COMMENTARIES
The National Prevention Strategy and Breast Cancer
Screening: Scientific Evidence for Public Health Action
Mammography screening Marcus Plescia, MD, MPH, and Mary C. White, ScD
rates in the United States
have remained fairly stable
OVERALL, ABOUT ONE IN FOUR recommendations across multi- subsidized state insurance exchanges,
over the past decade, and
women in the United States aged ple settings: elimination of and elimination of cost sharing.
screening rates remain low
50 to 74 years have not had health disparities, empowered Nevertheless, many women
for some groups.
a mammogram within the past two people, healthy and safe com- with financial access to health care
We examined insights
from recent public health re- years, as is recommended.1 Mam- munity environments, and clini- are not being screened.1 Among
search on breast cancer mography use is substantially cal and community preventive insured women, those with fee-for-
screeningtoidentifypromis-
lower for certain subgroups, such services. service care are only half as like-
ing new approaches to im-
as low-income women, women The purpose of this analysis was ly to receive mammograms as
prove screening rates and
without health insurance, and to examine insights gained from those in health maintenance orga-
address persistent health
women without a usual source of recent research on breast cancer nizations, and those with public
disparities in mammogra-
care.1---3 In addition, breast cancer screening in the context of these insurance are less likely than
phy use. We considered this
screening rates have not improved four strategic directions for pre- women with private insurance
research in the context of
in almost a decade1,4,5 and the vention. Integrating efforts in a co- to receive them.9 Analyses of na-
the four strategic directions
Healthy People 2010 target that ordinated public health effort may tional Medicare data11 reveal
of the National Prevention
70% of women aged 40 to 74 result in improved mammography that, despite coverage for mam-
Strategy: elimination of
health disparities, empow- years received a mammogram in utilization, reduction in breast mography services for women
ered people, healthy and the past two years was not cancer mortality, and improve- aged 65 years or older, only 64%
safe community environ-
achieved.6 The Healthy People ment in longstanding health dis- of eligible woman have had a
ments, and clinical and com-
2020 cancer objective uses new parities. mammogram within the previous
munity preventive services.
age guidelines and calls for a 10% two years. Women who use
This research points to
improvement in the proportion of ELIMINATION OF HEALTH Medicare whose family incomes
the value of direct outreach
women aged 50 to 74 years who DISPARITIES are less than 100% of the federal
and case management ser-
received a mammogram in the poverty rate have only a 51%
vices, interventions to sup-
previous two years, as well as A recent review of 195 re- screening rate.11 A North Carolina
port more patient-centered
a reduction in late-stage female search studies that included a total study of women aged 50 years
models of care, and more
breast cancer (an intermediate of 4.8 million US women found and older with Medicaid coverage
organized, population-based
approaches to identify wom- outcome of cancer screening that lack of insurance was a strong, found that only 51% had received
en who are eligible to be success).7 statistically significant predictor of appropriate breast cancer screen-
screened, encourage partici- Current efforts and approaches women not obtaining recommen- ing within the previous two
pation, and monitor results.
are clearly not sufficient to meet ded mammography screening.9 In years.12 Nonfinancial factors that
(Am J Public Health. 2013;
these national goals. New ap- 1992, Congress authorized the may influence a women s ability to
103:1545 1548. doi:10.
proaches are needed to further Centers for Disease Control and access screening services include
2105/AJPH.2013.301305)
increase mammography utiliza- Prevention to implement the Na- language, geography, cultural dif-
tion to achieve Healthy People tional Breast and Cervical Cancer ferences, provider biases, lack of
2020 objectives. Whether Early Detection Program to pro- social support, and lack of knowl-
a woman receives a mammogram vide screening services to medi- edge.9 Mammography use has
is influenced by a range of per- cally underserved, low-income been shown to vary by race and
sonal, social, and economic factors, women for breast and cervical ethnicity, and to be lower for
and these factors are interrelated. cancer. However, this program specific subgroups of Hispanic and
The use of scientific evidence from serves only a small percentage of Asian women and for foreign-born
extensive research on the deter- eligible women in the United women with less than 10 years
minants of mammography utiliza- States.10 When fully enacted, of US residence.1
tion could increase effective public components of the Affordable Mammography alone has no
health practice. The National Pre- Care Act will help address major benefit if appropriate follow-up
vention Strategy8 outlined four barriers to cancer screening does not occur after an abnormal
strategic directions to integrate through Medicaid expansion, finding. Racial/ethnic minorities
September 2013, Vol 103, No. 9 | American Journal of Public Health Plescia and White | Peer Reviewed | Commentaries | 1545
COMMENTARIES
and those from lower socioeco- that they were not at high risk associated with later-stage breast rates.31---33 These include re-
nomic backgrounds are less likely for breast cancer because of cancer diagnosis.25 In addition, minders to clients and providers
to have timely follow-up after an a negative family history, regard- screening rates vary considerably to ensure that people are
abnormal screening test and are less of age.19 Barriers identified in by geography and are lowest in screened according to recom-
more likely to be diagnosed with an extensive literature review west-central states and the states mendations, and assessment of
late-stage disease, which is associ- also included pain associated with the lowest population densi- providers including feedback on
ated with greater mortality.13,14 with the procedure or a lack of ties as well as the fewest mam- their performance in screening
Case management services have knowledge regarding breast can- mography facilities.3,5 for cancer. However, widespread
been shown to improve the time to cer detection and treatment.9 This association between mam- implementation of these ap-
diagnosis among low-income Several studies have found that mography availability and mam- proaches is difficult in our frag-
