Wealthier women get more breast cancer screenings, regardless of benefit

By Steve Tokar

Among women 65 and older, wealthy women in poor health are more likely to receive screening mammography for breast cancer even when they are unlikely to benefit from the test, while poor women in good health are less likely to receive screening mammography even when they are likely to benefit. The results are in a study led by researchers at the San Francisco VA Medical Center.

All of the women in the study were on Medicare, which would minimize cost as a potential barrier to screening, says lead author Brie A. Williams, MD, a staff physician at SFVAMC and an assistant professor of medicine at the University of California, San Francisco.

While the study did not investigate reasons for the disparity, Williams says that wealthier women may be more likely to request mammograms and to have fewer financial and time barriers in getting to mammography appointments. Regardless, she says, “Wealth is associated with more screening, whether you are healthy or unhealthy.”

Guidelines recommend screening mammography for women 65 and older only when they are in good health and likely to live for at least five years. This is because the harms that older women in poor health could potentially suffer from screening—including false positive results, invasive tests, and treatments for tumors that are not likely to be fatal—would outweigh any potential benefit, Williams explains.

She says that the study, which appears in the March 10, 2008 issue of the Archives of Internal Medicine, is the first to examine the effects of both health and wealth on rates of screening mammography in older women.

The study authors analyzed the wealth, health status, five-year survival prognosis, and recent mammography history of 4,222 women age 65 and older who were participants in the Health and Retirement Study, an ongoing national prospective study sponsored by the National Institute on Aging. The NIA study is examining the relationship between health, income, and wealth over time.

Among women who were likely to survive at least five years, 82 percent of women with a net worth of more than $100,000 had received a screening mammogram in the preceding two years. Seventy-one percent of women with a net worth between $100,000 and $10,000 had received a screening, while 68 percent of women with a net worth of less than $10,000 had been screened.

Among women who were likely to survive less than five years, the screening rates were 48 percent for wealthy women, 38 percent for mid-net worth women, and 32 percent for poor women.

Speculating on reasons for the disparity, Williams says, “Many times it is appropriate for patients to take an active role in requesting more breast cancer screening and interventions, and many times it is the physician’s role to tell patients when those screenings and interventions are no longer appropriate. In this case, it appears that wealthier women might be better aware of what their options are in terms of medical interventions, and thus more likely to request them.” Plus, she says, the wealthy women’s physicians might not be comfortable telling them that it is time to “stop screening and start focusing on improving their known health problems—which can be a difficult conversation to have.”

She notes that previous studies have shown a number of reasons why poorer women do not receive as many screening mammograms: “Non-medical expenses might be much more of a burden for them. For example, there could be high transportation costs or a long bus ride to the other side of town. Perhaps the woman is the sole provider for her grandchild at home and cannot afford the time—or she might simply not have regular health care access.”

The lesson for physicians, Williams says, is that “screening decisions should be made on the basis of the health and prognosis of each older woman, individually. Unfortunately, with poorer women, this doesn’t seem to be happening as much.”

Co-authors of the study were Karla Lindquist, MS, of UCSF, and Rebecca L. Sudore, MD, Kenneth E. Covinsky, MD, and Louise C. Walter, MD, of SFVAMC and UCSF.

The study was supported by funds from the United States Department of Defense and the National Institute on Aging, some of which were administered by the Northern California Institute for Research and Education. Dr. Williams is a Hartford Foundation Geriatrics Health Outcomes Research Scholar. Dr. Walter is a VA Advanced Research Career Development Awardee and a Robert Wood Johnson Physician Faculty Scholar.

NCIRE—the Veterans Health Research Institute—is the largest research institute associated with a VA medical center. Its mission is to improve the health and well-being of veterans and the general public by supporting a world-class biomedical research program conducted by the UCSF faculty at SFVAMC.

SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.