Trends in Cervical & Breast Cancer Screening Practices among Women in

Rural & Urban Areas of the United States

AcademyHealth 2008Gender and Health Interest Group Meeting

June 7, 2008

Mark P. Doescher, MD, MSPHJ. Elizabeth Jackson, MA

Department of Family MedicineUniversity of Washington School of Medicine

Background

Disparities in cancer screening for rural women have been reported by others

A more refined definition of rural residence may allow identification of areas where need for services is especially great

Guidelines

Periodic screening for breast cancer and cervical cancer can reduce risk of premature death

USPSTF recommendations: Mammogram for women aged 40+ every two

years Papanicoloau (Pap) smear for women aged

18+ every three years

Disparities

Rates of Pap screening fall short of Healthy People 2010 goal of 90%

Less frequent use of preventive services among rural women may be due to: Greater distance to medical facilities Less accessibility of services Inadequate health insurance coverage

Rural disparity more pronounced among racial/ethnic minorities

Study Aims

Aim 1

To examine the prevalence of and trends in mammography and Pap smear screening among adult women living in rural and urban locations between 1994 and 2004.

Aim 2

To explore the uptake of these tests among groups of rural women who might be relatively unlikely to benefit from any temporal improvements in screening.

Data and Methods

Data

Behavioral Risk Factor Surveillance System (BRFSS)

Women aged 18+ for Pap screening and 40+ for mammography

Annual samples from 1994-2000, 2002 and 2004 (1994 n=105,853, 2004 n=303,822)

United States (excluding District of Columbia, New Jersey, Rhode Island and Alaska, and territories)

Data –

Dependent Measures

Women were asked: If they had ever had a mammogram and the

date of their most recent mammogram If they had ever had a Pap smear and the date

of their most recent test; also asked whether they had had a hysterectomy

Classified as up-to-date if: Mammogram within prior two years Pap smear within prior three years

Data –

Key Independent Measures

Rural/urban residence classified by county by 2003 Urban Influence Code (UIC) Metropolitan Non-metro: 1) adjacent non-metro; 2) remote

micropolitan; 3) remote non-core

Sociodemographic factors examined: age; race/ethnicity; educational attainment; household income; labor force participation

Analysis

Logistic regression used to estimate rates of screening overall and by selected factors

SuDaAn 8.0 [RTI 2001] adjusts standard errors for complex sample design

Predicted marginal percentages are presented

Trends were examined by comparing estimates from individual years

Results

Percent Women with Current Mammogram or Pap Screening by Rural/Urban (2004)

Chi2 p-value

Mammogram, Aged 40+

Unadjusted 75.7 71.2 71.8 68.3 0.000Adjusted 75.4 73.4 73.7 71.1 0.000

Pap, Aged 18+

Unadjusted 86.1 83.4 83.2 81.7 0.000Adjusted 86.0 85.4 85.2 84.9 0.257

MetroAdjacent to Metro

Remote Micropolitan

Remote Non-Core

Adjusted Percent Women Aged 40+ with Current Mammogram by Race/Ethnicity (2004)

Chi2

% % p-value

Overall 75.4 ( 74.9 , 76.0) 73.0 ( 72.2, 73.9) 0.000

Racewhite 74.3 ( 73.7 , 74.9) 72.0 ( 71.1, 72.8) 0.714african american 79.6 ( 78.0 , 81.3) 76.7 ( 74.2, 79.1)asian/pac islander 66.4 ( 60.9 , 71.9) 71.3 ( 57.0, 85.6)native american 72.6 ( 65.6 , 79.5) 71.9 ( 65.6, 78.3)hispanic 80.9 ( 78.9 , 82.9) 77.0 ( 72.4, 81.5)

(95% CI) (95% CI)

Metro Non-Metro

Adjusted Percent Women Aged 40+ with Current Mammogram by Age (2004)

Chi2

% % p-value

Overall 75.4 ( 74.9 , 76.0) 73.0 ( 72.2, 73.9) 0.000

Age40-49 66.6 ( 65.4 , 67.7) 64.7 ( 62.9, 66.4) 0.02750-64 80.2 ( 79.3 , 81.0) 78.9 ( 77.7, 80.0)65+ 79.1 ( 78.1 , 80.1) 75.1 ( 73.8, 76.5)

(95% CI) (95% CI)

Metro Non-Metro

Adjusted Percent Women Aged 40+ with Current Mammogram by Educational Attainment (2004)

Chi2

% % p-value

Overall 75.4 ( 74.9 , 76.0) 73.0 ( 72.2, 73.9) 0.000

Education< high school 71.8 ( 69.7 , 73.8) 65.6 ( 63.5, 67.7) 0.014high school 75.1 ( 74.4 , 75.9) 73.4 ( 72.4, 74.4)college degree 77.9 ( 76.9 , 78.9) 75.8 ( 74.1, 77.5)

(95% CI) (95% CI)

Metro Non-Metro

Adjusted Percent Women Aged 40+ with Current Mammogram by Income (2004)

Chi2

% % p-value

Overall 75.4 ( 74.9 , 76.0) 73.0 ( 72.2, 73.9) 0.000

I ncome< 25K 69.7 ( 68.4 , 70.9) 65.6 ( 64.0, 67.2) 0.070>= 25K, < 50K 75.3 ( 74.2 , 76.4) 73.8 ( 72.4, 75.2)>= 50K, < 75K 79.1 ( 77.7 , 80.4) 78.9 ( 76.4, 81.3)75K + 81.0 ( 79.7 , 82.3) 80.9 ( 78.8, 83.0)

(95% CI) (95% CI)

Metro Non-Metro

Adjusted Percent Women Aged 40+ with Current Mammogram by Labor Force Participation (2004)

