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: