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Women living in areas with primary care shortages are less likely to have regular mammograms than women living elsewhere (Phillips et al, 1998).
Role of Patient Beliefs, Knowledge, and Racial Or Socioeconomic Characteristics in Screening
A lack of awareness of the benefits of cancer screening can pose as significant a barrier as lack of insurance or distance from screening facilities. Many individuals know little about cancer, and do not know that it can be successfully treated or when and why screening tests are useful (Grady et al., 1992; Myers et al., 1991). Low level of education (which usually occurs in conjunction with low household income) is associated with lower cancer screening (and re-screening) use (Lannin et al., 1998; Mickey, 1997; Rutledge et al., 1988).
Concerns about inconvenience, discomfort, trouble, embarrassment, fear of radiation, and pain involved in screening are among the reasons people forgo cancer screening tests (Davis et al., 1996; Glanz et al., 1996; Myers et al., 1991; Stein et al., 1990). Other attitudes—fatalism, a feeling that one's health cannot be affected by traditional medicine, and religious or cultural beliefs—may also preclude cancer screening (Kagawa-Singer, 1997; Lannin et al., 1998; Mo, 1992).
In one breast cancer study, culturally based attitudes and beliefs were more predictive of advanced stage at diagnosis (suggesting low screening rates) than were social class and race (Lannin et al., 1998). In this study, African-American women had three times the odds of white women (i.e., an "odds ratio" of 3) of being diagnosed with late-stage disease (Stages III and IV). When social class was taken into account in the analysis, the odds ratio decreased to 1.8. When measures of cultural beliefs (e.g., the devil can cause you to get cancer, air causes cancer) were also controlled for in the analysis, African-American women no longer had increased odds of late-stage disease.
Use of mammography appears to account for much of the variation of stage at diagnosis of breast cancer that can be attributed to race (Breen and Figueroa, 1996; Mandelblatt et al., 1995). Studies have found the following:
There were no differences in stage at diagnosis among women who were regular mammography users according to comparisons of mammography histories of elderly African-American and white women. However, among women who had not participated in screening mammography, the odds of being diagnosed with late-stage breast cancer were 2.5 times greater for African-American than for white women (McCarthy et al., 1998).
Women who receive medical care through the Department of Defense, and who should therefore all have the same access to care, demonstrate no difference in stage among Caucasian, African-American, and Hispanic women diagnosed with breast cancer (Zaloznik, 1995, 1997).
Among elderly women, African-Americans as compared to whites use mammography less often. More frequent use of mammography is associated with more visits to a primary care physician in both groups, but the deficit for African-American women persists at each income level, even after primary care use is considered. Primary care visits are less likely to "boost" mammography use for African-American women than for white women (Burns et al., 1996).