Study raises concerns about timely follow-up to positive mammogram for the uninsured

Uninsured women under age 65 who received their mammogram at community screening clinics in North Carolina were less likely to get follow-up within a year of a positive mammogram, and had higher odds of missing a 60-day window for follow-up care, according to a study Louise Henderson, PhD, and her colleagues published in Cancer Epidemiology, Biomarkers & Prevention.

Study raises concerns about timely follow-up to positive mammogram for the uninsured click to enlarge Louise Henderson, PhD, a UNC Lineberger member and assistant professor in the UNC School of Medicine Department of Radiology and UNC Gillings School of Global Public Health
Study raises concerns about timely follow-up to positive mammogram for the uninsured click to enlarge Katherine Reeder-Hayes, MD, MBA, is a UNC Lineberger member and an assistant professor in the UNC School of Medicine.

A study by University of North Carolina Lineberger Comprehensive Cancer Center researchers has found that younger, uninsured women in North Carolina had higher odds of missing a 60-day window for getting follow-up after an abnormal mammogram, even though research underscores the importance of timely follow-up.

In the journal Cancer Epidemiology, Biomarkers & Prevention, researchers report that uninsured women under age 65 who received their mammogram at community screening clinics in North Carolina also were less likely to get follow-up within a year of a positive mammogram.

“If we’re going to use mammography to screen women for breast cancer, we need to make sure that women with a positive result receive the needed follow-up care, regardless of her insurance,” said the study’s senior author Louise Henderson, PhD, a UNC Lineberger member and assistant professor in the UNC School of Medicine Department of Radiology and UNC Gillings School of Global Public Health. “As expected, women without insurance may need more support to make sure they get timely follow-up care.”

Approximately 40 million mammography exams are conducted in the U.S. each year. The U.S. Preventive Service Task Force, citing studies that link mammography exams to reduction in breast cancer deaths, recommends women aged 50 to 74 years have a mammogram every other year. The American Cancer Society advises women to undergo annual screening starting at age 45, and that women between age 40 and 44 years should have the opportunity to begin annual screening as well.

Previous studies have found that one in 10 mammograms require additional follow-up, although the majority do not result in cancer diagnosis. Another study found that a three-to-six-month delay to treatment from symptom onset was linked to larger tumor sizes at diagnosis, and lower survival.

In their study, UNC Lineberger researchers wanted to know if insurance influenced how quickly patients were able to get a follow-up appointment after a positive mammogram. They analyzed data from the Carolina Mammography Registry, a collection of breast imaging information for patients who have gone to community radiology facilities – excluding academic centers ­­­— in North Carolina. They used data gathered between 1995 and 2010 for 43,026 women aged 40 years and older who had a positive screening mammogram.

Their analysis found that women younger than age 65 with no insurance had 60 percent higher odds of not having follow-up within the recommended 60 days of a positive mammogram. Even after a year, they were still less likely to receive follow-up. They were 53 percent less likely to have follow-up in a year.

In terms of overall numbers, 18 percent of women under age 65 without insurance did not get follow-up within 60 days, compared to 11 percent of women in that age group with private insurance.

“We found there are women who aren’t getting follow-up after a positive screening mammogram, and we need to understand why so that we can determine what to do about it. It does seem to vary by insurance, based on some of the data that we present,” Henderson said. “While it is possible that women could have received care outside of the group of community clinics that participated in our study, we don’t know if this is the case.”

There are resources available to help women gain access to mammograms through the Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program, but Henderson said there could be a need for additional resources.

“I think we found something that isn’t unexpected, but is unfortunate, and that is that women who are uninsured may have more trouble getting timely follow-up after an abnormal mammogram,” said study co-author Katherine Reeder-Hayes, MD, MBA, a UNC Lineberger member and an assistant professor in the UNC School of Medicine. “We know that these are some of the same women who don’t have good access to care in other places in the cancer care continuum.”

Danielle Durham, PhD, the study’s first author and a former graduate research assistant at the Carolina Mammography Registry, highlighted the need for more research to determine if any of the women in the study went for follow-up outside of the study’s catchment area.

“It’s important to remember that this is a particular population of people who have sought care,” said Durham, who is now a Cancer Prevention Fellow at the National Cancer Institute. “It would be interesting to see if these trends would be replicated in other populations in the United States.”

In addition to Durham, Henderson, and Reeder-Hayes, other study authors include Whitney R. Robinson, Sheila S. Lee, Stephanie B. Wheeler, J. Michael Bowling, and Andrew F. Olshan.

The study was funded by the National Cancer Institute.