Mammography and Clinical Breast Examinations Among Women Aged 50 Years and Older -- Behavioral Risk Factor Surveillance System, 1992

Breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer deaths among women in the United States (1). A national health objective for the year 2000 is to reduce breast cancer deaths to no more than 20.6 per 100,000 women (age-adjusted baseline: 22.9 per 100,000 women in 1987) (objective 16.3) (2). To increase early detection of breast cancer, CDC's National Breast and Cervical Cancer Early Detection Program recommends use of mammography and clinical breast examinations at prescribed intervals, especially for older, minority, poor, and less educated women. For asymptomatic women aged greater than or equal to 50 years, the American Cancer Society (ACS) and the National Cancer Institute (NCI) recommend both an annual screening mammogram and an annual screening clinical breast examination as essential elements of routine preventive health services (3). This report summarizes state-specific and state-aggregate findings from CDC's 1992 Behavioral Risk Factor Surveillance System (BRFSS) regarding use of screening mammography, screening clinical breast examination, and both examinations among women aged greater than or equal to 50 years.

In 1992, health departments in 48 states and the District of Columbia participated in the BRFSS using a standard questionnaire to conduct random-digit-dialed telephone surveys in which each state selected a multistage probability sample of adults aged greater than or equal to 18 years (4); this report presents state-specific and state-aggregate results for female respondents aged greater than or equal to 50 years. The questionnaire included questions about clinical breast examination (defined as an examination during which a doctor, nurse, or other medical professional felt the breast for lumps) and mammography. This report is restricted to screening examinations (defined as an examination that was part of a routine check-up). Women who reported that they had ever had a mammogram or clinical breast examination were asked the duration since their last examination and whether the last examination was part of a routine check-up, because of a breast problem other than cancer, or because of previously diagnosed breast cancer.

In 1992, the percentages of women aged greater than or equal to 50 years who reported receiving screening examinations for breast cancer during the year preceding the interview varied widely among the states (Table_1). The percentage of women who reported having had a mammogram ranged from 32.4% to 60.2% (median: 45.1%); a clinical breast examination, from 37.6% to 72.9% (median: 56.9%); and both examinations, from 22.8% to 55.0% (median: 38.8%) (Table_1). Overall, 39.8% of women reported having had both examinations during the year preceding the interview (Table_2).

Respondents were more likely to report having had a clinical breast examination (57.5%) than a mammogram (46.1%) during the year preceding the interview (Table_2). Of women who reported having had a clinical breast examination, 30.8% had that procedure only; of those who reported having had a mammogram, 13.7% had that procedure only. The percentage of women reporting having had either or both examinations during the year preceding the interview increased with years of education and with income but decreased with age (Table_2). There were no differences across racial/ethnic groups in the prevalence of breast cancer screening. Reported by the following BRFSS coordinators: L Eldridge, Alabama; P Owen, Alaska; J Contreras, Arizona; L Lund, California; M Leff, Colorado; M Adams, Connecticut; F Breukelman, Delaware; C Mitchell, District of Columbia; D McTague, Florida; E Pledger, Georgia; VF Ah Cook, Hawaii; J Mitten, Idaho; B Steiner, Illinois; R Guest, Indiana; S Schoon, Iowa; K Pippert, Kansas; K Bramblett, Kentucky; S Kirkconnell, Louisiana; R Schwartz, Maine; A Weinstein, Maryland; R Lederman, Massachusetts; H McGee, Michigan; N Salem, Minnesota; E Jones, Mississippi; J Jackson-Thompson, Missouri; P Smith, Montana; S Huffman, Nebraska; M Atherton, Nevada; K Zaso, New Hampshire; G Boeselager, New Jersey; L Pendley, New Mexico; C Baker, New York; CR Washington, North Carolina; M Maetzold, North Dakota; E Capwell, Ohio; N Hann, Oklahoma; J Grant-Worley, Oregon; C Becker, Pennsylvania; J Buechner, Rhode Island; M Lane, South Carolina; B Miller, South Dakota; D Ridings, Tennessee; R Diamond, Texas; R Giles, Utah; P Brozicevic, Vermont; R Schaeffer, Virginia; T Jennings, Washington; F King, West Virginia; E Cautley, Wisconsin. Disease Surveillance Br, and Behavioral Risk Factor Surveillance Br, Office of Surveillance and Analysis, and Div of Cancer Prevention and Control, and Office of the Director, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Mammography and clinical breast examination combined are more effective in detecting breast cancer than either examination alone (5), and ACS and NCI guidelines for breast cancer screening recommend that women aged greater than or equal to 50 years receive both examinations annually. The BRFSS findings described in this report indicate that, during the year preceding the survey, approximately 64% of the women aged greater than or equal to 50 years reported having had either a screening clinical breast examination or a screening mammogram; however, a substantially lower percentage reported having both examinations. The prevalence of incomplete screening may reflect the practices of respondents' physicians, differential recall by respondents of having had examinations, or differential compliance by respondents. In addition, women who had clinical breast examinations were more likely to have had that procedure only than women who had mammograms; the most important factor in influencing women to have a mammogram is encouragement from physicians (6), but the medical specialty, age, and sex of the physician may influence provision of screening services (7).

