- Email: [email protected]
Whatever happened to clinical breast examinations?
Whatever Happened to Clinical Breast Examinations? Helen I. Meissner, PhD, Nancy Breen, PhD, K. Robin Yabroff, PhD Background: The purpose of this study was to examine trends in the use of clinical breast examinations (CBE), mammography, and both tests between the years 1990 and 2000. Methods:
Receipt of breast cancer screening tests (CBE, mammography, and both tests combined) for white, black, and Hispanic women in 1990, 1994, 1998, and 2000 were examined by sociodemographic, access, and health risk indicators using data from the National Health Interview Survey.
Results:
The use of mammography increased from 1990 to 2000, but the proportion of women reporting a recent CBE decreased for almost all groups of women. Differential use of CBE by sociodemographic characteristics is consistent with what has been documented for mammography.
Conclusions: Although the use of mammography has increased since 1990, there has been a downward trend in the use of CBE. Healthcare providers should be aware of the lower rates of CBE, particularly among women with compromised access to health care, and should not assume that women who get mammograms have received comprehensive screening for breast cancer. (Am J Prev Med 2003;25(3):259 –263)
Introduction
M
ost major medical organizations that issue guidelines for breast cancer screening recommend periodic clinical breast examination (CBE) along with mammography.1–3 Although current evidence supports mammography as the most effective method for detecting breast cancer, a thorough CBE is nevertheless considered to play a complementary role to that of mammography because CBE also has the potential to detect early-stage cancers.4,5 Use of screening mammography increased substantially in the 1990s. In 1998, about 68% of U.S. women aged 40 and older reported a mammogram within the previous 2 years, compared with fewer than 30% of women in 1987.6 Less is known about trends in use of CBE, either alone or as a component of comprehensive breast cancer screening. Healthcare providers report barriers to performing CBE, including clinician or patient embarrassment,7 patient refusal,8 lack of confidence in performing the examination,9,10 lack of time,10,11 and reliance on mammography as the preferred method of screening.9 Gender and specialty also may influence whether a physician performs a CBE.7,12 Patient barriers to CBE are
From the Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland Address correspondence and reprint requests to: Helen I. Meissner, PhD, National Cancer Institute, 6130 Executive Boulevard, EPN 4102, MSC 7335, Bethesda MD 20852-7335. E-mail: [email protected].
Am J Prev Med 2003;25(3) Published by Elsevier Inc.
much like those noted for mammography and include sociodemographic factors, such as less than high school education, low income, lack of health insurance, low levels of acculturation, and nonwhite race.13–17 In this report, trends in the use of CBE, mammography, and both tests between the years 1990 and 2000 are examined.
