Summary
This paper explores barriers to the use of standard screening and breast cancer treatment that result in systematic differences in health outcomes. We review available data on individual, socioeconomic, and health system determinants of access to standard breast cancer care, including screening, diagnostic, and treatment services. Based on this review, we discuss the combination of factors which result in underservice. We argue that a broad framework which considers health system and social class as well as individual factors is useful for analyzing how structures of health care delivery tend to provide less than standard care to women who are older, have less income, or are less educated, black, or Hispanic. Data collection efforts which do not include structural and socioeconomic variables may result in an incomplete or misleading understanding of the determinants of underservice. These factors also need to be considered in the design and evaluation of public health policies and interventions meant to ameliorate the effects of underservice.
References
Greenwald P, Cullen JW: The scientific approach to cancer control. CA Cancer J Clin 34:328–332, 1984
US Department of Health and Human Services: Cancer Control Objectives for the Nation: 1985–2000. 1986
Greenwald HP: Who Survives Cancer? University of California Press, 1992
Dawson DA, Thompson GB: Breast Cancer Risk Factors and Screening: United States, 1987. Vital and Health Statistics, Series 10, No. 172. DHHS Pub. No. (PHS) 90-1500. National Center for Health Statistics, Hyattsville MD, 1989
Calle EE, Flanders WD, Thun MJ, Martin LM: Demographic predictors of mammography and Pap smear screening in U.S. women. Am J Public Health 83:53–60, 1993
Breen N, Kessler L: Changes in the use of screening mammography: evidence from the 1987 and 1990 National Health Interview Surveys. Am J Public Health 84:62–67, 1994
Makuc DM, Freid VM, Parsons PE: Health insurance and cancer screening among women. Adv Data 254, Aug 3:1–11, 1994
Brown ML, Fintor L: U.S. screening mammography services with mobile units: Results from the National Survey of Mammography Facilities. Radiology 195:529–532, 1995
McWhorter WP, Mayer WJ: Black/white differences in type of initial breast cancer treatment and implications for survival. Am J Public Health 77: 1515–1517, 1987
Axtell LM, Myers MH: Contrasts in survival of black and white cancer patients, 1960–1973. J Natl Cancer Inst 60:1209–1215, 1978
Funch DP: Socioeconomic status and survival for breast and cervical cancer.In: Stellman SD (ed) Women and Cancer. Harrington Park Press, New York, 1987, pp 37–50
Devesa S: Cancer mortality, incidence, and patient survival among American women.In: Stellman SD (ed) Women and Cancer. Harrington Park Press, New York, 1987, pp 7–21
Krieger N: Overcoming the absence of socioeconomic data in medical records: Validation and application of a census-based methodology. Am J Public Health 82:703–710, 1992
Figueroa JB, Breen N: Significance of underclass residence on the stage of breast or cervical cancer diagnosis. Am Econ Rev, May, 1995
Howard J, Hankey BF, Greenberg RS, Chen VW, Durako S: A collaborative study of differences in the survival rates of black patients and white patients with cancer. Cancer 69:2349–2360, 1992
Eley JW, Hill HA, Chen VW, et al: Racial differences in survival from breast cancer — Results of the National Cancer Institute Black/White Cancer Survival Study. JAMA 272:947–954, 1994
Devesa SS, Diamond LE: Association of breast cancer and cervical cancer incidence with income and education among whites and blacks. J Natl Cancer Inst 65:515–528, 1980
McWhorter WP, Schatzkin AG, Horn JW, Brown CC: Contribution of socioeconomic status to black/white differences in cancer incidence. Cancer 63:982–987, 1989
Gordon NH, Crowe JP, Brumberg DJ, Berger NA: Socioeconomic factors and race in breast cancer recurrence and survival. Am J Epidemiol 135: 609–618, 1992
Wells BL, Horn JW: Stage at diagnosis in breast cancer: race and socioeconomic factors. Am J Public Health 82:1383–1385, 1992
Hunter CP, Redmond CK, Chen VW, et al: Breast cancer: factors associated with stage at diagnosis in black and white women. Black/White Cancer Survival Study Group. J Natl Cancer Inst 85:1129–1137, 1993
Rogers RG: Living and dying in the USA: Sociodemographic determinants of death among blacks and whites. Demography 29:287–303, 1992
