Barriers to Breast Cancer Screening and Mammograms

Abstract

The mammography screening recommendations have been ambiguous and disagree with suggesting institute to institute.  Thus, it is up to women to make choices about mammogram inspection based on their personal health beliefs.  This paper explores 6 published articles that report results from various research conducted on women with an average risk of breast cancer. These studies examined the connection between observed benefits and alleged barriers to mammography and compliance with mammography screening in women age 40 and older and among minorities.  It also discusses the latest findings and guidelines according to the American Cancer Society.  Other articles discuss their reviews to support mammogram screening for women under 50, a systemic review of the benefits and harms of breast cancer screening and factors that influence breast cancer screening in Asian countries.

Introduction

Currently, breast cancer is one of the most common cancers in women and one of the chief causes of death worldwide. (Oeffinger,Fontham, Etzioni, et al.)  According to the American Cancer Society 2015, it is the leading contributor to cancer mortality in women aged 40 to 55.  Several risk factors increase the likelihood of the disease occurring.  These factors include: (1) aging, (2) personal history of breast cancer, (3) family history of breast cancer, (4) history of benign breast disease, (5) menarche younger than 12 years, (6) nulliparous, or a first child after age 30, (7) higher education or socioeconomic level, (8) obesity and/or high fats diets, (9) menopause after age 50, (10) lengthy exposure to cyclic estrogen and (11) environment exposure (American Cancer Society, 2015).  The cause of breast cancer is still unspecified, yet these risk factors are known to play a part in the risk of developing this disease.  Essentially all women can be considered at risk.  No successful cure or preventative methods exist, and early recognition offers the best opportunity for decreasing morbidity and mortality.

Literature Review

The first article that I reviewed is titled “Benefits and Harms of Breast Cancer Screening, A Systemic Review”.  According to Myers, et al., mortality from breast cancer has declined substantially since the 1970’s, a drop attributable to both the accessibility of screening methods, particularly mammography, and better-quality treatment of more advanced cancer.  This literature pointed out that, although there has been stable evidence that screening with mammography reduces breast cancer mortality, there are a number of possible harms, including false-positive results, which result in both needless biopsies and added distress and anxiety associated to the potential diagnosis of cancer.  In addition, screening may lead to over diagnosis of cancers that may not have become life-threatening.  With their investigation in the meta-analyses of RTCs (randomized clinical trials) that stratified by age, screening women younger than 50 years was constantly associated with a statistically significant reduction in breast cancer mortality of approximately 15% while screening women 50 years or older was linked with slightly greater mortality reduction (14-23%).  In general, based on their research, they have concluded that “regular screening with mammography in women 40 years or older at average risk of breast cancer reduces breast cancer mortality over at least 13 years of follow-up, but there is uncertainty about the magnitude of this association, particularly in the context of current practice in the United States.”

In summary, this review concluded that among women of all ages at average risk of breast cancer, screening was related with a reduction in breast cancer mortality of approximately 20%, although there was ambiguity about quantitative estimates of the association of different breast cancer screening strategies in the United States.  These findings and the related uncertainty should be considered when making suggestions based on judgments about the balance of benefits and harms of breast cancer screening. (Myers et al. 2015).

Mammography can pinpoint tumors too small to be detected by palpitation of the breast by the woman or her health care provider.  Early detection of breast cancer in women improves the possibility of successful treatment and thus cuts morbidity and mortality from the disease (American Cancer Society, 2015).  Yet, there still exists an observable lack of compliance with the recommended screening guidelines.  According to an article in the Journal of the American College of Radiology by Monticciolo, et al. (2015), they pointed out that previous to the presentation of widespread mammographic screening in the mid-1980s, the mortality rate from breast cancer in the US had stayed unaffected for more than 4 decades.  From 1990, the fatality rate has fallen by at least 38%.  Considerably, this change is recognized to prompt detection with mammography. 

In this next article, Miranda-Diaz, et al. (2016) studied the Hispanics Puerto Rican subjects, inner-city women and determinants of breast cancer screening and suggested that women with low incomes and education were less likely to partake in mammography.  Lack of submission of breast cancer screening tests is more prevalent among minorities.  They added that Hispanic women are less likely to receive a Physician’s recommendation for breast cancer screening, therefore, it was the primary reason for not doing a mammogram.  Other barriers for lack of compliance among Hispanic women and Latinas living in California are lack of health insurance, age, usual source of care, having a busy schedule, fear, cost and feeling uncomfortable during the procedure.

