Breast cancer screening, incidence, and mortality in West Virginia.
Abstract: Situated entirely in the Appalachian region, West Virginia (WV) as a state is characterized by a diverse population, with a major portion of the population residing in rural areas. Breast cancer is the most commonly diagnosed cancer among women residents of the state. Using different data sources, we have reported the most recent screening, incidence, and mortality information associated with breast cancer in WV. In 2006, roughly one-fourth of women >40 years of age had not had a mammogram in the past two years. Sociodemographic factors were found to be associated with lack of mammography screening among these women. The leveling off of the increase in the in-situ breast cancer incidence rates in WV since 1999 is closely associated with the bottoming out of the proportion of women without mammography that has been seen since early this decade. Counties in southern and northern part of the state generally have higher invasive breast cancer incidence rates than those in the central part. Breast cancer-related mortality is higher among southern counties in comparison to counties in northern and central part of the state, with mortality rates higher than the national average in McDowell, Mingo, Wayne, and Mason Counties. There is a compelling need to increase access to mammography screening among women residents in the state.
Subject: Breast cancer (Diagnosis)
Breast cancer (Care and treatment)
Breast cancer (Prevention)
Breast cancer (Demographic aspects)
Mammography (Usage)
Cancer (Diagnosis)
Cancer (Usage)
Authors: Khanna, Rahul
Bhanegaonkar, Abhijeet
Colsher, Pat
Madhavan, S. Suresh
Halverson, Joel
Pub Date: 10/01/2009
Publication: Name: West Virginia Medical Journal Publisher: West Virginia State Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 West Virginia State Medical Association ISSN: 0043-3284
Issue: Date: Oct, 2009 Source Volume: 105 Source Issue: S1
Geographic: Geographic Scope: West Virginia Geographic Code: 1U5WV West Virginia
Accession Number: 218949137
Full Text: Objectives

Breast cancer is the most commonly diagnosed cancer among women in West Virginia (WV). The objectives of this study were to: 1) determine the proportion of women >40 years of age who have not had a mammography screening in the past two years in 2006 in WV; 2) determine socio-demographic and health care access factors associated with lack of mammography screening; 3) report incidence rates of invasive breast cancer by county; and 4) report breast cancer-related mortality rates by county.

Analysis of the 2006 Behavioral Risk Factor and Surveillance System (BRFSS) showed that 25.5% of women respondents >40 years of age in WV reported not having a screening in the past two years. Women in the age group 40-44 years, an annual household income of less than $25,000, without health insurance, without a personal doctor, and those who had not had a routine check up in more than two years were more likely to report not having a mammogram in the past two years. Counties in northern and southern part of the state had generally higher incidence rates as compared to those in the central part of the state. Southern counties especially McDowell, Mingo, Wayne, and Mason had a higher burden of breast cancer-related mortality as compared to counties in the central and northern (with exception of Marion and Taylor) part of the state.

Introduction

Breast cancer is the second leading cause of cancer-related mortality among women in the United States (US) after lung cancer (1). In 2007, ~178,480 women were expected to be diagnosed with invasive breast cancer and 40,460 women were expected to die due to breast cancer in the US (2). Risk factors for breast cancer include personal or family history of breast cancer, delayed pregnancy, use of oral contraceptives, hormone replacement therapy, early menarche, or late menopause (3). Screening mammography is considered to be the gold standard for identifying early stage breast cancer (4). The American Cancer Society (ACS) recommends annual mammography screening for all women [greater than or equal to]40 years of age with an average risk of breast cancer (5).

