PREVENTIVE MEDICINE 25, 118–125 (1996)ARTICLE NO. 0037

Use of Screening Mammography and Clinical Breast Examinationsamong Black, Hispanic, and White Women

EMMA L. FRAZIER, PH.D.,*,1 RUTH B. JILES, PH.D.,† AND ROBERT MAYBERRY, PH.D.‡

*Office of Surveillance and Analysis, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Controland Prevention, Atlanta, Georgia 30341; †Tulane University Medical Center, School of Public Health and Tropical Medicine, New

Orleans, Louisiana 70118; and ‡Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia 30322

182,000 women would be diagnosed with breast cancerBackground. Breast cancer screening can be an ef- and that about 46,000 women would die from the dis-

fective tool in the early detection of breast cancer but ease in 1994 (2). ACS has estimated that approximatelyremains underused by women in the United States. 1 in every 9 women will develop breast cancer by age

Methods. We analyzed data from 22,657 women (2,068 85 years (2).black women, 707 Hispanic women, and 19,882 white In the past 2 decades, the incidence of breast cancerwomen) who participated in the 1990 Behavioral Risk

has increased about 2% per year; death rates have re-Factor Surveillance state-based telephone survey. Us-mained relatively stable (1). Racial differences in theing the recommended guidelines of the American Can-incidence and mortality of breast cancer are reflectedcer Society for breast cancer screening, we examinedin a variety of measures. The years of potential life lostutilization rates by demographic and selected vari-before age 65 years from breast cancer were reported asables, stratified by ethnic groups.215 per 100,000 white women and as 253.5 per 100,000Results. Of the women included in the analysis, 47%black women (3). Although the incidence of breast can-of both black and Hispanic women and 50% of whitecer is 17% lower for black women than for whitewomen reported having had a recent mammogram,women, the 5-year survival rate for black women (64%)and 68% of black women, 59% of Hispanic women, andwas 16% lower than the rate for white women (81%)66% of white women reported having had a recent clin-

ical breast examination (CBE). Important predictors from 1983 to 1989 (1, 3).of the use of breast cancer screening procedures for Several risk factors for breast cancer have been citedeach group were having had a routine examination in (4, 5). However, early detection and treatment arethe past year, having seen an obstetrician or gynecolo- viewed as the most important methods to reduce breastgist or specialist during the last routine examination, cancer mortality (6, 7). The recommended proceduresand more than a high school education. for early detection of breast cancer are mammography

Conclusions. Many women are not having mammog- screening and clinical breast examinations (CBEs) (8,raphy and CBEs. Efforts to increase screening must 9). Estimates from the 1987 National Health Interviewfocus on encouraging providers to use CBEs as a Survey (NHIS) indicated that 81% of women age 40screening tool and to recommend mammography. years and older reported ever having had a CBE andStrategies should be developed to increase the use of

only 38% had ever had a mammogram (10). Recentthese procedures among women, particularly thosestudies indicate that the percentage of women whoof low income and low education levels. q 1996 Academichave ever had a mammogram is increasing (11–15).Press, Inc.Results from the NHIS showed that the percentage ofKey Words: mammography; clinical breast examina-women who reported a screening mammogram in thetions; breast cancer screening; ethnic groups.year prior to interview almost doubled between 1987(17%) and 1990 (33%) (15).

The racial differences in the 5-year survival ratesINTRODUCTION and the stage at which the disease is diagnosed are of

particular concern. Differences in breast cancer screen-Breast cancer is the second leading cause of cancer ing practices between racial groups could account for

deaths among women in the United States (1). The both incidence and survival differences, i.e., more andAmerican Cancer Society (ACS) estimated that over earlier stage cancer detected among women being

screened (16). Indeed, studies have shown that screen-ing behaviors may differ among age and race/ethnic1 To whom correspondence and reprint requests should be ad-groups (17–20).dressed at CDC, 4770 Buford Highway, NE, Mailstop K10, Atlanta,

GA 30341-3724. Using the guidelines and objectives for breast cancer

1180091-7435/96 $18.00Copyright q 1996 by Academic Press, Inc.All rights of reproduction in any form reserved.

