|Year : 2017 | Volume
| Issue : 2 | Page : 63-69
Health-related factors associated with adherence to breast cancer screening
Joke Schoofs, Katrien Krijger, Jan Vandevoorde, Dirk Devroey
Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Laarbeeklaan 103, B-1090 Brussels, Belgium
|Date of Web Publication||16-Jun-2017|
Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel, Laarbeeklaan 103, B-1090 Brussels
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: In Belgium, an effective preventive program for breast cancer exists but as in many countries to few women participates in the screening. This study aims to describe the factors that affect the participation in the national breast cancer screening program. Methods: The participants were aged between 50 and 69 years and were recruited during an exhibition at the Brussels Exhibition Centre. Medical history and health-related parameters of the participants were recorded. Results: In total, 350 women aged between 50 and 69 years participated. After adjustment for age and region, 81.5% of the participants had a mammography during the past 2 years. The multivariate analysis confirms the association between not having had a mammography and (a) having an older age (odds ratio [OR]: 0.25–0.87), (b) having diabetes (OR: 0.08–0.80), (c) having a family history of coronary heart disease (OR: 0.16–0.80), (d) not following a cholesterol diet or treatment (OR: 0.10–0.91) and (e) having a higher body mass index (OR: 0.39–0.97). Having had a mammogram was associated with adherence to cervical smear screening (OR: 2.74–11.21). Conclusions: Most of these associations are most likely related to socioeconomic status. However, the relationship with diabetes offers opportunities to increase the participation in breast cancer screening programs because these patients have regular contacts with their family physicians.
Keywords: Breast cancer screening, prevention, primary care, risk factors
|How to cite this article:|
Schoofs J, Krijger K, Vandevoorde J, Devroey D. Health-related factors associated with adherence to breast cancer screening. J Mid-life Health 2017;8:63-9
|How to cite this URL:|
Schoofs J, Krijger K, Vandevoorde J, Devroey D. Health-related factors associated with adherence to breast cancer screening. J Mid-life Health [serial online] 2017 [cited 2018 Jul 20];8:63-9. Available from: http://www.jmidlifehealth.org/text.asp?2017/8/2/63/208225
| Introduction|| |
Breast cancer is one of the leading causes of illness and is associated with a significant personal and socioeconomic burden.
Breast cancer in women counts for more than one-third of all malignant tumors, with an age-standardized rate of 170/100,000 women-year in the 35–49 years age group, 369/100,000 in women aged 50–69 years, and 350/100,000 in the elderly group. It is within the entire female population, the most frequent malignant disease and the leading cause of death from cancer, accounting for one in five female deaths. The mean age at diagnosis is 62 years.
Screening for breast cancer
An effective preventive approach for breast cancer is invaluable. In the eighties, the emphasis of screening for breast cancer was mainly on self-examination and clinical examination. Nowadays, these methods are not longer recommended for the early detection of breast cancer.
The effectiveness of early detection of breast cancer by mammography has been suggested by several studies. These studies reported a reduced mortality rate in women between 50 and 69 years. To have a population-based decrease of the mortality, a large proportion of the population needs to be screened. To obtain a 30% decrease in the mortality rate, at least 70% of the target population needs to be screened every 2 years.
Overall, the early detection and adjuvant therapy resulted in a reduced mortality for breast cancer of 25%–38%. However, population-based breast cancer screening remains controversial and might not be worthwhile because recent studies report only a little effect on mortality.,, For women between 40 and 49 years of age, the effectiveness of early detection with conventional mammography is also controversial.,
The decrease of mortality in recent decades in many Western countries is not due to mammographic screening. The better diagnostic and therapeutic options and the increased “breast awareness” among women may probably play also an important role.
Since 2000, there is in Belgium a national program for the early detection of breast cancer. The program was established under the impulse of Europe against cancer and is in line with the criteria established by the European Commission. The activities of the Belgian national program were launched in June 2001 in the Flemish Region and 1 year later in the French Community, the Brussels Region and the German-speaking Community. Women between 50 and 69 are invited by the local authorities and their family physician for a mammography, free of charge, in accredited mammography units in their neighborhood.
Despite the national prevention program, it appears that a significant portion of the female target population is not screened for breast cancer.
The Belgian Health Interview Survey (HIS), conducted in 2008 by the Institute of Public Health, reported a coverage of 73% for breast cancer screening in the target population.
The coverage of the target population is higher than 70% coverage needed to obtain a 30% decrease in the mortality rate. However, this is not optimal because some hard to reach populations do not participate in the screening. There is some evidence that the coverage is the lowest among women from the lowest socioeconomic classes., This population is very hard to reach and to convince. We were interested to evaluate the opportunity to motivate women attending a food exhibition to participate in a screening.
