Why Aren’t Some Women Getting Screening Mammograms? Social Factors May Be to Blame

Factors such as social isolation, lack of transportation, and financial concerns are preventing some women from getting recommended screening mammograms, a CDC Vital Signs report found.

The study “shows that experiencing health-related social needs can serve as barriers to receiving healthcare,” Debra Houry, MD, MPH, the CDC’s chief medical officer, said Tuesday on a phone call with reporters. “Understanding how these health-related social needs can affect women getting a mammogram could help improve cancer control efforts and reduce breast cancer.” She noted that although breast cancer death rates have declined, 40,000 women in the U.S. still die each year from the disease.

The report examined results from the 2022 Behavioral Risk Factor Surveillance System (BRFSS) survey, an annual nationwide landline and cellphone survey of civilian, non-institutionalized adults ages 18 and up. The survey collects information on health risk behaviors, preventive health practices, healthcare access, chronic diseases and conditions, and health outcomes.

The 2022 survey included a special module on health equity and social determinants of health (SDOH); data for this portion came from 39 states plus the District of Columbia. For this module, participants were asked about health-related social needs such as life dissatisfaction, lack of social and emotional support, feelings of social isolation, receipt of food stamps, and mental distress. They were also queried regarding SDOH, including lost or reduced hours of employment, food insecurity, housing insecurity, threats of shutting off utilities, and lack of reliable transportation. The core data set also included a question about cost as a barrier to accessing care (“Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?”).

The study authors focused on women ages 40 to 74. After excluding participants who declined to answer one or more mammogram questions, answered “don’t know/not sure,” or had a personal history of breast cancer, the final sample included 117,466 women, or 82.4% of female respondents in that age group.

Use of mammography within the previous 2 years was 59.1% among women ages 40-49 and 76.5% among women ages 50-74, the researchers found. Mammography use varied by state, from a low of 44.5% in New Mexico to a high of 77.8% in South Dakota in the younger age group, and from 64.0% in Wyoming and 85.5% in Rhode Island among the older respondents.

Mammography use also varied by demographic characteristics. Black women had the highest prevalence of mammogram use, at 65.2% in the 40-to-49 group and 82.9% in the 50-to-74 group. Among those without health insurance, mammography rates were 32.7% in the younger group and 37.4% in the older group.

The finding regarding Black women was not particularly surprising, co-author Captain Jacqueline Miller, MD, told MedPage Today, even though Black women tend to receive less of other types of healthcare — such as maternity care — compared to other groups. “We have seen this trend over the last few years, that the mammogram rates among Black women have been higher,” said Miller, who is medical director of the CDC’s National Breast and Cervical Cancer Early Detection Program. “So it’s not a total surprise.” However, she added, “these are reports that are not verified on medical records or anything in a healthcare system. So we have to remember that [this] is [just] what they report.”

The presence or absence of health-related social needs and adverse SDOH also were linked to mammogram use, the investigators found. For instance, among older women who reported no adverse SDOHs or health-related social needs, mammogram use stood at 83.2%, while among those with three or more such issues, 65.7% had undergone a mammogram within the previous 2 years.

“Among women aged 50-74 years, reporting life dissatisfaction, feeling socially isolated, experiencing lost or reduced employment hours, receiving food stamps, lacking reliable transportation, and reporting cost as a barrier to healthcare access were all associated with not having had a mammogram within the previous 2 years,” the authors wrote. “Among women in both age groups, cost as a barrier to healthcare access was the measure most strongly associated with not having had a mammogram within the previous 2 years.”

Physicians can do their part to reduce some of the barriers to mammography access, Houry said. “I know that physicians are really busy in their clinical practice, but a lot of this can be done during intake or on the patient questionnaires that are done — asking questions [like] ‘Do they have access to reliable transportation? Do they have enough to eat?'” she said. Equally as important, once those questions are asked, is making sure “that whether it’s the nurse or the physician, somebody actually looks at those answers and then discusses it with the patient to make sure they’re linked to services. Asking these questions is critically important.”

The study had several limitations in addition to the fact that the data were self-reported, the authors noted. Those included the fact that “the mammography use question does not distinguish between screening and diagnostic testing, which might lead to overestimating up-to-date mammography use per screening recommendations.” In addition, the analysis might have included women at high risk for developing breast cancer, for whom U.S. Preventive Services Task Force recommendations do not apply because they require more frequent screening, they said. Also, the SDOH and health-related social needs assessed in this analysis are not specifically related to mammography use and are not available for all states, which might limit generalizability. Finally, they wrote, “because the BRFSS response rate was 45%, the findings might not be representative of the total adult population.”

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