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Age, race, income, and other factors contribute to disparities in screening for breast and cervical cancer

Older, poor, and minority women are more likely to die of breast and cervical cancer than other women. Yet these women are less apt to be screened for these diseases than other women. A recent study supported by the Agency for Healthcare Research and Quality (HS08395) makes recommendations for breast and cervical cancer screening for older women. A second AHRQ-supported study (National Research Service Award fellowship F32 HS00137) focuses on another group of vulnerable women. It shows that overweight and obese women, who die more often from breast and cervical cancer than thinner women, are less apt than their thinner counterparts to be screened for these conditions with Pap smears and mammography. Both studies are summarized here.

Mandelblatt, J.S., and Yabroff, K.R. (2000, July). "Breast and cervical cancer screening for older women: Recommendations and challenges for the 21st century." Journal of the American Medical Women's Association 55, pp. 210-215.

There have been impressive gains in the use of screening for breast and cervical cancer over the past two decades. However, certain vulnerable women, such as older and minority women, remain underscreened. Most older women visit a doctor at least once a year, providing an opportunity for their doctor to screen them for breast and cervical cancer. A major reason women cite for not undergoing screening is that their physicians never recommended it. Unfortunately, doctors are less likely to offer such screening to older patients compared with younger women.

This may be due to conflicting professional recommendations for screening older women and lack of inclusion of older women in clinical trials of screening efficacy. Doctors also may underscreen older women because of the many competing causes of mortality with increasing age and possible negative attitudes held by doctors and their older female patients, notes this recent commentary on the subject.

The authors suggest several ways to improve cancer control among older women for the next century. They propose developing definitions of groups of women most likely to benefit from screening based on age, disease risk, competing mortality, and quality of life. They recommend improving regular ongoing use of early detection and providing physician education to dispel negative attitudes related to age and race. Finally, they call for research on age-mediated differences in breast or cervical cancer biology that could affect screening recommendations.

Wee, C.C., McCarthy, E.P., Davis, R.B., and Phillips, R.S. (2000, May). "Screening for cervical and breast cancer: Is obesity an unrecognized barrier to preventive care?" Annals of Internal Medicine 132(9), pp. 697-704.

This study found an inverse relationship between body weight and cervical and breast cancer screening, suggesting that obesity may be an unrecognized barrier to preventive care. The researchers assessed screening by analyzing responses to questionnaires completed by 11,435 women who responded to the "Year 2000 Supplement" of the 1994 National Health Interview Survey. They measured weight by body mass index (BMI)—BMI is body weight in kilograms divided by height in meters squared. They found that among women 18 to 75 years of age who had not had a hysterectomy, 78 percent of overweight (BMI, 25 to less than 30 kg/m2) and obese (BMI 30 or more kg/m2) women compared with 84 percent of normal-weight women reported having Pap smears in the prior 3 years. In women 50 to 75 years of age, fewer overweight women (64 percent) and obese women (62 percent) than normal-weight women (68 percent) had received a mammogram in the previous 2 years.

Heavier women were usually older, were less likely to be white or to have private health insurance, had lower socioeconomic status, and suffered a greater burden of illness. Yet there was still a 3 to 5 percent difference in screening rates after adjustment for these and other known barriers to care. Overall, mammography rates decreased as BMI increased, and adjusted rates of Pap smears decreased significantly among women whose BMIs were greater than 25 kg/m2. Rate differences according to BMI seemed stronger among white women than black women.

The researchers estimated that during a 3-year screening interval, a national reduction in cervical cancer screening of 3.5 percent in overweight women and 3.7 to 6 percent in obese women could result in missed or delayed diagnoses for 1,219 women with invasive cervical cancer. Similarly, among overweight and obese women 50 to 75 years of age, national differences in adjusted mammography rates of 2.8 percent and 4.5 to 8.8 percent, respectively, could result in more than 3,027 deaths from breast cancer by 80 years of age.

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