Because the risk for breast cancer increases with age (8), the finding in this report that the percentage of women who reported having had breast cancer screening examinations decreased dramatically with age is of particular concern. Even though the sensitivity of both clinical breast examination and mammography to detect breast cancer increases with age (9), the BRFSS findings indicate that women in the older age groups, who are at highest risk for breast cancer, are least likely to receive breast cancer screening. Reasons for the decreased use are unclear but may include an inaccurate perception among older women of their actual risk for breast cancer (i.e., that risk increases with age), the belief that breast cancer screening examinations are necessary only if a lump is detected during breast self-examination, and the inability of women on limited incomes to pay for annual examinations. In addition, some women aged greater than or equal to 65 years may be unaware that screening mammography on a biennial basis is a reimbursable benefit of Medicare.

The BRFSS findings also are consistent with previous reports indicating that the levels of breast cancer screening are lowest among women with less than a high school education and with low incomes. Barriers to screening among women of low socioeconomic status include limited access to health care, the cost of screening, and fear of finding breast cancer (10). The differences in the level of compliance with the breast cancer screening recommendations across age groups and income and educational levels were greater than those across racial/ethnic groups, reinforcing the need for intervention programs directed toward older, poorer, and less educated women regardless of race or ethnicity.

The importance of breast cancer screening should be emphasized through continuing physician education and public awareness campaigns. These efforts should be aimed at increasing 1) the percentage of women who receive both clinical breast examinations and mammograms; 2) the level of screening among women aged greater than or equal to 50 years, women with incomes less than $10,000 per year, and women with less than a high school education; and 3) the overall level of screening among all women. To increase access to breast cancer screening, physician education, and public awareness, CDC implemented the National Breast and Cervical Cancer Early Detection Program in 1991. This comprehensive program assists state health agencies in developing effective public health support systems for the early detection process (11).

October is National Breast Cancer Awareness Month. During this month, nationwide educational activities are planned to increase the public's awareness of the importance of screening for breast cancer. Additional information is available from the American Cancer Society, telephone (800) 227-2345 or the National Cancer Institute's Cancer Information Service, telephone (800) 422-6237.

References

1. American Cancer Society. Cancer facts and figures, 1992. Atlanta: American Cancer Society, 1992; publication no. 5008.920LE.

2. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

3. Hayward RSA, Steinberg EP, Ford DE, Roizen MF, Roach KW. Preventive care guidelines: 1991. Ann Intern Med 1991;114:758-83.

4. Frazier EL, Franks AL, Sanderson LM. Behavioral risk factor data. In: CDC. Using chronic disease data: a handbook for public health practitioners. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992:4-1-4-17.

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

6. Grady KE, Lemkau JP, McVay JM, Reisine ST. The importance of physician encouragement in breast cancer screening of older women. Prev Med 1992;21:766-80.

7. Lurie N, Slater J, McGovern P, Ekstrum J, Quam L, Margolis K. Preventive care for wom en: does the sex of the physician matter? N Engl J Med 1993;329:478-82.

8. Qualters JR, Lee NC, Smith RA, Aubert RE. Breast and cervical cancer surveillance -- United States, 1973-1987. In: CDC surveillance summaries (April). MMWR 1992;41(no. SS-2):1-15.

9. Foster RS, Worden JK, Costanza MC, Solomon LJ. Clinical breast examination and breast self-examination: past and present effect on breast cancer survival. Cancer 1992; 69(suppl):1992-8.