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119USE OF BREAST CANCER SCREENING PROCEDURES

screening proposed by the ACS and adopted by numer- women age 50 years and older. Those who had everhad a mammogram were asked whose idea it was toous medical and professional organizations (21–25), we

evaluate the screening practices of women in the have their last mammogram. Women who reportedthat they had not received a mammogram were askedUnited States. To analyze these practices, we used the

following ACS criteria: CBE every year and a mammo- why. Respondents were also asked to specify the lasttime they had a routine checkup and to identify thegram every 1–2 years for asymptomatic women ages

40–49 years and a CBE and a mammogram every year type of doctor who performed their last routine exami-nation.for asymptomatic women age 50 years and older (25).

The analyses presented here are designed to present We included the following demographic variables inthe analyses: age, level of education, marital status,data on the use of mammography and CBEs stratified

by race/ethnic groups for women who participated in employment status, total annual family income, andthe region in which the woman lived. The percentagethe Behavioral Risk Factor Surveillance System

(BRFSS) in 1990. The focus of this analysis is to present of all women who had ever had breast cancer screeningservices and who had recent screening services wasfactors that are common among each group, not to sta-

tistically compare the three groups. One goal is to iden- stratified by each race/ethnic and demographic group.Results were weighted to reflect the age-, sex-, andtify common factors among women stratified by race/

ethnic groups that may independently predict whether race-specific distribution of the most recent state popu-lation estimates for each of the 44 states and the Dis-a woman received breast cancer screening. We ana-

lyzed data from the 1990 BRFSS because 1990 is the trict of Columbia. We used SAS to calculate all percent-ages and odds ratios and SESUDAAN to account for1st year in which data were collected on CBEs.the complex survey design and calculate standard er-rors (29, 30).METHODS

Multiple logistic regression models were used to as-sess independent predictors of and control simultane-The BRFSS is a state-based telephone survey of non-

institutionalized, civilian adults age 18 years and older. ously for potential confounders of use of screening pro-cedures among black, Hispanic, and white women. WeTo obtain this sample, most states use a multistage

cluster design that is based on the Waksberg method included all variables in the initial full model. Stepwiselogistic models were used to eliminate variables in sub-of random-digit dialing (26). All states use a standard

core questionnaire and the interviews are conducted sequent analytic runs if they were not significant pre-dictors of use of the recommended breast cancer screen-on a monthly basis. The history and methods for the

survey have been explained in detail elsewhere (27). ing procedures.The study population was drawn from 25,550 women

age 40 years or older who responded to the 1990 BRFSS RESULTSin 44 states (excluding Alaska, Arkansas, Kansas, NewJersey, and Wyoming) and the District of Columbia. Of the 22,657 women 40 years and older, 2,068 wereWomen who reported that their race/ethnicity was non-Hispanic black women (9.1%), 707 were Hispanicother than black, Hispanic, or white were not included women (3.1%), and 19,882 were non-Hispanic whitein the analysis because of small sample sizes. We also women (87.8%). Thirty-one percent of black women,excluded 2,893 women (189 non-Hispanic black, 96 His- 38% of Hispanic women, and 28% of white women werepanic, and 2,608 non-Hispanic white) who reported between 40 and 49 years old (Table 1). Forty-six per-their last screening procedure for breast cancer was cent of black women, 39% of Hispanic, and 22% of whiteperformed because of a health problem. women reported having had less than a high school

The overall response rate (calculated as number of education. An annual family income of $20,000 or lesscompletes/number of eligibles for interview) was 82% was reported by 58% of black women, 49% of Hispanicand ranged from 45 to 93%. The Council of American women, and 42% of white women. Most women re-Survey Research Organization response rate (28), ported that they had had a routine checkup in the pastwhich takes into account telephone numbers with an year.unknown status, was 66% and ranged from 38 to 92%.