Methods Data reported were from the 1990, 1994, 1998, and 2000 National Health Interview Surveys (NHIS). The NHIS is an annual nationwide household survey of the civilian U.S. population. The data were obtained through inperson interviews using a clustered, randomized sample of households. NHIS questions are designed to yield comparable results over time. In particular, the questions on utilization of mammography and CBE for the years reported were similar and also would be expected to yield comparable results. Estimates and 95% confidence intervals (CIs) were calculated using the SUDAAN software (Research Triangle Institute, Research Triangle Park NC, 1997) to account for the complex sample design. Because recommended intervals for breast cancer screening vary from 1 to 2 years, outcomes (CBE, mammogram, and CBE with mammogram) for having the tests within the 2 years before the interview are reported. The samples were restricted to white non-Hispanic, black non-Hispanic, and Hispanic women because numbers of responses for other women were too small to make meaningful comparisons. For this analysis, age groups were based on screening recommendations and other age-related influences on screening, such as Medicare benefits for women aged 65
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Table 1. Proportion of women aged ⱖ40 years reporting receipt of test within past 2 years
Characteristic
Received CBE 1990 % (95% CI)
Age (years) 40–49 82.6 (81.0–84.1) 50–64 78.3 (76.7–80.0) 65⫹ 70.7 (69.1–72.4) Race/ethnicity Hispanic 73.6 (68.5–78.6) Non-Hispanic black 79.9 (77.5–82.4) Non-Hispanic white 77.0 (75.9–78.1) Immigrant status Born in United 77.4 (76.4–78.4) States In United States 74.3 (69.4–79.2) 10⫹ years In United States 63.5 (49.0–78.0) ⬍10 years Educational attainment ⬍ High school 67.1 (64.9–69.3) graduation High school 77.3 (75.8–78.7) graduation, GED, or equivalent Some college, no 83.1 (81.3–85.0) degree College degree or 88.0 (86.0–90.0) more Insurance No insurance 63.7 (59.8–67.6) Public (no private/ 66.9 (64.3–69.6) military) Private/military 79.7 (78.6–80.8) (may have public) Has usual source of care Yes 80.8 (79.8–81.9) No 50.4 (47.2–53.5) Had doctor visit in last 2 years Yes 81.8 (80.8–82.7) No 29.8 (26.3–33.3) Smoking status Current 73.3 (71.0–75.7) Former 80.7 (79.1–82.2) Never 77.0 (75.7–78.3) Health status Excellent/very 78.6 (77.5–79.8) good Good 76.7 (74.9–78.6) Fair/poor 73.2 (71.1–75.3)
Received CBE 2000 % (95% CI)
Received mammogram 1990 % (95% CI)
Received mammogram 2000 % (95% CI)
Received CBE & mammogram 1990 % (95% CI)
Received CBE & mammogram 2000 % (95% CI)
76.0 (74.3–77.7) 55.1 (53.3–57.0) 65.1 (63.0–67.1) 54.1 (52.3–56.0) 58.4 (56.3–60.4) 78.9 (77.3–80.4) 56.4 (54.4–58.4) 79.2 (77.4–80.9) 55.2 (53.2–57.1) 71.8 (70.0–73.7) 67.7 (65.9–69.6) 43.4 (41.3–45.4) 68.1 (66.2–69.9) 41.1 (39.1–43.1) 58.2 (56.3–60.2) 61.7 (58.1–65.3) 45.2 (40.4–50.0) 61.4 (58.1–64.7) 43.3 (38.6–47.9) 48.3 (45.0–51.6) 74.4 (71.6–77.2) 46.0 (42.8–49.1) 68.0 (64.8–71.2) 43.9 (40.9–46.9) 59.4 (56.0–62.8) 75.7 (74.6–76.8) 52.7 (51.3–54.0) 72.1 (70.8–73.4) 51.2 (49.9–52.6) 64.8 (63.6–66.1) 75.7 (74.6–76.7) 52.1 (50.8–53.4) 71.8 (70.6–73.0) 50.6 (49.3–51.8) 64.3 (63.1–65.5) 64.3 (60.2–68.5) 47.3 (43.4–51.2) 64.9 (61.1–68.7) 45.6 (41.6–49.6) 52.6 (48.4–56.8) 50.1 (39.5–60.6) 32.4 (23.0–41.8) 43.1 (31.5–54.8) 29.7 (20.5–38.9) 32.7 (22.3–43.2) 60.2 (57.8–62.7) 36.6 (34.4–38.8) 57.7 (55.3–60.1) 34.7 (32.6–36.8) 46.5 (44.2–48.8) 73.4 (71.7–75.1) 52.7 (51.1–54.4) 70.1 (68.3–71.9) 51.4 (49.7–53.0) 61.9 (60.0–63.8) 78.0 (76.2–79.9) 59.0 (56.7–61.4) 73.0 (71.1–74.9) 57.5 (55.1–59.9) 66.1 (63.9–68.2) 85.1 (83.4–86.8) 67.1 (64.5–69.7) 81.8 (79.9–83.7) 65.9 (63.3–68.5) 76.3 (74.3–78.3) 51.0 (47.4–54.7) 29.1 (25.3–32.9) 41.2 (37.4–45.0) 27.5 (23.9–31.1) 34.1 (30.6–37.7) 64.0 (61.5–66.4) 32.5 (29.9–35.1) 62.3 (59.6–65.0) 30.7 (28.3–33.1) 50.6 (48.0–53.2) 79.2 (78.1–80.3) 56.1 (54.8–57.4) 76.0 (74.8–77.2) 54.6 (53.3–55.9) 68.8 (67.5–70.1) 77.1 (76.1–78.1) 55.0 (53.7–56.3) 73.7 (72.6–74.8) 53.5 (52.2–54.8) 65.8 (64.6–66.9) 40.6 (36.6–44.6) 26.7 (24.0–29.3) 34.1 (30.0–38.2) 25.4 (22.8–27.9) 27.8 (23.8–31.8) 77.2 (76.1–78.2) 55.5 (54.2–56.8) 73.6 (72.5–74.7) 54.0 (52.7–55.2) 65.6 (64.4–66.7) 16.1 (11.8–20.4) 13.6 (11.1–16.0) 11.8 (8.3–15.3) 12.4 (10.1–14.7) 7.7 (5.0–10.4) 70.1 (67.7–72.4) 43.4 (41.0–45.7) 60.5 (57.9–63.1) 42.4 (40.0–44.7) 53.9 (51.3–56.5) 79.7 (77.8–81.6) 58.7 (56.6–60.8) 77.2 (75.3–79.0) 57.0 (54.9–59.1) 70.5 (68.4–72.6) 73.4 (72.1–74.8) 51.5 (49.9–53.1) 71.4 (69.9–72.8) 49.9 (48.3–51.5) 62.5 (61.0–64.1) 77.7 (76.3–79.1) 54.7 (53.2–56.2) 74.0 (72.5–75.5) 42.4 (40.0–44.7) 66.8 (65.3–68.4) 72.0 (70.2–73.7) 50.4 (48.5–52.3) 67.9 (65.8–70.0) 57.0 (54.9–59.1) 60.2 (58.1–62.3) 68.4 (66.2–70.6) 44.6 (42.2–47.0) 66.0 (63.5–68.5) 49.9 (48.3–51.5) 55.6 (53.0–58.1)
Data source: National Health Interview Surveys for 1990 and 2000. CBE, clinical breast exam; GED, general educational development.
years and older. The data provided in Table 1 are for women 40 years and older, whereas Figure 1 includes data for women aged 30 to 39 years.
Results Table 1 displays the use of CBE, mammography, and both examinations for women aged 40 years and older for 1990 and 2000 by sociodemographic, access, and health risk indicators. Although the use of mammography increased for every group from 1990 to 2000, the 260
percentage of women reporting a recent CBE decreased for almost all groups of women. Only women aged 50 – 64 years appeared to be receiving CBE at about the same rate in 2000 as they did in 1990 (78.3% in 1990 v 78.9% in 2000). Although the percentage of women reporting both CBE and mammography increased, more women received mammography alone than received CBE and mammography. Differential use of CBE by sociodemographic characteristics was consistent with what has been documented
American Journal of Preventive Medicine, Volume 25, Number 3
Figure 1. Percentage of black, white, and Hispanic women with breast cancer–screening tests.
for mammography,6 with higher use among women with the following characteristics: born in the United States or immigrated to the United States more than 10 years ago; had more than a high school education, health insurance, a usual source of health care, and a recent doctor’s visit; were not current smokers; and reported having excellent or very good health. Particularly striking is how much having a usual source of
health care and a recent doctor’s visit influenced the use of both tests. Figure 1 displays the trends in use of CBE and mammography from 1990 to 2000 by age. Reported use of mammography was low and declined in women aged 30 –39 years; the test is not generally recommended for women younger than 40. Use of CBE, in contrast, was high in the 30 –39 year-old age group but declined Am J Prev Med 2003;25(3)
261
between 1990 and 2000. Mammography use increased between 1990 and 2000 for all women older than 40 years, but use of both CBE and mammography changed little between 1998 and 2000. Among women 40 and older, the use of CBE was much higher than mammography in 1990, but the trend in mammography since then has moved toward rates close to that of CBE.