Chi2

% % p-value

Overall 75.4 ( 74.9 , 76.0) 73.0 ( 72.2, 73.9) 0.000

Employment Statusemployed 74.8 ( 73.9 , 75.7) 73.4 ( 72.2, 74.5) 0.153unemployed 76.9 ( 74.5 , 79.2) 72.9 ( 68.5, 77.3)out of labor force 76.0 ( 75.1 , 76.8) 72.8 ( 71.6, 74.0)

(95% CI) (95% CI)

Metro Non-Metro

Adjusted Percent Women Aged 18+ with Current Pap Smear by Race/Ethnicity (2004)

Chi2

% % p-value

Overall 86.0 ( 85.5 , 86.4) 85.3 ( 84.6, 86.0) 0.088

Racewhite 85.6 ( 85.0 , 86.1) 84.6 ( 83.8, 85.4) 0.602african american 89.0 ( 87.8 , 90.2) 90.3 ( 88.7, 91.9)asian/pac islander 68.5 ( 63.9 , 73.1) 67.6 ( 57.6, 77.6)native american 83.5 ( 77.6 , 89.4) 83.6 ( 78.3, 88.9)hispanic 88.0 ( 86.6 , 89.3) 87.6 ( 85.0, 90.2)

(95% CI) (95% CI)

Metro Non-Metro

Adjusted Percent Women Aged 18+ with Current Pap Smear by Age (2004)

Chi2

% % p-value

Overall 86.0 ( 85.5 , 86.4) 85.3 ( 84.6, 86.0) 0.088

Age18-34 87.2 ( 86.4 , 88.1) 88.7 ( 87.5, 90.0) 0.00035-49 89.2 ( 88.5 , 89.9) 86.7 ( 85.5, 88.0)50-64 86.2 ( 85.2 , 87.2) 84.7 ( 83.3, 86.1)65+ 75.9 ( 74.3 , 77.6) 74.0 ( 72.0, 76.0)

(95% CI) (95% CI)

Metro Non-Metro

Adjusted Percent Women Aged 18+ with Current Pap Smear by Educational Attainment (2004)

Chi2

% % p-value

Overall 86.0 ( 85.5 , 86.4) 85.3 ( 84.6, 86.0) 0.088

Education< high school 84.4 ( 82.9 , 85.9) 81.6 ( 79.8, 83.4) 0.117high school 84.8 ( 84.1 , 85.4) 84.3 ( 83.4, 85.2)college degree 89.5 ( 88.8 , 90.2) 89.5 ( 88.2, 90.8)

(95% CI) (95% CI)

Metro Non-Metro

Adjusted Percent Women Aged 18+ with Current Pap Smear by Income (2004)

Chi2

% % p-value

Overall 86.0 ( 85.5 , 86.4) 85.3 ( 84.6, 86.0) 0.088

I ncome< 25K 82.8 ( 81.8 , 83.7) 81.4 ( 80.0, 82.8) 0.598>= 25K, < 50K 87.6 ( 86.8 , 88.5) 86.9 ( 85.7, 88.1)>= 50K, < 75K 88.9 ( 87.7 , 90.1) 89.5 ( 87.8, 91.2)75K + 91.0 ( 90.0 , 92.0) 91.3 ( 89.5, 93.2)

(95% CI) (95% CI)

Metro Non-Metro

Adjusted Percent Women Aged 18+ with Current Pap Smear by Labor Force Participation (2004)

Chi2

% % p-value

Overall 86.0 ( 85.5 , 86.4) 85.3 ( 84.6, 86.0) 0.088

Employment Statusemployed 86.6 ( 86.0 , 87.3) 86.0 ( 85.0, 87.0) 0.996unemployed 87.0 ( 85.3 , 88.7) 86.4 ( 83.7, 89.0)out of labor force 85.1 ( 84.4 , 85.9) 84.3 ( 83.2, 85.4)

(95% CI) (95% CI)

Metro Non-Metro

Adjusted Percent of Women Aged 40+ with Current Mammogram (1994-2004)

55

65

75

85

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

metro

adjacent

micro

non-core

Adjusted Percentage of Women Aged 18+ with Current Pap Smear (1994-2004)

70

75

80

85

90

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

metro

adjacent

micro

non-core

Adjusted Percent Women Aged 40+ with Current Mammography in Rural Counties by State

Adjusted Percent Women Aged 18+ with Current Pap Smear in Rural Counties by State

Discussion

Factors Influencing Screening Behavior Rural residence is an independent risk factor for

lacking current mammography

Low SES and advanced age are risk factors for lacking cervical and breast cancer screening

Rural disparities are pronounced for those without a high school diploma

Rural African Americans lagged behind urban counterparts in mammography

Latinas were more likely than whites to have current screening regardless of residence

Screening Trends

Mammography Participation improved 1994-2004 However, rates lower in all rural areas Rural areas of many states lagged behind

Healthy People 2010 target of 70% screened

Pap screening No significant increase in any area Below Healthy People 2010 target of 90%

screened

Variation by State

Wide variability by state in breast and cervical cancer screening in rural counties

Also wide variability by state in: per-capita health spending Medicaid spending per enrollee

States with higher personal spending tended to have higher screening rates

Limitations

Households without telephones were excluded

Attitudes and beliefs that may affect screening behavior could not be examined

Potential recall bias of self-report data

Data aggregated by county may overlook intra-county differences

Population-based research on travel distance and out-of-pocket costs needed to determine the effect of access to radiographic facilities

Policy Implications

Improvements in mammography are needed for rural residents

Improved access to mammography and Pap screening is needed for women with risk factors

Preservation and expansion of Medicaid coverage would improve screening rates for racial/ethnic minority groups

Expansion of programs like the National Breast and Cervical Cancer Early Detection Program (NBCCEDP)