We used responses from the Women’s Health Section Use of Breast Cancer Screening Proceduresof the BRFSS core questionnaire that ascertained if,when, and why a women received mammography and Among all women, 47% of black and Hispanic women

and 50% of white women reported having had a recentCBE. Women who had a CBE and a mammogramwithin the time frame recommended by the ACS were mammogram. For CBE, 68% of black women, 59% of

Hispanic, and 66% of white women reported havingconsidered as having had a recent screening procedure:CBE within the past year and a mammogram within had a recent CBE. Of all women who reported that

they had a CBE within the past year, 67% had alsothe past 1–2 years of women ages 40–49 years or aCBE and a mammogram within the past year for had a recent mammogram (61% of black, 66% of His-

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120 FRAZIER, JILES, AND MAYBERRY

TABLE 1

Characteristicsa of Black, Hispanic, and White Women Age 40 Yearsand Older—Behavioral Risk Factor Surveillance System, 1990

Percentageb distribution

Black Hispanic WhiteN Å 2,068 N Å 707 N Å 19,882

Characteristics Mean age: 58.4 56.5 60.4

Age40–49 years 31.0 38.2 28.050–64 years 34.9 32.7 31.0§65 years 34.0 29.1 41.0

Incomeõ$10,000 36.7 25.3 20.1$10,000–19,999 21.0 23.8 21.4$20,000–34,999 14.2 17.8 20.7§$35,000 9.8 15.1 21.3Unknown 18.4 18.0 16.7

Educationc

õHigh school 45.5 39.3 22.4High school 27.9 27.2 36.5Some college 15.5 21.2 22.4College graduate 10.9 11.6 18.3

Marital statusc

Married 31.4 51.6 51.7Divorced or separated 25.8 21.1 13.9Widowed 34.1 20.9 30.0Unmarried 8.6 5.2 4.5

Employment statusc

Employed 42.5 44.8 40.6Not employed 19.0 25.7 19.3Retired 38.4 29.1 40.0

Time since last checkup£1 year ago 88.3 80.6 77.4ú1 year ago 10.4 17.0 20.8Never or unknown 1.3 2.4 1.9

Region in which women livedNortheast 9.3 12.9 16.2Midwest 14.2 10.3 28.0South 72.9 33.8 33.9West 3.6 43.0 22.0

a Only includes women who reported their race/ethnicity as black, white, or Hispanic; excludes all women who reported that their lastmammogram or clinical breast exam was performed because of a health problem.

b Percentages may not add to 100 because of rounding errors or because of exclusions of the unknown responses. Percentages areunweighted.

c Unknown responses are not shown for this category. Percentage of unknowns õ1.0%.

panic, and 67% of white women). Of all women who have a mammogram was based on their doctor’s recom-mendation and about 30% of women (30% of blackreported that they had had a recent mammogram, 88%

had also had a recent CBE in the past year (89% of both women, 35% of Hispanic women, and 28% of whitewomen) said that it was their idea to have the lastblack and white women and 83% of Hispanic women).

Stratified analyses by race/ethnic groups showed that mammogram (data not shown).the lowest screening rates for each procedure were re-ported by women age 50 years old or older, who had less Reasons for Not Having Had a Mammogramthan a high school education, and who had a routineexamination more than a year ago (Table 2). Women who reported that they had never had a

mammogram were asked to report the most importantWomen who reported that they had ever had a mam-mogram were asked if having the procedure was their reason for not ever having had one. Of the 8,016 women

(35% of all women) who said they never had a mammo-idea, their doctor’s idea, or someone else’s idea. Mostwomen (68% of black women, 62% of Hispanic women, gram, 33% said they did not need a mammogram (33%

of black and white women and 43% of Hispanicand 70% of white women) reported that the decision to

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121USE OF BREAST CANCER SCREENING PROCEDURES

TABLE 2

Percentage of Womena Who Had a Breast Cancer Screening Procedure—BehavioralRisk Factor Surveillance System, 1990

