Nonclinical factors prejudice breast ca screening, SLNB

Universal healthcare has been a hot button topic in the 2008 US presidential race. But there is more to universal healthcare than insurance coverage. A truly universal system would address—and possibly even eradicate—disparities in healthcare that are based on nonclinical factors, such as socioeconomics and gender.

Two recent papers took a closer look at the discrepancies in breast cancer screening and diagnosis. One group focused on how wealth and prognosis influence mammographic screening, while another looked at how income and other factors affect whether women are offered a less invasive diagnostic test.

Wealth and prognosis

Brie Williams, MD, and her colleagues at the University of California, San Francisco, Division of Geriatrics, mined their data from the 2002 and 2004 Health and Retirement Study (HRS). Their sample size consisted of 4,222 women who self-reported on their mammography use during HRS. Each woman’s net worth was calculated based on her assets and debts in 2002. The authors then calculated various predictor variables (see Table 1).

Women with higher net worth had a better life expectancy than those with a low net worth: 58% had a good prognosis (substantial life expectancy) while 4% had a limited prognosis (50% chance of dying within 5 years) vs 33% and 14%, respectively for those with a low net income.

Overall, 68% of the women underwent screening mammography. The authors found that 75% of women who fell into the higher net worth category had received a screening mammogram vs 60% of middle-income women and 56% of low-income women.

A higher net worth was associated with higher screening rates across all prognostic categories. Among the women with good prognoses who were more likely to benefit from screening, 82% fell into the high-net-worth category vs 68% of the women who met the same prognostic criteria but were considered low income.

Among the women with limited prognosis, who were less likely to benefit from mammography, 48% with a high net worth still underwent screening, compared with 32% of subjects with a low net worth.

Finally, among older women (age 80 and above) with a high net worth, 54% underwent screening while 41% of women in that same age group with a low net worth were screened.

“Guidelines recommend screening mammography for older women only when they have a favorable prognoses,” the authors said, citing screening criteria promoted by the American Cancer Society (ACS), American Geriatrics Society, and U.S. Preventive Services Task Force (Arch Intern Med 168:514-520, 2008).

They said that based on their analysis, women with limited prognoses and lower income were actually screened according to those guidelines. Unfortunately, appropriate guidelines-based screening had not been extended to low-income women with a good prognosis, they said.

Education would be a key in closing this gap, Dr. Williams’ group wrote. First, referring physicians need a better understanding of prognostic indices and whether their patients, regardless of income level, will benefit from screening based on those criteria.

Second, once women are properly informed of their prognosis based on age and other factors, there is a chance that they may chose to forgo screening.