Health maintenance and screening in breast cancer survivors in the United States

https://doi.org/10.1016/j.cdp.2005.06.012Get rights and content

Abstract

Background: The general health maintenance and follow-up of breast cancer survivors has not been well-studied. In a population-based sample we sought to investigate the health practices of breast cancer survivors and to compare rates of screening to women with no history of breast cancer. Methods: Subjects were participants of the medical expenditure survey in the years 1996 and 1998, years for which information on screening were available. We used a matched cohort design. Breast cancer survivors aged 40 and older were matched (on age and race/ethnicity) to women with no breast cancer history. We performed logistic regression to estimate the odds of receiving appropriate health care services in breast cancer survivors versus women with no breast cancer history. In addition, we examined demographic and socioeconomic differences between breast cancer survivors who reported appropriate screening and survivors who had inadequate screening. Results: A small minority of breast cancer survivors report inadequate mammography (18%) and clinical breast exam (12%) follow-up. A significant portion of breast cancer survivors report inadequate screening for Pap smear (40%), general physical exam (GPE) (30%) and flu shot (33%). The odds of receiving appropriate screening were higher in survivors versus matched women for mammography, clinical breast and cholesterol screening. There were no differences for other screening. Across all health maintenance and screening practices, breast cancer survivors who did not receive appropriate screening were less likely to have private insurance, to be married and to be above the mean income level, though these differences were non-significant. Conclusions: Although survivors report high levels of screening, a small minority of women report inadequate mammography and clinical breast exam follow-up which is concerning given their risk of recurrence and second primary breast cancer. Additionally, a significant portion of survivors report inadequate screening for general health maintenance issues. Demographic and socioeconomic factors were associated with lower screening rates. However, the deficits in screening among breast cancer survivors appears to be smaller compared to women in the general population.

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.

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