High poverty rates and health care disparities characterize the Appalachian region (6-8). Studies have reported higher incidence rates of cancer and other chronic diseases in Appalachia compared to the rest of the country (9-13). A recent study by Wingo and colleagues reported invasive breast cancer to be the most common type of cancer among Appalachian women (13). West Virginia (WV) is the only state situated entirely in Appalachia and has a large rural population characterized by poverty, low levels of education, and underserved healthcare needs. As is the case with the entire Appalachian region, breast cancer is one of the most prevalent cancers among women in WV (14). In 2004, self reported annual mammography screening rate among women aged [greater than or equal to]40 years in WV was 58.1%, which is lower than the national mammography screening rate of 58.3% and also below the Healthy People 2010 target of 70% (2,15).

Given the unique environmental and socio-demographic setting of the Appalachia, researchers have investigated the screening rates for breast cancer in the region. Studies have found mammography screening rates to be lower among women who are less educated, unemployed, residing in rural location, have low income, and lack health insurance (16,17). Though these studies provide useful information about breast cancer screening in the Appalachian region, the most recent estimate of the proportion of women who have not had mammography screening and factors associated with lack of mammography screening are not known for the state of WV. A review of the literature reveals that no previous study has collectively described breast cancer screening, incidence, and mortality rate among WV women. The purpose of this study is to: 1) determine the proportion of women >40 years of age who have not had a mammography screening in the past two years in 2006 in WV; 2) determine factors associated with lack of mammography screening; 3) report incidence rates of invasive breast cancer by county; and 4) report breast cancer-related mortality rates by county.

Data Sources and Methods

Given our study objectives, multiple data sources were used to ascertain breast cancer specific information for the state of WV. The study employed 2006 Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor and Surveillance System (BRFSS), WV Cancer Registry (WVCR), and the CDC Wide-ranging Online Data for Epidemiologic Research (WONDER) data to ascertain breast cancer screening, incidence, and mortality related information, respectively.

Established by the CDC, and undertaken on a collaborative basis between the CDC and state health departments, the BRFSS is a state-based surveillance system that tracks information related to health behaviors and risk factors on a yearly basis. Using random-digit-dialing telephone survey technique, trained interviewers collect information from non-institutionalized adults of 18 years of age or older. Further details about the BRFSS survey, design, and methodology have been described elsewhere (18).

In the 2006 BRFSS, the WV Bureau of Public Health (BPH) of the State Department of Health and Human Resources collected information related to mammography screening from women residents in the state. Women respondents were asked if they had ever had a mammogram, and how long had it been since their last mammogram. For the purpose of this study, the 2006 BRFSS data related to women [greater than or equal to]40 years of age in the state of WV was analyzed. The variables of interest were: age, education, annual household income, race, health insurance, access to a personal doctor, time since last doctor visit for a routine checkup, and whether the respondent was unable to see a doctor in the past 12 months because of cost. Though age was measured on a continuous scale in the 2006 BRFSS, it was categorized for analysis in this study. Since >95% of WV residents are white, respondents were classified into two groups for the purpose of analysis--white and others. The purpose of analyzing the 2006 BRFSS data was to determine the proportion of women [greater than or equal to]40 years of age in the state of WV who had not had a mammogram in the past two years and determine its association with different demographic and health care access characteristics.

Study analyses were conducted using SAS 9.1[R]. Weighted proportions and 95% confidence intervals (CIs) were generated using PROC SURVEYFREQ. Chi-square test was used to determine significant relationships for categorical variables. Logistic regression analysis (PROC SURVEYLOGISTIC) was conducted to determine the demographic and healthcare access-related characteristics that are associated with lack of mammography.

The study also utilized breast cancer incidence data generated by the WVCR and described in their "Cancer Incidence in West Virginia: 2008' report. Established in 1991, the WVCR collects data related to cancer diagnosed and/or treated among the residents of the state and reports incidence rates by type of cancer, gender, race, and other factors. For the purpose of this study, WVCR data related to the yearly trends in the age-adjusted incidence rates (/100,000) of in-situ breast cancer for the state of WV were used and reported in this study. In addition, county specific incidence rates (/100,000) of age-adjusted invasive breast cancer, as reported in the WVCR 2008 report were used.