Discussion Although the decade between 1990 and 2000 saw an increase in screening mammography for women aged 40 years and older, there was a concomitant decline or stabilization in the use of CBE. It does not appear that women are visiting a doctor less often now than previously. Rather, it appears that women and their doctors may be relying exclusively on mammography for detecting breast cancer. It also is possible that the apparent decline in CBE is related to access to health care. Women without health insurance, recent immigrants, and women of Hispanic ethnicity showed the greatest reductions in the use of CBE between 1990 and 2000. Although programs offering free or low-cost breast cancer screening have facilitated access to mammography for many low-income and uninsured women, the programs may not have been as effective in providing access to clinical services, such as CBE. If CBE is indeed an important component of breast cancer screening, then this trend is a cause of concern. Women who might otherwise have received diagnostic mammography based on an abnormal clinical examination may now be getting less-intensive screening mammography because they did not receive a CBE before the mammogram.17 Use of mammography and CBE that were reported in this study were based on women’s responses to survey questions. Although self-report may overstate screening use compared with chart or medical record review,18 –20 any over-reporting is likely to be consistent during the time period of this study. Thus, interpretation of trends is unlikely to be affected. Mammography screening guidelines for women older than 69 are unclear, due in part to the lack of data from trials, as well as the questionable benefits derived from detecting and treating cancers or preinvasive disease in women whose life expectancy may be less than 5 years.21 As a result, it has been suggested that CBE may be particularly appropriate for women older than 70 years because changes in the fatty tissue of the breasts make it easier to detect lumps as women age.22,23 Likewise, it is not known whether CBE could contribute to early detection of breast cancer in premenopausal women, where mammography is less sensitive and screening guidelines also are controversial.5,23 262
Questions regarding the role of CBE in screening for breast cancer remain. Because none of the breast cancer–screening trials examined the benefits of CBE alone (i.e., without mammography),24 uncertainty persists regarding the benefits and risks of screening with CBE alone or as a combined strategy with mammography. Nevertheless, healthcare providers should be aware of the lower rates of CBE, particularly among women with compromised access to health care, and should not assume that women who get mammograms have received comprehensive screening for breast cancer.
References 1. Smith R, Cokkinides V, von Eschenbach AC, et al. American cancer society guidelines for the early detection of cancer. CA Cancer J Clin 2002;52:8 – 22. 2. Morrison BJ. Screening for breast cancer, the Canadian guide to clinical preventive health care. Ottawa, Canada: Canada Communication Group, 1994, 787–94. 3. Zoorob R, Anderson R, Cefalu C, Sidani M. Cancer screening guidelines. Am Fam Physician 2001;63:1101–12. 4. Miller AB, To T, Baines CJ, Wall C. Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50 –59 years. J Natl Cancer Inst 2000;92:1490 –9. 5. Baines CJ, Miller AB. Mammography versus clinical examination of the breasts. J Natl Cancer Inst Monogr 1997;125–9. 6. Breen N, Wagener DK, Brown ML, Davis WW, Ballard-Barbash R. Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 national health interview surveys. J Natl Cancer Inst 2001;93:1704 –13. 7. Desnick L, Taplin S, Taylor V, Coole D, Urban N. Clinical breast examination in primary care: perceptions and predictors among three specialties. J Womens Health 1999;8:389 –97. 8. Goldman DA, Simpson DM. Survey of El Paso physicians’ breast and cervical cancer screening attitudes and practices. J Community Health 1996;19:75–85. 9. Lane DS, Messina CR. Current perspectives on physician barriers to breast cancer screening. J Am Board Fam Pract 1999;12:8 –15. 10. Wiecha JM, Gann P. Provider confidence in breast examination. Fam Pract Res J 1993;13:37–41. 11. Lane DS, Burg MA. Promoting physician preventive practices: needs assessment for CME in breast cancer detection. J Continuing Education Health Professions 1989;9:245–56. 