October is Breast Cancer Awareness Month, an annual campaign to increase awareness of the disease and to encourage preventive measures and early detection.  According to The Centers for Disease Control and Prevention (CDC), in 2009[1], approximately 211,700 women in the United States were diagnosed with breast cancer.[2]

According to the American Cancer Society (ACS), breast cancer is the most common cancer among women in this country, except for skin cancers, and about one in eight women in the U.S. will develop invasive breast cancer during their lifetime.[3]  The ACS provides specific recommendations for early breast cancer detection.  These recommendations include yearly mammograms starting at age 40 and continuing for as long as a woman is in good health.  ACS recommends that women are informed of the benefits, limitations, and potential harms associated with regular screenings.  In addition, clinical breast exams are recommended about every three years for women in their 20s and 30s, and every year for women 40 and older.[4]

Public Health Management Corporation’s Center for Data Innovation and Community Health Data Base (CHDB) track utilization of preventive health screenings, including mammograms and clinical breast exams, through the Southeastern Pennsylvania (SEPA) Household Health Survey.  The Household Health Survey is a telephone survey of more than 10,000 households in the SEPA region, including Bucks, Chester, Delaware, Montgomery, and Philadelphia Counties.  The survey asks female respondents about how long it has been since their last mammogram (for women 40+) or clinical breast exam (for women 18+) and provides a range of timeframes as response options. 

This article uses data from the 2012 SEPA Household Health Survey to examine regional use of these important breast health screenings.

Clinical Breast Exam

According to the ACS, clinical breast exams (CBE) work side-by-side with mammograms and provide an opportunity for women and their health care providers to discuss early detection testing and possible risk factors.[5]

• In the Southeastern Pennsylvania Region, one-third of women 18 years of age or older (33%) did NOT have a clinical breast exam in the past year, representing approximately 552,900 women.
• When looking at age breakdowns and whether or not women age 40 and older in this region are following the ACS’s guidelines, it is evident that many women are forgoing this health screening.
  •  Approximately 352,900 women 40+ did not receive a clinical breast exam in the past year (32%).
  • Specifically, three in ten women 40-49 did not receive a clinical breast exam in the past year (30%), 31% of women 50-59, 27% of women 60-74, and 44% of women 75+.
• There is little variation in the percentages of women 18 years of age or older who have not received a breast exam in the past year among the Southeastern Pennsylvania Counties.
• More than one-half of Asian women 18 years of age or older (53%) did not have a breast exam in the past year compared with one-third of White women and Latina women (33%), 29% of Black women, and 37% of women who identify as an Other race/ethnicity. (Figure 1)
• When looking at educational attainment, women 18 years or older with less than a high school degree are more likely to not have had a clinical breast exam in the past year (43%) compared with 40% of women with a high school degree, 34% of women with some college or a technical degree, and 25% of women with a college degree or more.
• Women 18 years of age or older living below 100% of the Federal Poverty Level are more likely to have forgone a clinical breast exam in the past year (40%) compared with 32% of women at or above 100% of the Federal Poverty Level. 

Mammogram

According to the ACS, evidence supporting the benefit of yearly mammograms for women 40 years of age or older is even stronger than in the past and confirms the substantial benefit for women in this age group.  At the same time, mammograms do have limitations, which health care providers should discuss with their patients.[6]

• Nearly four in ten women 40 years of age or older (37%) did NOT have a mammogram in the past year, representing an estimated 418,100 women.
• Women between the ages of 40-49 and 50-59 are slightly more likely to not have had a mammogram in the past year (40% and 37% respectively) compared with women 60-74 (30%).  Women 75 and older are the most likely to have forgone a mammogram in the past year (44%).
•  Women 40 years of age and older in Bucks and Chester Counties are more likely to not have had a mammogram in the past year (41% and 40% respectively) compared with 36% of women in Delaware County and 35% of women in Montgomery and Philadelphia Counties.
• Similar to clinical breast exams, Asian women 40 years of age and older are more likely to not have had a mammogram in the past year (52%) compared with White women and Latina women (38%), Black women (30%), and women of an Other race/ethnicity (45%). (Figure1)
•  As educational attainment increases, the percentage of women (40+) who did not have a mammogram in the past year decreases.  Specifically, 43% of women with less than a high school degree did not get screened in the past year, 40% of women with a high school degree, 36% of women with some college or a technical degree, and 32% of women with a college degree or more.
• Women (40+) living below 100% of the Federal Poverty Level are slightly more likely to have forgone a mammogram in the past year (41%) compared with non-poor women (36%).

Breast Health Screenings and Access to Care Indicators

• Women 18 years of age or older who do not have a regular source of care are more than twice as likely to not have had a breast exam in the past year (12%) compared with those with a regular source of care (6%).
• Uninsured women 18 years of age or older are three times more likely to not have had a breast exam in the past year (18%) compared with women with health insurance (6%).  Similarly, uninsured women 40 years of age or older are three times more likely to not have had a mammogram in the past year (12%) compared with insured women (4%). (Figure 2)
• Women who were sick at some point in the last year, but did not seek care due to the cost are less likely to have had a breast exam (for women 18+) (18% compared with 10%) and a mammogram (for women 40+) (15% compared with 7%) than women who did not experience cost barriers to care.

Conclusion

It is clear that breast cancer continues to present a serious health challenge to women in this country, and mammograms and clinical breast exams play an important role in early detection and overall breast health awareness.  Many women in the Southeastern Pennsylvania region, specifically, are not receiving regular clinical breast exams and mammograms.  Cost-related and other barriers to health care, including a lack of health insurance and a regular source of care, are key factors in women forgoing these preventive health screenings.   

For more information about these findings, please contact Sarah Ingerman at singerman@phmc.org.