Breast Cancer Screening Preferences Among Hospitalized Women

Introduction

Breast cancer is now the most commonly diagnosed cancer globally among women and the leading cause of cancer death. ¹ In the United States during 2012, an estimated 226,870 new cases of invasive breast cancer and 39,510 breast cancer deaths are expected among women. ² Mortality from breast cancer has steadily decreased in women since 1990 as a result of progress in early detection, improved treatment, and recently decreased incidence. ² Mammography remains the screening test of choice ³ and has reduced breast cancer mortality by 22%–35% among women age 50 years and older. ⁴ Despite the steady utilization of screening mammography (67.1% in 2008), studies suggest that women older than 50 years, low-income, uninsured, and minorities (especially African Americans) are initiating mammography later than recommended, not having mammography at recommended intervals, and not receiving appropriate follow-up after a positive screen. ^{5 –7}

According to the National Health Interview Survey, women aged 40 years and older reporting a mammogram within the past two years increased from 29% in 1987 to 70% in 2000. ⁸ Thereafter, the prevalence of mammogram screenings has been gradually trending down. Breen et al. reported that breast cancer screening was on a decline from 2000 to 2005—with the largest drop occurring among women 50–59 years old. ⁹ The mammography rates remain lowest among the uninsured (35.6 %), and low income women. ^{8 –10} Studies have also shown that physicians tend to recommend mammography more frequently to well-educated, white women who have annual incomes above $20,000. ¹¹ This unequal emphasis may partially explain the lower screen rates seen among the uninsured, minorities, and low income women. ^8,11,12 Daily and colleagues found that women living in disadvantaged areas were less likely to have screening mammography, even after adjusting for individual-level socioeconomics and access to health care. ¹³ Some of the well documented barriers to an outpatient screening mammogram, including patient preferences, appear to be even greater obstacles in these low socioeconomic areas. ^14,15

Breast cancer screening is traditionally offered exclusively in outpatient settings, however for some women having a screening mammography while an inpatient may be a more practical and preferable option that has not been studied. The purpose of this study is to identify characteristics and barriers associated with non-adherence of mammographic screening among an ethnically diverse, predominantly low socioeconomic class of hospitalized population and evaluate their receptivity to screening during their inpatient stay.

Methods

Results

The mean age for the total study population was 60 years; 32% of the women were African American, 60% of women reported annual household income less than $20,000, and 5% were uninsured (Table 1). Average 5-year Gail risk of breast cancer was 1.6%. One-third of the study population (32%) was at high risk for breast cancer based on a 5-year-risk prediction of ≥1.7% using the Gail model. Thirty-nine percent of the hospitalized women in our study were overdue for a screening mammogram (non-adherent), including 13% who had never had a mammogram; 28% of the non-adherent women were also at high risk for breast cancer (Gail score ≥1.7%).

Characteristics for adherent and non-adherent women are shown in Table 1. More non-adherent women had annual incomes of less than $20,000 and a history of a prior stroke. Ninety-four percent of adherent group had a primary care provider versus 85% of the non-adherent group (p=0.04). Non-adherence rates were not statistically different across the age groups (36%, 43%, and 39% in the 50–59, 60–69, and 70–75 years age groups respectively [p=0.69], as shown in Fig 1).

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FIG. 1.

Percentage of adherence and non-adherence for screening mammography by age group. *Chi-Square test–p value for difference in percentage of non-adherent women between age groups.

As shown in Table 2, the most commonly cited barrier to breast cancer screening was “I have other problems more important than getting a mammogram.” Several barriers to breast cancer screening were perceived differently between the two groups, including “I cannot remember to schedule a mammogram” (27% among adherent and 16% in non-adherent, p=0.05) and “No transportation to get to the test” (17% among adherent and 29% in non-adherent, p=0.04). There were no statistical differences between the two groups about knowledge or perceived susceptibility. The two groups were also equally aware of the benefits of screening mammography (Table 2).

In evaluation of preference for inpatient screening among hospitalized women (Table 3), only 5% (n=11) of women reported that someone had talked to them about breast cancer screening during their inpatient stay, and 3% (n=7) of women reported having a clinical breast examination during that time. Almost all women (91%) believed that it is important for healthcare providers to discuss breast cancer screening while patients are in the hospital. Three-quarters of the women studied (n=159, 76%) indicated that they would agree to have an inpatient screening mammogram if it was due and it was offered. Eighty percent of the adherent women and sixty-eight percent of the non-adherent women (p=0.04), including 27% of women who had never had a mammogram, confirmed that they would be willing to have a screening mammogram during the hospital admission.

