Journal of Urban Health

, 85:677

Racial and Geographic Differences in Mammography Screening in St. Louis City: A Multilevel Study



To examine racial differences in mammography use and its determinants in the City of St. Louis, MO, USA, we recruited women age 40 or older using random-digit dialing to (1) examine the difference in mammography use between white women and African American women and (2) identify individual- and census-tract-level risk factors of nonadherence to mammography. During telephone interviews, we inquired about mammography use and several demographic, psychosocial, and health behavior variables. We determined the residential census tracts of study subjects using a geographic information system. The rate of mammography use was 68.0% among white women and 74.7% among African American women (P = 0.022). African American women were more likely to have mammograms than white woman (adjusted odds ratio [OR] = 1.71; 95% confidence interval [CI] = 1.09–2.69). System-level barriers to mammography and heavy smoking were associated with lower mammography use among both white and African American women. Personal-experience barriers to mammography and no physician recommendation also were independently associated with mammography use among white women. White women residing within a historic geographic cluster area of late-stage breast cancer were less likely to have mammograms (adjusted OR = 0.42, 95% CI = 0.22–0.80), while African American women residing within a historic geographic cluster area of late-stage breast cancer were equally likely to have mammograms (adjusted OR = 0.79, 95% CI = 0.28–2.24). Neither individual- nor census-tract-level socioeconomic status was associated with mammography screening. These findings suggest that there may be a greater need for increasing mammography use among white women, especially in the historic cluster area of late-stage breast cancer in St. Louis.


