Patients' Reports of Counseling on Mammography Screening by Health-Care Providers -- North Carolina, 1997

Regular mammography screening combined with timely and appropriate treatment can reduce mortality from breast cancer by 30% in women aged 50-69 years and 16% in women aged 40-49 years (1,2). A physician's recommendation has been strongly associated with a patient having a mammogram (3). This report analyzes data collected during 1997 in North Carolina as part of the Behavioral Risk Factor Surveillance System (BRFSS), which indicated that 23% of women aged greater than or equal to 40 years who had had a routine physical examination during the 2 years preceding the survey did not recall having a discussion about mammography with a health-care provider.

BRFSS is an annual, state-based, standardized, random-digit-dialed telephone survey of noninstitutionalized U.S. adults aged greater than or equal to 18 years (4). The overall survey response rate in 1997 was 78%. In the 1997 BRFSS, women aged greater than or equal to 40 years were asked "Has a doctor or other health professional ever talked with you about having a mammogram as part of your routine health-care?" Women who responded "yes" then were asked how many years ago the discussion had occurred. The sample was restricted to the 1209 (92%) who reported having had a routine physical examination during the previous 2 years. Responses were weighted to reflect the age, race, and sex distribution of adults in North Carolina, and the probability of selection; 95% confidence intervals were calculated using Survey Data Analysis (SAS) software (5).

In this sample of women aged greater than or equal to 40 years who reported having had a routine examination during the previous 2 years, 77% reported that a health-care provider had discussed mammography with them during this time (Table 1). This percentage was highest among women aged 50-59 years (86%) and 60-69 years (86%), and declined to 54% among women aged greater than or equal to 80 years. Reported mammography discussion increased with education, from 63% among women with a grade school education or less to 82% among women with at least some college. Of women with an annual household income of less than $15,000, 65% reported a discussion about mammography compared with 80%-82% of women in higher income groups. Women with health-care coverage were more likely than those without to report a discussion on mammography, but this difference was not significant because of the small number of women without coverage. No significant difference by race was observed.

Reported by: E Conlisk, PhD, H Herrick, MSPH, K Passaro, PhD, North Carolina Dept of Health and Human Svcs. Div of Cancer Prevention and Control, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Despite strong evidence that regular mammography screening reduces breast cancer mortality, one fourth of women aged greater than or equal to 40 years who received a routine physical examination in the 2 years before the survey did not recall a health-care provider discussing mammography. The percentage varied by age and might reflect the conflicting recommendations regarding mammography screening for women aged 40-49 years and the unknown benefit of screening women aged greater than or equal to 70 years. The lower percentage among older women also might reflect that older women are less likely to receive a routine physical examination from an obstetrician/gynecologist, the specialist most likely to recommend mammography screening (6).

The 1997 North Carolina BRFSS data indicated that black women were as likely as white women to report a discussion with their health-care provider about mammography. Other data indicated that black women were as likely as white women to have had a mammogram during the previous 2 years, a finding consistent with the 1994 National Health Interview Survey (7). BRFSS data also indicated that reported mammography was lower for women without health-care coverage, with less education, and with annual household incomes of less than $15,000, suggesting that presumed financial barriers may make providers less likely to discuss screening. Providers need to be aware of changes in Medicare and Medicaid mammography screening schedules and the availability of inexpensive and no-cost screening through the National Breast and Cervical Cancer Early Detection Program (8). Because the percentage of women who had had a routine physical examination during the previous 2 years declines with income, education, and health-care coverage in the BRFSS sample, women with these characteristics are even less likely to learn of the importance of regular screening.

The findings in this report are subject to at least three limitations. First, these data are based on respondent recall and may not reflect accurately the actual discussions. Also, the respondent was asked only whether a discussion had occurred and not whether a recommendation was made. Second, the survey was conducted by telephone, excluding approximately 5% of North Carolina households with no telephone. Third, the sample size in some subgroups was small, making it difficult to control for confounding factors in the analysis.

The importance of provider recommendation is evident from other data in the survey. For example, 86% of women who reported a provider discussion of mammography during the previous 2 years also reported having had a mammogram during the previous 2 years versus 44% of women who did not report such a discussion. Also, one third of women who did not have a recent mammogram cited lack of provider recommendation as the main reason they had not been screened. Health-care providers in North Carolina should recommend mammography screening for all women aged greater than or equal to 40 years.

References

1. Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S. Report of the international workshop on screening for breast cancer. J Natl Cancer Inst 1993;85:1644-56.
2. National Institutes of Health Consensus Development Panel. National Institutes of Health Consensus Development Conference Statement: breast cancer screening for women ages 40-49, January 21-23, 1997. J Natl Cancer Inst 1997;89:1015-26.
3. Zapka JG, Stoddard A, Maul L, Costanza ME. Interval adherence to mammography screening guidelines. Med Care 1991;29:697-707.
4. Gentry EM, Kalsbek WD, Hogelin GC, et al. The Behavioral Risk Factor Surveys: II. Design, methods, and estimates from combined data. Am J Prev Med 1985;1:9-14.
5. Shah B, Barnwell B, Bieler G. SUDAAN user's manual, release 7.5. Research Triangle Park, North Carolina: Research Triangle Institute, 1997.
6. Herman C, Lengerich E, Stoodt G. Variation in recommendations for breast and cervical cancer screening among primary care physicians in North Carolina, 1991. South Med J 1996;89:583-90.
7. National Center for Health Statistics. Health, United States, 1998 with socioeconomic status and health chartbook. Hyattsville, Maryland: US Department of Health and Human Services, CDC, National Center for Health Statistics, 1998:293-4.
8. Henson RM, Wyatt SW, Lee NC. The National Breast and Cervical Cancer Early Detection Program: a comprehensive public health response to two major health issues for women. Journal of Public Health Management 1996;2:36-47.

Table 1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Percentage* of women aged >=40 years who reported a recent
discussion with a health-care provider about breast cancer screening+
-- North Carolina, 1997
========================================================================
                          Provider discussed having a
                                mammogram during
Characteristic                  previous 2 years          (95% CI&)
------------------------------------------------------------------------
Age group (yrs)
 40-49                                75.0                (+/- 4.9)
 50-59                                85.6                (+/- 5.0)
 60-69                                85.7                (+/- 4.5)
 70-79                                67.3                (+/- 6.3)
  >=80                                53.6                (+/-10.1)

Education
 Grade school or less                 62.8                (+/- 9.2)
 Some high school                     74.1                (+/- 6.8)
 High school graduate                 76.5                (+/- 4.7)
 Some college                         82.4                (+/- 3.6)

Annual household income
        <$15,000                      65.1                (+/- 7.1)
 $15,000-$24,999                      80.1                (+/- 5.6)
 $25,000-$49,999                      82.0                (+/- 4.7)
       >=$50,000                      81.2                (+/- 6.1)

Has health-care coverage
 Yes                                  77.5                (+/- 2.6)
 No                                   68.3                (+/-12.1)

Race@
 Black                                79.3                (+/- 3.0)
 White                                76.5                (+/- 5.5)

Total                                 76.9                (+/- 2.6)
------------------------------------------------------------------------
* Data were weighted to reflect the age and race distribution of the
  North Carolina female population and the probability of selection in
  the survey.
+ Sample restricted to women who reported having seen a provider for a
  routine examination during the previous 2 years.
& Confidence interval.
@ Numbers for races other than white and black were too small for
  meaningful analysis.
========================================================================

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