Finally, the Compressed Mortality File (CMF) from the CDC WONDER was utilized to determine county level age-adjusted mortality rates (/100,000) for breast cancer in WV over a five year period from 20012005. Information related to state of residence, rural-urban status of the place of residence, age category, racial origin, gender, year of death, and International Classification of Disease (ICD) codes from ninth (ICD-9) and tenth (ICD-10) revision denoting cause of death, are included in the CMF. The ICD-10 codes for malignant neoplasm of breast (C50.0C50.6 and C50.8-C50.9) were used to retrieve mortality data for breast cancer for counties in WV. Age-adjusted breast cancer rates were calculated using this information.

Results

Breast Cancer Screening In 2006 BRFSS, of the total 160,465 women respondents' [greater than or equal to]40 years of age, 1,750 women were from WV. Nationwide, 23.4% (C.I. 22.923.8) of women respondents' >40 years of age reported not having a mammogram in the past two years. In comparison, 25.5% (C.I. 23.2-27.8) of women respondents' [greater than or equal to]40 years of age in WV reported not having a mammogram in the past two years. In terms of demographic distribution of the 1,750 women respondents in WV, ~38% were aged 65 years and above, 41.9% had attended or graduated college, 21% had an income of [greater than or equal to]$50,000, and 96.4% were white. Table 1 reports the proportion of women [greater than or equal to]40 years of age in WV that had not had a mammogram in the past two years by demographic categories. With respects to age, the proportion of respondents who had not had a mammogram in the past two years decreased significantly until the age of 64 years, and then reversed trend for those who were 65 years and above (p<0.001). As education level increased, the proportion of women who had not had a mammogram in the past two years also decreased significantly (p<0.001). The proportion of women who had not had a mammogram in the past two years decreased with increasing levels of annual household income (p<0.001). In terms of race, there were no significant differences observed in terms of the proportion of respondents who had not had a mammogram in the past two years between those who were white and others.

Figure 1 presents the difference in the proportion of women respondents' [greater than or equal to]40 years of age in WV who had not had a mammogram in the past two years by healthcare access characteristics. A significantly higher proportion of respondents without insurance had not had a mammogram in the past two years as compared to those with insurance (57.2% versus 21.9%, p<0.001). The proportion of respondents who had not had a mammogram in the past two years was higher among those who reported not having a personal doctor in comparison to those who had a personal doctor (59.9% versus 21.7, p<0.001). Respondents who had not visited a doctor for a routine checkup in more than 2 years were more likely to report not having a mammogram in the past two years in comparison to those who had a routine checkup in the last 2 years (75.2% versus 19.9%, p<0.001) Respondents who reported not being able to see a doctor in the past 12 months because of cost were more likely to not have a mammogram in the past two years in comparison to those who were able to see a doctor (46.8% versus 21.5%, p<0.001).

Table 2 presents the results of multivariate logistic regression analysis, which was conducted by regressing demographic and healthcare access characteristics on the variable describing whether or not women respondents had a mammogram in the past two years. In comparison to respondents who were 65 years of age and above, the odds of not having a mammogram in the past two years were 1.7 times (C.I. 1.1-2.6) higher among those in 40-44 year age group. The odds of not having a mammogram in the past two years were lower (OR = 0.7; C.I. 0.5-0.9) among respondents in the age group 45-64 years as compared to those 65 years of age and above. The odds of not having a mammogram in the past two years were 1.8 times (C.I. 1.2-2.8) higher among respondents who had an annual household income of less than $25,000 in comparison to those with an annual household income of [greater than or equal to]$50,000. Respondents without health insurance were 1.9 times (C.I. 1.2-3.2) more likely to report not having a mammogram in the past two years as compared to those who had health insurance. The probability of not having a mammogram in the past two years was 2.9 times (C.I. 1.9-4.5) higher among respondents without a personal doctor as compared to those who had a personal doctor. Compared with respondents who had visited a doctor in the past two years for a routine checkup, those who had not had a routine checkup in more than 2 years were 8.5 times (C.I. 5.3-13.4) more likely to not have had a mammogram in the past two years. Finally, respondents who were unable to see a doctor in the past 12 months because of cost were 1.5 times (C.I. 1.1-2.2) more likely to not have had a mammogram in the past two years as compared to those who were able to see a doctor.