12. Burns RB, Freund KM, Ash AS, Shwartz M, Antab L, Hall R. As mammography use increases, are some providers omitting clinical breast examination? Arch Intern Med 1996;156:741–4. 13. Frazier EL, Jiles RB, Mayberry R. Use of screening mammography and clinical breast examinations among black, Hispanic, and white women. Prev Med 1996;25:118 –25. 14. Tang TS, Solomon LJ, McCracken LM. Cultural barriers to mammography, clinical breast exam, and breast self-exam among Chinese-American women 60 and older. Prev Med 2000;575– 83. 15. Lane DS, Zapka JG, Breen N, Messina CR, Fotheringham DJ. A systems model of clinical preventive care: the case of breast cancer screening among older women. Prev Med 2000;31:481–93. 16. Vernon SW, Vogel VG, Halabi S, Jackson GL, Lundy RO, Peters GN. Breast cancer screening behaviors and attitudes in three racial/ethnic groups. Cancer 1992;69:165–74. 17. McGreevy KM, Baron LF, Hoel DG. Clinical breast examination practices among women undergoing screening mammography. Radiology 2002;224: 555–9. 18. Paskett ED, Tatum CM, Mack DW, Hoen H, Case LD, Velez R. Validation of self-reported breast and cervical cancer screening tests among low-income minority women. Cancer Epidemiol Biomarkers Prev 1996;5: 721–6.
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19. Etzi S, Lane DS, Grimson R. The use of mammography vans by low-income women: the accuracy of self-reports. Am J Public Health 1994;84:107–9. 20. Suarez L, Goldman DA, Weiss NS. Validity of Pap smear and mammogram self-reports in a low income Hispanic population. Am J Prev Med 1995;11: 94–8. 21. Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA 2001;285:2750 –6.
22. Repetto L, Balducci L. A case for geriatric oncology. Lancet 2002;289 – 97. 23. Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA 1999;282:1270 –80. 24. U.S. Preventive Services Task Force. Screening for breast cancer: recommendations and rationale. Ann Intern Med 2002;137:344 –6.
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Receipt of breast cancer screening tests (CBE, mammography, and both tests combined) for white, black, and Hispanic women in 1990, 1994, 1998, and 2000 were examined by sociodemographic, access, and health risk indicators using data from the National Health Interview Survey.
Results:
The use of mammography increased from 1990 to 2000, but the proportion of women reporting a recent CBE decreased for almost all groups of women. Differential use of CBE by sociodemographic characteristics is consistent with what has been documented for mammography.
Conclusions: Although the use of mammography has increased since 1990, there has been a downward trend in the use of CBE. Healthcare providers should be aware of the lower rates of CBE, particularly among women with compromised access to health care, and should not assume that women who get mammograms have received comprehensive screening for breast cancer. (Am J Prev Med 2003;25(3):259 –263)
Introduction
M
ost major medical organizations that issue guidelines for breast cancer screening recommend periodic clinical breast examination (CBE) along with mammography.1–3 Although current evidence supports mammography as the most effective method for detecting breast cancer, a thorough CBE is nevertheless considered to play a complementary role to that of mammography because CBE also has the potential to detect early-stage cancers.4,5 Use of screening mammography increased substantially in the 1990s. In 1998, about 68% of U.S. women aged 40 and older reported a mammogram within the previous 2 years, compared with fewer than 30% of women in 1987.6 Less is known about trends in use of CBE, either alone or as a component of comprehensive breast cancer screening. Healthcare providers report barriers to performing CBE, including clinician or patient embarrassment,7 patient refusal,8 lack of confidence in performing the examination,9,10 lack of time,10,11 and reliance on mammography as the preferred method of screening.9 Gender and specialty also may influence whether a physician performs a CBE.7,12 Patient barriers to CBE are
From the Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland Address correspondence and reprint requests to: Helen I. Meissner, PhD, National Cancer Institute, 6130 Executive Boulevard, EPN 4102, MSC 7335, Bethesda MD 20852-7335. E-mail: [email protected].
