Article

Delay in Diagnostic Testing After Abnormal Mammography in Low-Income Women

Debra Wujcik

Yu Shyr

Ming Li

Margaret F. Clayton

Lee Ellington

Usha Menon

Kathi Mooney

mammography
ONF 2009, 36(6), 709-715. DOI: 10.1188/09.ONF.709-715

Purpose/Objectives: To identify factors associated with diagnostic delay after an incomplete or abnormal mammogram among women participating in a state mammography screening program.

Research Approach: Retrospective case-control design using bivariate and multivariate logistic regression analyses to explore the associations between age, race, ethnicity, marital status, breast cancer history, and self-reported breast symptoms and delay.

Setting: A statewide program of free screening mammography for women who are under- or uninsured.

Participants: 11,460 women enrolled in a free, statewide screening program from 2002-2006.

Methodologic Approach: Using the Tennessee Breast and Cervical Cancer Screening Program database, further analyses were conducted.

Main Research Variables: The outcome measure was delay in completion of all diagnostic tests and was defined as women who did not complete testing within 60 days.

Findings: Thirty-seven percent of women required follow-up, and of a subset used in the analysis, 30% experienced delay of more than 60 days. Controlling for marital status, age, and breast cancer history, women who experienced delay were more likely to be African American versus Caucasian (odds ratio [OR] = 1.45, 95% confidence interval [CI] = 1.13, 1.85) or Hispanic (OR = 0.72, 95% CI = 0.55, 0.93) and to have self-reported breast symptoms (OR = 1.50, 95% CI = 1.27, 1.77).

Conclusions: In a sample of women with low income needing mammography follow-up, delay was associated with three intrapersonal variables, potentially reducing the effectiveness of mammography screening for women who were African American, or Hispanic, or had self-reported breast symptoms.

Interpretation: Nurses providing cancer screening examinations are uniquely positioned to assess the knowledge, beliefs, and resources of women using the program and to navigate women through barriers to completion. Knowledge of factors associated with delay is valuable for planning interventions and allocating program resources.