Trends in Breast Cancer Screening and Incidence Figure 2 present trends in the proportion of women [greater than or equal to]40 years of age that had not had a mammogram in the past two years (1990-2006) and age-adjusted incidence rates per 100,000 of in-situ breast cancer among women (1993-2005) in WV. The proportion of women who reported not having a mammogram in the past two years decreased from 44.2% in 1990 to 25.5% in 2006. However, since 2000 this proportion has remained fairly constant. Between 1993 and 2005, the age-adjusted incident rates of in-situ breast cancer increased from 11. 1/100,000 to 25.1/100,000. As with screening, the incidence rate of in-situ breast cancer has remained fairly constant between 1999 and 2005.

Figure 3 presents WV county specific age-adjusted average annual (2001-2005) invasive breast cancer incidence rates per 100,000 women. Counties with an incidence rate higher than that for the state were Cabell and Hancock. There was an uneven distribution of invasive breast cancer incidence rates among counties in WV, with counties in northern and southern part of the state having generally higher incidence rates as compared to those in the central part of the state.

Breast Cancer Mortality Figure 4 presents WV county specific age-adjusted average annual mortality rate per 100,000 attributable to breast cancer. Southern counties especially McDowell, Mingo, Wayne, and Mason had a higher burden of breast cancer-related mortality as compared to counties in the central and northern (with exception of Marion and Taylor) part of the state. Also, southern counties including Mercer, Logan, Cabell, Greenbrier, and Fayette had a high mortality rate for breast cancer in comparison to rest of the state.

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

Discussion

West Virginia is characterized by a geographically diverse population that is socio-economically underprivileged and is the only state whose borders are entirely within the Appalachian region. Breast cancer is the most commonly diagnosed cancer among women in the state and results in significant suffering and economic impact on its population (14). Our study was undertaken to report breast cancer screening and burden (as measured by incidence and mortality), respectively, in the state of WV. Using multiple data sources, this study describes the factors that are associated with lack of mammography screening, trends in in-situ breast cancer incidence rate, and WV county-specific distribution of invasive breast cancer incidence and mortality rate, respectively.

In terms of breast cancer screening, our results show that a higher proportion of women >40 years of age in WV had not had a mammogram in the past two years in comparison to the entire country. This result is consistent with previous studies that have found lower rates of mammography screening in WV in comparison to the entire country (19). In addition, the proportion of women who had not had a mammogram in the past two years seems to be bottoming out, with this proportion remaining fairly constant for much of this decade (2000-2006). As determined in our study, socioeconomic status seems to be an important factor contributing to the lack of mammography screening among women residents of the state. In our study, women without health insurance and from lower socioeconomic strata (based on income) of the society were more likely to not have had a mammogram in the past two years. In their study of breast and cervical cancer screening among Appalachian women, Hall and colleagues found similar results, wherein women with health insurance were found to be more likely to be screened than those without insurance (17). Though Medicare and WV Medicaid cover mammography screening once every year for women enrollees, many WV women residents under 65 years of age with household income above Medicaid eligibility and without employer provided health insurance may not have coverage (20). In addition, women who are not continuously enrolled in the Medicaid program may not have regular access to screening services. Expanding public health insurance coverage to those underinsured or uninsured is one way of tackling this issue of access to screening.

