Health maintenance and screening in breast cancer survivors in the United States
Introduction
Little attention has been paid to the health maintenance and screening of breast cancer survivors. Breast cancer accounts for 31% of new cancer cases in women [1]. Although the lifetime risk of developing breast cancer is 12.6%, a woman's risk of dying from breast cancer is significantly lower (3.6%) [2]. Five and 10 years survival rates are 85 and 61%, respectively; 2 million of the estimated 10 million cancer survivors in the US are survivors of breast cancer [3], making it the largest single cancer group represented among survivors. As women live longer with a breast cancer diagnosis, attention to their general health maintenance and medical care becomes increasingly important.
Breast cancer survivors require follow-up medical care that addresses surveillance for recurrence, increased risk of diseases due to previous cancer treatments and general health maintenance [4], [5], [6]. In addition to risk of recurrence, breast cancer survivors are also at increased risk of a second primary breast cancer [7]. For tamoxifen users, there is a well-documented increased risk of endometrial cancer [8], [9], [10]. Chemotherapy can induce menopause in women treated for breast cancer and such women are generally not considered candidates for hormone replacement therapy. There is a well-documented increased risk of cardiovascular disease in women who undergo premature menopause [11] and do not receive hormone replacement therapy. In addition, radiation and the commonly used chemotherapeutic agent doxorubicin can damage the heart, which may have more long-term cardiac effects [12], [13]. These potential cardiac complications of cancer treatment necessitate aggressive management of cardiovascular risk factors [5]. The risk of recurrence, second primary breast cancers and potential health complications of breast cancer treatments make general physical exams (GPE), cardiovascular risk screening and gynecologic exams essential for breast cancer survivors.
We were interested in examining the health screening practices of breast cancer survivors in the US. Further, we wanted to explore the demographic and social factors associated with inadequate screening among survivors. Finally, we wished to see whether a history of breast cancer would adversely affect a woman's receipt of general medical care as compared to women without a breast cancer history. We hypothesized that breast cancer survivors would be more likely to receive appropriate follow-up for mammograms and clinical breast exam (CBE) because of increased vigilance of women and their physicians for recurrence of breast cancer. On the other hand, we anticipated that breast cancer survivors would receive less intensive follow-up for Pap smear (PAP), cholesterol screening, blood pressure screening, influenza vaccine and general physical exams due to competing demands on a physician's time, or perceptions that breast cancer survivors are unlikely to benefit from such health maintenance given their cancer diagnosis.
Section snippets
Study population
Subjects were individuals who participated in the household component of the medical expenditure panel survey (MEPS) in years 1996 or 1998, years for which information on health maintenance and screening were available. The MEPS is a population-based, nationally representative sample of non-institutionalized individuals living in the US. It is co-sponsored by the Agency for Health Care Research and Quality and the National Center for Health Statistics. The sampling frame is drawn from the
Results
Women with a history of breast cancer were not significantly different from women without a history of breast cancer on demographic characteristics except they had significantly higher mean incomes (Table 1) US$ 24,290 versus US$ 19,539 (p < 0.001). We controlled for income in each of our logistic regression models. Almost all women received blood pressure screening (survivors 97.6%, matches 92.8%). Therefore, we did not model the odds of receiving this screening.
Most breast cancer survivors
Discussion
Although some studies have examined screening and health maintenance among cancer survivors [6], [24], [25], [26], [27], previous studies have examined mammography screening alone [25], [26], [27], or a restricted study population, such as medicare recipients [24], [26]. This is the first study to our knowledge that has examined these issues in breast cancer survivors in a nationally representative population.
Previous studies that compared mammography screening in breast cancer survivors to
Acknowledgement
This research was supported in part from a grant by the Agency for Health Care Research and Quality, grant # HS 00011–18.
References (33)
- et al.
Follow-up care of breast cancer survivors
Crit Rev Oncol Hematol
(2003) - et al.
Follow-up care of breast cancer survivors
Semin Oncol
(2003) - et al.
Evolving perspectives in contralateral breast cancer
Eur J Cancer
(1998) - et al.
Cardiac effects of adjuvant therapy for early breast cancer
Semin Oncol
(2003) - et al.
Country characteristics and racial and ethnic disparities in the use of preventive services
Prev Med
(2004) - et al.
Racial, ethnic, socioeconomic and access disparities in the use of preventive services among women
Prev Med
(2003) - et al.
The influence of previous breast cancer upon mammography utilization
Womens Health Issues
(2003) - et al.
The effect of health insurance coverage on the appropriate use of recommended clinical preventive services
Am J Prev Med
(1997) - et al.
Cancer statistics, 2002
CA Cancer J Clin
(2002) - et al.
The lifetime risk of developing breast cancer
J Natl Cancer Inst
(1993)
Cancer prevalence and survivorship issues: analyses of the 1992 national health interview survey
J Natl Cancer Inst
Primary care for survivors of breast cancer
N Engl J Med
Tamoxifen therapy for breast cancer and endometrial cancer risk
J Natl Cancer Inst
Endometrial cancer in tamoxifen-treated breast cancer patients: findings from the national surgical adjuvant breast and bowel project (NSABP) B-14
J Natl Cancer Inst
Tamoxifen for prevention of breast cancer: report of the national surgical adjuvant breast and bowel project P-1 study
J Natl Cancer Inst
Menopause and the risk of coronary heart disease in women
N Engl J Med
Cited by (37)
Access to preventive health care for cancer survivors
2013, American Journal of Preventive MedicineCitation Excerpt :These findings provide an important baseline for understanding the effects of health insurance expansions on cancer survivorship care. Findings of equivalent or greater reported preventive services use for older survivors compared to older individuals without a cancer history, regardless of health insurance, though consistent with other studies14,18,20 conducted in samples of prevalent cancer survivors differs from most SEER-Medicare cohort studies, even when stratified by time since diagnosis. Prior studies15,17 using Medicare claims conducted in cohorts of cancer survivors aged ≥65 years with a single type of cancer and single time since diagnosis generally reported less use of preventive services by cancer survivors.
Discharge patterns after radical cystectomy: Contemporary trends in the United States
2012, Journal of UrologyCitation Excerpt :As such, uniformity in patient management as well as equal quality of care should be warranted at all institutions performing RC, regardless of volume or academic status. Moreover, numerous reports indicate that insurance is associated with decreased access to health care screening and treatment resources as well as increased risk adjusted morbidity and mortality.10–15 Our findings show that insurance is also an important predictor of discharge disposition as well as of pLOS.
Preventive service utilization among low-income cancer survivors
2022, Journal of Cancer SurvivorshipCancer surveillance and preventive services in a diverse sample of breast and colorectal cancer survivors
2021, Journal of Cancer SurvivorshipRacial and socioeconomic disparities in adherence to preventive health services for ovarian cancer survivors
2019, Journal of Cancer Survivorship