In conclusion, the authors of this article did a study that was limited by the small sample size and may not be generalizable to the entire population of the island. In order to improve compliance as well as educating health care providers about the importance of referral, a tailored health education interventions directed to describe the nature and benefit of cancer screening test needed to be put in place.

Similarly, another article stated that early detection of breast cancer, while the tumor is still small and localized, provides the opportunity for the most effective treatment. (Mandelblatt, Armetta, Yabroff, et al.) According to the American Cancer Society 2015, detection guidelines recommended that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years.  Women aged 45- 54 years should be inspected annually and women 55 years and older should changeover to biennial screening or have the opportunity to begin annual screening between the ages of 40 and 44 years.  The suggested outcome of the guideline would result in earlier detection because breast cancers found by mammography in women in their forties are smaller and more treatable than those found by self-breast exam or clinical breast exam.  Consequently, earlier detection by mammography could save lives.

According to an article by Kathy Boltz, Ph.D. (2013), amid the 609 definite breast cancer deaths, 29% were including women who had been screened with mammography, while 71% were among unscreened women.  In tally, her investigation found that of all breast cancer deaths, only 13% happened in women aged 70 years or older, but 50% occurred in women under 50 years old. Her studies were done to support mammogram screening for women under age 50.  In the meantime, Dr. Cady, MD, Professor of Surgery of Harvard Medical School in Boston, Massachusetts, and his teammates set out to deliver complete information on the value of mammography screening through a technique called “failure analysis”.  Such evaluations look backward from the time of death to determine the connections at diagnosis, rather than looking forward from the start of a study.  Only one other failure analysis related to cancer has been published to date.  In this evaluation, invasive breast cancers analyzed at Partners HealthCare hospitals in Boston between 1990 and 1999 were followed through 2007.  Facts for the study comprised demographics, mammography use, surgical and pathology reports, and recurrence and death dates.  The article also stated that the study showed a dramatic shift in survival from breast cancer associated with the introduction of screening.  In 1969, half of the women diagnosed with breast cancer had died by 12.5 years after diagnosis.  Between the women with aggressive breast cancer in this review who were spotted between 1990 and 1999, only 9.3% had expired.  “This is a remarkable achievement, and the fact that 71% of the women who died were women who were not participating in screening clearly supports the importance of early detection,” said co-author Daniel Kopans, MD, also of Harvard Medical School.

The study of the “perception of breast cancer risk and screening effectiveness” was studied by Black, Nease, & Tosteson (1995).  The purpose of the study was to determine how women 40-50 years of age perceive their risk of breast cancer and the effectiveness of screening and how these perceptions compare with estimates derived from epidemiologic studies of breast cancer incidence and randomized clinical trials of screening. A random sample of 200 women, age 40-50 years old who had no history of breast cancer was chosen through the computerized medical records of Dartmouth-Hitchcock Medical Center.  Thirty-nine percent had an annual family income of $50,000 to $100,000, and 62% had at least a college education.  The subjects received the questionnaire in the mail which asked questions pertaining to breast cancer risk and screening effectiveness.  Seventy-three percent responded with a complete questionnaire.  The results showed that the women overestimated their probability of dying of breast cancer within ten years by more than twenty times.  When asked about their relative risk reduction from breast cancer screening, they overestimated by six times.  These results are based on assuming a 10% relative risk reduction from cancer screening.  Eighty-eight percent of the subjects agreed that the benefits to screening mammography outweighed the barriers.  The generalizability of this study is very limited because of this population is better educated and of higher income than the general U.S. population of women of the same age range.  Also, the subjects’ breast cancer risk was not precisely known, and the effectiveness of modern screening mammography is unknown.  The limitations also include the questionnaire which has not been previously tested.  