10. Harper AP. Mammography utilization in the poor and medically underserved. Cancer 1993; 72(suppl):1478-82.

11. CDC. Update: National Breast and Cervical Cancer Early Detection Program, 1992-1993. MMWR 1993;42:747-9.

Table_1
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TABLE 1. Percentage of women aged >=50 years who reported having had a screening *
mammogram, a screening clinical breast examination, + or both during the year
preceding the interview, by state -- Behavioral Risk Factor Surveillance System, 1992 &
==========================================================================================================
                                                             Clinical
                                  Mammogram             breast examination           Both examinations
                             -------------------        --------------------        --------------------
State                         %       (95% CI @)          %        (95% CI)           %        (95% CI)
--------------------------------------------------------------------------------------------------------
Alabama                      49.6      (+/- 5.0)         59.7      (+/- 4.9)         42.1      (+/- 5.1)
Alaska                       53.7      (+/-10.7)         66.3      (+/-10.1)         48.2      (+/-11.0)
Arizona                      40.7      (+/- 6.8)         51.1      (+/- 6.4)         34.3      (+/- 6.1)
California                   53.7      (+/- 4.0)         58.5      (+/- 4.0)         45.3      (+/- 4.0)
Colorado                     51.0      (+/- 5.8)         67.3      (+/- 5.4)         44.3      (+/- 6.0)
Connecticut                  54.0      (+/- 5.2)         64.8      (+/- 4.9)         46.4      (+/- 5.3)
Delaware                     48.9      (+/- 5.6)         60.6      (+/- 5.5)         44.3      (+/- 5.4)
District of Columbia         60.2      (+/- 6.1)         72.9      (+/- 5.3)         55.0      (+/- 6.1)
Florida                      46.9      (+/- 4.0)         58.9      (+/- 3.9)         40.3      (+/- 3.9)
Georgia                      42.3      (+/- 5.0)         57.7      (+/- 5.6)         38.0      (+/- 5.0)
Hawaii                       45.1      (+/- 6.2)         37.6      (+/- 6.4)         22.8      (+/- 5.4)
Idaho                        36.0      (+/- 5.4)         55.3      (+/- 5.5)         33.7      (+/- 5.3)
Illinois                     46.4      (+/- 4.7)         66.4      (+/- 4.7)         44.6      (+/- 4.7)
Indiana                      38.4      (+/- 4.5)         47.7      (+/- 4.5)         31.2      (+/- 4.2)
Iowa                         43.3      (+/- 5.0)         54.3      (+/- 5.0)         39.5      (+/- 4.8)
Kansas                       42.0      (+/- 5.8)         54.1      (+/- 5.9)         37.7      (+/- 5.7)
Kentucky                     36.8      (+/- 4.4)         46.7      (+/- 4.6)         32.9      (+/- 4.3)
Louisiana                    41.8      (+/- 5.7)         45.6      (+/- 5.5)         33.9      (+/- 5.3)
Maine                        53.8      (+/- 6.4)         64.9      (+/- 6.2)         49.5      (+/- 6.4)
Maryland                     51.3      (+/- 5.4)         68.5      (+/- 5.1)         48.4      (+/- 5.4)
Massachusetts                50.0      (+/- 6.5)         56.9      (+/- 6.5)         40.3      (+/- 6.4)
Michigan                     50.6      (+/- 4.6)         53.0      (+/- 4.4)         41.2      (+/- 4.5)
Minnesota                    50.5      (+/- 3.8)         57.4      (+/- 3.9)         43.3      (+/- 3.8)
Mississippi                  32.4      (+/- 5.1)         49.0      (+/- 5.4)         27.0      (+/- 4.7)
Missouri                     45.2      (+/- 5.9)         59.8      (+/- 5.4)         40.1      (+/- 5.7)
Montana                      42.3      (+/- 6.3)         58.2      (+/- 6.3)         36.2      (+/- 6.2)
Nebraska                     34.3      (+/- 5.1)         49.0      (+/- 5.3)         29.8      (+/- 4.9)
Nevada                       43.2      (+/- 5.8)         49.9      (+/- 5.9)         33.5      (+/- 5.5)
New Hampshire                49.4      (+/- 6.2)         52.6      (+/- 6.2)         40.2      (+/- 6.1)
New Jersey                   41.0      (+/- 5.8)         55.1      (+/- 6.0)         36.9      (+/- 5.7)
New Mexico                   50.1      (+/- 6.4)         55.3      (+/- 6.8)         40.4      (+/- 6.5)
New York                     44.8      (+/- 5.1)         60.2      (+/- 4.7)         40.4      (+/- 4.9)
North Carolina               45.8      (+/- 4.8)         65.0      (+/- 4.6)         42.6      (+/- 4.7)
North Dakota                 43.2      (+/- 5.4)         52.5      (+/- 5.4)         36.9      (+/- 5.2)
Ohio                         42.8      (+/- 5.9)         59.8      (+/- 5.8)         38.8      (+/- 5.8)
Oklahoma                     41.3      (+/- 5.0)         58.4      (+/- 5.0)         38.2      (+/- 5.0)
Oregon                       49.9      (+/- 3.7)         60.0      (+/- 3.7)         42.6      (+/- 3.7)
Pennsylvania                 48.6      (+/- 4.5)         54.6      (+/- 4.5)         38.6      (+/- 4.4)
Rhode Island                 51.5      (+/- 5.1)         61.8      (+/- 5.3)         41.8      (+/- 5.1)
South Carolina               41.6      (+/- 5.2)         52.3      (+/- 5.1)         36.0      (+/- 5.1)
South Dakota                 41.0      (+/- 4.9)         52.3      (+/- 5.0)         32.9      (+/- 4.8)
Tennessee                    38.0      (+/- 4.2)         60.5      (+/- 4.3)         33.9      (+/- 4.1)
Texas                        45.4      (+/- 4.9)         55.7      (+/- 5.0)         38.8      (+/- 4.8)
Utah                         41.0      (+/- 5.5)         51.8      (+/- 5.9)         35.5      (+/- 5.3)
Vermont                      51.2      (+/- 5.0)         66.7      (+/- 4.8)         47.0      (+/- 5.1)
Virginia                     50.3      (+/- 5.6)         54.1      (+/- 5.8)         37.9      (+/- 5.6)
Washington                   48.4      (+/- 4.6)         59.7      (+/- 4.5)         42.0      (+/- 4.6)
West Virginia                34.4      (+/- 3.9)         48.8      (+/- 4.2)         29.1      (+/- 3.7)
Wisconsin                    41.1      (+/- 6.4)         54.7      (+/- 6.5)         34.4      (+/- 6.2)