Percentage of Women Who Had a Recent Mammogramb

Black (N Å 2,068) Hispanic (N Å 707) White (N Å 19,882)

Characteristics %c {(CI)d % {(CI) % {(CI)

Total 46.5 (3.2) 46.7 (5.9) 50.0 (1.2)Age group

40–49 years 53.2 (5.8) 50.0 (9.3) 58.5 (2.1)50–64 years 42.1 (5.5) 46.4 (10.6) 51.7 (2.1)§65 years 43.2 (5.4) 42.4 (10.7) 41.6 (1.8)

Level of educationõHigh school 39.1 (4.7) 41.8 (9.0) 35.9 (2.3)High school 44.5 (6.3) 53.1 (10.8) 49.0 (1.9)úHigh school 59.5 (6.2) 51.4 (10.4) 57.9 (1.8)

Income levelõ$10,000 39.4 (5.1) 43.1 (10.1) 34.6 (2.5)$10,000–19,999 43.9 (7.0) 43.1 (11.9) 40.7 (2.4)$20,000–34,999 58.2 (8.8) 48.5 (13.6) 51.8 (2.5)§$35,000 63.4 (10.0) 53.9 (15.3) 65.5 (2.4)

Time since last examinationCheckup £1 year ago 50.7 (3.5) 54.8 (6.3) 58.1 (1.3)Checkup ú1 year ago 18.9 (7.6) 13.1 (7.6) 21.9 (2.1)

Percentage of Women Who Had A Recent CBEb

Total 67.7 (3.0) 59.0 (6.0) 65.9 (1.1)Age group

40–49 years 75.9 (4.9) 63.3 (9.1) 69.2 (1.9)50–64 years 66.2 (5.5) 59.5 (10.3) 67.5 (2.0)§65 years 59.6 (5.2) 52.2 (10.0) 61.8 (1.7)

Level of educationõHigh school 53.8 (4.7) 55.8 (9.1) 55.7 (2.4)High school 67.9 (6.1) 65.0 (10.3) 66.3 (1.8)úHigh school 81.6 (4.5) 61.2 (10.1) 70.7 (1.6)

Income levelõ$10,000 56.8 (5.1) 50.8 (11.8) 55.1 (2.5)$10,000–19,999 73.5 (6.3) 63.4 (11.6) 61.7 (2.4)$20,000–34,999 72.8 (7.9) 63.4 (12.4) 69.0 (2.3)§$35,000 88.6 (5.4) 70.5 (14.0) 74.6 (2.2)

Time since last examinationCheckup £1 year ago 73.9 (3.0) 69.9 (6.5) 79.2 (1.0)Checkup ú1 year ago 27.5 (8.9) 14.1 (10.0) 19.9 (2.0)

a Only includes women who reported their race/ethnicity as black, white, or Hispanic; excludes all women who reported that their lastmammogram or clinical breast examination was performed because of a health problem.

b Recent screening procedure: clinical breast examination (CBE) in the past year and mammogram in the past 2 years for women 40–49, CBE and mammogram in the past year for women 50 and older.

c Weighted percentages.d 95% confidence interval.

women), 30% said their physician did not recommend all women, we focused our analysis on persons who hada routine examination in the past year (i.e., the strongestit (36% of black women, 26% of Hispanic women, and

30% of white women), 8% said that the procedure was independent predictor of use of breast cancer screeningservices). Results of models for the receipt of mammogra-too expensive or that they did not have insurance to

cover the cost, and less than 1% of the women said they phy and CBE screening for black, Hispanic, and whitewomen who reported that they had had a routine exami-never heard of a mammogram.nation in the past year are reported.