Am J Prev Med 2003;25(3) Published by Elsevier Inc.
much like those noted for mammography and include sociodemographic factors, such as less than high school education, low income, lack of health insurance, low levels of acculturation, and nonwhite race.13–17 In this report, trends in the use of CBE, mammography, and both tests between the years 1990 and 2000 are examined.
Methods Data reported were from the 1990, 1994, 1998, and 2000 National Health Interview Surveys (NHIS). The NHIS is an annual nationwide household survey of the civilian U.S. population. The data were obtained through inperson interviews using a clustered, randomized sample of households. NHIS questions are designed to yield comparable results over time. In particular, the questions on utilization of mammography and CBE for the years reported were similar and also would be expected to yield comparable results. Estimates and 95% confidence intervals (CIs) were calculated using the SUDAAN software (Research Triangle Institute, Research Triangle Park NC, 1997) to account for the complex sample design. Because recommended intervals for breast cancer screening vary from 1 to 2 years, outcomes (CBE, mammogram, and CBE with mammogram) for having the tests within the 2 years before the interview are reported. The samples were restricted to white non-Hispanic, black non-Hispanic, and Hispanic women because numbers of responses for other women were too small to make meaningful comparisons. For this analysis, age groups were based on screening recommendations and other age-related influences on screening, such as Medicare benefits for women aged 65
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Table 1. Proportion of women aged ⱖ40 years reporting receipt of test within past 2 years
Characteristic
Received CBE 1990 % (95% CI)
Age (years) 40–49 82.6 (81.0–84.1) 50–64 78.3 (76.7–80.0) 65⫹ 70.7 (69.1–72.4) Race/ethnicity Hispanic 73.6 (68.5–78.6) Non-Hispanic black 79.9 (77.5–82.4) Non-Hispanic white 77.0 (75.9–78.1) Immigrant status Born in United 77.4 (76.4–78.4) States In United States 74.3 (69.4–79.2) 10⫹ years In United States 63.5 (49.0–78.0) ⬍10 years Educational attainment ⬍ High school 67.1 (64.9–69.3) graduation High school 77.3 (75.8–78.7) graduation, GED, or equivalent Some college, no 83.1 (81.3–85.0) degree College degree or 88.0 (86.0–90.0) more Insurance No insurance 63.7 (59.8–67.6) Public (no private/ 66.9 (64.3–69.6) military) Private/military 79.7 (78.6–80.8) (may have public) Has usual source of care Yes 80.8 (79.8–81.9) No 50.4 (47.2–53.5) Had doctor visit in last 2 years Yes 81.8 (80.8–82.7) No 29.8 (26.3–33.3) Smoking status Current 73.3 (71.0–75.7) Former 80.7 (79.1–82.2) Never 77.0 (75.7–78.3) Health status Excellent/very 78.6 (77.5–79.8) good Good 76.7 (74.9–78.6) Fair/poor 73.2 (71.1–75.3)
