In total, the survey was sent to 1031 providers and 295 people responded to the survey, for a response rate of 28.6%. Incomplete surveys were accepted, and therefore, each question was analyzed individually with its own “n.” Several respondents had to be excluded due to no longer practicing medicine (9/265) or not seeing female patients over the age of 30 in their practice (1/254). Of 265 respondents, 64.1% (170/265) were doctors, 25.7% (68/265) were NPs, 5.3% (14/265) were PAs, and 1.5% (4/265) were midwives; 3.4% (9/265) of respondents answered “none of the above, or I no longer practice in Southeastern Wisconsin.” Of physicians, 65.3% (111/170) practiced family medicine, 25.3% (43/170) practiced internal medicine, and 9.4% (16/170) practiced obstetrics and gynecology. Most (72.7%, 194/267) responders were employees of large health systems, 13.5% (36/267) were employees in organizations not associated with a university, 7.1% (19/267) were full or part-owner of a physician practice, 2.6% (7/267) were employees of a physician-owned practice, and the remainder (2.6%, 7/267) claimed affiliations with a group or staff model HMO, university hospital, clinic, or other. Over half (56.6%, 81/143) of physicians surveyed were female, and the majority (95%, 57/60) of non-physician clinicians (NP, PA, midwives) surveyed were female. The majority (84.1%, 175/208) of responders said their primary care practice agreed to implement national guidelines for breast cancer screening. Most respondents (59%, 124/210) received annual feedback regarding their rates of breast cancer screening compliance, while 37.1% (78/210) did not and 3.8% (8/210) were unsure. There was no statistically significant difference between provider type and time from last continuing medical education (CME) credit on breast cancer screening.
The average patient population of the providers surveyed had the following racial distribution: 67.7% white, 19.63% black, 14.87% Hispanic or Latina, 5.45% Asian, and 2.14% American Indian or Alaska Native. Nearly three fourths (74.49%) of patients seen by these providers were 40+ years old.
Most providers (77.7%, 136/175) stated that 0–5% of their patients were uninsured; 19.4% (34/175) believed that their uninsured patient population was between 6 and 26% of all their patients, and 46.1% (89/193) of respondents stated that between 6 and 26% of their patients were insured by Medicaid or other local health coverage assistance programs.
Perceived Efficacy of Breast Cancer Screening Modalities
Nearly half (48.8%, 119/244) of providers believed that the clinical breast exam is “somewhat effective” with 35.2% (86/244) stating that it is not effective; the response was similar for breast self-exam with providers answering 49.6% (121/244) and 35.2% (86/244), respectively. Mammography was believed to be “very effective” for 74.6% (182/244) of respondents for patients aged 50–74 years old; this percentage decreased to 47.5% (116/244) for patients aged 40–49 years old and 20.1% (49/244) for patients greater than 75 years old. Non-physician clinicians were statistically more likely to believe in the effectiveness of clinical breast exams, self-breast exams, and mammograms for women of all ages compared to physicians (p < .001) (Fig. 1).
Influence of Guidelines on Screening Practice
The USPSTF was reported as being “very influential” for 60.5% (144/238) of providers. The next most influential organization was the ACS with 46.8% (110/235) of respondents reporting it as “very influential,” followed by 40.4% (95/235) for the AAFP and the ACOG at 39.7% (93/234). When this was divided by provider type, non-physician clinicians favored ACS guidelines over USPSTF recommendations. Roughly 5% (11/238) of those questioned were not familiar with USPSTF guidelines and 39.5% (92/233) were unaware of NCCN guidelines. Despite having these organizational guidelines, most respondents (83.1%, 197/237) only “usually” followed the guidelines they find most influential, while 12.7% (30/237) of providers responded that they “always” followed their preferred guidelines (Fig. 2).
For patients 40–49, the majority (75.6%, 170/225) of providers surveyed performed clinical breast exams, most (91.8%, 156/170) of which were done annually. Over half (58.5%, 131/224) of providers encouraged breast self-exams in this patient population. Mammography was recommended to this population by 80.7% (197/244) of those surveyed; the screening interval most commonly recommended was annually at 72.5% (140/193). Only 12.1% (27/224) of providers did not recommend mammography at all for women 40–49 years old.
For women 50+ years old, 78.7% (177/225) of respondents performed clinical breast exams, again most (92%, 160/174) of which were done annually. Self-breast exams were recommended by 61.2% (137/224) of providers for this age group. Nearly all responders (99.6%, 223/224) recommended mammography in women 50+ years old. Most (77.7%, 167/215) of those who recommended screening recommended annual screening, while 20.5% (44/215) recommended biennial mammography. Almost half (45.1%, 133/295) of responders never stopped recommending mammography based on age. However, of the 54.9% (162/295) that did, the mean age was 77.3 years old.
When survey responses were further divided into physician versus clinician (NP, PA, midwives), there was no statistically significant difference in the use of clinical breast exams or self-breast exams. Mammography was more likely to be recommended annually for women aged 40–49 rather than every 2 years by clinicians as compared to physicians (p < .001). Otherwise, there was no statistically significant difference in mammography screening practices.