Application of Logistic Regression Model Mammography. The following common measureswere predictive of mammography use among black andSubsequent to the examination of several analytic mod-

els for each race/ethnic group, including the full model for white women who had a routine examination in the

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122 FRAZIER, JILES, AND MAYBERRY

TABLE 3

Full Model of Predictors of Use of Mammography among Black, Hispanic, and White Women Who Had A RoutineExamination in the Past Year—Behavioral Risk Factor Surveillance System, 1990

Mammography Screening

Black (N Å 1,817) Hispanic (N Å 564) White (N Å 15,274)

Variables Oddsa (CI)b Odds (CI) Odds (CI)

Age group40–49 years 1.1 (0.8, 1.6) 1.2 (0.7, 2.0) 1.2 (1.0, 1.3)50–64 years 0.8 (0.6, 1.0) 0.9 (0.6, 1.5) 1.3 (1.2, 1.4)§65 years 1.0c 1.0c 1.0c

Educational levelõHigh school 1.0c 1.0c 1.0c

High school 1.2 (1.0, 1.5) 1.2 (0.8, 1.9) 1.3 (1.2, 1.4)úHigh school 1.7 (1.3, 2.2) 1.3 (0.8, 2.1) 1.7 (1.5, 1.9)

Income levelõ$10,000 1.0c 1.0c 1.0c

$10,000–19,999 1.0 (0.8, 1.4) 0.7 (0.5, 1.2) 1.1 (1.0, 1.2)$20,000–34,999 1.6 (1.1, 2.3) 0.7 (0.4, 1.4) 1.3 (1.2, 1.5)§$35,000 1.7 (1.1, 2.5) 1.3 (0.6, 2.7) 2.1 (1.8, 2.4)Unknown 1.0 (0.7, 1.3) 1.0 (0.6, 1.8) 1.3 (1.1, 1.4)

Marital statusNot married 1.0c 1.0c 1.0c

Married 0.9 (0.7, 1.1) 2.4 (1.6, 3.5) 1.4 (1.3, 1.5)Employment status

Not employed 1.0c 1.0c 1.0c

Employed 0.8 (0.7, 1.1) 1.1 (0.7, 1.6) 1.1 (1.0, 1.2)Type of doctor seen during last examination

Family/General practitioner 1.0c 1.0c 1.0c

Obstetrician/Gynecologist 2.1 (1.5, 3.1) 0.7 (0.4, 1.4) 2.1 (1.9, 2.4)Other specialist 1.1 (0.9, 1.5) 1.8 (1.2, 2.9) 1.3 (1.2, 1.4)

Region in which women livedSouth 1.0c 1.0c 1.0c

Northeast 1.3 (1.0, 1.6) 1.7 (1.0, 3.0) 1.1 (1.0, 1.2)Midwest 1.2 (1.0, 1.6) 1.4 (0.6, 3.3) 1.0 (0.9, 1.1)West 2.0 (1.3, 3.0) 1.0 (0.7, 1.6) 1.2 (1.1, 1.3)

a Adjusted for all other variables in the model.b 95% confidence interval.c Reference category.

past year: more than a high school education, an an- income above $35,000 (Table 4). Common measurespredictive of CBE screening among black and whitenual family income of more than $20,000, having seen

an obstetrician/gynecologist (Ob/Gyn) at the last rou- women were age 40–49 years, more than a highschool education, and having seen an Ob/Gyn at theirtine examination and living in the West (Table 3). Com-

mon measures predictive of mammography screening last routine examination. A common predictor forCBE screening among Hispanic and white womenamong white and Hispanic women were being married,

an annual income of $35,000 or more, having seen a was having seen a specialist for the last routine ex-amination.specialist other than an Ob/Gyn, and residing in the

Northeast. White women ages 50–64 years were sig-nificantly more likely to report having had a screening DISCUSSIONmammogram in the past year than white women inother age groups. Conversely, black women ages 50–

Despite evidence that screening is an effective tool in64 years were significantly less likely to report havingreducing breast cancer mortality (5–7), many womenhad a screening mammogram than black women agewho are of the appropriate age are not undergoing these65 and older.screening procedures. The majority of women (51%) didnot have a screening mammogram within the time speci-Clinical breast examination. Similar measures

among all women that were predictive of CBE screen- fied by the ACS guidelines, approximately 35% never hada mammogram, and 10% never had a CBE. We showing were being married and having an annual family

