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Patient and provider determinants of breast cancer screening among Ontario women aged 40–49: a population-based retrospective cohort study

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Abstract

Purpose

Canadian breast cancer screening guidelines state that mammography screening for women 40–49 should be individualized based on risk assessment and preferences. This retrospective cohort study describes the frequency of screening in women aged 40–49 and identifies patient and provider-level associations with screening.

Methods

Administrative databases were linked. The overall cohort included Ontario women aged 40–49 between April 1, 2009 and March 31, 2019. Subgroups were created: the “screen” group included women who received a mammogram defined as screening (using a set of exclusion criteria) and the “routine screen” group included women with three or more screening mammograms. A multivariable multilevel logistic regression model accounting for patient and provider characteristics was fit to determine characteristics associated with routine screening. The intracluster correlation co-efficient was used to quantify the degree of variation across providers.

Results

Of approximately 2 million eligible women, there were 532,596 (25.5%) in the screen group and 90,651 (4.3%) the routine screen group. There was an average of 0.30 and 0.52 screening mammograms per woman year, in the screen and routine screen groups, respectively. Routine screening was associated with periodic health exams (OR 1.21, 95% CI 1.20–1.22), receiving pap smears (OR 1.38, 95% CI 1.37–1.39), and fee-for-service models of care (OR 1.32, 95% CI 1.27–1.36). Over 20% of the variation in screening was due to systematic between-provider differences.

Conclusions

Approximately 4.3% of women aged 40–49 in Ontario received routine breast cancer screening with substantial variation across providers. Routine screening is associated with periodic health examinations, receipt of pap smears, and fee-for-service models of care.

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Data Availability

The dataset from this study is held securely in coded form at ICES. While data sharing agreements prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS. The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Parts of this material are based on data and/or information compiled and provided by the Canadian Institute for Health Information (CIHI), Cancer Care Ontario (CCO), Ontario Registrar General (ORG), and Immigration, Refugees and Citizenship Canada (IRCC). However, the analyses, conclusions, opinions, and statements expressed herein are those of the authors and not necessarily those of CIHR, CIHI, CCO, ORG, Ministry of Government Services, or IRCC; no endorsement is intended or should be inferred.

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Funding

This research was supported by the Isenberg family fund and Princess Margaret Cancer Foundation. Dr. Michelle B. Nadler was supported as a Dream Hold ‘Em for Life clinical oncology fellow. Dr. Noah M. Ivers is supported by a Canada Research Chair (tier 2) in Implementation of Evidence-Based Practice and as a Clinician Scientist by the University of Toronto Department of Family and Community Medicine. Dr. Aisha Lofters is supported by a CIHR New Investigator award, as a Clinician Scientist by the University of Toronto Department of Family and Community Medicine and as Chair in Implementation Science at the Peter Gilgan center for Women’s Cancers at Women’s College Hospital, in partnership with the Canadian Cancer Society. Dr. Peter Austin is supported by a Mid-Career Investigator award from the Heart and Stroke Foundation. Dr. Brooke E. Wilson was supported as a National Breast Cancer Foundation of Australia International Fellow. Dr. Alexandra Desnoyers was supported as a Hold’Em clinical oncology fellow.

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Authors and Affiliations

  1. Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre, 700 University Ave, 7-821, Toronto, ON, M5G 1Z5, Canada

    Michelle B. Nadler, Brooke E. Wilson, Alexandra Desnoyers & Eitan Amir

  2. University of Toronto, Toronto, Canada

    Michelle B. Nadler, Noah Ivers, Aisha Lofters, Brooke E. Wilson, Alexandra Desnoyers & Eitan Amir

  3. ICES, G106, 2075 Bayview Avenue, Toronto, M4N 3M5, Canada

    Noah Ivers, Alex Marchand-Austin, Aisha Lofters & Peter C. Austin

  4. Women’s College Research Institute, Women’s College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada

    Noah Ivers & Aisha Lofters

  5. Department of Family and Community Medicine, University of Toronto, Toronto, Canada

    Noah Ivers & Aisha Lofters

  6. Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

    Noah Ivers & Peter C. Austin

Authors
  1. Michelle B. Nadler
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  2. Noah Ivers
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  3. Alex Marchand-Austin
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  4. Aisha Lofters
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  5. Peter C. Austin
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  6. Brooke E. Wilson
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  7. Alexandra Desnoyers
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  8. Eitan Amir
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Contributions

Study conception & design: MBN, NI, and EA. Coding and ICES Calculations: AMA. Data analysis: MBN, NI, AL, PCA, BEW, AD, and EA. Manuscript writing: MBN with input from all authors.

Corresponding author

Correspondence to Michelle B. Nadler.

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Conflict of interest

Dr. Aisha Lofters is the Provincial Primary Care Lead, Cancer Screening at Ontario Health (Cancer Care Ontario). Dr. Eitan Amir reports personal fees from Genentech/Roche, personal fees from Apobiologix, personal fees from Myriad Genetics, and personal fees from Agendia, outside the submitted work. Drs Peter Austin, Alexandra Desnoyers, Noah M. Ivers, Alex Marchand-Austin, Michelle B. Nadler, and Brooke E. Wilson declare that they have no conflict of interest.

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Nadler, M.B., Ivers, N., Marchand-Austin, A. et al. Patient and provider determinants of breast cancer screening among Ontario women aged 40–49: a population-based retrospective cohort study. Breast Cancer Res Treat 189, 631–640 (2021). https://doi.org/10.1007/s10549-021-06344-y

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  • DOI: https://doi.org/10.1007/s10549-021-06344-y

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