Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Thursday, April 24, 2008

Breast Cancer Screening: Public Health Is Failing To Use Mammography To Reach All Women Equally – Alicia Agnoli

A body of evidence indicates that a significant proportion of breast cancer deaths can be prevented through effective screening (1, 2). Under this rationale, breast cancer screening via mammography has become an important and widespread practice, and even an explicit public health policy (1). In fact, all major United States Medical organizations expressly recommend mammography screening for women of 40 years or older (3). However, despite both the proven efficacy and widespread endorsement of mammography, rates of screening continue to be substantially lower among minority women and women of low socioeconomic status (4, 5).

The significant disparities in rates of screening across certain demographic categories indicate that, in its current form, mammography-centered screening is not being optimally utilized by the field of public health. Public Health has failed to sufficiently employ the tool of mammography among all women because it does not account for key factors that directly affect the likelihood of participation among certain women. This critique will highlight three specific factors that the field of public health must consider in order to lessen the ethnic and socioeconomic disparities in rates of breast cancer screening.

Public Health has not adequately examined the psychological and psychosocial factors that influence an individual’s screening behavior.
Many psychological factors, including fear and anxiety, directly influence an individual’s decision to participate in breast cancer screening. However, these factors are not adequately incorporated in the current implementation of the public health approach. Stress and health awareness disparities associated with age, SES, marital status, and ethnicity need to be examined in correlation with screening behaviors. Doing so would allow the field to better understand specific causal factors underlying trends in individual health decisions and to most precisely identify areas and strategies for intervention. One study found that vast differences in styles of emotional regulation may exist across ethnic groups, which can have an important implication on screening behavior (2). Another study cited specifically Hispanic women and the plausible correlation between larger average tumor size, poor screening rates, and documented “fatalistic view of disease” (6). These studies both underscore the important and often culturally-specific connection between women’s emotional influences and mammography choices.

By failing to examine the multitude of psychological and psychosocial factors at play for women, the field of public health is missing a critical point of understanding why certain groups of women are more or less likely to participate in breast cancer screening. Effective interventions must incorporate an understanding of these factors, and particularly the ways in which they affect the health decisions of specific demographic groups.

Public Health has not sufficiently educated physicians in cultural competency so as to reduce the effects of disparities in practitioner screening recommendations.
Though breast cancer awareness is at a cultural high, evidence shows that women’s screening behaviors are most directly influenced by the advice of their healthcare providers. In fact, women who receive a recommendation for a breast cancer screening from a healthcare provider are far more likely than those who do not to undergo mammography (7). However, the research indicating this positive correlation also reveals distinct trends in physician recommendations for mammograms. Studies conducted by O’Malley et al revealed that identified “vulnerable women” (i.e. older, lower SES, lower educational attainment) received significantly fewer recommendations for mammography (8). In subsequent investigation, the group found that recognition of social stigmas was largely responsible for the low rate of recommendations given to vulnerable women, citing physician concerns about these groups’ inability to afford the services and a lack of confidence in their compliance (7).

The existing public health approach has failed to adequately scrutinize these patterns of physician recommendations regarding breast cancer prevention. In doing so, the field of public health has overlooked a pivotal causal factor in disparate rates of screening participation. With a better understanding of recommending practices, the field of public health would be able to better tailor practitioner-level interventions so as to overcome the disparities in the resultant screening behaviors of certain demographic groups. Public health has an obligation to educate physicians in cultural competency so as to overcome social stigmas and mitigate the inherent bias seen in the recommending practices towards vulnerable populations.

The field of public health has not made low-cost alternative screening options sufficiently available and well-publicized to the women who need them.
Despite the progress made to provide financially-sensitive screening alternatives (e.g.. free and subsidized mammography clinics, mobile screening vans) to women who need them, many barriers to access still prevent women from participating in breast cancer screening who otherwise would. Mammography alone can seem prohibitively costly and otherwise inaccessible for many women, especially among women who are uninsured or under-insured. The current public health approach does not sufficiently include efforts to overcome such perceived financial barriers. In light of abundant evidence indicating the negative correlation between low socioeconomic status and mammography participation (5, 7), the field must make a more comprehensive effort to overcome these apparent issues of access experienced by medically underserved women. In one study, researchers found that economic barriers were directly correlated with decreased mammography use. These barriers were associated with a perceived high cost of the screening technology and low awareness of accessible public services (5).