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123USE OF BREAST CANCER SCREENING PROCEDURES

TABLE 4

Full Model of Predictors of Use of Clinical Breast Examination among Black, Hispanic, and White WomenWho Had a Routine Examination in the Past Year—Behavioral Risk Factor Surveillance System, 1990

Clinical Breast Examination Screening

Black (N Å 1,817) Hispanic (N Å 564) White (N Å 15,274)

Variables Oddsa (CI)b Odds (CI) Odds (CI)

Age group40–49 years 2.1 (1.4, 3.0) 1.0 (0.6, 1.8) 1.2 (1.0, 1.4)50–64 years 1.2 (0.9, 1.6) 0.9 (0.5, 1.6) 1.2 (1.1, 1.4)§65 years 1.0c 1.0c 1.0c

Level of educationõHigh school 1.0c 1.0c 1.0c

High school 1.3 (1.0, 1.8) 0.8 (0.5, 1.3) 1.3 (1.2, 1.5)úHigh school 2.0 (1.5, 2.8) 0.8 (0.5, 1.4) 1.6 (1.5, 1.8)

Income levelõ$10,000 1.0c 1.0c 1.0c

$10,000–19,999 1.8 (1.3, 2.5) 1.2 (0.7, 2.1) 1.3 (1.2, 1.5)$20,000–34,999 1.1 (0.7, 1.6) 2.1 (1.0, 4.4) 1.7 (1.4, 1.9)§$35,000 2.5 (1.4, 4.6) 5.4 (2.0, 15.0) 1.9 (1.6, 2.3)Unknown 1.1 (0.8, 1.5) 0.9 (0.5, 1.5) 1.1 (1.0, 1.2)

Marital statusNot married 1.0c 1.0c 1.0c

Married 1.3 (1.0, 1.6) 1.7 (1.1, 2.5) 1.2 (1.1, 1.3)Employment status

Not employed 1.0c 1.0c 1.0c

Employed 0.8 (0.6, 1.1) 1.1 (0.7, 1.8) 1.3 (1.2, 1.5)Type of doctor seen during last examination

Family/General practitioner 1.0c 1.0c 1.0c

Obstetrician/Gynecologist 2.3 (1.4, 3.9) 1.8 (0.8, 4.1) 4.6 (3.7, 5.8)Other specialist 1.2 (0.8, 1.6) 1.7 (1.0, 2.7) 1.1 (1.0, 1.2)

Region in which women livedSouth 1.0c 1.0c 1.0c

Northeast 2.0 (1.5, 2.8) 1.5 (0.8, 2.6) 1.0 (0.9, 1.1)Midwest 0.8 (0.6, 1.1) 2.6 (0.8, 8.0) 0.9 (0.8, 1.0)West 1.0 (0.6, 1.7) 0.7 (0.5, 1.2) 1.2 (1.1, 1.4)

a Adjusted for all other variables in the model.b 95% confidence interval.c Reference category.

that overall rates between black and Hispanic women all women who had a routine examination within thepast year for recent mammography use. Black andwere similar for mammography use according to ACS

guidelines. However, Hispanic women were less likely white women shared a number of common predictors ofmammography use: having greater than a high schoolthan whites or blacks to have CBE according to the guide-

lines. Calle et al. (17) reported similar rates for black and education, having an annual income of $20,000 orhigher, and having seen an Ob/Gyn for their last rou-white women for both ever and recent use of mammogra-

phy. They also found that Hispanic women appeared to tine exam. White and Hispanic women had two similarpredictors for mammography use: being married andbe underserved regardless of income level. Other studies

suggest that the race/ethnicity differences in breast can- having seen a specialist for the last routine examina-tion. Black and white women were more likely to havecer screening procedures are independent of socioeco-

