Factors associated with annual-interval mammography for women in their 40s

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Abstract

Background: Evidence is mounting that annual mammography for women in their 40s may be the optimal schedule to reduce morbidity and mortality from breast cancer. Few studies have assessed predictors of repeat mammography on an annual interval among these women. Methods: We assessed mammography screening status among 596 insured Black and Non-Hispanic white women ages 43–49. Adherence was defined as having a second mammogram 10–14 months after a previous mammogram. We examined socio-demographic, medical and healthcare-related variables on receipt of annual-interval repeat mammograms. We also assessed barriers associated with screening. Results: 44.8% of the sample were adherent to annual-interval mammography. A history of self-reported abnormal mammograms, family history of breast cancer and never having smoked were associated with adherence. Saying they had not received mammography reminders and reporting barriers to mammography were associated with non-adherence. Four barrier categories were associated with women's non-adherence: lack of knowledge/not thinking mammograms are needed, cost, being too busy, and forgetting to make/keep appointments. Conclusions: Barriers we identified are similar to those found in other studies. Health professionals may need to take extra care in discussing mammography screening risk and benefits due to ambiguity about screening guidelines for women in their 40s, especially for women without family histories of breast cancer or histories of abnormal mammograms. Reminders are important in promoting mammography and should be coupled with other strategies to help women maintain adherence to regular mammography.

Introduction

Although rates of ever [1] and recent mammography screening (within past two years) [2] have increased dramatically over the last two decades, fewer than half of age-eligible women report obtaining repeat mammograms (two consecutive screening mammograms) on recommended schedules [3], [4]. Although there have been debates about how the recommended schedule should be defined, [5], [6], [7], [8], [9], [10] evidence is mounting that annual screening for women in their 40s, [8], [11], [12], [13], [14], [15] as well as for women 50 and older, [13], [16] may be the optimal schedule to reduce morbidity and mortality from breast cancer. However, controversy remains around the efficacy and frequency of screening for women in their 40s and annual mammography has not been recommended universally for women in their 40s in the United States and abroad. Few studies have addressed repeat mammography on an annual interval among these younger women. Yet, this is the screening interval recommended by on of the U.S.’ most influential cancer organization, the American Cancer Society [8]. Irrespective of how the interval is defined, most medical organizations in the U.S. now recommend screening for women aged 40 and older.

Women in their 40s are an important population for several reasons. First, mammography use varies across age groups [17], [18], [19], [20]. Some studies have reported that younger women are less likely to adhere to repeat screening compared to older women [16], [20], [21], [22], [23]. Barriers to regular mammograms may vary among women of different age groups. Additionally, understanding mammography use among women in their 40s should take into account the shifting medical recommendations in the U.S. and abroad that have contributed to confusion about screening guidelines for this age group [9], [24], [25], [26], [27].

Most of what we know about repeat mammography use comes from studies that either did not include women under age 50 or used a biennial schedule to assess adherence. Only a few studies have examined annual-interval mammography in samples that included women in their 40s [16], [20], [21], [22], [27], [28]. While useful, these studies have limitations, such as only including women from one ethnic group [21], use of administrative dataset reviews that did not include other important variables, such as beliefs, attitudes, and perceptions about mammography [16], [22], or samples limited to women with elevated breast cancer risk [22]. Other studies that were fielded before or shortly after annual screening recommendations for women in their 40s were publicized [27], [28] have not yielded a consistent picture of factors associated with annual-interval mammography for women in their 40s.

Our study is one of the first after a period in which most major medical organizations in the U.S. agreed upon the potential benefit of mammography for women in their 40s [8], [11], [13], [29], [30], [31]. We assessed the prevalence of annual-interval mammography for insured women in their 40s. We examined socio-demographic, medical history and systems-related characteristics, theory-informed attitude/belief variables and barriers to annual-interval mammography. We focused specifically on variables that may have implications for intervention development (e.g., barriers, ambivalence) and targeting to subgroups (e.g., history of abnormal mammograms, breast cancer family history). We analyzed not only the total number of barriers but also the specific types of barriers (e.g., logistics, cost, physician-related). This knowledge could enhance future intervention efforts to promote repeat mammography for women in their 40s irrespective of the interval recommended.

Section snippets

Methods

Data are from pre-intervention baseline interviews conducted as part of Personally Relevant Information about Screening Mammography (PRISM), a National Cancer Institute funded intervention study to enhance mammography maintenance. The eligible sample frame included North Carolina women residents enrolled with the North Carolina State Health Plan for Teachers and State Employees (State Health Plan) for two or more years prior to sampling, had their last screening mammograms between September

Mammography use

While organizations differ on recommended intervals, we focus on the American Cancer Society guidelines that recommend annual mammograms for women aged 40–49 [8]. Annual-interval mammography use was defined as having a second mammogram no sooner than 10 months and no later than 14 months after a previous mammogram. The 10-month boundary excludes likely diagnostic mammograms; the 14-month boundary provides a two-month window for scheduling. Many mammography facilities have waiting queues for

Sample description

Most participants were white (88.6%), college educated (64.2%), married or living as married (82.9%), and perceived their financial status as having enough to buy special things (53.3%) (Table 1). A plurality reported living with three or more people (44.1%), 39% had previous histories of abnormal mammograms, and 16.6% had family histories of breast cancer. Over half (52.6%) reported receiving mammography reminders in the past year. The large majority reported a regular source of care (94.3%),

Discussion

This report extends previous research on mammography through examination of socio-demographic characteristics, theoretically informed attitudinal variables, and barrier types associated with annual-interval mammography use for women in their 40s. Few studies have focused on women in their 40s; far fewer have examined annual-interval mammography for this population.

Overall, 44.8% of women in this sample were adherent to annual-interval mammography—slightly lower than other studies of reported

Conflict of interest

None.

Acknowledgments

This study was supported by grant # 5R01 CA105786 from the National Cancer Institute. At the time of this research, Suzanne O’Neill, PhD, was funded by the Battelle Postdoctoral Fellowship and Jennifer M. Gierisch, PhD, was funded by the NRSA Pre-doctoral Fellowship through the Cecil G. Sheps Center for Health Services Research. The authors thank UNC team members Deborah Usinger and Tara Strigo for their work on the project. We also thank Isaac Lipkus, PhD, for his assistance on drafts of this

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