[FIGURE 4 OMITTED]

A notable result of this study was the greater probability of not having a mammogram in the past two years among women without a personal doctor and who had not had visited a doctor in the past two years for a routine checkup as compared to women who had a personal doctor and had a routine checkup in the past two years, respectively. This result highlights the lack of screening among women without adequate primary care services and suggests the need for a patient centered medical home model of care delivery for women residents of the state. The basic premise of the medical home model is that patient care will improve if each patient has an ongoing relationship with a personal physician who leads a team of qualified healthcare professionals to provide continuous and comprehensive care to the patient. The concept of medical home model was recently discussed in the WV legislature. A medical home model will not only help improve mammography screening rates in the state, but also improve health outcomes and lower costs associated with breast cancer.

Given the lack of county level information from BRFSS, we could not establish the impact of geographic/rural location on screening. However, previous studies have documented the impact of "rurality' on screening, with women residing in rural areas being less likely to report having had a mammogram in the past two years as compared to women residing in metropolitan areas (21). With roughly 45% of the population residing in rural areas, geographical topography could be a major barrier towards perceived and actual access to mammography screening sites in WV. To alleviate the impact of socio-economic and geographic constraints on screening, the use of mobile screening units could be beneficial. The use of mobile mammography vans could significantly improve the access to mammography screening among underprivileged and rural women residents of the state. Prior studies have suggested the importance of mobile mammogram programs in improving access to breast cancer screening (17). The success of these mobile units in providing screening services to underprivileged women has also been documented (22).

Though roughly one-fourth of women in our study reported not undertaking a mammogram in the past two years, it is important to realize the significant decrease in the proportion of these women since early 1990s. Credit goes to all the state agencies and state health care providers who have worked diligently over the years to reduce the burden of breast cancer in the state. One of the major programs that have contributed significantly to this decline in the proportion of women without screening is the West Virginia Breast and Cervical Cancer Screening Program (WVBCCSP). The WVBCCSP has played an instrumental role in providing easy access and payments for breast and cervical cancer screening and appropriate follow-up to uninsured and underinsured women residents of the state.

An important relationship was seen in our study between decrease in the proportion of women without screening and increase in the incident rate of in-situ breast cancer. Early breast cancer detection due to screening was said to be one of the factors responsible for the increasing incidence of breast cancer in the US in early 1990s (23). This relationship could be the factor behind the increasing incidence rate of in-situ breast cancer from 1993 to 1999 as reported in this study. However, it is notable that the increase in in-situ breast cancer incidence has leveled off since early 2000, a trend which closely resembles the bottoming out of the proportion of women without screening. The earlier a woman is diagnosed with breast cancer, the better the prognosis. Therefore, there is a need to further strengthen the effort of improving access to mammography screening among WV women.

The study also reports notable information related to the incidence of invasive breast cancer and breast cancer mortality across WV counties. The burden of breast cancer in terms of incidence and mortality seems to be generally higher in the southern and northern part of the state as compared to the central part. In terms of breast cancer-related mortality, southern counties especially McDowell, Mingo, Wayne, and Mason have mortality rates that exceed the national breast cancer mortality rate (24). The high poverty index (25) of these counties could be a factor associated with greater breast cancer burden in these counties. The high mortality burden of breast cancer in southern counties calls for a concerted effort on the part of state healthcare administrators and policy makers, healthcare providers, and the overall community.

There are a few limitations in this study which must be considered. To document screening in WV, we used the 2006 BRFSS. Given the cross sectional nature of the survey, causal inference cannot be made between variables studied in this paper. In addition, BRFSS results are based on self-reporting of screening among women, which may have lead to the introduction of self-report bias. In addition, the number of women under "other' race category was less than 50, which could have resulted in biased estimates. However, except for race, all variables in our study had a cell size greater than 50.

Conclusions

The proportion of women [greater than or equal to]40 years of age in WV who have not had a mammogram in the past two years was higher than the national estimates in 2006. In addition, this proportion seems to have been unchanged for most of this decade. Certain socio-demographic and healthcare access factors were associated with the lack of mammography screening among women in the state. The burden of breast cancer in terms of incidence and mortality is higher among southern and northern counties than counties in the central part of the state. There is an immediate need to renew focus towards improving breast cancer screening in WV, especially in southern counties which have high breast cancer-related mortality rates.