Blendon RJ, Aiken LH, Freeman HE, Corey CR: Access to medical care for black and white Americans. JAMA 261:278–281, 1989
Kessler R, Neighbors HW: A new perspective on the relationships among race, social class, and psychological distress. J Health Soc Behav 27:107–115, 1986
Byrd WM, Clayton LA: An American health dilemma: A history of blacks in the health system. J Natl Med Assoc 84:189–200, 1992
Krieger N, Rowley DL, Herman AA, Avery B, Phillips MT: Racism, sexism, and social class: implications for studies of health, disease, and well-being. Am J Prev Med 9:82–122, 1993
Ruiz P: Cultural barriers to effective medical care among Hispanic-American patients. Annu Rev Med 36:63–71, 1985
Burack RC, Liang J: The early detection of cancer in the primary-care setting: Factors associated with the acceptance and completion of recommended procedures. Prev Med 16:739–751, 1987
SEER Cancer Statistics Review: 1973–1990. National Cancer Institute, NIH Pub. No. 93-2789, 1993
Satariano WA, Belle SH, Swanson GM: The severity of breast cancer at diagnosis: A comparison of age and extent of disease in black and white women. Am J Public Health 76:779–782, 1986
Goodwin JS, Samet JM, Key CR, Humble C, Kutvirt D, Hunt C: Stage at diagnosis of cancer varies with the age of the patient. J Am Geriatr Soc 34:20–26, 1986
Roetzheim RG, Vandurme DJ, Brownlee HJ, et al: Reverse targeting in a media-promoted breast cancer screening project. Cancer 70:1152–1158, 1992
Older Women and the Medicare Mammography Benefit: 1992 Awareness and Usage Levels. AARP, 1993
Silliman RA, Guadagnoli B, Weitberg AB, Mor V: Age as a predictor of diagnostic and initial treatment intensity in newly diagnosed breast cancer patients. J Gerontol 44(2):46–51, 1989
Greenfield S, Blanco DM, Elashoff RM, Ganz PA: Patterns of care related to age of breast cancer patients. JAMA 257:2766–2770, 1987
Chu J, Diehr P, Feigl P, et al: The effect of age on the care of women with breast cancer in community hospitals. J Gerontol 42:185–190, 1987
Rimer BK, Trock B, Engstrom PF, Lerman C, King E: Why do some women get regular mammograms? Am J Prev Med 7:69–74, 1991
Zapka JG, Stoddard AM, Costanza ME, Greene HL: Breast cancer screening by mammography: Utilization and associated factors. Am J Public Health 79:1499–1502, 1989
Zapka JG, Stoddard A, Maul L, Costanza ME: Interval adherence to mammography screening guidelines. Med Care 29:697–707, 1991
Burg MA, Lane DS, Polednak AP: Age group differences in the use of breast cancer screening tests. The effects of health care utilization and socioeconomic variables. J Aging Health 2:514–530, 1990
Bernstein AB, Thompson GB, Harlan LC, Applied Research Branch, Division of Cancer Prevention and Control, National Cancer Institute: Screening for cancer in HMOs: Data from the 1987 National Health Interview Survey. 1989 (unpublished)
Hayward RA, Shapiro MF, Freeman HE, Corey CR: Who gets screened for cervical and breast cancer? Results from a new national survey. Arch Intern Med 148:1177–1181, 1988
Rimer BK, Ross E, Balshem A, Engstrom PF: The effect of a comprehensive breast screening program on self-reported mammography use by primary care physicians and women in a health maintenance organization. J Am Board Fam Pract 6:443–451, 1993
Rakowski W, Rimer BK, Bryant SA: Integrating behavior and intention regarding mammography by respondents in the 1990 National Health Interview Survey of Health Promotion and Disease Prevention. Public Health Rep 108:605–624, 1993
Rakowski W, Fulton JP, Feldman JP: Women's decision making about mammography: A replication of the relationship between stages of adoption and decisional balance. Health Psychol 12:209–214, 1993
Breen N, Kessler L: Stat Bite: Increases in screening mammography: U.S. women 40 and older. J Natl Cancer Inst 84:1549, 1993
Urban N, Anderson GL, Peacock S: Mammography screening: How important is cost as a barrier to use? Am J Public Health 84:50–55, 1994
Stein JA, Fox SA, Murata PJ: The influence of ethnicity, socioeconomic status, and psychological barriers on use of mammography. J Health Soc Behav 32:101–113, 1991
Longman AJ, Saint-Germain MA, Modiano M: Use of breast cancer screening by older Hispanic women. Public Health Nurs 9:118–124, 1992
Fox SA, Stein JA: The effect of physician-patient communication on mammography utilization by different ethnic groups. Med Care 29:1065–1082, 1991
U.S. Preventive Services Task Force: Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. William & Wilkins, Baltimore, 1989