In addition to the lack of awareness of low-cost mammography options among the women who need them, public health has failed to adequately provide medically underserved women with alternatives to mammography. The current USPSTF recommendations for breast cancer screening did not include an explicit recommendation for routine breast self-examination (BSE), citing "insufficient evidence" (1). This practice should be incorporated into the options presented to those women at risk for not obtaining routine mammography. Low income women need to be adequately and consistently educated in how to do the BSE. Public health has a two-fold responsibility to vulnerable women to raise awareness about breast cancer screening options and to make these options more accessible.

The issue with mammography-centered breast cancer screening does not lie in the efficacy of the tool; indeed, it is impressively successful in preventing breast cancer mortality and morbidity (3). The issue, rather, lies with the failure of public health to employ this tool to its fullest potential so as to screen all groups of women sufficiently. To do so, public health needs to thoroughly understand the reasons why certain groups of women—those of low SES and minority status—do not undergo mammography screening as often as other women. The key factors of psychosocial inhibitions, the differential recommending practices of physicians, and insufficient access to affordable screening options need to be better examined and incorporated into the strategies of breast cancer screening implementation.

1. U.S. Preventive Services Task Force (USPSTF). Screening for Breast Cancer : Recommendations and Rationale. Available at: URL:
2. Consedine NS, Magai C, Krivoshekova YS, Ryzewicz LR, Neugut AI. 2003. Fear, Anxiety, Worry, and Breast Cancer Screening Behavior: A Critical Review. Cancer Epidemiology, Biomarkers & Prevention [Internet]. 2004 April; 13(4):501-510. Available from: URL:
3. Elmore JG, Armstrong K, Lehman CD, Fletcher SW. Screening for Breast Cancer. JAMA [Internet]. 2005 March 9; 293(10):1245-1256. Available from: URL:
4. Marbella AM, Layde PM. Racial Trends in Age-Specific Breast Cancer Mortality Rates in US Women. Am J Public Health [Internet]. 2001 January; 91(1):118-121. Available from: URL:
5. Coughlin SS, King J, Richards TB, Ekwueme DU Breast Cancer Screening and Socioeconomic Status --- 35 Metropolitan Areas, 2000 and 2002. MMRW [serial online] 2005 October 7; 54(39):981-985. Available from: URL:
6. Hedeen AN, White E. Breast Cancer Size and Stage in Hispanic American Women, by Birthplace: 1992-1995. Am J Public Health [Internet]. 2001 January; 91(1):122-125. Available from: URL:
7. O’Malley MS, Earp JA, Hawley ST, Schell MJ, Mathews HF, Mitchell J. The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: Who gets the message about breast cancer screening? Am J Public Health [Internet]. 2001 January; 91(1):49-54. Available from: URL:
8. O’Malley MS, Earp JA, Harris RP. Race and Mammography Use in Two North Carolina Counties. Am J Publich Health [Internet]. 1997 May; 87(5):782-786. Available from: URL:
9. McCoy CB, Pereyra M, Metsch LR, Collado-Mesa F, Messiah SE, Sears S. A community-based breast cancer screening program for medically underserved women: Its effect on disease stage at diagnosis and on hazard of death. Rev Panam Salud Publica[Internet]. 2004;15(3):160-7. Available at: URL:
10. Whitman S, Ansell D, Lacey L, Chen EH, Ebie N, Dell J, Phillips CW. Patterns of Breast and Cervical Cancer Screening at Three Public Health Centers in an Inner-City Urban Area. Am J Public Health [Internet]. 1991 December; 81(12): 1651–1653. Available from: URL:
11. Lostao L, Joiner TE, Pettit JW, Chorot P, Sandin B. Health beliefs and illness attitudes as predictors of breast cancer screening attendance. Euro J Public Health [Internet]. 2001; 11(3):274-279. Available from: URL:

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  • At April 24, 2008 at 9:28 AM , Blogger Abha said...

    I agree with the points you raise in your paper. I also think that in class the other week we learned that ad campaigns that aim to raise breast cancer awareness among minority women were also effective. I think that could be another way to increase screenings!


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