Aim of the study
This research aims to describe the coverage for breast cancer screening among the visitors of a food exhibition in Brussels and to describe the nonsocioeconomic factors that affect the participation in the national screening program such as measurements of blood pressure, blood sugar, and cholesterol.
| Methods|| |
The participants were recruited during an exhibition at the Brussels Exhibition Centre from October 6 to October 21, 2012. All adult visitors were allowed to participate as far that they were not pregnant, did not take Vitamin K antagonists, did not show signs of addiction to alcohol, medication or drugs, nor suffered from a hypersensitivity to blood, and/or fingerpricks. For the present study, only women aged between 50 and 69 years were retained.
Participants were asked whether they knew their length, weight, abdominal circumference, blood pressure, cholesterol level, and blood sugar level. These parameters were measured if the participants did not know them. Furthermore, participants were asked about their medical history (coronary heart disease, hypercholesterolemia, diabetes, hypertension, and other diseases) and their family history (breast cancer, coronary heart disease, diabetes, and colon cancer). They were also asked about their latest tetanus vaccination, cervix cancer screening, and breast cancer screening.
Participants used a visual analogue scale (VAS) to score their self-reported health (SRH). The scale ranged between 0 and 100 with 0 corresponding to the worst health participants can imagine and 100 meaning the best health participants can imagine. Such a VAS scale is used in the EQ-5D questionnaire. The VAS scale was completed after the participants recorded their age, gender, and zip-code but before other health-related questions were asked.
Weight was measured with a digital personal scale Seca Sensa 804. The measurement of the height was done with a Seca 206 wall-mounted measuring tape. The abdominal circumference was measured with a Seca 201 ergonomic circumference measuring tape. Blood pressure was measured with a calibrated DS-54 Welch Allyn sphygmomanometer blood pressure device. Blood sugar was measured with a OneTouch device using capillary blood. Total cholesterol was measured with a Accutrend Plus monitor using capillary blood. Capillary blood was obtained with a fingerprick in the index finger. The food and beverage intake during the 2 h before the measurement were carefully noted.
Approval of the Ethical Committee
The study protocol was approved by the ethical committee of the University Hospital Brussels. Visitors of the exhibition were allowed to participate after they read the patient-information leaflet and signed the informed consent. After the questionnaire was completed, the patients received a health advice and a sample of margarine free of charge.
The data were introduced through an online custom made user interface based on a PHP and recorded in a MySQL database centrally managed at the Faculty of Medicine and Pharmacy of the Vrije Universiteit Brussel. The data were stored anonymously. It was not possible to identify patients from the recorded personal information (gender, year of birth, and zip code). Body mass index (BMI) was generated by the system. Cardiovascular risk was estimated from the SCORE risk tables. Two groups were created: one with a low SRH and another group with a high SRH. As a cut-off, the median (71.4) for the SRH was used, permitting to compare two groups of a similar size.
Incomplete data sets were eliminated from the database. Analyses were done with SPSS 20 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Released 2011). For the detection of statistically significant differences between discrete variables, the cross-tables and the Chi-square test was used. For continuous variables, the t-test was used.
Coverage figures were adjusted for age and region, according to the demographics of the Flemish, Walloon, and Brussels region in 2012.
A logistic regression was done to determine variables linked with high or low SRH. The following variables were entered: gender, age-groups, language, region, hypertension, hypercholesterolemia, diabetes, coronary heart disease, no disease, family history of coronary heart disease, family history of colon cancer, family history of diabetes, family history of breast cancer, no family history, tetanus vaccination up-to-date, weight, length, abdominal circumference, does know blood pressure, does know blood sugar level, does know cholesterol level, no treatment or diet for cholesterol, diet for cholesterol, statin for cholesterol, plant stanol for cholesterol, cervix cancer screening, SRH, smoker, alcohol abuse, physical activity, BMI (four groups), and cardiovascular risk groups (SCORE low, intermediate and high).
| Results|| |
Adherence to breast cancer screening
In total, 350 female visitors aged between 50 and 69 years participated [Table 1]. Most of the participants (78%) lived in the Flemish region, 17% in the Brussels Region and 5% in the Walloon Region. After adjustment for age and region, 81.5% of the participants had a mammography done during the past 2 years.
Association with risk factors
In an univariate analysis, we found a significant association between not having had a mammography during the past 2 years and not having had a pap smear during the past 3 years. Not having had a mammography during the past 2 years was also associated with not knowing ones blood sugar level, not having a treatment for hypercholesterolemia and having a high BMI.