Median                             45.1                       56.9                       38.8
--------------------------------------------------------------------------------------------------------
* Defined as an examination that was part of a routine check-up.
+ An examination during which a doctor, nurse, or other medical professional felt the breast for lumps.
& Data were weighted to the age, race, and sex distribution and probability of selection in each state.
@ Confidence interval.
==========================================================================================================

TABLE 2. Percentage of women aged >=50 years who reported having had a screening *
mammogram, a screening clinical breast examination, + or both during the year
preceding the interview, by age group, race/ethnicity, & level of education, @ and income
-- Behavioral Risk Factor Surveillance System, 1992 **
================================================================================================
                                                             Clinical
                                                              breast                Both
                                        Mammogram           examination         examinations
                          Sample    ------------------    ----------------    ----------------
Category                   size       %    (95% CI ++)     %     (95% CI)      %     (95% CI)
----------------------------------------------------------------------------------------------
Age group (yrs)
  50-54                    3,435     50.8    (+/-2.4)     63.7    (+/-2.3)    45.2    (+/-2.4)
  55-59                    3,099     51.6    (+/-2.6)     61.3    (+/-2.5)    45.2    (+/-2.6)
  60-64                    3,248     48.2    (+/-2.5)     58.4    (+/-2.5)    42.2    (+/-2.5)
  65-69                    3,420     47.7    (+/-2.5)     57.5    (+/-2.4)    41.0    (+/-2.5)
  70-74                    3,246     45.7    (+/-2.5)     55.7    (+/-2.5)    39.0    (+/-2.5)
   >=75                    5,153     35.6    (+/-1.9)     50.4    (+/-2.0)    29.1    (+/-1.8)

Race/Ethnicity
  White, non-Hispanic     18,694     46.3    (+/-1.0)     57.8    (+/-1.0)    40.1    (+/-1.0)
  Black, non-Hispanic      1,688     45.3    (+/-3.5)     58.0    (+/-3.5)    38.4    (+/-3.4)
  Hispanic &&                670     44.7    (+/-5.7)     52.8    (+/-5.7)    38.6    (+/-5.6)

Education (yrs)
  <12                      5,911     35.4    (+/-1.8)     46.7    (+/-1.9)    27.9    (+/-1.7)
   12                      7,940     47.7    (+/-1.6)     59.3    (+/-1.6)    41.4    (+/-1.6)
  >12                      7,679     52.3    (+/-1.7)     63.6    (+/-1.6)    46.8    (+/-1.7)

Annual income
         <$10,000          5,206     34.3    (+/-2.0)     47.9    (+/-2.1)    28.4    (+/-1.9)
  $10,000-$20,000          4,986     43.9    (+/-2.1)     55.8    (+/-2.0)    36.8    (+/-2.0)
         >$20,000          7,232     54.1    (+/-1.7)     64.9    (+/-1.6)    48.3    (+/-1.7)
  Unknown/Refused          4,177     45.7    (+/-2.2)     55.2    (+/-2.2)    38.8    (+/-2.2)

Total                     21,601     46.1    (+/-1.0)     57.5    (+/-1.0)    39.8    (+/-1.0)
----------------------------------------------------------------------------------------------
 * Defined as an examination that was part of a routine check-up.
 + An examination during which a doctor, nurse, or other medical professional felt the breast
   for lumps.
 & A total of 549 respondents identified themselves as other than black, white, or Hispanic;
   the numbers in the "other" category were too small for analysis.
 @ A total of 71 respondents refused to provide years of education or reported that they did
   not know; the numbers were too small for analysis.
** Aggregated, weighted data.
++ Confidence interval.
&& Persons of Hispanic origin may be of any race.
================================================================================================

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