*Family Nurse Practitioner, East Brunswick, New Jersey.
Address correspondence to: Judith Greif, RN, MS, APNC, Family Nurse Practitioner, 50 Central Avenue, East Brunswick, NJ 08816. E-mail: grifcommedical@aol.com.
Despite the fact that mammography is an effective screening tool that continues to improve with new digital technology, with efforts made to improve access and affordability, women do not always follow the advice of public health officials and their healthcare practitioners and have the test. The American Cancer Society, the American College of Obstetricians and Gynecologists, and the US Preventive Services Screening Task Force recommend screening mammography every 1 to 2 years for women aged 40 or older.1-3 These guidelines are supported by research funded by the National Cancer Institute (NCI) and others indicating that early detection, in combination with timely and effective treatment, can reduce mortality from breast cancer. Although there has been a steady decline in breast cancer mortality rates since the early 1990s, data from the US Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), and NCI reveal that breast cancer remains the second most common form of cancer among women (200 000 women are diagnosed annually). It is also a leading cause of cancer mortality (second only to lung cancer) and is responsible for nearly 41 000 deaths annually.4 According to the US Department of Health and Human Services, mortality rates are highest among minority women. African American women aged between 35 and 44 have more than twice the numbers of deaths as Caucasian women, and Hispanic women are 20% more likely than their white counterparts to be diagnosed in the latest stages of the disease. Of great concern are the apparent inequities between mammography screening rates for Caucasian versus minority women that may be attributable, at least in part, to attitudes toward mammography that differ across various ethnicities, cultures, and backgrounds.
For over 20 years, epidemiologists have been tracking the percentages of women from various ethnic groups who undergo screening mammography. According to the CDC, in 1987, only 19% of Hispanic and 24% of African American women had the examination performed compared to 30% of Caucasian women. By 2003, the numbers of white and black women were equal and had improved significantly to 70%; however, women from Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander backgrounds still lagged behind (with rates of 65%, 63%, and 58%, respectively).5 Researchers have attempted to determine the reasons for this disparity. In general, women give several reasons for avoiding the annual examination, including fears that the test itself will be painful or that a cancer will be detected. They also voice concerns about not being able to afford the test, or they rationalize avoiding mammography because they have been cancer-free up to that point, and because they perform breast self-examination, the test is unnecessary. 6 In Hispanic populations, specifically, social networks (eg, close friends, relatives, or church membership) may play a role in decisions about cancer screening. Suarez et al conducted a telephone survey to collect data from 2383 women aged 40 or older who comprised 4 distinct Hispanic groups: Mexican American, Central American, Puerto Rican, and Cuban American. The authors hypothesized that if societal and economic barriers made it less likely for women in these minority groups to seek mammography screening, support from others with whom they have a social relationship might have a positive impact on their health behaviors (by providing "affection, affirmation, and aid"). For example, for less educated women and those with less access to health information and services, informal networks may assist with practical resources, such as money and transportation, in addition to less tangible assistance in the form of education and emotional support. The researchers concluded that such social networks do have a "modest effect" that was strongest for Mexican American women and least important for Puerto Rican women.7 Similar studies conducted with African American women found that women who scored high on a tool evaluating their social network were more likely than those with lower social network index scores to seek routine mammography.8
However, it is important to emphasize that degree of social integration is only 1 factor in determining who seeks cancer screening, and other stronger influences include insurance coverage, knowledge of and availability of services, and physician recommendation.7,9 Predictors of the use of mammography determined in other studies also include ever having had a clinical breast examination or a Pap smear,10 in addition to having attained a higher educational level than high school.11
Education about mammography was at the crux of the findings of a recent survey conducted by physicians at Boston University Medical Center and presented at the annual meeting of the Radiological Society of North American in November. Nazia Jafri, MD, a medical intern involved in the study, noted, "Limited understanding of mammography still exists across different ethnic and socioeconomic groups . . . Increased community outreach and education targeted at minority and underserved women may lead to better breast cancer prognoses in these groups." Researchers questioned 1011 women from diverse educational, socioeconomic, and ethnic backgrounds. They were interested in discovering their level of understanding of mammography and their attitudes concerning follow-up (being called back) for a suspicious result on a screening mammography. With regard to the information a mammogram is able to provide, nearly 33% of African American and Hispanic women seemed to be misinformed about its sensitivity, believing that mammography would detect more cancers than it does. In addition, attitudes about results were dramatically different across various ethnic groups, with Caucasian women strongly preferring to be called back because of the possibility that early detection would lead to a better prognosis, whereas African American, Caribbean, Haitian, and Hispanic women did not. This news is troubling, especially because, as Priscilla J. Slanetz, MD, MPH, principal investigator for this study and associate professor of radiology at Boston University Medical Center, points out, "Most recalls are for benign causes and should not deter further screening."
Again, when questioned about their reaction to a false positive report, 76% of Caucasian women stated that they would continue to have screening mammograms, whereas only 56% of African American women and 48% of Hispanic women would. According to Dr Jafri, more research is needed to determine how minority women's attitudes can be influenced in a positive way to try to improve screening rates and follow-up care. Early diagnosis and appropriate, timely follow-up would hopefully help toward achieving the ultimate goal of having a positive impact on the disparities that currently exist in mortality rates. According to Dr Slanetz, "Women's healthcare decisions and adherence to routine health screenings are affected by cultural factors, educational background, and access to medical care. Our study shows that we need to improve breast health education among minority and underserved women . . . Mammography does save lives, but only when cancer is detected early."
References
1. Smith RA, Saslow D, Sawyer KA, et al. American cancer society guidelines for breast cancer screening: update 2003. CA Cancer J Clin. 2003;53:141-169.
2. American College of Obstetricians and Gynecologists (ACOG). ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 42, April 2003. Breast cancer screening. Obstet Gynecol. 2003;101:821-831.
3. US Preventive Services Task Force. Screening for breast cancer. Available at: http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm. Accessed February 4, 2008.
4. US Cancer Statistics Working Group. United States cancer statistics: 2004 incidence and mortality. Available at: http://www.cdc.gov/print.do?url=http%3A%2F%2Fwww.cdc.gov%2Fcancer%2Fbreast%2Fstatistics%2F. Accessed January 8, 2008.
5. Center for Disease Control and Prevention. Mammography: mammography percentages by race and ethnicity. Available at: http://www.cdc.gov/cancer/breast/statistics/screening.htm. Accessed February 4, 2008.
6. Harvard Center for Cancer Prevention. Annual mammograms: one test you don't want to miss. Available at: http://www.hsph.harvard.edu/cancer/cancers/breast/screening/annual_mammo.htm. Accessed February 4, 2008.
7. Suarez L, Ramirez AG, Villarreal R, et al. Social networks and cancer screening in four US Hispanic groups. Am J Prev Med. 2000;19:47-52.
8. Kang SH, Bloom JR. Social support and cancer screening among older black Americans. J Natl Cancer Inst. 1993;85:737-742.
9. Valdez A, Banerjee K, Ackerson L, et al. Correlates of breast cancer screening among low-income, low-education Latinas. Prev Med. 2001;33:495-502.
10. Zambrana RE, Breen N, Fox SA, Gutierrez-Mohamed ML. Use of cancer screening practices by Hispanic women: analyses by subgroup. Prev Med. 1999;29:466-477.
11. Frazier EL, Jiles RB, Mayberry R. Use of screening mammography and clinical breast examinations among black, Hispanic, and white women. Prev Med. 1996;25:118-125.