Women not having had a mammography during the past 2 years had a higher body weight, a higher systolic blood pressure, a higher blood sugar level, a higher abdominal circumference, a higher BMI and a lower SRH [Table 2].
|Table 2: Mean values of parameters according to the adherence to breast cancer screening|
Click here to view
All parameters were dichotomized where possible and included in a logistic regression [Table 3]. Age was divided into 10-year age groups, BMI into four groups and cardiovascular risk into three groups. This multivariate analysis confirms the association between not having had a mammography and having a older age, having diabetes, having a family history of coronary heart disease, not having a cervical smear in the past 3 years, not following a cholesterol-lowering diet or treatment, and having a higher BMI.
|Table 3: Logistic regression: Factors related to breast cancer screening|
Click here to view
| Discussion|| |
In our study, there was an overrepresentation of participants from the Flemish region. As we never aimed to include a representative sample of the Belgian population, this will not hamper the interpretation of our results. We aimed to describe the correlation of objective health-related factors with the breast cancer screening in an arbitrary sample of the Belgian population.
The studied sample was biased by the fact that all participants were visitors of an exhibition and for that reason disabled or seriously ill people were less likely to participate in the study.
Adherence to mammography
Our age and region adjustment coverage for breast cancer was 82%. According to the Belgian HIS, 72% of the women from the target population were screened. Our study as well as the HIS relate to self-reported data. In Spain, the national health survey demonstrated a screening coverage of 84%. The lower figures found in the Belgian HIS must be seen in the perspective that they relate to 2008 and that the coverage is rising systematically in Belgium. According to a European study based on the figures of 2006, the adherence was the lowest in Denmark (<30%) and highest in The Netherlands and France (<80%). This European study mentions for Belgium an adherence of almost 80% in 2006.
Factors associated with breast cancer screening
This multivariate analysis confirms the relationship between not having had a mammography and having an older age. This association was also found in the HIS were the highest coverage was seen in the age group between 50 and 59 years. Many other studies-related older age with higher coverage.,,, In a European comparison, the mean age of the screened women in Belgium is among the lowest in Europe (62.6 years) but not suggesting a higher participation in the younger age group.
In our study, there was a strong association between having a cervical smear in the last 3 years and the adherence to breast cancer screening. As well in the United States as in Canada, having had a Pap test within the last 3 years was the strongest and most consistent predictor of compliance with the adherence to breast cancer screening.
This is one of the most important findings of our study. There is a higher chance that patients not attending for a mammography did also not attend for a pap smear and vice versa. Although the age groups and timings for pap smears and mammograms are different, physicians should check the medical records for both screening examinations in the overlapping age group.
We also detected a strong association between not participating in the breast cancer screening and having diagnosed diabetes. This is surprising because these patients should at least every three months attend their family physician for their diabetes. We can hypothesize that this lower participation in diabetics screening is related to the lower social class to which diabetics might belong or to the fact that diabetics are already overburdened with the screening for diabetes complications. A similar association was found among American Indian women with type 2 diabetes. They also participated less in screening programs for breast cancer and cervical cancer.
A study on the adherence to breast and cervical cancer screening in postmenopausal women with coronary heart disease found no relation between low adherence to mammography and having a coronary heart disease. This is in line with our findings. However, the relation between low adherence to mammography and having a family history of coronary heart disease cannot be confirmed by other studies. As for diabetes, we can suggest that the lower participation is related to the lower social class of these patients or to the fact that they are already overburdened with the screening for cardiovascular conditions.
Surprisingly, the adherence to breast cancer screening was not related to a positive family history of breast cancer. In a USA study, this association was found. It is to be expected that women with a family history might pay more attention to breast cancer screening than others. According to their estimated risk, these women should have an adapted and earlier screening program than women without a family history.
An increased BMI was also associated with a low adherence to breast cancer screening. Furthermore, the National Ambulatory Medical Care Survey revealed that in 2005–2007 obese patients were significantly less likely to receive cancer screening such as breast cancer screening and pap smears. Furthermore, in the Spanish study, obesity was associated with a lower coverage.
Similarly, adherence to breast cancer screening was higher among the women following a cholesterol diet or treatment. This suggests that maybe those women following diets are more concerned about their health and are more likely to participate in screening programs.
Weaknesses of the study
In this study, we emphasized on chronic conditions, SRH, and lifestyle of the participants. Initially, we choose not to record sociodemographic parameters because many publications already reported about them. In retrospect, the registration of sociodemographic parameters such as marital status, educational level, monthly income, and nationality might have contributed to a better understanding of our findings.
| Conclusions|| |
Our study among women belonging to the target population for breast cancer screening could detect an association between not having had a mammography and older age, diabetes, a family history of coronary heart disease, not having a cervical smear in the past 3 years, not following a cholesterol diet or treatment, and having a higher BMI.
