The U.S. Preventive Services Task Force recommends women 50 to 74 years old undergo screening mammography every two years. Other guidelines promote annual studies and push age limits to include younger and older women as well. Yet amid the din of debates about overuse, some women still remain underserved.
“We are happy if a woman comes in even every other year,” says Bridget A. Oppong, MD, a breast surgeon and assistant medical director at the Capital Breast Cancer Center (CBCC) in Washington, D.C., a screening facility that serves minority and underserved women in the district, Virginia and Maryland that stresses annual screening as the standard of care. “Our problem is we have women who come in once and they feel, ‘I have a clean bill of health; I am done with that.’”
Statistics from the American Cancer Society and Centers for Disease Control and Prevention paint a blurry and sometimes bleak picture for routine mammography in Hispanic and black women, two populations that CBCC targets. Overall, about 75 percent of women ages 40 and older and 80 percent between 50 and 74 years old reported in 2010 having a mammogram within the past two years. Analyses on prevalence of use by Hispanic women varied, from a high of 75.4 percent to a low of 46.5 percent. Screening for black, non-Hispanic women appeared to be a bright spot, at 78.6 percent, but a study that accounted for overreporting placed the figure at 59 percent.
Education, income and health insurance status also factor into the equation, with women with less education, less money and no insurance more likely to skip screening. In all of these underserved populations, lower use of mammography may translate into missed opportunities to diagnose cancer at an earlier stage with the potential for good outcomes.
“Minority populations, populations that I consider high risk because they may lack health access, have higher rates of presenting with more advanced cancers,” Oppong says. Black women have a lower incidence rate for breast cancer than white women, but they are more likely to die from the disease. “A lot of it is because of screening underutilization.”
Expecting overlooked and underserved women to take the initiative to schedule screening mammograms may be an unrealistic approach. Researchers have identified numerous perceived barriers to screening mammography that vary by patient population and location. They include past experiences, distrust, transience, limited or no insurance, transportation and work issues, lack of child care, language deficits, fear of pain, inconvenience, inhibitions, misunderstanding or disbelief in breast cancer risks and more.
Cookie-cutter outreach likely won’t cut it, either. Kimberly K. Engelman, PhD, associate professor of preventive medicine and public health at the University of Kansas Medical School in Kansas City, is recruiting Latina and American Indian women to participate in a randomized study to test an intervention that, if successful, will improve screening rates. American Indian women have one of the lowest mammography use rates, at 63.9 percent. To effectively engage women in mammography initiatives, planners needed to design programs based on feedback from community members that recognized each group’s cultural nuances. All in all, it took 18 to 24 months to design the initiative and six months to refine and pilot test.
Make that revise, refine and pilot test. For the Latina community, Engelman’s group trained “promoters of health,” community health workers who educate women about the importance of breast cancer screening. “However, this model has not worked well with our American Indian community, so we have had to backtrack and come up with a plan,” she says. In partnership with the university’s Center for American Indian Community Health, they instead recruited and trained individuals in the American Indian community rather than community health workers.
The initiative requires representatives to meet one-on-one with Latina or American Indian women at community events. Using a computerized “implementation intentions” program in English or Spanish, they provide educational materials and walk women though screening logistics, allowing the women to think through potential setbacks that might deter them from getting an exam. At the end, women sign a contract to reinforce their commitment.
Women in the trial’s control group receive only education on general breast cancer prevention. The trial