Discussion

More than one-third of the hospitalized women surveyed in our study were non-adherent and therefore overdue for a screening mammogram despite being aware of the potential benefit. The majority of these women responded that they would be agreeable to breast cancer screening performed during the hospitalization. While this study did not delve deeper into this willingness to be screened during the current hospital admission, time in the hospital is known to promote reflection and deeper consideration of health and behaviors. ²⁴ Notwithstanding the recent change in the breast cancer screening interval recommendations from annual to biennial by USPSTF, ¹⁶ significant barriers to the screening still exist. Access to mammography during a hospital admission, which eliminates barriers like transportation and convenience, makes the offering of inpatient mammogram germane for increasing screening rates. ^25,27 This study confirms prior reports that have shown decreased breast cancer screening among women from low socioeconomic status and those lacking primary care providers. ^{27 –31} For hospitalized women, particularly those at high risk of developing breast cancer, seizing the moment and performing inpatient mammography at a time when potential barriers are negated seems like a judicious strategy.

Some of the barriers that women cited in our study need to be further explored, like “I have other problems more important than getting a mammogram.” While “other problems” may have been interpreted widely by patients, medical comorbidities must have been among those at the forefront of their minds given the context of the hospitalization for acute illness. Further, while it is likely that multiple comorbidities may deter women from having screening tests, we did not detect significant differences in comorbidities between adherent and non-adherent groups. With the evolution of hospital medicine over the last decade, hospitalists have affirmed their expertise in providing comprehensive medical care to their patients and partnering with outpatient provider to deliver quality. Huth et al. retrospectively reviewed breast cancer screening practices among hospitalized women and concluded that hospital providers failed to seize the opportunity to initiate breast cancer screening during the hospitalization. ³² In Huth's study, women were hospitalized for a median of 6 days, breast cancer screening history was documented in 25% of cases, breast examination was performed on 37% of women, and mammography history was recorded in only 7.5% of hospital admissions. ³² No prior study of which we are aware has assessed breast cancer risk or preferences related to breast cancer screening among the hospitalized women. Consistent with the data above, we found that breast examination and breast cancer screening education during the hospital stay occurred infrequently. This is likely because breast issues were not tied to the reason for the acute hospitalization. However, because 91% of the women studied believed that it was important for hospital-based providers to discuss breast cancer screening during the hospitalization, the failure to do this could result in a missed opportunity for early detection of breast cancer.

A significant proportion of the non-adherent women (28%) carried a high 5-year-risk for breast cancer (using Gail model ≥1.7%). Thus, mammography needs to be a high priority whenever and wherever these patients interface with the healthcare system. Ethicists might suggest that inpatient providers who are not ordering mammograms for women known to be at very high risk for developing breast cancer and who are overdue for the test might be failing to abide by the physician charter's principle of the primacy of patient welfare. ³³ One feature of accountable care will be to offer patients recommended testing when they interface with our systems of care. ³⁴ It is interesting to note that some states mandate hospitals to offer all inpatient women over the age of 18 a Papanicolaou (Pap) test to screen for cervical cancer unless the patient refuses, there is documentation of a Pap within the past 12 months, or the physician orders otherwise. ³⁵ However, no such legislation exists for breast cancer screening.

Physician recommendations for screening have consistently been shown to strongly influence patient behaviors. ³⁶ Over the course of several days as hospitalists forge trusting relationships with patients, these physicians can prompt and inspire patients to consider, if not undergo, cancer screening that is overdue. This time together may result in partnerships that can result in shared decision-making between patients and healthcare providers around critical decisions, related both to health maintenance and the presenting illness. ¹⁵ Currently, hospital physicians do not see prevention and screening as critical components of their jobs or roles. ²⁴ However, if medicine is a public trust in which we must always put the patient first, expanding the role of the hospital practitioner to include mammography screening may be necessary.

Several limitations of this study should be considered. First, this study was conducted at a single hospital. Second, although patients' preferences were evaluated in this study, we did not solicit input about the potential impact of prevention and screening on hospital providers and nursing staff. Screening tests that may seem difficult to coordinate in hospitals today may become easier as hospitals become more patient centered. Third, we anticipate that most women will agree to have mammograms if they were ordered. In our experience caring for hospitalized patients for many years at multiple institutions, few patients refuse tests that are recommended by the physicians caring for them in the hospital.

Conclusion

Since early detection translates into reduced mortality, there is a need to optimize cancer prevention for breast cancer. It appears that women admitted to the hospital would value the opportunity to have breast cancer screening addressed during their stay. Because hospitalization is a unique time during which patients are a captive audience who are reflecting upon their health, there is tremendous potential for hospitalists to provide comprehensive care for the whole patient. This could in turn have a major impact on public health, particularly if these patients share their new knowledge and perspectives with those in their sphere of influence—friends and family. Future studies are required to evaluate the practical aspects such as the feasibility and financing of prevention and screening for breast cancer while patients are hospitalized.