CME Post-Test

13. T or F Breast cancer is the second leading cause of cancer-related mortality among women in the United States (US) after lung cancer.

14. T or F Based on the analysis of 2006 Behavioral Risk Factor and Surveillance System (BRFSS) data, a higher proportion of women >40 years of age in West Virginia (WV) reported not having a mammogram in the past two years in comparison to the entire country.

15. Which of the following represents a plausible relationship between the rates of mammography screening and in-situ breast cancer incidence presented in this article?

a. [down arrow] mammography screening ~ fin-situ breast cancer incidence

b. [up arrow] mammography screening ~ fin-situ breast cancer incidence

c. [up arrow] mammography screening ~ jin-situ breast cancer incidence

d. [down arrow] mammography screening ~ jin-situ breast cancer incidence

16. T or F According to the article, the incidence and mortality rates of breast cancer were generally higher in counties in the central part of WV in comparison to counties in the southern and northern part of the state.

References

(1.) United States Preventive Services Task Force (2002). Screening for Breast Cancer: Recommendations and Rationale. Agency for Healthcare Research and Quality, Rockville, MD.

(2.) American Cancer Society (2008). Breast Cancer Facts & Figures 2007-2008. Atlanta: American Cancer Society, Inc.

(3.) American Cancer Society (2008). Breast Cancer: What Are the Risk Factors for Breast Cancer? Atlanta: American Cancer Society, Inc.

(4.) Hansen NM, Growney A. Breast cancer: pre- and postoperative imaging for staging. Surg Oncol Clin N Am, 2007;16(2):447 463.

(5.) Smith RA, Cokkinides V, Eyre HJ. Cancer screening in the United States, 2007: a review of current guidelines, practices, and prospects. CA Cancer J Clin, 2007;57(2):90-104.

(6.) Couto RA, Simpson KN, Harris G. Sowing seeds in the mountains: Community based coalitions for cancer prevention and control. National Cancer Institute, 1994.

(7.) Appalachian Regional Commission (2000). Recent trends in poverty in the Appalachian region: The Implications of the U.S. Census Bureau Small Area Income and Poverty Estimates on the ARC Distressed Counties Designation. Report Prepared by Applied Population Laboratory, University of Wisconsin. Accessed February 26, 2009 from http:// www.arc.gov/images/reports/poverty/ARCAPLFinal.pdf

(8.) Behringer B. Rural health care: Surviving on the edge of change. Medical Group Management Journal, 1992;39(5):1819,22.

(9.) Hendryx M. Mortality from heart, respiratory, and kidney disease in coal mining areas of Appalachia. Int Arch Occup Environ Health, 2009;82(2):243-249.

(10.) Halverson JA, Ma L, Harner EJ (2004). An analysis of disparities in health status and access to health care in the Appalachian region. Appalachian Regional Commission, Washington, DC.

(11.) Cakmak S, Dales RE, Judek S. Respiratory health effects of air pollution gases: modification by education and income. Arch Environ Occup Health, 2006;61:5-10.

(12.) Barnett E, Halverson JA, Elmes GA, Braham VE. Metropolitan and non metropolitan trends in coronary heart disease mortality within Appalachia, 19801997. Ann Epidemiol, 2000;10:370-379.

(13.) Wingo PA, Tucker TC, Jamison PM, et al. Cancer in Appalachia, 2001-2003, Cancer, 2008;112(1):181-92.

(14.) West Virginia Department of Health and Human Resources. The West Virginia 2010 Objectives. Accessed February 20, 2009 from http://www.wvdhhr.com/bph/ hp2010/objective/3.htm

(15.) U.S. Department of Health and Human Services. Healthy People 2010. Volume II: Objectives for Improving Health (Part B). 2nd ed. Washington, DC: U.S. Government Printing Office; 2000.

