PREVENTIVE MEDICINE 11, 454-463 (1982)
Cancer Preventive Screening Behavior among Elderly Women I*
DAVID D. CELENTANO, SAM SHAPIRO, AND CAROL S.WEISMAN
Health Services Research and Development Center, The Johns Hopkins Medical Institutions, 624 North Broadway, Baltimore, Maryland 21205
Screening procedures and recommendations for early detection of cervical and breast cancer are reviewed with special reference to suggested guidelines for screening among the elderly. Data on preventive practices related to cancer detection were obtained from 675 women in Maryland by telephone interviews. The elderly (65 years of age and older) re- ported fewer detection tests of any type; specifically, 23% report never having had a Pap test and an additional 28% have not had one within 5 years, compared with women under the age of 65, where 98% report having had a Pap test and 79% have had one within the past two years. Elderly women were also less likely than younger women to report receiving routine breast examinations by their physicians, to perform BSE, or to have been taught BSE by a health professional. Type of provider utilized, having a personal physician, and going to a gynecologist account for a significant proportion of the variance in screening practices.
Malignant neoplasms are the second leading cause of death in adult women, accounting for some 23% of all mortality, and breast cancer is the leading site among all cancer deaths in women (1). Both the age-specific incidence and mor- tality rates for breast cancer increase with age (14). Approximately 36% of breast cancer incidence occurs in women aged 65 years and older; an even larger propor- tion of the mortality from breast cancer, 48%, is found in the aged population (3, 21). Similarly, approximately one-quarter (24%) of cervical cancer incidence (excluding carcinoma in situ) and almost 41% of all cervical cancer deaths occur in the population 65 years and older (21).
Secondary prevention approaches that promote the early detection of these diseases are available and seemingly accessible to all women (2). For breast cancer, breast palpation performed by a health professional is recommended (4, 23). Breast self-examination (BSE), while not conclusively proven to decrease the extent of breast disease when measured by stage, tumor size, or lymph node involvement (6,9, 15, 17, 19, 20), has been widely recommended by the American Cancer Society as a monthly procedure for every woman (4). Screening for cervi- cal cancer by the Pap test is widely accepted, although questions are raised peri- odically about the effkacy of this detection method (5, 10, 13). While the recom- mended periodicity of Pap testing has recently been revised by the ACS, it is currently suggested that asymptomatic women receive Pap tests every 3 years
Supported in part by Grant CA20322 from the National Cancer Institute. A preliminary version of this paper was presented at the Annual Meeting of the American Public
Health Association, Detroit, Mich., October 23, 1980.
454 0091.7435/82/040454-10$02.00/O Copyright @ 1982 by Academic Press, Inc. AU rights of reproduction in any form reserved.
CANCER PREVENTIVE SCREENING BEHAVIOR 455
after two negative annual Pap tests are found (unless women are at high risk) (4). These recommendations hold for women through the age of 65 years, at which point routine screening is discontinued.
The cancer prevention and gerontology literatures (7,8, 18) make little mention of the special needs and problems of the elderly in participating in cancer detec- tion efforts. Indeed, there is almost no mention of any preventive actions to be taken to prevent or detect disease or to promote health (7, 16). Given the high incidence of cancer among the elderly for many cancers, the present study ad- dresses the extent to which the elderly are following recommended preventive ac- tions for the early detection of cancer. In this paper, factors which differentiate elderly women (here referred to most frequently as those women aged 65 years and older) from younger women in cancer screening participation will be explored.
The data on preventive health behaviors related to cancer detection were col- lected in two waves of a telephone survey of a random sample of households listed in telephone directories in four nonmetropolitan counties in Maryland during 1979 and 1980. Households were predesignated to be either female interview or male interview households prior to interview in order to maximize the number of males to be interviewed (since it has generally been found in the telephone survey literature that women are more frequently found at home and that they are more likely to answer the telephone than are men among married couples). A total of 1600 household listings were sampled from the telephone directories; in 87.1% of the cases an interview was possible (in the remaining 206 cases the telephone number was no longer connected). Of the 1,394 eligible numbers, interviews were attempted with 795 women (i.e., in 57% of the eligible households. either a female was predesignated for interview or a male interview household did not have a male present), with 675 completed interviews obtained, yielding an overall re- sponse rate of 84.9%. Of the 120 women who were not interviewed, 101 refusals were obtained (12.7%) and there were 19 incomplete interviews (breakoffs). In households where more than one eligible woman was found, the female head of household was selected, resulting in a sample which is slightly older than that of the general population.
The structured interviews lasted approximately one-half hour and were con- ducted by trained, professional interviewers contracted by the study team. These interviewers were all experienced in conducting medically related interviews; no major discrepancies between the 11 interviewers were determined on any of the major variables of interest.
The surveys were conducted as part of the outreach program of a regional oncology center for the development of cancer control activities and organization in local communities (22). These nonmetropolitan areas were known to have few formal cancer control programs at the time of the surveys. Each was served by one community hospital, and local providers and agencies were interested in developing cancer control programs. The surveys encompassed rura,l and subur- ban (commuting distance to Baltimore) communities with a wide range of socio- economic levels and large numbers of the elderly. While there is some truck
456 CELENTANO, SHAPIRO, AND WEISMAN
farming and fishing industry, these communities can best be characterized as rural non-farm, for there is some light industry in each area. As the communities are predominantly white, data on nonwhites are excluded from the analyses, resulting in a base number of 634 women for the analysis. As no significant differences were found across the four communities, the data from each is com- bined herein. Further, the results from this study are generalizable only to non- metropolitan communities, for no urban populations were sampled. Also, while the sample was limited to those households with listed telephone numbers, thereby again reducing the generalizability of the Iindings, the prevalence of un- listed numbers in these communities is extremely low and telephone subscription is nearly universal.
Table 1 shows the proportion by age of women who report ever having had any test to detect cancer, in response to an open-ended question that did not define what such tests were but rather was designed to elicit respondents percep- tions of what cancer detection tests are. The proportion is constant for women aged 18 to 64 years, where approximately four in five report having had some test. At age 65, the proportion drops off to approximately two-thirds of women report- ing ever having had any detection test, while only one-half of respondents 75 years and older report ever having had any detection test.
With respect to cervical cancer screening specifically, women over the age of 65 years reveal deficient screening histories. Thirty-eight percent of women 75 years and older and 14% of women aged 65-74 years report never having had a Pap test. Further, 28% of the women 65 years and older who have ever had a Pap test reported that their last Pap test was performed at least 5 years previously. Thus, nearly one-half (5 1.2%) of elderly women in this sample have either never had a Pap test or have not had one in a long time. These findings are in distinct contrast to the findings for younger women, where some 98% of women under 65 years report having received a Pap test at some point in their lives, and 7% report receiving a Pap test within the past 24 months.
Figure 1 shows the distributions by age for the recency of the last Pap test reported by respondents. Recency has been defined as follows: (a) those who received their last Pap test within the past 2 years; (b) those reporting the most recent Pap test was at least 2 years previously (where the average time was 5l/2 years before); and (c) those who report never having had a Pap test. It can be seen that there is a strong, negative linear relationship between age and the proportion of women reporting a recent Pap test.
In attempting to account for these strong relationships with age, many factors were considered, including the usual source of medical care, types of medical care providers utilized in the past year, perceived health status, and attitudes and knowledge about cancer. Table 2 shows the usual source of medical care reported by women in this study. Women aged 55 years and older were more likely than women under 55 years to identify a family physician or general practitioner as the regul