Received CBE 2000 % (95% CI)
Received mammogram 1990 % (95% CI)
Received mammogram 2000 % (95% CI)
Received CBE & mammogram 1990 % (95% CI)
Received CBE & mammogram 2000 % (95% CI)
76.0 (74.3–77.7) 55.1 (53.3–57.0) 65.1 (63.0–67.1) 54.1 (52.3–56.0) 58.4 (56.3–60.4) 78.9 (77.3–80.4) 56.4 (54.4–58.4) 79.2 (77.4–80.9) 55.2 (53.2–57.1) 71.8 (70.0–73.7) 67.7 (65.9–69.6) 43.4 (41.3–45.4) 68.1 (66.2–69.9) 41.1 (39.1–43.1) 58.2 (56.3–60.2) 61.7 (58.1–65.3) 45.2 (40.4–50.0) 61.4 (58.1–64.7) 43.3 (38.6–47.9) 48.3 (45.0–51.6) 74.4 (71.6–77.2) 46.0 (42.8–49.1) 68.0 (64.8–71.2) 43.9 (40.9–46.9) 59.4 (56.0–62.8) 75.7 (74.6–76.8) 52.7 (51.3–54.0) 72.1 (70.8–73.4) 51.2 (49.9–52.6) 64.8 (63.6–66.1) 75.7 (74.6–76.7) 52.1 (50.8–53.4) 71.8 (70.6–73.0) 50.6 (49.3–51.8) 64.3 (63.1–65.5) 64.3 (60.2–68.5) 47.3 (43.4–51.2) 64.9 (61.1–68.7) 45.6 (41.6–49.6) 52.6 (48.4–56.8) 50.1 (39.5–60.6) 32.4 (23.0–41.8) 43.1 (31.5–54.8) 29.7 (20.5–38.9) 32.7 (22.3–43.2) 60.2 (57.8–62.7) 36.6 (34.4–38.8) 57.7 (55.3–60.1) 34.7 (32.6–36.8) 46.5 (44.2–48.8) 73.4 (71.7–75.1) 52.7 (51.1–54.4) 70.1 (68.3–71.9) 51.4 (49.7–53.0) 61.9 (60.0–63.8) 78.0 (76.2–79.9) 59.0 (56.7–61.4) 73.0 (71.1–74.9) 57.5 (55.1–59.9) 66.1 (63.9–68.2) 85.1 (83.4–86.8) 67.1 (64.5–69.7) 81.8 (79.9–83.7) 65.9 (63.3–68.5) 76.3 (74.3–78.3) 51.0 (47.4–54.7) 29.1 (25.3–32.9) 41.2 (37.4–45.0) 27.5 (23.9–31.1) 34.1 (30.6–37.7) 64.0 (61.5–66.4) 32.5 (29.9–35.1) 62.3 (59.6–65.0) 30.7 (28.3–33.1) 50.6 (48.0–53.2) 79.2 (78.1–80.3) 56.1 (54.8–57.4) 76.0 (74.8–77.2) 54.6 (53.3–55.9) 68.8 (67.5–70.1) 77.1 (76.1–78.1) 55.0 (53.7–56.3) 73.7 (72.6–74.8) 53.5 (52.2–54.8) 65.8 (64.6–66.9) 40.6 (36.6–44.6) 26.7 (24.0–29.3) 34.1 (30.0–38.2) 25.4 (22.8–27.9) 27.8 (23.8–31.8) 77.2 (76.1–78.2) 55.5 (54.2–56.8) 73.6 (72.5–74.7) 54.0 (52.7–55.2) 65.6 (64.4–66.7) 16.1 (11.8–20.4) 13.6 (11.1–16.0) 11.8 (8.3–15.3) 12.4 (10.1–14.7) 7.7 (5.0–10.4) 70.1 (67.7–72.4) 43.4 (41.0–45.7) 60.5 (57.9–63.1) 42.4 (40.0–44.7) 53.9 (51.3–56.5) 79.7 (77.8–81.6) 58.7 (56.6–60.8) 77.2 (75.3–79.0) 57.0 (54.9–59.1) 70.5 (68.4–72.6) 73.4 (72.1–74.8) 51.5 (49.9–53.1) 71.4 (69.9–72.8) 49.9 (48.3–51.5) 62.5 (61.0–64.1) 77.7 (76.3–79.1) 54.7 (53.2–56.2) 74.0 (72.5–75.5) 42.4 (40.0–44.7) 66.8 (65.3–68.4) 72.0 (70.2–73.7) 50.4 (48.5–52.3) 67.9 (65.8–70.0) 57.0 (54.9–59.1) 60.2 (58.1–62.3) 68.4 (66.2–70.6) 44.6 (42.2–47.0) 66.0 (63.5–68.5) 49.9 (48.3–51.5) 55.6 (53.0–58.1)
Data source: National Health Interview Surveys for 1990 and 2000. CBE, clinical breast exam; GED, general educational development.
years and older. The data provided in Table 1 are for women 40 years and older, whereas Figure 1 includes data for women aged 30 to 39 years.
