In the U.S., cancer remains the second leading cause of mortality, behind heart disease. Among women, breast cancer is the most frequently diagnosed form of cancer and the second leading cause of cancer-related mortality. Early detection, through regular mammograms and clinical breast exams, while not foolproof, remains critical in identifying early stages of malignancy, which may prevent early mortality. With advancements in both early detection and medical treatment options, the relative five-year survival rate for women diagnosed with breast cancer is roughly 90%. Nearly 35 years ago, the relative five-year survival rate for women diagnosed with breast cancer was approximately 75%.

In recognition of October as Breast Cancer Awareness Month, the following article presents information from PHMC’s 2006 Household Health Survey on breast cancer screenings among women residing in the five-county Southeastern Pennsylvania (SEPA) region. More specifically, this article focuses on mammogram screenings among women 40 years of age and older and clinical breast exam screenings among women 18 years of age and older. According to the American Cancer Society’s Guidelines for Early Breast Cancer Detection, women 40 years of age and older, at average risk, should receive an annual mammogram and depending upon age, women of average risk should receive a clinical breast every year or three years. This article focuses primarily on women who have not received either screening within the past year.

Breast cancer mortality, SEPA

The Healthy People 2010 initiative, which establishes and promotes national health benchmarks for various health domains, specifically aims to reduce mortality associated with breast cancer to 22.3 deaths per 100,000 females by 2010. Within the SEPA region, however, the average annualized (1999-2002) mortality rate from breast cancer is 30.7 deaths per 100,000 females. According to the American Cancer Society, racial and ethnic disparities have been identified for breast cancer mortality—with African-American women more likely than their racial and ethnic counterparts to die from the disease. Similar to national trends, locally, the breast cancer mortality rate is highest for African-American women (39.8), followed by White (29.3), Latina (20.7), and Asian (11.7) women in SEPA.

Mammogram and clinical breast exam screenings, SEPA

Within Southeastern Pennsylvania, more than one-third of women 40 years of age and older (34.9%) have not had a mammogram within the past year; this percentage amounts to approximately 351,000 women in the region. Moreover, 12.4% of women 40 years of age and older either received their last mammogram screening more than five years ago or have never received a mammogram screening. With some fluctuation over the past decade, the percentage of women 40 years of age and older who have not received a mammogram within the past year has hovered around one-third (Figure 1). In addition, more than one-quarter of women 18 years of age and older (27.0%) have not had a clinical breast exam within the past year. The percentage of women 18 years of age and older who have not received this exam within the past year has increased slightly over the past decade (Figure 1).

Demographic characteristics of women not screened within the past year, SEPA

Among population subgroups, a woman’s risk of developing breast cancer gradually increases with age. And while, nationally, white women are more likely to be diagnosed with breast cancer, compared to their racial and ethnic counterparts, African-American women are more likely to die from the disease. Therefore, receiving timely mammogram and clinical breast exam screenings may lead to early detection, when the prognosis is better.

· In the SEPA region, nearly two-fifths of women 40-49 years (41.3%) have not received a mammogram within the past year, compared to women 50-59 years (32.7%), women 60-74 years (29.1%), and women 75+ years (35.2%).  Nearly one-third of women 75+ years (32.0%) did not receive a clinical breast exam in the past year, while younger age groups hover around roughly one-quarter: 18-29 years (28.0%), 30-39 years (25.4%), 40-49 years (26.6%), 50-59 years (26.3%), and 60-74 years (26.2%).

· Two-fifths of Latina women (40+ years) have not received a mammogram in the past year (39.8%), compared to African-American (34.5%) and white (34.3%) women. Latina women (18+ years) are also more likely than their racial and ethnic counterparts to have not had a clinical breast exam within the past year: 36.0% (Latina women), 26.0% (African-American women), and 25.8% (white women).

· More than two-fifths of women (40+ years) living below 150% of the Federal Poverty Level (45.2%), compared to one-third of women living at or above poverty (32.4%), have not had a mammogram within the past year. Similarly, nearly two-fifths of women (18+ years) living below 150% of poverty (38.6%), compared to nearly one-quarter of women living at or above poverty (23.9%), have not had a clinical breast exam in the past year.

Access to care, SEPA

Having access to a regular source of care can help ensure that routine preventive screenings, including mammograms and clinical breast exams, are performed in a timely manner. However, for women without access to health care services, receiving these vital screenings can be delayed.

· In SEPA, more than one-half of women (40+ years) without a regular source of care (53.4%), compared to one-third of women with a regular source of care (33.7%), did not receive a mammogram in the past year (Figure 2). Moreover, more than two-fifths of women (18+ years) without a regular source of care (44.9%), compared to one-quarter of women with a regular source of care (25.6%), have not received a clinical breast exam in the past year.

· More than two-thirds of women (40+ years) without any form of public or private health insurance coverage (68.9%), compared to one-third of insured women (33.3%), have not had a mammogram within the past year (Figure 2).  In addition, three-fifths of women (18+ years) without health insurance coverage (57.0%), compared to one-quarter of women with health insurance coverage (24.8%), have not had a clinical breast exam in the past year.

Conclusion

Findings presented in this article reveal that specific population subgroups have not received breast cancer screenings. More specifically, Latina women are more likely than African-American and white women to have not received a mammogram screening or a clinical breast exam screening within the past year. Also, women living below 150% of the Federal Poverty Level are more likely than women living at or above the poverty level have not received a mammogram or a clinical breast exam within the past year. In addition, barriers to care, such as no health insurance coverage or no regular source of care, also impact opportunities to receive preventive screenings. Women without a regular source of care are more likely than women with a regular source of care to have not received a mammogram or a clinical breast exam in the past year. And women without health insurance coverage are more than twice as likely as women with health insurance coverage to have not received a mammogram or clinical breast exam within the past year. As the Healthy People 2010 deadline approaches, of which reducing breast cancer mortality remains an important target, receiving timely screenings can help in early detection and increased treatment options. For more information about the findings presented in this article, please contact Nicole Dreisbach at nicoled@phmc.org.

References:
National Cancer Institute. Fact Sheet: Cancer Advances in Focus, Breast Cancer. Bethesda: National Cancer Institute, 2007. Available at:  http://www.cancer.gov/aboutnci/cancer-advances-in-focus/breast

American Cancer Society, American Cancer Society Guidelines for the Early Detection of Cancer. Atlanta: American Cancer Society, 2007. Available at: ttp://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp

American Cancer Society, Cancer Facts and Figures 2007. Atlanta: American Cancer Society, 2007. Available at: http://www.cancer.org/downloads/STT/CAFF2007PWSecured.pdf

Smith, RA, et al. (2003). American Cancer Society Guidelines for Breast Cancer Screening: Update 2003. CA: A Cancer Journal for Clinicians, 53, 141-169.

Notes:
Data do not include Asian adults, due to a small sample size.

Age-adjusted death rates are the number of deaths for any death or a cause-specific death, with age-adjustments. Age-adjusted rates are computed by the direct method, using the 2000 U.S. standard million population. Rates are per 100,000 population.