Most of these associations are probably related to socioeconomic status. However, the relationship between no adherence to breast cancer screening and having diabetes is an important finding, because the regular contact between diabetic patients and their family physician offers opportunities to increase the participation in breast cancer screening programs.
The authors thank all participants, David Proot for the English language editing, Unilever Belgium andBrussels Fairs and Exhibitions for their collaboration.
The study was sponsored by Unilever Belgium.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Renard F, Van Eycken L, Arbyn M. High burden of breast cancer in Belgium: Recent trends in incidence (1999-2006) and historical trends in mortality (1954-2006). Arch Public Health 2011;69:2.
Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L; U.S. Preventive Services Task Force Screening for breast cancer: An update for the U.S. Preventive Services Task Force. Ann Intern Med 2009;151:727-37, W237-42.
Recommendations on cancer screening in the European union. Advisory Committee on Cancer Prevention. Eur J Cancer 2000;36:1473-8.
Berry DA, Cronin KA, Plevritis SK, Fryback DG, Clarke L, Zelen M, et al.
Effect of screening and adjuvant therapy on mortality from breast cancer. N Engl J Med 2005;353:1784-92.
Bonneux LG, Autier P. Population-based breast cancer screening is not worthwhile. Screening has little effect on mortality. Ned Tijdschr Geneeskd 2011;155:A3774.
Mukhtar TK, Yeates DR, Goldacre MJ. Breast cancer mortality trends in England and the assessment of the effectiveness of mammography screening: Population-based study. J R Soc Med 2013;106:234-42.
Biller-Andorno N, Jüni P. Abolishing mammography screening programs? A view from the Swiss Medical Board. N Engl J Med 2014;370:1965-7.
Kerlikowske K. Screening mammography in women less than age 50 years. Curr Opin Obstet Gynecol 2012;24:38-43.
Krieger N. Defining and investigating social disparities in cancer: Critical issues. Cancer Causes Control 2005;16:5-14.
Bigby J, Holmes MD. Disparities across the breast cancer continuum. Cancer Causes Control 2005;16:35-44.
Nord E. EuroQol: Health-related quality of life measurement. Valuations of health states by the general public in Norway. Health Policy 1991;18:25-36.
De Bacquer D, De Backer G. Predictive ability of the SCORE Belgium risk chart for cardiovascular mortality. Int J Cardiol 2010;143:385-90.
Martín-López R, Hernàndez-Barrera V, De Andres AL, Garrido PC, De Miguel AG, García RJ. Breast and cervical cancer screening in Spain and predictors of adherence. Eur J Cancer Prev 2010;19:239-45.
Wübker A. Explaining variations in breast cancer screening across European countries. Eur J Health Econ 2014;15:497-514.
Martín-López R, Jiménez-García R, Lopez-de-Andres A, Hernàndez-Barrera V, Jiménez-Trujillo I, Gil-de-Miguel A, et al.
Inequalities in uptake of breast cancer screening in Spain: Analysis of a cross-sectional national survey. Public Health 2013;127:822-7.
Centers for Disease Control and Prevention (CDC). Vital signs: Breast cancer screening among women aged 50-74 years - United States, 2008. MMWR Morb Mortal Wkly Rep 2010;59:813-6.
Barrett K, Legg J. Demographic and health factors associated with mammography utilization. Am J Health Promot 2005;19:401-5.
Blackwell DL, Martinez ME, Gentleman JF. Women's compliance with public health guidelines for mammograms and pap tests in Canada and the United States: An analysis of data from the Joint Canada/United States Survey Of Health. Womens Health Issues 2008;18:85-99.
Gonzales KL, Harding AK, Lambert WE, Fu R, Henderson WG. Perceived experiences of discrimination in health care: A barrier for cancer screening among American Indian women with type 2 diabetes. Womens Health Issues 2013;23:e61-7.
Castellano PZ, Wenger NK, Graves WL. Adherence to screening guidelines for breast and cervical cancer in postmenopausal women with coronary heart disease: An ancillary study of volunteers for hers. J Womens Health Gend Based Med 2001;10:451-61.
Cui Y, Peterson NB, Hargreaves M, Wen W, Patel K, Drake J, et al.
Mammography use in the Southern Community Cohort Study (United States). J Health Care Poor Underserved 2007;18 4 Suppl:102-17.
Hernandez-Boussard T, Ahmed SM, Morton JM. Obesity disparities in preventive care: Findings from the National Ambulatory Medical Care Survey, 2005-2007. Obesity (Silver Spring) 2012;20:1639-44.
Cabeza E, Esteva M, Pujol A, Thomas V, Sànchez-Contador C. Social disparities in breast and cervical cancer preventive practices. Eur J Cancer Prev 2007;16:372-9.
[Table 1], [Table 2], [Table 3]