(16.) National Cancer Institute. Cancer Screening Consortium for Underserved Women. Breast and cervical cancer screening among underserved women. Baseline survey results from six states. Arch Fam Med, 1995;4:617-624.

(17.) Hall HI, Uhler RJ, Coughlin SS, Miller DS. Breast and Cervical Cancer Screening among Appalachian Women. Cancer Epidemiol Biomarkers Prev, 2002;11:137 142.

(18.) Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Operational and User's Guide. Atlanta, Ga: Centers for Disease Control and Prevention; 2005. Available at http://www.cdc.gov/brfss/pdf/ userguide.pdf

(19.) Blackman DK, Bennett EM, Miller DS. Trends in self-reported use of mammograms (1989-1997) and Papanicolaou tests (1991-1997) Behavioral Risk Factor Surveillance System.MMWR CDC Surveill Summ, 1999;48(SS-6):1-22.

(20.) West Virginia Department of Health and Human Resources (2004). Covered services, limitations, and exclusions for laboratory and radiology services. Accessed February 20, 2009 from http:// www.wvdhhr.org/bms/manuals/Common Chapters/bms manuals Chapter 500 Lab Rad.pdf

(21.) Coughlin SS, Thompson TD, Hall HI, Logan P, Uhler RJ. Breast and cervical carcinoma screening practices among women in rural and nonrural areas of the United States, 1998-1999. Cancer, 2002;94(11):2801-2812.

(22.) Litch B. Mobile mammography units. Denver program provides screenings to uninsured women. Healthc Exec, 2006;21(5):38:41-42.

(23.) Miller BA, Feuer EJ, Hankey BF. Recent incidence trends for breast cancer in women and the relevance of early detection: an update. CA Cancer J Clin, 1993;43(1):27-41.

(24.) Centers for Disease Control and Prevention (CDC). 1999-2004 Incidence and Mortality Web-based Report. Accessed February 21, 2009 from http:// apps.nccd.cdc.gov/uscs/

(25.) US Census Bureau. Small area income and poverty estimates for 2007. Accessed March 1, 2009 from http://www.census. gov/did/www/saipe/county. htm l.

Rahu [1] Khanna, MS, MBA [1,4] Abhijeet Bhanegaonkar, MPH [1,4] Pat Colsher, PhD [2] S. Suresh Madhavan, MBA, PhD [1,3,4] Joel Halverson, PhD [1,3,4]

[1] Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV.

[2] West Virginia Cancer Registry, Charleston, WV.

[3] Mary Babb Randolph Cancer Center, West Virginia University School of Medicine, Morgantown, WV.

[4] Supported in part by a Susan G. Komen for the Cure national grant, Dallas, TX.
Table 1. Demographic characteristics of West Virginia females aged 40
years and older that have not had a mammogram in the past two years,
Behavioral Risk Factor Surveillance System (2006).

                                                       Actual
                                                       Respondents (a)
Characteristics                                        (N)

                   40-44 Years                         197
Age ***            45-54 Years                         429
                   55-64 Years                         463
                   [greater than or equal to]65 Years  661

                   Less than high school               308
                   Graduated high school               706
Education ***      Attended college/technical
                     school                            388
                   College graduate                    345

                   Less than $15,000                   322
                   $15,000-$24,999                     365
Income ***         $25,000-$49,999                     430
                   $50,000-$74,999                     187
                   Greater than $75,000                181

Race               White                               1,688
                   Other (b)                           61

Total Females--    [greater than or equal to]40 years  1,750
West Virginia

Total Females--    [greater than or equal to]40 years  160,465
United States (c)

                   Weighted proportion of females
                   [greater than or equal to]40
                   years who have not had a
                   mammogram in the past two years
Characteristics    (95%CIs)

                   42.8 (35.1-50.6)
Age ***            24.6 (20.2-29.0)
                   17.8 (14.1-21.6)
                   24.8 (21.1-28.4)

                   35.8 (29.8-41.8)
                   25.8 (22.1-29.4)
Education ***
                   26.3 (21.2-31.3)
                   15.4 (11.4-19.4)

                   36.4 (30.5-42.2)
                   32.9 (27.4-38.4)
Income ***         24.4 (19.9-28.9)
                   19.7 (13.4-25.9)
                   13.0 (7.4-18.7)

Race               25.5 (23.2-27.9)
                   26.4 (14.3-38.5)

Total Females--    25.5 (23.2-27.8)
West Virginia

Total Females--    23.4 (22.9-23.8)
United States (c)

(a) Total number of respondents within each category could be
different.

(b) Other includes females who were Black, Asian, Native Hawaiian or
other Pacific Islander, American Indian or Alaskan Native,
Multiracial, and those that reported "other race".

(c) Includes all (United States) female respondents in 2006 BRFSS who
were [greater than or equal to]40 years and had responded (Yes/No) to
the question of whether they had a mammogram in the past two years or
not. Remaining numbers/proportions in the table correspond
specifically to West Virginia.

*** p<0.001

CIs--Confidence Intervals

Table 2. Results of logistic regression model determining factors
associated with no mammography in the past two years among West
Virginia females aged 40 years and older, Behavioral Risk Factor
Surveillance System (2006).

                                                      Adjusted
                                                      Odds Ratio (a)
Characteristics                                       (95%CIs)

                  40-44 Years                         1.7 (1.1-2.6) ***
Age               45-64 Years                         0.7 (0.5-0.9) ***
                  [greater than or equal to]65 Years  Reference

                  Less than high school               2.2 (1.3-3.6)
                  Graduated high school               1.3 (0.8-1.9)
Education         Attended college/technical school   1.4 (0.9-2.2)
                  College graduate                    Reference

                  [less than or equal to]$24,999      1.8 (1.2-2.8) **
Income            $25,000-$49,999                     1.3 (0.8-2.0)
                  [greater than or equal to]$50,000   Reference

                  White                               1.2 (0.5-2.7)
Race              Other (b)                           Reference

                  Yes                                 Reference
Health insurance  No                                  1.9 (1.2-3.2) *

                  Yes                                 Reference
Personal doctor   No                                  2.9 (1.9-4.5) ***

Last routine      [less than or equal to]2 Years      Reference 8.5
checkup           >2 Years                            (5.3-13.4) ***

Unable to see     Yes                                 1.5 (1.1-2.2) ***
doctor in the     No                                  Reference
past 12 months
because of cost

(a) Adjusted for all variables included in the table.

(b) Other includes females who were Black, Asian, Native Hawaiian or
other Pacific Islander, American Indian or Alaskan Native,
Multiracial, and those that reported "other race".

*** p<0.001; ** p<0.01; * p<0.05

CIs--Confidence Intervals

Figure 1.

Differences in the proportion of West Virginia females aged 40 years
and above who had not had a mammogram in the past two years based on
healthcare access characteristics, Behavioral Risk Factor
Surveillance system (2006).

Proportion without Mammogram
in Past Two Years

A) Health insurance

Yes   21.9 (19.6-24-2)
No    57.2 (48.8-64.7)

Proportion without Mammogram
in Past Two Years

B) Personal doctor

Yes   21.7 (19.4-23.9)
No    59.9*** (51.9-68.0)

Proportion without Mammogram
in Past Two Years

C) Last routine checkup

[less than or equal to]Years   19.9 (17.7-22.2)
>2 Years                       75.2*** (67.9-82.6)

Proportion without Mammogram
in Past Two Years

D) Unable to see doctor in the past 12 months because of cost

Yes   46.8*** (40.0-53.6)
No    21.5 (19.2-23.9)

Note: Table made from bar graph.
Gale Copyright: Copyright 2009 Gale, Cengage Learning. All rights reserved.