Study: Obesity, age, income pose screening mammo barriers

Obesity presented “a significant hurdle to mammogram completion” and researchers suggested funding target interventions to minimize barriers identified by women rather than additional patient reminders, according to a two-phase retrospective cohort study published in the February issue of Journal of Women’s Health. The study identified multiple barriers to screening mammography participation among insured women including: age younger than 60 years, health plan membership less than five years, family income less than $40,000 annually and obesity.

With more than 30 percent of eligible women bypassing regular mammographic screening exams, researchers at Kaiser Permanente Northwest in Portland, Ore., sought to identify potential and less obvious barriers among insured women. Specifically, despite excellent mammographic access, consistent reminders and assignment to primary care providers, a significant portion of Kaiser Permanente Northwest plan participants do not complete screening mammograms.

Conducted from January 1 to July 1, 2007, the first phase of the study examined patient characteristics available through the EMR for their association with screening mammogram completion among a cohort of 4,708 women aged 50 to 69.

Phase two incorporated a survey of a subset of 677 women who failed to comply with screening reminders. Three hundred forty women returned the survey. In the survey phase, researchers oversampled women who had important barriers identified in phase 1 to further elucidate factors associated with the barriers, explained the researchers, who were led by Adrianne C. Feldstein, MD, of the Center for Health Research, Kaiser Permanente Northwest.

A multivariate model predicting mammography completion at 10 months among the phase one cohort indicated women under 60 years of age, women with health plan memberships of less than five years, women with family income under $40,000 per year and women who were obese had reduced odds of completing a mammogram. In contrast, researchers reported that visiting a primary care provider or obstetrician/gynecologist during follow-up increased the odds of completing a mammogram.

Patient-reported barriers to mammography included being “too busy,” feeling embarrassed about having a mammogram and the option that the mammogram caused “too much pain.”

Women younger than age 60 were significantly more likely to be “too busy” to get mammograms and to have more worries about mammographic accuracy and unnecessary surgery than those over age 60, reported Feldstein and colleagues.

The authors observed that younger women’s concerns related to mammographic accuracy and subsequent missed cancers or unnecessary surgery “highlights the need for assistance with informed decision making in younger women and the continued need for improved technologies for breast cancer screening.”

They also found that nearly 25 percent of respondents reported “too much pain” from mammograms, with 31.3 percent of obese women versus 18.8 percent of nonobese women referring to pain. Possible pain-mediating solutions include patient-controlled compression or alternative screening technologies, offered Feldstein and colleagues.

“[T]his study serves to highlight that access to mammograms through health insurance and reminding patients that mammograms are due does not completely alleviate patient barriers,” wrote Feldstein. The authors concluded that: “important barriers to mammography remain. … [R]emaining patient barriers are not likely to be overcome with more reminders and interventions with clinicians.” Instead, they suggested researchers focus on understanding and addressing barriers related to obesity.