women.15,16 A recent analysis of women who had received screen- mography use has also been mented health care system. In
the effect of the Centers for Dis- ing in the past were more likely to documented in smaller geographic a study of primary care physi-
ease Control and Prevention s be screened again.9 Research on analyses; counties with no mam- cians practices, just 40%
early detection program on breast factors associated with rescreening mography units have the lowest reported that they had a system to
cancer mortality estimated that found that women were less likely mammography utilization.26 remind women to come in for
medically underserved women to be rescreened if they felt Marked geographic differences breast cancer screening.34
screened through the program, embarrassed or if scheduling an have been documented in mam- Although most clinicians are
which provides follow-up and re- appointment was not conve- mography capacity. Counties with familiar with the recommenda-
ferral services, experienced more nient.20 On the other hand, having no mammography facilities were tions of the US Preventive Services
life-years saved than similar no primary care provider and not the poorest, had the lowest level of Task Force, the American Can-
women who were screened with- having visited a physician within health insurance coverage, and cer Society, and specialty profes-
out the program, and even greater the past year reduced mammog- had the lowest density of primary sional associations, wide gaps
life-years saved than women raphy utilization.9 Among work- care physicians.27 Even in areas have been documented between
who had not been screened.17 ing women aged 40 years and with adequate mammography ca- guidelines and clinical practice.35
older, those with paid sick leave pacity, spatial accessibility can still These include the persistent use
EMPOWERED PEOPLE were more likely to have had be a barrier for women who de- of in-office rectal examination
a mammogram within the previ- pend on public transportation. In with stool guaiac testing to screen
Many factors influence a woman s ous two years than were those Atlanta, for example, the median for colorectal cancer36 and failure
intent to access screening services. without it.21 Women with disabil- time to a mammography facility to adopt longer screening
A 2003 report by the Institute of ities were found to be less likely to when one used public transporta- intervals in women with a normal
Medicine reviewed research that obtain a mammogram at recom- tion was almost 51 minutes, com- Papanicolaou test or human
documented a wide range of bar- mended screening intervals.22 pared with six minutes with papillomavirus---negative cervi-
riers to use of mammography a vehicle. Women who lived in cal cancer screening test re-
screening based on a woman s HEALTHY AND SAFE communities that were primarily sults.37 With regard to mammog-
knowledge and attitudes about COMMUNITY Black had longer travel times, re- raphy, recent research points to
the risk of breast cancer and the ENVIRONMENTS gardless of vehicle availability.28 discordant recommendations
benefits of screening.18 A recent for screening for those who are
focus group study conducted with Community characteristics pro- QUALITY CLINICAL AND unlikely to benefit fromscreening
women from multiple racial and vide the environmental context in COMMUNITY PREVENTIVE including screening for women
ethnic backgrounds including which screening decisions are SERVICES who are terminally ill38 as well as
White non-Hispanic, Black non- made. Public health interventions mammography use among
Hispanic, Hispanic, Japanese that change the environmental Another frequently mentioned women younger than 40 years.39
American, and American Indian/ context in which individuals live reason for not participating in To maximize the quality of
Alaskan Native found that time can be highly effective because breast cancer screening is that screening, abnormal results must
needed to schedule appointments, they have broad reach and a provider did not recommend the be followed up. However, inade-
competing time demands, and require less individual effort.23 test.29 For example, a national quate identification, diagnosis, and
concern about radiation exposure Several measures are associated survey of unscreened women follow-up of positive screening
were some of the factors that re- with mammography use in the found that about 70% reported tests also occur persistently, even
duced their likelihood of obtain- United States, such as the num- that they had not received a pro- among patients with insurance.40
ing a repeat mammogram, there- ber of health centers or clinics in vider recommendation for mam- A study of practice cancer regis-
fore causing these women to be a county.24 Also, a lower number mography.30 Evidence-based tries from 16 community health
nonadherent with current rec- of office-based physicians per interventions have been shown centers found that although all
ommendations.19 Many believed 100 000 women has been to increase cancer screening centers reported breast cancer
1546 | Commentaries | Peer Reviewed | Plescia and White American Journal of Public Health | September 2013, Vol 103, No. 9
COMMENTARIES
Note. The findings and conclusions in
screening data, reporting of clinical preventive services and to promoting healthy behaviors)
this article are those of the authors and do
follow-up after diagnosis was not guide quality improvement efforts. has been documented to improve
not necessarily represent the official
consistent.41 Only 50% reported Approaches that address cancer screening efforts and help
position of the Centers for Disease Control
whether women had received no- the environmental context of mitigate racial and ethnic dispar- and Prevention.
tification of mammography results mammography utilization and ities.48---50 Patient navigation
Contributors
within 30 days, 12.5% reported geographic disparities in the (i.e., assistance in understanding
Both authors participated in the
on follow-up of an abnormal availability of services can be medical terms and procedures,
conceptualization and writing of this
mammogram within 60 days, and developed to better guide and in coping with challenges to
article and approved the final version.
6.25% reported on whether population-based outreach. receiving services such as a lan-
treatment was initiated within 90 Interventions to develop more guage or cultural barriers, trans-
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1548 | Commentaries | Peer Reviewed | Plescia and White American Journal of Public Health | September 2013, Vol 103, No. 9