Jump to a section

    References

    American Cancer Society. (2009a). Cancer facts and figures 2009. Retrieved September 12, 2009, from http://www.cancer.org/downloads/STT/500809web.pdf
    American Cancer Society. (2009b). Cancer facts and figures for African Americans 2009-2010. Retrieved September 29, 2009, from http://www.cancer.org/downloads/STT/cffaa_2009-2010.pdf
    Andersen, M.R., Yasui, Y., Meischke, H., Kuniyuki, A., Etzioni, R., & Urban, N. (2000). The effectiveness of mammography promotion by volunteers in rural communities. American Journal of Preventive Medicine, 18(3), 199-207.
    Arnsberger, P., Fox, P., Ryder, P., Nussey, B., Zhang, X., & Otero-Sabogal, R. (2006). Timely follow-up among multicultural women with abnormal mammograms. American Journal of Health Behavior, 30(1), 51-61.
    Bedell, M.B., Wood, M.E., Lezotte, D.C., Sedlacek, S.M., & Orleans, M.M. (1995). Delay in diagnosis and treatment of breast cancer: Implications for education. Journal of Cancer Education, 10(4), 223-228.
    Bloom, J.R., Stewart, S.L., Johnston, M., Banks, P., & Fobair, P. (2001). Sources of support and the physical and mental well-being of young women with breast cancer. Social Science and Medicine, 53(11), 1513-1524.
    Bradley, C.J., Given, C.W., & Roberts, C. (2001). Disparities in cancer diagnosis and survival. Cancer, 91(1), 178-188.
    Burack, R.C., Simon, M.S., Stano, M., George, J., & Coombs, J. (2000). Follow-up among women with an abnormal mammogram in an HMO: Is it complete, timely, and efficient? American Journal of Managed Care, 6(10), 1102-1113.
    Buseman, S., Mouchawar, J., Calonge, N., & Byers, T. (2003). Mammography screening matters for young women with breast carcinoma: Evidence of downstaging among 42-49-year-old women with a history of previous mammography screening. Cancer, 97(2), 352-358.
    Caplan, L.S., Helzlsouer, K.J., Shapiro, S., Freedman, L.S., Coates, R.J., & Edwards, B.K. (1995). System delay in breast cancer in whites and blacks. American Journal of Epidemiology, 142(8), 804-812.
    Chu, K.C., Lamar, C.A., & Freeman, H.P. (2003). Racial disparities in breast carcinoma survival rates: Separating factors that affect diagnosis from factors that affect treatment. Cancer, 97(11), 2853-2860.
    Drageset, S., & Lindstrom, T.C. (2005). Coping with a possible breast cancer diagnosis: Demographic factors and social support. Journal of Advanced Nursing, 51(3), 217-226.
    Eheman, C.R., Benard, V.B., Blackman, D., Lawson, H.W., Anderson, C., Helsel, W., et al. (2006). Breast cancer screening among low-income or uninsured women: Results from the National Breast and Cervical Cancer Early Detection Program, July 1995-March 2002 (United States). Cancer Causes and Control, 17(1), 29-38.
    Elmore, J.G., Armstrong, K., Lehman, C.D., & Fletcher, S.W. (2005). Screening for breast cancer. JAMA, 293(10), 1245-1256.
    Gorin, S.S., Heck, J.E., Cheng, B., & Smith, S.J. (2006). Delays in breast cancer diagnosis and treatment by racial/ethnic group. Archives of Internal Medicine, 166(20), 2244-2252.
    Gotzsche, P.C., & Nielsen, M. (2006). Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews, (4), CD001877.
    Gwyn, K., Bondy, M.L., Cohen, D.S., Lund, M.J., Liff, J.M., Flagg, E.W., et al. (2004). Racial differences in diagnosis, treatment, and clinical delays in a population-based study of patients with newly diagnosed breast carcinoma. Cancer, 100(8), 1595-1604.
    Haas, J.S., Cook, E.F., Puopolo, A.L., Burstin, H.R., & Brennan, T.A. (2000). Differences in the quality of care for women with an abnormal mammogram or breast complaint. Journal of General Internal Medicine, 15(5), 321-328.
    Jemal, A., Siegel, R., Ward, E., Hao, Y., Xu, J., & Thun, M.J. (2009). Cancer statistics, 2009. CA: Cancer Journal for Clinicians, 59(4), 225-249.
    Johnson, N.J., Backlund, E., Sorlie, P.D., & Loveless, C.A. (2000). Marital status and mortality: The national longitudinal mortality study. Annals of Epidemiology, 10(4), 224-238.
    Kerlikowske, K., Smith-Bindman, R., Ljung, B.M., & Grady, D. (2003). Evaluation of abnormal mammography results and palpable breast abnormalities. Annals of Internal Medicine, 139(4), 274-284.
    Kothari, A., & Fentiman, I.S. (2003). Diagnostic delays in breast cancer and impact on survival. International Journal of Clinical Practice, 57(3), 200-203.
    Kravdal, O. (2001). The impact of marital status on cancer survival. Social Science and Medicine, 52(3), 357-368.
    Olivotto, I.A., Gomi, A., Bancej, C., Brisson, J., Tonita, J., Kan, L., et al. (2002). Influence of delay to diagnosis on prognostic indicators of screen-detected breast carcinoma. Cancer, 94(8), 2143-2150.
    Osborne, C., Ostir, G.V., Du, X., Peek, M.K., & Goodwin, J.S. (2005). The influence of marital status on the stage at diagnosis, treatment, and survival of older women with breast cancer. Breast Cancer Research and Treatment, 93(1), 41-47.
    Peek, M.E., & Han, J.H. (2004). Disparities in screening mammography. Current status, interventions, and implications. Journal of General Internal Medicine, 19(2), 184-194.
    Poon, E.G., Haas, J.S., Puopolo, A.L., Gandhi, T.K., Burdick, E., Bates, D.W., et al. (2004). Communication factors in the follow-up of abnormal mammograms. Journal of General Internal Medicine, 19(4), 316-323.
    Richards, M.A., Westcombe, A.M., Love, S.B., Littlejohns, P., & Ramirez, A.J. (1999). Influence of delay on survival in patients with breast cancer: A systematic review. Lancet, 353(9159), 1119-1126.
    Rojas, M., Mandelblatt, J., Cagney, K., Kerner, J., & Freeman, H. (1996). Barriers to follow-up of abnormal screening mammograms among low-income minority women. Cancer Control Center of Harlem. Ethnicity and Health, 1(3), 221-228.
    Sallis, J.F., & Owen, N. (2002). Ecogogical models of health behavior. In K. Glanz, B.K. Rimer, & F.M. Lewis (Eds.), Health behaviors and health education: Theory, research, and practice (3rd ed., pp. 462-484). San Francisco: Jossey-Bass.
    Schootman, M., Myers-Geadelmann, J., & Fuortes, L. (2000). Factors associated with adequacy of diagnostic workup after abnormal breast cancer screening results. Journal of the American Board of Family Practice, 13(2), 94-100.
    Smedley, B.D., Stith, A.Y., & Nelson, A.R. (2005). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.
    Strzelczyk, J.J., & Dignan, M.B. (2002). Disparities in adherence to recommended follow-up on screening mammography: Interaction of sociodemographic factors. Ethnicity and Disease, 12(1), 77-86.
    Taplin, S.H., Ichikawa, L.E., Kerlikowske, K., Ernster, V.L., Rosenberg, R.D., Yankaskas, B.C., et al. (2002). Concordance of breast imaging reporting and data system assessments and management recommendations in screening mammography. Radiology, 222(2), 529-535.
    Wells, K.J., Battaglia, T.A., Dudley, D.J., Garcia, R., Greene, A., Calhoun, E., et al. (2008). Patient navigation: State of the art or is it science? Cancer, 113(8), 1999-2010.
    Wujcik, D., & Fair, A.M. (2008). Barriers to diagnostic resolution after abnormal screening mammography: A review of the literature. Cancer Nursing, 31(5), E16-E30. Retrieved October 20, 2009, from http://journals.lww.com/cancernursingonline/Abstract/2008/09000/Barrier… http://journals.lww.com/cancernursingonline/Abstract/2008/09000/Barriers_to_Diagnostic_Resolution_After_Abnormal.15.aspx
    Yabroff, K.R., Breen, N., Vernon, S.W., Meissner, H.I., Freedman, A.N., & Ballard-Barbash, R. (2004). What factors are associated with diagnostic follow-up after abnormal mammograms? Findings from a U.S. National Survey. Cancer Epidemiology, Biomarkers and Prevention, 13(5), 723-732.
    Zapka, J.G., & Lemon, S.C. (2004). Interventions for patients, providers, and healthcare organizations. Cancer, 101(5, Suppl.), 1165-1187.