Some evidence suggests that certain racial and ethnic groups that appear to have adequate access to care are not getting appropriate screening services. In one study, women living in Appalachia and Hispanic women living in urban Texas had relatively low cancer screening rates despite having access to care (NCI, 1995b). Hispanics and some Asian groups (e.g., Chinese, Vietnamese) tend to have lower screening rates than whites or African Americans, which may be attributable, at least in part, to language and cultural barriers on the part of patients and providers (Hiatt and Pasik, 1996). Studies have found that

  • physicians discussed mammography less often with Hispanic than with non-Hispanic patients (Fox and Stein, 1991),
  • African-American women enrolled in managed care plans were less likely than white women to have had a doctor advise them to get a mammogram. Nevertheless, African-American and white women had similar self-report mammography use (Glanz et al., 1996); and
  • African-American patients were less likely to report receiving advice about cancer screening or receiving screening tests than white patients seeing the same physicians (Gemson et al., 1988).

The older people are, the less likely they are to be screened for breast and cervical cancers (Fox et al., 1994; Hedegaard et al., 1996; NCHS, 1997; NCI, 1995). The elderly may hold beliefs that inhibit testing, but they are likely to comply with physicians' recommendations to be screened (Fox et al., 1994; Mandelblatt et al., 1991). Some physicians may also mistakenly believe that routine cancer screening is unimportant in elderly patients (Weisman et al., 1989).

Many people who are screened for cancer once do not have the tests repeated at recommended intervals. Rates of adherence to regular or ''interval" screening are significantly lower than for the initial screening procedure (Burack and Gimotty, 1997; De Waard et al., 1984). Adherence to lifetime cancer screening is measured as the number of cancer screens received per number recommended. For example, if five screens were recommended for a 55-year-old woman and she had received only four of the five, she would be considered 80 percent adherent. The effect of age on adherence to interval screening appears to vary by cancer type, with higher screening rates observed for the elderly with colorectal cancer (Brown et al., 1990; Mandelblatt et al., 1996), but lower rates for cervical cancer (De Waard et al., 1984; Fink et al., 1972; Mandelblatt et al., 1998). One study indicates that adherence to lifetime breast cancer screening is higher among women who are younger, are members of a higher social class, and have access to care, especially membership in an HMO (the study compared women of similar age, race, education, and income) (Philips et al., 1998).

Role of the Physician in Cancer Screening Access

With or without insurance, lacking a regular source of care also leads to lower rates of cancer screening (Bindman et al., 1996; Fox et al., 1994; Gordon et al., 1998; Zapka, 1994; Zapka et al., 1992). In one study, women who did not have a regular doctor were 3.5 times more likely to be diagnosed with late-stage breast cancer than women who had seen their regular doctor within the past year (Lannin et al., 1998). In a study of multiethnic black and Hispanic women in New York,



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