Big bias in who gets screened for breast cancer
COLUMBUS, Ohio – Certain women may miss out on routine tests that screen for early signs of breast cancer.
Elderly women, women with publicly funded health insurance and women who don't go to an obstetrician and gynecologist for routine exams are all less likely than others to get a clinical breast exam and a recommendation for a mammogram.
“A physician's recommendation is why many women undergo screening in the first place,” said Rajesh Balkrishnan, the Merrell Dow professor of pharmacy at Ohio State University. “Foregoing these exams can increase a woman's risk of developing an advanced stage of breast cancer. There are several reasons why a physician may not give a patient a clinical breast exam or recommend a mammogram.”
Balkrishnan led a study that uncovered some of these possible reasons. The findings currently appear online at the website of the journal Breast Cancer Research and Treatment.
The researchers gathered data from the National Ambulatory Medical Care Survey (NAMCS), a database run by the Centers for Disease Control and Prevention. The NAMCS contains information on a nationally representative sample of practicing physicians and patient visits throughout the United States. The researchers restricted their data set to physician office visits by women 40 and older from 1996 through 2004.
During that time, these women made an estimated 2.5 billion office visits, and physicians performed some 198 million clinical breast exams and made 110 million recommendations for mammograms. During a clinical breast exam, a physician feels the breast and surrounding tissue for any irregularities.
The researchers created a number of categories in order to determine which women were more likely to receive a clinical breast exam or a recommendation for a mammogram. The categories included patient age, a history of breast surgery or breast cancer diagnosis, type of insurance coverage and physician specialty.
The researchers found that women who see an ob-gyn for routine check ups were 18 times more likely to receive a clinical breast exam than if they visited any other kind of physician, including internists or family physicians. Ob-gyns were also 13 times more likely to recommend that their patients schedule a mammogram.
The type of insurance coverage a woman had was also a decisive factor. Compared to women with private health insurance, women with public health insurance (such as Medicaid and Medicare) were up to 30 percent less likely to receive a clinical breast exam. Doctors were up to 55 percent less likely to recommend that these women schedule a mammogram.
“Almost every medical association in the country recommends that a woman 45 and older get screened annually or at least every two years,” Balkrishnan said. “Medicare and Medicaid pay for at least a portion of the cost of both exams for covered individuals. But patients and physicians may not be aware of this.”
“Even if physicians are aware of this, they may receive lower payouts from Medicare and Medicaid,” said Monali Bhosle, a study co-author and a graduate research associate in Ohio State's department of pharmacy practice and administration.
Age also played a determining role. Women younger than 75 were roughly 1.5 times more likely to receive a clinical breast exam, and up to twice as likely to get a recommendation for a mammogram.
“We confirmed another commonly held belief – that elderly patients are less likely to get these screenings than younger patients,” Balkrishnan said. “This may be due to increasing dependence on federal forms of health care insurance. Also, physicians may feel that early detection and treatment may not be cost-effective, that such treatment may not help to prolong life at this age.”
Women with a history of breast surgery for any reason were 28 times more likely to receive a clinical breast exam, but only slightly more likely (1.6 times) to receive a recommendation for a mammogram. Women with a previous breast cancer diagnosis were 22 times more likely to get a clinical breast examination by their doctor, and four times more likely to get a recommendation for a mammogram.
“The effectiveness of mammography screening is usually lower in women who had breast cancer surgery,” Bhosle said. “Mammography picks up irregularities in the tissue, and these irregularities may be due to the aftermath of surgery and the body's healing process. That may be a reason why doctors didn't recommend that many of these women get a mammogram.
“But clinical breast exams are simple and inexpensive as compared with mammography,” she continued. “Researchers believe that regular exams are comparable to yearly mammograms in detecting breast cancer. Since women with a history of breast cancer and surgery are at higher risk for breast cancer, physicians may prefer the clinical breast exam over a mammogram.”
Balkrishnan and Bhosle conducted the study with Electra Paskett, the Marion N. Rowley Professor of Cancer Research in the School of Public Health at Ohio State and other colleagues from Ohio State and the University of Texas School of Public Health.
Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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