Use of Cervical and Breast Cancer Screening Among Women With and Without Functional Limitations -- United States, 1994-1995

The national health objectives for 2000 include increasing to at least 85% the proportion of all women aged greater than or equal to 18 years who have received a Papanicolaou test within the preceding 3 years and increasing to at least 80% the proportion of women aged greater than or equal to 40 years who have ever had a mammogram (1). However, national data on breast and cervical cancer screening specifically for women with disabilities is limited. During 1994-1995, CDC, 12 other federal agencies, and one foundation sponsored a disability survey as a special supplement to the National Health Interview Survey (NHIS). In 1994, questions on breast and cervical cancer screening were included in the NHIS Health Promotion/Disease Prevention Year 2000 Objectives Supplement. This report provides the findings of an analysis of these linked data, which indicate that women with functional limitations (FLs) were less likely than women without FLs to have had a Pap test within the previous 3 years, and women aged greater than or equal to 65 years with three or more FLs were less likely to have ever had a mammogram compared with similarly aged women with no limitations.

The combination of the 1994 disability survey and the Health Promotion/Disease Prevention supplement provided a sample size of 11,399 women aged greater than or equal to 18 years. Participants in the 1994 Health Promotion/Disease Prevention supplement were asked whether their last Pap test was within the previous year, between 1 and 3 years ago, or greater than 3 years ago, and women aged greater than or equal to 30 years were asked how long it had been since they had had a mammogram. Disability was defined as having one or more FLs (unable to do any of the following: lift 10 pounds; walk up 10 steps without resting; walk a quarter of a mile; stand for approximately 20 minutes; bend down from a standing position; reach up over the head or reach out; use fingers to grasp or handle something; and hold a pen or pencil). SUDAAN{Registered} * was used to compute 95% confidence intervals (CIs). In the tables, nonresponses to the Pap and mammogram examination questions were included in the denominator for calculating the percentages. If they had not been included in the denominator, the percentages of those screened would have been higher.

In 1994, approximately 16% of women aged greater than or equal to 18 years surveyed had at least one FL (n=2119). The prevalence of having at least one FL increased with age, from 6.4% of women aged 18-44 years to 39.5% of women aged greater than or equal to 65 years.

Approximately 91% of women aged greater than or equal to 18 years surveyed had received at least one Pap test. Among women with FLs, women aged greater than or equal to 65 years were significantly less likely to have ever had a Pap test than women aged 18-44 years; there was no difference by age among women with no FLs (Table_1). Women with FLs were as likely as women without FLs to have ever had a Pap test (one to two FLs, 92.3%; three or more FLs, 90.0%; and none, 90.8%). Within the preceding 3 years, an estimated 76.1%, 64.8%, and 60.6% of women aged greater than or equal to 18 years with no FLs, with one or two FLs, and with three or more FLs, respectively, had received a Pap test (Table_1). Women aged greater than or equal to 65 years were significantly less likely to have received Pap tests within the preceding 3 years than were younger women. Women with FLs were less likely than women without FLs to have received a recent Pap test (one to two FLs, 64.8%; three or more FLs, 60.6%; and none, 76.1%).

Among women aged greater than or equal to 40 years, 76.2% had had at least one mammogram. An estimated 77.5%, 73.9%, and 70.9% of women aged greater than or equal to 40 years with no FLs, with one or two FLs, and with three or more FLs, respectively, had ever had a mammogram (Table_2). Among women with no FLs and among women with three or more FLs, those aged greater than or equal to 65 years were significantly less likely to have had a mammogram (none, 73.3% {95% CI=70.7%-75.9%}; and three or more, 64.7% {95% CI=60.4%-69.0%}) than women aged 50-64 years (none, 80.6% {95% CI=78.0%-83.2%}; and three or more, 80.9% {95% CI=75.2%-86.6%}) and were significantly less likely to have had a mammogram within the previous 2 years. For women with one or two FLs, there was no statistically significant difference by age in ever having had a mammogram and in having a recent mammogram. Among women aged greater than or equal to 65 years, women with three or more FLs were less likely to have ever had a mammogram and were less likely to have recent mammograms than women with no limitations. The differences in having ever had and in having had a recent mammogram by FL status for the younger age groups were not statistically significant.

Reported by: MA Nosek, PhD, Baylor College of Medicine, Houston, Texas. CJ Gill, PhD, Univ of Illinois, Chicago. Div of Health Interview Statistics, National Center for Health Statistics; Office on Disability and Health, National Center for Environmental Health, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that although the percentages of women who had had Pap tests and mammograms are below the national health objectives, the gaps are larger for women with FLs than for other women. Older age and degree of FL combine to increase the probability of not having had recommended screenings.

Several barriers reduce the likelihood that women with physical limitations will receive pelvic examinations. Women with physical disabilities have been refused care by a physician because of their disability (2). Clinicians may forego Pap tests altogether under the assumption that the severity of the woman's disability precludes sexual activity, putting her at little risk for cervical cancer. They may end an examination early if symptoms such as pain, spasticity, or autonomic hyperreflexia become problematic. The reason most frequently cited by women with physical disabilities for not going for pelvic examinations was difficulty mounting standard examination tables (3 ). Adjustable-height examination tables are available to accommodate most physical limitations; however, few medical offices use them (4).

