Use of Mammography -- United States, 1990

In 1989, promotion of mammography increased through expanded media coverage, national and local information efforts, and screening programs. To determine whether mammography use increased as a result of the increased promotion, in February 1990, the Mammography Attitudes and Usage Study (MAUS) was conducted for the Jacobs Institute of Women's Health* with technical assistance from the National Cancer Institute (NCI). This report summarizes findings from this survey, which indicate that in February 1990 almost two thirds of women aged greater than or equal to 40 years had had at least one mammogram--a substantial increase over percentages reported in earlier national surveys (1)--but less than one third of women aged greater than or equal to 40 years were following mammography screening guidelines**.

The MAUS used a multistage cluster sample of households with telephones, based on the Waksberg method of random-digit-dialing (2). Nine hundred eighty women aged greater than or equal to 40 years (which included 863 white and 83 black women) were interviewed. The data were weighted to reflect the age-, education-, and race-specific distribution of U.S. women in 1989 and to reflect the respondents' probability of selection. The response rate was 64%; characteristics of the remaining 36% are unknown.

In 1990, use of mammography was higher among white women than among black women and higher among women with a higher income and more education (Table 1, page 627). Use was most prevalent among women 50-59 years of age, then decreased inversely with age (Table 1). Other characteristics of women most likely to have had a mammogram included having a household income of greater than or equal to $50,000 (77%), having a college degree or higher education level (74%), and being married (70%).

Twenty-three percent of the women surveyed reported having had their first mammogram within the past 2 years. Thirty-nine percent had had their first mammogram greater than 2 years before this survey.

Thirty-five percent of the study population had had more than one mammogram, and 31% were following mammography guidelines established by NCI, the American Cancer Society (ACS), and 11 other medical organizations. The guidelines state that women aged 40-49 years should have a mammogram every 1-2 years, then once every year thereafter. Compliance with the guidelines decreased with increasing age (Figure 1).

Nearly three fourths of women greater than or equal to 40 years of age who had had a mammogram reported they did so because their doctor recommended it, a finding that was consistent across age, race, income, and education categories. Forty-five percent of women who had never had a mammogram reported that their physician did not tell them to have a mammogram. This same group was also more likely to be uncomfortable in asking their physician for a mammogram if the physician did not mention it first.

Approximately 50% of the women reported they would not pay $150 per year for a mammogram; nearly 40% reported they thought "mammograms cost too much."

Many women who had never had a mammogram did not believe they were at risk for breast cancer. For about 40%, the reason for not having a mammogram was "No one in my family has had breast cancer"; for 26%, the reason was "I am not at risk for breast cancer." The latter group was most likely to believe that a mammogram is important only for women who feel a lump or have other symptoms of breast cancer.

Of the women who had had only one mammogram and were not following the guidelines, 35% indicated that the following statement applied to them: "My first mammogram showed no problems, so I don't need to have any more." Twenty-nine percent of these women agreed that "Mammograms cost too much," and 27% believed that because no one in their families had had breast cancer, they did not need to have additional mammograms. Ninety-five percent did not agree with the statement "I had a bad experience with my first one."

Cost of mammograms and fear of radiation were cited as concerns by women who had had a mammogram but were not in compliance with mammography guidelines and women who had never had a mammogram. Most (91%) women agreed that breast cancer found in its earliest stage is highly curable, and most (88%) agreed that a mammogram can find breast cancer even in women with no symptoms. Similarly, most (93%) women correctly disagreed with the statement "After menopause, women do not have to worry about breast cancer." Rates were consistent for all age categories for these statements. Reported by: DJ Marchant, MD, Tufts Univ School of Medicine, Boston, Massachusetts, and Jacobs Institute of Women's Health, Washington, DC. SM Sutton, PhD, Office of Cancer Communications, National Cancer Institute, National Institutes of Health. Cancer Prevention and Control Br, Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The MAUS findings show that the proportion of women aged greater than or equal to 40 years who had had at least one mammogram has nearly doubled since the 1987 National Health Interview Survey (NHIS) and indicate that mammography use increased during the period of increased publicity encouraging women to have mammograms. Although the interview methodology was different, the percentage of women interviewed in the MAUS telephone survey who had had a mammogram by 1987 was comparable to the percentage found in the NHIS in-person interviews. MAUS findings by age, race, income, and education were similar to findings of the National Knowledge, Attitudes, and Behavior Survey (NKAB) conducted by NCI from April 1989 to February 1990 (Table 1). NKAB used random-digit-dialed telephone interviews of 836 women aged greater than or equal to 40 years (which included 584 white and 189 black women); data were weighted for the distribution of U.S. women in 1988 by age, education, and race.

Further evidence of an increase in mammography use includes the Behavioral Risk Factor Surveillance System, which demonstrated an increase in mammography use from January to December 1987 (3), as well as surveys conducted by NCI's Breast Cancer Screening Consortium for 1988 and 1989, which indicated that 51%-74% of women greater than or equal to 50 years of age had had a mammogram (4).

Breast cancer death rates could be decreased by an estimated 30% if women received mammograms at recommended intervals (5,6). However, if death rates are to be decreased, mammography use rates must continue to increase, and women must return for repeat mammograms at recommended intervals. Special efforts are needed to ensure that older women and women with low levels of income and education receive mammograms. Physicians are key motivators of women to use mammography. Physicians' referral rates are increasing (7), and ACS, NCI, and CDC are working with the Jacobs Institute of Women's Health and other medical organizations to facilitate these increases. In addition, efforts to attain higher mammography use should include informing women that the radiation from a mammogram is negligible and should not deter them from receiving regular mammograms. The expense of mammograms is being addressed by local efforts to reduce costs and by legislation in an increasing number of states (8). As of July 1990, 29 states required insurance companies to provide some level of coverage for mammography (9).

References

1. National Cancer Institute. Cancer statistics review 1973-1986, including a report on the status of cancer control. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1989; NIH publication no. 89-2789.

2. Waksberg JS. Methods for random digit dialing. J Am Stat Assoc 1978;73:40-6.

3. CDC. Trends in screening mammograms for women 50 years of age and older--Behavioral Risk Factor Surveillance System, 1987. MMWR 1989;38:137-40.

4. National Cancer Institute Breast Cancer Screening Consortium. Screening mammography: a missed clinical opportunity? Results of the NCI Breast Cancer Screening Consortium and National Health Interview Survey Studies. JAMA 1990;264:54-8.

5. Shapiro S, Venet W, Strax P, Venet L. Periodic screening for breast cancer: the Health Insurance Plan Project and its sequelae, 1963-1986. Baltimore, Maryland: The Johns Hopkins University Press, 1988;1-214.

6. Eddy DM. Screening for breast cancer. Ann Intern Med 1989;111:389-99.

7. American Cancer Society. 1989 Survey of physicians' attitudes and practices in early cancer detection. CA 1990;40:77-101.

8. Thompson GB, Kessler LG, Boss LP. Breast cancer screening legislation in the United States: a commentary. Am J Public Health 1989;79:1541-3.

9. National Cancer Institute. Mammography backgrounder. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, September 1990:3. *An independent, nonprofit organization founded by the American College of Obstetricians and Gynecologists. **Women were counted as following the guidelines if they were 1) aged 40-49 years and reported that they have a mammogram at least every 2 years, 2) aged greater than or equal to 50 years and reported that they have a mammogram at least yearly, or 3) aged 40-42 years and had had their first and only mammogram within the past 2 years. In addition, women who had had a mammogram whenever their physician recommended it were assumed to be following the guidelines.

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