How Much Influence Do Chronic Diseases Exert on Mammography Screening?

The number of chronic diseases a woman living in the Appalachian region of the United States has dictated her likelihood of going for a mammogram according to breast cancer screening recommendations, according to study results published this week in the journal Women’s Health.

Whereas the presence of 1 chronic disease and having visited a primary care provider was associated with a greater chance of having had a screening mammography in the past 2 years, having several chronic diseases was negatively correlated with receiving guideline-concordant care, the study’s authors reported.

Factors that may have influenced their results include being of a racial minority, education level, poverty level, living in a rural area, availability of transportation, and lack of both health care provider availability and recommendation for mammography. Meanwhile, previous research shows that Appalachian residents have higher cancer-related mortality and comorbidity.

They enrolled 3306 women 65 years or older (mean age, 76 years; range, 65-99 years) who had breast cancer diagnosed between 2006 and 2008. All of the women lived in 4 Appalachian states—Kentucky, North Carolina, Ohio, and Pennsylvania—and had Medicare, which has covered mammography as a preventive service since 1991. They also had to be enrolled in Medicare from 2 years before to at least 1 year after receiving their diagnosis. Data were extracted from these states’ cancer registries.

With the primary outcome being adherence to 2009 breast cancer screening guidance per the US Preventive Services Task Force, the independent variable of chronic disease presence included the following, among many chronic diseases: arthritis, emphysema, chronic lung disease, diabetes, and substance abuse.

Results show that older age (70-79 years) indicated a greater chance of being screened for breast cancer, as well as that 50% underwent a preventive mammogram. These odds, however, decreased with older age.

“Screenings rates of 50% are low given that this population of women has health insurance that covers mammograms,” the authors noted.

Sixteen percent of the women also had no chronic disease, but of those who did, 59% had 1 or 2 chronic diseases, followed by 19% with 3 or 4, and 6% with 5 or more. Among the women with chronic disease, those with at least 1 had a 35% (CI, 1.122-1.637) greater chance of being screened for breast cancer, a result that carried over when considering county-level variables (odds ratio [OR], 1.40; CI, 1.159-1.696), as did those with 1 or 2 (OR, 1.51; CI, 1.25-1.84).

However, higher numbers of chronic diseases decreased the likelihood of adhering to breast cancer screening guidance:

• 3 to 4 chronic diseases: 33% lower odds (CI, 0.51-0.88)
• 5 or more chronic diseases: 41% lower odds (CI, 0.42-0.86)

“Closing gaps in the delivery of clinical preventive services is one of the public health strategies for improving the health and quality of life of older adults,” they concluded. “Considering an increase in the percentage of the population 65 or older by 2050, this study provides evidence to assist the nation’s efforts to prevent and control chronic diseases so that these added years translate into quality years.”

To prevent chronic disease from continuing to be a barrier to receiving adequate preventive care, the authors presented several solutions:

1. Investigate how chronic disease condition and severity influence visits to health care providers or screening decisions
2. Target screening interventions specifically to vulnerable populations (eg, older women, those without a primary care physician)
3. Perform longitudinal studies to delineate long-term screening patterns
4. Educate physicians on the possibility that they may have a conscious or unconscious bias toward recommending breast cancer screening

Reference

Elewonibi B, Nkwonta C. The association of chronic diseases and mammography among Medicare beneficiaries living in Appalachia. Womens Health (Lond). Published online June 15, 2020. doi:10.1177/1745506520933020