Breast cancer Cluster Geocoding Mammography Random digit dialing 


  1. 1.
    Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2007. CA Cancer J Clin. 2007;57:43–66.PubMedGoogle Scholar
  2. 2.
    Elmore JG, Armstrong K, Lehman CD, et al. Screening for breast cancer. JAMA. 2005;293:1245–1256.PubMedCrossRefGoogle Scholar
  3. 3.
    Breen N, Wagener DK, Brown ML, et al. Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys. J Natl Cancer Inst. 2001;93:1704–1713.PubMedCrossRefGoogle Scholar
  4. 4.
    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. Morb Mortal Wkly Rep CDC Surveill Summ. 1999;48:1–22.Google Scholar
  5. 5.
    Swan J, Breen N, Coates RJ, et al. Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey. Cancer. 2003;97:1528–1540.PubMedCrossRefGoogle Scholar
  6. 6.
    Jones AR, Caplan LS, Davis MK. Racial/ethnic differences in the self-reported use of screening mammography. J Commun Health. 2003;28:303–316.CrossRefGoogle Scholar
  7. 7.
    Benjamins MR, Kirby JB, Bond Huie SA. County characteristics and racial and ethnic disparities in the use of preventive services. Prev Med. 2004;39:704–712.PubMedCrossRefGoogle Scholar
  8. 8.
    Coughlin SS, Leadbetter S, Richards T, et al. Contextual analysis of breast and cervical cancer screening and factors associated with health care access among United States women, 2002. Soc Sci Med. 2008;66:260–275.PubMedCrossRefGoogle Scholar
  9. 9.
    Breen N, Cronin KA, Meissner HI, et al. Reported drop in mammography: is this cause for concern? Cancer. 2007;109:2405–2409.PubMedCrossRefGoogle Scholar
  10. 10.
    Ryerson AB, Miller J, Eheman CR, et al. Use of mammograms among women aged >/= 40 years—United States, 2000–2005. Morb Mortal Wkly Rep. 2007;56:49–51.Google Scholar
  11. 11.
    Roche LM, Skinner R, Weinstein RB. Use of a geographic information system to identify and characterize areas with high proportions of distant stage breast cancer. J Public Health Manag Pract. 2002;8:26–32.PubMedGoogle Scholar
  12. 12.
    Schootman M, Jeffe DB, Gillanders WE, et al. Geographic clustering of adequate diagnostic follow-up after abnormal screening results for breast cancer among low-income women in Missouri. Ann Epidemiol. 2007;17:704–712.PubMedCrossRefGoogle Scholar
  13. 13.
    Sheehan TJ, DeChello LM. A space-time analysis of the proportion of late stage breast cancer in Massachusetts, 1988 to 1997. Int J Health Geogr. 2005;4:15.PubMedCrossRefGoogle Scholar
  14. 14.
    MacKinnon JA, Duncan RC, Huang Y, et al. Detecting an association between socioeconomic status and late stage breast cancer using spatial analysis and area-based measures. Cancer Epidemiol Biomarkers Prev. 2007;16:756–762.PubMedCrossRefGoogle Scholar
  15. 15.
    Lane DS, Zapka J, Breen N, et al. A systems model of clinical preventive care: the case of breast cancer screening among older women. For the NCI Breast Cancer Screening Consortium. Prev Med. 2000;31:481–493.PubMedCrossRefGoogle Scholar
  16. 16.
    Mandelblatt JS, Yabroff KR, Kerner JF. Equitable access to cancer services: a review of barriers to quality care. Cancer. 1999;86:2378–2390.PubMedCrossRefGoogle Scholar
  17. 17.
    US Preventive Services Task Force. Summaries for patients. Screening for breast cancer: recommendations from the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:I–47.Google Scholar
  18. 18.
    Leitch AM, Dodd GD, Costanza M, et al. American Cancer Society guidelines for the early detection of breast cancer: update 1997. CA Cancer J Clin. 1997;47:150–153.PubMedCrossRefGoogle Scholar
  19. 19.
    Behavioral Risk Factor Surveillance System. Technical Information and Data: Summary Data Quality Reports. Accessed on May 26, 2007.
  20. 20.
    Fletcher SW, Elmore JG. Clinical practice. Mammographic screening for breast cancer. N Engl J Med. 2003;348:1672–1680.PubMedCrossRefGoogle Scholar
  21. 21.
    Krieger N, Chen JT, Waterman PD, et al. Geocoding and monitoring of US socioeconomic inequalities in mortality and cancer incidence: does the choice of area-based measure and geographic level matter? the Public Health Disparities Geocoding Project. Am J Epidemiol. 2002;156:471–482.PubMedCrossRefGoogle Scholar
  22. 22.
    Harris RP, Fletcher SW, Gonzalez JJ, et al. Mammography and age: are we targeting the wrong women? A community survey of women and physicians. Cancer. 1991;67:2010–2014.PubMedCrossRefGoogle Scholar
  23. 23.
    Caplan LS, Wells BL, Haynes S. Breast cancer screening among older racial/ethnic minorities and whites: barriers to early detection. J Gerontol. 1992;47:101–110.PubMedGoogle Scholar
  24. 24.
    Breen N, Kessler L. Changes in the use of screening mammography: evidence from the 1987 and 1990 National Health Interview Surveys. Am J Public Health. 1994;84:62–67.PubMedGoogle Scholar
  25. 25.
    Hardy RE, Ahmed NU, Hargreaves MK, et al. Difficulty in reaching low-income women for screening mammography. J Health Care Poor Underserved. 2000;11:45–57.PubMedGoogle Scholar
  26. 26.
