Perspectives in Disease Prevention and Health Promotion Trends in Screening Mammograms for Women 50 Years of Age and Older -- Behavioral Risk Factor Surveillance System, 1987

Although the American Cancer Society (ACS) and the National Cancer Institute (NCI) recommend that women greater than or equal to50 years of age have an annual screening mammogram, most have never had one (1). Efforts to increase screening of women for breast cancer include public (2) and private (3) promotional campaigns, legislation to make mammograms a reimbursable service, and educational efforts to increase awareness among health-care professionals (4). For example, the ACS conducted a media campaign from March through May of 1987 to promote screening for breast cancer. In addition, considerable media attention followed the early detection of former First Lady Nancy Reagan's breast cancer by a screening mammogram in October 1987.

To assess whether the media attention to breast cancer screening and the promotional efforts in 1987 were paralleled by increases in screening of women greater than or equal to50 years of age, CDC analyzed data from 33 states that participated in the 1987 Behavioral Risk Factor Surveillance System (BRFSS). In the BRFSS, state health departments conduct monthly random digit-dialed telephone interviews of adults greater than or equal to18 years of age throughout the year (5).

Beginning in January 1987, each woman who was interviewed was asked questions about knowledge and health behaviors relating to mammograms. Mammograms done because of a breast problem or a history of breast cancer were not considered screening mammograms. Analysis was also limited to women who had seen a physician for a routine examination in the previous 12 months. After women who had not had a routine examination or who had had mammograms because of a breast problem or a personal history of breast cancer were excluded, the survey group comprised 8402 women.

The results presented here were weighted to account for the age and race distribution of women residing in each state as well as for the respondents' probability of selection. The results, therefore, are representative of the total population of women greater than or equal to50 years of age who reside in the 33 states surveyed. Based on the 1986 intercensal population estimates, 73% of U.S. women aged greater than or equal to 50 years reside in these 33 states.

Overall, 29% of the study group reported having had a screening mammogram in the last year. When the respondents were grouped by month of interview, the percentage of women who reported having had a screening mammogram in the last year showed a relative increase of nearly 50%, from 26% for women interviewed in January and February to 38% for women interviewed in November and December (Figure 1). The percentage of women who reported being screened increased coincident with the ACS's spring promotional campaign and again after the diagnosis of Mrs. Reagan's breast cancer (Figure 1). Reported by: CW Heath, MD, DJ Fink, MD, American Cancer Society, Atlanta, Georgia. The state BRFSS coordinators: R Strickland, Alabama; T Hughes, Arizona; L Parker, California; M Rivo, District of Columbia; S Hoecherl, Florida; JD Smith, Georgia; E Tash, Hawaii; J Mitten, Idaho; B Steiner, Illinois; S Joseph, Indiana; K Bramblett, Kentucky; R Schwartz, Maine; A Weinstein, Maryland; L Koumijian Yandel, Massachusetts; N Salem, Minnesota; N Hudson, Missouri; R Moon, Montana; R Thurber, Nebraska; K Zaso, New Hampshire; L Pendley, New Mexico; H Bzduch, New York; C Washington, North Carolina; B Lee, North Dakota; E Capwell, Ohio; J Cataldo, Rhode Island; D Lackland, South Carolina; L Post, South Dakota; D Riding, Tennessee; J Fellows, Texas; C Chakley, Utah; K Tollestrup, Washington; R Anderson, West Virginia; R Miller, Wisconsin. Office of Surveillance and Analysis, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The BRFSS information presented here generally agrees with data from other surveys. A Gallup poll conducted in December 1987 showed that 40% of women aged greater than or equal to40 years had had a mammogram in the previous 1-3 years, an 18% increase from 1983. Similarly, data from the National Health Interview Survey, collected in the first quarter of 1987, showed that 31% of women aged greater than or equal to 40 years had had screening mammograms, about half within the previous year (6). However, these data also indicated that black women were less likely than white women to have had mammograms.

The importance of screening mammograms for early detection of breast cancer in women and for subsequent reduction of breast cancer mortality is well established. Consequently, the ACS recommends annual mammograms for all women aged greater than or equal to50 years, mammogram at 1-2-year intervals for women aged 40-49 years, and a baseline mammogram for comparative purposes for women aged 35-39 years (7). In addition, the ACS recommends women begin monthly breast self-examination at age 20 years and receive annual breast examinations by a health-care provider beginning at age 40 years and every 3 years from age 20 to 40 years. NCI recommends a mammogram every 1-2 years for women aged 40-49 years and annually for women greater than or equal to 50 years. NCI also encourages monthly breast self-examination and encourages physicians to do clinical breast examination as part of a periodic examination (8).

Early breast cancer detection is promoted nationwide by the ACS. During the past 2 years, these efforts have been emphasized to alert women and health professionals to the life-saving potential of appropriate screening for breast cancer.

The data from the 1987 BRFSS suggest that the media events and educational activities were accompanied by increases in screening mammograms. Although the observed increases may be related to enhanced public awareness during the ACS spring campaign and after Mrs. Reagan's diagnosis, the BRFSS data only generally support that notion. Baseline data from the BRFSS are not available for comparison, and many other factors (e.g., education, convenience, cost) can influence the response to cancer-control recommendations. Increased understanding of how such factors interact to influence prevention behavior will require more detailed survey information. For example, trends in different locations may vary by time. In states where ACS programs for early detection of breast cancer have been operating longest, increased use of screening mammograms might be expected. Data from the BRFSS regarding geographic patterns of mammogram use would help in examining this hypothesis.

Because many factors may have influenced the increase in the percentage of women who reported being screened, the observed month-to-month changes cannot be directly attributed to any specific events that occurred during 1987. However, the BRFSS data suggest that efforts to promote the use of screening mammograms combined with media attention to the early detection of breast cancer may have resulted in an increased use of screening mammograms during 1987. Increased use of screening mammograms and targeting of cancer-control efforts at lower socioeconomic segments of the population (where cancer risks are often higher and health- care access is more difficult) should result in earlier detection of breast cancer and a subsequent reduction of mortality from breast cancer.

References

1. American Cancer Society. 1986 survey of awareness and use of mammograms. Princeton, New Jersey: The Gallup Organization, 1987. 2.CDC. Use of mammography for breast cancer screening--Rhode Island, 1987. MMWR 1988;37:357-60. 3.Vogel VG, Peters GN, Fueger JJ, Beinvenu OJ, Wilson E. The American Cancer Society Texas Breast Screening Project (Abstract). In: Program and abstracts of Prevention '88: prevention and primary care. Atlanta: American College of Preventive Medicine, American College of Teachers of Preventive Medicine, 1988:22. 4.US Preventive Services Task Force. Recommendations for breast cancer screening. JAMA 1987;257:2196. 5.Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based Behavioral Risk Factor Surveillance: 1981-87. Public Health Rep 1988;103:366-75. 6.CDC. Provisional estimates from the National Health Interview Survey supplement on cancer control--United States, January-March 1987. MMWR 1988;37:417-20,425. 7.American Cancer Society. Mammography 1982: a statement of the American Cancer Society. CA 1982;32:226-30. 8.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.

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