Effectiveness in Disease and Injury Prevention Program to Increase the Accessibility of Screening Mammography --- Rhode Island, 1987 - 1988

The Rhode Island Department of Health's (RIDH) Breast Cancer Screening Program (RIBCSP) was initiated in 1987; it includes a broad promotional effort targeting women and physicians, a strong quality-assurance program, reductions in the cost of the breast cancer screening examination, and a telephone appointment and tracking system for screening examinations and follow-up care. This report describes and summarizes an evaluation of the RIBCSP.

Although the program is designed to increase the use of mammography among all Rhode Island women, the telephone appointment and tracking system was implemented specifically to meet the needs of three target groups: women whose primary-care providers do not recommend mammography, women who do not have a primary-care provider, and women of low income. The system serves as a referral for mammography, schedules appointments for screening mammograms, and links women who have abnormal mammography results with a primary-care physician.

To be eligible, participants must be at least 40 years of age, be neither pregnant nor breastfeeding, have no breast symptoms (e.g., pain, a palpable mass, or nipple discharge), not have had a mammogram within the preceding 12 months, and agree to provide informed consent and permit clinical follow-up. Mammograms obtained through the appointment system cost $50; for low-income women, they are provided at lower or no cost. Print and broadcast media have been used to publicize the system throughout the state.

To evaluate the program, the RIDH conducted two telephone surveys. First, in September 1987, random-digit--dialing was used to identify a representative sample of 852 women greater than or equal to 40 years of age to establish baseline data about knowledge, attitudes, and behavior regarding breast cancer screening in Rhode Island and to characterize women in the three target populations. Second, in October 1988, 350 women who had telephoned (i.e., ``callers'') the appointment system were interviewed about their experiences in the system and with breast cancer screening.

Compared with the representative sample of Rhode Island women aged greater than or equal to 40 years, callers were more likely to have received a provider's recommendation for screening mammography (54% vs. 44%), have no primary-care provider (24% vs. 19%), and have a family income 200% or more of the federal poverty level (71% vs. 57%).

Among women who had never received a provider's recommendation for screening mammography, callers were younger, more affluent, and better educated than women in the statewide survey (Table 1). In addition, callers were less likely to be married and more likely to have ever had a mammogram (39% vs. 29%). Among women without a primary-care provider, callers were better educated and more affluent than women in the statewide sample and, although they were similar with respect to ever having had a mammogram (49% vs. 46%), callers were less likely to have had a mammogram recently.* Compared with other low-income women in the statewide sample, low-income callers were more likely to be older, to have a high school diploma, and to be currently married. Low-income callers were less likely ever to have had a mammogram, and far less likely than their counterparts in the state to have had a mammogram recently.

In each of the three target groups, a minimum of 93% of callers participated in screening, including 97% of those without primary-care providers. In each group, 1%--4% of women missed initial appointments made through the system but were generally screened within 30 days. Two percent to 4% had not been screened by the time of the survey. Of those women screened, 13% had abnormal results. In each of the three target populations, 86%--93% of women with abnormal results had contacted a provider after being notified about the need for additional testing or treatment. However, women in low-income groups were less likely (86%) to have done so than women in other target groups (92%--93%). All women with abnormal findings received intensive follow-up by the RIBCSP and eventually were evaluated by a physician. Reported by: JP Fulton, PhD, EF Donnelly, MPH, JP Feldman, MD, DF DiOrio, MEd, JS Buechner, PhD, HD Scott, MD, BA DeBuono, MD, State Epidemiologist, Rhode Island Dept of Health. Cancer Prevention and Control Br, Div of Chronic Disease Control and Community Intervention, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note:

Breast cancer is a leading cause of death from cancer among women in the United States (1). Although early detection with mammography reduces breast cancer mortality, many women do not receive mammograms according to current guidelines for at least three reasons (2). First, the use of mammography is strongly influenced by providers\' recommendations (3,4). Second, many radiologists will not accept patients for mammography if they have not been referred by a physician because of the need for follow-up when results are abnormal (5). Third, the cost of a mammographic examination may limit access for women of low income (6--8).

Because physicians in Rhode Island and other states are actively promoting screening mammography (9,10), the RIDH is modifying the telephone appointment system to focus more on low-income women, especially those with no health insurance. In addition, the system's original publicity strategy has been supplanted by such methods as peer recruitment among low-income women, regular reminders to women who use neighborhood health centers for primary health care, and a multifaceted media campaign (e.g., posters, selected radio stations, and community newspapers). Mammograms provided by this system continue to cost less than or equal to $50.

In Rhode Island, the telephone appointment system has been successful in providing screening mammography for callers and ensuring follow-up for women who have abnormal mammography results. As a growing proportion of Rhode Island women begin to participate in breast cancer screening and as providers become more active in referring women for mammography, the RIBCSP is placing greater emphasis on meeting the screening needs of low-income women. Clerical procedures are being modified to improve the cost-effectiveness of client tracking.

References

1. Gloeckler-Ries LA, Hankey BF, Edwards BK, eds. Cancer statistics review, 1973--1987. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1990; NIH publication no. 90-2789.

2. Dawson DA, NCHS. Breast cancer risk factors and screening: United States, 1987. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1990; DHHS publication no. 90-1500. (Data from the National Health Interview Survey; series 10, no. 172).

3. Fox SA, Klos DS, Tsau CV. Underuse of screening mammography by family physicians. Radiology 1988;166:431--4.

4. NCI Breast Cancer Screening Consortium. Screening mammography---a missed clinical opportunity? Results of the NCI Breast Cancer Screening Consortium and National Health Interview Survey studies. JAMA 1990;264:54--8.

5. Sickles EA. Mammography screening and the self-referred woman. Radiology 1988;166:271--3.

6. Destouet JM, Monsees B. Low-cost breast screening program takes to the road in St. Louis. Diagnostic Imaging 1987;35:81--9.

7. Burack RC, Liang J. The early detection of cancer in the primary care setting: factors associated with the acceptance and completion of recommended procedures. Prev Med 1987;16:739--51.

8. National Cancer Institute. Mammography screening: state level activities and a review of the literature. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1989.

9. CDC. Trends in breast cancer screening---Rhode Island, 1987--1989. MMWR 1989;38:569--71. 10. American Cancer Society. Survey of physicians' attitudes and practices in early cancer detection. CA 1990;402:77--99. *Recent mammography was defined as: a mammogram within 2 years of the survey for women aged 40--49 years and a mammogram within 1 year of the survey for women aged greater than or equal to 50 years. Not recent mammography was defined as: a mammogram greater than 2 years before the survey for women aged 40--49 years and a mammogram greater than 1 year before the survey for women aged greater than or equal to 50 years.

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