The last article is a literature review of “factors influencing breast cancer screening in Asian countries.”  Studies done by Ahmadian and Samah (2012), found that breast cancer arises in the younger age group of Asian women, 40 to 49 years old compared to the other Western counterparts, where the peak prevalence is realized between 50 to 59 years.  According to multiple sources and authors, in Singapore, Malaysia, Iran, Thailand, Pakistan, and Arab women in Palestine, more than half of new cases of breast cancer were diagnosed in women below the age of 50 years and in advanced stages III or IV.   Schwartz et al. (2008), discovered that breast cancer screening activities among Asian women living in their native country are low and mammography screening in Middle Eastern countries are also low.  Analyses of the information have shown that only 23% of Turkish people testified having at least one mammogram.  Fewer women about 10.3% in the United Arab Emirates had mammography, which was attributed to poor knowledge of breast cancer screening and infrequent offering of screening by healthcare workers (Schwartz et al., 2008)  In conclusion of this article, the authors stated that in order to improve women’s participation in breast cancer prevention programs/ screenings, especially among the at-risk subgroup, the intervention strategies should be tailored to their knowledge and socio-demographic factor.  The approaches accepted should also take into account the women’s emotional and ethnic matters in order to support lifelong mammography screening practice for Asian people which is based on hypothetical interventions. In addition, healthcare professionals working with Asian women should cautiously tackle the misapprehensions such as worry about mammogram devices and fatalism. (Ahmadian & Samah, 2012)

Conclusion

In summary, after reading and reviewing the 6 related articles pertaining to breast cancer and mammogram screening for women under 50, I have concluded that there are both pros and cons, benefits and harms, perceived benefits and alleged barriers, and compliance factors that affect women worldwide.

Breast cancer has claimed millions of lives throughout the world and women should be encouraged to be mindful of and to consider their family history and medical history with a physician to determine if early detection is a warrant.  If the woman has an average risk of developing breast cancer, the American Cancer Society supports a discussion of screening around the age of 40 years.  According to the guideline, ACS recommends that women be provided with information about risk factors, risk reduction, and the benefits, limitations, and harms associated with mammography screening.  While it is recognized that there is a balance of risks and benefits to the mammogram, women should be provided with guidance so that they can make the best choice about when to start and stop screening and how frequently to be screened for breast cancer.  So, if you or your loved ones have an average risk of breast cancer and over 40 years old, would you prefer to have a checkup once a year or once every two years?  This is rather a personal choice but with early detection, the benefit of mammogram will prove to outweigh the risk and could possibly save your life.

References

Ahmadian, M and Samah, A.(2012) A Literature Review of Factors Influencing Breast Cancer Screening in Asian Countries.Life Sci J 2012;9(2):585-594.  (ISSN: 1097-8135).  http://www.lifesciencesite.com.  Accessed January 16, 2018

Breast Cancer Screening and Diagnosis (version 1.2015).  National Comprehensive Cancer Network. http://www.nccn.org/professionals/physician_gls/PDF/breast-screening.pdfAccessed January 16, 2018.

Mandelblatt, JS, Cronin, KA, Bailey, S, et al. (2009) Breast Cancer Working Group of Cancer             Intervention and Surveillance Modeling Network.  Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann Intern. Med. 2009;15(10):738-747.

Mandeltblatt, JS, Armatta, C, Yabroff, R, Liang, W, Lawrence, W. (2004) Descriptive Review of the Literature on Breast Cancer Outcomes: 1990 Through 2000. JNCI Monographs, Volume 2004, Issue 33, 1 October 2004, Pages 8-44.

https://academic.oup.com/jncimono/article/2004/33/8/933605Accessed January 17, 2018.

Oeffinger, KC, Fontham, ETH, Etzioni, R, et al. (2015). Breast Cancer Screening for Women at average risk: 2015 Guideline Update from the American Cancer Society. Jama.2015. doi:10.1001/jama.2015.12783.

https://provimaging.com/wp-content/uploads/2015/11/JAMA-Network-_-JAMA-_-Breast-Cancer-Screening-for-Women-at-Average-Risk_-20.pdfAccessed January 17, 2018.

Schwartz, LM, Woloshin, S, Sox, HC, Fischloff, B, Welch, HG.(2000) US Women’s Attitudes to False Positive Mammography Results and Detection of Ductal Carcinoma in Situ:  Cross Sectional Survey. BMJ. 2000;320 (7250): 1635-1640.

http://www.bmj.com/content/320/7250/1635.Accessed January 20, 2018