Factors Related to Breast and Cervical Cancer Screening
Factors Related to Breast and Cervical Cancer Screening
ABSTRACT & COMMENTARY
Synopsis: In this report from the University of Alabama-Birmingham, a retrospective medical record review of 1764 women who were patients in their clinic was undertaken to see if there was an association between the presence of chronic disease and the use of breast and cervical screening tools. Despite increased clinic use by patients with chronic disease, less mammography, clinical breast exams, and Pap smears were performed. The authors speculate that this might reflect an inherent bias against screening in individuals who they estimate have a shorter life expectancy or a lesser quality of life.
Source: Kiefe CI, et al. Chronic disease as a barrier to breast and cervical cancer screening. J Gen Intern Med 1998;13:357-365.
There are approximately 100 million americans with at least one diagnosed chronic illness. Although these individuals are likely to visit physicians more frequently than those without illness, there are conflicting data about the influence of chronic disease on cancer screening. In this report, medical records were abstracted from women older than 43 years (n = 1764) who were recurrent visitors to one of two clinics (General Internal Medicine or Family Practice) at the University of Alabama-Birmingham. Study outcomes were whether women had been screened for breast or cervical cancer according to the United States Preventive Services Task Force (USPSTF) guidelines. For breast cancer, these include mammography every two years for women ages 50-74 and clinical breast exam (CBE) every year (all ages). For cervical cancer, the recommendation is for a Pap smear every three years for all women younger than 65 years.
The Charlson Index was used to assess level of comorbidity. In this index, a score of zero reflects no disease and scores above that indicate an increased number of chronic illnesses. The Charlson Index weighs the severity of various conditions. For example, the presence of congestive heart failure adds one point, whereas diabetes with end organ failure adds two, metastatic cancer adds three, and AIDS adds six points. The maximum Charlson Index score in this series was 8.
Overall, 58% of women had received mammograms, 43% a CBE, and 66% a Pap smear at the appropriate interval. As comorbidity increased, screening rates decreased. After appropriate adjustments, each unit increase in the Charlson Index corresponded to a 17% decrease in the likelihood of mammography, 13% decrease in CBE, and 20% decrease in Pap smears. Thus, in this outpatient setting, screening rates decreased as comorbidity increased.
COMMENTARY
The findings reported here probably come as no surprise, as there is a commonly held notion (although, as yet unsubstantiated by data) that physicians are less likely to screen for cancer in patients who are elderly or whose life expectancy is reduced by an already existing disease. Nonetheless, patients with illness are more likely to frequent the clinic and the opportunity for appropriate screening would seem greater. Indeed, in this report, there was a positive correlation of screening with number of clinic visits per year (41% for those who came only once in 12 months, 57% for those who visited 2 or 3 times, and more than 66% for those requiring 4 or more visits). Yet, for those with a Charlson Score of 0, 62% received mammography, whereas for those with scores of 3 or more, the rate of mammography was 53% (P = 0.018).
The study really does not address mammography in the elderly and this is because the use of this screening tool has not been adequately studied in older women. However, this will become an issue in the decades to come as the geriatric population expands dramatically. Furthermore, older women today are more health conscious, are actually healthier, and have a greater life expectancy than older women a generation ago. Thus, the time has come to reassess the USPSTF guidelines that currently draw the line for mammography recommendations at 69 years.1 This is distressing given that breast cancer is a disease with a median age of 70 years.2
The study does address the issue of chronic disease, which is also a national concern. It is estimated that 100 million Americans have at least one chronic illness. Many of these individuals could be expected to benefit from screening. Of course, this is a single institutional experience in an academic center, and may not be generalizable to the population as a whole. Nevertheless, the findings are of sufficient concern to warrant further investigation to establish whether there is a screening bias against patients with chronic disease and to demonstrate whether such a bias is justified.
References
1. US Preventive Services Task Force. Guide to Clinical Preventive Services. Baltimore, MD. Williams and Wilkins: 1996.
2. Ries LAG, et al. SEER cancer statistics review, 1973-1993: Tables and graphs. In NIH. Bethesda, MD: US PHS, 1996.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.