Results Table 1 displays the use of CBE, mammography, and both examinations for women aged 40 years and older for 1990 and 2000 by sociodemographic, access, and health risk indicators. Although the use of mammography increased for every group from 1990 to 2000, the 260
percentage of women reporting a recent CBE decreased for almost all groups of women. Only women aged 50 – 64 years appeared to be receiving CBE at about the same rate in 2000 as they did in 1990 (78.3% in 1990 v 78.9% in 2000). Although the percentage of women reporting both CBE and mammography increased, more women received mammography alone than received CBE and mammography. Differential use of CBE by sociodemographic characteristics was consistent with what has been documented
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Figure 1. Percentage of black, white, and Hispanic women with breast cancer–screening tests.
for mammography,6 with higher use among women with the following characteristics: born in the United States or immigrated to the United States more than 10 years ago; had more than a high school education, health insurance, a usual source of health care, and a recent doctor’s visit; were not current smokers; and reported having excellent or very good health. Particularly striking is how much having a usual source of
health care and a recent doctor’s visit influenced the use of both tests. Figure 1 displays the trends in use of CBE and mammography from 1990 to 2000 by age. Reported use of mammography was low and declined in women aged 30 –39 years; the test is not generally recommended for women younger than 40. Use of CBE, in contrast, was high in the 30 –39 year-old age group but declined Am J Prev Med 2003;25(3)
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between 1990 and 2000. Mammography use increased between 1990 and 2000 for all women older than 40 years, but use of both CBE and mammography changed little between 1998 and 2000. Among women 40 and older, the use of CBE was much higher than mammography in 1990, but the trend in mammography since then has moved toward rates close to that of CBE.
Discussion Although the decade between 1990 and 2000 saw an increase in screening mammography for women aged 40 years and older, there was a concomitant decline or stabilization in the use of CBE. It does not appear that women are visiting a doctor less often now than previously. Rather, it appears that women and their doctors may be relying exclusively on mammography for detecting breast cancer. It also is possible that the apparent decline in CBE is related to access to health care. Women without health insurance, recent immigrants, and women of Hispanic ethnicity showed the greatest reductions in the use of CBE between 1990 and 2000. Although programs offering free or low-cost breast cancer screening have facilitated access to mammography for many low-income and uninsured women, the programs may not have been as effective in providing access to clinical services, such as CBE. If CBE is indeed an important component of breast cancer screening, then this trend is a cause of concern. Women who might otherwise have received diagnostic mammography based on an abnormal clinical examination may now be getting less-intensive screening mammography because they did not receive a CBE before the mammogram.17 Use of mammography and CBE that were reported in this study were based on women’s responses to survey questions. Although self-report may overstate screening use compared with chart or medical record review,18 –20 any over-reporting is likely to be consistent during the time period of this study. Thus, interpretation of trends is unlikely to be affected. Mammography screening guidelines for women older than 69 are unclear, due in part to the lack of data from trials, as well as the questionable benefits derived from detecting and treating cancers or preinvasive disease in women whose life expectancy may be less than 5 years.21 As a result, it has been suggested that CBE may be particularly appropriate for women older than 70 years because changes in the fatty tissue of the breasts make it easier to detect lumps as women age.22,23 Likewise, it is not known whether CBE could contribute to early detection of breast cancer in premenopausal women, where mammography is less sensitive and screening guidelines also are controversial.5,23 262
Questions regarding the role of CBE in screening for breast cancer remain. Because none of the breast cancer–screening trials examined the benefits of CBE alone (i.e., without mammography),24 uncertainty persists regarding the benefits and risks of screening with CBE alone or as a combined strategy with mammography. Nevertheless, healthcare providers should be aware of the lower rates of CBE, particularly among women with compromised access to health care, and should not assume that women who get mammograms have received comprehensive screening for breast cancer.
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19. Etzi S, Lane DS, Grimson R. The use of mammography vans by low-income women: the accuracy of self-reports. Am J Public Health 1994;84:107–9. 20. Suarez L, Goldman DA, Weiss NS. Validity of Pap smear and mammogram self-reports in a low income Hispanic population. Am J Prev Med 1995;11: 94–8. 21. Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA 2001;285:2750 –6.
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