for both procedures occurred among the poor. Since 92% of all women had seen a physician in the previous year, the observed variations in screening practices with age, education, and income do not appear to stem from differing frequencies of contact with the medical-care system (Table 1).

The proportion of women who had had both a physical breast examination and a mammogram in the past year was 35%, just below the proportion who had had a mammogram. When respondents were grouped by age, education, and income, the proportion having had both screening procedures follows closely the total proportion having had a mammogram. Of the women who reportedly had a mammogram in the past year, 96% also had had a physical breast examination. Of those who had not had a mammogram, 54% had had a physical breast examination in the past year.

Women who had not had a mammogram in the past 3 years were asked--in an open-ended question--for the reason. Many (32%) responded that they did not believe it was necessary, usually because they currently had no symptoms, or that mammography had not been recommended to them (23%), and they had not thought to request it (Table 2). Others reported fear or dislike of physicians or the procedure itself (11%), procrastination (8%), lack of time (4%), or their physician's recommendation not to have a mammogram (3%). Very few respondents said that their main reason for not having a mammogram was the cost of the procedure.

Forty-four percent of the women surveyed said that their physicians had ever recommended that they have a mammogram for screening purposes, i.e., as a routine examination when no symptoms are present. Of those women aged greater than or equal to40 who had received such a recommendation from their physician, 60% had had a screening mammogram in the past year. Of those not receiving such a recommendation, 8% had had a screening mammogram in the past year. Reported by: JS Buechner, PhD, JP Fulton, PhD, RB Kaufmann, DF DiOrio, RN, MEd, HD Scott, MD, MPH, BA DeBuono, MD, MPH, State Epidemiologist, Rhode Island Dept of Health. D Kovenock, MS, Northeast Research, Orono, Maine. Div of Chronic Disease Control, Center for Environmental Health and Injury Control, CDC. Editorial Note: The use of mammography for breast cancer screening has been shown to reduce breast cancer mortality among women, whether performed with or without a breast examination by a physician (2,3). On the basis of these findings, the National Cancer Institute has recommended the increased use of mammography as a key cancer screening objective for the year 2000 (5). Both the National Cancer Institute and the American Cancer Society recommend annual physical breast examinations for women aged greater than or equal to40. Both organizations also recommend that women aged 40-49 have a mammogram every 1 or 2 years and that women aged greater than or equal to50 have a mammogram every year (6,7).

Despite the demonstrated efficacy of mammography in screening for breast cancer, most previous studies have shown that few women in the recommended age group are screened regularly (8). The preponderance of evidence from national surveys indicates that 20% or fewer women in the target groups for breast cancer screening have ever had a mammogram. Although most of these data were collected nearly 10 years ago, more recent evidence suggests that national screening rates are lower than those observed for Rhode Island. The Health Promotion and Disease Prevention Supplement to the 1985 National Health Interview Survey of the National Center for Health Statistics showed that only 45% of women aged 45-64 and 39% of women aged greater than or equal to65 had had a physical breast examination in the previous year (9). Data from the first quarter of 1987 obtained from the Cancer Control Supplement to the 1987 National Health Interview Survey indicate that, nationwide, an estimated 16% of women aged greater than or equal to40 had had a mammogram in the past year that was not performed because of a health problem (10). Compared with national data, the survey of Rhode Island women showed unexpectedly high levels of recent breast cancer screening even among women with lower levels of education and income. Approximately 70% of women aged greater than or equal to40 reported having had a physical breast examination, and 31% reported having had a mammogram for screening purposes, i.e., not because of a health problem, in the past year. Explanations for these differences are unclear, but they may be partly due to the higher degree of urbanization and access to health care in Rhode Island than in the United States as a whole.

Clearly, a major focus of any breast cancer screening program should be to increase the proportion of primary-care physicians who recommend screening mammograms. A nationwide survey of physicians sponsored by the American Cancer Society in 1984 revealed the attitudes that must be overcome (11). When mammography is performed, it is nearly always part of a complete screening regimen for breast cancer, according to these data. In Rhode Island, a recommendation by a physician appears to have increased a woman's compliance with guidelines for mammographic screening more than sevenfold. Given the apparent motivating force of a physician's recommendation, as shown by the Rhode Island data, the number of physicians who endorse and recommend mammography must increase if promotional programs for breast cancer screening are to be successful. References

1. Riggan WB, Van Bruggen J, Acquavella JF, Beaubier J, Mason TJ. U.S. cancer mortality rates and trends, 1950-1979. Washington, DC: National Cancer Institute, US Environmental Protection Agency, 1983.

2. Shapiro S, Venet W, Strax P, Venet L, Roeser R. Ten- to fourteen-year effect of screening on breast cancer mortality. JNCI 1982;69:349-55.

3. Tabar L, Fagerberg CJG, Gad A, et al. Reduction in mortality from breast cancer after mass screening with mammography: randomised trial from the Breast Cancer Screening Working Group of the Swedish National Board of Health and Welfare. Lancet 1985;1:829-32.

4. US Department of Health and Human Services. Annual update of the poverty income guidelines. Federal Register 1987;52:5340-1.

5. National Cancer Institute. Cancer control objectives for the nation: 1985-2000. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, 1986; DHHS publication no. (NIH)86-2880. (NCI monograph no. 2).

6. American Cancer Society. Mammography: two statements of the American Cancer Society. New York: American Cancer Society Professional Education Publications, 1983.

7. National Cancer Institute. Working guidelines for early cancer detection: rationale and supporting evidence to decrease mortality. Washington, DC: US Department of Health and Human Services, Public Health Service, 1987.

8. Howard J. Using mammography for cancer control: an unrealized potential. CA 1987; 37:33-48.

9. National Center for Health Statistics. Health promotion data for the 1990 objectives: estimates from the National Health Interview Survey of Health Promotion and Disease Prevention: United States, 1985. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1986; DHHS publication no. (PHS)86-1250. (Advance data from vital and health statistics; no. 126).

10. Kessler L. Cancer screening knowledge and behavior. Presented at the 115th annual meeting of the American Public Health Association, New Orleans, Louisiana, October 18-22, 1987.

11. American Cancer Society. Survey of physicians' attitudes and practices in early cancer detection. CA 1985;35:197-213.

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