Coll PP, O'Connor PJ, Crabtree BF, Besdine RW: Effects of age, education, and physician advice on utilization of screening mammography. J Am Geriatr Soc 37:957–962, 1989
Rimer BK, Keintz MK, Kessler HB, Engstrom PF, Rosan JR: Why women resist screening mammography: patient-related barriers. Radiology 172:243–246, 1989
Lackland DT, Dunbar JB, Keil JE, Knapp RG, O'Brien PH: Breast cancer screening in a biracial community: the Charleston tricounty experience. South Med J 84:862–866, 1991
Glockner SM, Holden MG, Hilton SV, Norcross WA: Women's attitudes toward screening mammography. Am J Prev Med 8:69–77, 1992
Vernon SW, Vogel VG, Halabi S, Jackson GL, Lundy RO, Peters GN: Breast cancer screening behaviors and attitudes in three racial/ethnic groups. Cancer 69:165–174, 1992
Houn F, Brown ML: Current practice of screening mammography in the U.S.: Data from the National Survey of Mammography Facilities. Radiology 190:209–215, 1994
Weinberger M, Saunders AF, Samsa GP, et al: Breast cancer screening in older women: practices and barriers reported by primary care physicians. J Am Geriatr Soc 39(1):22–29, 1991
Fajardo LL, Saint-Germain M, Meakem TJ, Rose C, Hillman BJ: Factors influencing women to undergo screening mammography. Radiology 184:59–63, 1992
Kiefe CI, McKay SV, Halevy A, Brody BA: Is cost a barrier to screening mammography for low-income women receiving Medicare benefits? A randomized trial. Arch Intern Med 154:1217–1224, 1994
Physician Payment Review Commission: The Cost of Providing Screening Mammography. Report to Congress. Submitted pursuant to section 204 (f) (1) of the Medicare Catastrophic Coverage Act of 1988. Washington DC, 1989
Breen N, Brown ML: The price of mammography in the United States: Data from the National Survey of Mammography Facilities. The Milbank Quarterly 72:431–450, 1995
Baker MS, Kessler LG, Smucker RC: Site-specific treatment costs for cancer: An analysis of the Medicare continuous history sample file.In: Scheffler RM, Andrews NC (eds) Cancer Care and Costs: DRG's and Beyond. Health Administration Press, Ann Arbor MI, 1989, pp 127–138
Sofaer S, Davidson BN: Illness-episode approach: costs and benefits of medigap insurance. Health Care Financ Rev 11:121–131, 1990
Stommel N, Given CW, Given BA: The cost of cancer home care to families. Cancer 71:1867–1874, 1993
Given BA, Given CW, Stommel M: Family and out-ofpocket costs for women with breast cancer. Cancer Pract 2:187–193, 1994
Schappert SM: Office Visits to Obstetricians and Gynecologists: United States, 1989–1990. Advanced data from Vital and Health Statistics, No. 223. NCHS, Hyattsville MD, 1992
Siminoff LA, Fetting JH: Factors affecting treatment decisions for a life-threatening illness: the case of medical treatment of breast cancer. Soc Sci Med 32:813–818, 1991
Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin JS: Geographic variation in the use of breastconserving treatment for breast cancer. N Engl J Med 326:1102–1107, 1992
Coleman EA, Kessler LG, Wun LM, Feuer EJ: Trends in the surgical treatment of ductal carcinoma in situ of the breast. Am J Surg 164:74–76, 1992
Lacey L: Cancer prevention and early detection strategies for reaching underserved urban, low-income black women. Cancer Supp 72(3):1078–1083, 1993
Suarez L, Nichols DC, Brady CA: Use of peer role models to increase pap smear and mammogram screening in Mexican-American and Black women. Am J Prev Med 9(5):290–296, 1993
Bracht N: Health Promotion at the Community Level. Sage Publ, Newberry Park CA, 1990
Katz SJ, Hofer TP: Socioeconomic disparities in preventive care persist despite universal coverage. Breast and cervical cancer screening in Ontario and the United States. JAMA 272:530–534, 1994
Haynes SG, Mara JR: The picture of health: How to increase breast cancer screening in your community. U.S. Department of Health and Human Services, P.H.S., N.I.H., Bethesda MD, 1993
Update: National Breast and Cervical Cancer Early Detection Program, 1992–1993. MMWR Morb Mortal Wkly Rep 42:747–749, 1993
Lillie-Blanton M, Martinez RM, Taylor AK, Robinson BG: Latina and African-American women: Continuing disparities is health. Int J Health Serv 23:555–584, 1993
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Breen, N., Kessler, L.G. & Brown, M.L. Breast cancer control among the underserved — An overview. Breast Cancer Res Tr 40, 105–115 (1996). https://doi.org/10.1007/BF01806006
Issue Date:
DOI: https://doi.org/10.1007/BF01806006