    Iezzoni LI, McCarthy EP, Davis RB, et al. Mobility impairments and use of screening and preventive services. Am J Public Health. 2000;90:955–961.PubMedCrossRefGoogle Scholar
  27. 27.
    Bryant H, Mah Z. Breast cancer screening attitudes and behaviors of rural and urban women. Prev Med. 1992;21:405–418.PubMedCrossRefGoogle Scholar
  28. 28.
    Champion VL. Instrument refinement for breast cancer screening behaviors. Nurs Res. 1993;42:139–143.PubMedCrossRefGoogle Scholar
  29. 29.
    Skinner CS, Arfken CL, Sykes RK. Knowledge, perceptions, and mammography stage of adoption among older urban women. Am J Prev Med. 1998;14:54–63.PubMedCrossRefGoogle Scholar
  30. 30.
    Champion VL. Beliefs about breast cancer and mammography by behavioral stage. Oncol Nurs Forum. 1994;21:1009–1014.PubMedGoogle Scholar
  31. 31.
    Fulton JP, Buechner JS, Scott HD, et al. A study guided by the Health Belief Model of the predictors of breast cancer screening of women ages 40 and older. Public Health Rep. 1991;106:410–420.PubMedGoogle Scholar
  32. 32.
    Aiken LS, West SG, Woodward CK, et al. Health beliefs and compliance with mammography-screening recommendations in asymptomatic women. Health Psychol. 1994;13:122–129.PubMedCrossRefGoogle Scholar
  33. 33.
    Smith RA, Haynes S. Barriers to screening for breast cancer. Cancer. 1992;69:1968–1978.PubMedCrossRefGoogle Scholar
  34. 34.
    Conry CM, Main DS, Miller RS, et al. Factors influencing mammogram ordering at the time of the office visit. J Fam Pract. 1993;37:356–360.PubMedGoogle Scholar
  35. 35.
    Ware JE Jr. The status of health assessment 1994. Annu Rev Public Health. 1995;16:327–354.PubMedCrossRefGoogle Scholar
  36. 36.
    Skinner CS, Sykes RK, Monsees BS, et al. Learn, share, and live: breast cancer education for older, urban minority women. Health Educ Behav. 1998;25:60–78.PubMedCrossRefGoogle Scholar
  37. 37.
    Crawford CB, Ferguson GA. A general rotation criterion and its use in orthogonal rotation. Psychometrika. 1970;35:321–332.CrossRefGoogle Scholar
  38. 38.
    Lautenschlager GJ. A comparison of alternatives to conducting Monte Carlo analyses for determining parallel analysis criteria. Multivariate Behavioral Research. 1989;24:365–395.CrossRefGoogle Scholar
  39. 39.
    Ware J, Kosinski M, Keller S. SF-12: How to Score the SF-12 Physical and Mental Health Summary Scales. 2nd ed. Boston, MA: The Health Institute, New England Medical Center; 1995.Google Scholar
  40. 40.
    Schootman M, Jeffe DB. Identifying factors associated with disability-related differences in breast cancer screening (United States). Cancer Causes Control. 2003;14:97–107.PubMedCrossRefGoogle Scholar
  41. 41.
    Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36:1–10.PubMedCrossRefGoogle Scholar
  42. 42.
    McCullagh P, Nelder JA. Generalized Linear Models. 2nd ed. London: Chapman and Hall; 1989.Google Scholar
  43. 43.
    Dailey AB, Kasl SV, Holford TR, et al. Neighborhood-level socioeconomic predictors of nonadherence to mammography screening guidelines. Cancer Epidemiol Biomarkers Prev. 2007;16:2293–2303.PubMedCrossRefGoogle Scholar
  44. 44.
    O’Malley AS, Renteria-Weitzman R, Huerta EE, et al. Patient and provider priorities for cancer prevention and control: a qualitative study in Mid-Atlantic Latinos. Ethn Dis. 2002;12:383–391.PubMedGoogle Scholar
  45. 45.
    Calvocoressi L, Kasl SV, Lee CH, et al. A prospective study of perceived susceptibility to breast cancer and nonadherence to mammography screening guidelines in African American and White women ages 40 to 79 years. Cancer Epidemiol Biomarkers Prev. 2004;13:2096–2105.PubMedGoogle Scholar
  46. 46.
    Hyndman JC, Holman CD, Dawes VP. Effect of distance and social disadvantage on the response to invitations to attend mammography screening. J Med Screen. 2000;7:141–145.PubMedCrossRefGoogle Scholar
  47. 47.
    Zenk SN, Tarlov E, Sun J. Spatial equity in facilities providing low- or no-fee screening mammography in Chicago neighborhoods. J Urban Health. 2006;83:195–210.PubMedCrossRefGoogle Scholar
  48. 48.
    Casey MM, Thiede Call K, Klingner JM. Are rural residents less likely to obtain recommended preventive healthcare services? Am J Prev Med. 2001;21:182–188.PubMedCrossRefGoogle Scholar
  49. 49.
    Missouri Cancer Registry. Cancer MICA. Accessed on September 26, 2007.
  50. 50.
    Chang SW, Kerlikowske K, Napoles-Springer A, et al. Racial differences in timeliness of follow-up after abnormal screening mammography. Cancer. 1996;78:1395–1402.PubMedCrossRefGoogle Scholar
  51. 51.
    Jones BA, Reams K, Calvocoressi L, et al. Adequacy of communicating results from screening mammograms to African American and White women. Am J Public Health. 2007;97:531–538.PubMedCrossRefGoogle Scholar

Copyright information

© The New York Academy of Medicine 2008

Authors and Affiliations

  1. 1.Department of MedicineWashington University School of MedicineSt. LouisUSA
  2. 2.Alvin J. Siteman Cancer Center, Barnes-Jewish HospitalWashington University School of MedicineSt. LouisUSA

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