Trends in Breast Cancer Screening -- Rhode Island, 1987-1989

In November 1987, the Rhode Island Department of Health initiated the Breast Cancer Screening Program in an effort to reduce breast cancer mortality by promoting regular screening for breast cancer, including physical breast examination and mammography, for women aged greater than or equal to 40 years (1). The program involves promotion, quality assurance, reduced charge for screening mammograms, and a system to facilitate self-referral for mammography. State legislation was independently enacted to require all private health insurers to cover screening mammograms as of September 1988.

To evaluate the program, surveys of Rhode Island women aged greater than or equal to 40 years were conducted before (September and October 1987) and after (January-April 1989) the program started. In both surveys, women were interviewed about their knowledge, attitudes, and practices related to screening for breast cancer; in the second survey, questions about awareness of the program were added. The two independent samples of Rhode Island households were selected by random-digit-dialing. Households that could be contacted were assessed for the presence of women aged greater than or equal to 40 years. In households with more than one possible respondent, one respondent was selected randomly. (Because the percentage of such households was 6% in 1987 and 5% in 1989, the analysis was not adjusted for the lower probability of selecting women living in households with other potential respondents.) In 1987, 852 interviews were completed (response rate of 78%); in 1989, 856 interviews were completed (response rate of 79%).

In 1989, 46% of women aged greater than or equal to 40 years reported having had a mammogram (screening or diagnostic) within the past year, compared with 37% in 1987. The proportion who reported having had a screening mammogram increased from 31% to 40% (p less than 0.05). In contrast, the proportion who reported having had a physical breast examination changed from 70% in 1987 to 73% in 1989.

For 1989, mammography use rates varied with age, education, and income level (Table 1). For example, the proportion of women below the poverty level who had had a mammogram within the past year increased from 21% in 1987 to 41% in 1989 (p less than 0.05), and the proportion having had a physical breast examination rose from 59% to 73% (p less than 0.05).

The proportion of women aged greater than or equal to 40 years who reported that a health professional had ever recommended a screening mammogram as part of a regular examination increased from 44% in 1987 to 57% in 1989 (p less than 0.05). In particular, 48% of women with incomes below the poverty level reported ever receiving such a recommendation in 1989, compared with 29% in 1987. In 1989, 58% of all women receiving such a recommendation had had a screening mammogram within the past year; in 1987, the proportion was 60%. However, in both surveys, the proportion of women reporting that a health professional had ever recommended a mammogram because of a breast problem was 17%, and the proportion who reported asking for a mammogram was 8% in 1987 and 9% in 1989. Among women who reported that a health professional had never recommended a screening mammogram, 16% in 1989 reported having had a screening mammogram in the past year, compared with 8% in 1987 (p less than 0.05).

The promotional efforts of the Rhode Island program reached greater than 60% of the target group in a relatively short time. Awareness of the program was high, and 33% of women surveyed specifically remembered receiving a promotional letter and brochure by direct mail. Reported by: JS Buechner, PhD, JP Fulton, PhD, JP Feldman, MD, BA DeBuono, MD, State Epidemiologist, Rhode Island Dept of Health. D Kovenock, MS, Northeast Research, Orono, Maine. Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Screening with mammography reduces breast cancer mortality among women aged greater than or equal to 50 years and possibly among women aged 40-49 years (3-7). Eleven national public and private agencies, including the National Cancer Institute and the American Cancer Society, have recommended that breast cancer screening include annual physical breast examinations for women aged greater than or equal to 40 years, annual mammograms for women aged greater than or equal to 50 years, and mammograms every 1 or 2 years for women aged 40-49 years.

Nationally, rates of participation in breast cancer screening are low (8,9); less than 30% of eligible women reported having had a mammogram in the previous year. The results from the Rhode Island surveys and from the 1987 Behavioral Risk Factor Surveillance System (10) indicate that participation rates can change dramatically over short periods. Low-income and less-educated women (who typically are less likely to undergo regular breast cancer screening than women in other groups) can increase their participation in screening (1). The use rates for mammography are only one of many outcome measures appropriate for the evaluation of a program of this kind. The effects of the program will be evaluated using additional data and a variety of analytic methods.

Physicians' recommendations may account for much of the increase in screening rates. However, nearly half of the women surveyed in 1989 reported that no health professional has ever recommended they get a screening mammogram, and an increasing proportion of women who were not referred by a physician for mammography are being screened through self-referral; special attention should be devoted to ensure appropriate follow-up of these women. Many factors may have contributed to the increase in screening rates, e.g., program effects, changes in policy and practice (including the availability of insurance coverage for screening), and national attention to breast cancer. In Rhode Island, adherence to screening guidelines by women and physicians is improving. These trends must continue if breast cancer screening is to become common practice among women at risk.

References

1. CDC. Use of mammography for breast cancer screening--Rhode Island,

1987. MMWR 1988;37:357-60.

2. US Department of Health and Human Services. Annual update of the poverty income guidelines. Federal Register 1988;53:4213-4.

3. Tabar L, Fagerberg CJG, Gad A, et al. Reduction in mortality from breast cancer after mass screening with mammography: randomised trial from the Breast Cancer Screening Working Group of the Swedish National Board of Health and Welfare. Lancet 1985;1:829-32.

4. Verbeek ALM, Hendriks JHCL, Holland R, Mravunac M, Sturmans F, Day NE. Reduction of breast cancer mortality through mass screening with modern mammography: first results of the Nijmegen Project, 1975-1981. Lancet 1984;1:1222-4.

5. Shapiro S, Venet W, Strax P, Venet L. Periodic screening for breast cancer: the Health Insurance Plan Project and its sequelae, 1963-1986. Baltimore: Johns Hopkins University Press, 1988.

6. Seidman H, Gelb SK, Silverberg E, LaVerda N, Lubera JA. Survival experience in the Breast Cancer Demonstration Project. CA 1987;37:258-90.

7. Chu KC, Smart CR, Tarone RE. Analysis of breast cancer mortality and stage distribution by age for the Health Insurance Plan Clinical Trial. JNCI 1988;80:1125-32.

8. CDC. Provisional estimates from the National Health Interview Survey supplement on cancer control--United States, January-March 1987. MMWR 1988;37:417-20,425.

9. CDC. State-to-state variation in screening mammograms for women 50 years of age and older--Behavioral Risk Factor Surveillance System, 1987. MMWR 1989;38:157-60. 10. CDC. Trends in screening mammograms for women 50 years of age and older--Behavioral Risk Factor Surveillance System, 1987. MMWR 1989;38:137-40.

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