nomic status (18). had a recent CBE if they were ages 40–49 years, hada high school education or more, or had seen an Ob/All women who had a routine examination within

the past year were more likely to have received a recent Gyn during their last exam.The principal reasons given for not having a mammo-mammogram or CBE than women who had a routine

examination more than 1 year ago. Common predictors gram were that it was not needed (35%) and that itwas not recommended by their physicians (30%). Blackfor recent CBE use among all women who had a routine

examination within the past year were having an an- women were the least likely to report that their physi-cian encouraged them to have a mammogram. Thisnual family income of $35,000 or more and being mar-

ried. There were no other common predictors among finding suggests disparities in recommendations made

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124 FRAZIER, JILES, AND MAYBERRY

by physicians and could account for some of the racial subgroups within the Hispanic group. Health behav-iors may differ among specific ethnic subgroups of His-variation in survival. Breen and Kessler reported that

the reason most often cited for not having a mammo- panics and may well account for the large confidenceintervals around the percentages in this study. Evengram was that it was not recommended by a physician

(15). This finding is also consistent with the report of though the confidence intervals are large and the sam-ple size is small, it is important that these data beGrady and colleagues (31). Interestingly, Hispanic

women ages 50–64 years were most likely to say that added to the literature to stimulate interest in moreresearch in Hispanic women.the reason for not having a mammogram was because

the procedure was not needed. This finding suggests Significant missed opportunities are occurring whenwomen have routine examinations and fail to have athat Hispanic women could benefit from language-ap-

propriate educational efforts that stress the impor- CBE or a mammogram. The results from this articlesuggest several important messages: primary care phy-tance of breast cancer screening (32).

Breen and Kessler (15) reported that among women sicians should be encouraged to conduct yearly CBEsand recommend the use of mammography during rou-age 40 years and older, 33% had a recent mammogram

(compared with 49% in BRFSS) and 65% had a recent tine physical examinations, continued physician educa-tion must occur to remind all primary care physiciansCBE (compared with 66% in BRFSS). They suggested

that most of the differences in mammography rates about the necessity of conducting and recommendingpreventive services, and women must be educatedamong black and white women in 1990 were attribut-

able to differences in income and education. While we about breast cancer screening and encouraged to haveboth regular and repeat CBEs and mammography inreport at least 10 percentage points higher recent

mammography utilization rates, the patterns are simi- accordance with recommended guidelines.Clearly, there is a need to enhance programs to reachlar. Differences between the rates reported could be

attributed to differences in the demographic distribu- special populations and to develop strategies that mustinclude specific, culturally sensitive materials fortion of women 40 and older in the samples. The BRFSS

includes only those respondents who have a telephone, women of all ethnic groups. To reduce mortality frombreast cancer, physicians and public health workerswhich are those who are more likely to have above a

high school education (40% in BRFSS versus 30% in must interact with, encourage, and follow-up womenof all cultural backgrounds to monitor compliance withNHIS) and a family income of $20,000 or more per year

(63% in BRFSS versus 51% in NHIS). The NHIS is recommended mammography screening procedures.Elderly women, women with low education and lowa face-to-face household interview survey, while the

BRFSS is a telephone survey. In addition, the defini- income levels, as well as black and Hispanic womenand the physicians who treat them should be particu-tion of mammography differs slightly between the two

instruments, which could also account for some of the larly targeted for health education efforts.differences.

The reasons for underutilization of breast cancer ACKNOWLEDGMENTSscreening procedures are unclear, but may include fac-

We gratefully acknowledge the programming assistance of Ms.tors such as access to preventive health care servicesCharlene Smith and Catherine Okoro. Appreciation is also extended(32), differential recommendations from physiciansto all BRFSS state coordinators and the Centers for Disease Control(33), an inaccurate perception of the risk of breast can- and Prevention for their data collection and processing.

cer, and the belief that breast cancer screening exami-nations are essential only if a lump has been detected.

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