The lack of statistical significance in the differences in having had mammograms between younger and middle-aged women with FLs may be due to relatively small sample sizes for women in these categories. Almost all mobile mammography trailers are inaccessible to women who use wheelchairs and are very difficult to access by women who have an impaired ability to ambulate. The evidence that younger and middle-aged women with disabilities are receiving mammograms despite these barriers may be explained in part by their high rate of use of medical services overall (2-4 ), implying a greater likelihood of receiving mammograms as part of an array of services.

The findings in this report are subject to at least four limitations. First, the sample includes only noninstitutionalized persons; thus, nursing home residents, who have high levels of FLs, are not represented. Second, the estimates have sampling errors that are relatively large for estimates based on small populations, such as persons with three or more FLs (2,3). Third, a few of the reported FLs (less than 1%) were not associated with chronic conditions and may have been temporary. Finally, proxy responses were allowed for questions on FL, and proxy respondents are known to report limitations differently from self-respondents (5).

Future research should examine barriers to these preventive services for women with FLs, including physical and social barriers in the health-care delivery system. Research on screening behaviors of women routinely should include measures of disability. Providers of screening services should be informed about the health-care needs of women with disabilities, offered techniques for conducting pelvic examinations and mammograms that accommodate such women, and provided information on managing disability-related symptoms that may interfere with examinations.

References

1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

2. Nosek MA, Howland CA, Rintala DH, Young ME, Chanpong GF. National study of women with physical disabilities, final report. Houston, Texas: Center for Research on Women with Physical Disabilities, Baylor College of Medicine, 1997.

3. Nosek MA, Howland CA. Breast and cervical cancer screening among women with physical disabilities. Arch Phys Med Rehabil 1997;78:S39-S44.

4. Krotoski D. Nosek MA. Turk MA, eds. Women with physical disabilities: achieving and maintaining health and well being. Baltimore, Maryland: Paul H. Brookes Publishers, 1996.

5. Magaziner J, Simonsick EM, Kashner TM, Hebel JR. Patient-proxy response comparability on measures of patient health and functional status. J Clin Epidemiol 1988;41:1065-74.

* Use of trade names and commercial sources is for identification only and does not imply endorsement by CDC or the U.S. Department of Health and Human Services.

TABLE 1. Percentage of women who had had a Papanicolaou test, by age and number
of functional limitations (FLs) -- United States, 1994
===============================================================================================
                                       Ever                            <=3 years
Age group (yrs)/               ---------------------             ---------------------
 No. of FLs                     %        (95% CI*)                %         (95% CI)     NR+
---------------------------------------------------------------------------------------------
18-44
 None                          89.8    (88.7%-90.9%)             80.2    (78.8%-81.6%)   3.3
 1-2                           95.9    (92.8%-99.0%)             77.8    (71.4%-84.2%)   2.7
  >=3                          95.8     (91.0%-100%)             79.4    (72.0%-86.8%)   2.6
45-64
 None                          94.6    (93.5%-95.7%)             75.7    (73.5%-77.9%)   3.4
 1-2                           96.8    (94.7%-98.9%)             70.2    (63.3%-77.1%)   2.2
  >=3                          94.8    (92.0%-97.6%)             74.4    (68.7%-80.1%)   2.0
>=65
 None                          87.9    (86.0%-89.8%)             58.1    (55.4%-60.8%)   4.8
 1-2                           86.5    (82.7%-90.3%)             51.6    (46.4%-56.8%)   4.2
  >=3                          85.1    (81.7%-88.5%)             46.0    (41.5%-50.5%)   7.1
>=18
 None                          90.8    (90.1%-91.5%)             76.1    (74.9%-77.3%)   3.5
 1-2                           92.3    (90.3%-94.3%)             64.8    (61.4%-68.2%)   3.2
  >=3                          90.0    (87.8%-92.2%)             60.6    (57.5%-63.7%)   4.7
---------------------------------------------------------------------------------------------
* Confidence interval.
+ Nonresponse rate.
===============================================================================================

TABLE 2. Percentage of women who had had a mammogram, by age and number of
functional limitations (FLs) -- United States, 1994
================================================================================
                             Ever                       <=2 years
Age group (yrs)/     ---------------------        ---------------------
 No. of FLs           %        (95% CI*)           %        (95% CI)      NR+
-----------------------------------------------------------------------------
40-49
 None                77.6    (75.1%-80.1%)        60.6    (58.0%-63.2%)   2.4
 1-2                 75.7    (67.3%-84.1%)        53.3    (44.2%-62.4%)   2.9
  >=3                77.2    (68.8%-85.6%)        58.5    (48.1%-68.9%)   2.5
50-64
 None                80.6    (78.0%-83.2%)        64.8    (62.1%-67.5%)   4.1
 1-2                 79.7    (73.3%-86.1%)        60.9    (53.6%-68.3%)   2.1
  >=3                80.9    (75.2%-86.6%)        60.9    (53.7%-68.1%)   3.3
>=65
 None                73.3    (70.7%-75.9%)        56.5    (53.8%-59.2%)   3.6
 1-2                 70.1    (65.0%-75.2%)        52.0    (47.0%-57.0%)   3.5
  >=3                64.7    (60.4%-69.0%)        42.5    (37.7%-47.3%)   6.5
>=40
 None                77.5    (75.9%-79.1%)        61.0    (59.4%-62.6%)   3.3
 1-2                 73.9    (70.3%-77.5%)        54.8    (50.9%-58.7%)   3.0
  >=3                70.9    (67.7%-74.1%)        49.8    (46.1%-53.5%)   5.0
------------------------------------------------------------------------------
* Confidence interval.
+ Nonresponse rate.
================================================================================

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